Distal versus conventional transradial access for coronary angiography and intervention: a systematic review and meta-analysis

Introduction

Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications and risk of superficial palmar arch ischemia in case of radial artery occlusion.

Purpose

In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention.

Method

We performed a comprehensive literature search using multiple databases from inception through February 2021 for all the studies that evaluated the efficacy and safety of DTRA for coronary angiography and intervention. The primary outcome of interest was access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion or spasm) and procedural characteristics (cannulation, fluoroscopy, and radial artery compression times). All meta-analyses were conducted using a random-effect model.

Results

A total of 8 studies including 1630 patients (805 underwent DTRA vs. 825 with CTRA), were included in the final analysis. Three of the included studies were randomized controlled trials (RCTs), and the remainder were observational studies. The access success rate was similar in the two groups (odds ratio (OR): 0.61; 95% confidence interval (CI): 0.18–2.09; P=0.43; I2=72%). Similarly, no difference was observed in the overall periprocedural local complications rate (OR 0.63, 95% CI 0.38–1.04, P=0.07, I2=25%). On subgroup analysis, the rate of radial artery occlusion was significantly lower in DRTA group (OR 0.33, 95% CI 0.13–0.82, P=0.02, I2=0%). Regarding the procedural characteristics, the two approaches were different only in the cannulation time favoring the CTRA group (mean difference in minutes [MD] 0.96, 95% CI 0.16–1.76; P=0.02).

Conclusions

The DTRA represents an alternative site for radial artery access for coronary angiography and interventions, with a high success rate accompanied by a low risk of complications. Although the cannulation time was longer for the DTRA, this can potentially improve with training, practice, and utilization of ultrasound-guided punctures. The major advantage provided by the DTRA is the trend toward a lower risk of radial artery occlusion, which is frequently observed with the conventional approach. Further adequately powered RCTs are needed to confirm the safety and efficacy of this approach.

Funding Acknowledgement

Type of funding sources: None. Central illustration

Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke

Background and Purpose:

Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals.

Methods:

Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital.

Results:

Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7]; P <0.001).

Conclusions:

Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.

[Quality of care of acute ischemic stroke in Germany 2018]

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

Nachuntersuchung 90 Tage nach Schlaganfall und transitorisch ischämischer Attacke im Qualitätssicherungsprojekt Rheinland-Pfalz

Hintergrund In Deutschland liefern Qualitätssicherungsprojekte zahlreiche Informationen zum akuten Schlaganfall, Daten aus Nachuntersuchungen liegen hingegen kaum vor. Ziel des Nachuntersuchungsprojekts war die Erhebung von Daten zu Lebenssituation, Rezidivereignissen, Medikation und Risikofaktoreneinstellung 3 Monate nach Schlaganfall oder TIA.

Material und Methoden Im zweiten Halbjahr 2012 wurden alle im Qualitätssicherungsprojekt „Akuter Schlaganfall“ in Rheinland-Pfalz erfassten Patienten zu einer Nachuntersuchung nach 90 Tagen mittels eines Fragebogens eingeladen.

Ergebnisse Von 8153 Patienten nahmen 3214 (39,4 %) an der Nachuntersuchung teil (Tod im Krankenhaus: n = 370, 4,5 %; dokumentierter Tod zwischen Entlassung und Tag 90: n = 268, 3,3 %; Widerspruch im stationären Aufenthalt n = 1423, 17,5 %; keine Teilnahme n = 2878; 35,3 %). Erneute TIAs/Schlaganfälle wurden bei 5,6 % der Patienten mit ischämischen Hirninfarkten (n = 2050) und bei jeweils 5,4 % der Patienten mit TIA (n = 934) oder intrazerebraler Blutung (ICB; n = 112) diagnostiziert; 316 (10,2 %) der Patienten gaben Krankenhausaufenthalte aus nicht zerebrovaskulären Gründen an. Mindestens eine Rehabilitationsbehandlung erhielten 64,2 % der Hirninfarkt-, 19,0 % der TIA- und 75,9 % der ICB-Patienten. Hilfe im Alltag benötigten 50,3 % der Hirninfarkt- und 63,4 % der ICB-Patienten, die überwiegend von Familienangehörigen geleistet wurde. In einem Alten-/Pflegeheim untergebracht waren 8,5 % der Patienten mit ischämischem Insult und 13,4 % der ICB-Patienten. Regelmäßige Blutdruckkontrollen berichteten 74,9 % und eine zielgerechte Blutdruckeinstellung (< 140 /90 mmHg) 52,7 % der Patienten. Unter den Rauchern gaben 51,7 % eine Beendigung des Nikotinkonsums an. Die Einnahmequote sank zwischen Entlassung und Tag 90 bei den Vitamin K-Antagonisten von 22,2 auf 12,8 %, bei Antihypertensiva von 82,4 % auf 72,9 % und bei Cholesterinsenkern von 74,8 % auf 54,5 %; 20,6 % aller Patienten nahmen an Tag 90 kein Antithrombotikum mehr ein. Bei den Patienten in Krankenhäusern mit überregionaler Stroke Unit (n = 6) lag im Vergleich zu Patienten in Krankenhäusern mit regionaler Stroke Unit (n = 22) oder ohne Stroke Unit (n = 45) (Strukturgruppen) die Teilnahmequote höher, das Durchschnittsalter, der Anteil an Frauen, die Prävalenz von arterieller Hypertonie und von Vorhofflimmern waren hingegen niedriger. Bei Entlassung und nach 90 Tagen erreichten die überregionalen Stroke Units bei einer Reihe von Endpunktparametern ein besseres Ergebnis, nach Adjustierung für Kovariablen fanden sich hingegen keine signifikanten Unterschiede

Diskussion Die Ergebnisse legen ein deutliches Verbesserungspotenzial bez. Therapieadhärenz, Risikofaktorkontrollen und der Vermeidung von Rezidivereignissen und Rehospitalisierungen nach Schlaganfällen nahe, wenngleich unsere Ergebnisse v. a. durch die Quote an nicht teilnehmenden Patienten limitiert sind. Unterschiede in den Ergebnisparametern zwischen den Strukturgruppen sind im Wesentlichen durch Differenzen bei demografischen Faktoren und Vorerkrankungen bedingt.

[Reasons for proximal femoral fracture surgery delays : Analysis of the structured dialog in Rheinland-Pfalz]

BACKGROUND

For the "preoperative stay" quality indicator , which is part of the external quality assurance for proximal femoral fractures (module 17/1), a tolerance range for surgery within 48 h after admission of ≤15 % is given.

MATERIALS AND METHODS

The structured dialog (2014) in Rheinland-Pfalz was analyzed with respect to reasons for delaying surgery for more than 48 h after admission.

RESULTS

A total of 331 cases were analyzed. In 60.7 % patient-related reasons and in 13.3 % administrative reasons were found. In 9.1 % the statements were not feasible. Due to a lack of software-related specifications in 7.3 % a wrong preoperative length of stay was generated. Wrong coding or a computer-related problem was found in 6.6 %. The most common reason for delay was the intake of an anticoagulant (25.7 %).

CONCLUSION

The significance of the quality indicator "Preoperative stay" without division into whether this was administrative or patient-related must be considered critically.

Stroke unit care in germany: the german stroke registers study group (ADSR)

BACKGROUND

Factors influencing access to stroke unit (SU) care and data on quality of SU care in Germany are scarce. We investigated characteristics of patients directly admitted to a SU as well as patient-related and structural factors influencing adherence to predefined indicators of quality of acute stroke care across hospitals providing SU care.

METHODS

Data were derived from the German Stroke Registers Study Group (ADSR), a voluntary network of 9 regional registers for monitoring quality of acute stroke care in Germany. Multivariable logistic regression analyses were performed to investigate characteristics influencing direct admission to SU. Generalized Linear Mixed Models (GLMM) were used to estimate the influence of structural hospital characteristics (percentage of patients admitted to SU, year of SU-certification, and number of stroke and TIA patients treated per year) on adherence to predefined quality indicators.

RESULTS

In 2012 180,887 patients were treated in 255 hospitals providing certified SU care participating within the ADSR were included in the analysis; of those 82.4% were directly admitted to a SU. Ischemic stroke patients without disturbances of consciousness (p < .0001), an interval onset to admission time ≤3 h (p < .0001), and weekend admission (p < .0001) were more likely to be directly admitted to a SU. A higher proportion of quality indicators within predefined target ranges were achieved in hospitals with a higher proportion of SU admission (p = 0.0002). Quality of stroke care could be maintained even if certification was several years ago.

CONCLUSIONS

Differences in demographical and clinical characteristics regarding the probability of SU admission were observed. The influence of structural characteristics on adherence to evidence-based quality indicators was low.

Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery

Background: The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Methods: Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Results: Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay; and it was inversely associated with microangiopathic etiology and discharge at home. In 34.5% of patients with recent/planned surgery, prior antithrombotic or anticoagulant medication had been interrupted. Conclusions: Recent or planned surgery imposes a considerable short-term stroke risk particularly by cardioembolism with cessation of medication as an important contributor. Stroke after surgery is associated with poor outcome and high mortality. Better strategies to reduce the burden of perioperative stroke are urgently required.

Identification and first characterization of SmEps8, a potential interaction partner of SmTK3 and SER transcribed in the gonads of Schistosoma mansoni

In eukaryotes the roles of protein kinases (PKs) regulating important biological processes such as growth and differentiation are well known. Molecular, biochemical, and physiological analyses trying to unravel principles of schistosome development have substantiated the importance for PKs also in this parasite. Amongst others the role of SmTK3 was studied, one of the first cellular PKs characterized from Schistosoma mansoni. Its function was demonstrated in mitogenic and differentiation processes in the gonads. Furthermore, first insights were obtained for the downstream part of a signal transduction cascade SmTK3 is involved in, which includes the diaphanous homolog SmDia. Here we attempted to further unravel the SmTK3 signaling cascade by searching for upstream interaction partners. Using yeast three-hybrid (Y3H) analyses we detected the epidermal growth factor receptor (EGFR) pathway substrate 8 of S. mansoni (SmEps8) as the most interesting candidate. By detailed interaction analyses we showed a contribution of the Src homology (SH) domains SH2 and SH3 of SmTK3 to binding, with a clear bias towards SH2. Compared to full-length SmEps8, binding was enhanced when only its 5' part including the phosphotyrosine binding domain (PTB) was used for interaction analyses including the SH2 domain of SmTK3, although phosphorylation seemed not to play a decisive role for binding. RT-PCR analyses and in situ hybridization experiments demonstrated similar transcription patterns of SmTK3 and SmEPS8, which co-localize in the reproductive organs. Furthermore, first evidence was obtained for SmEps8 interaction and colocalization with SER, one of the epidermal growth factor receptor (EGFR) homologs detected in S. mansoni. The results of this study provide first evidence for a SER-SmEps8-SmTK3-SmDia signal transduction pathway controlling differentiation processes in the gonads of S. mansoni.

The quality of acute stroke care- an analysis of evidence-based indicators in 260 000 patients

BACKGROUND

Stroke patients should be cared for in accordance with evidence-based guidelines. The extent of implementation of guidelines for the acute care of stroke patients in Germany has been unclear to date.

METHODS

The regional quality assurance projects that cooperate in the framework of the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutscher Schlaganfall-Register, ADSR) collected data on the care of stroke patients in 627 hospitals in 2012. The quality of the acute hospital care of patients with stroke or transient ischemic attack (TIA) was assessed on the basis of 15 standardized, evidence-based quality indicators and compared across the nine participating regional quality assurance projects.

RESULTS

Data were obtained on more than 260 000 patients nationwide. Intravenous thrombolysis was performed in 59.7% of eligible ischemic stroke patients patients (range among participating projects, 49.7-63.6%). Dysphagia screening was documented in 86.2% (range, 74.8-93.1%). For the following indicators, the defined targets were not reached for all of Germany: anti-aggregation within 48 hours, 93.4% (range, 86.6-96.4%); anticoagulation for atrial fibrillation, 77.6% (range, 72.4-80.1%); standardized dysphagia screening, 86.2% (range, 74.8-93.1%); oral and written information of the patients or their relatives, 86.1% (range, 75.4-91.5%). The rate of patients examined or treated by a speech therapist was in the target range.

CONCLUSION

The defined targets were reached for most of the quality indicators. Some indicators, however, varied widely across regional quality assurance projects. This implies that the standardization of care for stroke patients in Germany has not yet been fully achieved.

Crystallization and preliminary X-ray diffraction studies of the glutathione S-transferase from Plasmodium falciparum

Glutathione S-transferases (GSTs) belong to a family of detoxification enzymes that conjugate glutathione to various xenobiotics, thus facilitating their expulsion from the cells. For high-resolution crystallographic investigations, GST from the human malarial parasite Plasmodium falciparum was overexpressed in bacterial cells and crystallized using hanging-drop vapour diffusion. X-ray intensity data to 2.8 A resolution were collected from an orthorhombic crystal form with unit-cell parameters a = 62.2, b = 88.3, c = 75.3 A. A search for heavy-atom derivatives has been initiated, along with phase-determination efforts by molecular replacement.

[Diameter of coronary arteries before and after bypass grafting (author's transl)]

Patients with patent coronary bypass grafts showed the followings: 1. a decrease in prestenotic coronary diameter due to a reduction in flow. 2. An increase of the poststenotic segment of the bypassed vessel due to an increase in flow via the venous graft. 3. An increase of the bypassed stenosis, mainly due to a general decrease of vessel diameter proximal to the stenosis. 4. No change in diameter in non bypassed arteries. The postoperative changes in diameter were not dependent on the time elapsed since surgery and were independent from the severity of coronary sclerosis and the number of risk factors. A correlation was found between the amount of the diameter changes and the amount of reduction in exercise induced ST-segment depression. The decrease in coronary diameter proximal to the stenosis is not due to progression of coronary sclerosis but to a functional change. A narrow poststenotic vessel does not constitute a contraindication for bypass grafting because its true diameter is flow dependent and cannot be judged with certainty from the preoperative angiogram.