Unraveling two distinct polymorph transition mechanisms in one n-type single crystal for dynamic electronics

Cooperativity is used by living systems to circumvent energetic and entropic barriers to yield highly efficient molecular processes. Cooperative structural transitions involve the concerted displacement of molecules in a crystalline material, as opposed to typical molecule-by-molecule nucleation and growth mechanisms which often break single crystallinity. Cooperative transitions have acquired much attention for low transition barriers, ultrafast kinetics, and structural reversibility. However, cooperative transitions are rare in molecular crystals and their origin is poorly understood. Crystals of 2-dimensional quinoidal terthiophene (2DQTT-o-B), a high-performance n-type organic semiconductor, demonstrate two distinct thermally activated phase transitions following these mechanisms. Here we show reorientation of the alkyl side chains triggers cooperative behavior, tilting the molecules like dominos. Whereas, nucleation and growth transition is coincident with increasing alkyl chain disorder and driven by forming a biradical state. We establish alkyl chain engineering as integral to rationally controlling these polymorphic behaviors for novel electronic applications.

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

Effectiveness of the lateral pedicled endonasal flap for prevention of restenosis in frontal sinus drillouts

BACKGROUND

Frontal sinus median drainage according to Draf is an established procedure for achieving maximum drainage of the frontal sinus. Despite great efforts and several modifications, restenosis of the neo-ostium is still a persistent problem. This study presents an approach by implementing local mucosal flaps to prevent restenosis and compares it with the conventional technique without using the flap.

METHODS

Description of endonasal, lateral pedicle mucosal flap. A Draf III procedure was performed on 156 patients between 2012 and 2021. Data for 123 of the included patients were retrospectively analyzed in terms of surgical indication, technique, postoperative aftercare and patency of the drainage pathway. The follow-up observation period was between 3 and 24 months.

RESULTS

Treatment with the pedicle mucosal flap took place in 86 cases. 37 patients were treated as a control group without this flap. The analysis showed a significant association to the event "total closure of the drainage pathway" for surgical technique, as well as in the case of the presence of an allergy and the existence of Samter's triad. Furthermore, there was a significant association between the onset of "near total closure of the frontal sinus ostium" and Samter's triad, CRS and revision surgery was involved.

CONCLUSIONS

Use of an endonasal lateral pedicle flap for reconstruction of mucosal defects in frontal sinus surgery improves the long-term chances of a patent drainage pathway. Bone exposed by drilling was covered with a local mucosal flap for a faster epithelialization, healing and less scarring.

Sex differences in etiology and short-term outcome in young ischemic stroke patients receiving mechanical thrombectomy

Background

Although there are well known sex differences in older patients with ischemic stroke receiving acute reperfusion treatments, there is paucity of data in younger patients.

Methods

We investigated sex-related differences in clinical presentation, stroke etiology and short-term outcomes in consecutive young patients with acute ischemic stroke (AIS) below the age of 50 years receiving mechanical thrombectomy (MT) between January 2011 and May 2021 in a tertiary stroke center.

Results

We identified a total of 202 young ischemic stroke patients with MT, with 51% being female. Young female AIS patients were significantly younger (39 ± 8 vs. 43 ± 7 years, p < 0.001), and presented with a trend for more severe stroke on admission (median NIHSS 12 vs. 9, p = 0.065), compared to males, respectively. Young female AIS patients had higher rates of embolic strokes of determined or undetermined sources in the anterior circulation, while young male AIS patients suffered more often strokes of arterio-arterial embolism. Complete reperfusion (TICI score 3) was achieved significantly less often in young female AIS patients (69% vs. 83%, p = 0.006), and in-hospital mortality was 2-times higher (5% vs. 2%, p = 0.271) compared to males.

Conclusions

Young female AIS patients receiving MT have higher rates of severe embolic strokes and less often complete reperfusion due to different occlusion sites and stroke etiology compared to males.

Characterization of the circumferential cevel of the pulmonary vein isolation area using pulsed-field catheter ablation: Spatial distribution and extent of insufficient and excessive isolation areas

Funding Acknowledgements

Type of funding sources: None.

Introduction

The cornerstone of pulmonary vein isolation (PVI) is a wide area circumferential ablation (WACA) resulting in an isolation area encompassing the PV antrum. Pulsed field ablation (PFA) is a new non-thermal "single-shot" PVI device with promising success rates. However, the circumferential level of its PV isolation area is still unknown.

Objective

To characterize the circumferential acute PV isolation area by assessing the spatial distribution (qualitative analysis) and extent (quantitative analysis) of insufficient PV antral and excessive LA isolation areas.

Methods

In this study, patients with paroxysmal or persistent atrial fibrillation (AF) underwent PVI with a pentaspline PFA catheter. Before and immediately after PVI, ultra-high-density (UHD) voltage maps using a 20-polar circular mapping catheter were created. The insufficient isolations areas per antral PV segment (10-segment model) and excessive isolation areas per LA region (8-region model) were quantified.

Results

Between November – December 2021, in forty consecutive patients (age 62 ± 6 years, 28/40 [70%] male, LA 41 ± 4 mm) acute PVI using PFA was achieved and pre (5469 ± 1822 points) and post mapping (6809 ± 2769 points) was performed. The anterior antral PV segments of the left PVs were the most frequent locations of insufficient isolation areas (Table 1, Figure 1). The largest extent of insufficient isolation areas at the PV antral level was located again on the anterior parts of both left PVs (Figure 2A), but also in the anterior lower segment of the right inferior PV (Figure 2B). The posterior wall and roof region of both LA sides were the most frequent locations of excessive isolation areas (Figure 4). The extent of this excessive isolation at the roof and the posterior wall on both LA sides even resulted in a connection of the both-sided low voltage areas in 18% and 8%, respectively.

Conclusion

When using PFA to achieve a circumferential antral PVI, efforts should be made to enhance anterior antral PV segment and prevent excessive posterior wall and roof ablation. For further optimizing the procedure, full integration of PFA catheter visualization into 3D-mapping systems is needed.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

The level of urbanization influences acute ischemic stroke care: A nationwide ecological study from Germany

BACKGROUND AND PURPOSE

Regional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany.

METHODS

The level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany.

RESULTS

Sparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P < 0.001), but a lower use of MT (5.7% versus 8.4%, P < 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021).

CONCLUSIONS

Although there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.

A full year of the COVID-19 pandemic with two infection waves and its impact on ischemic stroke patient care in Germany

Background and purpose

Many countries worldwide, including Germany, reported that the first wave of the coronavirus disease 2019 (COVID‐19) pandemic in early 2020 influenced the care of acute ischemic stroke (AIS) patients, but data are lacking for further pandemic wave periods.

Methods

We conducted a nationwide, retrospective, cross‐sectional study of all hospitalized patients with the main diagnosis of AIS in 2019 and 2020. Primary outcomes were the number of hospitalizations for AIS, the application of stroke unit care, intravenous thrombolysis (IVT), and mechanical thrombectomy (MT), as well as the in‐hospital mortality during the different pandemic periods in 2020 compared to the corresponding periods in 2019. Secondarily, we analyzed differences in outcomes between patients with and without concurrent COVID‐19.

Results

We included 429,841 cases with AIS, of which 1268 had concurrent COVID‐19. Hospitalizations for AIS declined during both pandemic wave periods in 2020 (first wave: −10.9%, second wave: −4.6%). MT rates were consistently higher throughout 2020 compared to 2019, whereas the IVT rate dropped during the second wave period (16.0% vs. 17.0%, p < 0.001). AIS patients with concurrent COVID‐19 frequently received recanalization treatments, with an overall MT rate of 8.4% and IVT rate of 15.9%. The in‐hospital mortality was high (22.8% vs. 7.5% in noninfected AIS patients, p < 0.001).

Conclusions

These findings demonstrate a smaller decline in hospitalizations for AIS in the more severe second wave of the COVID‐19 pandemic. AIS patients with and without concurrent COVID‐19 who did seek acute care continued to receive recanalization treatments in Germany.

Letter to the Editor: Analysis of stroke patient migration for mechanical thrombectomy and changes in neurointerventional center size in Germany

AIM AND METHODS

To analyse nationwide changes in neurointerventional center size of all German hospitals performing mechanical thrombectomy (MT) in stroke patients from 2016 to 2019. Furthermore, we assessed cross-district patient migration for MT for the first time using hospitals' structured quality reports and German Diagnosis-Related Groups data in 2019.

FINDINGS

Number of hospitals performing more than 100 MT procedures/year doubled in Germany from 2016 (n = 36) to 2019 (n = 71), and these neurointerventional centers performed 71% of all MT procedures in 2019. The overall increase in MT procedures was largely driven by these high-volume neurointerventional centers with ability to perform MT 24/7 (121% increase as compared with 8% increase in hospitals performing less than 100 MT procedures/year). The highest cross-district patient mobility/transfer of stroke patients for MT was observed in districts adjacent to these high-volume neurointerventional centers with existing neurovascular networks.

CONCLUSION

The substantial increase in MT procedures observed in Germany between 2016 and 2019 was almost exclusively delivered by high-volume stroke centers performing more than 100 MT procedures per year in established neurovascular networks. As there is still a reasonable number of districts with low MT rates, further structural improvement including implementation of new or expansion of existing neurovascular networks and regional tailored MT triage concepts is needed.

Acute ischemic stroke care in Germany - further progress from 2016 to 2019

Background

Stroke Unit Care (SUC), intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are evidence-based treatment options for acute ischemic stroke (AIS). Using nationwide comprehensive administrative data from Germany, we recently reported nationwide development of AIS admissions, SUC rates, IVT rates and MT rates in Germany between 2010 and 2016. In this update paper, we analyze data on the further development of these data to 2019 after publication of time window extensions for recanalization therapies.

Methods

We considered all hospitalized cases with the main diagnosis of the ICD-10-GM code I63 (AIS) for the year 2019. We identified stroke therapies by using the corresponding Operating and Procedure Keys for IVT, MT and SUC out of the DRG statistics. Regional analyses are based on data from the 412 German administrative districts and cities. We compared the results with those from 2016.

Results

Number of hospitalized AIS patients showed a mild decrease in 2019 (n = 225,531) compared with 2016 (n = 227,687), with significant more AIS patients treated on a stroke unit in 2019 (n = 167,799; 74.4% vs. n = 164,270; 72.1%, p < 0.001). The rate of IVT further increased from 14.9% (n = 33,916) in 2016 to 16.3% (n = 36,745) in 2019 (p < 0.001). Similarly, the MT rate increased from 4.3% (n = 9795) in 2016 to 7.2% (n = 16,135) in 2019 (p < 0.001). There was still a high regional variability for MT (1.4 to 15.2%) according to the place of residence of the AIS patients.

Conclusions

In Germany, the rates of recanalization therapies in patients with AIS continued to increase from 2016 to 2019. Compared to IVT-rates and numbers, the respective data for MT procedures showed an even more pronounced increase.

[Neurovascular manifestations of COVID‑19]

Bereits früh nach Beginn der COVID‑19(„coronavirus disease 2019“)-Pandemie wurden Schlaganfälle als Manifestation oder Komplikation einer SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Infektion beschrieben. Aktuelle Metaanalysen berichten eine Schlaganfallrate von etwa 1,5 %. Schlaganfälle bei COVID‑19-Patienten treten zwar häufiger bei schweren Verläufen der Infektion und bei älteren Patienten mit kardiovaskulären Risiken auf. Nicht selten sind aber auch junge Patienten ohne Risikofaktoren betroffen. Die Schlaganfallmechanismen sind vorwiegend embolisch, die Thromben verschließen häufig große intrakranielle Gefäße und betreffen in mehr als 20 % mehrere Gefäßterritorien, während mikroangiopathische Infarkte selten sind. Die genaue Emboliequelle bleibt bei über 40 % der Betroffenen kryptogen. Die durch das Zusammentreffen einer SARS-CoV-2-Infektion und eines Schlaganfalls bedingte Mortalität beträgt mehr als 15–30 %. Während es in manchen europäischen Regionen zu erheblichen Einschränkungen der Akutversorgung von Schlaganfällen gekommen ist, sind die Behandlungsraten für die Rekanalisationstherapie in Deutschland während der 1. Pandemiewelle weitgehend stabil geblieben. Es stellten sich aber 20–30 % weniger Patienten mit v. a. leichteren Schlaganfällen und transitorischen ischämischen Attacken in Krankenhäusern vor. Die vorliegende Übersichtsarbeit fasst die aktuellen Erkenntnisse zur Epidemiologie und Pathogenese COVID‑19-assoziierter Schlaganfälle zusammen und beschreibt die bisherigen Auswirkungen der Pandemie auf die Schlaganfallakutversorgung.

Photoinduced formation of persistent free radicals, hydrogen radicals, and hydroxyl radicals from catechol on atmospheric particulate matter

Catechol is speculated to be a potential precursor of environmentally persistent free radicals (EPFRs) in the atmosphere. EPFRs absorbed on PM_2.5 have attracted public attention because their toxicity is similar to cigarette smoke. In this study, we found that catechol could produce EPFRs, which were oxygen-centered phenoxy and semiquinone radicals. These free radical species had half-lives of up to 382 days. CaO, CuO, and Fe₂O₃ markedly promoted EPFR formation from catechol. The valence states of Cu and Fe changed during the photochemical reactions of catechol but no valence state changed for Ca. Alkaline nature of CaO is possibly the key for promoting the free radical formations through acid-base reactions with catechol. In addition to hydroxyl free radicals, hydrogen free radicals and superoxide anions formed from the photochemical reactions of catechol were first discovered. This is of concern because of the adverse effects of these free radicals on human health.

•

Photochemical mechanism of persistent free radicals from catechol was clarified

•

Significant free radicals were formed via photochemical reactions of catechol

•

•H and O₂^•− were first discovered from the photochemical reactions of catechol

•

This study is important for better recognizing DNA damage of air inhalation of PM_2.5

Establishing an objective biomarker for corneal cystinosis using a threshold-based Spectral domain optical coherence tomography imaging algorithm

PURPOSE

The purpose of the present study was to establish a semi-automated threshold-based image segmentation algorithm to detect and objectively quantify corneal cystine crystal deposition in ocular cystinosis with anterior segment optical coherence tomography (AS-OCT).

METHODS

This prospective, observational, comparative study included 88 eyes of 45 patients from the German Cystinosis Registry Study as well as 68 eyes of 35 healthy control subjects. All eyes were imaged with AS-OCT (Cirrus HD-OCT 5000, Carl Zeiss Meditec AG, Jena, Germany). As an initial step, B-scan images were subjectively analysed for typical changes in morphology in comparison to healthy controls. Based on the experience gained, an objective semi-automated B-scan image segmentation algorithm was developed using a grey scale value-based threshold method to automatically quantify corneal crystals.

RESULTS

On AS-OCT B-scans, corneal crystals appeared as hyperreflective deposits within the corneal stroma. The crystals were distributed either in all stromal layers (43 eyes, 49%) or confined to the anterior (23 eyes, 26%) or posterior stroma (22 eyes, 25%), respectively. The novel automatic B-scan image segmentation algorithm was most efficient in delineating corneal crystals at higher grey scale thresholds (e.g. 226 of a maximum of 255). Significant differences in suprathreshold grey scale pixels were observable between cystinosis patients and healthy controls (p < 0.001). In addition, the algorithm was able to detect an age-dependent depth distribution profile of crystal deposition.

CONCLUSION

Objective quantification of corneal cystine crystal deposition is feasible with AS-OCT and can serve as a novel biomarker for ocular disease control and topical treatment monitoring.

Female Stroke: Sex Differences in Acute Treatment and Early Outcomes of Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Men and women are differently affected by acute ischemic stroke (AIS) in many aspects. Prior studies on sex disparities were limited by moderate sample sizes, varying years of data acquisition, and inconsistent inclusions of covariates leading to controversial findings. We aimed to analyze sex differences in AIS severity, treatments, and early outcome and to systematically evaluate the effect of important covariates in a large German stroke registry.

METHODS

Analyses were based on the Stroke Registry of Northwestern Germany from 2000 to 2018. We focused on admission-stroke severity and disability, acute recanalization treatment, and early stroke outcomes. Potential sex divergences were investigated via odds ratio (OR) using logistic regression models. Covariates were introduced in 3 steps: (1) base models (age and admission year), (2) partially adjusted models (additionally corrected for acute stroke severity and recanalization treatment), (3) fully adjusted models (additionally adjusted for onset-to-admission time interval, prestroke functional status, comorbidities, and stroke cause). Models were separately fitted for the periods 2000 to 2009 and 2010 to 2018.

RESULTS

Data from 761 106 patients with AIS were included. In fully adjusted models, there were no sex differences with respect to treatment with intravenous thrombolysis (2000-2009: OR, 0.99 [95% CI, 0.94-1.03]; 2010-2018: OR, 1.0 [0.98-1.02]), but women were more likely to receive intraarterial therapy (2010-2018: OR, 1.12 [1.08-1.15]). Despite higher disability on admission (2000-2009: OR, 1.10 [1.07-1.13]; 2010-2018: OR, 1.09 [1.07-1.10]), female patients were more likely to be discharged with a favorable functional outcome (2003-2009: OR, 1.05 [1.02-1.09]; 2010-2018: OR, 1.05 [1.04-1.07]) and experienced lower in-hospital mortality (2000-2009: OR, 0.92 [0.86-0.97]; 2010-2018: OR, 0.91 [0.88-0.93]).

CONCLUSIONS

Female patients with AIS have a higher chance of receiving intraarterial treatment that cannot be explained by clinical characteristics, such as age, premorbid disability, stroke severity, or cause. Women have a more favorable in-hospital recovery than men because their higher disability upon admission was followed by a lower in-hospital mortality and a higher likelihood of favorable functional outcome at discharge after adjustment for covariates.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Background

Recent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO).

Methods

We performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10).

Results

Successful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation.

Conclusion

Direct or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.

Analysis of Nationwide Stroke Patient Care in Times of COVID-19 Pandemic in Germany

BACKGROUND AND PURPOSE

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many countries have introduced strict hygiene measures of social distancing to prevent further spreading of the disease. This may have led to a decreased presentation to hospital of patients with acute medical conditions and time-dependent management, such as stroke.

METHODS

We conducted a nationwide cohort study using administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke (AIS), transient ischemic attack, or intracerebral hemorrhage. Data from a total of 1463 hospitals in Germany were included. We compared case numbers and treatment characteristics of pandemic (March 16 to May 15, 2020) and prepandemic (January 16 to March 15, 2020) cases and also with corresponding time period in 2019.

RESULTS

We identified a strong decline for hospitalization of AIS (-17.4%), transient ischemic attack (-22.9%), and intracerebral hemorrhage (-15.8%) patients during the pandemic compared with prepandemic period. IVT rate in patients with AIS was comparable (prepandemic versus pandemic: 16.4% versus 16.6%, P=0.448), whereas mechanical thrombectomy rate was significantly higher during the pandemic (8.1% versus 7.7%, P=0.044). In-hospital mortality was significantly increased in patients with AIS during the pandemic period (8.1% versus 7.6%, P=0.006).

CONCLUSIONS

Besides a massive decrease in absolute case numbers, our data suggest that patients with AIS who did seek acute care during the pandemic, continued to receive acute recanalization treatment in Germany.

Comparison of stroke care parameters in acute ischemic stroke patients with and without concurrent Covid-19. A Nationwide analysis

BACKGROUND

Comparing health care parameters of acute ischemic stroke (AIS) patients with and without concurrent coronavirus disease 2019 (Covid-19, SARS-CoV-2 infection), may be helpful in terms of optimizing clinical and public health care during pandemic.

METHODS

We evaluated a nationwide administrative database of all hospitalized patients with main diagnosis of acute ischemic stroke with/without diagnosis of Covid-19 who were hospitalized during the time period from January 16th to May 15th, 2020. Data from a total of 1463 hospitals in Germany were included. We compared case numbers, treatment characteristics (intravenous thrombolysis, IVT; mechanical thrombectomy, MT; treated on an intensive care unit, stroke unit or regular ward) and in-hospital mortality of AIS with and without concurrent diagnosis of Covid-19.

RESULTS

From a total of 30,864 hospitalized Covid-19 patients during the evaluation period in Germany, we identified a subgroup of 213 patients with primary diagnosis of AIS. Compared to the 68,700 AIS patients without Covid-19, this subgroup showed a similar rate of IVT (16.4% vs. 16.5%, p = 0.985) but a significantly lower rate of MT (3.8% vs. 7.9%, p = 0.017). In-hospital mortality rate was significantly higher in patients with AIS and concurrent Covid-19 compared to non-infected AIS patients (22.5% vs. 7.8%, p < 0.001).

CONCLUSION

These nationwide data point out differences in mortality and medical treatment regime between AIS patients with and without concurrent Covid-19. Since the pandemic is still ongoing, these data draw attention to AIS as a less frequent but often fatal comorbidity in Covid-19 patients.

Rapid-Scan Electron Paramagnetic Resonance of Highly Resolved Hyperfine Lines in Organic Radicals

X-band (ca. 9 GHz) fluid solution rapid-scan electron paramagnetic resonance spectra are reported for radicals with multiline spectra and resolution of hyperfine lines as narrow as 30 mG. Highly-resolved spectra of 3-carbamoyl-2,2,5,5-tetramethylpyrrolidin-1-yloxy, diphenylnitroxide, galvinoxyl, and perylene cation radical with excellent signal-to-noise are shown, demonstrating the capabilities of the rapid-scan technique to characterize very small, well-resolved hyperfine couplings. To acquire high resolution spectra the signal bandwidth must be less than the resonator bandwidth. Signal bandwidth is inversely proportional to linewidth and proportional to scan rate. Resonator bandwidth is inversely proportional to resonator Q. Proper selection of scan rate and resonator Q is needed to achieve resolution of closely-spaced narrow EPR lines.

Stroke care during the COVID-19 pandemic: experience from three large European countries

In order to cope with the exponentially increasing number of patients infected with SARS-CoV-2, European countries made enormous efforts to reorganize medical assistance and several diseases, including stroke, were particularly impacted. We report the experience of stroke neurologists from three European countries (Italy, France and Germany) that faced the pandemic at diverse time points and with different approaches, depending on their resources and healthcare system organization. Pre-hospital and in-hospital acute stroke pathways were reorganized to prioritize COVID-19 management and, in severely affected regions of Italy and France, stroke care was centralized to a limited number of centers, whereas the remaining stroke units were dedicated to patients with COVID-19. Access to acute stroke diagnostics and time-dependent therapies was limited or delayed because of reduced capacities of emergency services due to the burden of patients with COVID-19. A marked reduction in the number of patients presenting with transient ischaemic attack and stroke was noted in the emergency departments of all three countries. Although we only have preliminary data, these conditions may have affected stroke outcome. These indirect effects of the COVID-19 pandemic could negate the efforts of stroke neurologists over the last few years to improve outcome and reduce mortality of stroke patients. Although the SARS-CoV-2 infection rate is slowing down in Europe, the effects of ending lockdown in the next months are unpredictable. It is important for the European and world stroke community to share what has been learned so far to be plan strategies to ensure stroke care in the future and upcoming challenging times.

[Autopneumonectomie. A Forgotten Disease]

HISTORY

 An 80-year old female was referred to our hospital with left internal carotid artery stenosis and a childhood history of hemoptysis.

INVESTIGATIONS AND DIAGNOSIS

 The ECG showed 2nd degree Mobitz atrio-ventricular block. The chest x-ray and computerized tomography identified a shift of the mediastinum and the heart to the left. The left lung was completely destroyed whilst the right lung was enlarged and crossed the midline. Pulmonary function tests revealed a moderate restrictive ventilation disorder. The diagnosis of autopneumonectomy was based on patient history together with radiological findings.

TREATMENT AND COURSE

 A pacemaker was implanted with two stimulation electrodes via a left cephalic venous cutdown. A carotid endarterectomy was also performed without any complication.

CONCLUSION

 After autopneumonectomy, postpneumonectomy like syndrome may occur in very rare cases, whereupon operative treatment is mandatory. Any respiratory infections should be treated with antibiotics. Pacemaker electrode placement via the subclavian vein is contraindicated due to the risk of a catastrophic pneumothorax.

55Non-invasive ECG-imaging for identification of atrial arrhythmogenic low voltage substrate in patients with persistent atrial fibrillation

Background/Introduction

Left atrial (LA) fibrosis is associated with increased arrhythmia recurrence rates after pulmonary vein isolation (PVI) and increased stroke risk in patients with atrial fibrillation (AF). So far, detection and quantification of LA fibrosis is only feasible by invasive electrophysiological mapping of low-voltage-substrate (LVS) or delayed enhancement areas in MRI.

Purpose

The aim of this study was to assess the distribution and extent of atrial fibrosis by non-invasive ECG-Imaging (ECGI) in patients with persistent AF prior to PVI.

Methods

Thirty-seven consecutive patients (66 ± 9 years, 84% male) presenting for their first PVI were included. Patients with AF were cardioverted into sinus rhythm (SR). One day prior to AF ablation procedure, patients underwent ECGI in SR using the 252-electrode-array (CardioInsight) and a low-X-ray-dose, non-injected cardiac CT-scan to assess the relationship between ECGI-electrodes and cardiac epicardial structures. Prior to PVI, high-density biatrial voltage and activation maps were acquired in SR (CARTO-3). Localization and extent of atrial LVS (relevant fibrosis: LA-LVS: ≥5cm2 at &lt;0.5mV threshold) and biatrial activation times depicted by CARTO were compared with atrial activation/conduction times assessed by non-invasive ECGI.  Presence of LA-LVS was classified according to its extent into 3 stages and compared to the inter- and intraatrial conduction delay in ECGI.

Results

Relevant atrial fibrosis was found in 17/37(46%) patients. Presence of biatrial LVS resulted in a linear increase of the biatrial activation time in CARTO-SR-maps (146 ± 18ms in patients without LVS vs 184 ± 27ms in patients with LVS, p &lt; 0.001) and in non-invasive ECGI (133 ± 11ms vs 170 ± 20ms, p &lt; 0.001).

Both the extent of biatrial LVS and invasively measured total activation time correlated well with non-invasive total atrial conduction time (TACT) in ECGI (r = 0.91 and r = 0.82, respectively, figure). Moreover, the extent of LA-LVS showed an excellent correlation to TACT in ECGI (r = 0.89).

A combination of inter-atrial (RA-LA) conduction delay and TACT in ECGI allowed to quantify the extent of LA-LVS and to distinguish between three stages of LA-LVS: Stage 1 (minimal LA-LVS: 1 ± 2cm2): ECGI revealed rapid RA&LA activation with short TACT 132 ± 9ms; Stage 2 (moderate LA-LVS: 14 ± 8cm2 involving the anteroseptal LA) was associated with delayed LA activation and prolonged TACT measuring 161 ± 7ms; Stage 3 (extensive LA-LVS involving the anteroseptal and posterior LA: 26 ± 17cm2) was characterized by a significantly delayed LA activation with a TACT of 178 ± 24ms in ECGI.

Conclusion

Analysis of interatrial conduction delay and total atrial conduction time (TACT) in non-invasive ECGI allows accurate staging of patients with arrhythmogenic atrial LVS who present an increased risk for arrhythmia recurrences and stroke.

Abstract Figure.

Changes in Renal Function After Switching From TDF to TAF in HIV-Infected Individuals: A Prospective Cohort Study

Background

Replacing tenofovir disoproxil fumarate (TDF) with tenofovir alafenamide (TAF) improves renal tubular markers in HIV-infected individuals but the impact on estimated glomerular filtration rate (eGFR) remains unclear.

Methods

In all participants from the Swiss HIV Cohort Study who switched from TDF to TAF-containing antiretroviral regimen or continued TDF, we estimated changes in eGFR and urine protein-to-creatinine ratio (UPCR) after 18 months using mixed-effect models.

Results

Of 3520 participants (26.6% women, median age 50 years), 2404 (68.5%) switched to TAF. Overall, 1664 (47.3%) had an eGFR &lt;90 mL/min and 1087 (30.9%) an UPCR ≥15 mg/mmol. In patients with baseline eGFR ≥90 mL/min, eGFR decreased with the use of TDF and TAF (−1.7 mL/min). Switching to TAF was associated with increases in eGFR of 1.5 mL/min (95% confidence interval [CI], .5–2.5) if the baseline eGFR was 60–89 mL/min, and 4.1 mL/min (95% CI, 1.6–6.6) if &lt;60 mL/min. In contrast, eGFR decreased by 5.8 mL/min (95% CI, 2.3–9.3) with continued use of TDF in individuals with baseline eGFR &lt;60 mL/min. UPCR decreased after replacing TDF by TAF, independent of baseline eGFR.

Conclusions

Switching from TDF to TAF improves eGFR and proteinuria in patients with renal dysfunction.

Incidence of Acute Kidney Injury After Computed Tomography Angiography±Computed Tomography Perfusion Followed by Thrombectomy in Patients With Stroke Using a Postprocedural Hydration Protocol

Background The risk of contrast-induced acute kidney injury (AKI) in patients with stroke receiving both computed tomography (CT) angiography and mechanical thrombectomy has been investigated only in small case series. No studies have investigated whether additional CT perfusion or chronic kidney disease (CKD) are associated with higher rates of AKI. Methods and Results Retrospective analysis of the AKI incidence in 1089 consecutive patients receiving CT angiography and mechanical thrombectomy from 2015 to 2017 and in subgroups with CKD (n=99) and CT perfusion (n=104) was performed. Patients received a standardized hydration protocol. Data on kidney function after mechanical thrombectomy were available in 1017 patients. A total of 59 (5.8%) patients developed AKI, and only 4 (6.8%) patients needed hemodialysis, all with known CKD. Patients with AKI significantly more often had known CKD (20.3% versus 8.4%, P=0.002), diabetes mellitus (33.9% versus 20.9%, P=0.018), and tandem occlusion (32.2% versus 16.2%, P=0.003) and a significantly higher in-hospital mortality (20.3% versus 7.0%, P<0.001) compared with patients without AKI. However, there were no significant independent predictors for AKI in multivariable logistic regression analysis. Sex (odds ratio [OR], 2.03; 95% CI, 1.17-3.52 [P=0.012]), higher National Institutes of Health Stroke Scale (OR, 1.10; 95% CI, 1.05-1.14 [P<0.001]), AKI (OR, 3.52; 95% CI, 1.63-7.64 [P=0.001]), diuretic use (OR, 1.80; 95% CI, 1.02-3.19), futile or incomplete recanalization (OR, 0.19; 95% CI, 0.09-0.40 [P<0.001]), and total volume of contrast agent volume (OR, 1.007; 95% CI, 1.002-1.011 [P=0.004]) were independently associated with in-hospital death. Two thirds of the patients with AKI died of severe brain damage and not AKI itself. Conclusions Post-contrast AKI rarely occurs in patients with stroke receiving a contrast agent for CT angiography/CT perfusion and subsequent mechanical thrombectomy. Patients with known CKD had higher rates of AKI and only these patients needed hemodialysis, but CKD was not independently associated with AKI or in-hospital mortality.

Short-Range Disorder in TeO2 Melt and Glass

High-resolution X-ray pair distribution functions for molten and glassy TeO₂ reveal coordination numbers n_TeO ≈ 4. However, distinct from the known α-, β-, and γ-TeO₂ polymorphs, there is considerable short-range disorder such that no clear cutoff distance between bonded and nonbonded interactions exists. We suggest that this is similar to disorder in δ-TeO₂ and arises from a broad distribution of asymmetric Te-O-Te bridges, something that we observe becomes increasingly asymmetric with increasing liquid temperature. Such behavior is qualitatively consistent with existing interpretations of Raman scattering spectra, and equivalent to temperature-induced coordination number reduction, for sufficiently large cutoff radii. Therefore, TeO₂ contains a distribution of local environments that are, furthermore, temperature dependent, making it distinct from the canonical single-oxide glass formers. Our results are in good agreement with high-level ab initio cluster calculations.

Anthropogenic control over wintertime oxidation of atmospheric pollutants

During winter in the mid-latitudes, photochemical oxidation is significantly slower than in summer and the main radical oxidants driving formation of secondary pollutants, such as fine particulate matter and ozone, remain uncertain, owing to a lack of observations in this season. Using airborne observations, we quantify the contribution of various oxidants on a regional basis during winter, enabling improved chemical descriptions of wintertime air pollution transformations. We show that 25-60% of NO_x is converted to N₂O₅ via multiphase reactions between gas-phase nitrogen oxide reservoirs and aerosol particles, with ~93% reacting in the marine boundary layer to form >2.5 ppbv ClNO₂. This results in >70% of the oxidizing capacity of polluted air during winter being controlled, not by typical photochemical reactions, but from these multiphase reactions and emissions of volatile organic compounds, such as HCHO, highlighting the control local anthropogenic emissions have on the oxidizing capacity of the polluted wintertime atmosphere.

Inpatient TIA and stroke care in adult patients in Germany - retrospective analysis of nationwide administrative data sets of 2011 to 2017

BACKGROUND

Comprehensive administrative data on TIA and stroke cases and treatment modalities are fundamental for improving structural conditions and adjusting future strategies of stroke care.

METHODS

The nationwide administrative database (German federal statistical office) was used to extract all adult inpatient TIA and stroke cases and corresponding procedural codes for the period 2011-2017. Numbers were specified according to age, sex, stroke unit (SU) and critical care treatment (ICU), early transfer, and in-hospital mortality.

FINDINGS

Inpatient adult TIA/stroke cases increased from annually 102,406 / 250,199 (2011) to 106,245 / 264,208 (2017). 84% of strokes were ischemic (AIS) also having the highest relative increase most likely due to more accurate coding within the time period, 68.2% of AIS were treated on SUs. 78% of hemorrhagic strokes were intracerebral hematomas (ICH; rather than subarachnoid hemorrhages [SAH]). Hemorrhagic strokes were increasingly treated on SUs (32.6% [2011], 37.8% [2017]). 68.8% of SAH were treated on ICUs (ICH:36.3%, AIS:10.3%). Early transfer in AIS increased (2.0 to 3.1%). Hemorrhagic strokes were associated with higher in-hospital mortality (SAH:19.6%, ICH:28.2%, AIS:7.3%).

INTERPRETATION

The absolute increase of strokes presumably reflects the aging society and more awareness for cerebrovascular disease. The relative increase of AIS may be attributable to an increased neurological expertise. The increasing amount of early transfers in AIS reflects new specialized treatment options. Our findings reflect the need for structural adjustments in inpatient stroke care.

Determination of Deoxynivalenol in Cereals and Cereal Products by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the UK Food Standards Agency to evaluate the effectiveness of an immunoaffinity column cleanup liquid chromatographic (LC) method for the determination of deoxynivalenol in a variety of cereals and cereal products at proposed European regulatory limits. The test portion was extracted with water. The sample extract was filtered and applied to an immunoaffinity column. After being washed with water, the deoxynivalenol was eluted with acetonitrile or methanol. Deoxynivalenol was quantitated by reversed-phase LC with UV determination. Samples of artificially contaminated wheat-flour, rice flour, oat flour, polenta, and a wheat based breakfast cereal, naturally contaminated wheat flour, and blank (very low level) samples of each matrix were sent to 13 collaborators in 7 European countries. Participants were asked to spike test portions of all samples at a range of deoxynivalenol concentrations equivalent to 200–2000 ng/g deoxynivalenol. Average recoveries ranged from 78 to 87%. Based on results for 6 artificially contaminated samples (blind duplicates), the relative standard deviation for repeatability (RSDr) ranged from 3.1 to 14.1%, and the relative standard deviation for reproducibility (RSDR) ranged from 11.5 to 26.3%. The method showed acceptable within-laboratory and between-laboratory precision for all 5 matrixes, as evidenced by HorRat values &lt;1.3.

Age and Sex Differences in Ischemic Stroke Treatment in a Nationwide Analysis of 1.11 Million Hospitalized Cases

Background and Purpose- To date, there is still uncertainty about age and sex differences in access to stroke unit treatment and use of intravenous thrombolysis (IVT), while age and sex differences have not been investigated for the new treatment option of mechanical thrombectomy (MT). We, therefore, undertook a complete nationwide analysis of all hospitalized ischemic stroke patients in Germany from 2013 to 2017. Methods- We used the nationwide administrative database of the German Federal Statistical Office and investigated access to stroke unit treatment, IVT, MT, and in-hospital mortality. Patients were subdivided into 6 predefined age groups (20-44, 45-59, 60-69, 70-79, 80-89, and >90 years). Pooled overall and age group estimates were calculated using the random-effects model. To evaluate potential sex disparities, we estimated odds ratios (ORs) with 95% CIs. Results- A total of 1 112 570 patients were hospitalized for first or recurrent ischemic stroke from 2013 to 2017. Overall, stroke unit treatment increased significantly from 66.8% in 2013 to 73.5% in 2017, as did IVT (from 12.4% to 15.9%) and MT (from 2.4% to 5.8%; all P<0.001). Although the difference became smaller over time, patients ≥80 years of age still received significantly less often treatments. Men of all age groups had a significantly higher probability receiving stroke unit treatment (OR, 1.11; 95% CI, 1.09-1.12) and lower in-hospital mortality (OR, 0.91; 95% CI, 0.89-0.93). No disparity was observed in the use of IVT (OR, 1.00; 95% CI, 0.98-1.01), while women of all ages were treated more often with MT (OR, 1.26; 95% CI, 1.22-1.30). Conclusions- Access to stroke unit treatment has to be increased in both older patients and women of all ages. While there was no sex difference in IVT use, it is important to further investigate the significantly higher frequency of MT in women with ischemic stroke irrespective of age.

Assessment of pops contaminated sites and the need for stringent soil standards for food safety for the protection of human health

Persistent organic pollutants (POPs) including PCDD/Fs, PCBs and organochlorine pesticides (OCPs) are among the most important and hazardous pollutants of soil. Food producing animals such as chicken, beef, sheep and goats can take up soil while grazing or living outdoors (free-range) and this can result in contamination. In recent decades, large quantities of brominated flame retardants such as polybrominated diphenyl ethers (PBDEs), short-chain chlorinated paraffins (SCCPs) and per- and polyfluorinated alkylated substances (PFAS) have been produced and released into the environment and this has resulted in widespread contamination of soils and other environmental matrices. These POPs also bioaccumulate and can contaminate food of animal origin resulting in indirect exposure of humans. Recent assessments of chicken and beef have shown that surprisingly low concentrations of PCBs and PCDD/Fs in soil can result in exceedances of regulatory limits in food. Soil contamination limits have been established in a number of countries for PCDD/Fs but it has been shown that the contamination levels which result in regulatory limits in food (the maximum levels in the European Union) being exceeded, are below all the existing soil regulatory limits. 'Safe' soil levels are exceeded in many areas around emission sources of PCDD/Fs and PCBs. On the other hand, PCDD/F and dioxin-like PCB levels in soil in rural areas, without a contamination source, are normally safe for food producing animals housed outdoors resulting in healthy food (e.g. meat, eggs, milk). For the majority of POPs (e.g. PBDEs, PFOS, PFOA, SCCP) no regulatory limits in soils exist. There is, therefore, an urgent need to develop appropriate and protective soil standards minimising human exposure from food producing animals housed outdoors. Furthermore, there is an urgent need to eliminate POPs pollution sources for soils and to control, secure and remediate contaminated sites and reservoirs, in order to reduce exposure and guarantee food safety.

Molten barium titanate: a high-pressure liquid silicate analogue

The structure of molten BaTiO₃ has been measured using laser heating, aerodynamic levitation and a combination of neutron diffraction with Ti isotope substitution, x-ray diffraction and spectroscopy. All measurements indicate a Ti-O coordination of n _TiO  =  4.4(2), far lower than the perovskite or hexagonal crystalline forms. However, n _TiO  >  4 suggests structural analogy with molten silicates at high pressures. We introduce methodology for ascertaining such analogies and demonstrate similarity with molten CaSiO₃ at upper mantle pressures circa 5 GPa. Although some topological differences exist, we propose that planetary melt analogues provide rich insight into important processes relevant to hot exoplanets and Earth's early history.

Why do sub-Saharan Africans present late for HIV care in Switzerland?

OBJECTIVES

Late presentation (LP) to HIV care disproportionally affects individuals from sub-Saharan Africa (SSA). We explored the reasons for late presentation to care among this group of patients in the Swiss HIV Cohort Study.

METHODS

The prevalence of LP was compared between patients from Western Europe (WE) and those from SSA enrolled between 2009 and 2012. Patients were asked about HIV testing, including access to testing and reasons for deferring it, during face-to-face interviews.

RESULTS

The proportion of LP was 45.8% (435/950) among patients from WE, and 64.6% (126/195) among those from SSA (P < 0.001). Women from WE were slightly more likely to present late than men (52.6% versus 44.5%, respectively; P = 0.06), whereas there was no sex difference in patients from SSA (65.6% versus 63.2%, respectively; P = 0.73). Compared with late presenters from WE, those from SSA were more likely to be diagnosed during pregnancy (9.1% versus 0%, respectively; P < 0.001), but less likely to be tested by general practitioners (25.0% versus 44.6%, respectively; P = 0.001). Late presenters from SSA more frequently reported 'not knowing about anonymous testing possibilities' (46.4% versus 27.3%, respectively; P = 0.04) and 'fear about negative reaction in relatives' (39.3% versus 21.7%, respectively; P = 0.05) as reasons for late testing. Fear of being expelled from Switzerland was reported by 26.1% of late presenters from SSA.

CONCLUSIONS

The majority of patients from SSA were late presenters, independent of sex or education level. Difficulties in accessing testing facilities, lack of knowledge about HIV testing and fear-related issues are important drivers for LP in this population.

Time Point, Etiology, and Short-Term Outcome of Repeated Mechanical Thrombectomy Due to Recurrent Large Vessel Occlusion

Background: Data on time point and etiology of repeated stroke caused by large brain vessel occlusion (LVO) resulting in repeated mechanical thrombectomy (MT) in acute stroke patients is very limited.

Methods: We retrospectively reviewed all acute stroke patients treated with MT with stent retrievers or aspiration systems between January 2010 and June 2018 to identify patients who received two or more MT treatments due to recurrent LVO in our tertiary neurovascular center. Short-term outcome was assessed using the NIH stroke scale score at discharge.

Results: We identified 35 out of 2,470 acute stroke patients treated with MT who had recurrent LVO and received repeated MT. Mean age at first MT was 69.3 (±15.8) years and the mean time interval between the first and second MT was 147 (±241) days, and 8 patients experienced short-term LVO recurrence within 3 days. Fifteen (43%) patients had cardioembolic, 9 (26%) arterioembolic, 4 (11%) mixed cardio-/arterioembolic, and 7 (20%) patients had unknown stroke etiology. Patients with cardioembolic stroke were substantially older, had no or insufficient oral anticoagulation at the time of the first and repeated LVO, and repeated LVO occurred very early in 50%. Seventeen (49%) patients had a NIHSS score of 0 or 1 at discharge and seven (20%) patients died in the hospital after repeated MT. No bleeding complications occurred.

Conclusions: Repeated MT due to recurrent LVO is a rarely performed, safe, and effective procedure in acute stroke patients. Missing or insufficient anticoagulation is the most frequent cause for recurrent LVO.

Distribution and evolution of acute interventional ischemic stroke treatment in Germany from 2010 to 2016

Background

Mechanical thrombectomy (MT) is a new evidence-based treatment option for large vessel occlusion in the anterior brain circulation. Using comprehensive administrative data from Germany, we analysed the nationwide development of intravenous thrombolysis (IVT) and MT in Germany between 2010 and 2016.

Methods

We considered all documented cases (n = 1,515,634) with a main diagnosis of the ICD-10-GM code I63 (ischemic stroke) and identified specific stroke recanalization therapy by using the corresponding Operating and Procedure Key for systemic thrombolysis and mechanical thrombectomy out of the DRG statistics. Regional analyses are based on data from the 413 German administrative districts and cities and the obligatory quality reports of all hospitals. We distinguished between rates of MT related to place of residence of patients and place of treatment.

Results

Coded ischemic strokes increased by 10.2% from 2010 (n = 206.688) to 2016 (n = 227.687). The rate of IVT increased from 8.9% in 2010 to 14.9% in 2016 and the rate of MT increased from 0.8% in 2010 to 4.7% in 2016 with a strong increase in 2015 and 2016. There was a high regional variability of MT according to place of residence of patients between 0 and 11.2% in 2016 with significant lower treatment rates in rural compared to urban areas (3.8 vs 5.4%). Mean age of patients treated with MT increased from 67.8 years in 2010 to 73.3 years in 2016 and almost reached the mean age of IVT treated patients (74.4 years). The number of hospitals coding MT increased from 91 to 193 from 2010 to 2016, but 80% of all MT procedures were performed in neurointerventional centers with ≥50 procedures/year in 2016.

Conclusions

The rate of IVT in patients with acute ischemic stroke in Germany continues to rise and has reached 14.9% nationwide. The increase of MT is even more pronounced and was triggered by the evidence after publication of the MT randomized trials. There is still a high regional variability with significant lower MT rates in rural areas.

Treatment Methods and Early Neurologic Improvement After Endovascular Treatment of Tandem Occlusions in Acute Ischemic Stroke

Background and Purpose: A tandem occlusion of the intracranial circulation and the extracranial carotid artery (ICA) occurs in 10–20% of all strokes based on large vessel occlusion (LVO). The optimal treatment strategy for those patients is unknown. We report our management strategy and the outcome in these patients in a large single-center cohort.

Materials and Methods: We retrospectively identified and analyzed all patients treated by Mechanical Thrombectomy (MT) for an intracranial LVO associated with an occlusion of the extracranial ICA between April 2009 and May 2016 (163/1,645, 9.9%). The following data was collected: Recanalization rate, occurrence of symptomatic intracranial hemorrhage (sICH), clinical result according to the early neurological improvement (ENI, NIHSS score improvement of ≥8 points after 24 h or NIHSS score of 0 or 1 after 3 days) and functional outcome and mortality during long term follow up. Secondary endpoints were the patency of the internal carotid artery at 24 h. Patient demographics and anti-aggregation regimen were recorded as co-variables.

Results: 163/1,645 (9.9%) MT patients had a tandem occlusion. All thrombectomy procedures were performed with stent retrievers. PTA with or without additional placement of a stent was performed in 149 vs. 14 patients. The overall rate of TICI IIB/III recanalization was 91.4%. An early neurological improvement was found in 79 of 163 patients (48.4%), 51% (76/149) in the stent group and 21% (3/14) in the non stent group. 120/163 patients (73.6%) had a long term favorable outcome (mRS 0–2). The ICA re-occlusion rate at 24 h was 5.4% (8/149) in the stent group and 42% (6/14) in the non stent group. The rate of symptomatic hemorrhage was 4.9%.

The regression analysis showed that only younger age (p = 0.002) and shorter recanalization times (p = 0.017) were associated with good outcome.

Conclusion: Stent-PTA of the ICA in addition to MT with a stent retriever was safe and effective in tandem occlusion of the anterior brain circulation. PTA and MT without stenting in tandem lesions showed a higher early re-occlusion rate and lower rate of early neurological improvement. The technical approach should aim for the fastest possible recanalization of the intracranial vessels, either with stenting first or last.

Inventory and substance flow analysis of polybrominated diphenyl ethers in the Nigerian transport sector-end-of-life vehicles policy and management

Recently, certain polybrominated diphenyl ethers (PBDEs) have been listed as persistent organic pollutants (POPs) in the Stockholm Convention. In this study, a preliminary material and substance flow analysis of commercial pentabromodiphenyl ether (c-PentaBDE) was conducted for motor vehicles-a major use sector for POP-PBDE in polyurethane (PUR) foam-for Nigeria. The methodology of the Stockholm Convention PBDE inventory guidance was used for the calculation of c-PentaBDE. Material/substance flow analysis was conducted applying the STAN software. The time frame for this analysis was 1980-2010, considering that this was the period when POP-PBDE-containing vehicles were largely imported into Nigeria.It is estimated that the approximately 19 million passenger cars imported from 1980 to 2010 contained ca. 270 t of POP-PBDEs in ca. 401,000 t of PUR foam. A major share of cars from the USA and only a small share of cars from Europe and Asia were impacted. This simplified material and substance flow of PUR foams and POP-PBDEs in motor vehicles demonstrated the potential for environmental/human contamination and pollution of recycling/reuse for Nigeria and other developing countries.The study developed the first preliminary inventory of end-of-life vehicles for Nigeria, following which the environment ministry has taken up the important issue of end-of-life vehicles management. Considering that a range of other pollutants are contained in vehicles (e.g. heavy metals, flame retardants, PCBs, chlorofluorocarbons, hydrofluorocarbons and waste oil), this initiated activity should finally lead to an integrated management of pollutants and resources from the transport sector.