Increased aortic repair in Germany correlates with reduction of death caused by aortic aneurysms but not aortic dissections.

INTRODUCTION: We asked if there is a significant correlation between the increasing trend in aortic repair (AR) and decreasing aortic aneurysm (AA) and aortic dissection (AD) mortality? Therefore, we retrospectively analyzed all aortic repairs in patients with AA and AD and its correlation with disease-specific death rates and hospitalizations for ruptured AA and AD in Germany. METHODS: We retrieved the number of cases hospitalized for AA and AD as well as the procedures in these cases from the Federal Bureau of Statistics (DRG statistics) and death rates from the national mortality statistic published by the Federal Statistical Office in Germany for the years 2006-2017. RESULTS: From 2006 to 2017, the total number of hospitalized cases admitted with principal diagnosis of AA increased by 25.8% and that of AD by 56.7%. That of cases with the principal diagnosis of ruptured AA (rAA) remained unchanged (-2.5%) and that with rAD increased by 54.6%. The number of (open and endovascular) procedures in cases hospitalized for AA increased by 39.4% and for AD by 126.4%. The age-adjusted death rates in Germany for AA decreased from 4.0 to 2.9 per 100,000 inhabitants and that for AD increased from 1.0 to 1.4. The decrease in death attributed to AA cases can be described by linear regression as y = -0.0003*y + 6.7076 (p < 0.0001). Accepting this association between increased elective procedures and reduced AA mortality, each/all 1000 procedures save 0.3 lives per 100,000 inhabitants. CONCLUSION: Despite increasing numbers of AR for AA and AD, only the mortality rate for all AAs decreased, while we did not observe a decrease in overall mortality of AD in Germany.

Can SARS-CoV-2 trigger new onset of autoimmune disease in adults? A case-based review.

Introduction: Although it has been proposed that SARS-CoV-2 can cause autoimmunity by inducing a transient immunodeficiency of both innate and acquired immunity components in which the immune system fails to identify autoantigens adequately, the exact mechanism that causes this disease remains unknown. We aim to systematically review of existing case reports for evidence of new autoimmune diseases in adults caused by SARS-CoV-2 infection. Methods: PRISMA-P 2020 method was used to search for literature in "PubMed" databases using the string "COVID-19 AND autoimmune disease AND complication". We used JBI Critical Appraisal Checklist to assess the articles' quality. Results: The literature search yielded 666 articles. 58 articles met our eligibility criteria. Based on our critical appraisal, we placed 35 articles in the good category and 23 articles in the medium category. Data was synthesized by grouping similar data into a table, including: gender, age, COVID-19 severity, types of autoimmune diseases, autoimmune profile and relevant findings, when autoimmune diseases are diagnosed, complications, and outcome to draw conclusions. The new onset of autoimmune disease in adult triggered by SARS-CoV-2 included Guillain-Barré syndrome and Miller Fisher syndrome, systemic lupus erythematosus, immune thrombocytopenia, autoimmune haemolytic anemia, latent autoimmune diabetes in adults, myositis, acute demyelinating encephalomyelitis, autoimmune encephalitis, central nervous system vasculitis, and autoimmune thyroid diseases. Conclusion: SARS-CoV-2 can trigger new onset of a variety of autoimmune diseases. Doctors who take care patients infected by COVID-19 must be aware of the complications of autoimmune diseases. Future cohort or cross-sectional studies on SARS-CoV-2-related autoimmune disease should be conducted.

Diagnostic accuracy of antibody-based rapid diagnostic tests in detecting coronavirus disease 2019: systematic review.

Introduction: The rapid transmission of coronavirus disease 2019 (COVID-19) requires a fast, accurate, and affordable detection method. Despite doubts of their diagnostic accuracy, rapid diagnostic tests (RDTs) are used worldwide due to their practicality. This systematic review aims to determine the diagnostic accuracy of antibody-based RDTs in detecting COVID-19. Material and methods: A literature search was carried out on five journal databases using the PRISMA-P 2015 method. We included all studies published up to February 2021. The risk of bias was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Diagnostic Test Accuracy Studies. Data regarding peer-review status, study design, test kit information, immunoglobulin class, target antigen, and the number of samples were extracted and tabulated. We estimated the pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with a 95% confidence interval. Results: Thirty-three studies met the eligibility criteria. The pooled data results showed that the combined detection method of IgM or IgG had the highest sensitivity and NPV, which were 73.41% (95% CI: 72.22-74.57) and 75.34% (95% CI: 74.51-76.16), respectively. The single IgG detection method had the highest specificity and PPV of 96.68% (95% CI: 96.25-97.07) and 95.97% (95% CI: 95.47-96.42%), respectively. Conclusions: Antibody-based RDTs are not satisfactory as primary diagnostic tests but have utility as a screening tool.

Increasing Use of Anticoagulants in Germany and Its Impact on Hospitalization for Tooth Extraction.

OBJECTIVES: This article aimed to compare nationwide time trends of oral anticoagulant prescriptions with the time trend of hospitalization for tooth extraction (TE) in Germany from 2006 through 2017. PATIENTS AND METHODS: We derived the annual number of hospital admissions for TE from the Nationwide Hospital Referral File of the Federal Bureau of Statistics and defined daily doses (DDD) of prescribed anticoagulants in outpatients from reports of the drug information system of the statutory health insurance. RESULTS: From 2005 to 2017, annual oral anticoagulation (OAC) treatment rates increased by 143.7%. In 2017, direct oral anticoagulants (DOACs) represented 57.1% of all OAC treatments. The number of cases hospitalized for TE increased by 28.0 only. From all the cases hospitalized for TE in Germany in 2006, 14.2% had a documented history of long-term use of OACs. This proportion increased to 19.6% in 2017. Age-standardized hospitalization rates for all TE cases with long-term use of OACs increased from 6.6 in 2006 to 10.5 cases per 100,000 person-years in 2014 and remained almost unchanged thereafter. CONCLUSION: Our comparison showed that the large increase in OAC treatment rates in general from 2006 to 2017 had only a small impact on hospitalized TE cases with long-term use of OAC which flattens since 2014.

Increasing use of anticoagulants in Germany and its impact on hospitalization rates for genitourinary bleeding.

The aim of the study was to compare nationwide time trends of prescribed oral anticoagulants (OAC) with the time trend of genitourinary bleedings (GUB) in Germany from 2005 through 2016. The annual numbers of hospitalized patients with GUB coded as "hematuria", "excessive, frequent and irregular menstruation", "postmenopausal bleeding" or "abnormal uterine and vaginal bleeding" were extracted from the nationwide hospitalization file by the Federal Bureau of Statistics. Hospitalization rates were age-standardized using the German standard population 2011. Defined daily doses (DDD) of prescribed anticoagulants among outpatients for the same calendar period were extracted from reports of the statutory health insurance drug information system. Based on DDD, drug treatment rates per 100,000 person years (py) were calculated. From 2005 to 2016, annual OAC treatment rates per 100,000 py increased by 135.8% (from 901.4 to 2125.9). Until 2011 direct oral anticoagulants (DOAC) represented less than 0.1% of all OAC, but 49.9% in 2016. In the same period age-standardized rates of hospitalizations for hematuria increased continuously (annual change of 1.03 (95% CI 0.94-1.11) per 100,000 py), that of "postmenopausal" (- 1.93; 95% CI - 2.38 to - 1.49) or "excessive, frequent and irregular menstruation" decreased (- 1.25; 95% CI -1.62 to - 0.87) and that of "abnormal uterine and vaginal haemorrhage" remained almost unchanged. From all cases with hematuria 5.3% received at least 1 red blood cell concentrate (RBC) in 2005 and 8.2% in 2016 whereas all cases with the other three types of bleeding counted for 1.9% in 2005 and 3.8% in 2016. The time trends for GUB in all subgroups changed steadily and showed no effect of the disproportional increase of DAOCs until 2011. Our ecologic nationwide comparison of OAC treatment rates in outpatients and hospitalization rates for GUBs revealed that despite increasing OAC treatment rates from 2011 to 2016 the hospitalization rates for GUB showed steady annual changes unaffected by the increasing prescription rates of DOACs since 2011.

Correlation between obesity and manual lymphatic drainage in Germany - a retrospective analysis from 2008 to 2016.

Backgrounds: Costs for manual lymphatic drainage (MLD) paid by the Statutory Health Insurances (SHI) have increased disproportionately in Germany in the last decade. There is no obvious reason that this increase is due to an increasing number of patients with lymph edema. We therefore assume that there are large numbers of patients with obesity and obesity-associated dependency syndrome who drive the cost of MLD and did a retrospective analysis of the correlation between hospitalization rates for lymph edema and obesity and MLD prescription rates in outpatients. PATIENTS AND METHODS: Roughly 90 % of the German population is insured by the Statutory Health Insurance. From its reports we extracted data regarding costs and numbers of MLD session prescribed annually. Hospitalization rates for lymph edema (codes I89.*, I97.2 and Q82.0) and for obesity (ICD E66.*) were provided by the Federal Statistical Office after a specific remote analyses. RESULTS: In the years 2008 to 2016, the MLD prescriptions in the individual federal states increased by + 43.5 % in Berlin to + 109.3 % in Mecklenburg-Western Pomerania. Number of hospitalizations with the principal diagnosis (condition, which caused the admission) hereditary and postmastectomy lymph edema are low and decreased in most federal states. Number of hospitalizations with the additional diagnosis (conditions that coexist at the time of admission or develop subsequently) obesity increased with a range from + 4.8 % in Baden-Württemberg to + 86.4 % in Mecklenburg-Western Pomerania. The correlation between the increase in prescribed MLD in the individual federal state and the increase in hospitalization rates per 1000 inhabitants of cases with obesity is greater (R2 0.4696) than with lymph edema (R2 0.0987). CONCLUSIONS: Our analysis is in line with the hypothesis that there is a correlation between the increasing prescription rate of MLD and the increasing burden of obesity in Germany.

Increasing use of anticoagulants in Germany and its impact on hospitalization for gastrointestinal bleeding.

OBJECTIVES: The aim of the study was to compare nationwide time trends of oral anticoagulant prescriptions with the time trend of gastrointestinal bleeding (GIB) in Germany from 2005 through 2016. PATIENTS AND METHODS: The annual number of hospital admissions for GIB associated with gastric ulcers, duodenal ulcers, hematemesis, melena, hematochezia, and unspecified gastrointestinal bleeding (USGIH) was taken from the nationwide hospital referral file by the Federal Bureau of Statistics. The hospitalization rates were age-standardized using the German Standard Population 2011. The defined daily doses (DDD) of prescribed anticoagulants in outpatients for the same calendar period were taken from reports of the drug information system of the statutory health insurance. Based on DDD, drug treatment rates were calculated per 100,000 people. RESULTS: From 2005 to 2016, the annual anticoagulant prescription rates per 100,000 persons increased by 135.8% (from 901.4 to 2125.9). By 2011, direct oral anticoagulants (DOAC) accounted for <0.1% of all anticoagulants, but 49.9% in 2016. Over the same period, age-standardized hospital admissions for GIBs per 100,000 person-years decreased by 14% (from 128.89 to 110.87). Hospitalization rates for gastric ulcer and duodenal ulcer decreased steadily, and those for hematoma, melena and hematochezia continued to increase. Only the USGIH decreased from 2005 to 2011 (annual change of -3.35 (95% CI -5.44; -1.25) per 100,000 person-years) and subsequently increased (0.61, 95% CI -0,42; 1.65). Of all GIB cases, 5.8% received at least 6 red blood cell concentrates in 2005 and 4.6% in 2016. The two-phase time trend for USGIH was no longer present in this subgroup. CONCLUSION: Our nationwide comparison of outpatient OAC treatment rates and hospitalization rates for GIBs showed that GIB hospitalization rates declined despite increasing OAC treatment rates from 2005 to 2016. With increasing impact of DOACs after 2011, this decline was not affected.

Thromboembolic disease in females and males aged 10 to 39 years in Germany.

BACKGROUND: We analysed differences in hospitalization rates for venous diseases such as pulmonary embolism (PE), deep vein thrombosis (DVT), sinus vein thrombosis (SVT), portal vein thrombosis (PVT), and Budd-Chiari syndrome (BCS) as well as for arterial diseases such as myocardial infarction (MI) and embolic stroke (ES) in females and males aged 10 to 39 years. PATIENTS AND METHODS: Detailed lists of hospitalizations with the principal and additional diagnoses for PE (ICD-code I26.0 + I26.9), DVT (I80.0-I80.9), SVT (I67.6), PVT (I81), BCS (I82.0), MI (I21.0-I21.9), and ES (I63.1 + I63.4) in males and females aged 10 to 39 years in the years 2006 to 2015 were provided by the Federal Statistical Office in Germany. RESULTS: Considering the 10-year period there were more female than male cases hospitalized with the principal diagnoses for PE, DVT, SVT, and BCS. Looking at the principal diagnosis of the year 2015, one can see a steep increase in numbers of hospitalization for PE, DVT, and SVT in females ranging from the ages 12 to 13 and 14 to 15 years compared to males. The curves of PE and DVT meet again in the age group between 32 and 33 years, but not for SVT. The greatest differences are seen at the end of the second and at the beginning of the third decade of life. In contrast, MI was more frequent in young males beginning at the age of 18 to 19 years. The number of female and male cases with ES and PVT were almost similar in the different age groups. CONCLUSIONS: The presented data show higher hospitalization rates for females in the age group 10 to 39 years for different venous thrombosis but not for MI and ES.

Mortality in endovascular and open abdominal aneurysm repair - trends in Germany.

BACKGROUND: We analysed trends in mortality of endovascular (EVAR) and open aortic repair (OAR) in patients hospitalized for abdominal aortic aneurysms (AAA) in Germany from 2005 to 2015. PATIENTS AND METHODS: We used national statistics published by the Federal Statistical Office in Germany to calculate mortality rate of patients hospitalized with ruptured (rAAA, n = 2,448 in 2005, n = 2,180 in 2015) and non-ruptured (iAAA, n = 11,626 in 2005, n = 14,205 in 2015) AAA. RESULTS: Considering only those who were treated with EVAR or OAR, treatment rates of iAAA with EVAR increased to 78.2 % in males and 72.6 % in females in 2015 and treatment rates of rAAA to 36.9 % and 40.7 %, respectively. In cases with iAAA, death rates associated with EVAR decreased in males from 2.1 to 1.1 % (p = 0.0005) in the period from 2005 to 2015 but not in females (1.8 % in 2005 and 2.3 % in 2015, p = 0.8511). Similar trends are seen in cases with rAAA (males 30.1 % and 24 %, p = 0.1034, females 36.4 to 37.3 %, p = 0.8511). Death rates associated with OAR increased in males from 4.7 % in 2005 to 5.7 % in 2015 (p = 0.0103) and tended to increase in females from 6.8 to 8.2 % (p = 0.1476). In cases of rAAA, there were no changes. EVAR treatment rates increased in cases with iAAA in both genders with age, as well as in males with rAAA, but not in females. OAR associated death rates increased with age in rAAA (from around 30 % in the sixth/seventh decade of life to almost 80 % in cases with patients over the age of 90) and in iAAA (from 1.1 to 20 %). CONCLUSIONS: The general increase in EVAR procedures in males and females hospitalized for rAAA and iAAA went along with a decrease in in-hospital mortality in males treated with EVAR for iAAA only and an increasing mortality in males treated with OAR for iAAA.

Lower Limb Amputation in Germany.

BACKGROUND: Declining amputation rates have been reported in multiple countries in recent years. It is not yet known whether amputation rates have declined in Germany as well. METHODS: On the basis of DRG (diagnosis-related group) data, we received a list from the German Federal Statistical Office of all major and minor amputations documented in German hospitals from 2005 to 2014. Changes over this period were studied with linear regression. RESULTS: The absolute number of amputations per year in Germany rose slightly from 55 689 in 2005 to 57 637 (+3.5%) in 2014. After the exclusion of cases in which the main diagnosis was trauma, intoxication, musculoskeletal disease, diseases of the skin and subcutaneous tissue, or neoplasia, the corresponding numbers were 48 043 in 2005 and 48 561 in 2014 (+1.1%). The age-adjusted rate of major amputations per 100 000 persons per year fell from 23.3 to 16.1 (-30.9%), while the rate of minor amputations rose from 35.0 to 43.9 (+25.4%). The percentage of major amputations that took place in patients with diabetes mellitus as the main diagnosis or a side diagnosis declined from 70.2% to 63.7%. For all of these changes, p <0.0001. CONCLUSION: From 2005 to 2014, the major amputation rate fell by 30.9% while the minor amputation rate rose by 25.4%. The goal of lowering amputation rates still further will be best served not only by applying the recognized preventive measures in patients with foot lesions, but also by further research into the causes of the recent changes in amputation numbers. Prospective registries will be needed.

Decrease in major amputations in Germany.

A decrease in rate of amputation has been reported from many countries. This study aims to study the trends in amputation rates in Germany. On the basis of DRG-system, detailed lists of all amputations coded as minor amputations (OPS 5-864) and major amputations (OPS 5-865) performed between 2005 and 2010 were provided by the Federal Statistical Office. There was a significant decrease in age-adjusted major amputation rates per 100 000 population in Germany from 27·0 in 2005 to 22·9 in 2010 (15·2%, P ≪ 0·001) in males and from 19·7 in 2005 to 14·4 in 2010 (26·9%, P ≪ 0·001) in females. Overall, minor amputation rates did not show such a decrease but increased in males (from 47·4 in 2005 to 57·8 in 2010, 21·9%, P ≪ 0·001) and remained almost unchanged in females (23·1 in 2005 and 23·9 in 2010, not significant). Reduction in major amputation rates were even more pronounced in people above 80 years, especially in males from 216 to 150 (30·5%) and in females from 168 to 117 (30·4%). The present data demonstrate an increasing overall burden of foot lesions as indicated by an increase in incidence of minor amputations but an ongoing success in the fight against amputation, resulting in a significant decrease in major amputation rates in Germany, in the 6-year period from 2005 to 2010.

Cranial and non-cranial embolism: incidence in hospitalised patients in Germany.

Using the information of the federal statistics, a detailed description of the hospitalisation rate for cranial and non-cranial embolic events in Germany is given for the years 2005-2010. Detailed lists of the ICD codes I63.0 (stroke) and I74 (arterial embolism and thrombosis) as principal diagnosis and of I48.0 (atrial fibrillation) as additional diagnosis for the years 2005-2010 were provided by the Federal Statistical Office. In the 6 years period total number of cases hospitalised for stroke increased by 24% (from 185.026 to 229.798) and those hospitalised for embolic events by 60% (from 64,106 to 92,428). The number of atrial fibrillation as a major cause of arterial embolism documented as additional diagnosis increased by 38% (from 1.06 to 1.48 Mio). Considering the rate per 100,000 inhabitants, intra-cranial embolism showed the most relevant increase with about 56% since 2005. Cranial embolism is around 2.5 to 4 times more frequent than non-cranial embolism in females aged 70 to 80 years, but only two times in females aged 40-50, 50-60 and 90 years and older. Males showed a similar distribution with a broader peak. From 2005 to 2010 the total number of embolic events increased, with a higher increase in cranial embolism compared to non-cranial embolism.

CHADS2 and CHA2DS2Vasc-Score in Peripheral Systemic Embolism.

Objectives: We analysed the characteristics of patients with an acute peripheral embolic event considering the possible use of the CHADS2-Score and the CHA2DS2Vasc-Score Patients and Methods: We retrospectively analyzed 163 cases of acute peripheral arterial embolism treated in the Department of Vascular Medicine of the HELIOS Klinik Krefeld, Germany, from 2008 to 2011. We retrospectively screened the medical form for information regarding atrail fibrillation (AF) and the risk factors necessary to calculate the CHADS2 and CHA2DS2vasc score. Results: Arterial hypertension and age > 75 years were the most frequent risk factors. Mean CHADS2 score was similar in males and females (2.3 ± 1.5 and 2.3 ± 1.4). 66% of the males and 63.3% of the females scored 2 and more points. Mean CHA2DS2Vasc score was 3.6 ± 2.0 in males and 4.6 ± 1.9 in females. 85.2% of the males and 95.4% of the females scored more than 2 points. In the medical forms AF was documented in 79 (48%) patients, of which 23 (43 %) were males and 56 (51%) females. Mean CHADS2 score and mean CHA2DS2Vasc score were slightly higher in those with AF compared to the total group, but not significantly different. The rate of patients with 2 and more points increased for both scores: CHADS2 score: males 82.6% and females 76.8%, CHA2DS2Vasc: males 100% and females 98.2%. Almost half of the patients with AF had had anticoagulation with phenprocoumon before (males 12 (52%), females 24 (43%), but only every 10th was within the therapeutic range (INR ≥2) Conclusion: The number of those with AF is high amongst patients with acute peripheral embolism. According to the CHADS2 and CHA2DS2Vasc score, most of these patients had an indication for oral anticoagulation independent form the embolic event.

Dementia and amputation.

OBJECTIVES: To our experience dementia seems to play an increasing role for major amputation in patients suffering from peripheral arterial disease (PAD). To confirm our impression, we analysed the rate of dementia associated with different surgical procedures using the information of the federal statistics in Germany. PATIENTS AND METHODS: Detailed lists of cases hospitalized with the principal diagnosis (PAD), abdominal aortic aneurysm (AAA), myocardial infarction (MI) and hip fracture (HF), and of the procedures minor or major amputation, endovascular aortic repair (EVAR), total endoprosthesis for hip replacement (THR) and coronary aortic bypass graft (CABG) in Germany in the years 2008 to 2010 were provided by the Federal Statistical Office. RESULTS: Dementia is documented as additional diagnosis in approximately one fourth of cases having the principal diagnosis HF, 5% to 6% of cases with the principal diagnosis MI and PAD, but only in approximately 2% of AAA cases. Dementia is documented as principal or additional diagnosis in one fourth of amputation procedures (major amputation approximately 18% and minor amputation approximately 8%), in approximately 5% THR, 2% of EVAR and only 0.3% of CABG. The rate of documentation of dementia is higher in patients treated by major amputation than in the hospitalized PAD population. Vice versa, the rate of documentation of dementia is lower in patients getting THR than in the hospitalized HF population. CONCLUSION: The presented analysis supports the assumption that dementia plays a relevant role in older patients suffering from PAD receiving major amputation in Germany.

Pulmonary embolism in young males and females in Germany: data from the Federal Statistical Office.

With the introduction of diagnosis-related groups (DRG) for reimbursement in 2003, detailed description of the prevalence of pulmonary embolism in hospitalized patients in Germany was possible for the first time. Thus, we analysed the incidence of pulmonary embolism in hospitalized young people and looked for a sex-specific difference in comorbidity. Detailed lists of all pulmonary embolism coded as I26 in hospitalized patients aged 10-40 years in 2005, 2006 and 2007 were provided by the Federal Statistical Office. Beginning at the age of 12-13 years females have higher numbers of pulmonary embolism and DVT documented as principal diagnosis compared with men. This sex-specific difference disappears at the ages of 32-33 years. The total numbers of pulmonary embolism distinguishing males and females within this 20 years life period is low and varied from 318-463 in the 3 years. The sex-specific difference is highest in the group of 16 to 17-year-old people (ratio of females to males varies from 3 to 5 in 2005-2007). Specific patterns of comorbidities associated with the higher numbers of pulmonary embolism in younger females could not be detected. Pregnancies account for a maximum of 73 in 2007, which reached only less than one-fifth of the absolute difference in pulmonary embolism between males and females in the single years. The presented data derived from the most reliable data basis for the estimation of pulmonary embolism in Germany show that compared with males there is a sharp increase in hospitalization for pulmonary embolism in females beginning at the age of 12-13 years. Males catch up by the ages of 32-33 year.

Amputations in PAD patients: data from the German Federal Statistical Office.

Much effort has been spent to reduce the number of amputees within the last two decades, but it remains unclear how effective the different strategies have been. We analyzed the prevalence of amputations in inpatient cases in the federal statistics. Detailed lists of all amputations coded as major amputations (OPS 5-864) and minor amputations (OPS 5-865) performed in 2005 and 2006, divided into the 4th and 5th number of the OPS-code, were provided by the Federal Statistical Office. In 2006, a total of 62,880 amputations affecting the lower extremities (2005: 63,005) were performed in Germany. Because of multiple amputations within a single case the corresponding cases amounted to 55,705 in 2006 and 55,689 in 2005. Based on these data age-adjusted incidence rates of major amputations per 100,000 inhabitants increased from 2 at the age of < 50 years to 201 at the age of > 80 years. For minor amputations the prevalence rates increased from 4 at the age of < 50 years to 209 at the age of > 80 years. It can be assumed that peripheral arterial disease or neurovascular disease as the underlying disease necessitating the amputation were present in 74.9% of all inpatient cases who finally underwent amputation. There were 12.9% with non-vascular or non-diabetic reasons for amputations. In patients presenting with gangrene, the rate of minor amputations decreased with age, whereas the rate of major amputations increased, especially within the 8th to 10th decades of life. In conclusion, amputations affecting the lower limbs are still a relevant problem in Germany. At the time of an aging German population it has to be an important goal to lower or at least to stabilize the rate of amputations. The DRG statistics enable the Federal Ministry of Health and health politics to monitor amputation rates easily.

Biomechanical incompatibility of popliteal stent placement.

Peripheral stents or endografts in specific arterial segments are exposed to extreme mechanical stress. Despite high rates of primary technical success, mechanical bending due to knee joint flexion can limit long-term patency of stents or endografts in the popliteal artery or the femoropopliteal segment. Every stent or endograft responds differently to bending during knee joint flexion, which can be revealed only by functional investigation. Mechanical bending has to be considered in future studies to assess the influence of differences in stent design, material, or postinterventional drug treatment on the long-term patency of endoprostheses in the femoropopliteal segment. To demonstrate the concept of biomechanical incompatibility, we present several illustrations of different stent designs placed in the popliteal artery.

Toe pressure measurements compared to ankle artery pressure measurements.

The Trans-Atlantic Inter-Society Consensus (TASC)-recommended absolute toe pressure is < 30-50 mm Hg for definition of chronic critical limb ischemia (CLI). Toe pressures can be measured by different techniques. The authors analyzed the clinical use of the Doppler technique and an automatic device with optical sensors and estimated their value in documentation of chronic critical limb ischemia compared to ankle artery pressures. Three different investigations were performed: (1) In 16 healthy subjects the digital artery pressures were measured by using 3 different optical sensors (transmission, reflection, and microcirculation sensor) and compared to the systolic brachial pressure. (2) In 50 patients with and without peripheral arterial occlusive disease the toe pressures at digits 1 and 2 of both feet were determined by Doppler technique (8 MHz) and by optical sensors (cuff width constant 1.5 cm) and were compared to the ankle artery pressure determined by Doppler technique. (3) In 175 patients the toe pressures were measured at 1 toe and the ankle artery pressures were determined. In this group they estimated the clinical use of the toe pressure in regard to the definition of CLI (toe pressure < 50 mm Hg) compared to the ankle pressure < 70 mm Hg. The digital artery pressures measured with the different optical sensors, and the systolic brachial pressures were not significantly different and the correlation coefficients were around 0.7. In 21 of 50 patients the toe pressure at D1 and D2 could not be measured by Doppler technique because with the applied cuff no Doppler signal could be detected at the tip of the toe, but in 24 of these 29 patients the optical measurement was possible. Mean toe pressures at D1 were 108 +/- 45 mm Hg and D2 102 +/- 45 mm Hg, which were statistically not different. The correlation coefficient for the highest ankle artery pressure and the highest toe pressure determined by the Doppler technique was 0.389; for the highest ankle artery pressure and the toe pressure measured by the optical sensors it was 0.369, and for the toe pressures measured by Doppler technique and the optical sensors it was 0.506. Defining systolic ankle artery pressure < or = 50 to 70 mm Hg as the golden standard for CLI, the sensitivity of optical toe pressure measurement for the detection of CLI was 8%, the specificity was 96%, the positive predictive value 12%, and the negative predictive value was 94%. Independent of technique the absolute systolic toe pressures did not correlate with the absolute systolic ankle pressures. The optical measurement was more suitable for toe pressure measurement because it could be used in 90% of all patients. All in all, toe pressure measurements are more useful to exclude CLI than to prove it.