Experience with homologous lyophilised nerve grafts in the treatment of peripheral nerve injuries

Report of a series of 18 late secondary nerve grafts using lyophilised (disantigenised and disenzymatised) homografts of the Braun Melsungen Company. In contrast to the publication of Kuhlendahl et al. (1972) 32% of the cases showed definitive signs of regeneration. Therefore, in spite of the fact that autografts give better results, further research into the possibilities of homografts seems desirable. Their potential usefulness obviously is restricted to cases in which from any reasons autologous nerve grafts are not available.

Sex related differences in vascular interventions and outcome of patients with critical limb threatening ischemia in a real-world cohort

Background

The prevalence of critical limb threatening ischemia (CLTI) is increasing worldwide and the focus is the reduction of outcome events like death or amputation of the lower limb (LL). Sex related differences in medical supply and outcome are a current matter of debate.

Purpose

In the present study, we included patients with CLTI in an unselected “real-world” cohort and studied sex related differences in their risk profile and vascular interventions, as well as their impact on long-term outcome.

Methods

We analyzed 119,953 unselected patients of the public health insurance in Germany (AOK), which were hospitalized between 2010 and 2017 for a main diagnosis of CLTI (Rutherford stage (RF) 4–6). In our data files, a baseline period of 2 years previous index hospitalization and a follow-up period until 2018 was included.

Results

In our cohort, more than half were male CLTI patients (57% male vs. 43% female), while female CLTI patients were at higher age (median: 73.8 years male vs. 81.4 years female). Male patients had higher ratios of diabetes, dyslipidemia, smoking, cerebrovascular disease and chronic coronary syndrome, whereas female CLTI patients show a higher prevalence of hypertension, atrial fibrillation, chronic heart failure and chronic kidney disease (all p<0.001). During index hospitalisation more than one quarter of all CLTI patients suffered from rest pain (RF 4), and approximately one third for minor (RF 5) and one third for major (RF 6) tissue lost. Female patients were more often diagnosed with RF 5 (32% male vs. 36% female), while the proportion of male patients was slightly higher at RF 4 (29% male vs. 27% female) and RF 6 (39% male vs. 37% female, all p<0.001).

During index hospitalization, almost 70% underwent any diagnostic angiography and in 63% of all patients a revascularization procedure was performed. Both were carried out more often in male patients (both p<0.001).The Kaplan Meier curve showed an increased mortality rate in female patients during follow up (figure 1), while no differences were observed for the combined endpoint amputation of the LL or death. Interestingly after adjustment for age and patients risk'constellation, female gender was associated with increased overall-survival (female HR 0.95; 95%-CI 0.94–0.96, p<0.001) and amputation-free survival which is a combined endpoint of amputation of the LL or death (female HR 0.84; 95%-CI 0.83–0.85, p<0.001).

Conclusion

Female patients with CLTI were older and showed lower rates of diagnostic angiography and revascularization procedures of the LL during index hopsitalization. Nevertheless, male sex was an independent risk factor for all-cause mortality and the combined endpoint amputation of the LL or death during long-term follow-up. These results indicate that further analyses are needed to determine the various individual needs of male and female CLTI patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The project upon which this publication is based was funded by The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051).

Acute and long-term outcomes of ST-elevation myocardial infarction in cancer patients

Background

Myocardial infarctions (MI) and cancer are each very serious morbidities. To evaluate their interaction in the “real world”, a retrospective analysis was performed in patients with ST-elevation MI (STEMI) and pre-existing cancer.

Methods

Anonymized data from patients admitted to hospital between 2010 and 2017 due to STEMI were analyzed from 24 months before and up to nine years after the index hospitalization by one of Germany's largest statutory Health Insurance Funds (Allgemeine Ortskrankenkasse - AOK). Qualitative data were tested via two-sided Chi-squared test and quantitative data were tested using a two- sided Wilcoxon test. The eight year overall survival (OS) rate was determined with a Kaplan Meier estimator. The endpoint OS was analysed using multivariable Cox-regression model.

Results

From 175,262 STEMI patients, 27,213 had cancer (15.5%). Most frequent were skin (24.9%), prostate (17.0%), colon (11.0%), breast (10.9%), urinary tract (10.6%), and lung cancer (5.2%). STEMI patients with malignancies were older, presented more often with coronary three-vessel-disease, classical risk factors, atrial arrhythmias, kidney disease, heart failure, cerebrovascular and peripheral artery disease (PAD) (each p<0.001). They showed more often previous MI, percutaneous coronary interventions (PCI), cardiac surgery, and stroke (all p<0.001). Acute PCIs were applied approximately 2–6 percent points less frequently compared to those without (w/o) cancer, with less drug-eluting and more often bare metal stents (all p<0.001). In-hospital adverse events occurred more frequently in cancer. Eight-year survival was 57.3% (95% CI 57.0% – 57.7%) w/o cancer, and ranged between 41.2% and 19.2% in distinct cancer types. Multivariable Cox regression for death during follow-up found e.g. lung cancer (HR 2.04, 95% CI 1.92–2.17), PAD stage 4–6 (HR 1.78, 95% CI 1.72–1.84) and previous stroke (HR 1.44, 95% CI 1.31–1.54) to have the strongest effect, while obesity (HR 0.95, 95% CI 0.93–0.97) was associated with lower mortality (all p<0.001).

Conclusion

In this large “real world” health insurance data from Germany, prognosis after STEMI was markedly reduced but differed widely between cancer types. No withholding of revascularization therapies in cancer patients could be observed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051).

Contemporary in-hospital and long-term prognosis of patients with acute ST-elevation myocardial infarction and chronic kidney disease in Germany

Background

Although acute myocardial infarction (AMI) incidence and mortality have decreased over the last decades, survival rates of AMI patients remain rather stable. About 25% of patients with ST-elevation myocardial infarction (STEMI) suffer from chronic kidney disease (CKD).

Purpose

We sought to determine short- and long-term mortality in STEMI patients with different stages of CKD.

Methods

We identified all patients who were hospitalised with a main diagnosis of STEMI between 2010 and 2017 from the dataset of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskasse), Germany. The patients were grouped according to their CKD stage at index hospitalisation. We analysed concomitant diseases, in-hospital treatment and complications. Overall survival was analysed using Kaplan Meier methods and predictors for overall survival were identified by Cox regression analysis.

Results

A total of 175,187 patients were identified with an index hospitalisation for STEMI, thereof 137,682 (78.6%) patients without CKD, 8,347 (4.8%) patients with CKD stage 2, 20,459 (11.7%) patients with CKD stage 3, and 4,960 (2.8%) patients with CKD stage 4. The CKD stages 1, 5 and 5d (dialysis dependent CKD) each comprised less than 1,500 patients (<1.0%). STEMI patients with CKD were older and had more often cardiovascular risk factors, e.g. diabetes (no CKD: 33.2% vs CKD stage 5: 66.1%, p<0.001). Overall, patients with CKD received percutaneous coronary interventions (no CKD: 84.4% vs CKD stage 4: 62.0%, p<0.001) less frequently, and suffered more often from complications like shock (no CKD: 12.5% vs. CKD stage 5: 27.7%, p<0.001) or requirement of invasive/non-invasive ventilation (no CKD: 17.3% vs. CKD stage 5: 42.7%, p<0.001) than patients without CKD. With increasing CKD stages, patients were more likely to die within 30 days after STEMI (30-day mortality no CKD: 13.7% vs. CKD stage 5d: 37.2%, p<0.001). Kaplan-Meier estimates showed dramatically decreasing survival with decreasing renal function (Figure 1). Multivariable time-dependent Cox regression analysis for overall survival showed that the CKD stages 4, 5 and 5d, as well as chronic limb threatening ischemia (CLTI) were associated with a higher risk for death (CKD stage 5d: hazard ratio (HR) 5.64; 95% CI 5.42–5.86; CKD stage 5: HR 2.55; 95% CI 2.37–2.73; CKD stage 4: 1.72; 95% CI 1.66–1.78; CLTI: 2.06; 95% CI 1.98–2.13; all p<0.001).

Conclusion

CKD is a frequent co-morbidity in patients with STEMI which is associated with a devastating prognosis especially for patients with advanced CKD stages. More research is needed to gain evidence on optimized treatment strategies for patients with STEMI and concomitant CKD in this highly vulnerable cohort.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The project upon which this publication is based was funded by The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051). Figure 1. Unadjusted Kaplan-Meier survival curves

Sex-specific differences in first event of st- elevation myocardial infarction; new insights on age-related mortality

Background

For patients with ST-elevation myocardial infarction (STEMI) as the primary manifestation of coronary artery disease (CAD), data on predictors and outcome are limited. We hypothesized that specifically age and sex influence short- and long-term outcome in patients after first event of STEMI.

Methods and results

Based on claims data of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskrankenkasse) (≈26 million insurance holders in Germany with ≈83 million inhabitants), adults with STEMI between 01/2014 to 12/2015 and no history of CAD were selected for further analysis. Patient demographics, details on in-hospital treatment as well as age- and sex-related differences in 30-day mortality, re-infarction/ death, major adverse cardiovascular events (MACE), overall and long-term survival were assessed.

Overall, 17,444 patients presented with STEMI as the primary manifestation of CAD throughout the study period, thereof 33% were women. At index, women were older compared to men (median age 74 years vs. 60 years) and suffered from more cardiovascular comorbidities such as diabetes (35.8% vs. 25.2% in men), chronic kidney disease (26.0% vs. 14.9% in men), and arterial hypertension (84.6% vs. 72.6%; all p<0.001). Women with STEMI underwent endovascular reperfusion (78.5% vs. 88.1%) or coronary artery bypass grafting (4.2% vs. 5.5%; both p<0.001) less frequently. In-hospital complications such as shock (19.2% vs. 16.0%) and resuscitation (15.1% vs. 12.9%; both p<0.001) were observed more often in women.

Female sex was independently associated with adjusted 30-day mortality (Odds Ratio 1.17; p=0.01). Long-term outcomes revealed women to be at increased risk of the combined end-point of re-infarction and/or death (Hazard ratio (HR) 1.09; p=0.01), MACE (HR 1.09; p=0.01) and all-cause mortality (HR 1.10; p=0.01). Particularly in patients younger than 60 years, female sex was a strong predictor of adverse outcomes. Surprisingly, among patients that survived at least 90 days after STEMI, no differences between the sexes were noted regarding long-term survival (HR 0.99; p=0.91) (see Figure for adjusted odds/hazard ratios presenting the association of sex with different endpoints depending on age after first event of STEMI).

Conclusion

On non-selective data, two-thirds of patients with STEMI as the primary manifestation of CAD were male. Women were observed to receive endovascular reperfusion less frequently than men and suffered from more in-hospital complications. Being female and younger than 60 years was associated with an increased risk of adverse outcomes specifically early after STEMI.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The study is part of the GenderVasc project funded by the joint federal committee, Germany.

[Postoperative long-term results in high-grade traumatic ruptures of the spleen in children]

BACKGROUND

Splenic rupture is the most common injury in blunt abdominal trauma at any age. The grade of rupture, haemodynamic stability and, in the case of operative treatment, the experience of the surgeon all play an important role in preserving the spleen. Due to its important immunological function preservation of the spleen should be the goal.

PATIENTS

From January 2000 to August 2009 five children (4 male/1 female) with isolated grade IV or V splenic rupture, according to the Organ Injury Score (OIS), were treated operatively. At the time of the trauma the patients were 8.8 ± 3.8 (mean ± standard deviation; range, 6–15) years old. Four patients with an OIS grade IV rupture were primarily treated with partially spleen-saving surgery: one resection of 2⁄3 of the spleen including the splenic vessels, one hemisplenectomy and two lower pole resections; in one patient with an OIS grade V rupture splenectomy was performed immediately.

RESULTS

In one patient treated with a spleen-preserving approach (hemisplenectomy) the remainder of the spleen had to be removed due to acute bleeding on the first postoperative day. This patient needed two units of blood transfused following the second operation. There were no other complications. The two patients with splenectomy and resection of ⅔ of the spleen developed a transient thrombocytosis indicating impaired clearance of the spleen. In a follow-up involving ultrasonography (median 13, range 1-101 months) all patients managed with partially spleen-saving surgery showed a large remnant spleen with arterial perfusion.

CONCLUSION

The majority of primarily partially spleen-preserving operations result from OIS grade IV ruptures of the spleen. Use of a partially spleen-saving surgical approach was successful in ¾ of these patients. Low morbidity and documented perfusion of the remnant spleen at long-term follow-up indicate that a spleen-preserving technique is warranted if an operative approach is required.