A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE

BACKGROUND

The efficacy and safety of thromboprophylaxis in pregnancy at intermediate to high risk of venous thrombo-embolism (VTE) is an area of ongoing research.

AIM

This study aimed to assess thrombosis and bleeding outcomes associated with thromboprophylaxis in women at risk of VTE.

METHODS

A cohort of 129 pregnancies, who received thromboprophylaxis for the prevention of VTE, were identified from a specialist obstetric clinic in Johannesburg, South Africa. Intermediate-risk pregnancies, with medical comorbidities or multiple low risks, were managed with fixed low-dose enoxaparin antepartum and for a median (interquartile range) of 4 (4) weeks postpartum. High-risk pregnancies, with a history of previous VTE, were managed with anti-Xa adjusted enoxaparin antepartum and for a median of 6 (0) weeks postpartum. Pregnancy-related VTE was objectively confirmed. Major bleeding, clinically relevant nonmajor bleeding (CRNMB) and minor bleeding were defined according to the International Society on Thrombosis and Hemostasis Scientific Subcommittee.

RESULTS

Venous thrombo-embolism occurred antepartum in 1.4% (95% CI: 0.04-7.7) of intermediate and 3.4% (95% CI: 0.4-11.7) of high-risk pregnancies. Bleeding events occurred in 7.1% (95% CI: 2.4-15.9) of intermediate and 8.5% (95% CI: 2.8-18.7) of high-risk pregnancies. Of these bleeding events, 3.1% (95% CI: 1.0-8.0) were classified as major bleeding. On univariate analysis, no independent predictors of bleeding were identified.

CONCLUSION

The rates of thrombosis and bleeding in this predominantly African population were consistent with similar studies and can be used to inform pregnant women of the benefits of anticoagulation and the risks of potential bleeding.

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

[Epidemiology of systemic lupus erythematosus in Reunion Island, Indian Ocean: A case-series in adult patients from a University Hospital]

OBJECTIVES

The study aimed at assessing the epidemiology and clinical features of systemic lupus erythematosus (SLE) in Reunion Island, South West of Indian Ocean.

PATIENTS AND METHODS

A retrospective study was conducted at the University Hospital of La Reunion (Saint-Denis) by charts review from 2004 to 2015. Patients with a SLE diagnosed over 15 years according to SLICC 2012 criteria were included. Incidence and prevalence were inferred from national health insurance database and population census results.

RESULTS

In total, 123 patients met inclusion criteria: 116 were women (94%) and mean age at diagnosis was 34.7±13.4 years. Ten percent of all patients had a least one parent with autoimmune disease, and 4% with lupus. The main manifestations were musculoskeletal (89%) and mucocutaneous with acute or subacute lesions (76%), alopecia (25%), ulcers (15%) and discoid lupus (11%). Lupus nephropathy occurred in 39%, serositis in 31% and neurological features in 15%. Antinuclear antibodies were positive in 99% (threshold >1/80), and associated to anti-DNA (70%), anti-SSA (47%), anti-RNP (42%), and anti-Sm (37%). APL syndrome was diagnosed in 15%. The average annual standardized incidence between 2010 and 2016 was 6.3 cases per 100,000 inhabitants (95% confidence interval [CI]: 5.6-6.9). The prevalence was 76 cases per 100,000 inhabitants in 2016 (95% CI: 70-82).

CONCLUSION

Lupus in the multi-ethnic population of Reunion Island is characterized by high incidence and high rates of articular and renal manifestations, as well as anti-ENA antibodies.

Cell Specific Matrix Metalloproteinase-1 Regulates Lung Metastasis Synergistically with Smoke Exposure

MMP1, a matrix metalloproteinase that degrades the extracellular matrix, is produced not only by cancer cells but also synthesized in stromal and inflammatory cells during tumorigenesis, invasion and lung metastasis. However, the function of MMP1 expression from host cells, especially tumor-associated macrophages (TAMs), and cells in the lung parenchyma remains to be elucidated. Here we demonstrate that in vitro macrophages co-cultured with tumor cells drastically enhance MMP1 expression, which is further exacerbated upon cigarette smoke exposure. In addition, in vivo, macrophage specific MMP1 was found to have a causative role in primary tumor development and lung metastasis, which was enhanced under smoke exposure as demonstrated in a transgenic mouse model that expressed human MMP1 specifically in macrophages (Mac-MMP1). In contrast, MMP1 from lung cells (Lung-MMP1) reduced colonization to the lung despite the fact that collagen deposition decreased in the Lung-MMP1 mouse tumors. These results demonstrate that the varying cellular source of MMP1 in tumors leads to the complexity observed in the tumor microenvironment. Furthermore, macrophage-specific inhibition of MMP1 secretion may be a potential therapy to aid in the reduction of lung metastasis.

Functionalized poly(3-hydroxybutyric acid) bodies as new in vitro biocatalysts

Cytochromes P450 play a key role in the drug and steroid metabolism in the human body. This leads to a high interest in this class of proteins. Mammalian cytochromes P450 are rather delicate. Due to their localization in the mitochondrial or microsomal membrane, they tend to aggregate during expression and purification and to convert to an inactive form so that they have to be purified and stored in complex buffers. The complex buffers and low storage temperatures, however, limit the feasibility of fast, automated screening of the corresponding cytochrome P450-effector interactions, which are necessary to study substrate-protein and inhibitor-protein interactions. Here, we present the production and isolation of functionalized poly(3-hydroxybutyrate) granules (PHB bodies) from Bacillus megaterium MS941 strain. In contrast to the expression in Escherichia coli, where mammalian cytochromes P450 are associated to the cell membrane, when CYP11A1 is heterologously expressed in Bacillus megaterium, it is located on the PHB bodies. The surface of these particles provides a matrix for immobilization and stabilization of the CYP11A1 during the storage of the protein and substrate conversion. It was demonstrated that the PHB polymer basis is inert concerning the performed conversion. Immobilization of the CYP11A1 onto the PHB bodies allows freeze-drying of the complex without significant decrease of the CYP11A1 activity. This is the first lyophilization of a mammalian cytochrome P450, which allows storage over more than 18days at 4°C instead of storage at -80°C. In addition, we were able to immobilize the cytochrome P450 on the PHB bodies in vitro. In this case the expression of the protein is separated from the production of the immobilization matrix, which widens the application of this method. This article is part of a Special Issue entitled: Cytochrome P450 biodiversity and biotechnology, edited by Erika Plettner, Gianfranco Gilardi, Luet Wong, Vlada Urlacher, Jared Goldstone.

Abstract P5-03-10: Development of a novel HER2 testing strategy, using image-based cell-sorting to isolate pure cell populations from FFPE upstream of FISH

Fluorescent in Situ Hybridization (FISH) guidelines defined by American Society of Clinical Oncology (ASCO) and the College of American Pathologists for determining HER2 status are set to improve accuracy and usefulness as a diagnostic marker in breast cancer. Despite these guidelines, many factors can influence HER2 testing results such as sample preparation, assay-conditions and interpretation of test results due to heterogeneous breast cancer samples. In this multi-site study, sample preparation was carried out using the DEPArray™ to recover pure tumor cell populations from formalin-fixed, paraffin-embedded (FFPE) breast tumor samples. We then compared HER2/CEP17 ratios obtained from the DEPArray™ processed samples from each laboratory to routine FISH on tissue sections.

Methods: Eight breast FFPE tumor tissue biopsies were obtained from commercial tissue banks. From the paraffin tissue blocks, four consecutive tissue curls (each 50 microns thick) were prepared. One curl from each of the 8 patient samples was distributed to four different laboratories for analysis following DEPArray™ based sample preparation. After an initial disassociation of each curl into a single-cell suspension, intact cells were sorted and then recovered based on cytokeratin/ vimentin/DAPI staining using the DEPArray™. Cytokeratin+/Vimentin-/DAPI+ tumor (~250) and Cytokeratin-/Vimentin+/DAPI+ stromal (~250) recovered cells were then deposited onto glass slides prior to standard dual-color HER2/CEP17 FISH analysis for comparison to conventional HER2 FISH result.

Results: Serially sectioned breast tumors from 8 negative/positive cases: 7 infiltrating ductal carcinoma (IDC) and 1 metastatic carcinoma were studied. All four sites demonstrated 100% concordance between FISH results compared to the conventional HER2 FISH result. Overall, >60% of DEPArray™ isolated cells were recovered from FFPE samples that ranged from 1- 15 years of age and reported to contain 60% to 80% tumor content. The use of pure sorted cells permitted the accurate determination of HER2 amplification status in only the tumor cells while the stromal cells consistently yielded a more normalized ratio of HER2 to centromere 17.

Conclusion: The preliminary results of this multi-site study demonstrate that use of DEPArray™ for sorted pure populations is reproducible as well as reliable method for subsequent analysis of HER2 by FISH on FFPE derived tumor cells. Given that traditional FFPE-based HER2 FISH results may be influenced by the tissue sectioning procedure, tissue heterogeneity and/or the scattering of few HER2 amplified tumor cells among normal stromal cells. The DEPArray™ allows analysis of immunofluorescence images and DNA content to isolate and recover pure and intact cell populations. This isolation of pure cell populations prior to FISH analysis is attractive for achieving precise determination of HER2 status on equivocal cases. A more formal analytical validation of this approach through CLIA is currently underway.

Citation Format: Gerber A, Konig L, Millner L, Strotoman L, Khurana A, Kasimir-Bauer S, Moore MW, Cotter PD, Bischoff F. Development of a novel HER2 testing strategy, using image-based cell-sorting to isolate pure cell populations from FFPE upstream of FISH [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-10.

Importance to question sinonasal symptoms and to perform rhinoscopy and rhinomanometry in cystic fibrosis patients

OBJECTIVES

Cystic fibrosis (CF) patients almost regularly reveal sinonasal pathology. The purpose of this study was to assess association between objective and subjective measurements of sinonasal involvement comparing nasal airflow obtained by active anterior rhinomanometry (AAR), nasal endoscopic findings, and symptoms assessed with the Sino-Nasal Outcome Test-20 (SNOT-20).

METHODS

Nasal cavities were explored by anterior rigid rhinoscopy and findings were compared to inspiratory nasal airflow measured by AAR to quantify nasal patency and subjective health-related quality of life in sinonasal disease obtained with the SNOT-20 questionnaire. Relations to upper and lower airway colonization with Pseudomonas aeruginosa, medical treatment, and sinonasal surgery were analysed.

RESULTS

A total of 124 CF patients were enrolled (mean age 19.9 ± 10.4 years, range 4-65 years). A significant association of detection of nasal polyposis (NP) in rhinoscopy was found with increased primary nasal symptoms (PNS) which include "nasal obstruction," "sneezing," "runny nose," "thick nasal discharge," and "reduced sense of smell." At the same time patients with pathologically decreased airflow neither showed elevated SNOT-20 scores nor abnormal rhinoscopic findings. Altogether, rhinomanometric and rhinoscopic findings are not significantly related.

CONCLUSIONS

Among SNOT-20 scores the PNS subscore is related to rhinoscopically detected polyposis and sinonasal secretion. Therefore, we recommend including short questions regarding PNS into CF-routine care. At the same time our results show that a high inspiratory airflow is not associated with a good sensation of nasal patency. Altogether, rhinomanometry is not required within routine CF-care, but it can be interesting as an outcome parameter within clinical trials. Pediatr Pulmonol. 2017;52:167-174. © 2016 Wiley Periodicals, Inc.

Role of steroid sulfatase in steroid homeostasis and characterization of the sulfated steroid pathway: Evidence from steroid sulfatase deficiency

The impact of steroid sulfatase (STS) activity in the circulating levels of both sulfated and unconjugated steroids is only partially known. In addition, the sulfated steroid pathway, a parallel pathway to the one for unconjugated steroids, which uses the same enzymes, has never been characterized in detail before. Patients with steroid sulfatase deficiency (STSD) are unable to enzymatically convert sulfated steroids into their unconjugated forms, and are a good model to elucidate how STS affects steroid biosynthesis and to study the metabolism of sulfated steroids. We quantified unconjugated and sulfated steroids in STSD serum, and compared these results with data obtained from serum of healthy controls. Most sulfated steroids were increased in STSD. However, androstenediol-3-sulfate and epiandrosterone sulfate showed similar levels in both groups, and the concentrations of androsterone sulfate were notably lower. Hydroxylated forms of DHEAS and of pregnenolone sulfate were found to be increased in STSD, suggesting a mechanism to improve the excretion of sulfated steroids. STSD testosterone concentrations were normal, but cholesterol and DHEA were significantly decreased. Additionally, serum bile acids were three-fold higher in STSD. Correlations between concentrations of steroids in each group indicate that 17α-hydroxy-pregnenolone-3-sulfate in men is mainly biosynthesized from the precursor pregnenolone sulfate and androstenediol-3-sulfate from DHEAS. These findings confirm the coexistence of two steroidogenic pathways: one for unconjugated steroids and another one for sulfated steroids. Each pathway is responsible for the synthesis of specific steroids. The equal levels of testosterone, and the reduced level of unconjugated precursors in STSD, support that testosterone is primarily synthesized from sulfated steroids. In consequence, testosterone synthesis in STSD relies on an enzyme with sulfatase activity other than STS. This study reveals that STS is a key player of steroid biosynthesis regulating the availability of circulating cholesterol.

[Rhinosinusitis in cystic fibrosis]

In cystic fibrosis (CF) mucociliary clearance of the entire respiratory system is impaired. This allows pathogens, such as Pseudomonas aeruginosa to persist and proliferate, which by progressive pulmonary destruction causes 90 % of premature deaths due to this inherited disease. The dramatic improvement in life expectation of patients due to intensive therapy has resulted in the inevitable but variably expressed sinonasal involvement coming into the clinical and scientific focus. Thereby, almost all CF patients reveal sinonasal pathology and many suffer from chronic rhinosinusitis. Recently, the sinonasal niche has been recognized as a site of initial and persistent colonization by pathogens. This article presents the pathophysiological background of this multiorgan disease as well as general diagnostic and therapeutic standards. The focus of this article is on sinonasal involvement and conservative and surgical options for treatment. Prevention of pathogen acquisition is an essential issue in the otorhinolaryngological treatment of CF patients.

World-wide architecture of osteoporosis research: density-equalizing mapping studies and gender analysis

OBJECTIVE

While research activities on osteoporosis grow constantly, no concise description of the global research architecture exists. Hence, we aim to analyze and depict the world-wide scientific output on osteoporosis combining bibliometric tools, density-equalizing mapping projections and gender analysis.

METHOD

Using the NewQIS platform, we analyzed all osteoporosis-related publications authored from 1900 to 2012 and indexed by the Web of Science. Bibliometric details were analyzed related to quantitative and semi-qualitative aspects.

RESULTS

The majority of 57 453 identified publications were original research articles. The USA and Western Europe dominated the field regarding cooperation activity, publication and citation performance. Asia, Africa and South America played a minimal role. Gender analysis revealed a dominance of male scientists in almost all countries except Brazil.

CONCLUSION

Although the scientific performance on osteoporosis is increasing world-wide, a significant disparity in terms of research output was visible between developed and low-income countries. This finding is particularly concerning since epidemiologic evaluations of future osteoporosis prevalences predict enormous challenges for the health-care systems in low-resource countries. Hence, our study underscores the need to address these disparities by fostering future research endeavors in these nations with the aim to successfully prevent a growing global burden related to osteoporosis.

Human CYP27A1 catalyzes hydroxylation of β-sitosterol and ergosterol

β-Sitosterol and ergosterol are the equivalents of cholesterol in plants and fungi, respectively, and common sterols in the human diet. In the current work, both were identified as novel CYP27A1 substrates by in vitro experiments applying purified human CYP27A1 and its redox partners adrenodoxin (Adx) and adrenodoxin reductase (AdR). A Bacillus megaterium based biocatalyst recombinantly expressing the same proteins was utilized for the conversion of the substrates to obtain sufficient amounts of the novel products for a structural NMR analysis. β-Sitosterol was found to be converted into 26-hydroxy-β-sitosterol and 29-hydroxy-β-sitosterol, whereas ergosterol was converted into 24-hydroxyergosterol, 26-hydroxyergosterol and 28-hydroxyergosterol.

The systemic control of circadian gene expression

The mammalian circadian timing system consists of a central pacemaker in the brain's suprachiasmatic nucleus (SCN) and subsidiary oscillators in nearly all body cells. The SCN clock, which is adjusted to geophysical time by the photoperiod, synchronizes peripheral clocks through a wide variety of systemic cues. The latter include signals depending on feeding cycles, glucocorticoid hormones, rhythmic blood-borne signals eliciting daily changes in actin dynamics and serum response factor (SRF) activity, and sensors of body temperature rhythms, such as heat shock transcription factors and the cold-inducible RNA-binding protein CIRP. To study these systemic signalling pathways, we designed and engineered a novel, highly photosensitive apparatus, dubbed RT-Biolumicorder. This device enables us to record circadian luciferase reporter gene expression in the liver and other organs of freely moving mice over months in real time. Owing to the multitude of systemic signalling pathway involved in the phase resetting of peripheral clocks the disruption of any particular one has only minor effects on the steady state phase of circadian gene expression in organs such as the liver. Nonetheless, the implication of specific pathways in the synchronization of clock gene expression can readily be assessed by monitoring the phase-shifting kinetics using the RT-Biolumicorder.

2β- and 16β-hydroxylase activity of CYP11A1 and direct stimulatory effect of estrogens on pregnenolone formation

The biosynthesis of steroid hormones in vertebrates is initiated by the cytochrome P450 CYP11A1, which performs the side-chain cleavage of cholesterol thereby producing pregnenolone. In this study, we report a direct stimulatory effect of the estrogens estradiol and estrone onto the pregnenolone formation in a reconstituted in vitro system consisting of purified CYP11A1 and its natural redox partners. We demonstrated the formation of new products from 11-deoxycorticosterone (DOC), androstenedione, testosterone and dehydroepiandrosterone (DHEA) during the in vitro reaction catalyzed by CYP11A1. In addition, we also established an Escherichia coli-based whole-cell biocatalytic system consisting of CYP11A1 and its redox partners to obtain sufficient yields of products for NMR-characterization. Our results indicate that CYP11A1, in addition to the previously described 6β-hydroxylase activity, possesses a 2β-hydroxylase activity towards DOC and androstenedione as well as a 16β-hydroxylase activity towards DHEA. We also showed that CYP11A1 is able to perform the 6β-hydroxylation of testosterone, a reaction that has been predominantly attributed to CYP3A4. Our results are the first evidence that sex hormones positively regulate the overall production of steroid hormones suggesting the need to reassess the role of CYP11A1 in steroid hormone biosynthesis and its substrate-dependent mechanistic properties.

Hepatitis B: global scientific development from a critical point of view

Hepatitis B is the tenth leading cause of death worldwide. Countries with high endemicity, such as China and Taiwan show high scientific productivity in this field and dominate the top ten list of the most productive authors worldwide, providing four of them. This is remarkable, as the USA and Europe usually maintain leading positions, not only regarding country-specific scientific productivity, but also top ten ranking of most productive and most cited authors in other important medical sectors. So far, a scientometric analysis of the topic 'hepatitis B' has not been generated despite an increased need for it in times of modified evaluation criteria for academic personnel and a subsequent tendency to co-authorship and author self-citation. In this study, scientometric methods and large-scale data analysis were used to evaluate quality and quantity of scientific research dealing with the topic 'hepatitis B' and to contribute to distinguish relevant research output. Data were gained from Pubmed and ISI-Web. In the time span of 1971-2011, 49 166 items were published by 250 countries, of which the USA have been the most productive supplier with 28% of all publications, followed in considerable distance by Germany, China, the United Kingdom, Japan, France, Italy and Taiwan, respectively. The USA have established their position as centre of international cooperation. Their cooperation with China proves to be the most productive one. The most prolific journals in the field of hepatitis b were 'Hepatology', the 'Journal of Hepatology' and the 'Journal of Medical Virology'. h-index, citation rate and impact factor, commonly used for assessment of scientific quality, were determined and discussed critically with regard to distortion by bias of self-citation and co-authorship.

Origin of anomalous magnetite properties in crystallographic matched heterostructures: Fe3O4(111)/MgAl2O4(111)

Magnetite films grown on crystallographically matched substrates such as MgAl2O4 are not expected to show anomalous properties such as negative magnetoresistance and high saturation fields. By atomic resolution imaging using scanning transmission electron microscopy we show direct evidence of anti-phase domain boundaries (APB) present in these heterostructures. Experimentally identified 1/4<101> shifts determine the atomic structure of the observed APBs. The dominant non-bulk superexchange interactions are between 180° octahedral-Fe/O/octahedral-Fe sites which provide strong antiferromagnetic coupling across the defect interface resulting in non-bulk magnetic and magnetotransport properties.

Primary tobacco prevention in China--a systematic review

OBJECTIVES

This systematic review of randomized controlled trials aims to identify and describe primary tobacco prevention programs conducted in China and to evaluate their quality and effectiveness.

METHODS

Published studies in English or Chinese were searched in MEDLINE, EMBASE, GLOBAL HEALTH, PsycINFO, Wanfang and CNKI. Eligible studies were randomized controlled trials tailored for a Chinese population. Primary preventive non-pharmacological interventions for smoking cessation or reduction were evaluated. Trials were included if they applied at least one predefined outcome suited for measuring the reduction of smoking rates or the reduction of smoking related morbidity. Two reviewers independently assessed studies for inclusion. The risk of bias in individual studies was evaluated by determining the adequacy of methodological quality criteria.

RESULTS

A total of 21 eligible studies investigating 53,520 patients (range 88 - 30,544) an age between 9.6 and 65 years were identified. All interventions were based on some kind of health education programs. In most cases standard health advice was given and booklets were distributed. The overall methodological quality of the studies was low. Seven studies (33%) showed a statistical significant effect of the described intervention in all predefined outcomes.

CONCLUSION

The documentation of smoking prevention interventions in China is not sufficient to develop effective and reliable action programs. A lack of quality in the design can be discerned rather than a lack in starting interventions. We therefore recommend future interventions to be planned, implemented and conducted in compliance with high quality standards for example Guideline for Good Clinical Practice. Furthermore for preparing reports of RCT findings we recommend the Consolidated Standards of Reporting Trials.

[IQWiG's methods for the cost-benefit assessment : Comparison with an international reference scenario]

Standardization of international health economic guidelines has been repeatedly requested. In this context, an international reference case was proposed, which constitutes an agreed approach for the key elements of health economic evaluation including study perspective, comparators, source of effectiveness data, role of modeling, main (economic) outcome, source of utilities, characterizing uncertainty. It is, however, questionable whether such a reference scenario can reasonably be applied across all health care systems. Our analysis pursues the question to which degree the Institute for Quality and Efficiency in Health Care's (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG) "General methods for evaluating the relation between cost and benefit" comply with the key elements of the reference case. In case of divergences, they will be described and discussed in light of the German social legislation and in consideration of current scientific evidence. In conclusion, the analysis revealed that IQWiG complied with the reference case in almost all aspects. Differences were found only with respect to the choice of main (economic) outcome and the source of utilities. These differences seem justified and well explained in the context of the German social legislation as well as in view of the weaknesses of the quality-adjusted life year (QALY) concept.

[Methods of health economic evaluation for health services research]

On August 30, 2010, the German Network for Health Services Research [Deutsches Netzwerk Versorgungsforschung e. V. (DNVF e. V.)] approved the Memorandum III "Methods for Health Services Research", supported by the member societies mentioned as authors and published in this Journal [Gesundheitswesen 2010; 72: 739-748]. The present paper focuses on methodological issues of economic evaluation of health care technologies. It complements the Memorandum III "Methods for Health Services Research", part 2. First, general methodological principles of the economic evaluations of health care technologies are outlined. In order to adequately reflect costs and outcomes of health care interventions in the routine health care, data from different sources are required (e. g., comparative efficacy or effectiveness studies, registers, administrative data, etc.). Therefore, various data sources, which might be used for economic evaluations, are presented, and their strengths and limitations are stated. Finally, the need for methodological advancement with regard to data collection and analysis and issues pertaining to communication and dissemination of results of health economic evaluations are discussed.

The nocebo effect: a reason for patients' non-adherence to generic substitution?

Substituting generic formulations of the same chemical agent is a common practice in German health care on the basis of so called rebate contracts. The substitution of a medication may affect the patients' adherence or result in adverse events. While adverse events which may be caused by the pharmacological activity of the agent itself can be explained, some non-specific side effects cannot be substantiated referring to pharmacological factors. These adverse reactions are summarized under the term nocebo effect. Since patients experiencing a nocebo effect can subsequently become non-adherent or even discontinue an appropiate therapy, the aim of this article is to study patients' adherence to generic substitution and the extent of the nocebo effect. In MEDLINE and EMBASE, a search was carried out for articles which were published between March 25th, 1989 and March 25th, 2009 by using the following search terms: generic substitution, adherence, non-adherence, non-persistence, rebate contracts, patients' attitude, nocebo, negative placebo effects, placebo adverse reactions, placebo induced side effects and negative placebo responses. In addition a manual search was performed in the reference lists of the articles retrieved. 14 studies met the inclusion and exclusion criteria and were included in this article. The generic substitution was generally accepted by over two thirds of the study populations. But up to 34% of patients being treated for psychological diseases confronted with a change of their medication had additional adverse events. On the basis of the studies analysed, the conclusion can be drawn that the nocebo effect can play a crucial role in the treatment of psychological diseases. Therefore, physicians and pharmacists should be responsible to prevent the nocebo effect through adequately educating the patients.

European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet): a multi-national general paediatric research network for better child health

BACKGROUND

In 2008, the European Academy of Paediatrics launched a paediatric-based research network - EAPRASnet (European Academy of Paediatrics Research in Ambulatory Setting network). The network has recruited primary care and general paediatricians from European and Mediterranean countries.

METHODS

Every paediatrician joining the network has been asked to complete a recruitment survey. The aims of the survey were to characterize paediatrician's demographics, practice arrangements and patient's demographics, to define main incentives for research, and to learn what paediatricians view as unsolved issues that need to be studied.

RESULTS

A total of 156 paediatricians from 19 countries were recruited with 144 completing the questionnaire (92%). Majority of respondents (89%) were general paediatricians for more than half of their time. Practice arrangement of 47% of paediatricians was solo practice, with 40% in group practice. Electronic medical records were being used by 72% of respondents. Over 70% of the paediatricians had more than 1000 patients under their clinical care, and patients younger than 6 years old contributed nearly half of the patient population. Areas of most interest for research were: quality of care indicators, communication with parents, obesity, attention deficit hyperactivity disorder and effective well child care. Main incentives for participation in a research project were interest in the topic (81%) and effort to improve quality of care (71%). Lack of time was the leading reported obstacle for research activity (72%). EAPRASnet is growing, and the network's structure, operation and funding are described. Methods for joining the network and the process of study development are presented.

CONCLUSION

A core group of EAP general paediatricians are committed to research in their practices. The information gathered will serve for future planning of research projects in the EAPRASnet to harmonize and optimize the care given to children in the primary care setting in Europe.

Analysis of genotype by environment interaction for milk yield traits in first lactation of Simmental cattle

The breeding goal for Simmental cattle is derived for intensively managed dairy farms. Its suitability for extensive farms was addressed by analysing possible genotype by environment interaction (G x E) between the management levels for first lactation milk yield traits. A first analysis was performed with the data collected from 300 000 purebred daughters of 278 second crop bulls born in Bavaria in 1993 and 1994. The farms were classified by herd-year-effect, using the sum of fat and protein yields into two levels of management, either with 33 or 10% quantiles, corresponding to approximately 100 000 cows and 30 000 cows, respectively. The comparison was based on 'daughter yield' deviations (DYD). Correlations between DYD of extensive and intensive environments were 0.90, 0.91 and 0.87 for milk, fat and protein yield (kg) for 33% quantiles, respectively. Corresponding correlations for 10% quantiles were 0.85, 0.83 and 0.77. Despite high correlations, 50 out of 149 sires showed significant differences between DYD in different environments. Bulls with higher DYD for milk yield on intensive farms were superior in all environments. For the second analysis extensive and intensive farms in northern and southern Bavaria were chosen at random. Approximately 20 000 cows in each management class were used for the estimation of genetic parameters. In both regions phenotypic and additive-genetic variances were higher in the intensively managed herds. Likewise heritabilities were higher for fat and protein yield, but not for milk where higher heritabilities were observed in 33% quantiles. Genetic correlations between extensive and intensive environments were 0.97 and above (33% quantiles). Ten per cent quantiles led to lower genetic correlations (0.90-0.95). Although no serious re-ranking effects of sires were evident, the scale effect and the differences in genetic parameters should be taken into consideration in practical breeding.

[Diabetes insipidus in a Swiss Braunvieh heifer with internal hydrocephalus]

This case report describes the findings in a seven-month-old heifer with diabetes insipidus attributable to internal hydrocephalus. The heifer was referred to the clinic because of reduced appetite, polydipsia, decreased faecal output and weight loss. The heifer was examined daily for 8 days. She was thin and weak and had a dull dry hair coat and decreased appetite. The heifer urinated frequently; the urine was clear and yel low, had a specific gravity of 1.015. A complete blood cell count, biochemical profile and blood gas analysis revealed increased serum urea, increased serum creatinine, hypernatraemia, hyperchloraemia, hypercalcaemia and hypophosphataemia. The heifer received 10 litres of water and 3 litres of ruminal fluid from a healthy cow per os daily for 5 days. The heifer had access to fresh water ad libitum. The general condition of the heifer did not improve after this treatment. Although the concentration of serum urea and creatinine decreased, the concentrations of sodium, chloride and calcium remained higher than normal. Based on the findings, a diagnosis of diabetes insipidus was made and the heifer was euthanatized. Postmortem examination revealed severe internal hydrocephalus, and a definitive diagnosis of central diabetes insipidus attributable to internal hydrocephalus was made.