Association of diabetic foot care and amputation rates in Germany.

Podologists are nurses who care for the diabetic foot (orthotics, offloading devices, blisters, calluses, treatment of fungus infection and patient education). In contrast to podiatrists, they are not qualified to perform any surgical treatment or wound care. We analysed whether there is an association between the decrease in major amputations and the number of podologic foot care (PFC) visits prescribed in Germany. Detailed list of all major lower limb amputations (OPS 5-864) performed from 2007 to 2011 was provided by the Federal Statistical Office. Data were separated for the 16 federal states in Germany. Detailed lists of the number of PFC treatments for each of the 5 years were derived from the federal report of the statutory health insurance. The total numbers of hospitalised cases per year having diabetes mellitus documented as an additional diagnosis were used to adjust for the different rates of people with diabetes in each federal state. Within a 5-year time period, population-based major amputations per 100 000 people dropped from 21·7 in 2007 to 17·5 in 2011 (-18·5%); whereas the number of PFC treatments per 1000 insured increased from 22 in 2007 to 60 in 2011 (+172·7%). The total number of major amputations divided by the total number of hospitalised cases with the additional diagnosis of diabetes mellitus (DM) shows an inverse correlation with the number of PFC treatments per 1000 insured (Pearson's correlation factor is -0·52049). The five countries with the highest increase in PFC compared with the five countries with the lowest increase (35·6 versus 15·4 per 1000 insured) will have only small differences in the decrease in major amputation rates in this period (-5·1 versus -3·4 per 100.000). There is a strong association between increasing utilisation PFC and decreasing major amputations in Germany. Further study is required to document the cost-effectiveness of this service.

Percutaneous endovascular treatment of peripheral arterial disease in Germany.

PURPOSE: The general distribution of balloon angioplasty, stenting and other endovascular interventions in treating peripheral arterial disease (PAD) is unclear. METHODS AND RESULTS: We used national statistics (DRG statistics) published by the Federal Statistical Office including data from almost all hospitals in Germany to calculate the rates and types of lower extremity endovascular procedures in 2012. In 2012 150,503 peripheral endovascular procedures were documented in Germany. The predominant procedures were percutaneous transluminal angioplasty (PTA) with 86.0% followed by thrombolysis with 7.2% and thrombectomy with 2.9%. In 50,092 (33.3%) of all peripheral endovascular procedures performed in the lower limb arteries a stent was placed: 66.7% in iliac, 34.3% in femoro-popliteal and 9.7% in cruro-pedal procedures. From these 50,092 procedures DES were coded in 3063 (6.1%) and covered stents in 1841 (3.7%). The highest rate of covered stents was placed in the aorta (8.6%) but the highest rate of DES was in the cruro-pedal arteries (23.1%). CONCLUSION: Pure PTA is still the most frequently performed procedure in peripheral arteries and in only one third of all procedures was a stent placed in Germany in 2012.

Decrease in major amputations in Germany.

A decrease in rate of amputation has been reported from many countries. This study aims to study the trends in amputation rates in Germany. On the basis of DRG-system, detailed lists of all amputations coded as minor amputations (OPS 5-864) and major amputations (OPS 5-865) performed between 2005 and 2010 were provided by the Federal Statistical Office. There was a significant decrease in age-adjusted major amputation rates per 100 000 population in Germany from 27·0 in 2005 to 22·9 in 2010 (15·2%, P ≪ 0·001) in males and from 19·7 in 2005 to 14·4 in 2010 (26·9%, P ≪ 0·001) in females. Overall, minor amputation rates did not show such a decrease but increased in males (from 47·4 in 2005 to 57·8 in 2010, 21·9%, P ≪ 0·001) and remained almost unchanged in females (23·1 in 2005 and 23·9 in 2010, not significant). Reduction in major amputation rates were even more pronounced in people above 80 years, especially in males from 216 to 150 (30·5%) and in females from 168 to 117 (30·4%). The present data demonstrate an increasing overall burden of foot lesions as indicated by an increase in incidence of minor amputations but an ongoing success in the fight against amputation, resulting in a significant decrease in major amputation rates in Germany, in the 6-year period from 2005 to 2010.

Endovascular treatment of chronic mesenteric ischemia.

PURPOSE: Data regarding endovascular treatment of chronic mesenteric ischemia (CMI) are sparse. Angioplasty is often accompanied by early restenosis and the need of further interventions. Thus we present our own patients' data and review the recent literature. METHODS: We retrospectively reviewed all endovascular CMI treatments performed from 2008 to 2012 (27 patients, 14 females, mean age 70 ± 9 years). Patients' data were retrieved from electronic health records. Patients' follow-up included routinely performed color-coded ultrasonography, and, if performed for other clinical reasons, computed tomography or angiography. In addition, data extracted from 11 studies focusing on endovascular CMI treatment were analyzed. RESULTS: Procedures were performed without clinical complications in all patients. Seven patients received pure angioplasty and 20 patients stent-assisted angioplasties using bare metal stents, respectively. Three patients died 3, 5 and 32 months after the intervention. Five patients underwent re-intervention (one early restenosis at day 4 after pure angioplasty with stent placement and four because of in-stent restenosis, 5 to 23 months after placement). Another patient was treated surgically because of stent occlusion and reoccurring abdominal angina 15 months after the intervention. The 11 studies found in the literature included 429 cases with 196 treatments of the coeliac trunk (truncus coeliacus = TC), 319 of the superior mesenteric artery (SMA) and 42 of the inferior mesenteric artery (IMA). Patency rates in the more recent studies were high with up to 80% within 1 year. Data of earlier studies report longer follow-up periods and indicate low patency rates after three years. Our 2-year patency rate of 50% is within the range of reported patency data. CONCLUSIONS: The presented data show that endovascular SMA treatment is a suitable and safe procedure in patients suffering from CMI, but long-term results are limited.

Ankle brachial index and pneumoplethysmographic pulse-volume recordings for detection of peripheral arterial disease.

BACKGROUND: The measurement of the ankle-brachial index (ABI) is a straightforward method for the detection of atherosclerosis in the lower limbs. Pneumoplethysmographic pulse-volume recordings (PVR) investigations are supposed to be less valid. Thus we compared the sensitivity of ABI and PVR in detection of PAD and its improvement by combining both methods. PATIENTS AND METHODS: 122 consecutive patients admitted for PAD treatment were included. All patients (81 females; mean age 70 ± 15 years) had angiographic imaging of their peripheral arteries, a standardized personal interview and a determination of the ABI based on the highest (ABI high) and lowest (ABI low) ankle pressure. PVR parameters were oscillometric index (OI) and time to normalisation (TN) after exercise. RESULTS: There was a small variation of ABI with different segmental manifestations of PAD. The OI did not vary with different segmental manifestations. TN was longest in iliac artery manifestation and got shorter with more distal manifestation. Correlation of TN and ABI high and ABI low was low. Sensitivity of ABI high in all legs was 78 %, but only 40 % in isolated crural manifestation. ABI low has higher sensitivities with 87 % in all legs, but a much lower specificity. Combining ABI and TN increases both sensitivity and specificity. The best sensitivity and specificity was seen using ABI low + TN in combination in all kinds of manifestations with 94 % and 96 %, respectively. CONCLUSIONS: Combined assessment of ABI low and TN in post-exercise PVR seems to be a highly sensitive but also specific method to look for PAD compared to ABI high alone.

Abdominal aortic calcification and its distribution in normal-sized and aneurysmatic abdominal aortas.

BACKGROUND: Multi-detector computed tomography (MDCT) is more and more used for evaluation and quantification of coronary artery calcification, but correlation between the degree of calcification and occurrence of clinical events is also known for other vascular beds such as the aorta. PURPOSE: To assess possible differences in amount and pattern of calcification in aneurysmatic and non-aneurysmatic abdominal aortas. PATIENTS AND METHODS: Thirty-four subjects displayed infrarenal abdominal aneurysm (AAA) and were compared to 33 patients with normal-sized aortas using MDCT. Quantitative and qualitative analysis was performed by two radiologists. Calcium scores were assessed for the whole abdominal aorta as well as separately for the supra- and infrarenal segments. Moreover, plaque patterns were evaluated and classified according to their thickness and size. Furthermore, calcium scores were correlated with a number of cardiovascular risk factors. RESULTS: Total calcium scores were comparable in patients with and without AAA (1,213 ± 1,351 and 1,211 ± 1,535, respectively), but significant differences were found regarding plaque density that was considerably higher both in the supra- and infrarenal segments in the non-aneurysmatic group (AAA: suprarenal, 0.01, infrarenal, 0.07; non-AAA: suprarenal, 0.06, infrarenal, 0.16). Plaque pattern were considerably different in the infrarenal segments in aneurysmatic aortas: they were thinner (1 and 2 mm) and smaller (< 100 mm2) than in normal-sized aortas (mainly > 3mm and > 100 mm2). Distribution of risk factors was similar in both groups with the highest mean calcium score being present in patients with 4 risk factors. Pearson's correlation coefficient indicating correlation between total calcium score and number of risk factors was almost the same in both groups: AAA, r = 0.67; non-AAA, r = 0.65. CONCLUSIONS: Compared to normal-sized aortas thinner and smaller plaques are present in AAA, which may be due to degenerative processes.

Cranial and non-cranial embolism: incidence in hospitalised patients in Germany.

Using the information of the federal statistics, a detailed description of the hospitalisation rate for cranial and non-cranial embolic events in Germany is given for the years 2005-2010. Detailed lists of the ICD codes I63.0 (stroke) and I74 (arterial embolism and thrombosis) as principal diagnosis and of I48.0 (atrial fibrillation) as additional diagnosis for the years 2005-2010 were provided by the Federal Statistical Office. In the 6 years period total number of cases hospitalised for stroke increased by 24% (from 185.026 to 229.798) and those hospitalised for embolic events by 60% (from 64,106 to 92,428). The number of atrial fibrillation as a major cause of arterial embolism documented as additional diagnosis increased by 38% (from 1.06 to 1.48 Mio). Considering the rate per 100,000 inhabitants, intra-cranial embolism showed the most relevant increase with about 56% since 2005. Cranial embolism is around 2.5 to 4 times more frequent than non-cranial embolism in females aged 70 to 80 years, but only two times in females aged 40-50, 50-60 and 90 years and older. Males showed a similar distribution with a broader peak. From 2005 to 2010 the total number of embolic events increased, with a higher increase in cranial embolism compared to non-cranial embolism.

CHADS2 and CHA2DS2Vasc-Score in Peripheral Systemic Embolism.

Objectives: We analysed the characteristics of patients with an acute peripheral embolic event considering the possible use of the CHADS2-Score and the CHA2DS2Vasc-Score Patients and Methods: We retrospectively analyzed 163 cases of acute peripheral arterial embolism treated in the Department of Vascular Medicine of the HELIOS Klinik Krefeld, Germany, from 2008 to 2011. We retrospectively screened the medical form for information regarding atrail fibrillation (AF) and the risk factors necessary to calculate the CHADS2 and CHA2DS2vasc score. Results: Arterial hypertension and age > 75 years were the most frequent risk factors. Mean CHADS2 score was similar in males and females (2.3 ± 1.5 and 2.3 ± 1.4). 66% of the males and 63.3% of the females scored 2 and more points. Mean CHA2DS2Vasc score was 3.6 ± 2.0 in males and 4.6 ± 1.9 in females. 85.2% of the males and 95.4% of the females scored more than 2 points. In the medical forms AF was documented in 79 (48%) patients, of which 23 (43 %) were males and 56 (51%) females. Mean CHADS2 score and mean CHA2DS2Vasc score were slightly higher in those with AF compared to the total group, but not significantly different. The rate of patients with 2 and more points increased for both scores: CHADS2 score: males 82.6% and females 76.8%, CHA2DS2Vasc: males 100% and females 98.2%. Almost half of the patients with AF had had anticoagulation with phenprocoumon before (males 12 (52%), females 24 (43%), but only every 10th was within the therapeutic range (INR ≥2) Conclusion: The number of those with AF is high amongst patients with acute peripheral embolism. According to the CHADS2 and CHA2DS2Vasc score, most of these patients had an indication for oral anticoagulation independent form the embolic event.

Prevalence and economic burden of pulmonary embolism in Germany.

The prevalence of pulmonary embolism (PE), PE mortality and treatment-associated costs for the years 2000 to 2006 were analysed using a statutory health insurance sample of AOK Hesse/KV Hesse, which contained information for an 18.75% random sample of 1.9 million persons insured with the AOK Hesse. Within the sample a PE diagnosis was accepted as valid if it was documented as the main discharge diagnosis or as an additional hospital diagnosis during hospitalization and if at least one of the following criteria was met: prescription of oral anticoagulants or heparins, PE documented for at least two quarterly periods or documented in only one quarter for patients who died within 28 days after hospital discharge. The economic burden from the perspective of the insurance fund was assessed by an analysis of resource consumption (direct costs) and by a matched pair analysis with controls without PE to estimate excess costs. A 99% winsorization of each cost category was performed to control for extreme outlying values. The prevalence of PE as the main discharge diagnosis and an additional hospital diagnosis varied from 55.3 to 71.7 per 100,000 insurants in the years 2000 to 2006. Insurants aged 80 years and more had a prevalence of 406.9 per 100,000 (year 2006). From 2001 to 2003 the in-hospital mortality rate ranged from 20.4% to 24.9% and decreased to 14% in 2006. A total of 85% of all patients with PE who survived the first year had at least one prescription of vitamin K antagonists. For patients who survived the first year, treatment costs exceeded € 20,000, with an estimation of additional costs of € 5816 for men and € 8962 for women in the matched-pair analysis. Owing to high in-hospital costs, the overall cost of treatment was highest for patients younger than 60 years. In conclusion, the prevalence rate of PE in Germany is comparable to international data. Treatment costs within the first year after hospital discharge are high, and there is a need to clarify the settings associated with PE in Germany with its high rate of prophylaxis.

Dementia and amputation.

OBJECTIVES: To our experience dementia seems to play an increasing role for major amputation in patients suffering from peripheral arterial disease (PAD). To confirm our impression, we analysed the rate of dementia associated with different surgical procedures using the information of the federal statistics in Germany. PATIENTS AND METHODS: Detailed lists of cases hospitalized with the principal diagnosis (PAD), abdominal aortic aneurysm (AAA), myocardial infarction (MI) and hip fracture (HF), and of the procedures minor or major amputation, endovascular aortic repair (EVAR), total endoprosthesis for hip replacement (THR) and coronary aortic bypass graft (CABG) in Germany in the years 2008 to 2010 were provided by the Federal Statistical Office. RESULTS: Dementia is documented as additional diagnosis in approximately one fourth of cases having the principal diagnosis HF, 5% to 6% of cases with the principal diagnosis MI and PAD, but only in approximately 2% of AAA cases. Dementia is documented as principal or additional diagnosis in one fourth of amputation procedures (major amputation approximately 18% and minor amputation approximately 8%), in approximately 5% THR, 2% of EVAR and only 0.3% of CABG. The rate of documentation of dementia is higher in patients treated by major amputation than in the hospitalized PAD population. Vice versa, the rate of documentation of dementia is lower in patients getting THR than in the hospitalized HF population. CONCLUSION: The presented analysis supports the assumption that dementia plays a relevant role in older patients suffering from PAD receiving major amputation in Germany.

Prevention of pressure ulcer: interaction of body characteristics and different mattresses.

We analysed the effect of different body features on contact area, interface pressure and pressure distribution of three different mattresses. Thirty-eight volunteers (age ranged from 17 to 73 years, 23 females) were asked to lie on three different mattresses in a random order: I, standard hospital foam mattresses; II, higher specification foam mattresses (Viscorelax Sure® ); III, constant low pressure devices (CareMedx® , AirSystems). Measurements were performed in supine position and in a 90° left- and right-sided position, respectively, using a full-body mat (pressure mapping device Xsensor X2-Modell). Outcome variables were contact area (CA) in cm(2) , mean interface pressure (IP) in mmHg and pressure distribution (PD) estimated as rate of low pressures between 5 and 33 mmHg on each mattress in percent. Mean CA was lowest in the standard hospital foam mattresses and increased in the higher specification foam mattresses and was highest in the constant low pressure device (supine position: 491 ± 86 cm(2) , 615 ± 95 cm(2) , 685 ± 116 cm(2) ). Mean IP was highest in the standard hospital foam mattresses and lower but similar in the higher specification foam mattresses and the constant low pressure devices (supine position: 22·3 ± 1·5 mmHg, 17·6 ± 1·7 mmHg, 17·6 ± 2·2 mmHg). Models were estimated for CA, IP and PD including the independent variables height, weight and waist-to-hip-ratio (WHR). They show that body morphology seems to play a minor role for CA, IP and PD, but very thin and tall patients and very small and obese people might benefit from different mattresses. Our data show that CA increases with increasing specification of mattresses. Higher specification foam mattresses and constant low pressure devices show similar IP, but constant low pressure devices show a wider pressure distribution. Body morphology should be considered to optimise prevention for single patients.

Cost associated with D-Dimer screening for acute aortic dissection.

INTRODUCTION: D-Dimer (DD) has been described as a useful predictor of both morphologic changes in acute thoracic aortic dissection (TAD) and of TAD-associated mortality. This study analyzed the use of DD screening to screen patients with chest pain for acute (TAD) to determine if it improves diagnosis and cost effectiveness. This study also looked at the association of DD levels with diagnoses frequently seen in patients with dyspnea or chest pain. METHODS: At the Helios Hospital, Krefeld, the authors analyzed the data of all patients (n = 1053, age (mean, SD) 62 ± 19 years, 49% males) admitted for chest pain to the nonsurgical emergency department (ED) in February 2010. Chest pain was the second most frequent symptom causing 138 (13.1%) admissions, 102 of which had DD testing (Inniovance® D-Dimer Assay, Dade Behring/Siemens, Germany). To assess the diagnostic reliability of DD testing, the sensitivity, specificity, and odds ratio, including 95% confidence interval, were estimated. RESULTS: None of the patients admitted were found to have acute TAD. Had the authors used a computerized tomography (CT) scan to rule out TAD in every patient with chest pain, actual costs would have been euro 12,328. A restriction of CT scans to patients with elevated DD levels would have lowered costs to euro 5360. The actual costs were euro 670.30 for CT scans and euro 540.60 for DD tests. On analyzing the association with other diagnoses, both sensitivity and specificity were low, with the exception of pneumonia. CONCLUSION: Owing to the low incidence of TAD, DD screening increases diagnostic efforts and costs but it remains unclear whether it would actually speed up TAD diagnosis. In a clinical setting DD did not help to discriminate other relevant diagnoses. Despite the high sensitivity of DD for aortic dissection published in the literature, the physician's clinical judgment remains paramount.

Pulmonary embolism in young males and females in Germany: data from the Federal Statistical Office.

With the introduction of diagnosis-related groups (DRG) for reimbursement in 2003, detailed description of the prevalence of pulmonary embolism in hospitalized patients in Germany was possible for the first time. Thus, we analysed the incidence of pulmonary embolism in hospitalized young people and looked for a sex-specific difference in comorbidity. Detailed lists of all pulmonary embolism coded as I26 in hospitalized patients aged 10-40 years in 2005, 2006 and 2007 were provided by the Federal Statistical Office. Beginning at the age of 12-13 years females have higher numbers of pulmonary embolism and DVT documented as principal diagnosis compared with men. This sex-specific difference disappears at the ages of 32-33 years. The total numbers of pulmonary embolism distinguishing males and females within this 20 years life period is low and varied from 318-463 in the 3 years. The sex-specific difference is highest in the group of 16 to 17-year-old people (ratio of females to males varies from 3 to 5 in 2005-2007). Specific patterns of comorbidities associated with the higher numbers of pulmonary embolism in younger females could not be detected. Pregnancies account for a maximum of 73 in 2007, which reached only less than one-fifth of the absolute difference in pulmonary embolism between males and females in the single years. The presented data derived from the most reliable data basis for the estimation of pulmonary embolism in Germany show that compared with males there is a sharp increase in hospitalization for pulmonary embolism in females beginning at the age of 12-13 years. Males catch up by the ages of 32-33 year.