Prognostic and predictive value of ultrasound-based estimated ankle brachial pressure index at early follow-up after endovascular revascularization of chronic limb-threatening ischaemia: a prospective, single-centre, service evaluation

Background

Ankle brachial pressure index can be estimated (eABPI) using cuffless ankle Doppler ultrasound. We evaluated the prognostic value of eABPI measured during pre- and post-procedural ultrasound exams to predict the clinical outcome after endovascular revascularisations.

Methods

In this prospective, single-centre, service evaluation, consecutive patients with symptomatic peripheral artery disease undergoing lower limb endovascular revascularisations between July, 26 2018 and January, 13 2022 at Surrey and Sussex Healthcare NHS Trust (Redhill, UK) were analysed. eABPI was determined using the higher acceleration index measured with angle-corrected duplex ultrasound in ankle arteries before and ≤1 month post-procedure. Clinical outcomes (mortality, major amputations, amputation-free survival [AFS], clinically driven target lesion revascularization [cdTLR], major adverse limb events [MALE; cdTLR and major amputation], wound healing) were assessed over 1 year.

Findings

Of 246 patients treated, for 219 patients (median 75 [IQR 66-83] years) pre- and post-procedural eABPI (0.50 [0.33-0.59] and 0.90 [0.69-1.0], p < 0.0001) were available, respectively. In n = 199 patients with chronic limb-threatening ischaemia (CLTI) Kaplan-Meier survival analyses showed that higher post-procedural, but not pre-procedural, eABPI was associated with favourable AFS, MALE, cdTLR, and wound healing. This was confirmed in Cox regression analysis and remained significant with adjustment for pre-procedural eABPI, age, sex, co-morbidities, treated levels, wound score, and foot infection. Whereas all clinical outcomes, except for survival, were significantly better at ≥0.7 vs <0.7, wound healing (unadjusted: HR 1.7 (95% CI 1.2-2.6), adjusted: HR 2.1 (95% CI 1.3-3.1), cdTLR, and MALE (unadjusted: HR 0.41 (95% CI 0.18-0.93), adjusted: HR 0.28 (95% CI 0.11-0.74) were significantly improved at ≥0.9 vs <0.9.

Interpretation

Post-procedural eABPI can provide valid, clinically important prognostic and predictive information. Our data indicate that revascularisations should target values of at least 0.9 to achieve optimal outcomes. Future studies need to confirm generalisability and cost-effectiveness in a wider context.

Funding

European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation.

Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study

We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.

Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial

BACKGROUND

Observational epidemiological studies have shown a positive association between hypertension and risk of incident dementia; however, the effects of antihypertensive therapy on cognitive function in controlled trials have been conflicting, and meta-analyses of the trials have not provided clear evidence of whether antihypertensive treatment reduces dementia incidence. The Hypertension in the Very Elderly trial (HYVET) was designed to assess the risks and benefits of treatment of hypertension in elderly patients and included an assessment of cognitive function.

METHODS

Patients with hypertension (systolic pressure 160-200 mm Hg; diastolic pressure <110 mm Hg) who were aged 80 years or older were enrolled in this double-blind, placebo-controlled trial. Participants were randomly assigned to receive 1.5 mg slow release indapamide, with the option of 2-4 mg perindopril, or placebo. The target systolic blood pressure was 150 mm Hg; the target diastolic blood pressure was 80 mm Hg. Participants had no clinical diagnosis of dementia at baseline, and cognitive function was assessed at baseline and annually with the mini-mental state examination (MMSE). Possible cases of incident dementia (a fall in the MMSE score to <24 points or a drop of three points in 1 year) were assessed by standard diagnostic criteria and expert review. The trial was stopped in 2007 at the second interim analysis after treatment resulted in a reduction in stroke and total mortality. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00122811.

FINDINGS

3336 HYVET participants had at least one follow-up assessment (mean 2.2 years) and were included: 1687 participants were randomly assigned to the treatment group and 1649 to the placebo group. Only five reports of adverse effects were attributed to the medication: three in the placebo group and two in the treatment group. The mean decrease in systolic blood pressure between the treatment and placebo groups at 2 years was systolic -15 mm Hg, p<0.0001; and diastolic -5.9 mm Hg, p<0.0001. There were 263 incident cases of dementia. The rates of incident dementia were 38 per 1000 patient-years in the placebo group and 33 per 1000 patient-years in the treatment group. There was no significant difference between treatment and placebo groups (hazard ratio [HR] 0.86, 95% CI 0.67-1.09); however, when these data were combined in a meta-analysis with other placebo-controlled trials of antihypertensive treatment, the combined risk ratio favoured treatment (HR 0.87, 0.76-1.00, p=0.045).

INTERPRETATION

Antihypertensive treatment in elderly patients does not statistically reduce incidence of dementia. This negative finding might have been due to the short follow-up, owing to the early termination of the trial, or the modest effect of treatment. Nevertheless, the HYVET findings, when included in a meta-analysis, might support antihypertensive treatment to reduce incident dementia.

Using the internet to deliver education on drug safety

BACKGROUND

Medication administration errors (MAEs) occur in 3-8% of all non-intravenous drug doses given in UK hospitals; higher rates have been reported for intravenous drugs. Educational interventions are often advocated as one way of reducing these rates. However, group education sessions are often not practical. We developed internet-based educational modules on drug safety, and evaluated their effect on MAEs.

METHODS

11 modules were developed on different aspects of drug safety and delivered via commercially available software. All nursing staff on one ward were encouraged to participate. MAEs were identified using observation; the denominator used to calculate MAE rates was the number of opportunities for error. We aimed to observe 56 drug rounds before and after asking staff to complete the package.

RESULTS

The 19 nurses who administered drugs on the study ward all agreed to participate. Of these, 12 (63%) nurses completed all 11 modules. Pre-education, 82 (6.9%) errors were identified in 1188 opportunities for error. Afterwards, 66 (5.0%) errors were identified in 1397 opportunities for error (95% confidence interval (CI) for the difference -3.8% to 0%). The MAE rate for non-intravenous drugs was 6.1% pre-education and 4.1% afterwards (95% CI for the difference -3.8% to -0.2%). Most errors with regard to intravenous doses were due to fast administration of bolus injections.

CONCLUSIONS

An interactive educational package focusing on patient safety was developed, with a high rate of uptake among nursing staff on the study ward. A reduction in non-intravenous MAEs was observed after the use of the package, but no significant change was seen in the overall error rate.

Women's reluctance to seek help for stress incontinence during pregnancy and following childbirth

OBJECTIVE

to identify whether women were made aware of stress incontinence around the time of childbirth, whether symptomatic women sought help from professionals caring for them at this time, to look at what help they receive in the first instance and to understand why some of those experiencing it chose not to seek help.

DESIGN

a qualitative survey was conducted using semi-structured interviews.

SETTING

interviews were conducted in participants' own homes.

PARTICIPANTS

42 women who reported symptoms of stress incontinence at eight weeks postpartum, and 15 women who were symptomatic one year following the birth of their baby.

FINDINGS

women were reluctant to seek help, although they were often inconvenienced and troubled by the condition. This was predominantly due to the nature of the condition itself, although the relationship with their health care professionals was also a consideration in some cases. The majority of women were not provided with information on the condition but wanted health professionals to provide a warning that the condition could occur. They also wanted health professionals to seek out information about symptoms, rather than the women themselves having to broach the subject. The first line of treatment at this time was usually a recommendation to perform pelvic floor exercises.

IMPLICATIONS FOR PRACTICE

health professionals caring for women during pregnancy or following the birth of their baby need to raise awareness of the condition, the treatment available, and to be pro-active in seeking out those experiencing incontinence rather than expecting women to approach them for help.

The instruction in pelvic floor exercises provided to women during pregnancy or following delivery

OBJECTIVES

to examine the instruction in pelvic floor exercises given to women during pregnancy or following delivery, to assess the quality of any instruction provided, and to consider these in light of the women's views about the service.

DESIGN

a postal questionnaire was sent to a sample of women when they reached 34 weeks of pregnancy and a second at 8 weeks postpartum. A sub-sample of women who reported symptoms of stress incontinence at 8 weeks postpartum were interviewed about the instruction in pelvic floor exercises that they received during their pregnancy, or in the puerperium.

PARTICIPANTS

of the 918 women who were sent the first questionnaire, 717 returned it completed (78%). Five-hundred-and-seventy-two of 894 women (64%) completed the second questionnaire. Forty-two of 179 symptomatic women (23%) took part in an interview.

FINDINGS

55% of women received some form of instruction in pelvic floor exercises by 34 weeks of pregnancy. Eighty-six percent received instruction following birth. The way the information was given varied, ranging from a brief reminder, to exercising in a class with an instructor. The information was provided by a range of health professionals, and no single profession appeared to undertake responsibility for the service. As a result, the views of the service varied. A few women reported that they had received good quality instruction, others were critical of it, and a small number reported that they had received no instruction at all. The widespread practice of leaving a leaflet by the women's beds during their stay in hospital, was criticised by a large proportion of the women.

KEY CONCLUSION

the instruction in pelvic floor exercises by health service professionals was provided on an ad hoc basis. In many instances, the programme of instruction did not meet recommendations made in the literature. It is likely that the success of randomised controlled trials reported in the literature would not be repeated in the 'real world' Implications for practice: there is a need for the service to be reorganised so that all women receive high-quality instruction during pregnancy, with a reminder to exercise following birth. This could help to prevent, or relieve, the symptoms of stress incontinence that frequently occur at these times.

The experience of stress incontinence after childbirth

BACKGROUND

Epidemiological studies have reported prevalence of stress incontinence ranging from 23 to 67 percent during pregnancy and 6 to 29 percent after childbirth, but little is known about how the condition affects women at this time. The purpose of this study was to examine the effects of stress incontinence on women in their childbearing years.

METHODS

Interviews were conducted with 42 women who experienced stress incontinence at 8 weeks postpartum and 15 women who reported symptoms one year after delivery. Analysis of the qualitative data involved exploring themes and patterns, relationships and connections, contradictions and contrasts, and the language used within individual accounts and across the spectrum of narratives.

RESULTS

The results are presented within a framework that the women themselves adopted: day-to-day activities, putting the condition in some form of perspective, and feelings and emotions. For some women, stress incontinence had a great impact on their lives in terms of both their daily routine and psychologically, but others described it as a minor inconvenience that rarely disturbed their routine. Major concerns comprised the restrictions placed on the women, the worry or continual awareness stemming from the condition, and feelings of embarrassment associated with it. Twelve months after childbirth the effects appeared to have lessened, but a few women were still significantly affected, both physically and psychologically.

CONCLUSIONS

Although many women experience physical and psychological symptoms of stress incontinence after delivery, this study demonstrated that few sought professional care or advice for their symptoms. Health professionals should be aware of the prevalence, and women's responses to, stress incontinence so that they can initiate appropriate support and care. Further research on stress incontinence on childbearing women is necessary.

The prevalence of stress incontinence during pregnancy and following delivery

OBJECTIVES

To examine the variation in findings from epidemiological studies which describe the prevalence of stress incontinence during and after pregnancy, and to undertake a prospective survey of the prevalence of stress incontinence during pregnancy and following childbirth in order to provide clarification of the findings presented in the literature.

DESIGN

A review of the literature was undertaken using the Medline and Popline CD Rom. A postal questionnaire was sent to a sample of women when they reached 34 weeks' gestation and repeated at 8 weeks postpartum.

PARTICIPANTS

1008 women were recruited to the study when they attended the antenatal clinic at two hospitals in the north west of England. Seven hundred and seventeen (71%) women responded to the first questionnaire and 572 (57%) completed the second questionnaire.

FINDINGS

The prevalence of stress incontinence during pregnancy reported in the literature ranges from 20 to 67%. Following delivery the reported prevalence is between 6 and 29%. In the present study 59% of women reported stress incontinence during pregnancy, and 31% following delivery. Ten per cent of the women had daily episodes of incontinence during their pregnancy, 2% of all women reported daily incontinence following delivery. An association was found between parity and stress incontinence, with women of higher parity being more likely to experience the condition. No difference in the prevalence of stress incontinence was found between women who had a normal delivery and those having an instrumental delivery. A caesarean section was found to be associated with a lower incidence of stress incontinence compared with a normal spontaneous delivery.

KEY CONCLUSION

A high proportion of women experienced stress incontinence during pregnancy and/or following delivery. Some women reported severe symptoms, with leakage on a daily basis. Women of higher parity were more likely to suffer from the condition. Whilst women who had a normal spontaneous delivery or an instrumental delivery reported a similar level of stress incontinence, women who had a caesarean section were less likely to have the condition.

A prospective study of women's views of factors contributing to a positive birth experience

OBJECTIVE

To explore the aspects of a woman's childbirth experience which she perceived as being important.

DESIGN

As part of a large randomised trial, which assessed the timing of intervention in prolonged labour, women's views were explored using a specifically-designed questionnaire. The questionnaire, which was administered on the second postnatal day, incorporated a rating scale followed by an open question. The responses to the open question are presented in this paper.

SETTING

Regional teaching hospital in the north west of England.

SAMPLE

615 primigravid women received a copy of the questionnaire. Of the 519 women who returned the questionnaire, 412 women answered the relevant section, the findings of which are presented in this paper.

ANALYSIS

The responses to the open-ended question were analysed by the generation of themes from the most frequently occurring responses.

MAIN FINDINGS

The main themes which emerged were support, information, intervention, decision making, control, pain relief and trial participation.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Most women are able to identify important contributors to a positive intrapartum experience. Midwives have an important role in identifying these contributors and supporting women to fulfil their individual needs.

The Homefinder service

This paper describes the establishment of a Homefinder service for elderly patients at Charing Cross Hospital in 1985. The contribution made by this service over a five-year period in reducing acute medical bed occupancy by long-stay patients is discussed.

Intermittent claudication: factors determining outcome

Two groups of patients were followed up for four to eight years after first referral or admission to hospital for intermittent claudication (IC) in a study of the natural history of the disease and of factors determining its outcome. In one series of 60 patients, those who stopped or reduced smoking after referral had a much improved prognosis. Thus even after the diagnosis of IC it is extremely important that patients should be encouraged to stop smoking, since this correctable factor appears to be of greater importance in determining outcome than other medical risk factors for the disease that are less amenable to treatment. In the second study, 160 patients were followed up for eight years after first hospital admission. They had a total of 480 hospital admissions and had spent 11 190 days in hospital; their life expectancy after the age of 60 was about half that of the general population. Age, coronary artery disease, cerebrovascular disease, and diabetes were associated with an adverse outcome.