Work of a stroke team: experience of transferring ischemic stroke patients from district hospitals to Krasnoyarsk Regional Vascular Center for thrombectomy

Modern high-technology methods for ischemic stroke treatment (systemic thrombolysis, mechanical thrombectomy, thrombaspiration, stenting of cerebral arteries) can improve the rehabilitation potential and survival of patients. Important tasks here are selection for reperfusion and its performance on the greatest possible number of peracute patients. Mechanical thrombectomy combined with systemic thrombolysis is the most effective reperfusion strategy in the therapeutic window, but the availability of endovascular methods is limited to highly specialized centres. One way to solve this problem is to organize effective logistics with stroke patients, which will provide high-tech care for patients living far from large treatment centers due to regulated interaction between institutions at different levels.The aim of the study was to improve emergency interaction related to transfer of peracute stroke patients from primary vascular units and district hospitals of the Krasnoyarsk region to Krasnoyarsk Regional Vascular Center for thrombectomy.

Remote clinical quality management of endovascular care

Aim. To assess the effectiveness of remote clinical quality management of endovascular care.Methods. The system of clinical quality management of medical care in myocardial infarction (MI) including the quality of remote control of endovascular care was developed and introduced into the health care system of the Moscow Region as a part of the comprehensive study in 2008–2020. The number of people under the study was 8375. The ground for assessing the effectiveness of remote clinical management in 2019–2020 was the health care system of megapolis. Based on the analysis of 2966 endovascular procedures protocols, the treatment tactics effectiveness of intraoperative decisions was studied after an emergency coronary angiography (ECA) had been performed by interventional cardiologists. The system of remote clinical quality management of endovascular care included a complex of audiovisual communications, computer system processes, mentoring and the algorithm for making an intraoperative decision. The effectiveness of remote clinical quality management of endovascular care was investigated on the number of percutaneous coronary interventions (PCI) in MI, mortality of patients with MI in the Regional vascular center in 2019–2020. The T-criteria was used to assess the reliability. The material statistical processing was carried out in the Statistica 6.0 package calculating adequate statistical indicators and their reliability at p≤0.005.Results. Ratio PCI/ECA in 2019, January-March 2020 counted up to 48.95%. In AprilDecember 2020 it increased up to 71.6% (p<0.001). The frequency of performing PCI increased by 1.46 times (p<0.001). Hospital mortality from MI decreased during the following period 2019, April-December 2020 from 9.7% to 8.2% (p = 0.005).Conclusion. Remote clinical management based on telemedicine and mentoring process technologies contributes to improving the quality of endovascular care in MI.

The Analysis of the Main Working Parameters of the Head Regional Vascular Center of N.V. Sklifosovsky Research Institute for Emergency Medicine

Introduction. The regional vascular centers (RVC) network was created throughout Russia to manage cardiovascular diseases. On the basis of N.V. Sklifosovsky Research Institute for Emergency Medicine in Moscow, a center was created, which received the status of the head RVC. A comprehensive analysis of its work has not yet been carried out.Aim of study. To assess the main performance indicators and development directions of the head RVC based on the analysis of data for 2012–2019.Results. Analysis of the data obtained showed that by 2019 the flow of patient admissions increased 2.3-fold. At the same time, the use of the hospital bed fund does not exceed 100%, and the use of the intensive care bed fund has increased to 123%. A significant proportion of patients come with not field-specific diagnosis. The mortality, which is the main indicator of the quality of treatment in patients treated at the RVC, remained within 2.33–3%, which turned out to be 3 times lower in similar patients treated in other departments of the Institute.Discussion. Against the background of a constant increase in the number of hospitalizations, resusci-tation provision turned out to be insufficient when the number of hospital beds corre-sponded to the flow of admissions. The general lack of intensive care beds in the center and the lack of specialized intensive care for the department of vascular surgery forces the use of other intensive care units of the Institute. The admission of patients with other (not specific for RVC) diagnosis to the vascular center reduces the volume of highly specialized care for specialized patients.Conclusion. The analysis of the performance indicators of the head regional vascular center on the basis of N.V. Sklifosovsky Research Institute for Emergency Medicine, identified the need to expand the resuscitation bed fund in the existing departments of the center and organize specialized resuscitation for patients of the vascular surgery department. Also, the lack of intensive care beds is aggravated by a large flow of non-core admissions. Their reduction with the existing structure will provide significant savings in resources and will increase the number of treated profile patients and improve the quality of highly specialized care.

Results of Surgical Ttreatment of Patients With Cerebral Aneurysms in the Acute Period of Hemorrhage Transported Over a Considerable Distance

Relevance. To provide emergency specialized neurosurgical care to patients living in rural areas, medical evacuation to a neurosurgical hospital is required. Despite the fact that medical evacuation is a necessary stage of medical care, there are not enough studies on the impact of transportation of patients with a ruptured cerebral aneurysm over long distances. There is little information about the time intervals for transportation, the timing of the start of treatment and the outcomes of the disease in patients who are at a considerable distance from the neurosurgical hospital.Aim of the study. To analyze the impact on the extensive results of surgical treatment of patients with cerebral aneurysm rupture.Material and methods. A retrospective analysis of the results of surgical treatment of 145 patients with cerebral aneurysm rupture in the acute period of hemorrhage, hospitalized in the regional vascular center of the State Budgetary Institution of the Sakha Republic (Yakutia) “Republican Hospital No. 2 — Center for Emergency Medical Aid” in the period from 01.01.2017 to 31.12.2018. Patients were divided into two groups: Group I — patients from remote areas of the Republic of Sakha (Yakutia) who underwent medical evacuation by the Disaster Medicine Service of the Sakha Republic (Yakutia); Group II — hospitalized from the territory of the city of Yakutsk and its nearest suburbs.Results. 145 patients were hospitalized at the regional vascular center in Yakutsk. Sanaviation (Sanitary Aviation) delivered 91 patients from the districts of the republic to the regional vascular center (62.8% of the total number of patients) (Group I), 54 patients (37.2%) were hospitalized from the territory of the urban district of Yakutsk (Group II). The distance of transportation by ambulance aircraft in Group I ranged from 45 to 1330 kilometers. Deterioration from admission to the local medical organization to admission to the regional vascular center was noted in 8 patients (8.8%), improvement in the condition in 25 (27.5%) patients, there were no dynamics of changes in the state of 58 (63.7%) patients. The total number of deaths in two groups of patients was 11 (12.1%) patients. Postoperative mortality had no statistically significant differences between the two study groups: in Group I — 7.7% (7 patients), in Group II — 7.4% (4 observations) (p=1,000).Conclusions. With an established system of medical evacuation, transportation over a considerable distance does not worsen the course of the disease and the results of surgical treatment of patients with cerebral aneurysm ruptures in the acute period of hemorrhage.

Causes, Predisposing Factors and Prevention Directions of Drug-induced Bradycardia (Based on the Results of the Hospital Register of Oardiac Medications Overdoses STORM)

Aim. Analysis of drug-induced bradiarrhythmia (DIB) causes and predisposing factors, followed by the development of recommendations for practitioners on its prevention.Material and methods. The register included consistently all cases of hospitalization at the Regional Vascular Center (Ryazan) due to DIB in 2017 (n=114), 2018 (n=167), and retrospectively in 2014 (n=44). In total, 325 cases were reported: men - 26.1%, age 76.0 [68.0; 82.0] years; patients >65 years - 83.7%, and patients >75 years - 57.9%. The dose of medications with bradycardic action (BCA) taken the day before was known in 227 cases (69.8%), which allowed us to analyze the correctness of the intake regime in these cases.Results. The excess of a single and / or daily medication dose (absolute overdose, AOD) occurred only in 10.6% of cases and was associated with the patient's attempt to cope with the deterioration of the disease or an acute clinical situation on their own. In other cases, there was no formal violation of the Instructions, but there was an inhibition of the heart's conducting system activity, characteristic of an overdose of medication (the so-called "relative” overdose, ROD). It was due to the summation/potentiation of BCA of several medications or changes in the medication pharmacokinetics. There were no differences in the clinical and demographic characteristics of patients and the provision of medical care in the groups with AOD and ROD (p>0.05). The exception was a high frequency of bradycardia <40 beats / min in AOD group (75.0% vs 49.8%, p=0.019) and, as a result, - management in the conditions of the Intensive Care Unit (66.7% vs 39.9%, p=0.012). Frequency of pre-admission receiving medications in AOD and ROD groups also did not differ (p>0.05): beta-blockers - an average of 64.3%, antiarrhythmic drugs with BCA- 41.0%, cardiac glycosides 25.1% (frequency each of these medicationsin DIB cases over the 5-year period has not changed), an agonist of the 11-imidazoline receptors - moxonidine (12.3%, its frequency has increased 8.9 times in 5 years, p=0.004), non-dihydropyridine calcium antagonists - 7.9% (decrease frequency over 5 years 4.0 times, p=0.002), other - 16.7%. In 56.8% of cases, medications with BCA were used in combination. At admission, a decrease in glomerular filtration rate (GFR) <45 ml/min/1.73 m2 was registered in 56.8% of cases, <30 ml/min/1.73 m2 - in 31.8%, <15 ml/min/1.73 m2 -in 10.9% (differences between groups with p>0.05). Hospital lethality in the AOD group is 4.2%, in the ROD group- 5.4% (p>0.05).Conclusion. The main reasons of DIB are excess of the recommended dose, unrecorded summation/potentiation of BCA of several medications, and / or changes in the medication pharmacokinetics. Predisposing factors are self-medication of patients with worsening cardiovascular disease or acute clinical situations (e.g., hypertensive crisis), taking multiple medications with BCA, accession of heart disease, manifested by bradyarrhythmia, decrease in GFR, elderly and senile age.

Vascular procedures during the COVID-19 pandemic in a high volume Eastern European interventional radiology department •

AimTo assess the impact of the COVID-19 outbreak on trends in hospital admissions and number of diagnostic and therapeutic procedures in the largest tertiary vascular center in Hungary.Patients and MethodsA retrospective analysis was carried out. The first wave of the COVID-19 pandemic occurred approximately from March 15 until June 1 in Hungary. We have compared the same period of 2020 to 2019. Electronic medical records were reviewed for the clinical status of the patients and treatment-related information.ResultsThe total number of diagnostic angiographies and therapeutic interventions in 2020 (N=233) decreased significantly (P=0.046) compared to 2019 (N=373). The ratio of Fontaine stage I–II cases to Fontaine stage III–IV cases for both diagnostic angiographies and therapeutic interventions was significantly lower (OR, 2.11; 95% CI, 1.26–3.59; P=0.007 and OR, 3.22; 95% CI, 1.67–6.52; P<0.001) in 2020 (0.36 and 0.27) than in 2019 (0.77 and 0.89). There was also a negative but not significant change in the number of supra-aortic (including internal carotid artery stenting) (P=0.128) and other vascular therapeutic interventions (superior vena caval stenting, hemodialysis access percutaneous transluminal angioplasty [PTA], visceral artery/vein PTA/stenting, embolization) (P=0.452) in 2020 (N=16 and N=21) compared to 2019 (N=39 and N=37).ConclusionThe first wave of the COVID-19 pandemic had a negative effect on the total number of endovascular procedures in the largest tertiary vascular center in Hungary.

Stenotic remodeling of coronary vessels in the elderly patients with high cardiovascular risk and the presence of multifocal atherosclerosis

Aim. Identifying persons who are distinguished by an increased frequency of stenosing atherosclerosis of the coronary arteries also affects the process of identifying the features of the analyzed disease. Material and methods. The main research method was the method of hierarchical analysis of categorical variables. At the same time, they differentiated into 3 clusters depending on the age and duration of the disease. The age of the analyzed patients is from 61 to 75 years. For diagnostics, a general assessment of the clinical condition, coronary angiography, and echodopleroscopy of a number of carotid and lower limb arteries were performed. The research base is the Regional Vascular Center of Ufa. Results. The work revealed that the age-related feature of 65+ is a stable lesion of the coronary vessels. At the same time, it was determined that both men and women suffer from this. Conclusion. It has been shown that this is characterized by an increased frequency of stenosing-type remodeling.