Left atrial low-voltage areas, but not volume, predict the recurrence of atrial fibrillation in repeat ablation procedures

INTRODUCTION

Left atrial (LA) low voltage areas (LVA) are a controversial target in atrial fibrillation ablation procedures. However, LVA and LA volume are good predictors of arrhythmia recurrence in ablation-naïve patients. Their predictive value in progressively diseased pre-ablated atria is uncertain.

METHODS

Consecutive patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT), who were scheduled for repeat LA ablation, were enrolled in the prospective Bernau ablation registry between 2016 and 2020. All patients received a complete LA ultrahigh-density map before ablation. Maps were analyzed for LA size, LVA percentage and distribution. The predictive value of demographic, anatomic, and mapping variables on AF recurrence was analyzed.

RESULTS

160 patients (50.6% male, 1.3 pre-ablations, 60% persistent AF) with complete LA voltage maps were included. Mean follow-up time was 16 ± 11 months. Mean recorded electrograms (EGMs) per map were 9754 ± 5808, mean LA volume was 176.1 ± 35.9 ml and mean rate of LVAs <0.5 mV was 30.6% ± 23.1%. During follow-up recurrence rate of AF or AT >30 s was 55.6%. Patients with recurrence had a significant higher percentage of LVAs (40.0% vs. 18.8%, p < .001) but no relevant difference in LA volume (172 vs. 178 mL, p = .299). ROC curves revealed LVA as a good predictor for recurrence (AUC = 0.79, p < .001) and a cut-off of 22% LVAs with highest sensitivity (73.0%) and specificity (71.8%). Based on this cut off, event free survival was significantly higher in the Low LVA group (p < .01).

CONCLUSION

Total LVA percentage has a good predictive power on arrhythmia recurrence in a cohort of advanced scarred left atria in repeat procedures independent of the applied ablation strategy. Left atrial volume seems to have minor impact on the rhythm outcome in our study cohort.

Evaluation von neuen Versorgungsformen für Menschen mit psychischen Erkrankungen: Pro & Contra zum Einsatz von GKV-Routinedaten – Ein Erfahrungsbericht

Der vorliegende Artikel stellt die Besonderheiten in der Evaluation von Versorgungsformen bei Menschen mit psychischen Erkrankungen in Deutschland dar. Es werden die Erfahrungen der Evaluation von Modellvorhaben in der psychiatrischen Versorgungsforschung basierend auf Routinedaten gesetzlicher Krankenversicherungen (GKV) von über 70 gesetzlichen Krankenkassen (EVA64-Studie) systematisch dargestellt. Am Beispiel der EVA64-Studie werden Empfehlungen für den Einsatz von GKV-Routinedaten im Bereich psychiatrischer Versorgungsforschung und allgemein abgeleitet. (1) Zunächst wird die Studie und der Einsatz der genannten Daten in dieser beschrieben und eingeordnet. (2) Dann werden die einzelnen Outcomes der Studie dargestellt und bewertet, (3) um danach Kriterien, Stärken und Einsatzmöglichkeiten dieser Daten darzustellen. (4) Abschließend werden Empfehlungen für die Weiterentwicklung von GKV-Routinedaten als Bewertungsgrundlage formuliert. The article presents the special features of an evaluation within mental health services research in Germany. The experiences of the evaluation of flexible and integrated treatment options with a global treatment budget in psychiatric hospitals based on routine data of more than 70 statutory health insurance (SHI) funds (EVA64 study) are systematically presented. Using the EVA64 study as an example, recommendations for the use of claims data in the field of mental health services research and in general are derived. (1) First, the study and the use of claims data in this study is described and classified. (2) Then, the individual outcomes of the study are presented and evaluated to (3) derive criteria, strengths and potential uses of claims data. (4) Finally, recommendations for the further development of claims data from SHI funds as a basis for evaluation are described.

Effects of Repeated Freeze and Thaw Cycles on the Genome-Wide DNA Methylation Profile of Isolated Genomic DNA

The characterization of DNA methylation patterns to identify epigenetic markers for complex human diseases is an important and rapidly evolving part in biomedical research. DNA samples collected and stored in clinical biobanks over the past years are an important source for future epigenetic studies. Isolated gDNA is considered stable when stored at low temperatures for several years. However, the effect of multiple use and the associated repeated thawing of long-term stored DNA samples on DNA methylation patterns has not yet been investigated. In this study, we examined the influence of up to 10 freeze and thaw cycles on global DNA methylation by comparing genome-wide methylation profiles. DNA samples from 19 healthy volunteers were either frozen at -80°C or subjected to up to 10 freeze and thaw cycles. Genome-wide DNA methylation was analyzed after 0, 1, 3, 5, or 10 thaw cycles using the Illumina Infinium MethylationEPIC BeadChip. Evaluation of the global DNA methylation profile by beta-value density plots and multidimensional scaling plots revealed an expected clear participant-dependent variability, but a very low variability depending on the freeze and thaw cycles. In accordance, no significant difference in any of the methylated cytosine/guanine sites studied could be detected in the performed statistical analyses. Our results suggest that long-term frozen DNA samples are still suitable for epigenetic studies after multiple thaw cycles.

Metabolomics analysis reveals novel serum metabolite alterations in cancer cachexia

Background

Cachexia is a body wasting syndrome that significantly affects well-being and prognosis of cancer patients, without effective treatment. Serum metabolites take part in pathophysiological processes of cancer cachexia, but apart from altered levels of select serum metabolites, little is known on the global changes of the overall serum metabolome, which represents a functional readout of the whole-body metabolic state. Here, we aimed to comprehensively characterize serum metabolite alterations and analyze associated pathways in cachectic cancer patients to gain new insights that could help instruct strategies for novel interventions of greater clinical benefit.

Methods

Serum was sampled from 120 metastatic cancer patients (stage UICC IV). Patients were grouped as cachectic or non-cachectic according to the criteria for cancer cachexia agreed upon international consensus (main criterium: weight loss adjusted to body mass index). Samples were pooled by cachexia phenotype and assayed using non-targeted gas chromatography-mass spectrometry (GC-MS). Normalized metabolite levels were compared using t-test (p < 0.05, adjusted for false discovery rate) and partial least squares discriminant analysis (PLS-DA). Machine-learning models were applied to identify metabolite signatures for separating cachexia states. Significant metabolites underwent MetaboAnalyst 5.0 pathway analysis.

Results

Comparative analyses included 78 cachectic and 42 non-cachectic patients. Cachectic patients exhibited 19 annotable, significantly elevated (including glucose and fructose) or decreased (mostly amino acids) metabolites associating with aminoacyl-tRNA, glutathione and amino acid metabolism pathways. PLS-DA showed distinct clusters (accuracy: 85.6%), and machine-learning models identified metabolic signatures for separating cachectic states (accuracy: 83.2%; area under ROC: 88.0%). We newly identified altered blood levels of erythronic acid and glucuronic acid in human cancer cachexia, potentially linked to pentose-phosphate and detoxification pathways.

Conclusion

We found both known and yet unknown serum metabolite and metabolic pathway alterations in cachectic cancer patients that collectively support a whole-body metabolic state with impaired detoxification capability, altered glucose and fructose metabolism, and substrate supply for increased and/or distinct metabolic needs of cachexia-associated tumors. These findings together imply vulnerabilities, dependencies and targets for novel interventions that have potential to make a significant impact on future research in an important field of cancer patient care.

Changes in patient care through flexible and integrated treatment programs in German psychiatric hospitals: meta-analyses based on a series of controlled claims-based cohort studies

BACKGROUND

Global treatment budgets, i.e. predefined budgets for patients treated in hospital independent of the setting within the hospital, together with flexible and integrated treatment (FIT) have been introduced in some German psychiatric hospitals since 2013. We investigated pooled changes in inpatient, day-care, outpatient treatment, and continuity of care for patients with mental disorders in 12 FIT-hospitals.

METHODS

We conducted a series of 12 controlled cohort studies regarding FIT hospitals using anonymized patient claims data from more than 70 German statutory health insurance funds. Each study compared one FIT-hospital to matched patients from equivalent non-FIT-hospitals (routine care). We included only those patients without treatment in the respective hospital within two years prior to first hospital treatment (either FIT or routine care). We contrasted results between the year prior to with the first and second year after patient's first treatment (treatment continuity: only group comparison) using multivariate multi-level models. To approximate the difference-in-difference effect in the meta-analysis, we used the interaction terms group (FIT hospital vs. routine care) x time (year before vs. first or second patient year after study inclusion) in the Poisson models.

RESULTS

The 12 studies included 36,069 patients with 2,358 patients from a Department of child and adolescent psychiatry. The pooled effect revealed a 5.1 days lower increase in inpatient treatment in FIT-hospitals during the first patient year compared to routine care. Results were statistically significant for adult care FIT-hospitals but not for child and adolescent FIT-hospitals. Utilization of day-care treatment increased more in most FIT-hospitals during the first year, while outpatient contacts increased in some and decreased in others. The odds of treatment continuity increased by 1.4 in FIT-hospitals compared to non-FIT-hospitals.

CONCLUSIONS

Global treatment budgets lead to the intended changes in mental health care in the majority of FIT-hospitals compared to routine care in this large real-world evidence study from Germany. For child and adolescent psychiatry, more evidence is needed to draw firm conclusions.

TRIAL REGISTRATION

This study was registered in the database "Health Services Research Germany" (trial number: VVfD_EVA64_15_003713).

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Incident autoimmune diseases in association with SARS-CoV-2 infection: a matched cohort study

OBJECTIVES

To investigate whether the risk of developing an incident autoimmune disease is increased in patients with prior COVID-19 disease compared to those without COVID-19, a large cohort study was conducted.

METHOD

A cohort was selected from German routine health care data. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through December 31, 2020. Patients were matched 1:3 to control patients without COVID-19. Both groups were followed up until June 30, 2021. We used the four quarters preceding the index date until the end of follow-up to analyze the onset of autoimmune diseases during the post-acute period. Incidence rates (IR) per 1000 person-years were calculated for each outcome and patient group. Poisson models were deployed to estimate the incidence rate ratios (IRRs) of developing an autoimmune disease conditional on a preceding diagnosis of COVID-19.

RESULTS

In total, 641,704 patients with COVID-19 were included. Comparing the incidence rates in the COVID-19 (IR=15.05, 95% CI: 14.69-15.42) and matched control groups (IR=10.55, 95% CI: 10.25-10.86), we found a 42.63% higher likelihood of acquiring autoimmunity for patients who had suffered from COVID-19. This estimate was similar for common autoimmune diseases, such as Hashimoto thyroiditis, rheumatoid arthritis, or Sjögren syndrome. The highest IRR was observed for autoimmune diseases of the vasculitis group. Patients with a more severe course of COVID-19 were at a greater risk for incident autoimmune disease.

CONCLUSIONS

SARS-CoV-2 infection is associated with an increased risk of developing new-onset autoimmune diseases after the acute phase of infection. Key Points • In the 3 to 15 months after acute infection, patients who had suffered from COVID-19 had a 43% (95% CI: 37-48%) higher likelihood of developing a first-onset autoimmune disease, meaning an absolute increase in incidence of 4.50 per 1000 person-years over the control group. • COVID-19 showed the strongest association with vascular autoimmune diseases.

Development of a risk score to identify patients at high risk for a severe course of COVID-19

Aim

We aimed to develop a risk score to calculate a person's individual risk for a severe COVID-19 course (POINTED score) to support prioritization of especially vulnerable patients for a (booster) vaccination.

Subject and methods

This cohort study was based on German claims data and included 623,363 individuals with a COVID-19 diagnosis in 2020. The outcome was COVID-19 related treatment in an intensive care unit, mechanical ventilation, or death after a COVID-19 infection. Data were split into a training and a test sample. Poisson regression models with robust standard errors including 35 predefined risk factors were calculated. Coefficients were rescaled with a min-max normalization to derive numeric score values between 0 and 20 for each risk factor. The scores' discriminatory ability was evaluated by calculating the area under the curve (AUC).

Results

Besides age, down syndrome and hematologic cancer with therapy, immunosuppressive therapy, and other neurological conditions were the risk factors with the highest risk for a severe COVID-19 course. The AUC of the POINTED score was 0.889, indicating very good predictive validity.

Conclusion

The POINTED score is a valid tool to calculate a person's risk for a severe COVID-19 course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01884-7.

Cardiac Resynchronization Therapy: Current Guidelines and Recent Advances Beyond Drug Treatment

Cardiac resynchronization therapy (CRT) is the therapy of choice for patients with symptomatic systolic heart failure (HF) and left bundle branch block (LBBB), despite optimal medical therapy (OMT). The recently published 2021 European Society of Cardiology (ESC) Guidelines on cardiac pacing and cardiac resynchronization therapy highlight the importance of CRT on top of OMT in HF patients with left ventricular ejection fraction (LVEF) ≤ 35%, sinus rhythm and typical LBBB with QRS duration ≥ 150 ms. In the presence of medically intractable or recurrent after catheter ablation atrial fibrillation (AF), AV nodal ablation as an adjuvant therapy becomes more relevant in patients qualifying for the implantation of a biventricular system. Furthermore, CRT may be considered in cases when increased pacing of the right ventricle is not desirable. However, alternative pacing sites and strategies are currently available, if the CRT is not feasible and effective in patients. However, strategies targeting "multi-sides" or using "multi-leads" have shown superiority over classic CRT. On the other hand, conduction system pacing seems to be a promising technique. Although early results are positive, consistency during the long term is pending. The indication for additional defibrillation therapy (ICD) may occasionally be unnecessary and has to be considered individually. Due to the great development and success of heart failure drug therapy, its positive effect on LV function can lead to enormous improvement. Physicians must await these effects and findings, which hopefully could lead to a relevant LV improvement resulting in a definitive decision against an ICD.

Post-COVID-19-associated morbidity in children, adolescents, and adults: A matched cohort study including more than 157,000 individuals with COVID-19 in Germany

BACKGROUND

Long-term health sequelae of the Coronavirus Disease 2019 (COVID-19) are a major public health concern. However, evidence on post-acute COVID-19 syndrome (post-COVID-19) is still limited, particularly for children and adolescents. Utilizing comprehensive healthcare data on approximately 46% of the German population, we investigated post-COVID-19-associated morbidity in children/adolescents and adults.

METHODS AND FINDINGS

We used routine data from German statutory health insurance organizations covering the period between January 1, 2019 and December 31, 2020. The base population included all individuals insured for at least 1 day in 2020. Based on documented diagnoses, we identified individuals with polymerase chain reaction (PCR)-confirmed COVID-19 through June 30, 2020. A control cohort was assigned using 1:5 exact matching on age and sex, and propensity score matching on preexisting medical conditions. The date of COVID-19 diagnosis was used as index date for both cohorts, which were followed for incident morbidity outcomes documented in the second quarter after index date or later.Overall, 96 prespecified outcomes were aggregated into 13 diagnosis/symptom complexes and 3 domains (physical health, mental health, and physical/mental overlap domain). We used Poisson regression to estimate incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). The study population included 11,950 children/adolescents (48.1% female, 67.2% aged between 0 and 11 years) and 145,184 adults (60.2% female, 51.1% aged between 18 and 49 years). The mean follow-up time was 236 days (standard deviation (SD) = 44 days, range = 121 to 339 days) in children/adolescents and 254 days (SD = 36 days, range = 93 to 340 days) in adults. COVID-19 and control cohort were well balanced regarding covariates. The specific outcomes with the highest IRR and an incidence rate (IR) of at least 1/100 person-years in the COVID-19 cohort in children and adolescents were malaise/fatigue/exhaustion (IRR: 2.28, 95% CI: 1.71 to 3.06, p < 0.01, IR COVID-19: 12.58, IR Control: 5.51), cough (IRR: 1.74, 95% CI: 1.48 to 2.04, p < 0.01, IR COVID-19: 36.56, IR Control: 21.06), and throat/chest pain (IRR: 1.72, 95% CI: 1.39 to 2.12, p < 0.01, IR COVID-19: 20.01, IR Control: 11.66). In adults, these included disturbances of smell and taste (IRR: 6.69, 95% CI: 5.88 to 7.60, p < 0.01, IR COVID-19: 12.42, IR Control: 1.86), fever (IRR: 3.33, 95% CI: 3.01 to 3.68, p < 0.01, IR COVID-19: 11.53, IR Control: 3.46), and dyspnea (IRR: 2.88, 95% CI: 2.74 to 3.02, p < 0.01, IR COVID-19: 43.91, IR Control: 15.27). For all health outcomes combined, IRs per 1,000 person-years in the COVID-19 cohort were significantly higher than those in the control cohort in both children/adolescents (IRR: 1.30, 95% CI: 1.25 to 1.35, p < 0.01, IR COVID-19: 436.91, IR Control: 335.98) and adults (IRR: 1.33, 95% CI: 1.31 to 1.34, p < 0.01, IR COVID-19: 615.82, IR Control: 464.15). The relative magnitude of increased documented morbidity was similar for the physical, mental, and physical/mental overlap domain. In the COVID-19 cohort, IRs were significantly higher in all 13 diagnosis/symptom complexes in adults and in 10 diagnosis/symptom complexes in children/adolescents. IRR estimates were similar for age groups 0 to 11 and 12 to 17. IRs in children/adolescents were consistently lower than those in adults. Limitations of our study include potentially unmeasured confounding and detection bias.

CONCLUSIONS

In this retrospective matched cohort study, we observed significant new onset morbidity in children, adolescents, and adults across 13 prespecified diagnosis/symptom complexes, following COVID-19 infection. These findings expand the existing available evidence on post-COVID-19 conditions in younger age groups and confirm previous findings in adults.

TRIAL REGISTRATION

ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT05074953.

Lengths of inpatient stay and sick leave of patients with mental diseases: disorder-specific effects of flexible and integrated treatment programs in Germany

Mental disorders pose a worldwide growing public health burden. One of the major challenges for healthcare systems remains to respond to the need of patients with mental disorders for continuous and flexible treatment. The EVA64 study evaluates novel programs of flexible and integrative treatment (FIT) in hospitals. This manuscript presents results from the evaluation of FIT hospitals in comparison to hospitals from regular routine care. In addition to data from adult patients, we also present data from affiliated child and adolescent psychiatric wards employing FIT programs. Using comprehensive claims data, primary outcomes are the utilization of inpatient care and sick leave for a priori defined clusters of mental disorders. We stratify between patients already under treatment (ongoing treatment) and patients with incident treatment cases (initial treatment) at the point of inclusion in the study. In the initial treatment group, we found a significant reduction in the length of inpatient stay of 4.1 days in FIT hospitals compared to routine care. While patients with mood affective disorders (-1.8 days) and patients with neurotic, stress-related, and somatoform disorders (-3.6 days) showed an even stronger effect of the reduction of inpatient lengths of stay, the effect was significantly weaker in patients with mental and behavioral disorders due to use of alcohol (+3.3 days). Regarding the duration of sick leave, we found no significant treatment effect of FIT programs compared to routine care. In the ongoing treatment group of adult patients, we found a significantly lower utilization of inpatient treatment by 1.3 days as well as a shorter duration of sick leave by 4.3 days in FIT hospitals compared to routine care. In the cohort of children and adolescent patients, we also did not observe a significant treatment effect in either the initial treatment group or the ongoing treatment group. Registration: this study was registered in the database "Health Services Research Germany" (trial number: VVfD_EVA64_15_003713).

Contributions of GeneXpert® to TB diagnosis in Myanmar

BACKGROUND: Xpert^® MTB/RIF, a rapid, molecular TB diagnostic assay, can detect Mycobacterium tuberculosis and rifampin resistance directly from clinical sputum samples in <2 h with high sensitivity and specificity. The added diagnostic value of Xpert over smear microscopy at a national level in Myanmar has not been previously reported.METHODS: We evaluated 339,358 Xpert and demographic records captured from January 2015 to December 2018 as part of the Myanmar National TB Program Data Utilization and Connectivity Project to examine the additional diagnostic yield of Xpert relative to smear for the detection of M. tuberculosis for TB diagnosis in Myanmar, with a focus on people living with HIV (PLHIV) and sample type.RESULTS: Use of Xpert increased TB case detection by 40% compared to smear microscopy results. Among PLHIV, use of Xpert increased TB case detection by almost 100% compared to smear microscopy results.CONCLUSION: Xpert testing identified more patients with TB than smear microscopy alone, particularly in cohorts with significant proportions of PLHIV. The use of Xpert as a screening tool in countries with a high burden of TB could lead to significantly increased diagnosis of TB at a regional and national level.

CRT „reloaded“ 2022 – die neuen Guidelines und technische Innovationen

Die kardiale Resynchronisationstherapie (cardiac resynchronization therapy, CRT) stellt für Patienten mit symptomatischer Herzinsuffizienz und Linksschenkelblock eine etablierte und erfolgreiche Therapieoption dar, wenn die konservative medikamentöse Therapie ausgeschöpft ist und alle anderen kausalen Ursachen wie Ischämie, Klappenfehler und Rhythmusstörungen behandelt worden sind. Die aktuellen Pacing-Guidelines der ESC betonen erneut den Stellenwert der CRT als primäre interventionelle Herzinsuffizienztherapie, besonders bei Sinusrhythmus, einer LVEF ≤ 35% und typischem Linksschenkelblock ≥ 150 ms. Bei gleichzeitig bestehendem unkontrollierbarem Vorhofflimmern gewinnt die AV-Knoten-Ablation an Bedeutung. Für den nicht zu vernachlässigenden Anteil von Herzinsuffizienzpatienten ohne klare CRT-Indikation oder mit unzureichender CRT-Response kann eine multimodale Bildgebung zusätzliche Informationen liefern. Alternative Pacingmethoden sollten bei anatomischen Hindernissen erwogen werden. Die Wahl eines zusätzlichen Defibrillators ist auch nach der aktuellen Studienlage häufig schwierig und bleibt individuell abzuwägen.

Evaluation of a flexible and integrative psychiatric care model in a department of child and adolescent psychiatry in Tübingen, Germany: study protocol (EVA_TIBAS)

BACKGROUND

Model projects for flexible and integrated treatment (FIT) in Germany aim at advancing the quality of care for people with mental disorders. A new FIT model project was established in 2017 at the Department of child and adolescent psychiatry (KJP) of the University Hospital Tübingen (Universitätsklinikum Tübingen, UKT). The study design of EVA_TIBAS presented here describes the evaluation of the FIT model project at the KJP of the UKT. This evaluation aims at quantifying the anticipated FIT model project changes, which are to improve patients' cross-sectoral care at the same maximum cost as standard care.

METHODS

EVA_TIBAS is a controlled cohort study using a mix of quantitative and qualitative methods. The FIT evaluation consists of three modules. In Module A, anonymized claims data of a statutory health insurance fund will be used to compare outcomes (duration of inpatient and day care psychiatric treatment, inpatient and day care psychiatric length of stay, outpatient psychiatric treatment in hospital, inpatient hospital readmission, emergency admission rate, direct medical costs) of patients treated in the model hospital with patients treated in structurally comparable control hospitals (estimated sample size = ca. 600 patients). In Module B, patient-reported outcomes (health related quality of life, symptom burden, return to psychosocial relationships (e.g. school, friends, hobbies), treatment satisfaction, societal costs) will be assessed quantitatively using validated questionnaires for the model and two control hospitals (estimated sample size = ca. 300 patients). A subsequent health economic evaluation will be based on cost-effectiveness analyses from both the insurance fund's and the societal perspective. In Module C, about 30 semi-structured interviews will examine the quality of offer, effects and benefits of the service offered by the social service of the AOK Baden-Württemberg (for stabilizing the overall situation of care in the family) in the model hospital. A focus group discussion will address the quality of cooperation between employees of the university hospital and the social services.

DISCUSSION

The results of this evaluation will be used to inform policy makers whether this FIT model project or aspects of it should be implemented into standard care.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov PRS (ID: NCT04727359 , date: 27 January 2021).

Leadless left ventricular endocardial pacing for CRT upgrades in previously failed and high-risk patients in comparison with coronary sinus CRT upgrades

AIMS

Cardiac resynchronization therapy (CRT) upgrades may be less likely to improve following intervention. Leadless left ventricular (LV) endocardial pacing has been used for patients with previously failed CRT or high-risk upgrades. We compared procedural and long-term outcomes in patients undergoing coronary sinus (CS) CRT upgrades with high-risk and previously failed CRT upgrades undergoing LV endocardial upgrades.

METHOD AND RESULTS

Prospective consecutive CS upgrades between 2015 and 2019 were compared with those undergoing WiSE-CRT implantation. Cardiac resynchronization therapy response at 6 months was defined as improvement in clinical composite score (CCS) and a reduction in LV end-systolic volume (LVESV) ≥15%. A total of 225 patients were analysed; 121 CS and 104 endocardial upgrades. Patients receiving WiSE-CRT tended to have more comorbidities and were more likely to have previous cardiac surgery (30.9% vs. 16.5%; P = 0.012), hypertension (59.2% vs. 34.7%; P < 0.001), chronic obstructive airways disease (19.4% vs. 9.9%; P = 0.046), and chronic kidney disease (46.4% vs. 21.5%; P < 0.01) but similar LV ejection fraction (30.0 ± 8.3% vs. 29.5 ± 8.6%; P = 0.678). WiSE-CRT upgrades were successful in 97.1% with procedure-related mortality in 1.9%. Coronary sinus upgrades were successful in 97.5% of cases with a 2.5% rate of CS dissection and 5.6% lead malfunction/displacement. At 6 months, 91 WiSE-CRT upgrades and 107 CS upgrades had similar improvements in CCS (76.3% vs. 68.5%; P = 0.210) and reduction in LVESV ≥15% (54.2% vs. 56.3%; P = 0.835).

CONCLUSION

Despite prior failed upgrades and high-risk patients with more comorbidities, WiSE-CRT upgrades had high rates of procedural success and similar improvements in CCS and LV remodelling with CS upgrades.

Plasma Metabolome Signature Indicative of BRCA1 Germline Status Independent of Cancer Incidence

Individuals carrying a pathogenic germline variant in the breast cancer predisposition gene BRCA1 (gBRCA1+) are prone to developing breast cancer. Apart from its well-known role in DNA repair, BRCA1 has been shown to powerfully impact cellular metabolism. While, in general, metabolic reprogramming was named a hallmark of cancer, disrupted metabolism has also been suggested to drive cancer cell evolution and malignant transformation by critically altering microenvironmental tissue integrity. Systemic metabolic effects induced by germline variants in cancer predisposition genes have been demonstrated before. Whether or not systemic metabolic alterations exist in gBRCA1+ individuals independent of cancer incidence has not been investigated yet. We therefore profiled the plasma metabolome of 72 gBRCA1+ women and 72 age-matched female controls, none of whom (carriers and non-carriers) had a prior cancer diagnosis and all of whom were cancer-free during the follow-up period. We detected one single metabolite, pyruvate, and two metabolite ratios involving pyruvate, lactate, and a metabolite of yet unknown structure, significantly altered between the two cohorts. A machine learning signature of metabolite ratios was able to correctly distinguish between gBRCA1+ and controls in ~82%. The results of this study point to innate systemic metabolic differences in gBRCA1+ women independent of cancer incidence and raise the question as to whether or not constitutional alterations in energy metabolism may be involved in the etiology of BRCA1-associated breast cancer.

Therapies with CCL25 require controlled release via microparticles to avoid strong inflammatory reactions

Background

Chemokine therapy with C–C motif chemokine ligand 25 (CCL25) is currently under investigation as a promising approach to treat articular cartilage degeneration. We developed a delayed release mechanism based on Poly (lactic-co-glycolic acid) (PLGA) microparticle encapsulation for intraarticular injections to ensure prolonged release of therapeutic dosages. However, CCL25 plays an important role in immune cell regulation and inflammatory processes like T-cell homing and chronic tissue inflammation. Therefore, the potential of CCL25 to activate immune cells must be assessed more thoroughly before further translation into clinical practice. The aim of this study was to evaluate the reaction of different immune cell subsets upon stimulation with different dosages of CCL25 in comparison to CCL25 released from PLGA particles.

Results

Immune cell subsets were treated for up to 5 days with CCL25 and subsequently analyzed regarding their cytokine secretion, surface marker expression, polarization, and migratory behavior. The CCL25 receptor C–C chemokine receptor type 9 (CCR9) was expressed to a different extent on all immune cell subsets. Direct stimulation of peripheral blood mononuclear cells (PBMCs) with high dosages of CCL25 resulted in strong increases in the secretion of monocyte chemoattractant protein-1 (MCP-1), interleukin-8 (IL-8), interleukin-1β (IL-1β), tumor-necrosis-factor-α (TNF-α) and interferon-γ (IFN-γ), upregulation of human leukocyte antigen-DR (HLA-DR) on monocytes and CD4⁺ T-cells, as well as immune cell migration along a CCL25 gradient. Immune cell stimulation with the supernatants from CCL25 loaded PLGA microparticles caused moderate increases in MCP-1, IL-8, and IL-1β levels, but no changes in surface marker expression or migration. Both CCL25-loaded and unloaded PLGA microparticles induced an increase in IL-8 and MCP-1 release in PBMCs and macrophages, and a slight shift of the surface marker profile towards the direction of M2-macrophage polarization.

Conclusions

While supernatants of CCL25 loaded PLGA microparticles did not provoke strong inflammatory reactions, direct stimulation with CCL25 shows the critical potential to induce global inflammatory activation of human leukocytes at certain concentrations. These findings underline the importance of a safe and reliable release system in a therapeutic setup. Failure of the delivery system could result in strong local and systemic inflammatory reactions that could potentially negate the benefits of chemokine therapy.

[Reduction of Days in Inpatient Care in Psychiatric Hospitals with Flexible and Integrated Treatment for Patient-Centered Care with a Global Budget - Results with Three-Year Follow-up from the Evaluation Study EVA64]

OBJECTIVE

This analysis describes the development of the duration of inpatient and daycare treatment as well as contacts in outpatient PIA in hospitals with flexible and integrated treatment (FIT) over a three-year follow-up period.

METHODS

Patients with treatment in the first year after FIT-onset and a follow-up period of three years were examined for 12 FIT-hospitals and compared with matched patients from hospitals providing routine care.

RESULTS

11,536 patients were analyzed. In the year after first treatment, the number of inpatient days was lower in almost all FIT-hospitals compared to routine care. On the other hand, the number of daycare treatment days was mostly higher than in routine care. FIT hospitals with a pre-existing FIT-like structure showed stronger effects. PIA utilization differed between FIT-hospitals.

CONCLUSION

This analysis supports evidence-based health policy decisions on the adoption of patient-centered global budget care concepts.

The retinal basis of vision in chicken

The Avian retina is far less known than that of mammals such as mouse and macaque, and detailed study is overdue. The chicken (Gallus gallus) has potential as a model, in part because research can build on developmental studies of the eye and nervous system. One can expect differences between bird and mammal retinas simply because whereas most mammals have three types of visual photoreceptor birds normally have six. Spectral pathways and colour vision are of particular interest, because filtering by oil droplets narrows cone spectral sensitivities and birds are probably tetrachromatic. The number of receptor inputs is reflected in the retinal circuitry. The chicken probably has four types of horizontal cell, there are at least 11 types of bipolar cell, often with bi- or tri-stratified axon terminals, and there is a high density of ganglion cells, which make complex connections in the inner plexiform layer. In addition, there is likely to be retinal specialisation, for example chicken photoreceptors and ganglion cells have separate peaks of cell density in the central and dorsal retina, which probably serve different types of behaviour.

863Leadless endocardial pacing improves symptoms in patients with failed conventional CRT implant in long term follow up

Funding Acknowledgements

EBR Systems, Inc

OnBehalf

WiSE-CRT and LV-SELECT study and POST-M REGISTRY

Background

The WiSE-CRT (Wireless stimulation endocardial) system has advantages over conventional epicardial CRT. Whenever conventional CRT failed to implant or failed to echocardiographic response, the WiSE-CRT was implanted as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) over the last 8 years. All these studies have reported high rates of clinical and echocardiographic response compared to conventional CRT.

Objectives

The purpose of this analysis was to determine the safety and clinical response in the largest available number of implanted patients (pts) with long term follow up of 2 years and the first, second and third generation of WiSE-CRT devices.

Method

All pts undergoing a WiSE-CRT implantation as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) were analysed (N = 165). Pts were followed-up for 24 months and considered CRT responders if an improvement in NYHA ≥ 1 class from baseline (pre-implant) was achieved.

Results

In total, 165 pts were implanted, demographics include: 68.2 ± 9.6 year’s old, 81.8% male, 49.7% with history of AFib and 54.5% non-ischaemic aetiology. The mean intrinsic QRS duration was 165.0 ± 32.3 msec (28 pts pace-maker dependent). 161 pts had the system successfully implanted with no major complications, 3 (1.8%) pts developed a pericardial effusion and 1 (0.6%) electrode was lost during implantation and recovered surgically. During the 24-month follow-up period, 20 (12.1%) pts died from any cause, 4 (2.4%) pts developed TIA or Stroke and 15 (9.1%) pts had pocket or transmitter infection. There was a significant improvement in NYHA functional class in 63.6% pts and an average improvement of -26.1 (-45.1, -7.1) msec in QRS duration.

Conclusion

Despite a history of failed conventional CRT implantation, pts undergoing CRT upgrades with a WiSE-CRT have a high success rate and a complication rate similar to previously described. In addition endocardial LV pacing led to symptomatic improvements in 64% of patients reaching the 24 month of follow up.

Abstract Figure 1: Forest Plot NYHA Responder Rat

SAT0020 MOMELOTINIB, A JANUS KINASE 1/2 AND ACTIVIN RECEPTOR 1 INHIBITOR, AMELIORATES JOINT INFLAMMATION, SYSTEMIC TH17 DIFFERENTIATION AND ARTHRITIS-LINKED ANEMIA IN PRE-CLINICAL AUTOIMMUNE RA

Background:

Janus kinases (JAKs) serve as signaling hubs orchestrating inflammation, innate and adaptive immunity and erythropoiesis. Unfortunately, some of these agents cause suppression of JAK-dependent erythropoiesis, thereby exacerbating inflammation-associated anemia, leading to potential under-dosing and reduced therapeutic benefit. We previously showed that the JAKi momelotinib (MMB) can correct anemia in a rat model of RA, an effect that has been clinically reproduced in myelofibrosis patients treated with MMB. Subsequently, the molecular basis for MMB’s anemia benefit was determined to be a consequence of its potent inhibition of Activin Receptor Type 1 (ACVR1), resulting in decreased hepcidin and, as a consequence, increased systemic iron availability and improved erythropoiesis.

Objectives:

The goal of the current study was to investigate the effects of MMB on arthritis in pre-clinical RA models.

Methods:

The anti-arthritic activity of daily administration of MMB was assessed in Streptococcus cell wall-induced arthritis in Lewis rats (PG-PS model) and in collagen antibody-induced arthritis (CAIA) in DBA/1 mice. Consecutive assessment of arthritis was performed by joint thickness measurements and paw scoring. Following 3 weeks of treatment, synovial immune cell infiltration and T cell subset differentiation was quantified. Cytokine gene expression was profiled by quantitative rt-PCR. Anemia was assessed by determination of blood hemoglobin and serum, spleen and liver iron levels.

Results:

MMB reduced inflammatory granulocyte and macrophage infiltration in synovial tissue by more than 60% at all tested doses as compared to vehicle treatment in PG-PS animals. Importantly, MMB treatment effectively decreased arthritogenic Th17 cell differentiation and overall CD4+ T cells in the synovia beginning at the lowest tested dose and coincided with complete remission of joint swelling at 25 mg/kg. Anti-arthritic activity of MMB was confirmed with significant reductions in arthritis scoring, which demonstrated non-inferiority versus the TNF-α inhibitor, etanercept, in the CAIA model. Consistent with its inhibitory activity on the ACVR1-hepcidin axis, MMB reduced circulating hepcidin levels and mobilized systemic iron, resulting in substantial improvement of the RA-associated anemia in rats.

Conclusion:

MMB is a highly efficacious anti-arthritic agent that ameliorates local joint inflammation and reduces the systemic differentiation of major arthritogenic effector cell population, Th17 lymphocytes. In accord with our previous report, MMB is distinct from other JAKi due to its ability to inhibit ACVR1 signaling leading to decreased plasma hepcidin, improved iron homeostasis and increased erythropoiesis. The dual anti-inflammatory and anemia-improving pharmacologic activities of MMB position it as a promising and differentiated therapeutic agent for the treatment of RA and other inflammatory diseases with an anemia component.

Disclosure of Interests:

Piotr Tymoszuk: None declared, Verena Petzer: None declared, Malte Asshoff: None declared, Andrea Schroll: None declared, Markus Seifert: None declared, Ryan Hansen Employee of: I’m a former employee of Sierra Oncology, Snezana Milutinovic Employee of: I’m a former employee of Sierra Oncology, Bryan Strouse Employee of: I’m an employee of Sierra Oncology, Christian Hassig Employee of: I am a former employee of Sierra Oncology, Guenter Weiss: None declared, Igor Theurl Grant/research support from: I have received research support from Sierra Oncology, Consultant of: I have consulted for Kymba Ltd.

Leadless left ventricular endocardial pacing in nonresponders to conventional cardiac resynchronization therapy

BACKGROUND

Endocardial pacing may be beneficial in patients who fail to improve following conventional epicardial cardiac resynchronization therapy (CRT). The potential to pace anywhere inside the left ventricle thus avoiding myocardial scar and targeting the latest activating segments may be particularly important. The WiSE-CRT system (EBR systems, Sunnyvale, CA) reliably produces wireless, endocardial left ventricular (LV) pacing. The purpose of this analysis was to determine whether this system improved symptoms or led to LV remodeling in patients who were nonresponders to conventional CRT.

METHOD

An international, multicenter registry of patients who were nonresponders to conventional CRT and underwent implantation with the WiSE-CRT system was collected.

RESULTS

Twenty-two patients were included; 20 patients underwent successful implantation with confirmation of endocardial biventricular pacing and in 2 patients, there was a failure of electrode capture. Eighteen patients proceeded to 6-month follow-up; endocardial pacing resulted in a significant reduction in QRS duration compared with intrinsic QRS duration (26.6 ± 24.4 ms; P = .002) and improvement in left ventricular ejection fraction (LVEF) (4.7 ± 7.9%; P = .021). The mean reduction in left ventricular end-diastolic volume was 8.3 ± 42.3 cm³ (P = .458) and left ventricular end-systolic volume (LVESV) was 13.1 ± 44.3 cm³ (P = .271), which were statistically nonsignificant. Overall, 55.6% of patients had improvement in their clinical composite score and 66.7% had a reduction in LVESV ≥15% and/or absolute improvement in LVEF ≥5%.

CONCLUSION

Nonresponders to conventional CRT have few remaining treatment options. We have shown in this high-risk patient group that the WiSE-CRT system results in improvement in their clinical composite scores and leads to LV remodeling.

Real-world experience of leadless left ventricular endocardial cardiac resynchronization therapy: A multicenter international registry of the WiSE-CRT pacing system

Background

Biventricular endocardial pacing (BiV ENDO) is a therapy for heart failure patients who cannot receive transvenous epicardial cardiac resynchronization therapy (CRT) or have not responded adequately to CRT. BiV ENDO CRT can be delivered by a new wireless LV ENDO pacing system (WiSE-CRT system; EBR Systems, Sunnyvale, CA), without the requirement for lifelong anticoagulation.

Objective

The purpose of this study was to assess the safety and efficacy of the WiSE-CRT system during real-world clinical use in an international registry.

Methods

Data were prospectively collected from 14 centers implanting the WiSE-CRT system as part of the WiCS-LV Post Market Surveillance Registry. (ClinicalTrials.gov Identifier: NCT02610673).

Results

Ninety patients from 14 European centers underwent implantation with the WiSE-CRT system. Patients were predominantly male, age 68.2 ± 10.5 years, left ventricular ejection fraction 30.6% ± 8.9%, mean QRS duration 180.7 ± 27.0 ms, and 40% with ischemic etiology. Successful implantation and delivery of BiV ENDO pacing was achieved in 94.4% of patients. Acute (<24 hours), 1- to 30-day, and 1- to 6-month complications rates were 4.4%, 18.8%, and 6.7%, respectively. Five deaths (5.6%) occurred within 6 months (3 procedure related). Seventy percent of patients had improvement in heart failure symptoms.

Conclusion

BiV ENDO pacing with the WiSE-CRT system seems to be technically feasible, with a high success rate. Three procedural deaths occurred during the study. Procedural complications mandate adequate operator training and implantation at centers with immediately available cardiothoracic and vascular surgical support.

The effect of sodium thiosulfate on the recovery of Mycobacterium chimaera from heater-cooler unit water samples

BACKGROUND

Heater-cooler units (HCUs) have been implicated in the recent global outbreak of invasive Mycobacterium chimaera infection among patients following cardiothoracic surgery. Because infected patients tend to remain asymptomatic for extended periods, detection of M. chimaera from HCUs in real time is essential to halting the ongoing M. chimaera HCU-associated outbreak. Sample collection protocols to evaluate the presence of M. chimaera offer conflicting recommendations regarding the addition of sodium thiosulfate (NaT) during the collection process.

AIM

To study the effect of NaT on M. chimaera recovery and culture contamination.

METHODS

Seventy-six paired HCU water samples (with and without NaT) were collected, processed and cultured simultaneously into Lowenstein-Jensen slants, Middlebrook 7H10 agar plates, and mycobacterial growth indicator tubes (MGITs), and incubated at 37°C. A subset of 31 paired samples was additionally cultured on MGITs and incubated at 30°C.

FINDINGS

Of 76 samples incubated at 37°C in each of the three media, with and without NaT, M. chimaera was identified in at least one aliquot of 21 samples.

CONCLUSION

The presence of NaT did not significantly increase the probability of recovering M. chimaera in a multi-variable conditional logistic model and culture contamination rates were similar between aliquots with and without NaT. In the subset of samples cultured on MGITs at both 30°C and 37°C, the presence of NaT again was not associated with M. chimaera recovery, but was significantly associated with reduced culture contamination.

Methodische Herausforderungen bei der Nutzung von Daten von mehr als 70 gesetzlichen Krankenkassen – Ein Werkstattbericht aus der EVA64-Studie

Ziel der Studie Die angemessene und bedarfsgerechte Betreuung psychisch erkrankter Patienten stellt besondere Anforderungen an die psychiatrische Versorgung. §64b SGB V eröffnet die Möglichkeit, psychisch Erkrankte durch multiprofessionelle, behandlungsphasen- und sektorenübergreifende Modellvorhaben zu betreuen und neue Finanzierungsformen zu implementieren. Diese Modellprojekte werden seit 2015 in einer prospektiven und retrospektiven sekundärdatenbasierten kontrollierten Kohortenstudie (EVA64) evaluiert.

Methode Im September 2016, und seitdem jährlich, erfolgte erstmalig die Datenbereitstellung aller an der Evaluation beteiligten gesetzlichen Krankenversicherungen (GKV) auf der Basis einer konsentierten Datensatzbeschreibung. Für die spätere Analyse sind die eindeutige Identifikation des Indexaufenthaltes und die Zuordnung zu Modell- oder Kontrollgruppe von Bedeutung. Die methodischen Herausforderungen der Datenbereitstellung durch die Dateneigner, das Einlesen, die formale und inhaltliche Prüfung sowie die anschließende Zusammenführung zu einem Auswertedatensatz werden ausführlich diskutiert und Fallstricke aufgezeigt.

Ergebnisse Insgesamt wurden bislang Daten von 71 Krankenkassen berücksichtigt. In jeweils 20 Tabellen pro Kasse wurden Leistungsdaten zur vertragsärztlichen, ambulanten und stationären Versorgung im Krankenhaus (inkl. Psychiatrische Insti-tutsambulanzen [PIA]), Arznei- und Heilmittelversorgung sowie Arbeitsunfähigkeit übermittelt. Nicht alle Tabellen konnten von den Krankenkassen vollständig gefüllt werden. Zudem bedingen neue inhaltliche Aspekte u. a. die Anpassung der Datenselektion. Trotz mehrmaliger Datenlieferungen kann noch nicht von einem Routinevorgehen gesprochen werden.

Schlussfolgerung Die kassenübergreifende Nutzung von Abrechnungsdaten zahlreicher GKVen im Rahmen einer Evaluationsstudie stellt eine große Herausforderung dar. Angesichts fehlender Richtwerte für Auffälligkeiten und Implausibilitäten war eine a-priori Festlegung von Prüfalgorithmen nur bedingt möglich; diese müssen vielmehr im Projektverlauf fortlaufend aktualisiert werden. Die resultierende individuelle Prüfung der Daten aller Krankenkassen gestaltet sich dadurch sehr aufwändig. Die ausführliche Dokumentation dieser Prüfprozesse und möglicher Fallstricke gibt Hilfestellung für zukünftige vergleichbare Studien.

Effectiveness of Global Treatment Budgets for Patients With Mental Disorders-Claims Data Based Meta-Analysis of 13 Controlled Studies From Germany

Background: Individuals with mental disorders need continuous and efficient collaboration between different sectors of care. In 2012, a new law in Germany enabled the implementation of novel budgets in psychiatry (flexible and integrated treatment = FIT). Hospitals implementing FIT programs have been evaluated in controlled cohort studies. We present first results based on a meta-analysis from 13 FIT hospitals. Methods/Design: We undertook a series of claims-data-based controlled cohort studies. Data from over 70 statutory health insurance (SHI) funds in Germany were analyzed. All patients insured by any of the participating SHI funds and treated in one of the FIT hospitals for any of 16 predefined mental disorders were compared with matched control patients from routine care. The patient collective was subdivided into hospital-new and hospital-known patients. Analyses included utilization of inpatient care, day care, outpatient PIA (psychiatrische Institutsambulanz) care, outpatient care with established practitioners, and durations of sick leave. Individual treatment effects of the 13 FIT hospitals were pooled in a random-effects meta-analysis. Meta-regression analysis was used to explore potential reasons for heterogeneity in model effectiveness. Results: The meta-analysis revealed a significant reduction by over 5 days of inpatient care in hospital-new patients in FIT hospitals compared to control hospitals. This effect was stronger among FIT hospitals with a preexisting FIT-like environment. There was no overall significant effect regarding sick leave between the two groups. Further meta-regression for hospital-new patients revealed a significantly reduced duration of sick leave by almost 13 days for patients in FIT hospitals with a preexisting FIT-like contract compared to FIT hospitals without such a contract. Conclusions: This study suggests positive effects of FIT programs for patients with mental disorders pointing toward a shorter duration of inpatient treatment. Furthermore, contracts already existent prior to initialization of FIT programs appear to have facilitated the transition into the new treatment environment. For FIT hospitals without such contracts, supposedly there is a certain implementation phase for effects to be apparent. The results should still be interpreted with caution as this manuscript only covers the first year of the 5 year evaluation period in 13 of 18 FIT hospitals. Clinical Trial Registration: This study was registered in the database "Health Services Research Germany" (trial number: VVfD_EVA64_15_003713).

Consumers' Impression of Minimally Processed Gala Apples Using Word Association

This study aimed to identify consumers' preferences and impressions of minimally processed "Gala" cultivar apples, using preference tests and word associations. The study was conducted online via the Google Docs tool and sent out via social networks. The participants were 607 individuals, mostly women, mainly between the ages of 18 and 45, with education up to undergraduate and postgraduate level. As regards the preference for minimally processed apples, the profile of the consumer did not influence the choice. The profiles analyzed were gender and education. For the word association test, 11-word categories were formed, and among these, the most important aspect was appearance, followed by taste and texture, which was confirmed by correspondence analysis. Sample A (0 days-no storage) was the most preferred one, differing significantly from the other samples, whereas sample B (3 days of storage) and sample C (6 days of storage) were associated with characteristics for choice of product. The word association methodology revealed the consumer's impressions of the product, in addition to demonstrating simplicity, low cost, speed, and an exploratory character. PRACTICAL APPLICATION: Gender and level of schooling did not influence the choice of minimally processed apples. Appearance was the most cited word in the word association test. Word association is a simple, fast, inexpensive, and projective technique.

[Septicemia and endocarditis with multiple implants : CIED, TAVI, MK clip and LAA occluders]

Infective endocarditis (IE) as well as septicemia in patients with implanted cardiac devices are severe diseases and diagnosis is often delayed due to a variety of misleading symptoms. Imaging with transesophageal echocardiography (TEE) and also microbiology play a key role in both the diagnosis and management. They are also useful for the prognostic assessment of patients with IE, for follow-up during treatment, during extraction of the implant and after surgery. In addition to antibiotic treatment, removal of the implant is also necessary, at least if vegetation is detected. Not only the removal of the implant but also the underlying cardiac disease, the frequently occurring severe cardiac insufficiency, the advanced age and the not uncommon high degree of fragility of the patients mean that decision making for treatment and management as well as renewed implantation after completion of treatment are a challenge. The optimal treatment is only possible with a close cooperation between various specialist disciplines and should therefore be carried out in experienced centers.

Percutaneous treatment of mitral regurgitation in patients with impaired ventricular function: Impact of intracardiac electronic devices (from the German Transcatheter Mitral Valve Interventions Registry)

OBJECTIVES

To identify prevalence/impact of previous implantation of cardiac electronic devices (CEDs), such as cardioverter defibrillator (ICD) and cardiac resynchronization (CRT), in a group of MitraClip (MC) candidates with LVEF < 30%.

BACKGROUND

MC therapy is nowadays often considered in patients with depressed left ventricular ejection fraction (LVEF%) and symptomatic severe secondary MR.

METHODS

Data from the German Transcatheter Mitral Valve Interventions (TRAMIs) registry were analyzed. Patients with pre-procedural LVEF <30% were selected and divided according to the presence of CEDs. Pre-procedural, peri-procedural, and 1-year follow-up data were analyzed.

RESULTS

Out of 689 MC patients, 235 had LVEF<30%. Of these, 23% (54/235) had CRT, 36.6% (86/235) ICD, and 40.4% (95/235) had no CEDs. Risk profile was similar (median STS score CRT 6.0 (IQR: 3.0-12.0); ICD 7.0 (IQR: 4.0-12.0); No-CED 6.5 (IQR: 2.0-10.0); p = 0.8). No procedural mortality was observed and hospital mortality was 5.6% in CRT, 2.3% in ICD, and 3.2% in No-CED (p = 0.5). At discharge, severe MV regurgitation was reported in 3.8% of CRT, 3.7% of ICD, and 1.1% of No-CED (p = 0.9). One year estimated survival (CRT 75.7%; ICD 75.8%; No-CED 78%; p = 0.94) and freedom from MACCE (CRT 73.6%; ICD 75.8%; No-CED 74.5%; p = 0.88) were similar.

CONCLUSIONS

A third of patients have been already submitted to CEDs implantation at time of referral for MC therapy and 40% of those with severely depressed LVEF% arrive to MC therapy before ICD/CRT implantation. The presence of CED does not impair acute MC therapy success. Mid-term follow-up outcomes are similar in patients with and without CEDs.

Prognosis associated with redo cardiac resynchronization therapy following complete device and lead extraction due to device-related infection

Aims

An increase in the number of cardiac resynchronization therapy (CRT) device implantations worldwide has led to a consequent increase in the number of infections associated with the device, making extraction of the CRT device inevitable. Redo CRT implantation after treatment and recovery following device extraction is challenging. This study aimed to evaluate the success rate, complications, and long-term prognosis of redo CRT implantation, including the rates of subclavian, cava, and coronary sinus (CS) vein thrombosis as well as re-infection.

Methods and results

Between 2007 and 2014, 1712 lead extractions were performed in 537 patients with device-related infection at Heart Center Brandenburg. Of the 537 patients, 125 (23%) underwent CRT device and lead extraction, including extraction of the left ventricular lead from the coronary sinus. Of these 125, 62 (50%) patients underwent redo CRT implantation (mean age, 68 ± 10 years); 34 patients had coronary artery disease (CAD) while 28 had dilated cardiomyopathy (DCM). The mean left ventricular ejection fraction was 27% ± 7%. The mean QRS duration of the left bundle branch block was 158 (range, 147-162) ms, and 25 patients had atrial fibrillation (AF). All these patients were followed up for a median duration of 29.6 (range, 15-43) months. In 53 of the 62 patients (85%), the CRT system was successfully re-implanted; however, the original CS vein could be used again only in 28 (45%) patients. The all-cause mortality rate was 7.1% after 1 year, and it was significantly higher in patients whose N-terminal pro B-type natriuretic peptide level was  ≥3,000 pg/mL (P < 0.001), those who were aged  ≥64 years (P = 0.028), those who had CAD (P = 0.042) or chronic kidney insufficiency (P = 0.001), those with AF (P = 0.001) and those whose blood cultures were positive for Staphylococcus aureus (P = 0.014).

Conclusion

Redo CRT implantation after device extraction owing to device-related infection has a low success rate and shows a higher rate of re-infection than that observed in patients who undergo CRT implantation for the first time. Further, patients whose blood cultures are positive for S. aureus show a particularly poor outcome.

[Leadless endocardial ultrasound based left ventricular stimulation : WISE CRT System: alternative to conventional methods]

There are still several limitations in delivering cardiac resynchronisation therapy (CRT). After 6 months, 20-40% of patients fail to have clinical benefit due to various reasons. Endocardial stimulation rather than conventional epicardial pacing has been shown to be more physiological, improves electrical stimulation of the left ventricle (LV), has less dispersion of electrical activity and results in better resynchronisation. The WiSE™ CRT System ("Wireless stimulation endocardial system"; EBR Systems, Sunnyvale, CA, USA) provides an option for wireless, LV endocardial pacing triggered by a conventional right ventricular pacing spike from a co-implant. The feasibility of the WiSE™ CRT System has been successfully demonstrated in a population of failed cardiac resynchronisation patients with either failed implantation of a conventional system, nonresponse to conventional therapy or upgrade from pacemaker or defibrillator, where a conventional system was not an option. The WiSE™ CRT System is an innovative technology with promising safety, performance and preliminary efficacy.

The biology and mathematical modelling of glioma invasion: a review

Adult gliomas are aggressive brain tumours associated with low patient survival rates and limited life expectancy. The most important hallmark of this type of tumour is its invasive behaviour, characterized by a markedly phenotypic plasticity, infiltrative tumour morphologies and the ability of malignant progression from low- to high-grade tumour types. Indeed, the widespread infiltration of healthy brain tissue by glioma cells is largely responsible for poor prognosis and the difficulty of finding curative therapies. Meanwhile, mathematical models have been established to analyse potential mechanisms of glioma invasion. In this review, we start with a brief introduction to current biological knowledge about glioma invasion, and then critically review and highlight future challenges for mathematical models of glioma invasion.

Phase transitions in huddling emperor penguins

Emperor penguins (Aptenodytes forsteri) are highly adapted to the harsh conditions of the Antarctic winter: they are able to fast for up to 134 days during breeding. To conserve energy, emperor penguins form tight groups (huddles), which is key for their reproductive success. The effect of different meteorological factors on the huddling behaviour, however, is not well understood. Using time-lapse image recordings of an emperor penguin colony, we show that huddling can be described as a phase transition from a fluid to a solid state. We use the colony density as order parameter, and an apparent temperature that is perceived by the penguins as the thermodynamic variable. We approximate the apparent temperature as a linear combination of four meteorological parameters: ambient temperature, wind speed, global radiation and relative humidity. We find a wind chill factor of -2.9 °C/(ms -1), a humidity chill factor of -0.5°C/% rel. humidity, and a solar radiation heating factor of 0.3 °C//(Wm 2). In the absence of wind, humidity and solar radiation, the phase transition temperature (50% huddling probability) is -48.2°C for the investigated time period (May 2014). We propose that higher phase transition temperatures indicate a shrinking thermal insulation and thus can serve as a proxy for lower energy reserves of the colony, integrating pre-breeding foraging success at sea and energy expenditure at land due to environmental conditions. As current global change is predicted to have strong detrimental effects on emperor penguins within the next decades, our approach may thus contribute towards an urgently needed long-term monitoring system for assessing colony health.

The influence of cross-sectoral treatment models on patients with mental disorders in Germany: study protocol of a nationwide long-term evaluation study (EVA64)

BACKGROUND

Close, continuous and efficient collaboration between different professions and sectors of care is necessary to provide patient-centered care for individuals with mental disorders. The lack of structured collaboration between in- and outpatient care constitutes a limitation of the German health care system. Since 2012, a new law in Germany (§64b Social code book (SGB) V) has enabled the establishment of cross-sectoral and patient-centered treatment models in psychiatry. Such model projects follow a capitation budget, i.e. a total per patient budget of inpatient and outpatient care in psychiatric clinics. Providers are able to choose the treatment form and adapt the treatment to the needs of the patients. The present study (EVA64) will investigate the effectiveness, costs and efficiency of almost all model projects established in Germany between 2013 and 2016.

METHODS/DESIGN

A health insurance data-based controlled cohort study is used. Data from up to 89 statutory health insurance (SHI) funds, i.e. 79% of all SHI funds in Germany (May 2017), on inpatient and outpatient care, pharmaceutical and non-pharmaceutical treatments and sick leave for a period of 7 years will be analyzed. All patients insured by any of the participating SHI funds and treated in one of the model hospitals for any of 16 pre-defined mental disorders will be compared with patients in routine care. Sick leave (primary outcome), utilization of inpatient care (primary outcome), utilization of outpatient care, continuity of contacts in (psychiatric) care, physician and hospital hopping, re-admission rate, comorbidity, mortality, disease progression, and guideline adherence will be analyzed. Cost and effectivity of model and routine care will be estimated using cost-effectiveness analyses. Up to 10 control hospitals for each of the 18 model hospitals will be selected according to a pre-defined algorithm.

DISCUSSION

The evaluation of complex interventions is an important main task of health services research and constitutes the basis of evidence-guided advancement in health care. The study will yield important new evidence to guide the future provision of routine care for mentally ill patients in Germany and possibly beyond.

TRIAL REGISTRATION

This study was registered in the database "Health Services Research Germany" (trial number: VVfD_EVA64_15_003713 ).