Real-world treatment patterns in patients with nontuberculous mycobacterial lung disease in general and pneumologist practices in Germany

Background

Nontuberculous mycobacterial lung disease (NTMLD) is a rare, progressive disease with an increasing incidence worldwide.

Aims

The aim of this retrospective study was to analyze the baseline characteristics and management of NTMLD in general and pneumologist practices in Germany.

Methods

This retrospective study included patients with a culture-confirmed diagnosis of NTMLD documented between October 1, 2014 and September 30, 2019 by 125 general practitioners (GP) and 31 office-based pulmonologists from the IMS Disease Analyzer Database (IQVIA).

Results

A total of 159 patients managed by German GPs (mean age 59 ± 19 years, 51% female) and 236 patients managed by pulmonologists (mean age 62 ± 14 years, 58% female) were analyzed. In total, 45% (72/159) and 40% (94/236) of patients managed by GPs and pulmonologists respectively received antibiotic therapy for NTMLD. This therapy lasted for ≥ 6 months in 42%, for ≥ 12 months in 24%, and ≥ 18 months in 8% of patients. The average therapy duration was longer in patients treated by pulmonologists (241 ± 196 days) than in patients treated by GPs (113 ± 152 days). A total of 27% of patients managed by GPs and 45% of those managed by pulmonologists respectively received guideline-based therapy (GBT), defined as combination therapy with macrolide (azi-/ clarithromycin) + ethambutol + rifabutin/rifampicin, at least once; however, almost all patients (100% in the GP group, 96% in the pulmonologist group) also received non-GBT regimens intermediately.

Conclusions

A considerable number of patients with NTMLD were not managed in accordance with the German guidelines and a substantial proportion also discontinue therapy prematurely. NTMLD management should be improved through appropriate referral pathways and collaboration between expert centers and primary or secondary care physicians.

Heart failure signs and symptoms, hospital referrals, and prescription patterns in patients receiving sacubitril/valsartan in primary care and cardiologist settings in Germany

Aims

The aim of this paper was to analyse heart failure (HF) signs and symptoms, hospital referrals, and prescription patterns in patients receiving sacubitril/valsartan (sac/val) in primary care and cardiology settings in Germany.

Methods and results

A retrospective cohort study of electronic medical records identified 1263 adults (aged ≥18 years) in the German IMS® Disease Analyzer database who were prescribed sac/val during 2016 and had at least 6 months of data following sac/val initiation. Clinical characteristics were collected during the 12 months before the first recorded sac/val prescription (index date) and 6 months post‐index. Details of sac/val dose and prescription patterns were also recorded in the 6 months post‐index. HF signs, symptoms, and all‐cause hospital referrals were evaluated for 90 days pre‐index and 30–120 days post‐index. Most patients (62%) were prescribed the lowest sac/val dose of 24/26 mg twice daily (b.i.d.) at index; only 14% of patients initiated on 24/26 mg or 49/51 mg b.i.d. were up‐titrated to the 97/103 mg b.i.d. target dose during the 6 months post‐index, while 6% of patients initiated on either 49/51 mg or 97/103 mg b.i.d. were stably down‐titrated. Evaluation of prescription patterns in relation to clinical characteristics did not clearly explain the reluctance to up‐titrate in the majority of patients. More patients experienced HF signs or symptoms or all‐cause referrals to hospital during the 90 days pre‐index than during the 30–120 days post‐index.

Conclusions

The majority of patients receiving sac/val are not up‐titrated, contrary to recommendations of the EU summary of product characteristics; this is not fully explained by patients' clinical characteristics. Further research is required to understand the reasons for clinician inertia.

Real-world treatment patterns of sacubitril/valsartan: a longitudinal cohort study in Germany

AIMS

To analyse real-world treatment patterns of sacubitril/valsartan (sac/val) using data from a pharmacy database in Germany.

METHODS AND RESULTS

A retrospective cohort study of 26 191 adult patients (aged ≥ 18 years) in the IMS® longitudinal prescriptions database in Germany who were dispensed sac/val from January 2016 to June 2017 was conducted. The analysis included sac/val dose titration assessed in the 6 months from first sac/val prescription; prescriptions of concomitant cardiovascular medications in the 6 months pre- and post-index and compliance and persistence during 12 months post-index. Two-thirds of patients were prescribed the lowest sac/val dose of 50 mg twice daily (b.i.d.) at index and up-titration during the first 6 months was attempted in 41% of these patients. Ten percent of patients prescribed 200 mg b.i.d. at index had to be stably down-titrated; among patients prescribed 50 or 100 mg b.i.d. at index that were up-titrated, > 80% remained on the higher dose. Overall, the mean daily diuretic dose decreased by 25% after initiation of sac/val. High compliance and persistence rates were observed across sac/val doses, increasing with higher sac/val dose at index. Prior dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker had only minor impact on first sac/val dose, compliance and persistence.

CONCLUSIONS

Most patients prescribed sac/val are not initiated on the recommended dose nor up-titrated as recommended by the EU Summary of Product Characteristics. Initiation of sac/val was associated with high persistence and compliance and a dose reduction of diuretics. Barriers to up-titration must be explored.

Increased depression symptom score in newly diagnosed type 2 diabetes patients

The aim was to investigate the association between diabetes duration and depressive symptoms in type 2 diabetes. The DIAREG registry used data of a nationwide general medicine practice database (Disease Analyzer, Germany) augmented by prospective data from patient reported outcomes (PRO) including Center of Epidemiological Studies Depression Scale (CES-D: <16 vs. ≥16) and the SF-36. Multiple logistic regression models were used to investigate the association of diabetes duration with PROs. Overall, 1807 type 2 diabetes patients were registered in 108 practices. From 270 (15%) patients complete PRO could be collected, which were similar with respect to age, sex, body mass index, HbA1c, diabetes duration and treatment to patients with incomplete data (p≥0.05). Patients with a longer diabetes duration (reference: <2 years) displayed a significantly increased odds of having no indication of depression (CES-D <16: 66%) (Odds Ratio, 95%CI: 2-<5 years: 5.9, 1.2-29.6; 5-<10 years: 6.2, 1.3-28.7; ≥10 years: 5.6, 1.2-23.1), after adjusting for age, sex, BMI, diabetes complications, antidepressants and glucose-lowering treatment. Patients with <2 years diabetes duration also exhibited a significantly decreased mean mental component score (SF-36: <2 years: 50, 2-<5 years: 69). In type 2 diabetes with a short duration an increased depressive symptom score was observed.

[Pregnancy after breast cancer in germany - results of a retrospective database analysis]

BACKGROUND

After the establishment of the FertiPROTEKT network in 2006, an impetus for possibilities of pregnancy during and after breast cancer was introduced. Nowadays, breast cancer survivors are confronted with the question how often women become pregnant after breast cancer and whether there have been significant changes in this respect during the past 10 years. The aim of the study was, therefore, to examine the change in frequency of pregnancies after breast cancer treatment and the time from the first breast cancer diagnosis to pregnancy over one decade, i. e., the period from 2010-2012 compared to the period from 2000-2002.

METHODS

The study is based on data from the IMS Disease Analyzer database, which enables access to anonymous data from registered physicians. Data from 102 gynecological practices were available for the present study. The study included women aged 20-45 with breast cancer.

RESULTS

A total of 179 pregnant women were included in this study from 2000-2002 and 2010-2012. 65 pregnancies were recorded in the period from 2000-2002, 114 pregnancies from 2010-2012. The time interval from the breast cancer diagnosis to pregnancy (analysed time period was 10 years) was 896 days (SD: 690) in the period from 2000-2002 and 552 days (SD: 696) in the period from 2010-2012 (p<0.001).

CONCLUSION

There was a significant increase in pregnancies within the first 2 years after the breast cancer diagnosis. These data are consistent with the intensified consultations after the introduction of the FertiPROTEKT network.

In situ kinetic trapping reveals a fingerprint of reversible protein thiol oxidation in the mitochondrial matrix

Reactive oxygen species (ROS) are released at the mitochondrial inner membrane by the electron transport chain (ETC). Increasing evidence suggests that mitochondrial H2O2 acts as a signaling molecule and participates in the (feedback) regulation of mitochondrial activity and turnover. It seems likely that key mitochondrial components contain redox-sensitive thiols that help to adapt protein function to changes in electron flow. However, the identity of most redox-regulated mitochondrial proteins remains to be defined. Thioredoxin 2 (Trx2) is the major protein-thiol-reducing oxidoreductase in the mitochondrial matrix. We used in situ mechanism-based kinetic trapping to identify disulfide-exchange interactions of Trx2 within functional mitochondria of intact cells. Mass spectrometry successfully identified known and suspected Trx2 target proteins and, in addition, revealed a set of new candidate target proteins. Our results suggest that the mitochondrial protein biosynthesis machinery is a major target of ETC-derived ROS. In particular, we identified mitochondrial methionyl-tRNA synthetase (mtMetRS) as one of the most prominent Trx2 target proteins. We show that an increase in ETC-derived oxidants leads to an increase in mtMetRS oxidation in intact cells. In conclusion, we find that in situ kinetic trapping provides starting points for future functional studies of intramitochondrial redox regulation.

Potent costimulation of human CD8 T cells by anti-4-1BB and anti-CD28 on synthetic artificial antigen presenting cells

The in vitro generation of cytotoxic T lymphocytes (CTLs) for anticancer immunotherapy is a promising approach to take patient-specific therapy from the bench to the bedside. Two criteria must be met by protocols for the expansion of CTLs: high yield of functional cells and suitability for good manufacturing practice (GMP). The antigen presenting cells (APCs) used to expand the CTLs are the key to achieving both targets but they pose a challenge: Unspecific stimulation is not feasible because only memory T cells are expanded and not rare naïve CTL precursors; in addition, antigen-specific stimulation by cell-based APCs is cumbersome and problematic in a clinical setting. However, synthetic artificial APCs which can be loaded reproducibly with MHC-peptide monomers and antibodies specific for costimulatory molecules could resolve these problems. The purpose of this study was to investigate the potential of complex synthetic artificial APCs in triggering the costimulatory molecules CD28 and 4-1BB on the T cell. Anti-4-1BB antibodies were added to an established system of microbeads coated with MHC-peptide monomers and anti-CD28. Triggering via CD28 and 4-1BB resulted in strong costimulatory synergy. The quantitative ratio between these signals determined the outcome of the stimulation with optimal results when anti-4-1BB and anti-CD28 were applied in a 3:1 ratio. Functional CTLs of an effector memory subtype (CD45RA(-) CCR7(-)) were generated in high numbers. We present a highly defined APC platform using off-the-shelf reagents for the convenient generation of large numbers of antigen-specific CTLs.

Selective redox regulation of cytokine receptor signaling by extracellular thioredoxin-1

The thiol-disulfide oxidoreductase thioredoxin-1 (Trx1) is known to be secreted by leukocytes and to exhibit cytokine-like properties. Extracellular effects of Trx1 require a functional active site, suggesting a redox-based mechanism of action. However, specific cell surface proteins and pathways coupling extracellular Trx1 redox activity to cellular responses have not been identified so far. Using a mechanism-based kinetic trapping technique to identify disulfide exchange interactions on the intact surface of living lymphocytes, we found that Trx1 catalytically interacts with a single principal target protein. This target protein was identified as the tumor necrosis factor receptor superfamily member 8 (TNFRSF8/CD30). We demonstrate that the redox interaction is highly specific for both Trx1 and CD30 and that the redox state of CD30 determines its ability to engage the cognate ligand and transduce signals. Furthermore, we confirm that Trx1 affects CD30-dependent changes in lymphocyte effector function. Thus, we conclude that receptor–ligand signaling interactions can be selectively regulated by an extracellular redox catalyst.

Merging clinical pathway programs as part of overall health system mergers: a ten-step guide. Spectrum Health

BACKGROUND

Mergers, acquisitions, and reorganizations can be stressful and accompanied by ambivalence, confusion, and uncertainty. Providing clear and simple steps for merging clinical pathways may help organizations move through the transition process more smoothly. The ten steps according to which Spectrum Health merged its pathway program-conduct an inventory of previous efforts, plan for the ideal program, bring staff together early in the merger process, decide on a common format, standardize the development and revision process, standardize a reporting tool, create a clinical pathway manual, implement an educational plan, present the program to key customers, and appoint an advisory group-need not be done sequentially. The ten-step pathway merger program uses pathways as a means to improve the quality of the care provided, with a focus on multidisciplinary clinical pathway teamwork. Before the merger, the two hospital systems' pathway programs used different approaches to operations and pathway format. When the announcement to merge came in September 1997, steps to merge the clinical pathway programs began.

DISCUSSION

More than two years into the merger, Spectrum Health continues to struggle with the evolution of the health system. Clinical pathways represent just one of the significant and extensive issues related to organizational mergers; organizational values, finances, vision, mission, customer relations, strategic priorities, and people issues are a few of the others. Focusing on merging programs such as clinical pathway programs can help put one large piece of the merger puzzle in place and reduce some of the ambiguity associated with all mergers. Executive support is critical to the success of the clinical pathway program.

Breast stimulation in late pregnancy. Effect on prostaglandin secretion

The effect of breast stimulation on the prostaglandin secretion was tested in 13 patients at 38-40 weeks of gestation. Uterine contractions following breast stimulation were documented in all cases. There was an increase in prostaglandin metabolite levels 10 min after breast stimulation.