Epidemiology of Pertussis and Pertussis-Related Complications in Adults: A German Claims Data Analysis

INTRODUCTION

Pertussis is a highly contagious respiratory infection. It affects people of all ages, yet evidence of the impact of pertussis in adults with underlying conditions (UCs) is scarce. This study investigated the incidence and complication rate of pertussis in adult patients with and without UC.

METHODS

A retrospective analysis was conducted using routinely collected German claims data between 2015 and 2019. Patients with and without different pneumological, cardiovascular, endocrinological, musculoskeletal, and psychological UCs were matched for incidence estimation. Logistic regression models were used to estimate the risk of pertussis depending on the presence of UCs. Negative binomial models were used to assess complication rates in patients with pertussis and with and without UC.

RESULTS

In total, 4383 patients were diagnosed with pertussis during the study period. Patients with any UC had an increased risk for pertussis compared to matched patients without UC (odds ratio [OR] 1.72; 95% confidence interval [CI]1.60-1.84, p < 0.0001). Underlying asthma had the highest risk of pertussis (OR 2.70; 95% CI 2.50-2.91, p < 0.0001), followed by chronic obstructive pulmonary disease (OR 2.35; 95% CI 2.10-2.60, p < 0.0001) and depression (OR 2.08; 95% CI 1.95-2.22, p < 0.0001). Severe complications occurred in 10.8% of the pertussis cohort (13.4% with UC vs. 9.5% without UC). The UC-attributable effect on the risk of severe pertussis-related complications was significantly increased for any UC (incidence rate ratio [IRR] 1.29, 95% CI 1.19-1.39). The severe complication risk was also increased for patients aged 60+ (IRR 1.59, 95% CI 1.46-1.72).

CONCLUSION

This study shows that adults with certain UCs have an increased risk for pertussis and are more likely to have complications. These results provide further evidence that pertussis is a relevant and impactful infectious disease in adults with and without certain UC, indicating that these patients need to be considered when developing vaccination recommendations to avoid pertussis and its associated complications. A graphical abstract is available with this article.

Prevalence of chronic conditions and influenza vaccination coverage rates in Germany: Results of a health insurance claims data analysis

BACKGROUND

The significant annual burden caused by seasonal influenza has led to global calls for increased influenza vaccination coverage rates (VCRs). We aimed to estimate the proportion of the German population at high risk of serious illness from influenza due to chronic conditions and to estimate age-specific VCRs of people with/without chronic conditions.

METHODS

Using health insurance claims data covering nine influenza seasons (2010-2019), we assessed up to 7 million insured individuals per season across all German regions. Individuals were classified according to age and presence of chronic health conditions. VCRs were estimated using outpatient healthcare utilization documentation.

RESULTS

In the 2018-2019 influenza season, 47.3% of individuals had ≥1 chronic condition. Most common were circulatory disorders, accounting for more than a third of individuals with ≥1 condition. Prevalence of chronic diseases, and therefore the proportion of high-risk individuals, increased slightly over time across most age groups. A downward trend in influenza VCRs was observed in all age groups until the 2017-2018 season, followed by a noticeable increase in the 2018-2019 season. Highest VCRs occurred among individuals of ≥60 years, with a 38.5% VCR for this age group in the 2018-2019 season. Several factors, including age, chronic condition type, and geographical location, affected VCRs.

CONCLUSIONS

Influenza VCRs in individuals at high risk of severe complications from influenza infection are insufficient. Our results suggest that intensified public health efforts are necessary to reach the World Health Organization vaccination coverage target of 75%.

Use of follow-on disease-modifying treatments for multiple sclerosis: Consensus recommendations

BACKGROUND

As patents for multiple sclerosis (MS) therapies expire, follow-on disease-modifying treatments (FO-DMTs) become available at reduced cost. Concerns exist that cheaper FO-DMTs are used simply to reduce healthcare costs. However, the well-being of people with MS should take priority.

OBJECTIVES

To identify best practices for FO-DMT development and use by agreeing on principles and consensus statements through appraisal of published evidence.

METHODS

Following a systematic review, we formulated five overarching principles and 13 consensus statements. Principles and statements were voted on by a multidisciplinary panel from 17 European countries, Argentina, Canada and the United States.

RESULTS

All principles and statements were endorsed by >80% of panellists. In brief, FO-DMTs approved within highly regulated areas can be considered effective and safe as their reference products; FO-DMTs can be evaluated case by case and do not always require Phase III trials; long-term pharmacovigilance and transparency are needed; there is lack of evidence for multiple- and cross-switching among FO-DMTs; and education is needed to address remaining concerns.

CONCLUSION

Published data support the use of FO-DMTs in MS. The consensus may aid shared decision-making. While our consensus focused on Europe, the results may contribute to enhanced quality standards for FO-DMTs use elsewhere.

Stakeholder Perspectives on the Development and Implementation of a Polypharmacy Management Program in Germany: Results of a Qualitative Study

Structured management programs have been developed for single diseases but rarely for patients with multiple medications. We conducted a qualitative study to investigate the views of stakeholders on the development and implementation of a polypharmacy management program in Germany. Overall, we interviewed ten experts in the fields of health policy and clinical practice. Using content analysis, we identified inclusion criteria for the selection of suitable patients, the individual elements that should make up such a program, healthcare providers and stakeholders that should be involved, and factors that may support or hinder the program’s implementation. All stakeholders were well aware of polypharmacy-related risks and challenges, as well as the urgent need for change. Intervention strategies should address all levels of care and include all concerned patients, caregivers, healthcare providers and stakeholders, and involved parties should agree on a joint approach.

Market access and value-based pricing of digital health applications in Germany

In December 2019, the Digital Health Care Act ("Digitale-Versorgung-Gesetz") introduced a general entitlement to the provision and reimbursement of digital health applications (DiGA) for insured persons in the German statutory health insurance. As establishing a new digital service area within the solidarity-based insurance system implies several administrative and regulatory challenges, this paper aims to describe the legal framework for DiGA market access and pricing as well as the status quo of the DiGA market. Furthermore, we provide a basic approach to deriving value-based DiGA prices.To become eligible for reimbursement, the Federal Institute for Drugs and Medical Devices evaluates the compliance of a DiGA with general requirements (e.g., safety and data protection) and its positive healthcare effects (i.e., medical benefit or improvements of care structure and processes) in a fast-track process. Manufacturers may provide evidence for the benefits of their DiGA either directly with the application for the fast-track process or generate it during a trial phase that includes temporary reimbursement. After one year of \]reimbursement, the freely-set manufacturer price is replaced by a price negotiated between the National Association of Statutory Health Insurance Funds and the manufacturer. By February 2022, 30 DiGA had successfully completed the fast-track process. 73% make use of the trial phase and have not yet proven their benefit. Given this dynamic growth of the DiGA market and the low minimum evidence standards, fair pricing remains the central point of contention. The regulatory framework makes the patient-relevant benefits of a DiGA a pricing criterion to be considered in particular. Yet, it does not indicate how the benefits of a DiGA should be translated into a reasonable price. Our evidence-based approach to value-based DiGA pricing approximates the SHI's willingness to pay by the average cost-effectiveness of one or more established therapy in a field of indication and furthermore considers the positive healthcare effects of a DiGA.The proposed approach can be fitted into DiGA pricing processes under the given regulatory framework and can provide objective guidance for price negotiations. However, it is only one piece of the pricing puzzle, and numerous methodological and procedural issues related to DiGA pricing are still open. Thus, it remains to be seen to what extent DiGA prices will follow the premise of value-based pricing.

Burden of Herpes Zoster in Adult Patients with Underlying Conditions: Analysis of German Claims Data, 2007-2018

INTRODUCTION

Several chronic underlying conditions (UCs) are known to be risk factors for developing herpes zoster (HZ) and to increase the severity of HZ and its risk of recurrence. The aim of this study was to investigate the incidence and recurrence of HZ in adult patients with one or multiple UCs.

METHODS

A retrospective cohort study based on claims data representing 13% of the statutory health insurance population from 2007 to 2018 in Germany was performed. Patients aged ≥ 18 years were included when at least one of the following UCs was diagnosed: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), depression, diabetes mellitus type 1 or 2, and rheumatoid arthritis (RA). Exact matching was used to account for differences in the distribution of age and sex between the case and matched control cohorts. Multi-morbidity was considered in sensitivity analyses by analyzing patients with only one UC.

RESULTS

Patients with asthma, CHD, COPD, depression, and RA had, on average, a 30% increased risk of developing acute HZ compared to patients without any UC. RA was found to have the highest odds ratio among these conditions, varying from 1.37 to 1.57 for all age groups. Patients with depression also showed a high risk of developing HZ. Analysis of recurrence indicated that patients with at least one UC in the age groups 18-49 years and 50-59 years had the highest risk for a recurrent HZ. After experiencing a first recurrence, patients, regardless of age group, had a two- to threefold higher risk for a second recurrence.

CONCLUSION

This study of representative claims data shows a higher HZ incidence and recurrence frequency in patients with UCs. These results provide relevant information for national health care guidelines and disease management programs.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

[Individual financial burden following a cancer diagnosis from the perspective of social services in Germany]

BACKGROUND

In addition to physical, psychological and social effects, economic effects and the associated financial burden of a cancer diagnosis may also gain in importance during prolonged disease progression. Counselling by social services is an important factor in coping with this burden.

METHODS

People employed in social work in oncology were invited to participate in a survey. The survey comprises 16 items on the perception of financial burdens, changes in the relevance of the topic, risk factors and current counselling practice.

RESULTS

81% of the respondents reported that the financial burden arising from a cancer diagnosis is a relevant topic of consultation for at least half of the patients. For 55%, this topic has become more important in recent years, which is due to higher survival rates, an increased number of younger patients, and poorer social security and working conditions.

DISCUSSION AND CONCLUSION

Despite comprehensive insurance coverage, the financial burden of cancer patients has also gained in importance in Germany and must be increasingly taken into account in everyday social service counselling. Due to numerous risk factors and complex reasons, further measures are required to enable the early identification of risk constellations and to improve the situation of those affected.

The patient-level effect of the cost of Cancer care - financial burden in German Cancer patients

BACKGROUND

Financial toxicity of cancer has so far been discussed primarily in the US health care system and is associated with higher morbidity and mortality. In European health care systems, the socio-economic impact of cancer is poorly understood. This study investigates the financial burden and patient-reported outcomes of neuroendocrine (NET) or colorectal (CRC) cancer patients at a German Comprehensive Cancer Center.

METHODS

This prospective cross-sectional study surveyed 247 advanced stage patients (n = 122 NET/n = 125 CRC) at the National Center for Tumor Diseases, in Germany about cancer-related out-of-pocket costs, income loss, distress, and quality of life. Multiple linear regression analysis was performed to demonstrate the effects of economic deterioration on patients' quality of life and distress.

RESULTS

81% (n = 199) of the patients reported out-of-pocket costs, and 37% (n = 92) income loss as a consequence of their disease. While monthly out-of-pocket costs did not exceed 200€ in 77% of affected patients, 24% of those with income losses reported losing more than 1.200€ per month. High financial loss relative to income was significantly associated with patients' reporting a worse quality of life (p < .05) and more distress (p < .05).

CONCLUSIONS

Financial toxicity in third-party payer health care systems like Germany is caused rather by income loss than by co-payments. Distress and reduced quality of life due to financial problems seem to amplify the burden that already results from a cancer diagnosis and treatment. If confirmed at a broader scale, there is a need for targeted support measures at the individual and system level.

Standardisierte Kostenberechnungen im deutschen Gesundheitswesen: Bericht der Arbeitsgruppe „Standardkosten“ des Ausschusses „ökonomische Evaluation“ der dggö

Hintergrund und Zielsetzung Kostenberechnungen sind ein wesentlicher Bestandteil gesundheitsökonomischer Evaluationen, weisen jedoch für den deutschen Versorgungskontext teilweise große Unterschiede im methodischen Vorgehen auf. Zielsetzung der vorliegenden Artikelserie ist es, einen konsentierten Vorschlag zu den Vorgehensweisen der Kostenberechnungen in verschiedenen Versorgungssektoren zu präsentieren und mit diesem einführenden Artikel allgemeine, Sektoren-unspezifische Aspekte in der Durchführung von Kostenberechnungen zu beschreiben.

Methodik In der Arbeitsgruppe „Standardkosten“ des Ausschusses „Ökonomische Evaluation und Entscheidungsfindung“ haben sich Wissenschaftlerinnen und Wissenschaftler von Universitäten und Entscheidungsträgern im Gesundheitswesen zusammengeschlossen, um die bestehenden Probleme bei Kostenberechnungen im Rahmen gesundheitsökonomischer Forschungen zu diskutieren und ein einheitliches Vorgehen zu erarbeiten. Zur Entwicklung der Empfehlungen fanden drei Arbeitstreffen sowie weitere Telefonkonferenzen statt. Die vorläufigen Ergebnisse wurden auf der 11. Jahrestagung der dggö der Fachöffentlichkeit vorgestellt.

Ergebnisse Im vorliegenden ersten Artikel einer zunächst fünf Artikel umfassenden Serie werden grundsätzliche Themen der Perspektivwahl, des Preis-Mengengerüstes, der Studienarten, der Kostenkomponenten, der Datenquellen, der Anpassung von Kostendaten über die Zeit oder über Ländergrenzen hinweg sowie der Umgang mit Unsicherheit behandelt und Empfehlungen zu diesen Themen gegeben. Des Weiteren wird die Gliederung von später folgenden vier Artikeln zu den Berechnungsmethoden in einzelnen Versorgungssektoren beschrieben.

[Efficacy of decision support systems to improve medication safety - results of the evaluation of the "Arzneimittelkonto NRW"]

Polypharmacy increases the risk of adverse drug reactions, especially in the elderly. Therefore, the reduction of potentially inadequate medication (PIM), an improvement in drug therapy safety and, in general, a more rational use of drugs is an objective of various interventions. The aim of this prospective single-arm interventional study is to investigate the potential of a decision support system (DSS; "Arzneimittelkonto NRW") to improve medication safety in outpatient care. 15 primary care physicians participating in the study recruited 874 patients. Prescription data and results of medication safety tests were available for 654 patients. Data of at least 12 months were available for 86% of these patients. PIM prevalence declined within 12 months (-11.3%), but not at a statistically significant level. The number of prescriptions after the introduction of the DSS is significantly below the prescription volume before the introduction of the DSS (-14.1%). Constantly high alteration rates of up to 85% were observed, for example, on drug interaction system warnings made by the DSS. Technical decision support systems have the potential to support a safer and cost-saving drug use. For the first time, this pilot study provides evidence for this in the context of standard outpatient care in Germany. However, further investigations are necessary to establish a robust body of evidence. A particular focus should be on the qualitative monitoring of the studies and the involvement of other actors in the care process.

Krankheitskosten – Finanzielle Belastung von Krebspatienten – Evidenz für den deutschen Versorgungskontext

Obwohl die Anzahl der Studien zur subjektiven finanziellen Belastung von Krebspatienten stetig steigt, ist die Studienlage für den deutschen Versorgungskontext noch sehr eingeschränkt. Aktuelle Studien deuten jedoch an, dass insbesondere Veränderungen in der Erwerbsfähigkeit ein wesentlicher Treiber des Armutsrisikos in Folge von Krankheit ist.

Genetic Potential of the Biocontrol Agent Pseudomonas brassicacearum (Formerly P. trivialis) 3Re2-7 Unraveled by Genome Sequencing and Mining, Comparative Genomics and Transcriptomics

The genus Pseudomonas comprises many known plant-associated microbes with plant growth promotion and disease suppression properties. Genome-based studies allow the prediction of the underlying mechanisms using genome mining tools and the analysis of the genes unique for a strain by implementing comparative genomics. Here, we provide the genome sequence of the strain Pseudomonas brassicacearum 3Re2-7, formerly known as P. trivialis and P. reactans, elucidate its revised taxonomic classification, experimentally verify the gene predictions by transcriptome sequencing, describe its genetic biocontrol potential and contextualize it to other known Pseudomonas biocontrol agents. The P. brassicacearum 3Re2-7 genome comprises a circular chromosome with a size of 6,738,544 bp and a GC-content of 60.83%. 6267 genes were annotated, of which 6113 were shown to be transcribed in rich medium and/or in the presence of Rhizoctonia solani. Genome mining identified genes related to biocontrol traits such as secondary metabolite and siderophore biosynthesis, plant growth promotion, inorganic phosphate solubilization, biosynthesis of lipo- and exopolysaccharides, exoproteases, volatiles and detoxification. Core genome analysis revealed, that the 3Re2-7 genome exhibits a high collinearity with the representative genome for the species, P. brassicacearum subsp. brassicacearum NFM421. Comparative genomics allowed the identification of 105 specific genes and revealed gene clusters that might encode specialized biocontrol mechanisms of strain 3Re2-7. Moreover, we captured the transcriptome of P. brassicacearum 3Re2-7, confirming the transcription of the predicted biocontrol-related genes. The gene clusters coding for 2,4-diacetylphloroglucinol (phlABCDEFGH) and hydrogen cyanide (hcnABC) were shown to be highly transcribed. Further genes predicted to encode putative alginate production enzymes, a pyrroloquinoline quinone precursor peptide PqqA and a matrixin family metalloprotease were also found to be highly transcribed. With this study, we provide a basis to further characterize the mechanisms for biocontrol in Pseudomonas species, towards a sustainable and safe application of P. brassicacearum biocontrol agents.

Methods for measuring financial toxicity after cancer diagnosis and treatment: a systematic review and its implications

Patients experiencing financial distress as a side-effect of cancer are not only reported in the United States, but also in third-party payer healthcare systems in Europe. Since validated survey instruments are a prerequisite for robust and comparable results, we aimed to compile and classify available instruments to enable both a better understanding of the underlying construct of financial toxicity and to facilitate further studies that are adjustable to various healthcare systems. We did a systematic literature search on studies that provide data on perceived cancer-related financial distress experienced by adult patients using PubMed, CINAHL and Web of Science databases up to 2018. We analyzed all detected instruments, items domains and questions with regard to their wording, scales and the domains of financial distress covered. Among 3298 records screened, 41 publications based on 40 studies matched our inclusion criteria. Based on the analysis of 352 different questions we identified 6 relevant subdomains that represent perceptions of and reactions to experienced financial distress: (i) active financial spending, (ii) use of passive financial resources, (iii) psychosocial responses, (iv) support seeking, (v) coping with care or (vi) coping with ones' lifestyle. We found an inconsistent coverage and use of these domains that makes it difficult to compare and quantify the prevalence of financial distress. Moreover, some existing instruments do not reflect relevant domains for patients in third-party payer systems. There is neither a consistent understanding of the construct of financial burden nor do available instruments cover all relevant aspects of a patients' distress perception. We encourage using the identified six domains to further develop survey instruments and adjust them to different health systems.

Influence of hyperoxia on diastolic myocardial and arterial endothelial function

OBJECTIVE

Hyperoxia is known to influence cardiovascular and endothelial function, but it is unknown if there are differences between younger and older persons. The aim of this study was to monitor changes in myocardial diastolic function and flow-mediated dilatation (FMD) in younger and elderly volunteers, before and after exposure to relevant hyperbaric hyperoxia.

METHODS

51 male patients were separated into two groups for this study. Volunteers in Group 1 (n=28, mean age 26 ±6, "juniors") and Group 2 (n=23, mean age 53 ±9, "seniors") received standard HBO₂ protocol (240kPa oxygen). Directly before and after hyperoxic exposure in a hyperbaric chamber we took blood samples (BNP, hs-troponin-t), assessed the FMD and echocardiographic parameters with focus on diastolic function.

RESULTS

After hyperoxia we observed a high significant decrease in heart rate and systolic/diastolic FMD. Diastolic function varied in both groups: E/A ratio showed a statistically significant increase in Group 1 and remained unchanged in Group 2. E/e' ratio showed a slight but significant increase in Group 1, whereas e'/a' ratio increased in both groups. Deceleration time increased significantly in all volunteers. Isovolumetric relaxation time remained unchanged and ejection fraction showed a decrease only in Group 2. There were no changes in levels of BNP and hs-troponin-t in either group.

CONCLUSION

Hyperoxia seems to influence endothelial function differently in juniors and seniors: FMD decreases more in seniors, possibly attributable to pre-existing reduced vascular compliance. Hyperoxia-induced bradycardia induced a more pronounced improvement in diastolic function in juniors. The ability of Group 1 to cope with hyperoxia-induced effects did not work in the same manner as with Group 2.

Epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany: a systematic review

OBJECTIVES

Despite the availability of vaccines and the existence of public vaccination recommendations, outbreaks of vaccine-preventable childhood diseases still cause public health debate. The objective of this systematic review was to provide an overview of the current epidemiology and economic burden of measles, mumps, pertussis, and varicella in Germany.

METHODS

We systematically reviewed studies published since 2000. The literature search was conducted using PubMed and EMBASE. Also, we used German notification data to give an up-to-date overview of the epidemiology of the four diseases under consideration.

RESULTS

Thirty-six studies were included in our review. Results suggest that there is still considerable morbidity due to childhood diseases in Germany. Studies providing cost estimates are scarce. Comparative analyses of different data sources (notification data vs. claims data) revealed a potential underestimation of incidence estimates when using notification data. Furthermore, several studies showed regional differences in incidence of some of the diseases under consideration.

CONCLUSIONS

Our findings underline the need for improved vaccination and communication strategies targeting all susceptible age and risk groups on a national and local level.

Genetic variants in transcription factors are associated with the pharmacokinetics and pharmacodynamics of metformin

One-third of type 2 diabetes patients do not respond to metformin. Genetic variants in metformin transporters have been extensively studied as a likely contributor to this high failure rate. Here, we investigate, for the first time, the effect of genetic variants in transcription factors on metformin pharmacokinetics (PK) and response. Overall, 546 patients and healthy volunteers contributed their genome-wide, pharmacokinetic (235 subjects), and HbA1c data (440 patients) for this analysis. Five variants in specificity protein 1 (SP1), a transcription factor that modulates the expression of metformin transporters, were associated with changes in treatment HbA1c (P < 0.01) and metformin secretory clearance (P < 0.05). Population pharmacokinetic modeling further confirmed a 24% reduction in apparent clearance in homozygous carriers of one such variant, rs784888. Genetic variants in other transcription factors, peroxisome proliferator-activated receptor-α and hepatocyte nuclear factor 4-α, were significantly associated with HbA1c change only. Overall, our study highlights the importance of genetic variants in transcription factors as modulators of metformin PK and response.

Dose-time dependency of hyperbaric hyperoxia-induced DNA strand breaks in human immune cells visualized with the comet assay

PURPOSE

Hyperbaric oxygen exposure may induce dose-dependent DNA damage in peripheral blood mononuclear cells (PBMCs), and repetitive exposures of man may have protective cellular effects.

METHOD

PBMCs, freshly isolated from non-divers and pure oxygen divers, were exposed to ambient air (21kPa) and hyperoxia at different levels: 100kPa, 240kPa, 400kPa and 600kPa) for up to 6.5 hours in an experimental pressure chamber. DNA double-strand breaks were studied in the comet assay by calculating the "tail moment" and an alternative "Yes or No" method for damaged nuclei. Previously, the experimental procedure had been optimized for human cell experiments: Pre-tests assured that DNA damage could be considered to be oxygen-induced; and cell viability remained over 95% during exposure time.

RESULTS

Visible DNA damage increased with the partial pressure of oxygen (pO2) and exposure time dose-dependently. Linear regressions revealed r2 between 0.61 and 0.98 with the Yes/No method, and significant differences in slopes from control. Tail moment showed similar results, but with less accuracy. The PBMCs of oxygen divers exposed to 400kPa pO2 (up to six hours) showed a significant lower slope in the linear regression.

CONCLUSION

Oxygen induces dose-dependent DNA double-strand breaks, and the Yes/No discrimination is superior to the tail moment in linearity and accuracy. Oxygen diver PBMCs seem to be more resistant to hyperbaric oxygen.

Encapsulation status of papillary thyroid microcarcinomas is associated with the risk of lymph node metastases and tumor multifocality

The management of papillary microcarcinoma (PMC) of the thyroid is controversial, especially after partial thyroid resection for benign thyroid disease. In order to detect prognostic factors for PMC, we analyzed 116 patients with PMC for encapsulation status and lymph node metastases. Between 10/1992 and 12/2010, 116 patients with PMC have been operated in our department (87 females, 29 males, median age 49 years). Eighty per cent of PMCs were diagnosed postoperatively. Seventy-six patients (66%) received a more extended resection with either thyroidectomy, near total thyroidectomy, or Dunhill operation either primarily or after completion operation, whereas 40 patients (34%) had only partial resection. Fifty patients (43%) received radioiodine (RIA) ablation. Lymph node metastases were found in 21 patients (18%). Univariate analysis showed four risk factors to be significantly associated with the risk of lymph node metastasis (p<0.05): male gender, younger age, age group<50 years and nonencapsulation of the tumor. Multivariate analysis demonstrated statistical significance for gender and tumor capsulation status. The tumor capsulation status also correlated with tumor multifocality. Our data show that the risk of lymph node metastases is significantly higher in partially or nonencapsulated PMC than in encapsulated specimens. We therefore suggest that the WHO classification should be extended to a compulsory notification of the encapsulation status in PMC.

Optimization of the interface between radiology, surgery, radiotherapy, and pathology in head and neck tumor surgery: a navigation-assisted multidisciplinary network

A navigation-assisted multidisciplinary network to improve the interface between radiology, surgery, radiotherapy, and pathology in the field of head and neck cancer is described. All implicated fields are integrated by a common server platform and have remote data access in a ready-to-use format. The margins of resection and exact locations of biopsies are mapped intraoperatively. The pathologist uses the numerical coordinates of these samples to precisely trace each specimen in the anatomical field. Subsequently, map-guided radiotherapy is planned. In addition to the benefits of image-guided resection, this model enables radiotherapy planning according to the specific coordinates of the resection defect plus any residually affected sites identified by the pathologist. Irradiation of adjacent healthy structures is thereby minimized. In summary, the navigation-assisted network described grants timely multidisciplinary feedback between all fields involved, attains meticulous pathological definition, and permits optimized coordinate-directed radiotherapy.

Influence of hyperoxia and physical exercise on *OH-radical stress in humans as measured by dihydroxylated benzoates (DHB) in urine

BACKGROUND

Hyperoxia and physical exercise are known to produce reactive oxygen species (ROS), and the *OH radical is the most aggressive among them. However, knowledge is limited about *OH stress during physical work under hyperoxic conditions.

METHODS

This study monitored *OH stress in human volunteers before and after a total of 135 exposures to ambient air (control), different levels of hyperoxia at rest and challenging open-water closed-circuit dives by measurement of dihydroxylated benzoates (DHB) with HPLC by electrochemical detection in urine.

RESULTS

Changes in DHB in urine after control were only 3.43 +/- 4.8% (n = 9). After exposures to 100 kPa oxygen (O2) for 110 minutes DHB revealed increases in urine of 23.14 +/- 5.12% (n = 9); exposures to 240 kPa O2 for 90 minutes increases of 22.38 +/- 8.91% (n = 8); and 280 kPa 02 for 30 minutes of 21.92 +/- 10.76% (n = 17). Closed-circuit dives in open water (45-54 minutes of 125-160 kPa O2) revealed DHB increases of 66.34 +/- 25.73% (n = 92). All results differed significantly from control (p < 0.001). The closed-circuit dives also differed significantly from all exposures to hyperoxia without exercise (p < 0.001). Standardization of "oxygen burden" during each exposure (pO2 x exposure time x VO2) allowed for comparison of different exposures vs. DHB changes and revealed goodness of linear fit of r2 = 0.432 (p < 0.0001).

CONCLUSIONS

Increases in urine DHB after exposures to different levels of hyperoxia at rest and during exercise are consistent with *OH stress that is greater during exercise than at rest, although other interpretations are possible. Standardization of the individual "oxygen burden" for a given exposure may become useful in future for the estimation of *OH stress.

Relationship between multimorbidity and direct healthcare costs in an advanced elderly population. Results of the PRISCUS trial

OBJECTIVES

The goal of this work was to analyze the impact of the extent of multimorbidity on health service resource utilization and, thus, direct healthcare costs of advanced elderly in the German population.

METHODS

Based on a cross-sectional sample aged 72 or above in Germany (n = 1,937), a bottom-up study assessing resource utilization and corresponding costs was performed. Main data sources were patient-reported information concerning morbidity and health service resource utilization administered via telephone interviews within the framework of the PRISCUS trial. To value resource utilization, unit costs were determined for all services under consideration. In order to estimate the impact of multimorbidity on mean annual direct costs, a cumulative multimorbidity index was constructed. Influencing factors on annual average costs were identified via multivariate linear regression models.

RESULTS

Mean annual direct costs of 3,315 EUR (95% confidence interval (CI) 3,118; 3,512) at 2010 prices were caused by the involved patients: 25% of mean annual costs were due to inpatient care, 20% to outpatient physician services, 20% to pharmaceuticals, 12% to assisted living and transportation, 8% to healthcare products and dentures, 7% to rehabilitation services, 5% to outpatient nonphysician providers, and 3% to spending from compulsory long-term care insurance. Each additional comorbidity was accompanied by a cost increase of 563 EUR (95% CI 488; 638). Participants with no diseases mentioned in the multimorbidity index caused average annual costs of 1,250 EUR. In contrast, respondents with 10 + diseases caused the highest mean annual costs of 6,862 EUR.

CONCLUSION

Longer life expectancy has become commonplace and is often associated with the simultaneous occurrence of several diseases. A clear understanding of the impact of multimorbidity on costs is highly relevant for health policy decision makers. The present study provides a well-founded basis to analyze the relationship between multiple morbidity and associated costs due to healthcare resource consumption of older adults in Germany.

Expression and mutation analysis of the tyrosine kinase c-kit in poorly differentiated and anaplastic thyroid carcinoma

Poorly differentiated and anaplastic thyroid carcinoma are aggressive tumors failing to res-pond to conventional therapy. Imatinib mesylate offers an effective therapeutic option in patients with various types of malignancies by inhibiting tyrosine kinases such as c-kit. In this study we investigated c-kit expression in anaplastic and poorly differentiated thyroid carcinoma compared to differentiated carcinoma and adenoma and the presence of c-kit mutations. In total, 224 thyroid tissues were analyzed by immunohistochemistry. Mutation analysis of exon 9, 11, 13, and 17 of the c-kit gene was performed in anaplastic and poorly differentiated carcinoma. c-Kit expression was negative in all anaplastic thyroid carcinoma, while c-kit expression of poorly differentiated carcinoma showed a high variability with a more intense staining in tumors showing obvious differentiated malignant follicular tumor areas. Differentiated carcinoma showed a slight, but not significantly stronger c-kit expression than poorly differentiated carcinoma. All tumors revealed wild type sequences of c-kit gene in exons 9, 11, 13, and 17. The low or lacking c-kit expression in undifferentiated thyroid carcinoma together with the lack of mutations argue against a crucial role of c-kit in thyroid carcinoma cell proliferation. Further molecular targets of imatinib mesylate have to be analyzed to estimate a potential benefit of this drug for patients with dedifferentiated thyroid carcinoma.

Predictors of chronotropic incompetence in the pacemaker patient population

AIMS

We prospectively evaluated results from cardiopulmonary exercise testing for chronotropic incompetence (CI) in a cohort of 292 pacemaker patients. In addition, we evaluated comorbidity and antiarrhythmic patient data as indicators of CI.

METHODS AND RESULTS

On the basis of exercise stress testing and application of the definition of CI by Wilkoff, 51% of our cohort was categorized as having CI. Indications for pacemaker implant for this patient group were 42% atrioventricular block, 56% sinus node disease, and 59% atrial fibrillation. Maximum oxygen uptake (VO(2) max) and exercise duration were significantly reduced among CI pacemaker patients, whereas oxygen uptake at the anaerobic threshold remained unchanged. The following clinical characteristics were significant predictors of CI: existence of coronary artery disease (P = 0.038), presence of an acquired valvular heart disease (P = 0.037), and former cardiac surgery (P = 0.041). Age, gender, arterial hypertension, cardiomyopathy, congenital heart disease, left ventricular ejection fraction, and time period between stress-exercise examination and pacemaker implantation were not significant predictors of CI. Chronic antiarrhythmic therapy with digitalis (P = 0.013), beta blockers (P = 0.036), and amiodarone (P = 0.045) were significant predictors of CI. In contrast, medication with class I and IV antiarrhythmics had no significant correlation with CI.

CONCLUSION

We found the following characteristics predictive of CI in this pacemaker patient population: VO(2) max, existence of coronary artery disease or acquired valvular heart disease, previous cardiac surgery, as well as medication with digitalis, beta blockers, and amiodarone.

[Mild head injury]

Mild injuries to the head are a common everyday occurrence. Only one out of 30,000 patients suffering mild traumatization of the brain subsequently goes on to develop a complication that requires treatment. Such patients can be identified on the basis of the Glasgow Coma Scale and the determination of risk factors, and these data also serve as an aid for deciding whether surveillance at home or hospitalization is indicated.

[Surgical pain management. A Germany-wide survey including the effect of clinical guidelines]

INTRODUCTION

Over the last few years, various studies have aimed at improving the diagnosis and therapy of perioperative and posttraumatic pain.

METHODS

In an anonymous postal survey, 2,393 German surgical clinics were asked to describe several aspects of their clinical pain treatment. In order to assess the influence of interdisciplinary guidelines on surgical pain therapy, the results of this survey were compared to a survey from 1997.

RESULTS

The response rate was 30.8% ( n=738). Pain was measured quantitatively in 11.4% ( n=80) of hospitals, a figure which is unchanged since 1997. In pain treatment,however, some changes were discernible: while 46.6% of all hospitals in 1997 used patient-controlled analgesia often or occasionally, this proportion has risen to 64.5%.Both, the national acute pain guidelines and the WHO chronic pain guidelines were well known (71.3% and 74.7%) and accepted (98.8% and 98.5%, respectively). Among those surgeons who knew the national guidelines,93.7% reported that they used them clinically. In 149 hospitals (20.2%), local guidelines have been developed either anew or from existing guidelines.

CONCLUSIONS

Although clinical guidelines are widely used, pain therapy in surgical patients has improved only marginally.

[Reconstruction after extended partial laryngeal and hypopharyngeal resections. A new method with rib cartilage, chondrosynthesis and free radial transplants]

Partial pharyngectomy combined with subtotal laryngectomy results in permanent tracheostomy and long lasting swallowing difficulties in many cases. Based on our prior experimental and clinical studies on laryngeal chondrosynthesis the objectives of this project were to develop a method for reconstruction of up to two thirds of the larynx and one pyriform sinus.

METHOD

The resected laryngeal framework is reconstructed with autogenous rib cartilage and stabilized with plates and screws. In addition a piece of cartilage is used as a buttress for apposition by the remaining mobile vocal cord. A free radial forearm flap covers the reconstructed framework and forms the sulcus of the pyriform sinus.

RESULTS

Up to now 7 patients have been operated with this technique. The follow up was 35 months on average. None of the patients has a clinically relevant aspiration. All patients have a well understandable voice and one of them--a teacher--could even resume his speech profession.

CONCLUSION

In selected patients these techniques enable functional rehabilitation of swallowing, breathing and speech even after extended partial pharyngolaryngectomy.

Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer

BACKGROUND

Despite significant advancements in rectal surgery, poor perineal wound healing after abdominoperineal resection (APR) of the anorectum continues to be a potential complication of the procedure. The aim of this prospective randomized multicenter study was to investigate the efficacy of a new mode of local antibiotic administration.

PATIENTS AND METHODS

Ninety-seven patients who had to undergo APR for low rectal carcinoma either received sacral drainage plus primary wound closure (control group, n = 48) or the same treatment and supplementary application of three resorbable gentamicin-impregnated collagen fleeces (Septocoll; Merck Biomaterial GmbH, Darmstadt, Germany; Genta group, 49). The following target criteria were investigated: bacteriologic efficacy with respect to the eradication of Enterobacteriaceae, Staphylococcus, and Pseudomonas organisms, and clinical efficacy with respect to perineal wound healing.

RESULTS

The Genta group showed a marked reduction in the investigated pathogens from the secretion obtained by sacral drainage on days 1 and 3, as well as high gentamicin concentrations (day 1, median 126.2 microg/mL; day 3, median 97.6 microg/mL). In total, bacteriologic efficacy amounted to 83.7% in the Genta group (41 of 49 patients) versus 60.4% (29 of 48 patients) in controls (P = 0.013). In concurrence with these bacteriologic results, the postoperative infection rate was significantly higher in controls: 10 patients (20.83%) in the control group versus 3 (6.1%) in the Genta group developed perineal or sacral infection (P <0.05). Postoperative complications in the recruited patients revealed no indication of gentamicin-induced adverse reactions.

CONCLUSIONS

The results of the study show that the specified dose of 3 Septocoll fleeces in patients with APR is liable to significantly eliminate enterobacteria, staphylococci, and pseudomonads. The clinical course is improved as a result of the bactericidal effect exerted by the gentamicin fleece. The use of Septocoll reduced the incidence of postoperative perineal and sacral infections. Local antibiotic carriers seem to be of great advantage in poorly perfused areas such as the sacral cavity or anatomically problematic regions as the rima ani. In locally contaminated or infected areas, local antibiotic carriers achieve greater concentrations of the active substance than those achieved with systemic antibiotics, even if the latter are administered by the parenteral route.

[Ileus in colorectal carcinoma. Preoperative implantation of self-expanding metal stents and early elective surgery as an alternative to emergency surgery]

INTRODUCTION

The objective of this study was to evaluate preoperative decompression with self-expanding metallic stents in patients with acute bowel obstruction due to colorectal carcinoma.

METHODS

In 28 patients, admitted to our clinic between January 1996 and May 1999 with suspicion of acute colonic obstruction caused by a colorectal carcinoma, we attempted to insert under fluoroscopic control a self-expanding metallic stent in the stenosis. After successful relief of obstruction, an elective one-stage surgical procedure followed.

RESULTS

The stent application was technically successful in 21 patients. In 19 patients symptom relief was reached within 2 days. One of these patients died perioperatively and two patients developed an anastomotic leakage. In eight of the other nine patients, in whom decompression was not possible, an emergency surgical procedure was performed; four of these patients died perioperatively. In only one of the five patients who survived, could a surgical procedure without an enterostoma be performed.

CONCLUSION

In cases of acute malignant colorectal obstruction, preoperative stent application under fluoroscopic control is a reliable method to allow single-stage surgical resection without requiring a protective enterostoma.

[Colorectal carcinoma in Cronkhite-Canada syndrome]

We report a 63-year-old lady with Cronkhite-Canada syndrome, who developed colorectal cancer. A hemicolectomy was performed, and the tumor specimen was prepared for DNA-analysis and immunohistochemical screening. We found a mutation of p53 gene without APC- and ras-gene alteration and expression of erbB2-protooncogen. The polyps in non-hereditary Cronkhite-Canada-syndrom are neither adenomatous nor hyperplastic, but patients often develop colorectal cancers. The steps of mutation do not follow the adenoma-carcinoma sequence, first described by Vogelstein 1988. This and previous observations suggest that carcinogenesis in Cronkhite-Canada syndrome follows another independent sequence.

[Biatrial pacing as an effective therapy method of paroxysmal atrial fibrillation]

For effective management of drug-refractory atrial fibrillation as the most common arrhythmia new methods are needed. In case of existing interatrial conduction disturbance the use of biatrial pacemaker with standard right atrial lead and additive coronary sinus lead for left atrial pacing shows an antiarryhthmic effect due to atrial resynchronisation. In order to demonstrate the antiarrhythmic effect of biatrial pacing, 74 pts. (26 f/48 m, mean age 63 +/- 9.4 y, follow-up 482 +/- 183 days) received a biatrial pacemaker (AAD-mode, AV-delay 0 msec, LOGOS, Fa. Biotronik) from 11/97 to 03/99. All patients had a prolongation of P-wave duration more than 100 msec (mean 122.3 +/- 23.1 msec). Preoperatively 9/74 (12%) pts. had monthly, 49/74 pts. (66%) had weekly, and 11/74 pts. (15%) had daily episodes of atrial fibrillation. Permanent atrial fibrillation > 6 month was seen in 5/74 pts. (7%, preoperative cardioversion). The intraoperative right atrial pacing threshold was 0.89 +/- 0.64 V (0.5 msec pulse width), the atrial signal amplitude 2.31 +/- 1.03 mV, the impedance signal 616 +/- 157 omega. Voltage recording in the coronary sinus showed a pacing threshold of 1.4 +/- 0.68 V (0.5 msec pulse width) and a potential of 3.47 +/- 1.44 mV. The impedance signal was 559 +/- 137 omega. The obtained P-wave duration was reduced for 33.9 +/- 20.1 msec. In 7/74 pts. (9.4%) we found a dislocation and in 4/74 pts. (5.4%) an excessive high pacing threshold of coronary sinus lead > 4 V/0.5 msec. All pts. with dislocated lead were reoperated. There were no perforations and thromboses of coronary sinus. The intervention led to a significant inhibition of atrial fibrillation in 11/74 pts. (14.9%) without and in 17/74 pts. (24.3%) with antiarrhythmic drugs. 17/74 pts. (24.3%) had a reduction of episodes without and 16/74 pts. (21.6%) with concomitant medication. The treatment did not have any influence on the prevalence of atrial fibrillation in 9/74 pts. (27%). In conclusion, the implantation of biatrial pacemaker leads to a significant reduction of atrial fibrillation episodes and has proven to be practicable and safe for clinical use.