Adding troponin to echocardiography improves preoperative abscess detection in infective endocarditis. A REMOVE Trial analysis

Background

Detection of cardiac abscess in patients with infective endocarditis (IE) is important for surgical planning and decision-making. While transesophageal echocardiography (TEE) is the method of choice for abscess detection, in many cases uncertainty remains. Since IE abscesses often affect ventricular muscle, biomarker release may be a helpful adjunct for abscess detection.

Purpose

We assessed the accuracy of TEE and the value of combining it with preoperative measurement of cardiac Troponin (cTn) in the diagnosis of abscess, using surgical inspection as a reference.

Methods

Data collected in the electronic clinical report form for patients included in the prospective, multicenter, randomized, controlled trial (REMOVE Trial) were analyzed. Continuous variables are presented as median (25th–75th percentile) and categorical data as absolute and relative frequencies. The diagnostic performance of TEE was identified by comparing preoperative TEE findings with intraoperative findings. The concordance rate is expressed as a percentage. Receiver operating characteristic (ROC) curve was used to assess the ability of cTn to predict the presence of abscess intraoperatively. Area under curve (AUC) with 95% confidence interval as well as sensitivity and specificity are provided as measures of accuracy. Youden index was used to estimate an optimal cut-off value for cTn.

Results

Among the 282 patients included, 84 had abscesses detected intraoperatively. The sensitivity and specificity of TEE to detect abscess were 58.3% and 86.4%, respectively. cTn-I and cTn-T were measured preoperatively in 113 and 96 patients, respectively. Median cTn-I in patients with abscess was 132 pg/ml (interquartile range (IQR): 54–1528) vs 53 pg/ml (IQR: 17–250) in patients without abscess, p=0.002. Median cTn-T in patients with abscess was 941 pg/ml (IQR: 387–1527) vs 697 pg/ml (IQR: 282–1423) in patients without abscess, p=0.353. The incidence of recent preoperative myocardial infarction was not different between patients with or without abscess (7.1% vs 5.6%, respectively, p=0.593). The AUC for predicting abscess was 0.69 (95% CI: 0.57 to 0.80, p=0.002) and 0.56 (95% CI: 0.43 to 0.69, p=0.353) for preoperative cTn-I and cTn-T, respectively. Optimal cut-offs according to the Youden index are 38 pg/ml for cTn-I and 1632 pg/ml for cTn-T. By adding preoperative cTn-I or cTn-T to the TEE findings, the AUC increased to 0.82 (95% CI: 0.73 to 0.91, p<0.001) and 0.72 (95% CI: 0.59 to 00.84, p=0.001), respectively.

Conclusion

The results suggest that using TEE alone is a poor method for abscess detection in IE. Adding preoperative troponin values to TEE findings significantly improved IE abscess detection.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Ministry of Education and Research (BMBF), Germany

Rediscovery after 25 years – first photographic documentation and DNA barcoding of the deep-sea pycnogonid species Ascorhynchus hippos Turpaeva, 1994 (Chelicerata, Pycnogonida, Ascorhynchidae) from the Kuril-Kamchatka Trench

The female specimen of Ascorhynchus hippos Turpaeva, 1994 was collected in 2015 during the Russian-German deep-sea expedition SokhoBio (Sea of Okhotsk Biodiversity Studies) at the abyssal western slope of the Kuril-Kamchatka Trench at a depth of 4469 m using a camera-epibenthic sledge. It is the first record of this species since the discovery of one female holotype and one male paratype in 1990. Ascorhynchus hippos is easily distinguishable from its congeners by the two prominent tubercles above the chelifore insertions, the absence of the eye tubercle and eyes, and the tubercles on the mid-dorsal trunk segments and the lateral processes. Here we present the first photographic documentation of all three known specimens of A. hippos and the COI barcode of the new specimen is also provided.

Reconstruction of evolutionary changes in fat and toxin consumption reveals associations with gene losses in mammals: a case study for the lipase inhibitor PNLIPRP1 and the xenobiotic receptor NR1I3

The inactivation of ancestral protein-coding genes (gene loss) can be associated with phenotypic modifications. Within placental mammals, repeated losses of PNLIPRP1 (gene inhibiting fat digestion) occurred preferentially in strictly herbivorous species, while repeated NR1I3 losses (gene involved in detoxification) occurred preferentially in strictly carnivorous species. It was hypothesized that lower fat contents of herbivorous diets and lower toxin contents of carnivorous diets cause relaxed selection pressure on these genes resulting in the accumulation of mutations and ultimately to convergent gene losses. However, since herbivorous and carnivorous diets differ vastly in their composition, a fine-grained analysis is required for hypothesis testing. We generated a trait matrix recording diet and semi-quantitative estimates of fat and toxin consumption for 52 placental species. By including data from 31 fossil taxa, we reconstructed the ancestral diets in major lineages (grundplan reconstruction). We found support that PNLIPRP1 loss is primarily associated with low levels of fat intake and not simply with herbivory/carnivory. In particular, PNLIPRP1 loss also occurred in carnivorous lineages feeding on a fat-poor diet, suggesting that the loss of this gene may be beneficial for occupying ecological niches characterized by fat-poor food resources. Similarly, we demonstrated that carnivorous species are indeed less exposed to diet-related toxins suggesting that the loss of NR1I3 and related genes (NR1I2, UGT1A6) resulted from relaxed selection pressure. This study illustrates the need of detailed phenotype studies to obtain a deeper understanding of factors underlying gene losses and to progress in understanding genomic causes of phenotypic variation in mammals.

The impact of establishing a regional infective endocarditis (IE) network on pre-operative IE-related complications and on post-operative outcome

Background

Infective endocarditis (IE) requires a high degree of suspicion and advanced level of multidisciplinary management. In 2015, the European guidelines recommended the formation of an endocarditis-team (ET) for optimal treatment of IE. In 2011, we already established an ET within the hospital that was only consulted on demand for certain patients. Since 2015, ET has been increasingly involved in the management of almost all patients with IE. In addition, we established in 2015 a statewide endocarditis- (E) network for the referring hospitals.

Purpose

We investigated the effect of E-network on reducing referral latency and pre-operative IE-related complications. We also investigated the adherence to the ET management recommendations in our hospital and its impact on post-operative stroke and mortality.

Methods

We retrospectively analyzed data from patients operated for IE in our center between 01/2007 and 03/2018. We conducted univariate analysis using Chi-square or Fisher's exact test, Multivariate logistic regression models for in-hospital mortality and post-operative stroke, and Kaplan-Meier estimate of 5-years survival.

Results

Among 630 patients operated for IE in our center, 409 (65%) underwent surgery in the 1st era before 12/2014. S. aureus IE was more frequent in the second era (34% vs 25%, p<0.001). The median time from the onset of symptoms to referral in the 2nd era was halved compared to the first one [7 days (IQR 2–19) vs 15 days (IQR 6–35)]. Patients in the 2nd era were admitted with less IE-related complications, i.e. less preoperative stroke (14% vs 27%, p<0.001), less heart failure (45% vs 69%, p<0.001) less cardiac abscesses (24% vs 34%, p=0.018), less acute renal insufficiency requiring hemodialysis (8% vs 14%, p=0.026). The lack of ET management recommendations was an independent predictor for in-hospital mortality (adjusted OR: 2.13, 95% CI: 1.27–3.53, p=0.004) and post-operative stroke (adjusted OR: 2.23, 95% CI: 1.12–4.39, p=0.02), and was associated with worse 5-years survival (59% compared to 40%, log rank<0.001).

Conclusion

Endocarditis-network led to earlier referral of patients, which resulted in less IE-related complications on admission. Lack of ET management recommendations was an independent predictor for post-operative stroke, in-hospital mortality and was associated with worse 5-years survival.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prostatic Artery Embolization: Influence of Cone-Beam Computed Tomography on Radiation Exposure, Procedure Time, and Contrast Media Use

Purpose

To evaluate the effect of cone-beam computed tomography (CBCT) on radiation exposure, procedure time, and contrast media (CM) use in prostatic artery embolization (PAE).

Materials and Methods

Seventy-eight patients were enrolled in this retrospective, single-center study. All patients received PAE without (group A; n = 39) or with (group B; n = 39) CBCT. Total dose-area product (DAP_total; Gycm²), total entrance skin dose (ESD_total; mGy), and total effective dose (ED_total; mSv) were primary outcomes. Number of digital subtraction angiography (DSA) series, CM use, fluoroscopy time, and procedure time were secondary outcomes. PAE in group A was performed by a single radiologist with 15 years experience, PAE in group B was conducted by four radiologists with 4 to 6 years experience.

Results

For groups A vs. B, respectively, median (IQR): DAP_total 236.94 (186.7) vs. 281.20 (214.47) Gycm²(p = 0.345); ED_total 25.82 (20.35) vs. 39.84 (23.75) mSv (p =  < 0.001); ESD_total 2833 (2278) vs. 2563 (3040) mGy(p = 0.818); number of DSA series 25 (15) vs. 23 (10)(p = 0.164); CM use 65 (30) vs. 114 (40) mL(p =  < 0.001); fluoroscopy time 23 (20) vs. 28 (25) min(p = 0.265), and procedure time 70 (40) vs.120 (40) min(p =  < 0.001). Bilateral PAE was achieved in 33/39 (84.6%) group A and 32/39 (82.05%) group B(p = 0.761), all other patients received unilateral PAE. There were no significant differences between clinical parameters and origins of the prostatic arteries (PA) (p = 0.206–1.00).

Conclusion

Operators with extensive expertise on PAE may not benefit from addition of CBCT to DSA runs, whereas for operators with less expertise, CBCT when used alongside with DSA runs increased the overall radiation exposure.

Risk factors for vertebral fractures and bone loss after denosumab discontinuation: A real-world observational study

BACKGROUND

Denosumab discontinuation without subsequent bisphosphonates (BPs) is associated with bone loss and multiple vertebral fractures.

OBJECTIVE

Identifying risk factors for bone loss and vertebral fractures after denosumab discontinuation.

METHODS

This retrospective study measured the outcome of 219 women with osteoporosis who discontinued denosumab treatment and received subsequent treatment with zoledronate, other BPs or a selective estrogen receptor modulator (SERM), or no therapy. Fracture rate, longitudinal bone mineral density (BMD) changes and bone turnover markers (BTMs) within 2 years after denosumab discontinuation were analysed. Linear regression analysis evaluated loss of BMD and age, BMI (kg/m²), denosumab treatment duration, pre-treatment, prior fracture state, baseline T-scores, use of glucocorticoids or aromatase inhibitors and BMD gains under denosumab therapy.

RESULTS

171 women received zoledronate after denosumab discontinuation, 26 had no subsequent treatment and 22 received other therapies (other BPs or a SERM). Zoledronate was associated with the fewest vertebral fractures (hazard ratio 0.16, p = 0.02) and all subsequent therapies retained BMD at all sites to some extent. Higher BMD loss was associated with younger age, lower BMI, longer denosumab treatment, lack of prior antiresorptive treatment and BMD gain under denosumab treatment. BTM levels correlated with denosumab treatment duration and bone loss at the total hip, but not the lumbar spine.

CONCLUSIONS

Compared to no subsequent therapy, zoledronate was associated with fewer vertebral fractures after denosumab. Further, BMD loss depended on denosumab treatment duration, age, prior BP therapy and BMD gain under denosumab therapy, whereas BTM levels were associated with bone loss at the total hip and denosumab treatment duration.

Outsourcing a visual neuropil - The central visual system of the median eyes of Galeodes granti Pocock, 1903 (Arachnida: Solifugae)

Only a few studies have examined the central visual system of Solifugae until now. To get new insights suitable for phylogenetic analysis we studied the R-cell (or retinula cell) projections and visual neuropils of Galeodes granti using various methods. G. granti possesses large median eyes and rudimentary lateral eyes. In this study, only the R-cells and neuropils of the median eyes were successfully stained. The R-cells terminate in two distinct visual neuropils. The first neuropil is located externally to the protocerebrum directly below the retina, the second neuropil lies in the cell body rind of the protocerebrum, and immediately adjacent is the arcuate body. This layout of the median eye visual system differs from Arachnopulmonata (Scorpiones + Tetrapulmonata). However, there are several similarities with Opiliones. In both, (1) the R-cells are connected to a first and second visual neuropil and not to any other region of the brain, (2) the first neuropil is not embedded in the cell body rind of the protocerebrum, it is rather external to the protocerebrum, (3) the second visual neuropil is embedded in the cell body rind, and (4) the second neuropil abuts the arcuate body. These findings may provide important new characters for the discussion on arachnid phylogeny.

COVID-19 financial support to small businesses in Switzerland: evaluation and outlook

We analyse small businesses' recourse to public support measures during the COVID-19 crisis using a survey of 1011 self-employed workers and small business owners in Switzerland. We find that "objective" measures of lockdown affectedness and economic structure explain fairly well how businesses availed of support measures to cover labour costs. Recourse to government-backed corona loans, however, appears to be driven to a larger extent by behavioural idiosyncrasies across firms. Specifically, previously indebted businesses took out corona loans more readily than those who had been debt-free before the pandemic. Since uptake is not well in line with firm fundamentals, we propose making loan repayments contingent on future profits. This will more effectively target and sustain businesses that are in trouble today but would be viable in the absence COVID-19.

Factors influencing GPs' perception of specialised palliative homecare (SPHC) importance - results of a cross-sectional study

Background

General Practitioners (GPs) are the main providers of primary palliative care (PPC). At the same time they are the main initiators of specialised palliative homecare (SPHC). In Germany, little is known about factors which influence GPs in their involvement of SPHC. Aim of our study is to identify factors that drive GPs to give value to and involve SPHC.

Methods

A cross-sectional survey was performed. In 2018, questionnaires were mailed to 6000 randomly selected GPs from eight German federal states, focusing on the extent of GPs’ palliative care activities and their involvement of SPHC.

Results

With a response rate of 19.4% and exclusion of GPs working in SPHC-teams, n = 1026 questionnaires were appropriate for analysis. GPs valued SPHC support as the most “important/very important” for both “technical/invasive treatment measures” (95%) and availability outside practice opening hours (92%).

The most relevant factor influencing perceived SPHC-importance was GPs’ self-reported extent of engagement in palliative care (β = − 0.283; CI 95% = − 0.384;−0.182), followed by the perceived quality of utilised SPHC (β = 0.119; CI 95% = 0.048;0.190), involvement in treatment of palliative patients after SPHC initiation (β = 0.088; CI 95% = 0.042;0.134), and conviction that palliative care should be a central part of GPs’ work (β = − 0.062; CI 95% = − 0.116;−0.008). Perceived SPHC-importance is also associated with SPHC-referrals (β =0.138; p < 0.001). The lower the engagement of GPs in palliative care, the more they involve SPHC and vice versa.

Conclusions

GPs with low reported activity in palliative care are more likely to initialise SPHC for palliative care activities they do not deliver themselves for various reasons, which might mean that the involvement of SPHC is substitutive instead of complementary to primary palliative care. This finding and its interpretation should be given more attention in the future policy framework for (specialised) palliative homecare.

Trial registration

German Clinical Trials Register DRKS00014726, 14.05.2018.

Changes in incidence of severe hypoglycaemia in people with type 2 diabetes from 2006 to 2016: analysis based on health insurance data in Germany considering the anti-hyperglycaemic medication

AIM

To investigate the incidence of severe hypoglycaemia over the past 10 years, taking into account changes in anti-hyperglycaemic therapy.

METHODS

This retrospective population-based study used German health insurance data. All adults diagnosed with documented type 2 diabetes (extrapolated to the German population: 6.6 million in 2006; 7.9 million in 2011; 8.86 million in 2016) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by Anatomical Therapeutic Chemical (ATC) code.

RESULTS

The event rate for severe hypoglycaemia was 460 per 100 000 people in 2006, 490 per 100 000 in 2011 and 360 per 100 000 in 2016. The proportion of people with severe hypoglycaemia receiving sulfonylureas, as well as receiving combination therapy of metformin and sulfonylureas decreased from 2006 to 2016 (23.6% vs. 6.2%) Among those with severe hypoglycaemia in 2006, there were no prescriptions for dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose co-transporter 2 (SGLT2) agonists. The proportions of people with severe hypoglycaemia receiving DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 agonists in 2011 and 2016 were low. The proportion of people receiving human insulin also decreased (from 11.3% in 2006 to 10.3% in 2011 and 4.3% in 2016); the proportion of people receiving insulin analogues increased from 5.4% in 2006 to 11.5% in 2016. Therapy with mixed insulins was used by 19.7% of people with severe hypoglycaemia in 2006, by 14.0% in 2011 and by 7.3% in 2016. People undergoing therapy with insulin analogues have the highest risk of severe hypoglycaemia adjusted by age, gender, nephropathy diagnosis and year of survey [odds ratio (OR) 14.4, 95% confidence interval (95% CI) 13.5-15.5].

CONCLUSION

The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, and decreased in 2016.

Taito adrik, a new harvestman species from the Área de Conservación Privada Panguana, Peruvian Amazonia (Opiliones: Laniatores: Cosmetidae)

A new species of the cosmetid harvestman genus Taito Kury Barros 2014 is described from the Área de Conservación Privada (ACP) Panguana, Peruvian Amazonia, which extends the distribution range of the genus to the south-west. The herein described species Taito adrik sp. nov. differs from all other known species of the genus by the distinct shape of the equuleus, the armature of leg IV in males, and the structure of male genitalia, in combination with features of the chelicerae and the anal operculum. In addition, COI barcodes of the new species are provided.

Does Pentaerytrithyltetranitrate reduce fetal growth restriction in pregnancies complicated by uterine mal-perfusion? Study protocol of the PETN-study: a randomized controlled multicenter-trial

Background

Affecting approximately 10% of pregnancies, fetal growth restriction (FGR), is the most important cause of perinatal mortality and morbidity. Impaired placental function and consequent mal-perfusion of the placenta is the leading cause of FGR. Although, screening for placental insufficiency based on uterine artery Doppler measurement is well established, there is no treatment option for pregnancies threatened by FGR. The organic nitrate pentaerithrityl tetranitrate (PETN) is widely used for the treatment of cardiovascular disease and has been shown to have protective effects on human endothelial cells. In a randomized placebo controlled pilot-study our group could demonstrate a risk reduction of 39% for the development of FGR, and FGR or death, by administering PETN to patients with impaired uterine artery Doppler at mid gestation. To confirm these results a prospective randomized placebo controlled double-blinded multicentre trial was now initiated.

Method

The trial has been initiated in 14 centres in Germany. Inclusion criteria are abnormal uterine artery Doppler, defined by mean PI > 1.6, at 19⁰ to 22⁶ weeks of gestation in singleton pregnancies. Included patients will be monitored in 4-week intervals. Primary outcome measures are development of FGR (birth weight < 10th percentile), severe FGR (birth weight < 3rd centile) and perinatal death. Placental abruption, birth weight below the 3rd, 5th and 10th centile, development of FGR requiring delivery before 34 weeks` gestation, neonatal intensive care unit admission, and spontaneous preterm delivery < 34 weeks` and 37 weeks` gestation will be assessed as secondary endpoints. Patient enrolment was started in August 2017. Results are expected in 2020.

Discussion

During the past decade therapeutic agents with possible perfusion optimizing potential have been evaluated in clinical trials to treat FGR. Meta-analysis and sub-analysis of trials targeting preeclampsia revealed ASS to have a potential in reducing FGR. Phosphodiesterase-type-5 inhibitors have recently been tested in a worldwide RCT for therapy of established FGR, failing to show an effect on neonatal outcome. The ongoing multicenter trial will, by confirming our previous results, finally provide a therapeutic option in cases at risk for FGR.

Trial registration

DRKS00011374 registered at September 29th, 2017 and NCT03669185, registered September 13th, 2018.

The visual system of Thelyphonida (whip scorpions): Support for Arachnopulmonata

Only a few studies have examined the central visual system of Thelyphonida (whip scorpions) until now. To obtain new insights suitable for phylogenetic analysis we studied the axonal trajectories and neuropil architecture of the central visual systems of two whip scorpion species (Mastigoproctus giganteus and Typopeltis dalyi) with different neuroanatomical techniques (Cobalt fills, Wigglesworth stains, and μCT). The central visual system of whip scorpion comprises one pair of median eyes and one pair of lateral eye triplets. The R-cells (or retinula cells) of both eye types each terminate in a first and a second visual neuropil. Furthermore, a few R-cell fibres from the median eyes leave the second median eye visual neuropil and terminate in the second and the first lateral eye neuropil. This means R-cell terminals from the lateral eyes and the median eyes overlap here. Additionally, the arcuate body and mushroom bodies are described. A detailed comparison of our findings with previously studied chelicerate central visual systems seems to support a monophyly of Arachnopulmonata, i.e. a clade comprising Tetrapulmonata (Thelyphonida, Schizomida, Amblypygi, and Araneae) and Scorpions. Furthermore, the architecture of the central visual systems hints at a close evolutionary relationship of Arachnopulmonata and Xiphosura.

Also looking like Limulus? - retinula axons and visual neuropils of Amblypygi (whip spiders)

BACKGROUND

Only a few studies have examined the visual systems of Amblypygi (whip spiders) until now. To get new insights suitable for phylogenetic analysis we studied the axonal trajectories and neuropil architecture of the visual systems of several whip spider species (Heterophrynus elaphus, Damon medius, Phrynus pseudoparvulus, and P. marginemaculatus) with different neuroanatomical techniques. The R-cell axon terminals were identified with Cobalt fills. To describe the morphology of the visual neuropils and of the protocerebrum generally we used Wigglesworth stains and μCT.

RESULTS

The visual system of whip spiders comprises one pair of median and three pairs of lateral eyes. The R-cells of both eye types terminate each in a first and a second visual neuropil. Furthermore, a few R-cell fibres from the median eyes leave the second median eye visual neuropil and terminate in the second lateral eye neuropil. This means R-cell terminals from the lateral eyes and the median eyes overlap. Additionally, the arcuate body and the mushroom bodies are described.

CONCLUSIONS

A detailed comparison of our findings with previously studied chelicerate visual systems (i.e., Xiphosura, Scorpiones, Pseudoscorpiones, Opiliones, and Araneae) seem to support the idea of close evolutionary relationships between Xiphosura, Scorpiones, and Amblypygi.

Feeding ecology in sea spiders (Arthropoda: Pycnogonida): what do we know?

Sea spiders (Pycnogonida) are a widespread and phylogenetically important group of marine arthropods. However, their biology remains understudied, and detailed information about their feeding ecology is difficult to find. Observations on pycnogonid feeding are scattered in the literature, often in older sources written in various languages, and have never been comprehensively summarized. Here we provide an overview of all information on feeding in pycnogonids that we have been able to find and review what is known on feeding specializations and preferences in the various pycnogonid taxa. We deduce general findings where possible and outline future steps necessary to gain a better understanding of the feeding ecology of one of the world's most bizarre animal taxa.

Increase in the incidence of severe hypoglycaemia in people with Type 2 diabetes in spite of new drugs: analysis based on health insurance data from Germany

AIM

To evaluate the use of new anti-hyperglycaemic agents that offer effective glycaemic control while reducing risk of hypoglycaemia, by analysing the incidence rates of severe hypoglycaemia in 2006 vs 2011 in relation to the medication.

METHODS

This cross-sectional, population-based study used German health insurance data. All adults diagnosed with Type 2 diabetes mellitus (extrapolated to the German population: 6.35 million in 2006 and 7.52 million in 2011) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by their Anatomical Therapeutic Chemical code, and defined daily doses of each medication were calculated.

RESULTS

The severe hypoglycaemic event rate was 460 per 100,000 people/year in 2006 and 490 per 100,000 people/year in 2011. In 2006 and 2011, 10.9% and 7.3%, respectively, of all people with severe hypoglycaemia were on sulfonylureas, while 12.7% and 9.3%, respectively, were on a combination therapy of metformin and sulfonylureas. Among those with severe hypoglycaemia, there were no prescriptions of dipeptidyl peptidase-4 inhibitors or glucagon-like peptide-1 receptor agonists in 2006, but in 2011, 1.55% and 0.17%, of those with severe hypoglycaemia were receiving the respective treatments. In 2006 vs 2011, human insulin was prescribed for 11.3% vs 10.3% of people with severe hypoglycaemia, while insulin analogues were prescribed for 5.4% vs 8.1%, and mixed human insulins for 19.7% vs 14.0% of patients with severe hypoglycaemia. People receiving insulin analogue therapy had a higher risk of severe hypoglycaemia than those receiving metformin, after adjusting for age, gender, nephropathy diagnosis and year of survey (odds ratio 14.6; CI 13.3-15.9).

CONCLUSION

The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, despite increased use of newer anti-hyperglycaemic agents and decreased use of insulins.

Testing species delimitation with larval morphology: scanning electron microscopy analysis of protonymphon larvae of two closely related sea spiders, Pallenopsis patagonica (Hoek) and Pallenopsis yepayekae Weis

We used scanning electron microscopy (SEM) to establish species-specific sets of characters for protonymphon larvae of two representatives of the ‘patagonica’ species group of Pallenopsis, P. patagonica and P. yepayekae. The larvae of both species are ‘typical’ protonymphon larvae sensu Bain (2003). Despite the close relationship of the two species, we observed numerous features that allow for differential diagnosis, e.g. general habitus, the number, arrangement and branching type of setules, the armature of the movable and immovable chelifore fingers, and the shape of the dactylus and setules of appendages II and III. SEM is particularly suitable for visualising these features. Our results further support the idea that protonymphon larvae can be identified to species level when adequate imaging techniques are used, as is also the case for larvae of other arthropods. Moreover, the status of the two studied species of Pallenopsis is fully supported by protonymphon larval morphology.

Changes in Quality of Diabetes Care and Morbidity over 20 Years in People with Type 1 Diabetes and Long Diabetes Duration: The JEVIN Trial

Background: The JEVIN trial started as a cross-sectional study in 1989/90 in Jena, a city of the former German Democratic Republic. At that time, the centralized diabetes care system was broken down and restarted 10 years later; structured treatment and teaching programs were implemented, blood glucose self-monitoring, insulin pump-systems and analogue insulin were introduced. We surveyed people with type-1-diabetes of the baseline JEVIN trial in a 20-year follow-up. Methods: 131 patients with type-1-diabetes were analyzed in 1989/90. Of the living population in 2009/10 (n=104), 83 persons were identified and 75 persons with a mean diabetes duration of 35 years were reexamined regarding HbA_1c, self-monitoring, diabetes therapy, severe hypoglycemia, diabetic late complications and compared with the results of the same persons in 1989/90. Results: HbA_1c decreased from 57.1 mmol/mol in 1989/90 to 52.7 mmol/mol in 2009/10 (7.4 -7.0%; p=0.049). Self-monitoring of blood glucose increased from 2 to 35 tests/week (p<0.001). 100%-use of animal insulin changed to human and analogue insulin therapy. The incidence of severe hypoglycemia increased from 0.1 to 0.16/patient-year. Retinopathy increased from 29 to 69% (p<0.001), nephropathy from 5 to 27% (p<0.001) and neuropathy from 13 to 43% (p<0.001). 17% had no diabetic late complications. Conclusions: The JEVIN trial shows a significant improve in HbA_1c in the past 20 years. Severe hypoglycemia occurred rarely and 17% were still free of any diabetic late complication after 35 years of diabetes. This indicates a good quality of diabetes care in a German setting.

The visual system of harvestmen (Opiliones, Arachnida, Chelicerata) - a re-examination

Background

The visual systems in chelicerates are poorly understood, even though they show strong variation in eye and visual neuropil architecture, thus may provide valuable insights for the understanding of chelicerate phylogeny and eye evolution. Comparable morphological characters are desperately sought for reconstructions of the phylogeny of Chelicerata, especially with respect to Arachnida. So far, reliable data exist only for Pycnogonida, Xiphosura, Scorpiones, and Araneae. The few earlier studies of the organisation of the visual system in harvestmen are contradictory concerning the number, morphology, and position of the visual neuropils.

Results

We undertook a descriptive and comparative analysis of the neuroanatomy of the visual system in several phalangid harvestmen species. Various traditional and modern methods were used that allow comparisons with previous results (cobalt fills, DiI/DiO labelling, osmium ethyl gallate procedure, and TEM). The R-cells (photoreceptor and arhabdomeric cells) in the eyes of Opiliones are linked to a first and a second visual neuropil. The first visual neuropil receives input from all R-cell axons, in the second only few R-cells terminate in the distal part. Hence, the second visual neuropil is subdivided in a part with direct R-cell input and a part without. The arcuate body is located in a subsequent position with direct contact to the second visual neuropil.

Conclusions

This re-examination comes to conclusions different from those of all previous studies. The visual system of phalangid Opiliones occupies an intermediate position between Pycnogonida, Xiphosura, and Scorpiones on the one side, and Araneae on the other side. The projection of the R-cells is similar to that in the former grouping, the general neuropil arrangement to that in the latter taxon. However, more research on the visual systems in other chelicerate orders is needed in order to draw inferences on phylogeny or eye evolution.

The effectiveness of the paclitaxel-coated Luminor® balloon catheter versus an uncoated balloon catheter in superficial femoral and popliteal arteries in preventing vessel restenosis or reocclusion: study protocol for a randomized controlled trial

BACKGROUND

The aim of this investigator-initiated trial is to evaluate the safety and efficacy of the novel Luminor® paclitaxel-coated drug-eluting balloon (DEB) catheter (iVascular, S.L.U., Barcelona, Spain) in inhibiting restenosis and in ensuring long-term vascular patency.

METHODS/DESIGN

This is a multicenter randomized controlled trial to evaluate the Luminor® paclitaxel-coated DEB catheter for stenotic or occlusive lesions (length ≤15 cm) in the superficial femoral artery (SFA) and the popliteal artery (PA) up to the P1 segment compared to the noncoated, plain old balloon angioplasty (POBA) catheter. In total 172 subjects will be treated with either the DEB catheter or the POBA catheter in 11 German study centers in a 1:1 randomization study design. The primary endpoint is late lumen loss (LLL) at 6 months. Secondary endpoints are patency rate, target lesion/vessel revascularization, quality of life (assessed with the Walking Impairment Questionnaire (WIQ) and the EQ-5D), change of Rutherford stage and ankle-brachial index, major and minor amputation rate at the index limb, number of dropouts and all-cause mortality.

DISCUSSION

EffPac represents a randomized controlled trial that will provide evidence on the effectiveness of the Luminor® paclitaxel-coated DEB catheter for the reduction of restenosis compared to the POBA catheter for the SFA and the PA. The results of EffPac will allow direct comparison to other already-completed RCTs applying paclitaxel-coated DEBs from different manufacturers with different coating technologies in the same target vessel.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02540018 , registered on 17 August 2015. Protocol version: CIP Version Final04, 11 February 2016. EUDAMED No: CIV-15-03-013204.

Gynaecological Prolapse Surgery in Very Old Female Patients: A Case-Control Study on Co-Morbidity and Surgical Complications

BACKGROUND

The aim of this study is to compare very elderly female patients with a younger control group after prolapse surgery with regard to co-morbidity and complications.

METHOD

In a case-control design, the consecutive data of patients after prolapse surgery at the age of over 80 years and those of a control group were analysed by means of the Clavien-Dindo (CD) classification of surgical complications, the Charlson Comorbidity Index and the Cumulative Illness Rating Scale Geriatrics (CIRS-G). Statistics: Student's t, Fisher's exact and Mann-Whitney U tests.

RESULTS

The analysis comprised n = 57 vs. n = 60 operations. In the very elderly patients there was often a grade IV prolapse (p < 0.001), apical fixations were more frequent (p < 0.001), but the operating times were not different. In the very elderly patients 21 % CD II+III complications were observed, in the control group 6.6 % (p = 0.031). No CD IV and V complications occurred in either group, the duration of inpatient stay amounted to 5 (± 1) vs. 4.1 (± 0.8; p < 0.001) days, the very elderly patients needed an inpatient follow-up more frequently (p < 0.001). The co-morbidities of the very elderly patients differed from those of the control group in number (median 2.0 vs. 1.5; p < 0.001), in CIRS-G (4.1 ± 2.2 vs. 2.4 ± 1.7; p < 0.01) and in Charlson Index (1.6 ± 1.6 vs. 0.5 ± 0.7; p < 0.001).

CONCLUSIONS

A prolapse in very elderly women can be safely managed by surgery. In no case did the complications require intensive care treatment nor were they life-threatening, but they did lead to a longer duration of hospital stay and more frequently to further treatment geriatric or inpatient internal medicine facilities.

Metabolic control and hypoglycaemia in people with type 2 diabetes on conventional or intensified insulin therapy: a 22 year retrospective single centre survey

BACKGROUND

Multiple insulin injection therapy can easily be adapted to the patient's needs. Therefore, it is supposed that more intensive insulin therapy is associated with better metabolic control and less hypoglycaemia compared with a conventional insulin strategy in patients with type 2 diabetes.

METHODS

HbA1c and incidence of non-severe and severe hypoglycaemia were analysed with regard to the strategy of insulin therapy [multiple insulin injection therapy with preprandial insulin with or without basal insulin or conventional insulin therapy with twice-daily premix insulin] from 20 943 visits of 1417 people treated with insulin with type 2 diabetes in a university outpatient department for endocrinology and metabolic diseases over a period of 22 years.

RESULTS

Multiple insulin injection therapy was used in 13 896 (66.4%) of all 20 942 visits. Compared with conventional insulin therapy, these patients were younger (62.0 vs 68.7 years; p < 0.001), had a slightly longer diabetes duration (16.5 vs 15.8 years; p < 0.001) and higher body mass index (32.8 vs 30.9 kg/m(2) ; p < 0.001), a higher insulin dose (76.4 vs 46.5 IU/day; p < 0.001), more frequent blood glucose monitorings/week (24.2 vs 14.8; p < 0.001), a slightly lower HbA1c [7.7 (61.2) vs 7.9% (62.9 mmol/mol); p < 0.001] but more non-severe hypoglycaemic incidences per week (0.3 vs 0.2; p = 0.01). Episodes of severe hypoglycaemia were rare and comparable (0.01/patient/year) with both insulin therapy strategies.

CONCLUSIONS

Multiple insulin injection therapy and conventional insulin therapy yielded comparable metabolic control with HbA1c below 8% (63.9 mmol/mol), but multiple insulin injection therapy is associated with higher body mass index and higher incidence of non-severe hypoglycaemia. Copyright © 2016 John Wiley & Sons, Ltd.

Knowledge and Implementation of the S3 Guideline on Gestational Diabetes among Gynecologists and Diabetologists Four Years after Publication: Results of a Survey of 773 Gynecologists and 76 Diabetologists on their Knowledge of the Guideline on Gestational Diabetes (AWMF 057-008, 2011)

BACKGROUND

An S3 guideline on the diagnosis and differentiated management of gestational diabetes (GDM) was published in Germany in 2011. This guideline replaced the previously applicable recommendations for the diagnosis and treatment of GDM and, for the first time, compiled evidence-based recommendations for the care of patients with GDM. The new guideline has focused particularly on the counselling offered to all patients with GDM about the associated long-term health risks. In this study we investigated the state of knowledge about the guideline among gynecologists and diabetologists in Thuringia and Lower Saxony.

METHOD

A questionnaire with 23 questions was sent out to 773 gynecologists and 76 diabetologists providing outpatient care in Lower Saxony and Thuringia. The statistical analysis was descriptive and inferential for comparisons between groups.

RESULTS

The response rate was 54 %; an average of 47.6 % of the individual questions were answered correctly in the completed questionnaires. The questions were answered correctly significantly more frequently by persons in the group with a good knowledge of the guidelines (75 vs. 61 %, p < 0.001). There were no significant differences between groups when differences between federal states or medical specialties were compared.

CONCLUSIONS

The results of our study show a good general state of knowledge of the guideline and point to a high level of willingness to implement the recommendations of the S3 guideline on GDM. With regard to the follow-up care provided to patients with GDM and depression, this study found a significant need for further training.

Principles of self-adjustment of insulin dose in people with diabetes type 2 and flexible insulin therapy

AIMS

Structured treatment and education programmes for people with type 2 diabetes mellitus (T2DM) and flexible insulin therapy provide rules for self-adjustment of insulin dose, that are extensively trained. The aim of this cohort study was to register current principles and the frequency of self-adjustment of insulin dose and their association with metabolic control in people with T2DM.

METHODS

Details of insulin dose adjustment were assessed by a structured interview in 149 people with T2DM on flexible insulin therapy (mean HbA1c 7.1%/53.8mmol/mol, age 65y, diabetes duration 19.0y, BMI 33.8kg/m(2)) in a tertiary care centre. The frequency of insulin dose adjustments was obtained from the last 28days of the patients' diaries.

RESULTS

Insulin dose adjustment by adjustment rules was used by 33 people (22.1%) and by personal experience/feeling in 111 participants (74.5%). People adjusting by rules were younger (60.9±9.8 vs. 65.7±9.2, p=0.011) and did more insulin dose adjustments per 28days (50.0±31.0 vs. 33.4±23.5, p=0.016). HbA1c and incidence of hypoglycaemia were comparable. There were no differences in satisfaction of treatment, quality of life as well as current well-being between the groups.

CONCLUSIONS

Only a fifth of the participants used the rule trained within the education programme to adjust their insulin dose. The majority adjusted their insulin dose by personal experience/feeling. However, people in both groups were able to adjust their insulin dose. Although people using adjustment rules adjust their insulin dose more frequently, HbA1c and the incidence of hypoglycaemia was similar compared to those using personal experience/feeling.

HbA1c and Age in Non-Diabetic Subjects: An Ignored Association?

Objective: Target HbA_1c values given in the most National Therapeutic Guidelines for patients with diabetes and cut-off HbA_1c values for diabetes diagnosis are usually not taking the age of the respective patients into account; despite the fact that an increase in HbA_1c in subjects without diabetes with age is known for some time. In order to further quantify the association between age and HbA_1c in non-diabetic subjects an analysis of one German register was performed. Methods: In this cross-sectional study we analyzed data from 7 699 visits of 2 921 patients without diabetes (age 46.6 y [range 18-93 y]; 69.1% women; BMI 27.6±6.4 kg/m²) who had at least one HbA_1c and blood glucose measurement. Data were drawn from an electronic patient record system (EMIL™) in which data were collected between 01/1992 and 01/2014. The patients were divided in 6 age groups (< 30 years [n=1 057];>30-40 years [n=1 160];>40-50 years [n=1 693];>50-60 years [n=1 523];>60-70 years [n=1 310];>70 years [n=956]) and the HbA_1c values of these groups were compared. Patients with: gestational diabetes_, use of systemic glucocorticoids, malignant neoplasm, age<18 y at time of first visit and IGT were excluded. HbA_1c measurements were DCCT adjusted. Results: Patients with age>70 years have a 0.47% [5.14 mmol/mol] higher HbA_1c compared to those<30 years. The mean HbA_1c of the age groups was:<30 4.98% [30.96 mmol/mol],>30-40 5.07% [31.99 mmol/mol],>40-50 5.17% [33.10 mmol/mol],>50-60 5.33% [34.79 mmol/mol],>60-70 5.42% [35.79 mmol/mol] and>70 years 5.45% [36.10 mmol/mol]. In a multiple linear model the regression coefficient for each year of age increase was β=0.0074 (p<0.001); thus age results in an increase of 0.074% in HbA_1c per decade. Conclusion: HbA_1c increases significantly with ageing in people without diabetes. The use of different cut-off values for every age range for diagnosis of diabetes should be discussed.