1
|
Foley KM, Kennedy KF, Lima FV, Secemsky EA, Banerjee S, Goodney PP, Shishehbor MH, Soukas PA, Hyder ON, Abbott JD, Aronow HD. Treatment Variability Among Patients Hospitalized for Chronic Limb-Threatening Ischemia: An Analysis of the 2016 to 2018 US National Inpatient Sample. J Am Heart Assoc 2024; 13:e030899. [PMID: 38240207 PMCID: PMC11056168 DOI: 10.1161/jaha.123.030899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/21/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Little is known about treatment variability across US hospitals for patients with chronic limb-threatening ischemia (CLTI). METHODS AND RESULTS Data were collected from the 2016 to 2018 National Inpatient Sample. All patients aged ≥18 years, admitted to nonfederal US hospitals with a primary diagnosis of CLTI, were identified. Patients were classified according to their clinical presentation (rest pain, skin ulceration, or gangrene) and were further characterized according to the treatment strategy used. The primary outcome of interest was variability in CLTI treatment, as characterized by the median odds ratio. The median odds ratio is defined as the likelihood that 2 similar patients would be treated with a given modality at 1 versus another randomly selected hospital. There were 15 896 (weighted n=79 480) hospitalizations identified where CLTI was the primary diagnosis. Medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, and amputation alone were used in 4057 (25%), 5390 (34%), 3733 (24%), and 2716 (17%) patients, respectively. After adjusting for both patient- and hospital-related factors, the median odds ratio (95% CI) for medical therapy alone, endovascular revascularization ± amputation, surgical revascularization ± amputation, any revascularization, and amputation alone were 1.28 (1.19-1.38), 1.86 (1.77-1.95), 1.65 (1.55-1.74), 1.37 (1.28-1.45), and 1.42 (1.27-1.55), respectively. CONCLUSIONS Significant variability in CLTI treatment exists across US hospitals and is not fully explained by patient or hospital characteristics.
Collapse
Affiliation(s)
- Katelyn M. Foley
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | | | - Fabio V. Lima
- University of California, San FranciscoSan FranciscoCA
| | | | - Subhash Banerjee
- Baylor Scott & White Cardiology Consultants of Texas – DallasDallasTX
| | | | | | - Peter A. Soukas
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - Omar N. Hyder
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | - J. Dawn Abbott
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown UniversityProvidenceRI
| | | |
Collapse
|
2
|
Rastogi A, Sudhayakumar A, Schaper NC, Jude EB. A paradigm shift for cardiovascular outcome evaluation in diabetes: Major adverse cardiovascular events (MACE) to major adverse vascular events (MAVE). Diabetes Metab Syndr 2023; 17:102875. [PMID: 37844433 DOI: 10.1016/j.dsx.2023.102875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS Drugs for diabetes are required to demonstrate cardiovascular safety through CV outcome trials (CVOT). The pre-defined end-points for cardiovascular outcome studies may not be sufficient to capture all clinically relevant atherosclerotic cardio vascular disease (ASCVD) events particularly peripheral arterial disease (PAD). METHODS We planned a scoping review and searched database to identify CVOT conducted in population with diabetes measuring lower limb events due to PAD as the primary outcome measure. We also searched CVOT for reported differential cardiovascular outcomes in population with PAD. RESULTS We identified that CV outcomes are measured as 3 point major adverse cardiovascular outcomes (3P-MACE) that includes nonfatal MI and nonfatal stroke or 4P-MACE that included additional unstable angina which is further expanded to 5P-MACE by the inclusion of hospitalization for heart failure (HHF). These CV end points are captured as surrogate for CV mortality based on the biological plausibility of relation between the surrogate and final outcome from pathophysiological studies. We found the prevalence of PAD is no lesser than other CV events in people with diabetes. Moreover, PAD contributes to the significant morbidity associated with diabetes as a surrogate for mortality. However, none of the CVOT with anti-diabetic drugs include PAD events as primary outcome measure despite the inclusion of 6-25 % participants with PAD in major CVOT. PAD outcomes are objectively measurable with tibial arterial waveforms and clinical end-point as lower extremity amputation. PAD outcomes do improve with treatment including intensive glycemic control and novel oral anticoagulants. We suggest the inclusion of PAD to MACE as a pre-specified outcome for a comprehensive capture of major adverse vascular event in future studies for people with diabetes. CONCLUSIONS MACE should be expanded to include PAD event as major adverse vascular event in cardiovascular outcome studies since PAD is clinically relevant and objectively measurable in diabetes.
Collapse
Affiliation(s)
- Ashu Rastogi
- Dept of Endocrinology, PGIMER, Chandigarh, 160012, India.
| | | | - Nicolaas C Schaper
- Division of Endocrinology, Department Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Edward B Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust and University of Manchester, Ashton under Lyne, UK
| |
Collapse
|
3
|
Dayya D, O'Neill OJ, Huedo-Medina TB, Habib N, Moore J, Iyer K. Debridement of Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2022; 11:666-686. [PMID: 34376065 PMCID: PMC9527061 DOI: 10.1089/wound.2021.0016] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/23/2021] [Indexed: 01/29/2023] Open
Abstract
Diabetic foot ulcerations have devastating complications, including amputations, poor quality of life, and life-threatening infections. Diabetic wounds can be protracted, take significant time to heal, and can recur after healing. They are costly consuming health care resources. These consequences have serious public health and clinical implications. Debridement is often used as a standard of care. Debridement consists of both nonmechanical (autolytic, enzymatic) and mechanical methods (sharp/surgical, wet to dry debridement, aqueous high-pressure lavage, ultrasound, and biosurgery/maggot debridement therapy). It is used to remove nonviable tissue, to facilitate wound healing, and help prevent these serious outcomes. What are the various forms and rationale behind debridement? This article comprehensively reviews cutting-edge methods and the science behind debridement and diabetic foot ulcers.
Collapse
Affiliation(s)
- David Dayya
- Division of Undersea and Hyperbaric Medicine, Department of Surgery, Phelps Hospital Northwell Health, Sleepy Hollow, New York, USA
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
- Department of Community Medicine, University of Connecticut, Storrs, Connecticut, USA
- Department of Emergency Medicine, SUNY – Upstate Medical University, Syracuse, New York, USA
- Department of Family Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
- Department of Medicine, Greenwich Hospital, Greenwich, Connecticut, USA
- Department of Medicine, Norwalk Hospital, Norwalk, Connecticut, USA
| | - Owen J. O'Neill
- Division of Undersea and Hyperbaric Medicine, Department of Surgery, Phelps Hospital Northwell Health, Sleepy Hollow, New York, USA
- Department of Emergency Medicine, SUNY – Upstate Medical University, Syracuse, New York, USA
- Department of Medicine, New York Medical College, Valhalla, New York, USA
| | - Tania B. Huedo-Medina
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
- Department of Community Medicine, University of Connecticut, Storrs, Connecticut, USA
| | - Nusrat Habib
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
- Department of Community Medicine, University of Connecticut, Storrs, Connecticut, USA
| | - Joanna Moore
- Department of Medicine, Norwalk Hospital, Norwalk, Connecticut, USA
| | - Kartik Iyer
- Department of Medicine, Norwalk Hospital, Norwalk, Connecticut, USA
| |
Collapse
|
4
|
Cawich SO, Islam S, Hariharan S, Harnarayan P, Budhooram S, Ramsewak S, Naraynsingh V. The economic impact of hospitalization for diabetic foot infections in a Caribbean nation. Perm J 2014; 18:e101-4. [PMID: 24626079 DOI: 10.7812/tpp/13-096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT Foot infection is the most common complication of diabetes mellitus in the Caribbean. Diabetic foot infections place a heavy burden on health care resources in the Caribbean. OBJECTIVE To evaluate the treatment-related costs for diabetic foot infections in a Caribbean nation. METHODS We identified all patients with diabetic foot infections in a 730-bed hospital serving a catchment population of approximately 400,000 persons from June 1, 2011 through July 31, 2012. The following data were collected: details of infection, antibiotic usage, investigations performed, number of physician consultations, details of operative treatment, and duration of hospitalization. Total charges were tallied to determine the final cost for inhospital treatment of diabetic foot infections. RESULTS There were 446 patients hospitalized with diabetic foot infections, yielding approximately 0.75% annual risk for patients with diabetes to develop foot infections. The mean duration of hospitalization was 22.5 days. Sixteen patients (3.6%) were treated conservatively without an operative procedure and 430 (96.4%) required some form of operative intervention. There were 885 debridements, 193 minor amputations and 60 major amputations, 7102 wound dressings, 2763 wound cultures, and 27,015 glucometer measurements. When the hospital charges were tallied, a total of US $13,922,178 (mean, US $31,216) were spent to treat diabetic foot infections in these 446 patients during 1 year at this hospital. CONCLUSIONS Each year, the government of Trinidad and Tobago spends US $85 million, or 0.4% of their gross domestic product, solely to treat patients hospitalized for diabetic foot infections. With this level of national expenditure and the anticipated increase in the prevalence of diabetes, it is necessary to revive the call for investment in preventive public health strategies.
Collapse
Affiliation(s)
- Shamir O Cawich
- Senior Lecturer in the Department of Clinical Surgical Sciences at the University of West Indies in Port of Spain, Trinidad and Tobago.
| | - Shariful Islam
- Senior Resident in the Department of Surgery at San Fernando General Hospital in San Fernando, Trinidad and Tobago.
| | - Seetharaman Hariharan
- Professor of Anesthesia in the Department of Clinical Surgical Sciences at the University of West Indies St Augustine Campus in Trinidad and Tobago.
| | - Patrick Harnarayan
- Lecturer in the Department of Surgery at the University of West Indies in San Fernando, Trinidad and Tobago.
| | - Steve Budhooram
- Lecturer in the Department of Surgery at the University of West Indies in San Fernando, Trinidad and Tobago.
| | - Shivaa Ramsewak
- House Officer in the Department of Clinical Surgical Sciences at the University of West Indies St Augustine Campus in Trinidad and Tobago.
| | - Vijay Naraynsingh
- Professor of Surgery in the Department of Surgery at the University of West Indies in Port of Spain, Trinidad and Tobago.
| |
Collapse
|
5
|
A Framework for the Evaluation of “Value” and Cost-Effectiveness in the Management of Critical Limb Ischemia. J Am Coll Surg 2011; 213:552-66.e5. [DOI: 10.1016/j.jamcollsurg.2011.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/11/2011] [Accepted: 07/14/2011] [Indexed: 11/20/2022]
|
6
|
Barshes NR, Menard MT, Nguyen LL, Bafford R, Ozaki CK, Belkin M. Infrainguinal bypass is associated with lower perioperative mortality than major amputation in high-risk surgical candidates. J Vasc Surg 2011; 53:1251-1259.e1. [DOI: 10.1016/j.jvs.2010.11.099] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 11/11/2010] [Accepted: 11/12/2010] [Indexed: 11/29/2022]
|
7
|
Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJE. Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 2010; 97:1348-53. [PMID: 20632310 DOI: 10.1002/bjs.7092] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the prevalence of lower extremity amputation in England, to establish the associated mortality, and to determine the relationship with diabetes mellitus and previous revascularization. METHODS Data on all patients who had a lower extremity amputation between 2003 and 2008 were extracted from the Hospital Episode Statistics database. Risk adjustment and linear regression were used to compare the data. RESULTS The major amputation rate was 5.1 per 100,000 population and did not change over the 5 years. The mortality rate for major leg amputation was 16.8 per cent (21.4 per cent for above-knee and 11.6 per cent for below-knee amputation); this decreased significantly over time (P < 0.001). There was a significant difference in amputation rate, mortality rate and the below-knee : above-knee amputation ratio between different areas of England (P < 0.001). Some 39.4 per cent of patients who underwent major amputation had diabetes mellitus. The odds of revascularization before amputation increased significantly over time (P = 0.035). CONCLUSION Major and minor amputation rates were stable across England between 2003 and 2008, accompanied by a significant reduction in perioperative mortality. There were significant geographical variations in amputation rates, mortality rates and the below-knee : above-knee amputation ratio.
Collapse
Affiliation(s)
- P W Moxey
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
| | | | | | | | | | | |
Collapse
|
8
|
Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients. Cardiovasc Intervent Radiol 2008; 31:713-22. [DOI: 10.1007/s00270-008-9366-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
|
9
|
Bosiers M, Kallakuri S, Deloose K, Verbist J, Peeters P. Infragenicular angioplasty and stenting in the management of critical limb ischaemia: one year outcome following the use of the MULTI-LINK VISION stent. EUROINTERVENTION 2008; 3:470-4. [DOI: 10.4244/eijv3i4a84] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
10
|
Particularities of peripheral arterial disease managed in vascular surgery in the French West Indies. Arch Cardiovasc Dis 2008; 101:23-9. [DOI: 10.1016/s1875-2136(08)70251-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
11
|
Abstract
Understanding reasons for the neglect of foot screening during the annual review of people with diabetes enables the development of solutions for this omission. This study explores the reasons within the context of health care delivery systems in terms of the professional, social, political and economic aspects of this screening. Information was obtained through reviewing publications on diabetic foot and health care reform. The omission of annual foot examination for people with diabetes is attributed to the nature of diabetes-related foot problems, people with diabetes, health care professionals and the current structure of health care delivery systems. Increasing the adherence to foot screening for those with diabetes requires short- and long-term strategies. Short- and long-term strategies for reminding patients and staff about foot screening are suggested.
Collapse
Affiliation(s)
- Ma'en Zaid Abu-Qamar
- Discipline of Nursing, The University of Adelaide, Adelaide, South Australia, Australia.
| |
Collapse
|
12
|
Hynes N, Mahendran B, Manning B, Andrews E, Courtney D, Sultan S. The Influence of Subintimal Angioplasty on Level of Amputation and Limb Salvage Rates in Lower Limb Critical Ischaemia: A 15-year Experience. Eur J Vasc Endovasc Surg 2005; 30:291-9. [PMID: 15939635 DOI: 10.1016/j.ejvs.2005.04.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Accepted: 04/04/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study is to assess the influence of subintimal angioplasty (SIA) on lower limb amputation rate and level in critically ischaemic limbs. METHODS Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. Eight hundred and twenty-nine patients underwent revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed. Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post-introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Outcome was assessed by the limb salvage rate, 30-day morbidity and mortality, and length of hospital stay. RESULTS The average number of revascularisation increased with the introduction of subintimal angioplasty, from 53 to 96 per year (p<0.001). The overall limb salvage rate increased significantly from 42 to 70% (p<0.001). The cumulative limb salvage rate following revascularisation rose from 72 to 86% (p<0.001). The level of amputation (AKA:BKA) did not vary significantly. Thirty-day morbidity, mortality and length of hospital stay were significantly lower in the post-angioplasty group. CONCLUSIONS Technical advances have resulted in a steadying of amputation numbers despite an ageing population.
Collapse
Affiliation(s)
- N Hynes
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University College Hospital, Galway, Ireland
| | | | | | | | | | | |
Collapse
|
13
|
Ragnarson Tennvall G, Apelqvist J. Health-Economic Consequences of Diabetic Foot Lesions. Clin Infect Dis 2004; 39 Suppl 2:S132-9. [PMID: 15306992 DOI: 10.1086/383275] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Diabetic foot complications result in huge costs for both society and the individual patients. Few reports on the health-economic consequences of diabetic foot infections have been published. In studies considering a wide societal perspective, costs of antibiotics were relatively low, whereas total costs for topical treatment were high relative to the total costs of foot infections. Total direct costs for healing of infected ulcers not requiring amputation are approximately 17,500 dollars (in 1998 US dollars), whereas the costs for lower-extremity amputations are approximately 30,000 dollars-33,500 dollars depending on the level of amputation. Prevention of foot ulcers and amputations by various methods, including patient education, proper footwear, and foot care, in patients at risk is cost effective or even cost saving. Awareness of the potential influence of reimbursement systems on prevention, management, and outcomes of diabetic foot lesions has increased. Despite methodological obstacles, modeling studies are needed in future health-economic evaluations to determine the cost effectiveness of various strategies.
Collapse
|
14
|
Girod I, Valensi P, Laforêt C, Moreau-Defarges T, Guillon P, Baron F. An economic evaluation of the cost of diabetic foot ulcers: results of a retrospective study on 239 patients. DIABETES & METABOLISM 2003; 29:269-77. [PMID: 12909815 DOI: 10.1016/s1262-3636(07)70036-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the cost of foot ulcers in diabetic patients. METHODS Retrospective pharmacoeconomic study using direct and indirect costs (sick leave days) from the perspective of French social security system. RESULTS 239 patients were included in the study by 80 physicians who treat diabetic patients suffering from foot ulcers. Initially identified by telephone survey, these physicians were primarily endocrinologists/diabetologists, general practitioners and surgeons. Average monthly costs in the treatment of foot ulcers were 697 euro; for outpatient care, 1556.20 euro; for hospital care (day treatment and short stays), and 34.76 euro; for sick leaves. When hospitalization was required, it represented approximately 70% of the average cost for foot ulcers. The portion of outpatient costs was principally generated by medical and paramedical treatments, and interventions carried out by healthcare personnel. On the other hand, medication only represented 10% of total costs. The initial severity of the pathology was a determinant clinical factor of high healthcare costs. In addition, the more recent the lesion was, the higher the cost of treatment. Amputation and follow-up by specialists were correlated to high costs as well, a logical result of these clinical factors. CONCLUSION This analysis is the first to evaluate the cost of treating foot ulcers in such a large population of diabetic patients. The economic outcomes should help direct public authorities in their choices, particularly as regards the interest of treating these diabetes-related complications as early as possible.
Collapse
|
15
|
Fraedrich G. Invited Commentary to:'The Value of Aortic Flush Angiography in Detecting Pedal Run-off Vessels in Diabetics'. Eur Surg 2003. [DOI: 10.1046/j.1682-4016.2003.03053_3.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
16
|
Raikou M, McGuire A. The economics of screening and treatment in type 2 diabetes mellitus. PHARMACOECONOMICS 2003; 21:543-564. [PMID: 12751913 DOI: 10.2165/00019053-200321080-00002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A systematic review of the literature was conducted to identify articles on the economics of type 2 diabetes mellitus. Articles were classified into two main categories: cost/burden-of-illness studies of type 2 diabetes and economic evaluations of type 2 diabetes interventions. This systematic review was supplemented by an overview of the findings relating to economic evaluations of associated diabetic complications. A number of conclusions emerge from this review, the most important of which is that intensive treatment of patients with type 2 diabetes appears to be relatively cost effective compared with more conservative strategies. This finding reflects the cost offsets that arise from the range and degree of complications attributable to diabetes. Primary prevention of type 2 diabetes also appears to be cost effective, particularly in high-risk groups. The evidence on screening for type 2 diabetes is less conclusive and further economic analysis is required.
Collapse
Affiliation(s)
- Maria Raikou
- LSE Health and Social Care, London School of Economics and Political Science, Cowdray House, Houghton Street, London WC2A 2AE, UK.
| | | |
Collapse
|
17
|
Murphy GJ, Kipgen D, Dennis MJS, Sayers RD. An aggressive policy of bilateral saphenous vein harvest for infragenicular revascularisation in the era of multidrug resistant bacteria. Postgrad Med J 2002; 78:339-43. [PMID: 12151687 PMCID: PMC1742379 DOI: 10.1136/pmj.78.920.339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The success of infragenicular revascularisation for lower limb ischaemia is limited by the high proportion of patients without ipsilateral long saphenous vein (LSV) of adequate length or quality. The aim of this study was to report the results of an autogenous vein only policy for infragenicular revascularisation utilising contralateral LSV when ipsilateral LSV is inadequate. The treatment and outcome of infection of autogenous grafts with methicillin resistant Staphylococcus aureus (MRSA) is also reported. PATIENTS AND METHODS The vascular audit database and patient case notes were reviewed retrospectively for patients with arterial occlusive disease requiring infragenicular reconstruction. There were 68 critically ischaemic legs in 65 patients of whom 48 were male: median age (range) 74 years (41-94), over a three year period. RESULTS Thirty six patients (53%) underwent revascularisation (eight infragenicular femoropopliteal bypass, 28 femorodistal), 24 (35%) underwent primary amputation and a further eight (12%) were found to have unsuitable distal vessels for revascularisation after tibial vessel exploration and intraoperative angiography. Thirty three grafts (92%) utilised LSV and three (8%) were polytetrafluoroethylene grafts. Thirteen patients (39%) lacked adequate ipsilateral LSV of whom 12 had the contralateral leg explored providing suitable LSV in 10/12 (83%). Contralateral LSV was used as a single length conduit in two cases and as a venovenous composite graft in eight cases. Primary, primary assisted, and secondary patency rates at two years were 38%, 77%, and 81% respectively. Actuarial limb survival and patient survival rates at two years were 86% and 61% respectively. Eleven patients developed ipsilateral wound complications (30%) including seven (21%) who developed MRSA infection of the ipsilateral leg wound. MRSA wound infection was treated successfully in all cases by antibiotic therapy (intravenous vancomycin). No patient subsequently required saphenous vein harvesting for a secondary reconstruction or coronary artery bypass graft. CONCLUSION Excellent long term results can be achieved using autogenous vein for infragenicular revascularisation and the contralateral LSV is an excellent alternative in the absence of suitable ipsilateral LSV. Autogenous vein may confer some protection against severe complications observed with MRSA infection seen in vascular patients and therefore its use is recommended.
Collapse
Affiliation(s)
- G J Murphy
- Department of Vascular Surgery, Leicester General Hospital NHS Trust, Gwendolen Road, Leicester LE5 4PW, UK
| | | | | | | |
Collapse
|
18
|
Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 2001; 24:1433-7. [PMID: 11473082 DOI: 10.2337/diacare.24.8.1433] [Citation(s) in RCA: 475] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients. RESEARCH DESIGN AND METHODS Randomly selected lower-extremity angiograms were examined according to the Bollinger system. Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died. RESULTS A total of 136 arteriograms obtained between 1992 and 1996 were analyzed. The age (mean +/- SD) of the patients was 64.7 +/- 10.8 years. Diabetic patients (43%) and nondiabetic patients were of similar age (63.9 +/- 10.4 vs. 65.3 +/- 11.1 years, P = 0.43), with a similar history of smoking (81.0 vs. 76.9%, P = 0.26), ischemic heart disease (41.4 vs. 37.2%, P = 0.54), and hypercholesterolemia (24.4 vs. 30.8%, P = 0.48). However, there were a greater proportion of hypertensive patients in the diabetic group (63.8 vs. 39.7%, P = 0.006). Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in the diabetic group (51.7 vs. 25.6%, OR 3.1, P = 0.002), and diabetic patients who died were younger at presentation than nondiabetic patients (64.7 +/- 11.4 vs. 71.1 +/- 8.7 years, P = 0.04). CONCLUSIONS In patients with peripheral arterial disease, diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients.
Collapse
Affiliation(s)
- E B Jude
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK.
| | | | | | | |
Collapse
|
19
|
Abstract
Approximately 40-60% of all amputations of the lower extremity are performed in patients with diabetes. More than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep infection or gangrene. The prevalence of diabetic foot ulcers has been estimated to be 3-8%. The complexity of these ulcers necessitates a multifactorial approach in which aggressive management of infection and ischemia is of major importance. For the same reason, a process-oriented approach in the evaluation of prevention and management of the diabetic foot is essential. Healing rates of foot ulcers are unknown with the exception of specialised centres where it is between 80-90%. The negative consequences of diabetic foot ulcers on quality of life include not only morbidity but also disability and premature mortality. Costs for healing ulcers are high and even higher for ulcers resulting in amputation, due to prolonged hospitalisation, rehabilitation, and need for home care and social service for disabled patients. Therefore, one of the most important steps to reduce cost in the management of the diabetic foot is to avoid amputations. A cost-effective management should not only be focused on the short-term cost until healing but also on the long-term cost, since foot ulcer and especially amputation are related to increased re-ulceration rate and lifelong disability. A multidisciplinary approach including preventive strategy, patient and staff education, and multifactorial treatment of foot ulcers has been reported to reduce the amputation rate by more than 50%.
Collapse
Affiliation(s)
- J Apelqvist
- The Division for Diabetes and Endocrinology, University Hospital, Lund, Sweden
| | | |
Collapse
|
20
|
Abstract
OBJECTIVE The objective of this study was to assess the level of reporting in economic studies in the area of peripheral vascular disease. Adequate reporting of data is necessary to judge the quality of economic studies by means of critical appraisal criteria. METHODS A systematic review of the journal literature between 1986 and the first half of 1997 was undertaken. Studies that have attempted to estimate the resource consequences of one or more vascular procedure were the focus of the review. The extent of reporting in each study was assessed by using published guidelines. RESULTS The review identified 30 articles from nine different countries for inclusion in the study. Of these, more than half were published in the last 2(1/2) years of the search period, indicating a recent and rapid growth in economic studies in this area. When subjected to the reporting guidelines, the studies performed rather poorly overall. CONCLUSIONS Although the vascular studies can be criticized for inadequate reporting of economic data, it appears from the limited evidence from elsewhere that inadequate reporting is a problem in other clinical areas. In view of the importance of reporting to the ability to critically assess studies-and thus separate the "good" from the "bad"-there is a need for reporting to improve future published studies.
Collapse
Affiliation(s)
- P Shackley
- Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, United Kingdom
| | | | | |
Collapse
|