Better outcome at lower costs after implementing a CRT-care pathway: a comprehensive evaluation of real-world data

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic plc.

Background

Cardiac resynchronization therapy (CRT) requires intensive, complex and multi-disciplinary care to maximize clinical benefit in heart failure patients. In current practice, this is often incomplete due to limitations in time, resources and coordination of care.

Purpose

We evaluated the effect of the introduction of a novel multidisciplinary, standardized CRT care pathway (CRT-CPW) compared with usual care, on clinical outcome and costs.

Methods

The CRT care pathway (CRT-CPW) design, based on an expert consensus of experienced European CRT specialists; focussed on structuring patient selection, implantation and follow-up heart failure treatment and device management. To facilitate and guarantee quality, checklists fitted to each moment in the care pathway were designed, to aid contributors. The CRT-CPW was implemented in the Maastricht University Medical Centre in 2014. Data from patients receiving usual care (2012-2014, 222 patients) and patients receiving care under the CRT-CPW (2015-2018, 241 patients) were compared. Data was extracted from the hospital information system. The primary outcome was the composite of all-cause mortality and heart failure (HF) hospitalization. Hospital-related costs of cardiovascular care after CRT implantation was analysed to address cost-effectiveness.

Results

Patient demographics were comparable in both groups, except that the CRT-CPW group showed more AF and previous myocardial infarction at baseline. The combined endpoint of death from any cause and admission for HF occurred in 127 patients (57.2%) in the usual care group and 64 patients (26.6%) in the CRT- CPW group (adjusted HR 0.68 (95% CI, 0.49 to 0.93), p = 0.015) (Figure 1A). Total costs for cardiology related hospitalizations reduced significantly in the CRT care pathway group (€ 19.177 ± 9.692 vs 20.613 ± 7.066, p< 0.001, Table 4). Bootstrap analyses revealed that 90.7% of samples would show improved outcomes as well as reduction in costs in the CRT-CPW treatment group (Figure 1B).

Conclusion

The introduction of a novel CRT-CPW resulted in improved clinical outcome and reduced costs. Abstract Figure 1 Clinical outcome and costs

Sharing primary percutaneous coronary intervention care: first experiences with South Limburg ST-elevation myocardial infarction network

Background

In the region of South Limburg, the Netherlands, a shared ST-elevation myocardial infarction (STEMI) networking system (SLIM network) was implemented. During out-of-office hours, two percutaneous coronary intervention (PCI) centres—Maastricht University Medical Centre and Zuyderland Medical Centre—are supported by the same interventional cardiologist. The aim of this study was to analyse performance indicators within this network and to compare them with contemporary European Society of Cardiology guidelines.

Methods

Key time indicators for an all-comer STEMI population were registered by the emergency medical service and the PCI centres. The time measurements showed a non-Gaussian distribution; they are presented as median with 25th and 75th percentiles.

Results

Between 1 February 2018 and 31 March 2019, a total of 570 STEMI patients were admitted to the participating centres. The total system delay (from emergency call to needle time) was 65 min (53–77), with a prehospital system delay of 40 min (34–47) and a door-to-needle time of 22 min (15–34). Compared with in-office hours, out-of-office hours significantly lengthened system delays (55 (47–66) vs 70 min (62–81), p < 0.001), emergency medical service transport times (29 (24–34) vs 35 min (29–40), p < 0.001) and door-to-needle times (17 (14–26) vs 26 min (18–37), p < 0.001).

Conclusions

With its effective patient pathway management, the SLIM network was able to meet the quality criteria set by contemporary European revascularisation guidelines.

Carriage of extended-spectrum β-lactamases in pig farmers is associated with occurrence in pigs

Livestock may serve as a reservoir for extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE). The objectives of this study were to determine the prevalence of carriage with ESBL-PE in pig farmers, family members and employees, and its association with carriage in pigs. Rectal swabs were taken from 2388 pigs (398 pooled samples) on 40 pig farms and faecal samples were obtained from 142 humans living or working on 34 of these farms. Presence of ESBL-PE was determined by selective plating (agar). ESBL genes were analysed by PCR or microarray analysis, and gene sequencing. Genotypes and plasmids were determined by multilocus sequence typing and PCR-based replicon typing for selected isolates. ESBL genes were detected in Escherichia coli from eight humans (6%) (blaCTX-M-1, n = 6; blaTEM-52, n = 1 and blaCTX-M-14, n = 1) on six farms. In 157 pig isolates (107 pooled samples) on 18 farms (45%) ESBL genes were detected (blaCTX-M-1, n = 12; blaTEM-52, n = 6; and blaCTX-M-14, n = 3). Human and pig isolates within the same farm harboured similar ESBL gene types and had identical sequence and plasmid types on two farms (e.g. E. coli ST-453, blaCTX-M-1, IncI1), suggesting clonal transmission. For the remaining farms, sequence types, but not plasmid types, differed. Human ESBL carriage was associated with average number of hours working on the farm per week (OR = 1.04, 95% CI 1.02-1.06) and presence of ESBLs in pigs (OR = 12.5, 95% CI 1.4-111.7). Daily exposure to pigs carrying ESBL-PE is associated with ESBL carriage in humans.

[Investigation on the blood pressure-independent nephroprotective effect of nilvadipine in type 2 diabetics]

BACKGROUND

The nephroprotective effect of ACE inhibitors and AT1 blockers has been demonstrated in manystudies. In particular, the effect produced by AT1 blockers has been described as being blood pressure-independent. The nephroprotective effect has been inconsistently observed in calcium antagonists; at the same time, it is always pointed out that calcium antagonists improve albumin excretion through a blood pressure-lowering mechanism.

GOAL AND METHODS

Up to now there was not enough data available on the nephroprotective effect of nilvadipine. The goal of this study was to study the blood pressure-independent effect of the calcium antagonist nilvadipine on glomerular and renal tubular insufficiency during a 48-week treatment in hypertensive type 2 diabetics. Tubular or glomerular insufficiency was characterized on the basis of tubular and glomerular proteinuria and classified accordingto severity.

RESULTS

Four of 24 patients showed an improvement in glomerular insufficiency after the 48-week treatment with a once-a-day dose of 16 mg nilvadipine. In 18 of the 24 patients, a progression in the disease was prevented. Renal tubular insufficiency was improved in 15 of 24 patients and progression in 20 of 24 patients was prevented. This nephroprotective effect on impaired tubular reabsorption, which has been ascribed to early damage in diabetic patients or as a possible prodromal stage of glomerular nephropathy in recent work, has not been observed in any other medicine.

[Rapidity of pain relief, medication requirement and patient satisfaction with reflux treatment in the physician's office]

Treatment of gastroesophageal reflux disease (GERD) with proton pump inhibitors was investigated in three controlled prospective, randomized open studies. Lansoprazole, omeprazole MUPS and esomeprazole were compared under doctor's office conditions. The outcomes of interest were the rapidity of pain relief achieved with a single dose, effectiveness and patient satisfaction with on demand therapy. In the first study, 180 patients with chronic and prolonged episodes of reflux were investigated. Time to pain relief following a single dose was 1.1 +/- 0.8 hours with 30 mg lansoprazole, 3.0 +/- 2.5 hours with 20 mgomeprazole MUPS and 2.1 +/- 1.2 hours with 40 mg esomeprazole. Studies 2 and 3 were designed as cross-over studies intended to investigate drug consumption. In study 2, the amount of lansoprazole consumed was approximately 50% less than that of omeprazole, and this translated to 81% patient satisfaction with lansoprazole compared with only 9.5% for omeprazole. In study 3 comparing lansoprazole and esomeprazole, consumption of the former was 85% that of the latter. 58% of the patients opted to continuetreatment with lansoprazole, compared with only 25% in the case of esomeprazole. The appreciably greater patient satisfaction with lansoprazole was due tothe faster pain relief achieved with this drug.

Cellular immunomodulation and safety of standardized aqueous mistletoe extract PS76A2 in tumor patients treated for 48 weeks

Non-selected tumor patients (n=12) with various solid carcinomas were treated continuously twice weekly over 48 weeks with the aqueous mistletoe extract PS76A2, standardized to active mistletoe lectin. The preparation was applied subcutaneously at a concentration of 15 ng mistletoe lectin per 0.5 ml. Cellular immune response and safety were determined at various times during and after the therapy. In the course of treatment, virtually all the investigated immunoparameters were raised compared to the baseline values at the start of treatment. The statistically significant rises in the cell count of total lymphocytes, monocytes and natural killer (NK) cells was noteworthy. The differences in comparison with the baseline values at the various measuring times during treatment were up to 35%. In the first weeks of treatment at least, the raised cell count of NK cells correlated with the significantly increased cytotoxic activity versus tumor cells ex vivo. The NK factor (product of NK cells and ex vivo activity) was determined to assess the total NK activity more accurately, which rose up to 50% compared to the baseline value. Other lymphatic subpopulations, for instance CD3+, CD8+, CD3+CD4+ and CD3+CD8+ cells, also revealed distinct rises in cell count in the course of treatment. Within 6 weeks after completion of treatment, the overall values dropped again; but for a series of immunoparameters--in particular for the NK cells--they were still raised in comparison to the baseline values. The extensive laboratory diagnostics (haematology, clinical chemistry) showed that treatment with the standardized mistletoe extract PS76A2 was well tolerated by all patients. In single cases, local reactions at the injection sites were of a minor nature and reversible within two days. Summarizing, it can be stated that the standardized mistletoe extract PS76A2 significantly improved the immune status of tumor patients and was administered safely over a long period.

[Short-term (6 days) eradication of Helicobacter pylori infection in the practice of a health insurance physician]

OBJECTIVE

To obtain epidemiological data concerning Helicobacter pylori (H.p.) infections and peptic ulcer in patients with upper abdominal pain in a routine non-hospital based health-insurance practice, as well as to test the efficacy of H.p. eradication, especially with a new shortterm treatment scheme in this setting.

PATIENTS AND METHODS

H.p. status and possible peptic ulceration (urease test, biopsies of gastric antrum and body) were determined in 1242 consecutive patients with upper abdominal pain examined gastroscopically. Patients who were H.p. positive and had a peptic ulcer or recurrent gastritis with erosions were given dual or triple medication (lansoprazole or pantoprazole with one or two antibiotics: amoxycillin, clarithromycin, azithromycin, tinidazole), under conditions of controlled compliance.

RESULTS

The H.p. infection rate was 45.9% for the whole group (mean age: 49.9 years). An acute ulceration was found in 10.4% of the whole group, i.e. 20.1% of the 129 H.p. positive patients. 194 patients were given an eradication treatment. In 62 of them, put on a new 6-day eradication regimen (azithromycin, 1 x 500 mg daily; tinidazole, 1 x 2000 mg/d; and pantoprazole, 2 x 40 mg/d), an eradication rate of 93% (under protocol) or 92% (intention to treat) was achieved.

INTERPRETATION

In routine non-hospital practice a 6-day modified triple-medication treatment with azithromycin, tinidazole and pantoprazole proved efficacious in eradicating H.p. infection. It not only caused few side effects and was cheap, but also achieved high patient compliance.

Functional aspect of a phosphopeptide derived from calf thymus nuclei and DNA

Phosphopeptides (PPs) isolated from highly purified calf thymus DNA (N-DNA) and extracted from calf thymus nuclei were fractionated, and the effect of one PP fraction on DNA replication has been examined. In the absence of inhibitors, the increasing PP concentration caused a linear decrease of 3H-thymidine uptake in L5178Y cells. If PP fraction was mildly hydrolysed with 1NHCl, the decrease in uptake was much steeper. The studies in which the inhibitors were used revealed that by the addition of the unhydrolysed PP fraction the inhibition of 3H-thymidine uptake by alpha-amanitin could be completely overcome, and that the inhibition by puromycin was reduced to 65-77% of the control. With puromycin, there was a gradual decrease of 3H-thymidine uptake with PP concentration above 3 mg/ml. The PPs gave an increase in incorporation of 3H-thymidine even after removal of alpha-amanitin and puromycin; thus, it is suggested that there is no direct interaction of either inhibitor with PP in the cell. Data on the utilization of 3H-cytidine for the synthesise of new DNA suggest that PP fraction might cause an acceleration of DNA replication.