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Building innovation networks to transform the energy landscape
The 'three Ds' of renewable energy — decarbonisation, decentralisation and digitalisation — are bringing new opportunities and transforming the energy sector. Innovations in technology, operations, policy, regulation, and business, are all interacting and re-enforcing each other's contributions to the power system transformation towards low-carbon energy.
To better understand the reproducibility and scalability of the energy sector's innovations and to accelerate the sector's transformation, IRENA organised in October 2017 two sessions to discuss developments directly with innovators at the European Utility Week 2017 (EUW2017) in Amsterdam, and the Global Science, Technology and Innovation Conference (G-STIC) in Brussels.
"Everywhere we see the signs of change. Utilities are key facilitators for the energy transformation. To be successful, they must embrace transformation driven by a power system with high shares of renewables that is increasingly distributed, digitised and interconnected," said IRENA Director-General Adnan Z. Amin at the opening of European Utility Week.
The trend is that consumers are turning into "prosumers" — becoming more informed and empowered, and taking an increasingly active role in the power sector. The two IRENA events created a space for stakeholders from utilities and consumers, to network and share their views about breakthrough innovations.
An innovation network
Through events like these and next June's Innovation Week, IRENA aims to strengthen its role as a platform for networking and open dialogue between the stakeholders — including the private sector and policy makers — to foster innovation for the energy transformation.
"Innovations emerging all over the world, have the potential to lead the energy transition and decarbonise not only the power sector, but associated sectors like transportation, industry and end-use sectors," says Dolf Gielen, the Director of the IRENA Innovation and Technology Centre.
"Close cooperation and collaboration between all stakeholders is needed, where the policymakers and regulators enable the emergence of new business models, where utilities and entrepreneurs come together and create new value streams for the consumers," Gielen says.
In addition, IRENA's forthcoming Innovation Landscape Report for the Power Sector Transformation aims to increase awareness of the emerging innovations among policymakers and guide them in what suits their country's context and needs best.
Leading-edge innovations
In IRENA's sessions during EU Utility Week and G-STIC, companies and projects presented their innovations that could support the energy transformation. Here are some of the highlights:
Along with increasing distributed generation, distributed storage has recently gained momentum with behind-the-meter storage, allowing customers to store electricity generated by their rooftop solar panels for later use. Using batteries, heat pumps, PV-panels, recycled-heat air ventilation systems, plastic window frames with triple glazing, and isolation facades 30 centimetres thick, the Dutch project Stroomversnelling, is refurbishing homes and making them energy neutral.
Electric vehicle (EV) innovation is bringing the transport and power sectors together, and potentially decarbonising both. In the power sector, EVs can be decentralised storage resources that can provide additional flexibility to support power system operation, but must be managed in a smart way to avoid power system disruption at peak load times.
The Parker Project, developed by the Technical University of Denmark, is a Grid Integrated Vehicle (GIV) concept, and the first 'vehicle to grid' hub in the country. GIVs increase a grid's flexibility allows for advanced grid services. VERBUND Solution GmbH, Austria's leading electricity company, is working on the first deployment of ultra-fast chargers for EVs in Austria and Germany.
As the world shifts towards greater interconnectivity, the wider use of smart meters, sensors and internet of things applications, has created opportunities to provide new services to consumers, enabling them to participate in the electricity market by controlling consumption and reducing electricity bills. Using artificial intelligence and machine learning techniques, BeeBryte, a French energy intelligence company, is making buildings smarter and cleaner by modulating energy consumption with sensors that control heating, cooling and battery storage.
Decentralisation and digitalisation has allowed for a variety of innovative business models to emerge. One of them is Virtual power plants, which aggregates distributed generation and demand response to sell electricity and ancillary services in the system. Paul Kreutzkamp from Next Kraftwerke, a virtual power plant operating in Germany and Belgium, believes that setting energy generation and demand should go hand in hand through price signals, spurring some utilities to consider new business models. The Dutch utility Eneco, is developing a network of home batteries into a virtual power plant to provide capacity and grid services to the Dutch grid (CrowdNett project).
Platform business models based around peer-to-peer power trading is aiding the democratisation of electricity. Lumenaza, a new software platform in Germany, lets utilities buy and sell 'regional electricity' by connecting up small producers with consumers.
Blockchain technology is coming to the energy sector and has the potential to change the paradigm by cutting-out the middlemen, and enabling peer-to-peer transactions based on smart contracts. SolarCoin, a blockchain-based digital asset, grants solar power producers 1Solar coin per MWh of energy produced.
Source: International Renewable Energy Agency (IRENA)
Global energy investment in 2017 fails to keep up with energy security and sustainability goals
The electricity sector attracted the largest share of energy investments in 2017, sustained by robust spending on grids, exceeding the oil and gas industry for the second year in row, as the energy sector moves toward greater electrification, according to the International Energy Agency's latest review of global energy spending.
Global energy investment totalled USD 1.8 trillion in 2017, a 2% decline in real terms from the previous year, according to the World Energy Investment 2018 report. More than USD 750 billion went to the electricity sector while USD 715 billion was spent on oil and gas supply globally.
State-backed investments are accounting for a rising share of global energy investment, as state-owned enterprises have remained more resilient in oil and gas and thermal power compared with private actors. The share of global energy investment driven by state-owned enterprises increased over the past five years to over 40% in 2017.
Meanwhile, government policies are playing a growing role in driving private spending. Across all power sector investments, more than 95% of investment is now based on regulation or contracts for remuneration, with a dwindling role for new projects based solely on revenues from variable pricing in competitive wholesale markets. Investment in energy efficiency is particularly linked to government policy, often through energy performance standards.
The report also finds that after several years of growth, combined global investment in renewables and energy efficiency declined by 3% in 2017 and there is a risk that it will slow further this year. For instance, investment in renewable power, which accounted for two-thirds of power generation spending, dropped 7% in 2017. Recent policy changes in China linked to support for the deployment of solar PV raise the risk of a slowdown in investment this year.
As China accounts for more than 40% of global investment in solar PV, its policy changes have global implications. This confirms past IEA reports that have highlighted the critical importance of policies in driving investment in renewable energy.
While energy efficiency showed some of the strongest expansion in 2017, it was not enough to offset the decline in renewables. Moreover, efficiency investment growth has weakened in the past year as policy activity showed signs of slowing down.
"Such a decline in global investment for renewables and energy efficiency combined is worrying," said Dr Fatih Birol, the IEA's Executive Director. "This could threaten the expansion of clean energy needed to meet energy security, climate and clean-air goals. While we would need this investment to go up rapidly, it is disappointing to find that it might be falling this year."
The share of fossil fuels in energy supply investment rose last year for the first time since 2014, as spending in oil and gas increased modestly. Meanwhile, retirements of nuclear power plants exceeded new construction starts as investment in the sector declined to its lowest level in five years in 2017.
The share of national oil companies in total oil and gas upstream investment remained near record highs, a trend expected to persist in 2018. Though still a small part of the market, electric vehicles now account for much of the growth in global passenger vehicle sales, spurred by government purchase incentives. For electric cars, nearly one quarter of the global value of EV sales in 2017 came from the budgets of governments, who are allocating more capital to support the sector each year.
Final investment decisions for coal power plants to be built in the coming years declined for a second straight year, reaching a third of their 2010 level. However, despite declining global capacity additions, and an elevated level of retirements of existing plants, the global coal fleet continued to expand in 2017, mostly due to markets in Asia. And while there was a shift towards more efficient plants, 60% of currently operating capacity uses inefficient subcritical technology.
The report finds that the prospects of the US shale industry are improving. Between 2010 and 2014, companies spent up to USD 1.8 for each dollar of revenue. However, the industry has almost halved its breakeven price, providing a more sustainable basis for future expansion. This underpins a record increase in US light tight oil production of 1.3 million barrels a day in 2018.
"The United States shale industry is at turning point after a long period of operating on a fragile financial basis," said Dr Birol. "The industry appears on track to achieve positive free cash flow for the first time ever this year, turning into a more mature and financially solid industry while production is growing at its fastest pace ever."
The improved prospects for the US shale sector contrast with the rest of the upstream oil and gas industry. Investment in conventional oil projects, which are responsible for the bulk of global supply, remains subdued. Investment in new conventional capacity is set to plunge in 2018 to about one-third of the total, a multi-year low raising concerns about the long-term adequacy of supply.
This edition of World Energy Investment, which is being released for free this year, provides a wealth of data and analysis for decision making by governments, the energy industry and financial institutions to set policy frameworks, implement business strategies, finance new projects and develop new technologies.
Off-grid Renewables are Growing, Bringing Socio-economic Benefits to Millions
Off-grid renewable energy has witnessed spectacular growth over the last decade. Since 2008 capacity has trebled and the number of people in rural communities served by the technology has witnessed six-fold growth. Today, up to 133 million people are receiving life-changing access to low-cost, secure renewable energy and benefit from the socioeconomic impact access delivers. Global off-grid investments in 2017 reached USD 284 million.
These findings feature in a new IRENA brief launched during the UN High-Level Political Forum in New York. The paper, entitled: Off-grid Renewable Energy Solutions, Global and Regional Status and Trends, builds on IRENA's statistical analysis to offer a global picture of the sector's trajectory and impact. The data highlights the extent to which off-grid renewables are emerging as a mainstream solution to the expansion of electricity services all over the world, contributing to sustainable development goal 7 (SDG 7) by broadening the reach of electricity beyond existing grid infrastructure.
"Off-grid renewable energy is an important contributor to energy access across the developing world having witnessed widespread, rapid growth in deployment over the last few years," said Dr. Rabia Ferroukhi, Deputy Director of the Knowledge, Policy and Finance at IRENA. "Our analysis captures this momentum whilst shedding light on the need to step-up efforts towards 2030 Sustainable Development Goals."
Africa has emerged as a dynamic, fast-moving hub for off-grid renewables. The development of solar lighting solutions and innovations in deployment and financing models, such as pay as you go options and mobile payment platforms have contributed to Africa's rapid advances. The continent's off-grid industry now serves around 53 million people – the equivalent of the entire population of South Africa – up from just over two million in 2011.
The brief identifies Asia as a global leader in off-grid renewables capacity deployment. Today, up to 76 million people across the continent may now benefit from such power sources.
South America, home to some of the highest rates of electricity access in the developing world, has also witnessed off-grid renewable growth the brief suggests, where the technology is considered key to 'last mile' electricity access.
Off-grid renewable energy solutions are being deployed to provide electricity services for a wide range of end-uses, including for powering agriculture, telecommunication infrastructure, healthcare centres, schools, and rural enterprises. The paper emphasises that linking delivery of off-grid solutions to energy service delivery can unlock substantial socio-economic benefits, contributing to multiple SDGs.
While dramatic cost reductions have been the primary driver of this acceleration, it is the multifaceted socioeconomic benefits that provide the greatest incentives for its deployment. Renewable energy's centrality to the SDG 7 goal on universal access to clean, reliable and affordable energy against a backdrop of a billion people who still live without it, is unquestionable. However, beyond energy itself renewables are a key contributor to sustainable development, generating jobs, stimulating growth, ensuring resource security and improving health.
The paper notes that in Bangladesh, around 133 000 jobs have been created through a Solar Home System programme and an off-grid renewables initiative in Rwanda aims to generate 7 000 jobs whilst delivering energy access to almost 80 000 people. Similarly, incomes in rural households benefit from lower cost solar lanterns, and remote health and educational facilities are enhanced through consistent availability of power.
"Renewables are a central pillar of SDG 7 and represent one of the most effective and economicmeans available in the pursuit of universal energy access," said Rabia Ferroukhi, Deputy-Director of Knowledge Policy and Finance at IRENA. "Yet beyond this, we are now beginning to truly understand the way in which distributed renewable electricity is transforming the lives of those receiving from it, bringing stability and opportunity to millions of people around the world."
Read the brief on the Off-grid Renewable Energy Solutions and the six case studies developed to showcase the socioeconomic impact of off-grid renewables in South East Asia.
CPEC and Pakistan-China Energy cooperation
The demands of global energy are substantially rising day by day in the 21st century, whereas the dependency on fossil fuels like coal, oil and natural gas have become a serious concern which is about 80% of the world's primary source of energy. The concerns about fossil fuels are due to their ever rising prices and their negative impact on the environment due to the harmful emission of greenhouse gases. Therefore, in this context the reliance on nuclear power energy is considered by various countries, including Pakistan, as a good alternative option of energy supply, which is comparatively cheaper also.
Pakistan has great strategic importance in South Asia because of its location, its dynamic young population, its vibrant economic potential, being a nuclear power, and now being a strategic partner of China in the backdrop of the construction of the China-Pakistan Economic Corridor (CPEC).The CPEC is a flagship project of China's Belt and Road (B&R) initiative and the completion of CPEC is likely to bring major economic advantages to China, Pakistan and South Asian region.
Like many other countries, for its economic development based on enhancing its industrial and agricultural production, energy is very important for Pakistan and it needs to address its current energy crises on an urgent basis. In this context signing of the CPEC agreement with China by Pakistan in 2015 is considered as a milestone achievement, as it includes many electricity generation projects, which will help address energy shortages of Pakistan.
Apart from developing other means of electricity generation in Pakistan, China is already helping Pakistan in nuclear energy production by supplying nuclear power reactors, under IAEA safeguards based on agreements signed in the field of nuclear cooperation. Apart from installing Chashma 1 and Chashma 2 power plants, which are already producing electricity in Pakistan, in 2017 China has signed another deal with Pakistan to also install Chashma 3 and Chashma 4 power plants. Out of these each power plant, after completion, will produce 1000 megawatts of electricity. As part of the CPEC project, China is also building two HUOLONG ONE nuclear reactors in Karachi that will become ready to use by 2021.
After signing the CPEC agreement China is very keen to help Pakistan in the energy production, as energy is required not only for the construction of CPEC projects but also for its subsequent operation. This is because China is also going to get huge trade benefits by trading with the outer world using the CPEC. In other words, apart from helping its friend Pakistan in energy production, this cooperation also serves China's economic interests in a major way. In this context, the CPEC is a win-win project that serves Pakistan and China's interest in a similar way.
As China is doing a lot to advance its interests by expanding its economic production by basing on its CPEC related exports, Pakistan should also take the CPEC as a big opportunity to develop its economy to become economically self reliant. In this context, it should focus on completing the construction of the CPEC and its related energy projects on time, so that it addresses its energy shortages and quickly moves on towards its economic development.
In fact, it is more important for Pakistan to work harder for completion of the CPEC related projects and make use of the CPEC to advance its industry and agriculture, increase trade, attract foreign direct investment and increase its revenues. This is important because Pakistan's economy needs a major boost to recover from its ever increasing budget deficits, inflation, domestic and foreign debt situations,widening gap of balance of payments due to constantly declining exports and falling foreign exchange reserves.
This is also important to repay the domestic debt and foreign debt in order to save Pakistan from becoming a defaulting state in the coming years. Above all it is necessary to avail the opportunity of reaping CPEC related economic advantages to develop Pakistan's economy in a reasonable time frame to meet its aforementioned obligations and finally to bring prosperity to Pakistan and its people.
In the light of above it is logical to say that Pakistan and China's cooperation in the energy field is beneficial for both countries and CPEC is a project that helps Pakistan in meeting its energy shortages, and it will be equally beneficial to Pakistan and China to advance their economic interests. Rather CPEC related energy projects and trade will be much more beneficial to Pakistan to meet its above discussed economic challenges.
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Countless non religious texts verify there was a man who walked the Earth around 2000 years ago who performed miracles named Jesus Christ.
Are you one of the 70% of Americans who identify as Christian?
Second, we provide marriage retreats to help couples experience dynamic transformation quickly.Luckily, is home to thousands of single Christians and they're just a few clicks away!We make it easy for you to meet fantastic people, and being the UK's best known dating site, we've already matched thousands of singles.In the mid-1990s, when I was seeing the man who became my husband, we talked on landline phones late at night (when rates dropped from 25 cents per minute to 10 cents), sent just a handful of e-mails (seemed impersonal), and never texted (weren't pagers mostly just for drug dealers back then? We desire to help believers develop Godly relationships through our four branches of ministry.

subset: commoncrawl


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United States: $12.6 Million Sandoz ASP Reporting Settlement Raises More Questions Than It Answers
Recently, HHS-OIG announced a first-of-its-kind settlement over pharmaceutical manufacturer reporting of Average Sales Price (ASP). Sandoz, Inc. agreed to pay a civil monetary penalty of $12.64 million for alleged failure to submit accurate ASP data to CMS.
ASP reporting was adopted in large part to create a mechanism
whereby government drug reimbursement rates for biologics and
physician-administered drugs are tied to the actual purchase price
of those drugs. ASP is used by Medicare, and some Medicaid
programs, to reimburse biologics and physician-administered drugs,
such as chemotherapy drugs. Federal law requires pharmaceutical
manufacturers to submit ASP information for each of these drugs to
CMS on a quarterly basis. The


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Lactation Consultation (CPMC San Francisco)
Private Lactation Consultation with an IBCLC at one of our two outpatient lactation centers here in San Francisco. We porcess insurance. Contact your insurance company to verify coverage.
Sutter Health offers a wide variety of Pregnancy classes and events throughout Northern California. Find a class or event located near you.
176results found for:
Private Lactation Consultation with an IBCLC at one of our two outpatient lactation centers here in San Francisco. We porcess insurance. Contact your insurance company to verify coverage.
Drop-in class. This informal drop-in group focuses on breastfeeding techniques, benefits, and emotional support. Facilitated by an Alta Bates Summit board-certified Lactation Consultant.
Birth Center Tours provide a valuable overview of what to expect during your hospital stay. Registration is required for weekends only. No registration is required for weekday evenings. See schedule of upcoming dates and times.
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Individual 1 to 1-1/2 hour private consultations with an Alta Bates Summit board-certified Lactation Consultant are available by appointment at (510) 204-6546 the Ashby Campus in Berkeley.
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The program covers day-to-day management of blood glucose levels during pregnancy and prevention of type 2 diabetes post partum.
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For Breastfeeding related questions and information! Call 415-600-6243
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Parenthood can be a wild ride, especially during the first few months. Join us to discuss the joys and anxieties of adjusting to new responsibilities and changed routines. Group is facilitated by Brett Collins, LCSW.
Tour the California Campus and ask questions about the logistics of your stay.
A free guided tour of our new birthing facility.
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For serious accidents, injuries and conditions that require immediate medical care.
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Convenient walk-in care clinics for your non-urgent health needs.


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Fill out the fields below and we will pray for your request.
We believe that God has given us the opportunity to not only be in His presence while on this earth, but to partner with him as He works in us and in the world around us. We are incredibly excited to be a part of what He is doing in our lives, as well as in the lives of those in our community, our nation and internationally. We feel truly blessed to have this opportunity to give and be able to partner with God in all He is doing!
You can read more on Pastor Jim's thoughts on blessings and the opportunity to give on our blog.


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Uploaded by: HeikeJulia
Date: 22.10.2013
Image "HEX" Code: #2478985
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Recent automotive trends, reviews, test drives and the latest news from the world of cars.Read the news section.
It is a question not of a trite fancy dress with ears, and about the main vehicle of the legendary hero - batmobile which can be got at auction opening on November 30 in Great Britain for only 90 000 pounds sterling (107 thousand euros).
The first images of the second generation Toyota Aygo, which makes its global debut at this week's Geneva Motor Show, the Internet arrived on Monday (3). The little one will be revealed in full tomorrow, on the first day of press conferences of the event.
The Mercedes-Benz revealed on Tuesday (11) S Class Coupe, days after the first official photo of the model have been conveyed. The presentation of the replacement Class CL to the public is scheduled for the Geneva Motor Show in March, and his arrival to European dealers will occur in the second half.
BMW has no plans to launch a new sedan entry to its range. The information was revealed by Herbert Diess, chief development officer of the manufacturer, the site Wards Auto.
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text:
Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular Intervention
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Background—Limited evidence suggests that women and men might be treated differently for peripheral arterial disease. This analysis evaluated sex-based differences in disease presentation and its effect on treatment modality among patients who underwent endovascular treatment for peripheral arterial disease.
Methods and Results—Using national registry data from the Vascular Quality Initiative between 2010 and 2013, we examined patient, limb, and artery characteristics by sex through descriptive statistics. We studied 26 750 procedures performed in 23 820 patients to treat 30 545 limbs and 44 804 arteries. Women presented at an older age (69 versus 67 years; P<0.001) and were less often current or former smokers (72% versus 85%; P<0.001). Transatlantic Inter-Society Consensus classification was similar among men and women (Transatlantic Inter-Society Consensus C or D: 37% in men versus 37% in women; P=0.81), as was mean occlusion length (4.5 cm in men versus 4.6 cm in women; P=0.04), even after accounting for lesion location. Women more frequently underwent treatment for rest pain (11% in men versus 16% in women; P<0.001) versus claudication (59% in men versus 53% in women; P<0.001) or tissue loss (28% in men versus 27% in women; P=0.75). Treatment modality did not differ by sex but was associated with disease severity (P for trend <0.001) and lesion location (P for trend <0.001).
Conclusions—Women undergo peripheral endovascular intervention for peripheral arterial disease at an older age with critical limb ischemia. Treatment modalities do not vary by sex but are determined by disease severity and site. Although there exist sex differences in presentation, these differences do not lead to differential treatment for women with peripheral arterial disease.
Studies suggest that women diagnosed with peripheral arterial disease are treated at an older age, present with advanced multilevel disease, and have poorer overall health.
Yet these investigations have limited descriptions of clinical indications, treatment modalities, and disease distribution by sex in addition to being underpowered to detect sex differences.
Using a large, national vascular registry of which 42% are women, this study:
Confirms that women present at an older age with more advanced disease;
Finds no sex differences in disease characteristics, including lesion length, occlusion length, Transatlantic Inter-Society Consensus score, and the type of artery treated;
Identifies no sex differences in treatment type instead, treatment modality driven by Transatlantic Inter-Society Consensus score and artery treated.
Elderly patients (age ≥65 years) constitute the fastest growing segment of the US population, and women outnumber men in this demographic group.1–3 As the population ages, the prevalence of peripheral arterial disease (PAD) will create substantial financial and resource burdens on the healthcare system.4 Moreover, according to the 2010 United States Census, the prevalence of PAD is higher in women than men.2 Yet PAD remains under-recognized and undertreated among women.2,5 Previous studies suggest that compared with men, women are treated at an older age, present with advanced multilevel disease,1 have poorer overall health status, including more severe symptoms and lower quality of life, and are at increased risk for morbidity and mortality.6
Solitary investigations examined several aspects of sex bias in therapy, but these were not the primary objective of investigations and were likely underpowered to determine sex-based differences.6,7 Furthermore, women remain an under-represented minority in most PAD studies, and many investigations have limited descriptions of clinical indications, treatment modalities, and disease distribution by sex.2,4,7 These factors were highlighted by the American Heart Association's call to evaluate sex-based differences in the presentation of PAD with a goal to identify the potential variation in treatment approaches, benefits and harms among men compared with women.8
To better understand sex-based treatments for PAD, we sought to investigate differences in patient presentation, disease distribution, and treatment modalities among men and women undergoing peripheral endovascular intervention (PVI) for PAD. We used the Society for Vascular Surgery Vascular Quality Initiative data set to analyze these characteristics among men and women.
Data Source
Established in 2011, the Vascular Quality Initiative prospectively collects data on >120 patient and procedure-level variables for commonly performed major vascular procedures, such as PVI, at >350 participating centers nationwide.9 For this project, we queried the Vascular Quality Initiative PVI data set and abstracted all relevant patient and procedure variables. The data and analytic methods are available to other researchers pending approval by the Research Advisory Committee at Vascular Quality Initiative.
Establishing the Cohort
Patients who underwent PVI from January 1, 2010, to December 31, 2013, were eligible for inclusion in our analysis. There were 35 199 eligible PVI procedures performed in 28 173 patients. We excluded procedures with missing information on sex, indication, side treated, and artery treated (n=2469; 7%). We also excluded interventions on a previously treated artery (n=2405; 7%), aneurysmal disease pathology (n=339; 1%), and acute limb ischemia as indication for treatment (n=3113; 9%). After applying these criteria, we had 26 873 procedures performed in 23 940 patients, 30 668 limbs, and 44 927 arteries (Figure 1). For analysis, we further excluded cases in which only the aorta was treated (n=123) because this is a different subgroup of pathology within our population of peripheral vascular disease. The final cohort for analysis included 26 750 procedures performed in 23 820 patients, 30 545 limbs, and 44 804 arteries.
The primary exposure was sex (men versus women). As shown in Figure 1, we analyzed our cohort in 3 different ways: by patient, by limb, and by artery treated. At the patient level, we studied sex-based differences in demographics and comorbidities. At the limb level, we examined the history of prior procedures, indication for treatment (claudication versus rest pain versus tissue loss), and unilateral versus bilateral treatment. Finally, at the artery level, we studied sex differences in type and number of arteries treated, lesion characteristics, and treatment modality used for each artery treated. Tibial arteries (anterior tibial, posterior tibial, peroneal, and tibioperoneal trunk) were grouped together for analysis given their individual low frequency of treatment.
Statistical Analysis
Descriptive univariate statistics were conducted for all characteristics, stratified by sex. We also present absolute standardized differences (d) between men and women, which is a measure of the effect size (difference in means or proportions divided by the SD). We used d>0.1 as an threshold for imbalance, or significant difference, between the groups.10 Statistical significance was determined using the χ2 test of independence and Student t test for continuous variables. Because the focus of this article is in the description of current practice, we did not use a formal method to account for multiple testing and present the uncorrected Pvalues. Although we refer to P<0.05 as a threshold for statistical significance, we focused on absolute difference of frequencies to identify significant and clinically meaningful findings. Linear trend analysis for categorical characteristics was conducted using simple logistic regression. All statistical analyses were performed using Stata 13.1 software (College Station, TX). Our study was designated as institutional review board exempt by the Center for the Protection of Human Subjects at the Geisel School of Medicine at Dartmouth.
Cohort Characteristics
Women comprised 42% of our cohort. The mean age of patients was 68 years. Unilateral limb treatment was performed in 84% of patients, and right and left limbs were treated with equal frequency. The aorta was primarily treated in conjunction with bilateral limb therapy (60% of all aortic treatments). The proportions of interventions at each arterial level were as follows, listed in descending order of frequency: superficial femoral artery (29%), common iliac artery (22%), popliteal artery (14%), external iliac artery (13%), anterior tibial artery (6%), tibioperoneal trunk (4%), posterior tibial artery (4%), peroneal artery (4%), common femoral artery (4%), profunda femoris artery (1%), and aorta (1%).
Characteristics at Presentation
Most demographic characteristics at time of the index procedure were similar for men and women (Table 1). However, women presented at an older age than men (69 versus 67 years; P<0.001; d=0.23) and were more likely to be black (15% versus 11%; P<0.001; d=0.14). Furthermore, women were less likely to have a history of coronary disease (26% versus 32%; P<0.001; d=0.14), less likely to be ambulatory (77% versus 82% ambulatory; P<0.001; d=0.11), and were more commonly nonsmokers (28% versus 15%; P<0.001; d=0.31). In terms of medications, women were less likely to be on a statin before the procedure (64% versus 70%; P<0.001; d=0.12).
Men and women differed slightly by indication for treatment (Table 1). Most interventions were performed for claudication, namely 59% and 53% of limbs treated in men and women, respectively (P<0.001). Rest pain was more prevalent in women, accounting for 16% of limbs treated among women compared with only 11% among men (P<0.001). Endovascular outflow procedures of the ipsilateral or contralateral limb were the most common previous interventions (15% of the cohort), but there were no meaningful differences in any prior procedure between men and women.
Number of Arteries Treated
The number of arteries treated per procedure ranged from 1 to 6, with a median number of 1 artery treated per limb. By sex, 54% men versus 51% women had a single artery treated (P<0.001), 31% men versus 34% women had 2 arteries treated (P<0.001), and 15% men versus 15% women had ≥3 arteries treated (P=0.71).
When we assessed the relationship between the number of arteries treated and indication, we noted among unilateral limb treatment (Figure 2A) a minor sex difference in rest pain patients, where 43% of women had ≥2 arteries treated compared with 39% in men (P=0.04). However, men and women with claudication or tissue loss had a similar number of arteries treated. In bilaterally treated limbs (Figure 2B), there was a slight sex difference in number of arteries treated for claudication (1 artery treated: 77% in men versus 74% in women; P=0.01), but no significant difference in those treated for rest pain or tissue loss. Taken in aggregate across different indications for intervention, the number of arteries treated was not associated with sex.
Disease severity, however, was significantly associated with the number of arteries treated. Among all patients who had bilateral treatment, increasing severity from claudication to rest pain to tissue loss lead to a significant increase in multilevel disease treatment (2+ arteries treated; P for trend <0.001) and significant decrease in single artery treatment (P for trend <0.001).
Distribution of Arteries Treated
Men and women had a similar distribution of arteries treated (Figure 3A). Figure 3B shows the proportion of treatments performed in men versus women at each artery level. Except for the aorta, the number of interventions at each artery level was higher in men than women. When calculating rates of treatment at artery levels, women were more likely to receive treatment in the aorta (risk ratio [RR]=2.0; 95% confidence interval [CI], 1.6–2.5), common iliac artery (RR=1.2; 95% CI, 1.1–1.2), superficial femoral artery (RR=1.03; 95% CI, 1.00–1.06), and popliteal artery (RR=1.1; 95% CI, 1.0–1.1). Women were less likely to have treatment in the external iliac artery (RR=0.9; 95% CI, 0.8–0.9) and tibial arteries (RR=0.8; 95% CI, 0.76–0.82). Women and men were equally likely to receive treatment in the common femoral artery (RR=0.97; 95% CI, 0.9–1.1) and profunda femoris artery (RR=0.9; 95% CI, 0.7–1.0).
We also studied sex differences in the distribution of common combinations of arteries treated at the limb level while accounting for unilateral versus bilateral treatment (Table I in the Data Supplement). We found no significant differences by sex.
Lesion Characteristics
Lesion characteristics included Transatlantic Inter-Society Consensus (TASC) score, treated length, occlusion length, and percent of lesions that were occluded (Table 2). Except in tibial arteries, TASC A lesions were the most commonly treated lesions, comprising between 30% of superficial femoral artery lesions treated and 56% of profunda femoris artery lesions treated. In the tibial arteries, TASC D lesions were the most common, accounting for 37% of all tibial artery lesions treated. Overall, men and women presented with similar TASC score lesions. Similarly, the mean occlusion length was similar in men and women (4.5 cm in men versus 4.6 cm in women; P=0.04). In general, at each artery level, men and women demonstrated similar lesion characteristics, including TASC score, treatment length, occlusion length, and frequency of occlusion (Table 2).
Treatment Types Delivered
Treatment types studied included percutaneous transluminal angioplasty, self-expanding stent, balloon-expandable stent, stent graft, atherectomy (including laser atherectomy, orbital atherectomy, and excisional atherectomy), and other treatments (including cryoplasty and cutting balloon angioplasty). Across indication and artery treated, men and women received the same treatment modality, with few exceptions (Figure 4). For example, in superficial femoral arteries treated for claudication, 41% were treated with a self-expanding stent in men versus 36% in women (P=0.04). See Table II in the Data Supplement for detailed results.
Disease severity and artery treated seem strongly associated with treatment type delivered (Figure 4). Descending from the common iliac to the tibial arteries, there is a significant linear trend in the increase of percutaneous transluminal angioplasty (P for trend <0.001) atherectomy (P for trend <0.001) and other treatment modalities (cutting balloon angioplasty or cryoplasty; P for trend <0.001) across all indications. Likewise, descending from the common iliac to tibial arteries, there is a significant linear trend in the decreased use of self-expanding stent (P for trend <0.001), balloon-expandable stent (P for trend <0.001), and stent graft (P for trend <0.001) across all indications.
The treatment of peripheral vascular disease in women has been suggested to present sex-specific challenges in technique and therefore initial approach.7 For example, some analyses found that women hospitalized for PAD are less likely to undergo a procedure compared with men.11 Furthermore, female sex has been associated with worse outcomes after endovascular and open vascular procedures.12,13 Yet differences in clinical and demographic factors have not been able to completely account for this noted sex bias in initial treatment presentation or treatment approach.6 We, therefore, sought to explore the underlying sex-based differences in the clinical presentation and endovascular treatment of patients with PAD using a large, validated quality improvement study cohort to address the lack of power and variation in information on patient, limb, and artery-specific data inherent to the current published literature.
We provide a brief overview of the most relevant sex-based studies in PAD patients in Table 3. As shown, there remains a fair amount of heterogeneity in the conclusions drawn while the limitations of each study make it difficult to draw any global conclusions in meta-analysis. This paucity of data leads to the current lack of consensus in the literature on sex-based differences among patients with PAD. Some of this conflict may be because of the pervasiveness of single-center, small sample studies with limited external validity on which prior literature conclusions are drawn.
Our study was designed to systematically assess sex-based variation in PVI considering these shortcomings with the aim to support, supplant, or expand the current knowledge base. Our findings add to this current literature in several important ways (Table 4). First, regarding the initial clinical patient presentation, we found few meaningful sex-based differences in terms of comorbidities or history of previous interventions. As such, our study reaffirms previously reported literature results. It seems consistent across ours and other authors' work that women more commonly present at an older age with more advanced disease, such as ischemic rest pain versus claudication, when compared with men. We also noted that men more commonly smoke or previously smoked compared with women. However, although current literature was inconclusive on sex differences in comorbidities such as hypertension, our much larger cohort showed no such differences. It is unclear whether socioeconomic or genetic factors are attributable in this consistent discrepancy in initial presentation.
Second, in terms of disease characterization, few single-center studies4,14 briefly addressed sex differences in lesion characteristics. As listed in Table 4, they suggest that men more commonly have tibial disease while women more commonly have iliac disease although others report no difference in TASC score or lesion length. Yet these analyses did not account for disease severity or disease location, that is, the type of artery that was treated, which may ultimately bias results. Our study was able to account for these confounders and noted no sex differences in disease characteristics on lesion length, occlusion length, or disease distribution as measured by TASC score or the type of artery treated.
Third, sex differences in endovascular treatment modality used in PVI have not been previously addressed in the literature (Table 4). Our meticulous analysis comparing various treatment types by sex found that there were no significant differences in men compared with women. However, we found a clear and persistent trend in the increasing use of percutaneous transluminal angioplasty with a concomitant decline in the use of stents or atherectomy as the treated arteries became more distal. This finding objectively confirms a common notion that smaller caliber vessels are less likely to receive stent placement or atherectomy and are more likely treated with percutaneous transluminal angioplasty only. Thus, rather than sex, the disease location and distribution were the major determinant of treatment type. Future work will examine how these decisions contribute toward treatment outcomes in PVI.
In addition, we identified a significant association between indication for treatment, or disease severity as assessed by rest pain versus tissue loss versus claudication, and the number of arteries treated. Similarly, disease severity was also strongly linked to the treatment modality used. In essence, the worse the disease process, the more aggressive the treatment as described by number of arteries treated and treatment modality used. The interaction of these characteristics has not been previously reported but seems often intuitive in the decision-making process about limb ischemia treatment.
This article serves as a real-world description of practice patterns among 24 000 men and women undergoing PVI across the United States. Although this cohort lacked significant representation from all racial and ethnic groups because most patients were white (83%) and non-Hispanic (96%), this might be the true representation of patients receiving PVI treatment and is in and of itself an important finding in health disparities studies. Furthermore, women represented a substantial (42%) proportion of the cohort, which is an uncommon strength in vascular disease studies.
Reported frequencies were not adjusted for patient risk factors given the descriptive nature of this project. To address potential confounding, we stratified by indication and artery type treated where appropriate. In addition, because this is an observational cohort study, causality cannot be assumed in proposed associations.
Missing data are limitations inherent to large registries. Any procedures that were missing critical information, such as sex, indication, and artery type treated, were excluded from the outset but comprised a small proportion of the cohort. No variables analyzed were missing >5% of observations except TASC score, which was missing in ≈10% of artery-level observations. To address this limitation, a stratified analysis of procedures by missing versus completed TASC classification was conducted for sex, indication, and artery type treated for which there was no statistically significant differences.
In summary, we identified that women clinically present at an older age with more advanced arterial disease but are less likely to have comorbid coronary artery disease or be actively smoking. These differences could be because of a varied disease pathophysiology or represent limitations to healthcare access, among others, for women compared with men and thus warrant further study. For instance, our future endeavors will analyze the associations between sex disparities in PAD treatment and postprocedural outcomes with emphasis placed on regional variations and socioeconomic status as predictive variables.
Men and women who undergo endovascular treatment for PAD in our national registry are largely equivalent in terms of disease characterization and treatment modality. Sex-based disease characterization in terms of number of arteries treated and artery type treated seems to be driven by indication. Likewise, treatment modality seems associated with indication and artery type treated, rather than sex. Further investigation is required to appreciate the effect of disease severity and treatment modality on patient outcomes after PVI.
We are grateful to Dr Todd Mackenzie for his statistical expertise and support.
Sources of Funding
This work was supported by the US Food and Drug Administration (FDA) Office of Women's Health. This project was supported, in part, by an appointment to the Oak Ridge Institute for Science and Education (ORISE) Research Participation Program at The Dartmouth Institute for Health Policy and Clinical Practice, FDA, administered by ORISE through an interagency agreement between the US Department of Energy and FDA.
N. Ramkumar, Dr Goodney, and. Dr Sedrakyan were supported by a grant from the Food and Drug Administration (FDA grant U01FD005478-01; Dr Sedrakyan, principal investigator) as part of The Vascular Implant Surveillance and Interventional Outcomes Network. N. Ramkumar and Dr Suckow were supported by an Oak Ridge Institute for Science and Education fellowship from the FDA. The other authors report no conflicts.
The Data Supplement is available at http://circinterventions.ahajournals.org/lookup/suppl/doi:10.1161/CIRCINTERVENTIONS.117.005749/-/DC1.
- Received July 28, 2017.
- Accepted November 29, 2017.
- © 2018 American Heart Association, Inc.
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- Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular InterventionNiveditta Ramkumar, Bjoern D. Suckow, Jeremiah R. Brown, Art Sedrakyan, Jack L. Cronenwett and Philip P. GoodneyCirculation: Cardiovascular Interventions. 2018;11:e005749, originally published January 11, 2018https://doi.org/10.1161/CIRCINTERVENTIONS.117.005749
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- Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular InterventionNiveditta Ramkumar, Bjoern D. Suckow, Jeremiah R. Brown, Art Sedrakyan, Jack L. Cronenwett and Philip P. GoodneyCirculation: Cardiovascular Interventions. 2018;11:e005749, originally published January 11, 2018https://doi.org/10.1161/CIRCINTERVENTIONS.117.005749