Population estimates of obstructive and non-obstructive hypertrophic cardiomyopathy in the UK and Germany

Background

While numerous publications have estimated the prevalence of diagnosed hypertrophic cardiomyopathy (HCM), none have quantified the real-world proportion of obstructive and non-obstructive HCM using nationally representative data sources in any European countries.

Purpose

To estimate the prevalence of diagnosed HCM and its subtypes in the UK and Germany.

Methods

Patients with HCM were identified in the UK from 01 Apr 2009 to 30 Oct 2020 and Germany from 2011 to 2019. UK patients with HCM were identified using electronic health records from the Clinical Practice Research Datalink (CPRD) primary care data linked with Hospital Episode Statistics (HES) secondary care data using ICD-10 (I42.1, I42.2), Read, Medcode, SNOMED, and OPCS codes. German patients with HCM were identified using a nationally representative administrative claims data pool (WIG2 Benchmark database) from several German Statutory Health Insurance (SHI)-insurances using ICD-10 and OPS codes. Obstructive HCM was identified as any obstructive HCM diagnosis, any HCM diagnosis with septal reduction therapy, and any HCM diagnosis and left ventricular outflow tract obstruction (LVOTO; not in German claims data). Non-obstructive HCM was any non-obstructive or unspecified HCM diagnosis without evidence of any obstructive HCM. Annual prevalence was calculated for each year in the respective study periods and average annual prevalence across the study period.

Results

The average annual prevalence rate of HCM was 4.15/10,000 in the UK and 8.61/10,000 in Germany, while the average annual prevalence rate of obstructive HCM was 2.84/10,000 in the UK and 4.18/10,000 in Germany (Table). The proportion of HCM that was obstructive HCM was 68% in the UK and 49% in Germany. The prevalence rates of diagnosed HCM and obstructive HCM tended to increase over time (Figure).

Conclusion

The prevalence of HCM, obstructive HCM and the proportion of HCM that is obstructive varied between the UK and Germany. The prevalence of HCM was generally consistent with previously published estimates. Although there are limitations with coding in administrative data, it is important to differentiate obstructive HCM from non-obstructive HCM given their unique treatments and disease progression and management, especially since at least 49–68% of HCM is obstructive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bristol Myers-Squibb

Only strongly enhanced residual FDG uptake in early response PET (Deauville 5 or qPET ≥ 2) is prognostic in pediatric Hodgkin lymphoma: Results of the GPOH-HD2002 trial

PURPOSE

In 2014, we published the qPET method to quantify fluorodeoxyglucose positron emission tomography (FDG-PET) responses. Analysis of the distribution of the quantified signals suggested that a clearly abnormal FDG-PET response corresponds to a visual Deauville score (vDS) of 5 and high qPET values ≥ 2. Evaluation in long-term outcome data is still pending. Therefore, we analyzed progression-free survival (PFS) by early FDG-PET response in a subset of the GPOH-HD2002 trial for pediatric Hodgkin lymphoma (PHL).

PATIENTS/METHODS

Pairwise FDG-PET scans for initial staging and early response assessment after two cycles of chemotherapy were available in 93 PHL patients. vDS and qPET measurement were performed and related to PFS.

RESULTS

Patients with a qPET value ≥ 2.0 or vDS of 5 had 5-year PFS rates of 44%, respectively 50%. Those with qPET values < 2.0 or vDS 1 to 4 had 5-year PFS rates of 90%, respectively 80%. The positive predictive value of FDG-PET response assessment increased from 18% (9%; 33%) using a qPET threshold of 0.95 (vDS ≤ 3) to 30% (13%; 54%) for a qPET threshold of 1.3 (vDS ≤ 4) and to 56% (23%; 85%) when the qPET threshold was ≥ 2.0 (vDS 5). The negative predictive values remained stable at ≥92% (CI: 82%; 98%).

CONCLUSION

Only strongly enhanced residual FDG uptake in early response PET (vDS 5 or qPET ≥ 2, respectively) seems to be markedly prognostic in PHL when treatment according to the GPOH-HD-2002 protocol is given.

Vedolizumab in the treatment of chronic, antibiotic-dependent or refractory pouchitis

BACKGROUND

The most common complication after ileal pouch anal anastomosis in up to 50% of patients is an acute pouchitis. The majority of patients respond to antibiotic treatment. However, 10%-15% develops chronic antibiotic-dependent or refractory pouchitis which is usually hard to treat.

AIM

To evaluate the effectiveness of vedolizumab in patients with chronic pouchitis.

METHODS

Patients with chronic antibiotic-dependent or refractory pouchitis were treated with vedolizumab (300 mg at week 0, 2, 6 and 10) in 10 IBD centres and retrospectively registered. Data were recorded until week 14 of vedolizumab treatment. In total 20 patients (12 male, median age 43 years) were included for analysis. The effectiveness was measured using the Oresland Score (OS) at week 2, 6, 10 and 14 and the pouch disease activity index (PDAI) at week 0 and 14.

RESULTS

The mean OS declined from 6.8 (range 2-12) to 3.4 (range 0-11). Concordantly, the mean PDAI after 14 weeks of treatment dropped from 10 (range 5-18) to 3 (range 0-10). Only three patients reported moderate side effects. No serious side effects were recorded. In addition, symptomatic co-medication such as loperamide and tincture of opium could be terminated in 8 out of 12 patients as well as antibiotic treatment could be stopped in 17 out of 19 patients.

CONCLUSION

Our data indicate that vedolizumab could be an option in the treatment of patients with chronic, antibiotic-dependent or refractory pouchitis.

Immunoscintigraphy with Anti-225.28S for Ocular Melanoma - a Comparison with Histology and Immunohistochemistry,

Aim: The purpose of this prospective study was to evaluate the value of Immunoscintigraphy (ISG) with anti-225.28S in clinically suspected ocular melanoma. Methods: For this purpose standardized ISG was performed in 36 patients using both planar acquisition and emission computed tomography (ECT). Ocular melanoma was present in 31 patients. In 21 patients therapy was enucleation of the eye. These specimens were evaluated by histology and immunohistochemistry in 11 of 21 patients. Results: Regarding the clinical diagnosis, ISG was positive only in 15 of 31 patients with ocular melanoma, regarding histology in 11 of 21 and regarding immunohistochemistry in 5 of 6 patients with a positive Immunoreaction. 5 patients showed no immunoreactivity, their ISG was negative. Conclusion: Thus a good correlation between ISG and immunohistochemistry was observed. However ISG using the cutaneous melanoma antibody 225.28S cannot be recommanded for the diagnostic work-up of an ocular melanoma considering the poor immunoreactivity.

How salt lakes affect atmospheric new particle formation: A case study in Western Australia

New particle formation was studied above salt lakes in-situ using a mobile aerosol chamber set up above the salt crust and organic-enriched layers of seven different salt lakes in Western Australia. This unique setup made it possible to explore the influence of salt lake emissions on atmospheric new particle formation, and to identify interactions of aqueous-phase and gas-phase chemistry. New particle formation was typically observed at enhanced air temperatures and enhanced solar irradiance. Volatile organic compounds were released from the salt lake surfaces, probably from a soil layer enriched in organic compounds from decomposed leaf litter, and accumulated in the chamber air. After oxidation of these organic precursor gases, the reaction products contributed to new particle formation with observed growth rates from 2.7 to 25.4nmh^-1. The presence of ferrous and ferric iron and a drop of pH values in the salt lake water just before new particle formation events indicated that organic compounds were also oxidized in the aqueous phase, affecting the new particle formation process in the atmosphere. The contribution of aqueous-phase chemistry to new particle formation is assumed, as a mixture of hundreds of oxidized organic compounds was characterized with several analytical techniques. This chemically diverse composition of the organic aerosol fraction contained sulfur- and nitrogen-containing organic compounds, and halogenated organic compounds. Coarse mode particles were analyzed using electron microscopy, energy dispersive X-ray spectroscopy and Raman spectroscopy. Ultra-high resolution mass spectrometry was applied to analyze filter samples. A targeted mass spectral analysis revealed the formation of organosulfates from monoterpene precursors and two known tracers for secondary organic aerosol formation from atmospheric oxidation of 1,8-cineole, which indicates that a complex interplay of aqueous-phase and gas-phase oxidation of monoterpenes contributes to new particle formation in the investigated salt lake environment.

The Cortical Signature of Central Poststroke Pain: Gray Matter Decreases in Somatosensory, Insular, and Prefrontal Cortices

It has been proposed that cortical structural plasticity plays a crucial role in the emergence and maintenance of chronic pain. Various distinct pain syndromes have accordingly been linked to specific patterns of decreases in regional gray matter volume (GMV). However, it is not known whether central poststroke pain (CPSP) is also associated with cortical structural plasticity. To determine this, we employed T1-weighted magnetic resonance imaging at 3 T and voxel-based morphometry in 45 patients suffering from chronic subcortical sensory stroke with (n = 23) and without CPSP (n = 22), and healthy matched controls (n = 31). CPSP patients showed decreases in GMV in comparison to healthy controls, involving secondary somatosensory cortex (S2), anterior as well as posterior insular cortex, ventrolateral prefrontal and orbitofrontal cortex, temporal cortex, and nucleus accumbens. Comparing CPSP patients to nonpain patients revealed a similar but more restricted pattern of atrophy comprising S2, ventrolateral prefrontal and temporal cortex. Additionally, GMV in the ventromedial prefrontal cortex negatively correlated to pain intensity ratings. This shows for the first time that CPSP is accompanied by a unique pattern of widespread structural plasticity, which involves the sensory-discriminative areas of insular/somatosensory cortex, but also expands into prefrontal cortex and ventral striatum, where emotional aspects of pain are processed.

[SPECT/CT diagnostics for skeletal infections]

CLINICAL/METHODICAL ISSUE

Skeletal infections are often a diagnostic and clinical challenge.

STANDARD RADIOLOGICAL METHODS

Nuclear imaging modalities used in the diagnostic workup of acute and chronic skeletal infections include three-phase bone scintigraphy and scintigraphy with labelled leucocytes.

METHODICAL INNOVATIONS

The introduction of hybrid technologies, such as single photon emission computed tomography/computed tomography (SPECT/CT) has dramatically changed nuclear medical imaging of infections.

PERFORMANCE

In general SPECT/CT leads to a considerably more accurate diagnosis than planar or SPECT imaging.

ACHIEVEMENTS

Given the integrated acquisition of metabolic, functional and morphological information, SPECT/CT has increased in particular the specificity of three-phase skeletal scanning and scintigraphy with labeled leucocytes.

[Nuclear medicine in Europe: education]

The technical developments that have taken place in the preceding years (PET, hybrid imaging) have changed nuclear medicine. The future cooperation with radiologists will be challenging as well as positioning nuclear medicine in an European context. It can also be expected that education in nuclear medicine will undergo a harmonization process in the states of the European Union. In this paper, we describe how nuclear medicine education is organized in several European countries. We aim to stimulate constructive discussions on the future development of the specialization in nuclear medicine in Germany.

Abu Dhabi's strategic tunnel enhancement programme: odour extraction system approaches

The Emirate of Abu Dhabi has experienced tremendous growth since the mid-1970s resulting in significant overloading of its existing sewerage system. Master planning determined that the best long-term wastewater collection and conveyance solution was construction of a deep tunnel sewer system. Implementation of this massive project faced numerous challenges, including the goal of no odours and limited odour control facilities. To accomplish this, the consultant team examined a unique approach of a single odour control system installed at the proposed downstream tunnel pumping station. Rigorous analysis utilising computer-based models confirmed the viability of this approach. However, other approaches including multiple satellite (localised or regional) odour extraction systems were considered. To better understand entrained air forces at vortex drops, and to confirm the preferred odour extraction approach, physical modelling of drop structures and overall tunnel system was implemented. Results and findings concluded that a regional odour extraction system approach was preferred over a single (centralised) extraction approach. This paper focuses on the process of selecting the preferred odour extraction approach and preliminary capacity sizing of regional systems.

Directional limits on persistent gravitational waves using LIGO S5 science data

The gravitational-wave (GW) sky may include nearby pointlike sources as well as stochastic backgrounds. We perform two directional searches for persistent GWs using data from the LIGO S5 science run: one optimized for pointlike sources and one for arbitrary extended sources. Finding no evidence to support the detection of GWs, we present 90% confidence level (C.L.) upper-limit maps of GW strain power with typical values between 2-20×10(-50)  strain(2) Hz(-1) and 5-35×10(-49)  strain(2) Hz(-1) sr(-1) for pointlike and extended sources, respectively. The latter result is the first of its kind. We also set 90% C.L. limits on the narrow-band root-mean-square GW strain from interesting targets including Sco X-1, SN 1987A and the Galactic center as low as ≈7×10(-25) in the most sensitive frequency range near 160 Hz.

The effect of naloxone-3-glucuronide on colonic transit time in healthy men after acute morphine administration: a placebo-controlled double-blinded crossover preclinical volunteer study

BACKGROUND

Constipation is a significant side effect of opioid therapy. We have previously demonstrated that naloxone-3-glucuronide (NX3G) antagonizes the motility-lowering-effect of morphine in the rat colon.

AIM

To find out whether oral NX3G is able to reduce the morphine-induced delay in colonic transit time (CTT) without being absorbed and influencing the analgesic effect.

METHODS

Fifteen male volunteers were included. Pharmacokinetics: after oral administration of 0.16 mg/kg NX3G, blood samples were collected over a 6-h period. Pharmacodynamics: NX3G or placebo was then given at the start time and every 4 h thereafter. Morphine (0.05 mg/kg) or placebo was injected s.c. 2 h after starting and thereafter every 6 h for 24 h. CTT was measured over a 48-h period by scintigraphy. Pressure pain threshold tests were performed.

RESULTS

Neither NX3G nor naloxone was detected in the venous blood. The slowest transit time was observed during the morphine phase, which was significantly different from morphine with NX3G and placebo. The pain perception was not significantly influenced by NX3G.

CONCLUSIONS

Orally administered NX3G is able to reverse the morphine-induced delay of CTT in humans without being detected in peripheral blood samples. Therefore, NX3G may improve symptoms of constipation in-patients using opioid medication without affecting opioid-analgesic effects.

Schwere Anaphylaxie nach Rocuronium

Muscle relaxant drugs are the most frequent cause of anaphylactic and anaphylactoid reactions during anaesthesia. We report a case of a life-threatening anaphylactic reaction during induction of anaesthesia with severe bronchospasm as the first clinical symptom. Mechanical ventilation was nearly impossible. The patient required a multimodal antiallergic therapy and a high-dose catecholamine therapy for stabilization. Rocuronium was identified as the allergic agent using intradermal testing.

Effects of prophylactic or therapeutic application of bovine haemoglobin HBOC-200 on ischaemia-reperfusion injury following acute coronary ligature in rats

BACKGROUND

Haemoglobin-based oxygen carriers (HBOCs) are assessed as blood substitutes in patients with perioperative anaemia including patients at risk for perioperative cardiac ischaemia. There is controversy as to whether HBOCs are beneficial or deleterious during ischaemia-reperfusion (I-R). Therefore the effects of HBOC-200 on I-R injury were evaluated in a randomized placebo-controlled animal trial.

METHODS

Animals were randomized to receive either placebo i.v. without I-R (sham group, n=9), placebo i.v. with I-R (control group, n=10), HBOC-200 0.4 g kg(-1) i.v. prior to I-R (prophylaxis group, n=12) or HBOC-200 0.4 g kg(-1) i.v. during I-R (therapy group, n=15). I-R consisted of 25 min of acute ligature of the left coronary artery followed by 120 min of reperfusion. Measurements included assessment of the area at risk and infarct size using triphenyl tetrazolium chloride (TTC) stain, DNA single-strand breaks (in situ nick translation with autoradiography/densitometry) and cardiac arrhythmias.

RESULTS

Infarct size within the area at risk was 62 (sd 15)% (control), 46 (10)% (prophylaxis, P<0.025 vs control) and 61 (9)% (therapy, P<0.85 vs control). The frequency of DNA single-strand breaks was reduced vs control in the sham (P<0.01) and prophylaxis (P<0.04) groups and was almost the same in the therapy group (P<0.75). The severity of cardiac arrhythmias during ischaemia was lower compared with control in the sham (P<0.001) and prophylaxis (P<0.039) groups, but there was no difference in the therapy group.

CONCLUSION

This study demonstrates that neither prophylactic nor therapeutic application of the cell-free haemoglobin solution HBOC-200 aggravates cardiac I-R injury. Furthermore, the prophylactic approach may offer a new opportunity for pretreatment of patients at risk for perioperative ischaemic cardiac events.

[Medicine in old age and in the elderly. Educational concepts in area Q7 of the accreditation requirements and its first evaluation by students]

Until very recently, medicine in old age was not an obligatory part of the medical students' education in Germany. This has been changed by an educational reform. However, there are no obliging recommendations or procedures on which issues of medicine in old age should be taught. Therefore, we describe the development of a new curriculum, first experiences with the teaching, and the results of its evaluation by the students at the University of Hamburg. As a result, the subjects and the didactic teaching were both well accepted by the students and judged as interesting and instructive.

High-grade decubitus ulcers in the elderly : A Postmortem Case-Control Study of Risk Factors

Some elderly persons develop high-grade decubitus ulcers, whereas others with comparable risk factors do not. In Germany, forensic pathologists are increasingly confronted by situations that necessitate an expert opinion on whether prevention of decubitus ulcers has been neglected in cases of suspected malpractice. This investigation was carried out in an attempt to identify risk factors for decubitus ulcers. We performed a postmortem case-control study in elderly persons who developed high-grade decubitus ulcers from 6 months to 14 days before death. Deceased with decubitus ulcers graded 3 or higher and controls at comparable risk were examined before cremation. After written informed consent had been obtained from the nearest living relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Decubitus ulcer cases and controls were matched according to age, gender, immobility, and cachexia. One-hundred cases of decubitus ulcers with 71 grade 3 decubitus ulcers and 29 grade 4 decubitus ulcers were compared with 100 controls with 27 decubitus ulcers graded 2 or lower and the maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The individuals with decubitus ulcers were more often severely disabled, had more immobility of joints, and were more often under treatment with antidepressive and/or sedative drugs (e.g., opioid analgesies, neurolepties, benzodiazepines). Patients' impaired ability or unwillingness to comply or cooperate with preventive and therapeutic measures was more often recorded in cases of decubitus than in the control group. There was no evidence that supplementary nutrition or use of preventive pressure relief and protective devices differed between the decubitus cases and the controls.

[Fall events in geriatric hospital in-patients. Results of prospective recording over a 3 year period]

For a period of 3 consecutive years, all fall events were prospectively recorded in geriatric hospital in-patients by using a standardized protocol. The incidence was 9.1 fall events/1000 hospital days in 5946 patients, and 41.0/1000 hospital days in 1015 patients (17.0%) who actually had falls. The fall rate varied between 35.0-57.0/1000 hospital days according to the main diagnostic group. Fall events were more often recorded in men than women. Recurrent falls (> or =3 falls) which contributed 13% to the 1596 falls were recorded more frequently in male patients. The majority of fall events (73.5%) occurred in patient rooms, another 20% on the floor between the patient's bedroom and toilet/bath, or in the toilet/bath, respectively. The absolute numbers of falls during night and day were not different. However, there were different patterns in the time distribution of high fall frequencies according to the main diagnostic groups. Confusion and dehydration were recorded more frequently with fall events in patients 80 years and older, and more often in fall events during the night. Injuries due to falls which had to be treated were rare, and fall-related fractures were very rare. The average duration of in-hospital stay was longer for patients with than without falls.

Dantrolene--a review of its pharmacology, therapeutic use and new developments

Human malignant hyperthermia is a life-threatening genetic sensitivity of skeletal muscles to volatile anaesthetics and depolarizing neuromuscular blocking drugs occurring during or after anaesthesia. The skeletal muscle relaxant dantrolene is the only currently available drug for specific and effective therapy of this syndrome in man. After its introduction, the mortality of malignant hyperthermia decreased from 80% in the 1960s to < 10% today. It was soon discovered that dantrolene depresses the intrinsic mechanisms of excitation-contraction coupling in skeletal muscle. However, its precise mechanism of action and its molecular targets are still incompletely known. Recent studies have identified the ryanodine receptor as a dantrolene-binding site. A direct or indirect inhibition of the ryanodine receptor, the major calcium release channel of the skeletal muscle sarcoplasmic reticulum, is thought to be fundamental in the molecular action of dantrolene in decreasing intracellular calcium concentration. Dantrolene is not only used for the treatment of malignant hyperthermia, but also in the management of neuroleptic malignant syndrome, spasticity and Ecstasy intoxication. The main disadvantage of dantrolene is its poor water solubility, and hence difficulties are experienced in rapidly preparing intravenous solutions in emergency situations. Due to economic considerations, no other similar drugs have been introduced into routine clinical practice.

[High-grade pressure sores in frail older high-risk persons. A retrospective postmortem case-control-study]

Some old persons at risk do develop, but others, at comparable risk, do not develop high-grade pressure sores. To evaluate potentially different risk factors, we performed a post mortem case-control study in old persons who developed high-grade pressure sores within six months until 14 days before death. Consecutive cases with pressure sores grade >/=3 and potential controls at comparably high risk for pressure sores were examined before cremation. After written informed consent had been obtained by the next relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Cases and controls were matched according to age, gender, immobility, and cachexia.A total of 100 cases with 71 pressure sores grade 3 and 29 pressure sores grade 4 were compared to 100 controls with 27 pressure sores grade </=2 and maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The cases were more often seriously disabled, had more often contractions of joints, and were on more drugs with intended or unwanted depressive/sedative effects (neuroleptics, benzodiazepines, centrally acting analgesics). Patient's impaired ability or low intention to comply/cooperate with preventive and/or therapeutic measures was more often recorded in cases than controls.A high degree of disablement and immobility, in particular, are risk factors for high-grade pressure sores in frail older high-risk persons. Sedative drug effects and impaired patient compliance with preventive and therapeutic measures may also be associated with the development of high-grade pressure sores in old persons at high risk.

Dekubitus: Kenntnis von Risikofaktoren und Bewusstsein von Problemen der Versorgungsqualität im Spiegel einer Befragung von Pflegekräften und Ärzten

A number of risk factors for pressure sores are well known. However, their causal relationship with the development of pressure sores is ambiguous. In fact, there is varying awareness of the problems in nursing staff and physicians caused by its' complexity and sometimes unclear evidence-even in standards and guidelines. In the present investigation, 256 members of a nursing staff and 245 physicians were asked by questionnaire about risk factors for pressure sores and problems with quality of care. The results revealed different views of the pathophysiology of pressure sores and also problems in the quality of care. There was agreement about the urgent need of consideration of these topics in education and postgraduate training.