Sex differences in stroke reperfusion therapy in Aotearoa (New Zealand).

BACKGROUND AND AIMS: Stroke is a leading cause of death in Aotearoa (New Zealand), and stroke reperfusion therapy is a key intervention. Sex differences in stroke care have previously been asserted internationally. This study assessed potential differences in stroke reperfusion rates and quality metrics by sex in Aotearoa (New Zealand). METHODS: This study used data from three overlapping sources. The National Stroke Reperfusion Register provided 4-year reperfusion data from 2018 to 2021 on all patients treated with reperfusion therapy (intravenous thrombolysis and thrombectomy), including time delays, treatment rates, mortality and complications. Linkage to Ministry of Health administrative and REGIONS Care study data provided an opportunity to control for confounders and explore potential mechanisms. T-test and Wilcoxon rank-sum analyses were used for continuous variables, while the chi-squared test and logistic regression were used for comparing dichotomous variables. RESULTS: Fewer women presented with ischaemic stroke (12 186 vs 13 120) and were 4.2 years older than men (median (interquartile range (IQR)) 79 (68-86) vs 73 (63-82) years). Women were overall less likely to receive reperfusion therapy (13.9% (1704) vs 15.8% (2084), P < 0.001) with an adjusted odds ratio of 0.83 (0.77-0.90), P < 0.001. The adjusted odds ratio for thrombolysis was lower for women (0.82 (0.76-0.89), P < 0.001), but lower rates of thrombectomy fell just short of statistical significance ((0.89 (0.79-1.00), P = 0.05). There were no significant differences in complications, delays or documented reasons for non-thrombolysis. CONCLUSIONS: Women were less likely to receive thrombolysis, even after adjusting for age and stroke severity. We found no definitive explanation for this disparity.

Effects of the COVID-19 pandemic on reperfusion therapy for acute ischemic stroke patients in Huizhou City, China.

BACKGROUND AND PURPOSE: The COVID-19 pandemic has impacted the reperfusion therapy for acute ischemic stroke (AIS) patients. Huizhou City utilized its experience with the SARS and MERS breakouts to establish a reperfusion treatment program for AIS patients. METHOD: This is a retrospective study on 8 certified stroke hospitals in Huizhou City from January 2020 to May 2020. We analyzed the number of AIS patients with reperfusion therapy, stroke type (anterior/posterior circulation stroke), modes of transport to hospital, NIHSS score, onset to door time (ODT), door to needle time (DNT), and door to puncture time (DPT). The analysis was compared with baseline data from the same time period in 2019. RESULT: In 2020, the number of AIS patients receiving reperfusion therapy decreased (315 vs. 377), NIHSS score increased [8 (4, 15) vs. 7 [ (1, 2)], P = 0.024], ODT increased [126 (67.5, 210.0) vs. 120.0 (64.0, 179.0), P = 0.032], and DNT decreased [40 (32.5, 55) vs. 48 (36, 59), P = 0.003]. DPT did not change. Seventy percent of AIS patients indicated self-visit as their main mode of transport to the hospital. In both periods, mild stroke patients were more likely to self-visit than utilize emergency systems [2019: 152 (57.6%) vs. 20 (45.6%), P = 0.034; 2020: 123 (56.9%) vs. 5 (14.7%), P < 0.001]. The NIHSS score for self-visiting patients was lower for patients who utilized the ambulance system in both years [self-visit: 6.00 (3.00, 12.00), ambulance: 14.00 (9.00, 19.00), P < 0.001]. The volume of reperfusion patients was lower in 2020; however, the decrease was only significant (P = 0.028) in February 2020. CONCLUSION: During the COVID-19 pandemic in 2020, the number of AIS patients receiving reperfusion therapy significantly decreased when compared to the same period in 2019. The patients' condition increased severity, ODT increased, and the DNT decreased. DPT was not significant for self-visiting and ambulance patients. Moderate to severe stroke patients were more likely to utilize ambulance services.

Impact of COVID-19 pandemic on acute stroke care: facing an epidemiological paradox with a paradigm shift.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) outbreak, a decrease of stroke's hospital admissions and reperfusion therapy has been reported worldwide. This retrospective observational study assessed the volume of stroke cases managed in the Emergency Department (ED) and reperfusion therapies in an Italian stroke network with a high incidence of COVID-19, particularly to evaluate if the in-hospital rerouting and the switch from a drip-and-ship to a mothership model could assure an adequate volume of acute treatments. METHODS: We compared data from March 2020 with those from previous years and formulated five PICO questions regarding (1) incidence of stroke cases in the ED; (2) relation between stroke cases and COVID-19; (3) differences in the number of reperfusion therapies, (4) in the call-to-needle and door-to-needle times for intravenous thrombolysis, and (5) in the call-to-groin and door-to-groin times for thrombectomy. RESULTS: We found (1) a 28% decreased of confirmed stroke cases managed in the ED, (2) a negative correlation between stroke cases in ED and COVID-19 progression (rs = - .390, p = .030), and (3) a similar number of treatments in March 2020 and March 2019. The adoption of the mothership model (4) did not delay alteplase infusion (median call-to-needle p = .126, median door-to-needle p = .142) but led to (5) a significant reduction in median call-to-groin (p = .018) and door-to-groin times (p = .010). CONCLUSION: The "hospital avoidance" of stroke patients during the "stay-at-home" appeals needs to be considered for future public health campaigns. A prompt reorganization of the stroke network can guarantee optimal performances at times of crisis.

Characterisation of an ischemia reperfusion model for the formation of a stage I pressure ulcer in mouse skin.

Pairs of magnets were applied to the loose skin on the backs of mice in order to cause ischemia for periods of 1.5, 2, 2.5 and 3 h followed by reperfusion. We found 1.5 h of ischemia resulted in the most reliable outcome of blanched skin but no redness or skin breakdown. Histological analysis at 4 h of reperfusion showed, in the centre of the insult, condensed nuclei in the epidermis and sebaceous glands with a build up of neutrophils in the blood vessels, and a reduction in the number of fibroblasts. At 24 h, spongiosis was seen in the epidermis and pockets of neutrophils began to accumulate under it, as well as being scatted through the dermis. In the centre of the insult there was a loss of sebaceous gland nuclei and fibroblasts. Four days after the insult, spongiosis was reduced in the epidermis at the edge of the insult but enhanced in the centre and in hair follicles. Leukocytes were seen throughout the central dermis. At 8 days, spongiosis and epidermal thickness had reduced and fibroblasts were reappearing. However, blood vessels still had leukocytes lining the lumen. The gap junction protein connexin 43 was significantly elevated in the epidermis at 4 h and 24 h reperfusion. Ischemia of 1.5 h generates a sterile inflammatory reaction causing the loss of some cell types but leaving the epidermis intact reminiscent of a stage I pressure ulcer.

Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States.

BACKGROUND AND PURPOSE: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. METHODS: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. RESULTS: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], P<0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], P<0.001). CONCLUSIONS: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

Acute Stroke in Times of the COVID-19 Pandemic: A Multicenter Study.

BACKGROUND AND PURPOSE: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. RESULTS: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (-85%, -46%, -42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, -60%; thrombectomy, -61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. CONCLUSIONS: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.

Pre-hospital stroke screening and notification of patients with reperfusion-eligible acute ischaemic stroke using modified Face Arm Speech Time test.

OBJECTIVES: To investigate the effects of pre-hospital stroke screening and notification on reperfusion therapy for patients with acute ischaemic stroke. METHODS: Pre-hospital stroke screening criteria were established based on a modified version of the Face Arm Speech Time (FAST) test. Screening was performed during ambulance transport by emergency medical service (EMS) personnel who completed a 2-hour training session on stroke screening. Temporal trends affecting acute ischaemic stroke investigation and intervention were compared before and after implementation of the pre-hospital screening. RESULTS: From July 2018 to October 2019, 298 patients with suspected stroke were screened by EMS personnel during ambulance transport prior to hospital arrival. Of these 298 patients, 213 fulfilled the screening criteria, 166 were diagnosed with acute stroke, and 32 received reperfusion therapy. The onset-to-door time was shortened by more than 1.5 hours (100.6 min vs 197.6 min, P<0.001). The door-to-computed tomography time (25.6 min vs 32.0 min, P=0.021), door-to-needle time (49.2 min vs 70.1 min, P=0.003), and door-to-groin puncture time for intra-arterial mechanical thrombectomy (126.7 min vs 168.6 min, P=0.04) were significantly shortened after implementation of the pre-hospital screening and notification, compared with historical control data of patients admitted from January 2018 to June 2018, before implementation of the screening system. CONCLUSION: Implementation of pre-hospital stroke screening using criteria based on a modified version of the FAST test, together with pre-arrival notification, significantly shortened the door-to-reperfusion therapy time for patients with ischaemic stroke. Pre-hospital stroke screening during ambulance transport by EMS personnel who complete a 2-hour focused training session is effective for identifying reperfusion-eligible patients with stroke.

Canadian survey on the rates of use of intraoperative diuretics and justification for their use during renal allograft reperfusion.

BACKGROUND: Mannitol and furosemide have been used as diuretics intraoperatively to facilitate early renal allograft function and reduce delayed graft function. As the evidence of any efficacy of these agents is limited, we sought to characterize the use of diuretics among transplant surgeons. METHODS: An anonymous online survey was sent to all Canadian transplant programs where kidney transplants are routinely performed. Questions were related to the use and indications for mannitol and furosemide. Responses were collected and analyzed as counts and percentages of respondents. We used χ2 analysis to assess the relationship between demographic factors and survey responses. RESULTS: Thirty-five surgeons completed the survey (response rate 50%). Seventy per cent of respondents reported performing 26 or more transplants per year, 88% had formal transplant fellowship training and 67% indicated that they currently train fellows. Only 24% and 12% reported believing that delayed graft function is reduced by mannitol and furosemide use, respectively. However, 73% routinely gave mannitol to patients and 53% routinely gave furosemide. The most common justification given for mannitol use was to induce diuresis (54%); 37% of respondents reported using mannitol because of training dogma. Likewise, 57% used furosemide for diuresis, with 23% reporting that their use of this agent was based on dogma. No relationship emerged between fellowship training, case volume or training program status and the use of any agent. Interestingly, 71% of respondents indicated that a randomized controlled trial evaluating the utility of intraoperative diuretics is needed and that they were interested in participating in such a trial. CONCLUSION: Use of intraoperative diuretics and the rationale for their use vary among surgeons. A substantial proportion of surgeons use these medications on the basis of dogma alone. A randomized controlled trial is needed to clarify the role of intraoperative diuretics in kidney transplant surgery.

CONTEXTE: On a utilisé le mannitol et le furosémide comme diurétiques peropératoires pour stimuler le fonctionnement précoce de l'allogreffe rénale et réduire le retard de fonctionnement du greffon. Comme les données probantes quant à l'efficacité de ces agents sont limitées, nous avons voulu caractériser l'utilisation des diurétiques chez les chirurgiens qui effectuent ces transplantations. MÉTHODES: Un sondage anonyme en ligne a été envoyé à tous les programmes de greffe canadiens où des greffes rénales sont couramment effectuées. Les questions avaient trait à l'utilisation et aux indications du mannitol et du furosémide. Les réponses ont été recueillies et analysées sous forme de nombres et de pourcentages des répondants. Le test du χ2 a été utilisé pour évaluer le lien entre les facteurs démographiques et les réponses au sondage. RÉSULTATS: Trente-cinq chirurgiens ont répondu au sondage (taux de réponse 50 %). Soixante-dix pour cent des répondants ont indiqué effectuer annuellement 26 greffes ou plus, 88 % avaient suivi une spécialisation formelle pour l'exécution des greffes et 67 % ont dit être en cours de spécialisation. Seulement 24 % et 12 % respectivement ont dit croire que le mannitol et le furosémide permettent de réduire le retard de fonctionnement du greffon. Toutefois, 73 % et 53 % respectivement administraient de routine du mannitol et du furosémide aux patients. La justification la plus fréquente de l'utilisation du mannitol était d'induire la diurèse (54 %); 37 % des répondants ont dit utiliser le mannitol parce que c'est ce qu'on leur a enseigné durant leur formation. De même, 57 % utilisaient le furosémide pour la diurèse, dont 23 % disaient que c'est ce qu'on leur avait enseigné durant leur formation. Aucun lien n'est ressorti entre la spécialisation, le volume de cas ou le statut à l'égard du programme de formation et l'utilisation d'un agent quelconque. Fait à noter, 71 % des répondants ont indiqué qu'un essai randomisé et contrôlé sur l'utilité des diurétiques peropératoires serait nécessaire et qu'ils y participeraient volontiers. CONCLUSION: L'utilisation de diurétiques peropératoires et la justification de leur utilisation varient d'un chirurgien à l'autre. En majeure partie, les chirurgiens utilisent ces médicaments sur la base des notions théoriques seulement. Un essai randomisé et contrôlé s'impose pour clarifier le rôle des diurétiques peropératoires dans la greffe rénale.

Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke.

BACKGROUND AND PURPOSE: This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke. METHODS: We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profiles, according to the volume of their Tmax >10s lesion volume (target mismatch, <100 mL; malignant mismatch, >100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (modified Rankin Scale, 0-2) at day 90 and radiographic outcomes at day 5. RESULTS: Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence (P=0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P=0.003). Compared with patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49-166] versus 43 [18-81] mL; P=0.006) and larger final infarct volumes (110 [61-155] versus 48 [21-99] mL; P=0.001). CONCLUSIONS: Compared with target mismatch patients, those with the malignant profile experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment benefit in patients with a malignant profile.

Strategic framework improves access to stroke reperfusion across the state of Victoria Australia.

BACKGROUND: In 2010, rapid access to stroke thrombolysis centres was limited in some regional areas in the Australian state of Victoria. These results, and planning for endovascular clot retrieval (ECR), have led to the implementation of strategies by the Victorian Stroke Clinical Network, the Victorian Stroke Telemedicine Program and local health services to improve state-wide access. AIMS: To examine whether access to stroke reperfusion services (thrombolysis and ECR) in regional Victoria have subsequently improved. METHODS: The locations of suspected stroke patients attended by ambulance in 2015 were mapped, and drive times to the nearest reperfusion services were calculated. We then calculated the proportion of cases with transport times within: (i) 60 min to thrombolysis centres; and (ii) 180 min to two ECR centres designated to receive regional patients. Statistical comparisons to existing 2010 data were made. RESULTS: In 2015, Ambulance Victoria attended 16 418 cases of suspected stroke (2.9% of all emergency calls), of whom 4597 (28%) were located in regional Victoria. Compared to 2010, a greater proportion of regional suspected stroke patients in 2015 were located within 60 min of a thrombolysis centre by road (77-95%, P < 0.001). A 3-h road travel time to the two ECR centres is currently possible for 88% of regional patients. CONCLUSION: A strategic and region-specific approach has resulted in improved access by road transport to reperfusion therapies for stroke patients across Victoria.

Access to Endovascular Treatment in Remote Areas: Analysis of the Reperfusion Treatment Registry of Catalonia.

BACKGROUND AND PURPOSE: Since demonstration of the benefit of endovascular treatment (EVT) in acute ischemic stroke patients with proximal arterial occlusion, stroke care systems need to be reorganized to deliver EVT in a timely and equitable way. We analyzed differences in the access to EVT by geographical areas in Catalonia, a territory with a highly decentralized stroke model. METHODS: We studied 965 patients treated with EVT from a prospective multicenter population-based registry of stroke patients treated with reperfusion therapies in Catalonia, Spain (SONIIA). Three different areas were defined: (A) health areas primarily covered by Comprehensive Stroke Centers, (B) areas primarily covered by local stroke centers located less than hour away from a Comprehensive Stroke Center, and (C) areas primarily covered by local stroke centers located more than hour away from a Comprehensive Stroke Center. We compared the number of EVT×100 000 inhabitants/year and time from stroke onset to groin puncture between groups. RESULTS: Baseline characteristics were similar between groups. Throughout the study period, there were significant differences in the population rates of EVT across geographical areas. EVT rates by 100 000 in 2015 were 10.5 in A area, 3.7 in B, and 2.7 in C. Time from symptom onset to groin puncture was 82 minutes longer in group B (312 minutes [245-435]) and 120 minutes longer in group C (350 minutes [284-408]) compared with group A (230 minutes [160-407]; P<0.001). CONCLUSIONS: Accessibility to EVT from remote areas is hampered by lower rate and longer time to treatment compared with areas covered directly by Comprehensive Stroke Centers.

Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence.

AIMS: Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS: From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION: Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.

Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis.

AIMS: The prevalence of peripheral arterial disease (PAD) and especially of critical limb ischaemia (CLI) is announced to rise dramatically worldwide, with a considerable impact on the health care and socio-economic systems. We aimed to characterize the recent trends in morbidity and in-hospital outcome of PAD among all hospitalized patients in the entire German population between 2005 and 2009. METHODS AND RESULTS: Nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009 were analysed regarding the prevalence of PAD, comorbidities, endovascular (EVR) and surgical revascularizations (SR), major and minor amputations, in-hospital mortality, and associated costs. From 2005 to 2009, total PAD cases increased by 20.7% (from 400 928 to 483 961), with an increase of CLI subset from 40.6 to 43.5%. Total EVR increased by 46%, while thromb-embolectomy, endarterectomy, and patch plastic increased by 67, 42, and 21%, respectively. Peripheral bypasses decreased by 2%. Major amputation decreased from 4.6 to 3.5%, while minor amputation slightly increased from 4.98 to 5.11%. The crude overall in-hospital mortality remained unchanged in claudicants (2.2%), while it decreased from 9.8 to 8.4% in CLI patients. However, mortality rate according to the Poisson model (n/1000 hospital residence days) increased significantly in claudicants (P < 0.001). Total reimbursement costs for PAD in-patient care increased by 21% with an average per case costs in 2009 of €4506 in a claudicant and €6791 in a CLI patient. CONCLUSION: This population-based analysis documents the significant rise of PAD, particularly of the CLI subset, and highlights the malign prognosis associated with PAD as indicated by high amputation and in-hospital mortality rates.

An Evaluation Trial of The National Perfusion Registry.

The International Consortium for Evidence-Based Perfusion (ICEBP) is a collaborative group whose mission is to improve, continuously, the delivery of care and outcomes for patients undergoing cardiac surgery. To achieve this end, the ICEBP supports the development of perfusion registries to evaluate clinical practices and has established evidence-based guidelines for perfusion. The Japanese Society of Extra-Corporeal Technology in Medicine (JaSECT) developed a perfusion registry to examine variation in perfusion practice in Japan. A pilot study was designed to determine the rate and accuracy of data extraction from patients' medical records and perfusion practice records and the subsequent entry of data into the registry form. We designed an input matching test using medical records and perfusion records from a sample of patients. Five institutions participated in data. extraction and entry from 10 randomly selected case records. Perfusionists entered data in the registry form in accordance with the instruction manual prepared by the JaSECT guideline committee. The time taken to input every case in the registry was measured. An interview-based survey was carried out across institutions after the completion of the pilot. The time required for data entry stabilized after approximately five cases to a rate that was 40% of the first case entry time. Data entered into the registry by perfusionists for multiple-choice items were accurate 65% of the time and accurate 25% of the time for numerical data. The interview-based survey identified a total of 38 opportunities for improvement in the input form and 58 recommended changes for the instruction manual. The accuracy of data may be improved by developing a method allowing the objective detection of deficient data when present in the perfusion case record by developing automatic data acquisition from the automatic perfusion recording system currently in use, and by changing as many numerical value input items as possible to multiple-choice items.

Reperfusion is a stronger predictor of good clinical outcome than recanalization in ischemic stroke.

PURPOSE: To assess the predictive value of reperfusion indices, recanalization, and important baseline clinical and radiologic scores for good clinical outcome prediction. MATERIALS AND METHODS: The study was approved by the local research ethics board. Written consent was obtained from all participants or their caregivers. Baseline computed tomography (CT) perfusion less than 4.5 hours after stroke symptoms, follow-up CT perfusion at 24 hours or less, and 5-7-day magnetic resonance images were obtained for 114 patients. Baseline imaging was assessed blinded to outcome. Recanalization status was determined at follow-up CT angiography. Reperfusion index was calculated on baseline and on follow-up at-risk tissue volume. Kruskal-Wallis, Mann-Whitney rank sum, and Spearman correlation were used for group comparisons and correlation studies. Univariate and multivariate logistic regression tested the association of clinical and imaging parameters with good outcome. Models with and without recanalization and reperfusion were compared by using Akaike information criterion. RESULTS: Reperfusion indices were significantly higher in patients with recanalization than in those without (P < .001). Despite significance of recanalization at univariate analysis, only reperfusion, age, and National Institutes of Health Stroke Scale score were significant after multivariate analysis (P < .01). Time to maximum reperfusion index had the highest accuracy (area under the receiver operating characteristic curve, 0.70) for good outcome, and reperfusion was defined as time to maximum volume of 59% or greater. Patients with reperfusion but no recanalization had significantly lower total infarct volume (P = .001) and infarct growth (P = .004) and had higher salvaged penumbra (P = .009) volumes than patients without reperfusion and recanalization. A final model with reperfusion but not recanalization was the most prognostic model of good clinical outcome. CONCLUSION: Reperfusion showed stronger association with good clinical outcome than did recanalization.

Predictors of in-hospital mortality in elderly patients with acute venous thrombo-embolism: the SWIss Venous ThromboEmbolism Registry (SWIVTER).

AIMS: Although acute venous thrombo-embolism (VTE) often afflicts patients with advanced age, the predictors of in-hospital mortality for elderly VTE patients are unknown. METHODS AND RESULTS: Among 1247 consecutive patients with acute VTE from the prospective SWIss Venous ThromboEmbolism Registry (SWIVTER), 644 (52%) were elderly (≥65 years of age). In comparison to younger patients, the elderly more often had pulmonary embolism (PE) (60 vs. 42%; P< 0.001), cancer (30 vs. 20%; P< 0.001), chronic lung disease (14 vs. 8%; P= 0.001), and congestive heart failure (12 vs. 2%; P< 0.001). Elderly VTE patients were more often hospitalized (75 vs. 52%; P< 0.001), and there was no difference in the use of thrombolysis, catheter intervention, or surgical embolectomy between the elderly and younger PE patients (5 vs. 6%; P= 0.54), despite a trend towards a higher rate of massive PE in the elderly (8 vs. 4%; P= 0.07). The overall in-hospital mortality rate was 6.6% in the elderly vs. 3.2% in the younger VTE patients (P= 0.033). Cancer was associated with in-hospital death both in the elderly [hazard ratio (HR) 4.91, 95% confidence interval (CI) 2.32-10.38; P< 0.001] and in the younger patients (HR 4.90, 95% CI 1.37-17.59; P= 0.015); massive PE was a predictor of in-hospital death in the elderly only (HR 3.77, 95% CI 1.63-8.74; P= 0.002). CONCLUSION: Elderly patients had more serious VTE than younger patients, and massive PE was particularly life-threatening in the elderly.

Quality improvement framework for major amputation: are we getting it right?

INTRODUCTION: The quality improvement framework for major amputation was developed with the aim of improving outcomes and reducing the perioperartive mortality to less than 5% by 2015. The aim of the study was to assess our compliance with the framework guidelines and look for the reasons for non-compliance. METHOD: All major amputations performed between 2008 and 2010 were included. The following data were collected: presence of infection ± tissue loss, status of arterial supply, revascularisation attempts, time to surgery, type of amputation, morbidity and mortality. RESULTS: A total of 81 patients were included (42 BKAs, 39 AKAs). Ninety percentage had formal preoperative arterial investigations and 84% had an attempted revascularisation procedure. Patients who were transferred late from non-vascular units (n = 12) had a 30-day mortality of 50% whereas patients who presented directly to our unit had a 30-day mortality of 7.2%. The number of amputations has decreased over the last 3 years from 34 to 21 per year, coinciding with the doubling of crural revascularisation procedures performed (from 60 to 120 per year). Ten patients underwent a revision from BKA to AKA because of an inadequate profunda femoris artery (PFA), whereas all those with a healed BKA stump either had a good PFA or a named crural vessel. CONCLUSION: The overall number of amputations is decreasing from year to year. By doubling our crural revascularisation procedures we are saving more limbs. Thirty-day mortality is higher than expected, particularly in patients who present late. Expeditious referral may potentially improve the mortality rate among this group of patients.

Trends and outcomes after surgical lower limb revascularization in England.

BACKGROUND: The aim was to analyse contemporary data on the number of surgical revascularization procedures performed each year in England, and their outcome. METHODS: Hospital Episode Statistics and Office for National Statistics data were used to quantify numbers and identify factors associated with outcome after all femoropopliteal and femorodistal bypass procedures performed between 2002 and 2006. Outcome measures were repeat bypass, major amputation, death and a composite measure. Single-level multivariable logistic regression modelling was used to quantify the effect of these variables on outcome. RESULTS: A total of 21,675 femoropopliteal and 3458 femorodistal bypass procedures were performed. Mean in-hospital mortality rates were 6·7 and 8·0 per cent respectively. One-year survival rates were 82·8 and 79·1 per cent; both increased over the study interval. The mean 1-year major amputation rate after femoropopliteal bypass was 10·4 per cent, which decreased significantly over the 5 years (P < 0·001); after distal bypass the rate of 20·8 per cent remained unchanged (P = 0·456). Diabetes mellitus and chronic kidney disease were significant predictors of adverse outcome for both procedures: odds ratio (OR) at 1 year 1·56 (95 per cent confidence interval 1·46 to 1·67; P < 0·001) and 2·15 (1·88 to 2·45; P < 0·001) respectively for femoropopliteal bypass. Previous femoral angioplasty was associated with an increased rate of major amputation 1 year after proximal bypass (OR 1·18, 1·05 to 1·33; P = 0·004). CONCLUSION: Although all mortality rates are improving, the major amputation rate remains high after femorodistal bypass. Adverse events occurred after 37·6 per cent of femoropopliteal and 49·7 per cent of femorodistal bypasses; diabetes and chronic renal failure were the main predictors of poor outcome.

Regional Disparity of Reperfusion Therapy for Acute Ischemic Stroke in Japan: A Retrospective Analysis of Nationwide Claims Data from 2010 to 2015.

Background We aimed to determine whether a regional disparity exists in usage of reperfusion therapy (intravenous recombinant tissue plasminogen activator [IV rt-PA] and endovascular thrombectomy [EVT]) and post-reperfusion 30-day mortality in patients with acute ischemic stroke, and which regional factors are associated with their usage. Methods and Results We retrospectively investigated 69 948 patients (mean age±SD, 74.9±12.0 years; women, 41.4%) with acute ischemic stroke treated with reperfusion therapy between April 2010 and March 2016 in Japan using nationwide claims data. Regional disparity was evaluated using Gini coefficients for age- and sex-adjusted usage of reperfusion therapy and 30-day post-reperfusion in-hospital death ratio in 47 administrative regions. The association between regional factors and reperfusion therapy usage was evaluated with fixed-effects regression models. During the study period, Gini coefficients showed low inequality (0.11-0.15) for use of IV rt-PA monotherapy and IV rt-PA and/or EVT and extreme inequality (0.49) for EVT usage in 2010, which became moderate inequality (0.25) by 2015. The densities of stroke centers and endovascular specialists, as well as market concentration, were associated with increased usage of reperfusion therapy whereas the proportion of rural residents and delayed ambulance transport were negatively associated with usage. Inequality in the standardized death ratio after EVT was extreme (0.86) in 2010 but became moderate (0.29) by 2015; inequality was low to moderate (0.17-0.23) for IV rt-PA monotherapy and IV rt-PA and/or EVT. Conclusions Scrutinizing existing data sources revealed regional disparity in reperfusion therapy for acute ischemic stroke and its associated regional factors in Japan.

Radial first or patient first: a case series and meta-analysis of transradial versus transfemoral access for acute ischemic stroke intervention.

BACKGROUND: Few studies have compared technical success and effectiveness of transradial access (TRA) versus transfemoral access (TFA) for mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We compared the two approaches for technical success, effectiveness, and outcomes. METHODS: We retrospectively compared TRA with TFA for AIS MT at our institute. We additionally performed a systematic review and meta-analysis of studies describing the use of TRA alone or in comparison with TFA for MT. Primary outcomes included rate of successful reperfusion (thrombolysis in cerebral infarction (TICI) >2b), number of passes, access-site complications, and 3- month mortality and favorable functional outcomes (modified Rankin Scale (mRS) score 0-2). RESULTS: A total of 222 consecutive patients (TRA=93, TFA=129) were included in our case series. The rate of successful reperfusion was significantly higher for the TFA cohort (91.4% vs 79.6%, P=0.01) with lower mean number of passes (1.8±1.2 vs 2.4±1.6, P=0.014). Three-month mortality in the TFA group was lower (22.1% vs 40.9% for the TRA cohort (P=0.004), with a higher rate of favorable functional outcomes (51.3% vs 34.1%, P=0.015). A meta-analysis of 10 studies showed significant heterogeneity in rates of successful reperfusion (57.1% to 95.6%, heterogeneity=67.55%, P=0.001). None of the previous comparative studies reported 3-month mortality and functional outcomes. CONCLUSIONS: This case series demonstrate a higher successful reperfusion rate, fewer passes, lower 3-month mortality, and improved 3-month functional outcomes with TFA. The systematic review highlights the inadequacy of existing evidence. Prospective comparative studies are needed before a 'radial-first' approach can be adopted for stroke intervention.