Prosthetic Fitting and Mortality after Major Lower Extremity Amputation

INTRODUCTION

Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit, however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality.

METHODS

We reviewed all patients who underwent LEA between 2015 and 2022 at two academic healthcare systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1- and 3-years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1- and 3-years of follow up.

RESULTS

Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n=488, 69.5%), predominantly Non-Hispanic Black (n=410, 58.4%), and nearly one-fifth were non-ambulatory prior to LEA (n=139, 19.8%). Of note, 14.3% of all subjects who were non-ambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow up and among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1- and 3-years of follow up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post-COVID pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio [aHR] 0.24; 95% CI, 0.14 - 0.40) as well as within 3 years (aHR 0.40; 95% CI, 0.29 - 0.55).

CONCLUSIONS

Prosthetic fitting is associated with improved survival and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the VA, such as prosthetic department evaluation of all amputees, may represent a 'best practice'.

Factors associated with 90-day reintervention following lower extremity revascularization

OBJECTIVE

Peripheral artery disease (PAD) represents a high-volume, high-cost burden on the health care system. The Centers for Medicare and Medicaid Services has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders.

METHODS

We conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and Centers for Medicare and Medicaid Services-linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010, and December 31, 2018. Procedures for acute limb ischemia and aneurysms were excluded. The primary outcome was 90-day reintervention. Reintervention at 30 days was a secondary outcome. Covariates of interest included demographics, comorbidities, and patient- and facility-level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions.

RESULTS

Among 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median age was 74 years (interquartile range, 69-80 years), 57.9% were male, and 84.3% were White. Chronic limb-threatening ischemia was the operative indication in 40.4% of the procedures. Overall, 42.8% were completed in the outpatient setting (40.3% outpatient, 2.5% office-based lab). Over 70% of procedures for chronic limb-threatening ischemia were completed as inpatient, whereas 60% of the claudication interventions were done as outpatient. The 90-day reintervention rate was 14.5%, and the 30-day reintervention rate was 5.5%. Compared with inpatient procedures, PAD interventions completed in the outpatient or office-based lab setting had significantly higher 90- and 30-day reintervention rates (reference, inpatient; outpatient 90-day reintervention: hazard ratio [HR], 1.41; 95% confidence interval [CI] 1.25-1.60; outpatient 30-day reintervention: HR, 1.90; 95% CI, 1.62-2.24; office-based lab 90-day reintervention: HR, 2.09; 95% CI, 1.82-2.41; office-based lab 30-day reintervention: HR, 3.54; 95% CI, 3.17-3.94). Open and hybrid approaches demonstrated lower risk of reintervention compared with endovascular procedures at 30 and 90 days and, compared with aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention, but no difference was noted at 30 days.

CONCLUSIONS

Although outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.

Pattern and value of Sperm DNA Fragmentation Index and its correlation with spermiogram in infertile South West Nigerian Men

Semen analysis has been used for a long time to assess male fertility due to its limitations sperm DNA fragmentation index (DFI), which describes the sperm DNA's condition, is an appropriate criterion for assessing male fertility. This study evaluated the pattern and value of DFI of infertile men in the South West of Nigeria. This is a cross-sectional and descriptive study that recruited two hundred and eighty-seven (287) patients from two fertility centers in Lagos, Nigeria. The Sperm DFI was determined using the Sperm chromatin structure assay (SCSA) test. The descriptive and inferential statistics of the study were carried out using R packages (R version 4.2.0) with the help of R functions using compiled code. The result showed that the mean age sperm concentration, total motility morphology, and DFI were as follows 42.96±7.09years, 40.18±4.19×106 per ml, 49%±19%, 56±17%, and 15.78±8.52 respectively. There is a significant negative correlation between sperm concentration and DFI at a P-value of 0.0018 with a regression model of Coefficient of determination is 0.305. The DFI value of infertile men negatively correlates with sperm concentration, thus increase sperm production may improve sperm quality.

Disparities in Diagnosis, Treatment, and Outcomes of Peripheral Artery Disease: JACC Scientific Statement

Disparities by sex, race, socioeconomic status, and geography exist in diagnosis, treatment, and outcomes for people with lower extremity peripheral artery disease (PAD). PAD prevalence is similar in men and women, but women have more atypical symptoms and undergo lower extremity revascularization at older ages compared to men. People who are Black have an approximately 2-fold higher prevalence of PAD, compared to people who are White and have more atypical symptoms, greater mobility loss, less optimal medical care, and higher amputation rates. Although fewer data are available for other races, people with PAD who are Hispanic have higher amputation rates than White people. Rates of amputation also vary by geography in the United States, with the highest rates of amputation in the southeastern United States. To improve PAD outcomes, intentional actions to eliminate disparities are necessary, including clinician education, patient education with culturally appropriate messaging, improved access to high-quality health care, science focused on disparity elimination, and health policy changes.

The spermiogram and correlation of seminal fluid parameters in patient attending fertility centre in Lagos, South West Nigeria

BACKGROUND

The determinant of the spermiogram of semen varies in different populations based on several factors ranging, from age to the pathological state of an individual to environmental factors. The aim of the study is to determine the spermiogram of patients that attend fertility clinics in southwest Nigeria and the relationship between the parameters.

METHODOLOGY

This is a cross-sectional study that recruited two hundred and ninety seven (297) patients from two fertility centers in Lagos, Nigeria for the period of January 2021 to November 2022. The sperm samples were collected following WHO standards. The spermiogram was analyzed using an automated sperm analyzer and the descriptive and inference statistics of the study were carried out using R packages (R version 4.2.0).

RESULTS

The result showed the mean age of 43.12±6.95years with median age of 42years. The mean of sperm count and concentration were 114×106 sperm cells and 42×106 per mL with the mean volume of the semen produced by the patients was 2.69mL and average motility (progressive and non-progressive) of the sperm is 47%±19%, 42%±17% has normal morphology. The distributions of the observed variables (seminal fluid parameters) were different from normal distributions in the studied population, such that almost all of them are skewed to the right. The degree of relationship between the sperm parameter were very weak. Nevertheless, specifically, there is a negative correlation between age and sperm count, age and motility, age and volume, and a positive correlation between age and abnormal morphology. The results showed that sperm morphology has a significant effect on motility while sperm morphology significantly depend on sperm count.

CONCLUSION

An increase in sperm volume and concentration improves the sperm morphology and boost the sperm motility, this may increasing the chance of fertility.

Association between readmission care fragmentation and outcomes after interventions for peripheral arterial disease

OBJECTIVE

Lower extremity revascularization (LER) for peripheral artery disease is complicated by the frequent need for readmission. However, it is unclear if readmission to a nonindex LER facility (ie, a facility different from the one where the LER was performed) compared with the index LER facility is associated with worse outcomes.

METHODS

This was a national cohort study of older adults who underwent open, endovascular, or hybrid LER for peripheral artery disease (January 1, 2010, to December 31, 2018) in the Vascular Quality Initiative who were readmitted within 90 days of their vascular procedure. This dataset was linked to Medicare claims and the American Hospital Association Annual Survey. The primary outcome was 90-day mortality and the secondary outcome was major amputation at 90 days after LER. The primary exposure was the location of the first readmission after LER (categorized as occurring at the index LER facility vs a nonindex LER facility). Generalized estimating equations logistic regression models were used to assess the association between readmission location and 90-day mortality and amputation.

RESULTS

Among 42,429 patients who underwent LER, 33.0% were readmitted within 90 days. Of those who were readmitted, 27.3% were readmitted to a nonindex LER facility, and 42.2% of all readmissions were associated with procedure-related complications. Compared with patients readmitted to the index LER facility, those readmitted to a nonindex facility had a lower proportion of procedure-related reasons for readmission (21.5% vs 50.1%; P < .001). Most of the patients readmitted to a nonindex LER facility lived further than 31 miles from the index LER facility (39.2% vs 19.6%; P < .001) and were readmitted to a facility with a total bed size of <250 (60.1% vs 11.9%; P < .001). Readmission to a nonindex LER facility was not associated with 90-day mortality or 90-day amputation. However, readmission for a procedure-related complication was associated with major amputation (90-day amputation: adjusted odds ratio, 3.33; 95% confidence interval, 2.89-3.82).

CONCLUSIONS

Readmission after LER for a procedure-related complication is associated with subsequent amputation. This finding suggests that quality improvement efforts should focus on understanding various types of procedure-related failure after LER and its role in limb salvage.

Perspectives on Lower Extremity Peripheral Artery Disease: A Qualitative Study of Early Diagnosis and Treatment and the Impact of Health Disparities

Lower-extremity peripheral artery disease (PAD), the accumulation of atherosclerotic plaque in the arteries of the legs, causes substantial morbidity and mortality. Frequent under- and delayed diagnosis result in poor outcomes, disproportionately affecting individuals from racial and ethnic minority groups. To understand barriers to early detection and treatment and factors contributing to disparities, American Medical Group Association (AMGA) conducted roundtable discussions and semistructured interviews in 2021. Eighteen participants discussed PAD evaluation, diagnosis, early medical management, and disparities in care. A qualitative case study approach and data reduction methods were used to generate themes, draw conclusions, and make actionable recommendations. Identified themes included lack of (1) prioritization of PAD for population health; (2) engagement of primary care providers in early evaluation and referral; (3) "ownership" of lower-extremity PAD within health systems; and (4) focus on disparities in care. Participant solutions included (1) financial impact of early PAD management, in the context of value-based payment; (2) embedding an advanced practice provider into a vascular surgery practice to facilitate evaluation and provide medical therapy; and (3) leveraging care coordination, multidisciplinary clinics, and telehealth technology to provide comprehensive care for patients with PAD and address disparities. A deliberate focused effort is necessary to close gaps and the accompanying disparities in early evaluation, diagnosis, and treatment for people with lower-extremity PAD. The authors describe 3 models that can be emulated to improve care for this high-risk population. With improved reimbursement and better medical therapies, now is the time to focus on early diagnosis and management of PAD.

Association of Health Care Utilization and Access to Care With Vascular Assessment Before Major Lower Extremity Amputation Among US Veterans

Importance

Patient-level characteristics alone do not account for variation in care among US veterans with peripheral artery disease (PAD). Presently, the extent to which health care utilization and regional practice variation are associated with veterans receiving vascular assessment prior to major lower extremity amputation (LEA) is unknown.

Objective

To assess whether demographics, comorbidities, distance to primary care, the number of ambulatory clinic visits (primary and medical specialty care), and geographic region are associated with receipt of vascular assessment prior to LEA.

Design, Setting, and Participants

This national cohort study used US Department of Veterans Affairs' Corporate Data Warehouse data from March 1, 2010, to February 28, 2020, for veterans aged 18 or older who underwent major LEA and who received care at Veterans Affairs facilities.

Exposures

The number of ambulatory clinic visits (primary and medical specialty care) in the year prior to LEA, geographic region of residence, and distance to primary care.

Main Outcomes and Measures

The main outcome was receipt of a vascular assessment (vascular imaging study or revascularization procedure) in the year prior to LEA.

Results

Among 19 396 veterans, the mean (SD) age was 66.78 (10.20) years and 98.5% were male. In the year prior to LEA, 8.0% had no primary care visits and 30.1% did not have a vascular assessment. Compared with veterans with 4 to 11 primary care clinic visits, those with fewer visits were less likely to receive vascular assessment in the year prior to LEA (1-3 visits: adjusted odds ratio [aOR], 0.90; 95% CI, 0.82-0.99). Compared with veterans who lived less than 13 miles from the closest primary care facility, those who lived 13 miles or more from the facility were less likely to receive vascular assessment (aOR, 0.88; 95% CI, 0.80-0.95). Veterans who resided in the Midwest were most likely to undergo vascular assessment in the year prior to LEA than were those living in other regions.

Conclusions and Relevance

In this cohort study, health care utilization, distance to primary care, and geographic region were associated with intensity of PAD treatment before LEA, suggesting that some veterans may be at greater risk of suboptimal PAD care practices. Development of clinical programs, such as remote patient monitoring and management, may represent potential opportunities to improve limb preservation rates and the overall quality of vascular care for veterans.

Racial Differences in Vascular Assessment Prior to Amputation in the Veterans Health Administration

Purpose

It is unclear whether disparities in the care provided before lower extremity amputation (LEA) is driven by differences in receipt of diagnostic work-up versus revascularization attempts.

Methods

We performed a national cohort study of Veterans who underwent LEA between March 2010 and February 2020 to assess receipt of vascular assessment with arterial imaging and/or revascularization in the year prior to LEA.

Results

Among 19,396 veterans (mean age 66.8 years; 26.6% Black), Black veterans had diagnostic procedures more often than White veterans (47.5% vs. 44.5%) and revascularization as often (25.8% vs. 24.5%).

Conclusion

We must identify patient and facility-level factors associated with LEA as disparities do not appear related to differences in attempted revascularization.

Arteriovenous fistula aneurysmorrhaphy is associated with improved patency and decreased vascular access abandonment

BACKGROUND

Upper extremity hemodialysis arteriovenous fistulas (AVFs) can become aneurysmal over time due to repeated cannulation and/or outflow steno-occlusive disease. The optimal surgical management of aneurysmal AVFs (aneurysmorrhaphy vs interposition graft) has remained unclear.

METHODS

We performed a retrospective review in which current procedural terminology codes were used to screen for patients who had undergone surgical treatment of aneurysmal AVFs between 2016 and 2021 at a single hospital system. The patients were included after a review of the operative reports. The cases were divided by surgical procedure (aneurysmorrhaphy vs interposition graft placement). The patients who had undergone primary AVF ligation or other types of repair were excluded. The primary outcomes were primary assisted and secondary patency, and the secondary outcome was dialysis access abandonment. Multivariable Cox proportional hazards regression was used to test the association between the type of AVF aneurysm repair and the primary and secondary outcomes.

RESULTS

From 2016 to 2021, 6951 patients had undergone 16,190 dialysis access procedures. Of these procedures, 381 (2.4%) were related to surgical treatment of an aneurysmal AVF. We excluded 58 primary AVF ligation cases and 20 cases involving other types of repair, leaving 303 cases for analysis. These were divided into two groups: aneurysmorrhaphy (n = 123; 41%) and interposition graft (n = 180; 59%). No differences were found between the groups in male gender (68% vs 63%), hypertension (98% vs 98%), or central stenosis (14% vs 22%). The patients who had undergone aneurysmorrhaphy were younger (median age, 54 years vs 59 years); had had a lower rate of diabetes (41% vs 59%), coronary artery disease (41% vs 58%), and congestive heart failure (41% vs 55%); and were less likely to have undergone upper arm access (72% vs 92%). The median follow-up was 11.1 months (interquartile range, 3.6-25.2 months). No differences were found in the incidence of 30-day wound complications (1% vs 3%) or surgical site infections (4% vs 6%). On multivariable Cox regression, interposition graft placement was associated with the loss of primary assisted patency (adjusted hazard ratio [aHR], 2.42; 95% confidence interval [CI], 1.18-4.95), loss of secondary patency (aHR, 3.10; 95% CI, 1.21-7.94), and abandonment of dialysis access (aHR, 3.07; 95% CI, 1.61-5.87; P < .05 for all) at 2 years.

CONCLUSIONS

AVF aneurysmorrhaphy was associated with improved primary assisted and secondary patency and decreased abandonment of dialysis access. We suggest using aneurysmorrhaphy when AVF aneurysms are indicated for repair. However, individual factors such as patient comorbidities, AVF anatomy, remaining dialysis access options, and patient preference should be considered when planning the surgical approach.

A review of disparities in peripheral artery disease and diabetes-related amputations during the COVID-19 pandemic

The COVID-19 pandemic has profoundly affected health care delivery. In addition to the significant morbidity and mortality associated with acute illness from COVID-19, the indirect impact has been far-reaching, including substantial disruptions in chronic disease care. As a result of pandemic disruptions in health care, vulnerable and minority populations have faced health inequalities. The aim of this review was to investigate how the COVID-19 pandemic has impacted vulnerable populations with limb-threatening peripheral artery disease and diabetic foot infections.

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities

BACKGROUND

Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma.

METHODS

All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated.

RESULTS

During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

An Overview of Telehealth in the Management of Cardiovascular Disease: A Scientific Statement From the American Heart Association

Telehealth enables the remote delivery of health care through telecommunication technologies and has substantially affected the evolving medical landscape. The COVID-19 pandemic accelerated the utilization of telehealth as health care professionals were forced to limit face-to-face in-person visits. It has been shown that information delivery, diagnosis, disease monitoring, and follow-up care can be conducted remotely, resulting in considerable changes specific to cardiovascular disease management. Despite increasing telehealth utilization, several factors such as technological infrastructure, reimbursement, and limited patient digital literacy can hinder the adoption of remote care. This scientific statement reviews definitions pertinent to telehealth discussions, summarizes the effect of telehealth utilization on cardiovascular and peripheral vascular disease care, and identifies obstacles to the adoption of telehealth that need to be addressed to improve health care accessibility and equity.

Advancing Peripheral Artery Disease Quality of Care and Outcomes Through Patient-Reported Health Status Assessment: A Scientific Statement From the American Heart Association

Peripheral artery disease (PAD) is chronic in nature, and individualized chronic disease management is a central focus of care. To accommodate this reality, tools to measure the impact and quality of the PAD care delivered are necessary. Patient-reported outcomes (PROs) and instruments to measure them, that is, PRO measures, have been well studied in the research and clinical trial context, but a shift toward integrating them into clinical practice has yet to take place. A framework to use PRO measures as indicators of the quality of PAD care delivered, that is, PRO performance measures (PRO-PMs), is provided in this scientific statement. Measurement goals to consider by PAD clinical phenotypes are provided, as well as an overview of potential benefits of adopting PRO-PMs in the clinical practice of PAD care, including reducing unwanted variability and promoting health equity. A central discussion with considerations for risk adjustment of PRO-PMs, individualized PAD care, and the need for patient engagement strategies is offered. Furthermore, necessary conditions in terms of required competencies and training to handle PRO-PM data are discussed because the interpretation and handling of these data come with great responsibility and consequences for designing care that adopts a broader framework of risk that goes beyond the inclusion of biomedical variables. To conclude, health system perspectives and an agenda to reach the next steps in the implementation of PRO-PMs in PAD care are offered.

Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study

OBJECTIVE

To evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.

DESIGN

Observational surveillance study.

SETTING

282 centers in the Vascular Quality Initiative Registry linked to United States Medicare claims (2003-18).

PARTICIPANTS

20 489 patients treated with four device types used for endovascular abdominal aortic aneurysm repair (EVAR): 40.6% (n=8310) received the Excluder (Gore), 32.2% (n=6606) the Endurant (Medtronic), 16.0% (n=3281) the Zenith (Cook Medical), and 11.2% (n=2292) the AFX (Endologix). Given modifications to AFX in late 2014, patients who received the AFX device were categorized into two groups: the early AFX group (n=942) and late AFX group (n=1350) and compared with patients who received the other devices, using propensity matched Cox models.

MAIN OUTCOME MEASURES

Reintervention and rupture of abdominal aortic aneurysm post-EVAR; all patients (100%) had complete follow-up via the registry or claims based outcome assessment, or both.

RESULTS

Median age was 76 years (interquartile range (IQR) 70-82 years), 80.0% (16 386/20 489) of patients were men, and median follow-up was 2.3 years (IQR 0.9-4.1 years). Crude five year reintervention rates were significantly higher for patients who received the early AFX device compared with the other devices: 14.9% (95% confidence interval 13.7% to 16.2%) for Excluder, 19.5% (18.1% to 21.1%) for Endurant, 16.7% (15.0% to 18.6%) for Zenith, and early 27.0% (23.7% to 30.6%) for the early AFX. The risk of reintervention for patients who received the early AFX device was higher compared with the other devices in propensity matched Cox models (hazard ratio 1.61, 95% confidence interval 1.29 to 2.02) and analyses using a surgeon level instrumental variable of >33% AFX grafts used in their practice (1.75, 1.19 to 2.59). The linked registry claims surveillance data identified the increased risk of reintervention with the early AFX device as early as mid-2013, well before the first regulatory warnings were issued in the US in 2017.

CONCLUSIONS

The linked registry claims surveillance data identified a device specific risk in long term reintervention after EVAR of abdominal aortic aneurysm. Device manufacturers and regulators can leverage linked data sources to actively monitor long term outcomes in real world practice after cardiovascular interventions.

Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial

Importance

Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair.

Objective

To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive.

Design, Setting, and Participants

In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021.

Interventions

Presurgical consultation using a decision aid vs usual care.

Main Outcomes and Measures

The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios.

Results

Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70).

Conclusions and Relevance

Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT03115346.

The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale

BACKGROUND

Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI.

METHODS

This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers.

RESULTS

A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American.

CONCLUSIONS

SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.

Relationship between blood type and outcomes following COVID-19 infection

Since the onset of the COVID-19 pandemic, a concentrated research effort has been undertaken to elucidate risk factors underlying viral infection, severe illness, and death. Recent studies have investigated the association between blood type and COVID-19 infection. This article aims to comprehensively review current literature and better understand the impact of blood type on viral susceptibility and outcomes.

COVID-19-associated venous thromboembolism portends worse survival

Patients with coronavirus disease 2019 (COVID-19) seem to be at high risk for venous thromboembolism (VTE) development, but there is a paucity of data exploring both the natural history of COVID-19-associated VTE and the risk for poor outcomes after VTE development. This investigation aims to explore the relationship between COVID-19-associated VTE development and mortality. A prospectively maintained registry of patients older than 18 years admitted for COVID-19-related illnesses within an academic health care network between March and September 2020 was reviewed. Codes from the tenth revision of the International Classification of Diseases for VTE were collected. The charts of those patients with a code for VTE were manually reviewed to confirm VTE diagnosis. There were 2,552 patients admitted with COVID-19-related illnesses. One hundred and twenty-six patients (4.9%) developed a VTE. A disproportionate percentage of patients of Black race developed a VTE (70.9% VTE v 57.8% non-VTE; P = .012). A higher proportion of patients with VTE expired during their index hospitalization (22.8% VTE v 8.4% non-VTE; P < .001). On multivariable logistic regression analysis, VTE was independently associated with mortality (odds ratio = 3.17; 95% confidence interval, 1.9-5.2; P < .001). Hispanic/Latinx ethnicity was associated with decreased mortality (odds ratio = 0.45; 95% confidence interval, 0.21-1.00; P = .049). Hospitalized patients of Black race with COVID-19 were more prone to VTE development, and patients with COVID-19 who developed in-hospital VTE had roughly nearly threefold higher odds of mortality. Further emphasis should be placed on optimizing COVID-19 anticoagulation protocols to reduce mortality in this high-risk cohort.

Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair

INTRODUCTION

Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial.

METHODS

Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference.

RESULTS

Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns.

CONCLUSION

Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.

Health care disparities during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a pandemic with more than 32 million cases and more than 500,000 deaths nationwide. With the significant health consequences seen secondary to COVID-19, health care disparities have been further exacerbated. Mechanisms that have been proposed to account for the increased disparity seen during the COVID-19 pandemic are multifactorial. This review of the literature outlines the unique barriers to health and disparities that are associated with vulnerable communities who have been most impacted by the COVID-19 pandemic in the United States.

Moving forward: Recommendations to overcome existing structural racism

A critical need exists to address structural racism within academic and community medicine and surgery and determine methods that will serve to repair its long-standing effects and alleviate the associated negative consequences. Because of our broad skillset and the populations we serve, vascular surgeons are uniquely positioned to identify and address the effects of structural racism in our places of work and for the populations we treat. Our goal is to discuss the effects of racism on healthcare outcomes and provide recommendations on how to combat these through equitable practices such as the diversification of the vascular surgery workforce, inclusivity as partners and leaders, and the promotion of improved outcomes among our most vulnerable patients from racial and ethnic minority groups. It is imperative that we stand for antiracism within our field through our societies, journals, clinical trials, training programs, clinical practice groups, and leadership.

Training Underrepresented Early-Career Faculty in Cardiovascular Health Research during COVID-19: Structural Inequities and Health Disparity

The COVID-19 pandemic has highlighted race-based health disparities and structural racism in the United States. Enhancing the training of early-career academic and health scientists from underrepresented minority groups (URM) is critical to reduce disparities affecting underserved population groups. A dedicated training program that has been proven to support URM can facilitate career development for junior faculty during the pandemic. This critical support ensures the retention of talented, racially diverse junior faculty who are poised to mitigate structural racism, rather than perpetuate it. We describe how the Cardiovascular Disease Programs to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE-CVD) summer institute successfully transitioned from a face-to-face format to a virtual format during the COVID-19 pandemic. As a result, early-career faculty continued to receive the PRIDE-CVD training on research methodology, grantsmanship, career development, and CVD health disparities, especially as related to the pandemic. In addition, the virtual format facilitated networking, promoted mental wellness, and allowed continual mentorship. Collectively, the program provided timely and relevant career development in the COVID-19 era and helped participants navigate the psychosocial challenges of being a URM in cardiovascular health research.

Premature atherosclerotic peripheral artery disease: An underrecognized and undertreated disorder with a rising global prevalence

Premature atherosclerotic peripheral artery disease (PAD) of the lower extremities is characterized by disease diagnosis before the age of 50 years. The global prevalence of premature PAD has increased, and the disease is often underdiagnosed given heterogenous patient symptoms. Traditional cardiovascular risk factors like smoking, diabetes, hypertension, and hyperlipidemia as well as non-traditional risk factors like elevated lipoprotein(a), family history of PAD, hypercoagulability, and systemic inflammation are associated with premature PAD. Patients with premature PAD tend to have an aggressive vascular disease process, a high burden of cardiovascular risk factors, and other concomitant atherosclerotic vascular diseases like coronary artery disease. Prevention of cardiovascular events, improvement of symptoms and functional status, and prevention of adverse limb events are the main goals of patient management. In this review, we discuss the epidemiology, risk factors, clinical evaluation, and management of patients with premature PAD.

Rationale and design of the granulocyte-macrophage colony stimulating factor in peripheral arterial disease (GPAD-3) study

BACKGROUND

Lower extremity peripheral arterial disease (PAD) is a public health problem and many patients with PAD experience claudication despite adequate medical and/or surgical management. Mobilization of endogenous progenitor cells using Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) is a novel therapeutic option that has shown promising results in experimental models and phase I/IIA clinical trials. The GPAD-3 trial will study the effect of two successive administrations of GM-CSF at 3-month interval for improving claudication among patients with lower extremity PAD.

METHODS

We plan to recruit 176 patients in this ongoing randomized, double-blind, placebo-controlled Phase IIB trial. After screening for inclusion and exclusion criteria, eligible subjects undergo a 4-week screening phase where they perform subcutaneous placebo injections thrice weekly and walk at least three times a day until they develop claudication. After the screening phase, eligible subjects undergo baseline testing and are randomized 2:1 to receive 500 μg/day of GM-CSF subcutaneously thrice weekly for three weeks or placebo injections. After 3 months, follow-up endpoint testing is performed and subjects in the GM-CSF group receive the second administration of the drug for three weeks while subjects in placebo group receive matching placebo injections. All participants undergo endpoint testing at six-month and nine-month follow-up. The primary endpoint is change in 6-min walk distance between baseline and 6-month follow-up.

CONCLUSION

GPAD-3 explores a novel approach to address the need for alternative therapies that can alleviate symptoms among patients with lower extremity PAD. If successful, this study will pave the way for a pivotal Phase III trial.

Farmers' choice of genotypes and trait preferences in tropically adapted chickens in five agro-ecological zones in Nigeria

This study aimed at determining chicken genotypes of choice and traits preference in chicken by smallholder farmers in Nigeria. Data were obtained from a total of 2063 farmers using structured questionnaires in five agro-ecological zones in Nigeria. Chi square (χ²) statistics was used to explore relationships between categorical variables. The mean ranks of the six genotypes and twelve traits of preference were compared using the non-parametric Kruskal-Wallis H (with Mann-Whitney U test for post hoc separation of mean ranks), Friedman, and Wilcoxon signed-rank (with Bonferroni's adjustments) tests. Categorical principal component analysis (CATPCA) was used to assign farmers into groups. Gender distribution of farmers was found to be statistically significant (χ² = 16.599; P ≤ 0.002) across the zones. With the exception of Shika Brown, preferences for chicken genotypes were significantly (P ≤ 0.01) influenced by agro-ecological zone. However, gender differentiated response was only significant (P ≤ 0.01) in Sasso chicken with more preference by male farmers. Overall, FUNAAB Alpha, Sasso, and Noiler chicken were ranked 1st, followed by Kuroiler (4th), Shika Brown (5th), and Fulani birds (6th), respectively. Within genotypes, within and across zones and gender, preferences for traits varied significantly (P ≤ 0.005 and P ≤ 0.01). Traits of preference for selection of chicken breeding stock tended towards body size, egg number, egg size, and meat taste. Spearman's rank order correlation coefficients of traits of preference were significant (P ≤ 0.01) and ranged from 0.22 to 0.90. The two PCs extracted, which explained 65.3% of the variability in the dataset, were able to assign the farmers into two groups based on preference for body size of cock and hen and the other ten traits combined. The present findings may guide the choice of appropriate chicken genotypes while the traits of economic importance may be incorporated into future genetic improvement and conservation programs in Nigeria.

Quality-of-life assessment as an outcomes measure in critical limb ischemia

Critical limb ischemia (CLI) is a diagnosis plagued by significant comorbidity and high mortality rates. Overall survival remains poor in this population regardless of the procedure-related success as demonstrated by freedom from amputation, intervention, and patency. The literature has traditionally focused on physician-centered and lesion-centered outcomes with regards to limb salvage procedures, but there remains a relative paucity of studies of CLI patients describing patient-centered outcomes such as quality of life (QoL), independent living, and ambulation status. Review of the available literature indicates patients do not always experience significant gains in their QoL after limb salvage interventions, despite reasonable graft patency, amputation-free survival, and limb salvage rates. Further research is required using QoL tools in a measurable and clinically relevant fashion to guide optimal quality care that maximizes patient-centered outcomes.

Unusual presentation of hemifacial microsomia

Hemifacial microsomia is a well known yet rare collection of developmental facial defects. Almost half of all known cases exhibit additional anomalies beyond the classic malformations of the first and second brachial arches. This case is unique in that it describes a child with hemifacial microsomia and an associated oropharyngeal stenosis, nasal stenosis and a v-shaped mandibular deformity.

Maternal post natal hospital readmission-trends and association with mode of delivery

The aim of this study is to examine the trend in maternal postnatal readmission within six weeks of discharge from childbirth hospitalisation. It is a retrospective review of the maternity computer records system, patient's clinical notes and HIPE data base. All women who delivered babies weighing > 500 g and/ > or = 24 weeks gestational age at Our Lady of Lourdes Hospital, Drogheda, Ireland from 1st January 2005 to 31st December 2008 who were re-hospitalised within six weeks of discharge from hospital following child birth were included in the study. A total of 15782 women were delivered over the four year study period. Of these, 236 were readmitted. A series of chi-square analysis were conducted to assess the difference in readmission rates between the year 2008 86 (2.03%) and the years 2005-51(1.46%), 2006-39 (1.01%) and 2007-60 (1.42%). The readmission rate was found to be significantly higher in 2008 compared with the three preceding years. Complications of Caesarean section and secondary postpartum haemorrhage following spontaneous vaginal delivery constitute the major indications for readmission.