Short Term Outcomes and Treatment Intensity of Major Cardiovascular Emergencies During the SARS-CoV2 Pandemic in Germany

OBJECTIVE

There has been a decline in hospital admission rates in many countries since the beginning of the SARS-CoV-2 pandemic. Thereby, the patient selection differed from episodes before the pandemic. This study investigates changes in baseline characteristics as well as short term mortality and probability of receiving an invasive procedure while considering sex disparities.

METHODS

Claims data provided by Germany's second largest insurance fund, BARMER, were used. Patients without COVID-19 who were treated for ST segment elevation (STEMI) and non-elevation (NSTEMI) myocardial infarction, acute limb ischaemia (ALI), and stroke between 1 January 2018 and 31 December 2021 were included. Outcomes were compared separately for both sexes between the years before the pandemic (2018/2019) and during the pandemic (2020/2021). Propensity scores with exact matching were used to balance confounders including age, drug prescriptions in previous year, federal state, month of admission, domiciliary care, and the Elixhauser comorbidities. Short term mortality and probability of invasive procedures were determined using cumulative incidence functions and Cox regressions.

RESULTS

The cohort consisted of 140 989 hospitalisations of 122 340 individual patients (48.3% females) with 102 960 matched cases. Baseline characteristics were similar between episodes in the unmatched cohort. Earlier discharge was observed for all strata except for males with ALI or STEMI, where the probability of early discharge was unchanged. The probability of receiving an invasive procedure was increased for both sexes with ALI, NSTEMI, and STEMI but not for stroke. The analyses suggested neither a statistically significant increase of in hospital mortality nor 30 day mortality since the pandemic started.

CONCLUSION

There was no evidence for a direct or indirect impact of the pandemic on major short term hospital outcomes. While the probability of receiving an invasive procedure increased for STEMI, NSTEMI, and ALI, the overall short term mortality was unaffected for both sexes.

Trends in cancer incidence by socioeconomic deprivation in Germany in 2007 to 2018: An ecological registry-based study

Age-standardized cancer incidence has decreased over the last years for many cancer sites in developed countries. Whether these trends led to narrowing or widening socioeconomic inequalities in cancer incidence is unknown. Using cancer registry data covering 48 million inhabitants in Germany, the ecological association between age-standardized total and site specific (colorectal, lung, prostate and breast) cancer incidence in 2007 to 2018 and a deprivation index on district level (aggregated to quintiles) was investigated. Incidence in the most and least deprived districts were compared using Poisson models. Average annual percentage changes (AAPCs) and differences in AAPCs between deprivation quintiles were assessed using Joinpoint regression analyses. Age-standardized incidence decreased strongly between 2007 and 2018 for total cancer and all cancer sites (except female lung cancer), irrespective of the level of deprivation. However, differences in the magnitude of trends across deprivation quintiles resulted in increasing inequalities over time for total cancer, colorectal and lung cancer. For total cancer, the incidence rate ratio between the most and least deprived quintile increased from 1.07 (95% confidence interval: 1.01-1.12) to 1.23 (1.12-1.32) in men and from 1.07 (1.01-1.13) to 1.20 (1.14-1.26) in women. Largest inequalities were observed for lung cancer with 82% (men) and 88% (women) higher incidence in the most vs the least deprived regions in 2018. The observed increase in inequalities in cancer incidence is in alignment with trends in inequalities in risk factor prevalence and partly utilization of screening. Intervention programs targeted at socioeconomically deprived and urban regions are highly needed.

Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States

OBJECTIVE

To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design.

BACKGROUND

Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies.

METHODS

We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups.

RESULTS

We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%-84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients.

CONCLUSIONS

This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.

Limb Related Outcomes of Endovascular vs. Open Surgical Revascularisation in Patients with Peripheral Arterial Occlusive Disease: A Report from the Prospective GermanVasc Cohort Study

OBJECTIVE

The goal of this study was to compare clinical outcomes in patients with peripheral arterial occlusive disease undergoing revascularisation by peripheral endovascular intervention (EVI), bypass surgery, endarterectomy (EA), and hybrid surgery in an unselected real world setting.

METHODS

This was a German, prospective, multicentre, comparative cohort study, enrolling patients at hospital admission for revascularisation at 35 vascular centres with 12 months of follow up. Primary composite endpoints were major amputation or death, major adverse limb events, and any minor or major amputation. Twelve month incidences and hazard ratios (HRs) for the four subgroups and 95% confidence intervals (CIs) were estimated using Kaplan-Meier functions and Cox proportional hazard models. Sociodemographic and clinical characteristics, pharmacological treatment, and comorbidities were used to adjust for patient differentials (unique identifier ClinicalTrials.gov: NCT03098290).

RESULTS

In total, 4 475 patients were analysed (mean age 69 years, 69.4% males, and 31.5% suffering from chronic limb threatening ischaemia). After 12 months of follow up, 5.3% (95% CI 3.6 - 6.9%) of the patients experienced either death or major amputation, 7.2% (95% CI 4.8 - 9.6%) major adverse limb event, and 6.6% (95% CI 5.0 - 8.2%) any minor or major amputation. Compared with EVI, bypass surgery was associated with an increased risk of amputation or death (HR 2.59, 95% CI 1.75 - 3.85), major adverse limb event (HR 1.93, 95% CI 1.11 - 3.36), and any minor or major amputation (HR 2.12, 95% CI 1.42 - 3.16), and hybrid surgery with an increased risk of amputation or death (HR 2.29, 95% CI 1.27 - 4.13) and major adverse limb event (HR 1.62, 95% CI 1.03 - 2.54). After adjusting for patient differentials, no significant differences among study groups remained.

CONCLUSION

More favourable outcomes after EVI were completely attributed to differentials in patient characteristics and not procedure type. The current study emphasised that all competing approaches performed similarly in a real world setting.

Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases

PURPOSE

In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group.

METHODS

Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence.

RESULTS

One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection).

CONCLUSION

Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Editor's Choice - Prevalence of Peripheral Arterial Disease, Abdominal Aortic Aneurysm, and Risk Factors in the Hamburg City Health Study: A Cross Sectional Analysis

OBJECTIVE

There is a paucity of current figures on the prevalence of carotid and lower extremity peripheral arterial disease (PAD) and abdominal aortic aneurysm (AAA) as well as the associated cardiovascular risk factors to support considerations on screening programmes.

METHODS

In the population based Hamburg City Health Study, participants between 45 and 74 years were randomly recruited. In the current cross sectional analysis of the first 10 000 participants enrolled between February 2016 and November 2018, the prevalence of carotid artery disease (intima-media thickness ≥ 1 mm), lower extremity PAD (ankle brachial index ≤ 0.9), and AAA (aortic diameter ≥ 30 mm) was determined. Multivariable logistic regression models were applied to determine the association between vascular diseases and risk factors. To account for missing values, multiple imputation was performed.

RESULTS

A total of 10 000 participants were analysed (51.1% females, median age 63 years, median body mass index 26.1 kg/m2). In medians, the intima media thickness was 0.74 mm (interquartile range [IQR] 0.65 - 0.84), the ankle brachial index 1.04 (IQR 0.95 - 1.13), and the aortic diameter 17.8 mm (IQR 16.1 - 19.6). Concerning risk factors, 64% self reported any smoking, 39% hypertension, 5% coronary artery disease, 3% congestive heart failure, 5% atrial fibrillation, and 3% history of stroke or myocardial infarction, respectively. In males, the prevalence of carotid artery disease, lower extremity PAD, and AAA were 35.3%, 22.7%, and 1.3%, respectively, and in females, 23.4%, 24.8%, and 0.2%, respectively. Higher age and current smoking were likewise associated with higher prevalence while the impact of variables varied widely.

CONCLUSION

In this large population based cohort study of 10 000 subjects from Hamburg, Germany, a strikingly high prevalence of PAD was revealed. Almost 45% suffered from any index disease, while AAA was only diagnosed in 1.3% of males and 0.2% of females. The high prevalence of atherosclerotic disease and associated cardiovascular risk factors underline that it is essential to increase awareness and fuel efforts for secondary prevention.

Cross-Sectional Association of Dietary Patterns and Supplement Intake with Presence and Gray-Scale Median of Carotid Plaques-A Comparison between Women and Men in the Population-Based Hamburg City Health Study

This population-based cross-sectional cohort study investigated the association of the Mediterranean and DASH (Dietary Approach to Stop Hypertension) diet as well as supplement intake with gray-scale median (GSM) and the presence of carotid plaques comparing women and men. Low GSM is associated with plaque vulnerability. Ten thousand participants of the Hamburg City Health Study aged 45-74 underwent carotid ultrasound examination. We analyzed plaque presence in all participants plus GSM in those having plaques (n = 2163). Dietary patterns and supplement intake were assessed via a food frequency questionnaire. Multiple linear and logistic regression models were used to assess associations between dietary patterns, supplement intake and GSM plus plaque presence. Linear regressions showed an association between higher GSM and folate intake only in men (+9.12, 95% CI (1.37, 16.86), p = 0.021). High compared to intermediate adherence to the DASH diet was associated with higher odds for carotid plaques (OR = 1.18, 95% CI (1.02, 1.36), p = 0.027, adjusted). Odds for plaque presence were higher for men, older age, low education, hypertension, hyperlipidemia and smoking. In this study, the intake of most supplements, as well as DASH or Mediterranean diet, was not significantly associated with GSM for women or men. Future research is needed to clarify the influence, especially of the folate intake and DASH diet, on the presence and vulnerability of plaques.

The Relationship Between Hospital Procedure Volume and Outcomes After Endovascular or Open Surgical Revascularisation for Peripheral Arterial Disease: An Analysis of Health Insurance Claims Data

OBJECTIVE

There is a paucity of data on the relationship between hospital procedure volume and outcomes after inpatient treatment of symptomatic peripheral arterial disease (PAD). This study aimed to generate meaningful hypotheses to support the ongoing discussion.

METHODS

Data derived from BARMER, Germany's second largest insurance provider, were linked with nationwide hospital procedure volumes from mandatory hospital quality reports. All endovascular (EVR) and open surgical revascularisations (OSR) provided to patients (≥ 40 years) with symptomatic PAD between 1 January 2013 and 31 December 2018 were included. Hospital volume was defined as the number of procedures performed by a hospital in the previous calendar year (in quartiles). Freedom from re-intervention, amputation, and overall mortality rate within 12 months after discharge were analysed using multivariable Cox proportional hazards models. In hospital mortality was determined by generalised estimating equations logistic regression models.

RESULTS

There were 88 187 revascularisations (72.4% EVR; EVR: 72.7 years and 45.2% females; OSR: 71.9 years and 41.9% females) registered by 668 hospitals. No statistically significant association was found between 12 month freedom from re-intervention and hospital volume (EVR: 4; quartile HR 1.05; 95% CI 0.94 - 1.16. OSR: 4; quartile HR 1.05; 95% CI 0.92 - 1.21). Patients with OSR had a decreased hazard of 12 month mortality in a high volume hospital compared with a low volume hospital (HR 0.85; 95% CI 0.73 - 0.98), but not with EVR (HR 1.03; 95% CI 0.91 - 1.16). Patients who were treated in hospitals with highest volumes showed decreased hazards of 12 month freedom from amputation when compared with low volume hospitals (EVR: HR 0.72; 95% CI 0.52 - 0.99. OSR: HR 0.61; 95% CI 0.44 - 0.85).

CONCLUSION

This large retrospective analysis of insurance claims suggests that higher procedure volume is associated with lower major amputation rates, although there is a need for standardisation of the definition of volume stratification. Future studies should address the impact of subsequent outpatient care and surveillance to further examine the complex interaction between treatment and outcomes.

The Impact of Chronic Kidney Disease on Mid-Term Outcomes after Revascularisation of Peripheral Arterial Occlusive Disease: Results from a Prospective Cohort Study

Objective: The current study aimed to determine the relationship between chronic kidney disease (CKD) and major 12-month outcomes for patients with in-hospital treatment for symptomatic peripheral arterial occlusive disease (PAOD). Methods: An analysis of the prospective longitudinal multicentric cohort study with 12-month follow-up was conducted including patients who underwent endovascular or open surgery for symptomatic PAOD at 35 German vascular centres (initial study protocol: NCT03098290). Severity of CKD was grouped into four stages combining information about the estimated glomerular filtration rate (eGFR) at baseline and dialysis dependency. Outcomes included overall mortality as well as the two composite endpoints of amputation or death, and of major cardiovascular events (MACE). 12-month incidences and adjusted hazard ratios were estimated using the Kaplan–Meier function and Cox proportional hazard models. Results: A total of 4354 patients (32% female, 69 years mean age, 68% intermittent claudication, 69% percutaneous endovascular revascularisation) were included and followed for 244 days in median. Thereof, 22% had any CKD and 5% had end stage kidney disease (ESKD) at baseline. The 12-month overall mortality rate was 3.6% (95% CI 2.3–4.9) with 96 events in the entire cohort: 147 were amputated or died (5.3%, 95% CI 5.2–5.3), and 277 had a MACE (9.5%, 95% CI 9.4–9.5). When compared with patients without kidney disease, ESKD was significantly associated with overall mortality (HR 1.9; 95% CI 1.1–3.5), amputation or death (HR 2.4; 95% CI 1.4–4.1), and MACE (HR 2.0; 95% CI 1.3–3.2). Conclusions: In the current study on mid-term outcomes after invasive revascularisation for symptomatic PAOD, one out of five patients suffered from any CKD while those few with ESKD had twice the odds of death, of amputation or death, and of major adverse cardiovascular events after twelve months. These results emphasise that concomitant CKD and its impact on outcomes should be considered by severity while mild and moderate grades should not lead to ineffectual treatment strategies.

The primary stability of two dental implant systems in low-density bone

Primary stability in low-density bone is crucial for the long-term success of implants. Tapered implants have shown particularly favourable properties under such conditions. The aim of this study was to compare the primary stability of tapered titanium and novel cylindrical zirconia dental implant systems in low-density bone. Fifty implants (25 tapered, 25 cylindrical) were placed in the anterior maxillary bone of cadavers meeting the criteria of low-density bone. The maximum insertion (ITV) and removal (RTV) torque values were recorded, and the implant stability quotients (ISQ) determined. To establish the isolated influence of cancellous bone on primary stability, the implantation procedure was performed in standardized low-density polyurethane foam bone blocks (cancellous bone model) using the same procedure. The primary stability parameters of both implant types showed significant positive correlations with bone density (Hounsfield units) and cortical thickness. In the cadaver, the cylindrical zirconia implants showed a significantly higher mean ISQ when compared to the tapered titanium implants (50.58 vs 37.26; P < 0.001). Pearson analysis showed significant positive correlations between ITV and ISQ (P = 0.016) and between RTV and ISQ (P = 0.035) for the cylindrical zirconia implants; no such correlations were observed for the tapered titanium implants. Within the limitations of this study, the results indicate that cylindrical zirconia implants represent a comparable viable treatment option to tapered titanium implants in terms of primary implant stability in low-density human bone.

Distribution of Mobile Health Applications amongst Patients with Symptomatic Peripheral Arterial Disease in Germany: A Cross-Sectional Survey Study

Background: Broadly available digital and mobile health applications (also known as mHealth) have recently gained increasing attention by the vascular community, but very little is known about the dissemination and acceptance of such technologies in certain target populations. The current study aimed to determine the user behaviour and acceptance of such digital technologies amongst patients with peripheral arterial disease (PAD). Methods: A cross-sectional survey of consecutively treated inpatients at 12 university institutions, as well as one non-university institution, was conducted. All admitted patients with symptomatic PAD were surveyed for 30 consecutive days within a flexible timeframe between 1 July and 30 September 2021. The factors associated with smartphone use were estimated via backward selection within a logistic regression model with clustered standard errors. Results: A total of 326 patients participated (response rate 96.3%), thereof 102 (34.0%) were treated for intermittent claudication (IC, 29.2% women, 70 years in median) and 198 were treated for chronic limb-threatening ischaemia (CLTI, 29.5% women, 70 years in median). Amongst all of the patients, 46.6% stated that they had not changed their lifestyle and health behaviour since the index diagnosis (four years in median), and 33.1% responded that they were not aware of the reasons for all of their medication orders. Amongst all those surveyed, 66.8% owned a smartphone (IC: 70.6%, CLTI: 64.1%), thereof 27.9% needed regular user support. While 42.5% used smartphone apps, only 15.0% used mobile health applications, and 19.0% owned wearables. One out of five patients agreed that such technologies could help to improve their healthy lifestyle. Only higher age was inversely associated with smartphone possession. Conclusions: The current survey showed that smartphones are prevalent amongst patients with peripheral arterial disease, but only a small proportion used mobile health applications and a considerable number of patients needed regular user support. Almost half of the patients did not change their lifestyle and one third were not aware of the reasons for their medication orders, emphasising room for improvement. These findings can further help to guide future projects using such applications to identify those target populations that are reachable with digital interventions.

Initiation of SGLT2 Inhibitors and the Risk of Lower Extremity Minor and Major Amputation in Patients with Type 2 Diabetes and Peripheral Arterial Disease: A Health Claims Data Analysis

OBJECTIVE

To assess the association between long term risk of hospitalisation for heart failure (HHF) and lower extremity minor and major amputation (LEA) in patients initiating sodium glucose cotransporter 2 inhibitors (SGLT2i) suffering from type 2 diabetes and peripheral arterial disease (PAD). Outcomes were compared with patients without PAD and evaluated separately for the time periods before and after the official warning of the European Medicines Agency (EMA) in early 2017.

METHODS

This study used BARMER German health claims data including all patients suffering from type 2 diabetes initiating SGLT2i therapy between 1 January 2013 and 31 December 2019 with follow up until the end of 2020. New users of glucagon like peptide 1 receptor agonists (GLP1-RAs) were used as active comparators. Inverse probability weighting with truncated stabilised weights was used to adjust for confounding, and five year risks of HHF and LEA were estimated using Cox regression. Periods before and after the EMA warning were analysed separately and stratified by presence of concomitant PAD.

RESULTS

In total, 44 284 (13.6% PAD) and 56 878 (16.3% PAD) patients initiated SGLT2i or GLP1-RA, respectively. Before the EMA warning, initiation of SGLT2i was associated with a lower risk of HHF in patients with PAD (hazard ratio, HR, 0.85, 95% confidence interval, CI, 0.73 - 0.99) and a higher risk of LEA in patients without PAD (HR 1.79, 95% CI 1.04 - 2.92). After the EMA warning, the efficacy and safety endpoints were no longer statistically different between groups.

CONCLUSION

The results from this large nationwide real world study highlight that PAD patients exhibit generally high amputation risks. This study refutes the idea that the presence of PAD explains the excess LEA risk associated with initiation of SGLT2i. The fact that differentials among study groups diminished after the EMA warning in early 2017 emphasises that regulatory surveillance measures worked in everyday clinical practice.

The prospective GermanVasc cohort study

Background: Previous observational studies reported a wide variation and possible room for improvement in the treatment of patients suffering from symptomatic peripheral artery disease (PAD). Yet, systematic assessment of everyday clinical practice is lacking. A General Data Protection Regulation (GDPR) compliant registry was developed and used to collect comprehensive data on clinical treatment and outcomes regarding PAD in Germany. Here, we report baseline characteristics of patients prospectively enrolled until the end of 2020. Methods: The GermanVasc registry study is a prospective longitudinal multicentre cohort study. Between 1^st May 2018 and 31^st December 2020, invasive endovascular, open-surgical, and hybrid revascularisations of patients suffering from chronic symptomatic PAD were prospectively included after explicit informed consent (NCT03098290). For ensuring high quality of the data, we performed comprehensive risk-based and random-sample external and internal validation. Results: In total, 5608 patients from 31 study centres were included (34% females, median 69 years). On-site monitoring visits were performed at least once in all centres. The proportion of chronic limb-threatening ischaemia was 30% and 13% were emergent admissions. 55% exhibited a previous revascularisation. Endovascular techniques made 69% among all documented invasive procedures (n=6449). Thirty-five percent were classified as patients with severe systemic disease, and 3% exhibited a constant threat to life according to the American Society of Anaesthesiologists classification. The risk profile comprised of 75% former or current smokers, 36% diabetes mellitus, and in 30% a current ischemic heart disease was present. At discharge, 93% of the patients received antiplatelets and 77% received statins. Conclusions: The GermanVasc registry study provides insights into real-world practice of treatment and outcomes of 5,608 patients with symptomatic PAD in Germany. The cohort covers a broader range of disease severity and types of interventions than usually found in trials. In future studies, comparative outcomes will be analysed in more detail.

Sex Disparities in Long-Term Mortality after Paclitaxel Exposure in Patients with Peripheral Artery Disease: A Nationwide Claims-Based Cohort Study

BACKGROUND

Randomized controlled trials have reported excess mortality in patients treated with paclitaxel-coated devices versus uncoated devices, while observational studies have reported the opposite. This study aims to determine the underlying factors and cohort differences that may explain these opposite results, with specific focus on sex differences in treatment and outcomes.

METHODS

Multicenter health insurance claims data from a large insurance fund, BARMER, were studied. A homogeneous sample of patients with an index of endovascular revascularization for symptomatic peripheral arterial occlusive disease between 2013 and 2017 was included. Adjusted logistic regression and Cox regression models were used to determine the factors predicting allocation to paclitaxel-coated devices and sex-specific 5-year all-cause mortality, respectively.

RESULTS

In total, 13,204 patients (54% females, mean age 74 ± 11 years) were followed for a median of 3.5 years. Females were older (77 vs. 71 years), and had less frequent coronary artery disease (23% vs. 33%), dyslipidemia (44% vs. 50%), and diabetes (29% vs. 41%), as well as being less likely to have a history of smoking (10% vs. 15%) compared with males. Mortality differences were mostly attributable to the female subgroup who were revascularized above the knee (hazard ratio, HR 0.78, 95% CI: 0.64-0.95), while no statistically significant differences were observed in males.

CONCLUSIONS

This study found that females treated above the knee benefited from paclitaxel-coated devices, while no differences were found in males. Ongoing and future registries and trials should take sex disparities into account.

A health insurance claims analysis on the effect of female sex on long-term outcomes after peripheral endovascular interventions for symptomatic peripheral arterial occlusive disease

OBJECTIVE

Several reports have addressed sex disparities in peripheral arterial occlusive disease (PAOD) treatment with inconclusive or even conflicting results. However, most previous studies have neither been sufficiently stratified nor used matching or weighting methods to address severe confounding. In the present study, we aimed to determine the disparities between sexes after percutaneous endovascular revascularization (ER) for symptomatic PAOD.

METHODS

Health insurance claims data from the second-largest insurance fund in Germany, BARMER, were used. A large cohort of patients who had undergone index percutaneous ER of symptomatic PAOD from January 1, 2010 to December 31, 2018 were included in the present study. The study cohort was stratified by the presence of intermittent claudication, ischemic rest pain, and wound healing disorders. Propensity score matching was used to adjust for confounding through differences in age, treated vessel region, comorbidities, and pharmacologic treatment. Sex-related differences regarding cardiovascular event-free survival, amputation-free survival, and overall survival within 5 years of surgery were determined using Kaplan-Meier time-to-event curves, log-rank test, and Cox regression analysis.

RESULTS

In the present study, 50,051 patients (47.2% women) were identified and used to compose a matched cohort of 35,232 patients. Among all strata, female patients exhibited lower mortality (hazard ratio [HR], 0.69-0.90), fewer amputations or death (HR, 0.70-0.89), and fewer cardiovascular events or death (HR, 0.78-0.91). The association between female sex and improved long-term outcomes was most pronounced for the patients with intermittent claudication.

CONCLUSIONS

In the present propensity score-matched analysis of health insurance claims, we observed superior cardiovascular event-free survival, amputation-free survival, and overall survival during 5 years of follow-up after percutaneous ER in women with symptomatic PAOD. Future studies should address sex disparities in the open surgical treatment of PAOD to illuminate whether the conflicting data from previous reports might have resulted from insufficient stratification of the studies.

Female Sex and Outcomes after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Propensity Score Matched Cohort Analysis

OBJECTIVE

Previous studies have showed a potential disadvantage of female patients who underwent abdominal aortic aneurysm (AAA) repair. The current study aims to determine sex-specific perioperative and long-term outcomes using propensity score matched unselected nationwide health insurance claims data.

METHODS

Insurance claims from a large German fund were used, covering around 8% of the insured German population. Patients who underwent endovascular aortic repair (EVAR) for intact AAA from 1 January 2011 to 30 April 2017 were included in the cohort. A 1:2 female to male propensity score matching was applied to adjust for confounding variables. Perioperative and long-term outcomes after 5 years were determined using matching and regression methods.

RESULTS

Among a total of 3736 patients (19.3% females, mean 75 years) undergoing EVAR for intact AAA, we identified 1863 matched patients. Before matching, females were more likely to be previously diagnosed with hypothyroidism, electrolyte disorders, rheumatoid disorders, and depression, while males were more often diabetics. In the matched sample, 23.4% of the females and 25.8% of the males died during a median follow-up of 776 and 792 days, respectively. Perioperatively, females were more likely to exhibit acute limb ischemia (5.3% vs. 3.2%, p = 0.031) and major bleeding (22.0% vs. 15.9%, p = 0.001) before they were discharged to rehabilitation (5.5% vs. 1.5%, p < 0.001) when compared to males. No statistically significant difference in perioperative (odds ratio 1.12, 95% CI 0.54-2.16) or long-term mortality (hazard ratio 0.91, 95% CI 0.76-1.08) was observed between sexes. This was also true regarding aortic reintervention rates after 1 year (2.0% vs. 2.9%) and 5 years (10.9% vs. 8.1%).

CONCLUSION

The current retrospective matched analysis of insurance claims revealed high early access-related morbidity in females when compared to their male counterparts. Short-term or long-term survival and reintervention outcomes were similar between sexes.

Editor's Choice - The GermanVasc Score: A Pragmatic Risk Score Predicts Five Year Amputation Free Survival in Patients with Peripheral Arterial Occlusive Disease

OBJECTIVE

Patients with peripheral arterial occlusive disease (PAOD) face an increased risk of both lower limb amputation and death. To date, it has been challenging to predict the long term outcomes for PAOD. The aim was to develop a risk score to predict worse five year amputation free survival (AFS).

METHODS

In this retrospective analysis of claims data, symptomatic PAOD patients were split into training and validation sets. Variables in the model were patient age and sex, Elixhauser comorbidities, and the 190 most common secondary diagnoses. Penalised Cox regression (least absolute shrinkage and selection operator [LASSO]) with tenfold cross validation for variable selection was performed and patients were categorised into five risk groups using the ten most important variables. All analyses were stratified by intermittent claudication (IC) and chronic limb threatening ischaemia (CLTI).

RESULTS

In total, 87 293 patients with PAOD (female 45.3%, mean age 71.4 ± 11.1 years) were included in the analysis. The most important variable predicting worse five year AFS was patient age >80 years. The GermanVasc score exhibited good predictive accuracy both for IC (c statistic = 0.70, 95% confidence interval [CI] 0.69-0.71) and CLTI (c statistic = 0.69, 95% CI 0.68-0.70) with adequate calibration due largely to alignment of observed and expected risk. Depending on the cumulative point score, the five year risk of amputation or death ranged from 9% (low risk) to 48% (high risk) for IC, and from 25% to 88% for CLTI.

CONCLUSION

The GermanVasc score predicts worse five year AFS stratified for inpatients suffering from IC and CLTI, with good predictive accuracy. By separating low from high risk patients, the GermanVasc score may support patient centred consent.

Sex Disparities in Long Term Outcomes After Open Surgery for Chronic Limb Threatening Ischaemia: A Propensity Score Matched Analysis of Health Insurance Claims

OBJECTIVE

Several studies suggest a disadvantage for women in peri-operative morbidity and mortality after open surgery in peripheral arterial occlusive disease. In addition to their heterogeneity regarding design and analysed cohorts, long term data are mostly missing. This study aimed to determine sex disparities in outcomes after open revascularisation in chronic limb threatening ischaemia (CLTI).

METHODS

Using health insurance claims data of the second largest insurance fund in Germany, BARMER, a large cohort of patients was sampled consecutively for analysis including index open surgical revascularisations of CLTI performed between 1 January 2010, and 31 December 2018. Propensity score matching was used to adjust for confounding. Sex related differences regarding overall survival, amputation free survival (AFS), and cardiovascular event free survival (CVEFS) during the five years after surgery were determined using Kaplan-Meier time to event curves, log rank test, logistic, and Cox regression.

RESULTS

Among 9 526 patients (49.5% women) in the entire cohort, 6 502 patients were matched. Before matching, women were older at presentation (78.0 vs. 71.8 years, p < .001) and suffered more often from multiple comorbidities (van Walraven score > 9, 55.5% vs. 50.6%, p < .001). During the hospital stay, there were 692 (7.3%) deaths, while 4 631 deaths (48.6%) occurred during the follow up. In the matched cohort, the median follow up was 746 days for women and 871 days for men. In the matched analyses, female sex was significantly associated with better overall survival (hazard ratio, HR, 0.80, log rank p < .001), AFS (HR 0.81, log rank p < .0001), and CVEFS (HR 0.84, log rank p < .001) five years after the index treatment.

CONCLUSION

In this largest propensity score matched analysis of health insurance claims to date from Germany, evidence was found for better long term outcomes in women after open surgical revascularisations for chronic limb threatening ischaemia. Future guidelines and studies should address the impact of sex on patient selection practice and outcomes to determine the underlying reasons for existing disparities.

Long-Term Effectiveness and Safety of Initiating Statin Therapy After Index Revascularization In Patients With Peripheral Arterial Occlusive Disease

Background An increasing number of patients with a peripheral arterial occlusive disease were put on statins during the past years. This study assessed whether statin therapy was effective and safe for these new users. Methods and Results Using health insurance claims data from Germany's second-largest insurance fund, BARMER, we identified patients with peripheral arterial occlusive disease who had index revascularization between 2008 and 2018 without prior statin therapy. We compared patients with and without statin therapy in addition to antithrombotics during the first quarter after discharge (new users versus nonusers). Outcomes were all-cause mortality, cardiovascular events, and incident major amputation for effectiveness and incident diabetes mellitus and incident myopathy for safety. Propensity score matching was used to balance the study groups. All analyses were stratified into patients with chronic limb-threatening ischemia and intermittent claudication. A total of 22 208 patients (mean age 71.1 years and 50.3% women) were included in the study. In 10 922 matched patients, statin initiation was associated with lower all-cause mortality (chronic limb-threatening ischemia: hazard ratio [HR], 0.75 [95% CI, 0.68-0.84]; intermittent claudication: HR, 0.80 [95% CI, 0.70-0.92]), lower risk of major amputation in patients with chronic limb-threatening ischemia (HR, 0.73; 95% CI, 0.58-0.93) and lower risk of cardiovascular events (hazard ratio, 0.80; 95% CI, 0.70-0.92) in patients with intermittent claudication during 5 years of follow-up. Safety outcomes did not differ among the study groups. Conclusions Initiating statin therapy in patients with peripheral arterial occlusive disease after index revascularization is efficient and safe with an effect size comparable to earlier studies. Awareness campaigns for evidence-based optimal pharmacological treatment among patients are recommended.

Immediate dental and skeletal influence of distractor position on surgically assisted rapid palatal expansion with or without pterygomaxillary disjunction

The outcome of surgically assisted rapid palatal expansion (SARPE) can be affected by pterygomaxillary disjunction (PMD) and the distractor position. In this study, SARPE was performed, with or without PMD, in 20 fresh cadaver heads. Transverse expansion was conducted twice using a bone-borne distractor in the anterior and posterior positions, resulting in four groups (n=10). Cone beam computed tomography scans were completed before and after SARPE to evaluate maxillary changes. A comparative anterior decrease and posterior increase in midpalatal opening resulted from SARPE with PMD combined with a posteriorly placed distractor. Significant differences in the internal transverse changes were found between the two SARPE techniques combined with an anterior distractor at the level of the premolars and molars for alveolar ridge width (P=0.040, P=0.024), and at the level of the molars for the dental crown width (P=0.017) and corresponding tooth cusp width (P=0.018). In contrast, using a posteriorly placed distractor led to a significant difference for tooth cusp width only (P=0.050). No statistically significant differences were found between external transverse changes or between distractor positions. PMD is more important in achieving a more uniform and parallel transverse expansion pattern than the distractor position. However, a posterior distractor seems to intensify the effects of PMD.

Long-term incidence of cancer after index treatment for symptomatic peripheral arterial disease - a health insurance claims data analysis

Background: Cancer as a concomitant condition in symptomatic peripheral arterial disease (PAD) patients could have an impact on further therapy and the long-term prognosis of these patients. Aim of this study was to investigate whether there is an increased incidence of cancer in PAD patients and to quantify the corresponding effect size. Materials and methods: Between January 1^st, 2008 and December 31^st, 2017, we analysed health insurance claims data from Germany's second-largest insurance fund, BARMER. Symptomatic PAD patients suffering from intermittent claudication (IC) or chronic limb-threatening ischaemia (CLTI) were stratified by gender at index treatment. PAD patients were then followed until an incident cancer diagnosis was recorded. To adjust for age and gender, standardized incidence ratios (SIR) were computed using the 2012 German standard population as reference. Results: 96,528 PAD patients (47% female, 44% IC, mean age 72 years) were included in the current study. When compared to the overall population, female and male PAD patients have a significantly increased risk of incident cancer of the lung (SIR 3.5 vs. 2.6), bladder (SIR 3.2 vs. 4.0), pancreas (SIR 1.4 vs. 1.6), and colon (SIR 1.3 vs. 1.3). During ten years of follow-up, some 7% of males and 4% of females developed lung cancer. For bladder, colon and pancreas cancer, the cumulative hazards were 1% vs. 3.2%, 2.2% vs. 2.8%, and 0.7% vs. 0.9%, respectively. Conclusions: Patients suffering from symptomatic PAD face a markedly higher risk for incident cancer in the long-term follow-up. The cancer risk increased continuously for certain types and PAD was strongly associated with cancer of the lung, bladder, pancreas, and colon. Taking these results into account, PAD patients could benefit from secondary and tertiary screening. These results also emphasize the impact of common risk factors such as tobacco smoke as target for health prevention.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

Aesthetic aspects of adjacent maxillary single-crown implants-influence of zirconia and titanium as implant materials

The purpose of this retrospective survey was to assess the esthetic aspects of adjacent zirconia and titanium implants in the anterior maxillary area. A total of 40 patients and 109 adjacent implants (17 patients with 47 titanium implants and 23 patients with 62 zirconia implants) was included. The primary aim of this survey was to assess the papillary fill (Jemt score). Additionally, further esthetic aspects were assessed. Papillae were fully present (Jemt score 3) around 39.1% of adjacent zirconia implants and 17.4% of adjacent titanium implants (p<0.01). The papilla deficit was significantly higher 1.64 mm (SD 1.35) around titanium compared to zirconia implants 0.92 mm (SD 0.94, p<0.01). The evaluation of the soft tissue recessions revealed no differences between implant materials, whereas titanium implants presented more visible implant shadows (p<0.01). Zirconia implants had more implants with papillae that filled the entire proximal space compared to titanium implants. Furthermore, titanium implants had a greater frequency of visible implant shadowing than the zirconia implants. Esthetic rules such as the interdental contact area and golden percentage rules did not differ significantly between the titanium and zirconia implants.

A retrospective cohort study on the provision and outcomes of pharmacological therapy after revascularisation for peripheral arterial occlusive disease: a study protocol

Background

Symptomatic peripheral arterial occlusive disease (PAOD) involves highly complex and costly revascularisations for preventing adverse limb events and impaired survival. Contrary to recommendations from valid guidelines, a large group of patients do not receive adequate pharmacological therapy after such interventions. Based on health insurance claims data, our study aims to assess (1) the extent of provision of pharmacological therapy after revascularisation and (2) related long-term outcomes for all patients and subgroups, that is, gender and disease severity.

Methods

A retrospective observational population-based cohort study will be based on data from the second largest statutory health insurance fund in Germany (BARMER) covering about 13% of the insured population (~10 million patients). Study entry is the index revascularisation for symptomatic PAOD. Study variables will be analysed and compared among subgroups using parametric and non-parametric tests, generalised linear regression analysis and survival models.

Discussion

This study will provide a comprehensive insight in the extent and time trends of adequate provision of pharmacological therapy and long-term outcomes for patients with symptomatic PAOD. This may help to identify those patients benefiting most from improved pharmacological therapy for increasing the success of revascularisations in general.

Trial registration

NCT03909022.

Editor's Choice - Long Term Survival after Femoropopliteal Artery Revascularisation with Paclitaxel Coated Devices: A Propensity Score Matched Cohort Analysis

OBJECTIVE

The aim of this study was to determine the survival of patients after use of paclitaxel coated devices (PCX), as a recent meta-analysis of randomised trials reported higher mortality in patients treated with PCX balloons and stents METHODS: A retrospective health insurance claims analysis of patients covered by the second largest insurance fund in Germany, BARMER, was used to identify index femoropopliteal arterial interventions between 1 January 2010 and 31 December 2018. To ensure first PCX exposure, patients with prior deployment of PCX were excluded. The study cohort was stratified into patients with chronic limb threatening ischaemia (CLTI) and intermittent claudication (IC), then into balloons vs. stents cohorts. Within each stratum PCX were compared with uncoated devices. Propensity score matching was used to balance the study groups. Survival was evaluated using the Kaplan-Meier method and Cox regression.

RESULTS

There were 37 914 patients (mean age 73.3 years; 48.8% female) included in the study. The annual proportion of PCX use increased from 3% to 39% during the study period for CLTI and from 4% to 48% for IC (both p < .001). Paclitaxel coated balloons and stents were associated with improved overall survival (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.77-0.90), amputation free survival (HR 0.85, 95% CI 0.78-0.91), and freedom from major cardiovascular events (HR 0.82, 95% CI 0.77-0.89) vs. uncoated devices at five years for CLTI. In IC cohort, mortality was significantly lower after using drug coated balloons (DCB) (HR 0.87, 95% CI 0.76-0.99) or combined DCB and drug eluting stents (HR 0.88, 95% CI 0.80-0.98).

CONCLUSION

In this large health insurance claims analysis, rapid adoption of PCX, higher long term survival, better amputation free survival, and lower rates of major cardiovascular events were seen after their use for the treatment of CLTI.

Detection of Rickettsia spp. and Bartonella spp. in Ctenocephalides felis fleas from free-ranging crab-eating foxes (Cerdocyon thous)

Fleas are insects with a worldwide distribution that have been implicated in the transmission of several pathogens. The present study aimed to investigate the presence of Rickettsia spp. (Rickettsiales: Rickettsiaceae) and Bartonella spp. (Rhizobiales: Bartonellaceae) in fleas from free-ranging crab-eating foxes Cerdocyon thous (Linnaeus, 1766) (Carnivora: Canidae) from Rio Grande do Sul, southern Brazil. Fleas were collected manually from animals and used for the molecular detection of Rickettsia spp. and Bartonella spp. Twenty-nine C. thous were sampled in six municipalities. Four foxes were parasitized by 10 fleas, all of which were identified as Ctenocephalides felis (Bouché, 1935) (Siphonaptera: Pulicidae). DNA from Rickettsia felis Bouyer et al., 2001 and Rickettsia asembonensis Maina et al., 2016 were found in three and eight fleas, respectively. In four fleas, DNA of Bartonella sp. was identified. Phylogenetic analysis grouped Bartonella sp. together with other genotypes previously reported in C. felis worldwide. The scenario described in the present study highlights a Neotropical canid parasitized by the invasive cosmopolitan cat flea, which in turn, is carrying potentially invasive vector-borne microorganisms. These findings suggest that C. felis is adapted to wild hosts in wilderness areas in southern Brazil, hypothetically exposing the Neotropical fauna to unknown ecological and health disturbances.

The new agreement of the international RIGA consensus conference on nasal airway function tests

The report reflects an agreement based on the consensus conference of the International Standardization Committee on the Objective Assessment of the Nasal Airway in Riga, 2nd Nov. 2016. The aim of the conference was to address the existing nasal airway function tests and to take into account physical, mathematical and technical correctness as a base of international standardization as well as the requirements of the Council Directive 93/42/EEC of 14 June 1993 concerning medical devices. Rhinomanometry, acoustic rhinometry, peak nasal inspiratory flow, Odiosoft-Rhino, optical rhinometry, 24-h measurements, computational fluid dynamics, nasometry and the mirrow test were evaluated for important diagnostic criteria, which are the precision of the equipment including calibration and the software applied; validity with sensitivity, specificity, positive and negative predictive values, reliability with intra-individual and inter-individual reproducibility and responsiveness in clinical studies. For rhinomanometry, the logarithmic effective resistance was set as the parameter of high diagnostic relevance. In acoustic rhinometry, the area of interest for the minimal cross-sectional area will need further standardization. Peak nasal inspiratory flow is a reproducible and fast test, which showed a high range of mean values in different studies. The state of the art with computational fluid dynamics for the simulation of the airway still depends on high performance computing hardware and will, after standardization of the software and both the software and hardware for imaging protocols, certainly deliver a better understanding of the nasal airway flux.

Is the Rise in the Prevalence of Renal Replacement Therapy at Older Ages the Price for Living Longer?

Background

Renal replacement therapy (RRT) is one of the most expensive in renal medicine. Cross-sectional studies suggest that life expectancy increases in the general population are associated with a higher burden of RRT. This study tests this hypothesis in a prospective setting among people aged 75+ living in Western Europe.

Methods

We gathered sex-specific data for 11 Western European countries in 2005-2014. RRT prevalence on country level was extracted from the ERA-EDTA registry, while data on population size and life expectancy for the 75+ age group came from the Eurostat database. GDP per capita was extracted from the OECD database. To measure the association between RRT prevalence and life expectancy, we performed Poisson regression models separately for each country and for all countries combined. To adjust for confounding, GDP per capita as well as time and country-fixed effects were included.

Results

Our analysis revealed that living longer coincides with rising RRT prevalence at ages 75+ in Western Europe between 2005 and 2014. On average, a 1-year increase in life expectancy was associated with a roughly 20% increase in RRT prevalence [(95% CI) 21-23% in men and 19-22% in women]. However, after adjustments for confounding were made, the association became insignificant among women and became weaker among men, falling to a level of 11% [(95% CI) 6-17%].

Conclusion

Living longer was not necessarily associated with a higher burden of RRT in Western European countries.