Long-term cost and complications of surgery in patients with ulcerative colitis: a claims data analysis.

OBJECTIVES: Use claims data to assess healthcare resource utilization (HCRU) and cost for patients with ulcerative colitis (UC) who had surgery and patients who did not. METHODS: UC patients from a German health insurance were included between 01/01/2010-31/12/2017. Patients with proctocolectomy or colectomy between 01/07/2010 and 31/12/2014 were identified, and surgery date was set as index. For patients with IPAA, the last surgery in the 6 months was taken as index. Non-surgery patients received random index. After propensity score matching, UC-related HCRU and cost were observed for three years post-index. RESULTS: Of 21,392 UC patients, 85 underwent surgery and 2655 did not. After matching, 76 were included in the surgery group and 114 in the non-surgery group. Matched cohorts did not differ in baseline characteristics and mortality rates where high in both groups (21.1% and 29.0%, respectively). The percentage of patients with at least one hospitalization in the follow-up period was higher in the surgery (53.9%) compared to the non-surgery group (25.4%, p<0.001). In contrast, the number of outpatient prescriptions of UC-related drugs in the non-surgery group (11.2) was almost twice as large as in the surgery group (5.8, p<0.001). Hospitalization cost was 4.6 times higher in the surgery (1955.5€) than in the non-surgery group (419.6€, p<0.001). Medication cost was three times higher in the non-surgery group (6519€) compared to the surgery group (2151.7€, p<0.001). CONCLUSIONS: Based on hospitalizations, outpatient visits, and medical treatment, results show a considerable patient burden in UC from surgery complications or disease exacerbation in case of colectomy.

Indicators of active disease and steroid dependency in patients with inflammatory bowel diseases not treated with biologics in a German real-world-setting.

BACKGROUND AND AIMS: While a minority of inflammatory bowel disease (IBD) patients receives biologics in Germany, little is known about therapeutic needs of patients receiving non-biologic therapies. This study aimed to identify indicators of active disease/steroid dependency in patients with moderate to severe Crohn's disease (CD) and ulcerative colitis (UC) treated with conventional therapies and to describe health care resource use (HCRU)/cost. METHODS: CD/UC patients treated with immunosuppressants (IS) and/or systemic or locally acting oral corticosteroids (CS) were identified in German claims data (2013-2017) and followed for 12 months post-therapy start. Indicators of active disease/steroid dependency during follow-up period were (i) ≥ 2 prescriptions of CS (sensitivity ≥ 4) or (ii) ≥ 1 IBD-related surgery or (iii) > 7 days IBD-related hospitalization(s). RESULTS: Of 9871 included IBD patients (5170 CD, 4701 UC), 25.7%/19.9% (CD/UC) received ≥ 2 prescriptions of CS (sensitivity, 17.4%/15.7%) (i), 3.2% experienced IBD-related surgeries (ii), and 2.5% > 7 days of hospitalizations (iii). Altogether, 44.4% had indicators of active disease/steroid dependency (sensitivity, 23.9%). Among patients with active disease/steroid dependency, 78.0% received CS monotherapy at baseline. Of these, 89.6% received a CS monotherapy in the follow-up period, too. Proportionally, fewer patients with CS monotherapy (57.4%) than IS therapy (91.0%) visited a specialist. HCRU/cost per patient year was significantly higher in patients with than without active disease/steroid dependency. CONCLUSIONS: A substantial percentage of biologic-naïve IBD patients suffers from active disease/steroid dependency. The majority receives a monotherapy with systemic CS. Referral to gastroenterologists for treatment optimization is recommended, also because active disease/steroid dependency is associated with increased HCRU/cost.

Evolutionary bottlenecks in brackish water habitats drive the colonization of fresh water by stingrays.

Species richness in freshwater bony fishes depends on two main processes: the transition into and the diversification within freshwater habitats. In contrast to bony fishes, only few cartilaginous fishes, mostly stingrays (Myliobatoidei), were able to colonize fresh water. Respective transition processes have been mainly assessed from a physiological and morphological perspective, indicating that the freshwater lifestyle is strongly limited by the ability to perform osmoregulatory adaptations. However, the transition history and the effect of physiological constraints on the diversification in stingrays remain poorly understood. Herein, we estimated the geographic pathways of freshwater colonization and inferred the mode of habitat transitions. Further, we assessed habitat-related speciation rates in a time-calibrated phylogenetic framework to understand factors driving the transition of stingrays into and the diversification within fresh water. Using South American and Southeast Asian freshwater taxa as model organisms, we found one independent freshwater colonization event by stingrays in South America and at least three in Southeast Asia. We revealed that vicariant processes most likely caused freshwater transition during the time of major marine incursions. The habitat transition rates indicate that brackish water species switch preferably back into marine than forth into freshwater habitats. Moreover, our results showed significantly lower diversification rates in brackish water lineages, whereas freshwater and marine lineages exhibit similar rates. Thus, brackish water habitats may have functioned as evolutionary bottlenecks for the colonization of fresh water by stingrays, probably because of the higher variability of environmental conditions in brackish water.

Treatment of age-related neovascular macular degeneration: the patient's perspective.

OBJECTIVES: The aim of this study was to assess patients' views and expectations with regard to neovascular age-related macular degeneration (nAMD) and intravitreal anti-VEGF therapy (IVT). METHODS: We conducted a multicenter, non-interventional, prospective cohort study including nAMD patients treated with IVT in Germany. Patients with at least one IVT before study enrollment and aged ≥50 years were included. Three telephone interviews were conducted during a 12-month observational period. Here, patient's beliefs/expectations with regard to the nAMD disease and the IVT treatment were discussed. Only patients who completed all three phone interviews were included in the analyses. We used a two-step cluster analysis to identify patient clusters regarding specific patient attitudes towards nAMD and its treatment. RESULTS: Three hundred and thirty-two patients completed all interviews (mean age of 76.4 ± 7.2 years, 59.0% women). Out of these, 57.8% acknowledged that they needed general assistance in daily life, while 77.4% stated being able to attend general medical appointments on their own. However, 64.7% needed a driver or an accompanying person to attend their IVT appointments. In addition, 3.9% of the patients were afraid of IVT side effects. Also, 87.3% and 43.1% of the patients could name their disease or the anti-VEGF drug administered, respectively. More than three-quarters of the patients (83.1%) were aware of possible consequences of nAMD by stating vision loss or blindness, but only 16.6% knew that nAMD is a chronic disease. Generally, patients were optimistic: 70.2%, 5.1% and 13.0% of them expected stable visual acuity (VA), a significant improvement or expected worsening of VA in the next year, respectively. Almost two thirds of patients who provided their therapy expectations (47.0%) anticipated fewer injections/discontinuation of IVT. We identified five patient clusters differing significantly from each other with regard to four variables: being afraid of IVT, nAMD disease awareness, optimism with regard to effectiveness of IVT, and nAMD disease and treatment knowledge. CONCLUSIONS: Only a minority of patients is aware of the chronic nature of nAMD. To motivate patients to accept a life-long IVT treatment, physicians and caregivers must know that there exist different patient types with significant differences in communication needs.

Can risk area designation help increase vaccination coverage for Tick-Borne Encephalitis? Evidence from German claims data.

BACKGROUND AND OBJECTIVES: Although vaccine preventable, the incidence of tick-borne encephalitis (TBE) increased in Germany from 2001 to 2021 by on average 2% each year, with a peak of more than 700 TBE infections documented in 2020. TBE-risk areas, as designated by district based on incidence of human cases, expanded north- and northeastward, present in 11 of the 16 Federal States as of 2022. Using claims data from a German statutory health insurance in the Federal States of Saxony and Thuringia (AOK PLUS), we aimed to assess whether official assignment of a district to a risk area had an impact on vaccination rates in Germany. METHODS: The data covered the period from 01/01/2010 to 31/12/2018 and included information on vaccine administrations from outpatient physicians. Yearly incident vaccination rates were reported overall and by district. To investigate the association between a new designation of an incident TBE-risk area and vaccination rates, a difference-in-difference analysis was conducted. RESULTS: Overall, the incident vaccination rates increased from 6.2 to 9.5 per 1,000 person-years between 2012 and 2018, with a peak of 12.2 in 2015. While districts that had been risk-areas for the whole study period had always a higher vaccination rate compared to districts that were never categorized as risk areas, the increase between 2012 and 2018 was comparable in the two groups (3.0 and 3.2 per 1,000 person-years, respectively). In contrast, districts that were newly designated risk districts during the study period experienced a significantly larger increase in vaccination rates, going from 5.8 to 14.7 per 1,000 person-years between 2012 and 2018, with a peak of 19.6 in 2015. CONCLUSION: The results suggest that the new designation of a district as risk area has a significant positive impact on vaccination rates, which is strongest immediately after designation of risk area.

[Patient pathways in thrombosis prophylaxis after hip and knee replacement surgery : results of a survey]. / Patientenpfade in der Thromboseprophylaxe nach Hüft- und Kniegelenkersatz : Ergebnisse eines Surveys.

A key element of patient care after hip and knee replacement is medication-based thrombosis prophylaxis. Due to decreasing lengths of acute hospital stays the question arises to what extent outpatients are taking responsibility thrombosis prophylaxis (patient pathway analysis).To analyze patient pathways a telephone survey of 668 patients was conducted. On average patients were interviewed 38 days following surgery with a focus on low molecular weight heparins. The analysis showed that nearly 90% of patients need to carry out thrombosis prophylaxis in an outpatient or home environment for at least 1 day and for 47.2% of patients a linking period between acute and rehabilitation stay is relevant. The obviously existing quantitative importance of outpatient thrombosis prophylaxis is also reflected by its duration and 45.7% of interviewed patients needed at least 5 days of outpatient prophylaxis.Outpatient thrombosis prophylaxis clearly makes high demands on the patients, in particular when combined with the task of administering complex forms of injections. Those involved in inpatient and outpatient provision of care should not assume that all patients carry out the necessary prophylaxis at the required level of reliability. On the contrary initial evidence shows that the non-adherence of patients during ambulatory thrombosis prophylaxis presents a genuine challenge to care providers.

Pleistocene phylogeography and phylogenetic concordance in cold-adapted spring snails (Bythinella spp.).

Previous studies on Pleistocene phylogeography of European taxa are biased towards (i) vertebrates, (ii) terrestrial taxa, (iii) single species, and (iv) taxa that survived the Pleistocene in southern refugia. Relatively little is known about whether evolutionary patterns of vertebrate and terrestrial taxa are also applicable to freshwater invertebrates, whether cold-adapted freshwater species could survive in extensive permafrost areas without retreating into refugia, and whether Pleistocene phylogeographical patterns are influenced by phylogeny. Here, the widespread and species-rich European spring snail genus Bythinella Moquin-Tandon, 1856 is utilized in an attempt to mitigate this bias. These strongly cold-adapted freshwater animals mostly occur in springs--highly isolated habitats that are relatively unaffected by anthropogenic influences. Phylogenetic and phylogeographical analyses based on mitochondrial DNA and nuclear DNA sequence data were conducted in 458 specimens from 142 populations occurring throughout Europe. The study provides evidence that most Bythinella spp. survived the Pleistocene in restricted northern glacial refugia that largely correspond to refugia previously recognized for other European biota. However, survival of Bythinella spp. in extensive permafrost areas outside of refugia can likely be rejected. Low dispersal ability and the isolation and fragmentation of spring habitats, as well as the distribution of perennial springs within permafrost regions, may account for this result. Tests involving a total of 29 nominal species showed that phylogenetically closely related Bythinella species did not occupy similar refugia. This lack of phylogenetic concordance could possibly be explained by the stochasticity of survival and dispersal in spring snails.

The solute carrier family SLC10: more than a family of bile acid transporters regarding function and phylogenetic relationships.

The solute carrier family 10 (SLC10) comprises two sodium-dependent bile acid transporters, i.e. the Na(+)/taurocholate cotransporting polypeptide (NTCP; SLC10A1) and the apical sodium-dependent bile acid transporter (ASBT; SLC10A2). These carriers are essentially involved in the maintenance of the enterohepatic circulation of bile acids mediating the first step of active bile acid transport through the membrane barriers in the liver (NTCP) and intestine (ASBT). Recently, four new members of the SLC10 family were described and referred to as P3 (SLC10A3), P4 (SLC10A4), P5 (SLC10A5) and sodium-dependent organic anion transporter (SOAT; SLC10A6). Experimental data supporting carrier function of P3, P4, and P5 is currently not available. However, as demonstrated for SOAT, not all members of the SLC10 family are bile acid transporters. SOAT specifically transports steroid sulfates such as oestrone-3-sulfate and dehydroepiandrosterone sulfate in a sodium-dependent manner, and is considered to play an important role for the cellular delivery of these prohormones in testes, placenta, adrenal gland and probably other peripheral tissues. ASBT and SOAT are the most homologous members of the SLC10 family, with high sequence similarity ( approximately 70%) and almost identical gene structures. Phylogenetic analyses of the SLC10 family revealed that ASBT and SOAT genes emerged from a common ancestor gene. Structure-activity relationships of NTCP, ASBT and SOAT are discussed at the amino acid sequence level. Based on the high structural homology between ASBT and SOAT, pharmacological inhibitors of the ASBT, which are currently being tested in clinical trials for cholesterol-lowering therapy, should be evaluated for their cross-reactivity with SOAT.

Stochastic field theory for a dirac particle propagating in gauge field disorder

Recent theoretical and numerical developments show analogies between quantum chromodynamics (QCD) and disordered systems in condensed matter physics. We study the spectral fluctuations of a Dirac particle propagating in a finite four-dimensional box in the presence of gauge fields. We construct a model which combines Efetov's approach to disordered systems with the principles of chiral symmetry and QCD. To this end, the gauge fields are replaced with a stochastic white-noise potential, the gauge field disorder. Effective supersymmetric nonlinear sigma models are obtained. Spontaneous breaking of supersymmetry is found. We rigorously derive the equivalent of the Thouless energy within our generic model implying the universality of this scale in QCD. Connections to other low energy effective theories, in particular, the Nambu-Jona-Lasinio model and chiral perturbation theory, are found.

Erhaia (Gastropoda: Rissooidea): phylogenetic relationships and the question of Paragonimus coevolution in Asia.

The human lung fluke Paragonimus is transmitted by gastropod taxa of two superfamilies: Ceritheoidea and Rissooidea. The question whether or not Paragonimus shows the same specificity of host-parasite coevolved relationship as the human blood fluke Schistosoma was inspired by the finding of two sympatric snail species as hosts for Paragonimus skrjabini in Fujian Province, China: Gammatricula and Erhaia. The former species can clearly be classified as Pomatiopsidae: Triculinae. The latter has previously been classified as Pomatiopsidae: Pomatiopsinae. However, this classification based on anatomical characteristics is uncertain. In order to obtain a robust phylogenetic hypothesis for Erhaia, we have studied three gene fragments from this taxon as well as from twelve related taxa. The data show that the species involved represent four families: Pomatiopsidae, Hydrobiidae, Cochliopidae (here raised to family status), and Amnicolidae. Erhaia fits securely into the Amnicolidae. This indicates that P. skrjabini has not coevolved with snail lineages. However, P. skrjabini has so far only been reported from rissooidean snails, whereas members of the Paragonimus westermani complex have only been found in ceritheoidean snails. The implication is that there is a host specificity on the superfamily level. However, Asian freshwater species of the Ceritheoidea and Rissooidea usually are not sympatric and often prefer different habitats. It is therefore possible that ecological niche partitioning plays the primary role for Paragonimus evolution.

Pharmacokinetics and metabolism of the antitumor agent sulfamic acid 1,7-heptanediyl ester (sulfamic acid diester) in the mouse and beagle dog.

The pharmacokinetics and metabolism of sulfamic acid diester were studied in the beagle dog and mouse. Elimination of sulfamic acid diester from the plasma and whole blood following i.v. administration at a dose of 193 mg/m2 was best approximated by a three-compartment model in both species. The compound was relatively rapidly cleared from the plasma, with a plasma beta half-life of 2.3 h and 0.9 h and a gamma half-life of 16 h and 3 h in the dog and the mouse, respectively. Sulfamic acid diester was taken up by blood cells and only slowly eliminated with a whole blood gamma half-life of 42 h in the dog and 32 h in the mouse. When sulfamic acid diester was infused i.v. to mice at 15 mg/kg over 8 h, the clearance for the parent drug was 13.2 ml/min kg from the plasma and 3.3 ml/min kg from the whole blood. Urine collected from mouse and dog contained the parent drug and three metabolic/breakdown products, namely, sulfamic acid 1,7-heptanemonoyl ester, sulfamic acid 3-hydroxyl-1,7-heptanediyl ester, and an unidentified product. Excretion of unchanged drug and products in mouse urine over 8 h accounted for less than 16% of the dose of sulfamic acid diester. Sulfamic acid diester did not react with glutathione in buffer, whole blood, or 100,000 g rat liver cytosol.

Disposition and metabolism of the antitumor agent pyrazine-2-diazohydroxide in mouse and beagle dog.

The pharmacokinetics and metabolism of pyrazine-2-diazohydroxide have been studied in the beagle dog and mouse. When pyrazine-2-diazohydroxide was administered to beagle dogs at a dose of 18.6 mg/kg (428 mg/m2) by i.v. bolus, the plasma half-life (t1/2) was 7.3 min, the apparent volume of distribution (Vd) 577 ml/kg, and the total body clearance (Cl) 55 ml/min per kg. In mice given pyrazine-2-diazohydroxide by i.v. bolus at 100 mg/kg (428 mg/m2), the t1/2 was 5.8 min, the Vd 250 ml/kg, and the Cl 30 ml/min per kg. When [2-14C]pyrazine-2-diazohydroxide was infused i.v. to mice at 100 mg/kg over 8 h, the Cl for parent drug was 122 ml/min per kg. The major product formed from pyrazine-2-diazohydroxide was 2-hydroxypyrazine, which accounted for 80% of the total radioactivity in the plasma after a 6-h drug infusion. There were three other metabolites in plasma, two more polar than pyrazine-2-diazohydroxide, which accounted for 7% of the radioactivity, and one less polar, which accounted for 5% of the radioactivity. Following an i.v. bolus dose of [2-14C]pyrazine-2-diazohydroxide, 79% of the radioactivity was excreted in the urine in 24 h, 3% in the feces, and 0.4% in the expired air; 18% remained in the carcass. The liver and kidney showed the highest tissue levels of radioactivity. 2-Hydroxypyrazine accounted for 45% of the urinary radioactivity, pyrazine-2-diazohydroxide for 14%, and a glucuronide or sulfate conjugate of 2-hydroxypyrazine for 17%. Twenty-four percent of the radioactivity eluted near the void volume on high-performance liquid chromatography and was not identified.

Preclinical pharmacologic studies of the new antitumor agent carmethizole (NSC-602668) in the mouse and beagle dog.

The chemical breakdown of carmethizole [1-methyl-2-methylthio-4,5-bis-(hydroxymethyl)imidazole-4',5'- bis(N-methylcarbamate)hydrochloride] and its pharmacokinetics in the mouse and beagle dog were studied. Carmethizole was relatively unstable in aqueous media, having a half-life of less than or equal to 1 h in 0.9% sodium chloride, human whole blood, human plasma, and dog urine at 37 degrees C. Its major breakdown product in 0.9% sodium chloride and pH 5.0 sodium phosphate buffer was carmethizole diol. When carmethizole was added to pH 7.0 or pH 9.0 sodium phosphate buffer, the major breakdown product was carmethizole diol-4'-monophosphate. Carmethizole reacted directly with glutathione at pH 8.0, forming a glutathione adduct of carmethizole monocarbamate. Elimination of the drug from the plasma of the beagle dog following i.v. bolus doses of 22.4 and 4.3 mg/kg was biphasic. At these doses the terminal half-life was 39 and 46 min, respectively, and the respective total body clearance was 4.6 and 7.7 ml/min per kg. The 22.4 mg/kg dose was lethal to the beagle dog by day 4. Elimination of carmethizole from the plasma of mice following an i.v. bolus dose of 115 mg/kg was monoexponential, with a half-life of 11.6 min and a total body plasma clearance of 43.6 ml/min per kg. When the drug was infused at 230 mg/kg over 8 h into mice, the total body clearance was 40.8 ml/min per kg. Following the i.v. bolus administration of carmethizole to mice, 30% of the total dose was excreted in urine over 3 h as carmethizole diol, 10%, as carmethizole diol-sulfate, 3.4%, as carmethizole 4'-monocarbamate, and 2.4%, as unchanged drug.

The evaluation of five commercial serum cortisol kits regarding precision and accuracy.

We evaluated Amerlex (Amersham International), Corti-Shure (Nuclear Medical Laboratories), Gammacoat (Clinical Assays), Coat-A-Count and DPC-direct (Diagnostic Products Corporation) radioimmunoassay kits for determination of cortisol in sera. The between- and within-batch precision (coefficient of variation) ranged between 4.4-12.5% and 3.0-10.9% respectively. No one kit exhibited a clearly better precision throughout the assay range. All kits displayed good sensitivity and parallelism. Cortisol concentrations determined by kit methods, in two assayed control sera, were 3-14% higher than by gas chromatography/mass spectrometry. Coat-A-Count and Gammacoat were technically the simplest assays while Corti-Shure and DPC-direct kits had the best designed standard curves over the diagnostic range. The Amerlex kit had the greatest sensitivity, showed least shift in the dose-response curve between assay and was the only assay that came to equilibrium within the specified incubation time.

Oncomelania hupensis (Gastropoda: rissooidea) in eastern China: molecular phylogeny, population structure, and ecology.

The rissooidean snail genus Oncomelania is of medical interest as various taxa are hosts for the human blood fluke Schistosoma and the lung fluke Paragonimus; because of close co-evolved host-parasite-relationships, snail diversity may reflect parasite diversity. There is a considerable amount of confusion regarding the identity of smooth- and ribbed-shelled populations of Oncomelania hupensis in eastern China. We therefore studied the genetic variation, population structure, phylogenetic relationships and ecology of five smooth- and five ribbed-shelled populations in Hubei, Hunan, Anhui, Zhejiang, and Jiangsu provinces. Based on sequencing data of a fragment of the mitochondrial gene for cytochrome oxidase I from 80 individuals, we found little genetic variability within the ingroup-individuals studied here (average pi=0.01922). Moreover, within the ingroup, smooth-shelled individuals cluster together with ribbed-shelled individuals. We therefore consider all smooth- and ribbed-shelled populations of Oncomelania throughout the lower Yangtze River basin to belong to the subspecies O. hupensis hupensis. Our data indicate that ribbing in O. h. hupensis is associated with the annual floods of the Yangtze River. The greatest haplotype (d(H)) and nucleotide diversities (pi) are found in aggregates of ribbed-shelled snails along areas of the Yangtze River drainage subject to flooding. In areas not affected by flooding, the shells are smooth and genetic diversity decreases significantly.