Implementation of prehospital thrombolysis in Sweden: components of delay until delivery of treatment and examination of treatment feasibility

OBJECTIVE: To evaluate the feasibility of prehospital thrombolysis in Sweden in terms of safety and to examine the various components of the delay between onset of symptoms and start of treatment. SETTING: A total of 16 hospitals in Sweden in both urban and less populated areas and the associated ambulance organisations. DESIGN: Prospective evaluation of patients with an ST-elevation infarction treated with reteplase. An ECG was recorded and transmitted to hospital. The ambulances were staffed by a physician in 1% of cases, a nurse in 67% and a staff nurse in 32%. RESULTS: Of the 148 patients who received treatment prior to hospital admission, six (4%) had a cardiac arrest prior to hospital admission and two (1%) died prior to arrival at hospital. One patient was given treatment despite an exclusion criterion (previous stroke) and died on the 1st day in hospital due to a cerebral haemorrhage. The overall 30-day mortality was 7.1% and 1-year mortality 9.8%. Treatment was initiated within 2 h after the onset of symptoms in 53% of patients and within 1 h in 17% of patients. The median interval between the arrival of the ambulance and sending an ECG was 13 min and the median interval between sending an ECG and the start of thrombolysis was 18 min. The delay was similar regardless of ambulance staff. CONCLUSION: Implementation of prehospital thrombolysis on a national basis in Sweden appears to be safe. More than half the patients can be given treatment less than 2 h after the onset of symptoms. There is potential for reducing this time still further.     

The NUGGET study: NIR ultra gold-gilded equivalency trial.

This study should clarify whether the gold-coated NIROYAL stent is equivalent to the stainless steel NIR stent. Patients were randomized to either NIR stent (n = 298) or a NIROYAL stent (n = 305). The primary endpoint was the minimum lumen diameter of the target lesion at 6 months postprocedure. Secondary endpoints focused on clinical events. At 30 days, adverse events were similar in both groups. At 6 months, the minimal lumen diameter was 1.83/1.64 mm (P < 0.001; 95% CI = 0.08-0.30) and the angiographic restenosis rate was 20.6%/37.7% (P < 0.001; 95% CI = -24.7 to -9.3) for NIR/NIROYAL. The 6-month MACE rates were NIR 7.4% and NIROYAL 10.5% (95% CI = -7.7 to 1.4). Compared to stainless steel stent, the NIROYAL stent demonstrated a smaller minimal lumen diameter, a higher late loss (i.e., higher neointimal hyperplasia in spite of a significantly better initial gain), with higher restenosis and similar MACE rates at 6 months.     

The risk of revision in total knee arthroplasty is not affected by previous high tibial osteotomy: A 15-year follow-up of 32,476 total knee arthroplasties in the Norwegian Arthroplasty Register

Background and purpose — Previous studies have found different outcomes after revision of knee arthroplasties performed after high tibial osteotomy (HTO). We evaluated the risk of revision of total knee arthroplasty with or without previous HTO in a large registry material.Patients and methods — 31,077 primary TKAs were compared with 1,399 TKAs after HTO, using Kaplan-Meier 10-year survival percentages and adjusted Cox regression analysis.Results — The adjusted survival analyses showed similar survival in the 2 groups. The Kaplan-Meier 10-year survival was 93.8% in the primary TKA group and 92.6% in the TKA-post-HTO group. Adjusted RR was 0.97 (95% CI: 0.77–1.21; p = 0.8).Interpretation — In this registry-based study, previous high tibial osteotomy did not appear to compromise the results regarding risk of revision after total knee arthroplasty compared to primary knee arthroplasty.High tibial osteotomy (HTO) is a well-established joint preserving procedure for the treatment of medial knee osteoarthritis. The goal is to achieve unloading of the affected medial compartment of the knee to prevent or postpone the need for an artificial knee joint. This is performed by slightly overcorrecting the knee joint from varus malalignment to valgus or neutral position. Osteotomy was a standard treatment option for unicompartmental knee osteoarthritis in earlier years before knee arthroplasty was a surgical option, but osteotomy lost importance in the 1980s because of the success of knee replacement surgery (Smith et al. 2013). However, there has been an increase in osteotomies during the last 15 years, especially in younger patients in some countries (Seil et al. 2013). National arthroplasty registers have demonstrated higher risk of revision for knee arthroplasty in younger patients (under the age of 60) (NAR 2014, SKAR 2013). The 2 most commonly used methods for HTO are lateral closing wedge and medial opening wedge osteotomy. Both methods have shown improvement in knee pain and function (Naudie et al. 1999, van Raaij et al. 2008, Efe et al. 2011, W-Dahl et al. 2012). Nevertheless, some patients later require a second procedure, a total knee arthroplasty (Naudie et al. 1999), depending on the degree of osteoarthritis, their level of pain and function, and the degree of correction achieved. Although total knee arthroplasty appears to be technically more challenging after HTO in cases with severe overcorrection, bone stock loss, altered joint line (Figures 1 and ​and2),2), or patella infera, only a few studies have found inferior results compared to primary TKA (Windsor et al. 1988, Parvizi et al. 2004, Haslam et al. 2007, Farfalli et al. 2012). The aim of this study was to evaluate the risk of revision after TKA, comparing primary TKA with and without previous high tibial osteotomy using data from the Norwegian Arthroplasty Register (NAR).Open in a separate windowFigure 1.Example of extra-articular malalignment after high tibial osteotomy (HTO) with opening wedge technique. The red line on the left radiograph (a) indicates the mechanical axis lateral to the knee joint. The radiograph to the right (b) indicates the extra-articular angulation of the tibia in the osteotomy area.Open in a separate windowFigure 2.Example of intra-articular malalignment after high tibial osteotomy (WTO) with closing wedge technique. The solid red line indicates that the tibial plateau has been elevated medially and is not perpendicular to the tibial axis.     

Activated pancreatic stellate cells can impair pancreatic islet function in mice

Background

Pancreatic or islet fibrosis is often associated with activated pancreatic stellate cells (PSCs). PSCs are considered not only to promote fibrosis, but also to be associated with glucose intolerance in some diseases. We therefore evaluated morphological and functional relationships between islets and PSCs in the normal mouse pancreas and transplanted islets.

Methods

Immunohistochemistry was used to map the presence of PSCs in the normal mouse pancreas and islets implanted under the renal capsule. We isolated and cultured mouse PSCs and characterized them morphologically by immunofluorescence staining. Furthermore, we measured their cytokine production and determined their effects on insulin release from simultaneously cultured islets.

Results

PSCs were scattered throughout the pancreas, with occasional cells within the islets, particularly in the islet capsule. In islet transplants they were found mainly in the graft periphery. Cultured PSCs became functionally activated and produced several cytokines. Throughout the culture period they linearly increased their production of interleukin-6 and mammalian keratinocyte-derived chemokine. PSC cytokine production was not affected by acute hyperglycemia. Syngeneic islets co-cultured with PSCs for 24–48 h increased their insulin release and lowered their insulin content. However, short-term insulin release in batch-type incubations was unaffected after 48 h of co-culture. Increased islet cell caspase-3 activation and a decreased islet cell replication were consistently observed after co-culture for 2 or 7 days.

Conclusion

Activated PSCs may contribute to impaired islet endocrine function seen in exocrine pancreatitis and in islet fibrosis associated with some cases of type 2 diabetes.     

Nerve function varies with hemoglobin A1c in controls and type 2 diabetes

Aims

To determine the cross-sectional threshold at which hemoglobin A1c (HbA1c) is associated with polyneuropathy in healthy controls, and the values associated with the most pronounced decline in nerve function in patients with diabetes.

Sex differences in neuropathic pain in longstanding diabetes: Results from the Canadian Study of Longevity in Type 1 Diabetes

Aim

Neuropathy and neuropathic pain are common complications of type 1 diabetes (T1D). We aimed to determine if sex-specific differences in neuropathic pain are present in adults with longstanding T1D.

Bipolar radiofrequency thermal ablation of the soft palate in habitual snorers without significant desaturations assessed by magnetic resonance imaging

Sleep-disordered breathing, including habitual snoring, is a major health problem. Treatment of primary habitual snoring should be individualized using both conservative and active treatment methods. Active surgical interventions are, however, associated with significant morbidity. Therefore, procedures causing far less morbidity should be preferred. Our aim was to assess the efficacy and acceptability of bipolar radiofrequency thermal ablation of the soft palate in habitual snorers without significant desaturations associated with excessive daytime sleepiness. We treated 20 nonobese habitual snorers (median age, 43 years, range 35-63). All the patients had the major site of obstruction at the level of the soft palate, and they were treated on an outpatient basis in two treatment sessions separated by 1 week. The pretreatment and post-treatment symptoms and findings as well as the overall efficacy of the procedure were evaluated by questionnaires, visual analogue scales, and magnetic resonance imaging. All the questionnaires showed a statistically significant change, indicating decreased snoring and daytime sleepiness. The magnetic resonance studies showed that the procedure induced notable T1-signal alterations in the treated tissue, and when compared with the pretreatment images, certain dimensions of the soft palate were significantly changed. Bipolar radiofrequency thermal ablation of the soft palate seems to be well tolerated and effective regarding primary habitual snorers without significant desaturations associated with excessive daytime sleepiness.