Evolution in Trends of Primary Lower-Extremity Amputations Associated With Diabetes or Peripheral Artery Disease From 2006 to 2019.

BACKGROUND: Given the importance in prevention of lower extremity amputations (LEAs) associated with diabetes or peripheral artery disease (PAD), we sought to document the trends of primary LEA in Québec, Canada, from years 2006 to 2019. METHODS: Using the Québec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of primary LEA associated with diabetes and PAD among adults ≥ 40 years (99% confidence intervals [CI]), and all-cause 1-year mortality proportion trends following a primary LEA (95% CI), stratified by minor or major as the highest level of LEA during the same hospital stay and age groups. Trends were assessed using multivariate regression models. RESULTS: In 2019, the crude rate of primary LEA was 116.0 per 100,000 (n = 825) with 93.7 and 21.9 per 100,000 of minor (n = 665) and major (n = 160) LEA, respectively. A tendency of decrease by 8% (-15.0 to 0.4%) of age-standardized incidence of primary LEA was observed between 2006 and 2019, while the absolute number of primary LEA increased from 610 to 825 cases. Minor LEA increased by 14.2% (3.7 to 25.9%) and major LEA decreased by 49.5% (-57.1 to -40.5%). Incidence trends remained stable among the 40 to 64 years, and declined by 14.6% and 20.1% for the 65 to 79 and ≥ 80 years of age groups, respectively. Major LEA decreased in all age groups, whereas minor LEA increased by 26.2% among the patients 40 to 64 years of age only. Age-standardized 1-year mortality decreased by 35.1% (95% CI, -43.4 to -25.7%) between 2006 and 2019, with a crude 1-year mortality of 11.3% in 2019. CONCLUSIONS: The reduction of major LEA and 1-year mortality are encouraging, although increased minor LEA, especially in younger age groups, emphasizes the importance to improve preventive care further.

Virtual home-based palliative care during COVID-19: A qualitative exploration of the patient, caregiver, and healthcare provider experience.

BACKGROUND: Due to the COVID-19 pandemic, many community palliative healthcare providers shifted from providing care in a patient's home to providing almost exclusively virtual palliative care, or a combination of in-person and virtual care. Research on virtual palliative care is thus needed to provide evidence-based recommendations aiming to enhance the delivery of palliative care during and beyond the pandemic. AIM: To explore the experiences and perceptions of community palliative care providers, patients and caregivers who delivered or received virtual palliative care as a component of home-based palliative care during the COVID-19 pandemic. DESIGN: Qualitative study using phone and video-based semi-structured interviews. Data were analyzed using thematic analysis. SETTING/PARTICIPANTS: A total of 37 participants, including community palliative care patients/caregivers (n = 19) and healthcare providers (n = 18) recruited from sites in Ottawa and Toronto, Ontario, Canada. RESULTS: Overall, participants preferred in-person palliative care compared to virtual care, but suggested virtual care could be a useful supplement to in-person care. The findings are presented in three main themes: (1) Impact of COVID-19 pandemic on community palliative care services; (2) Factors influencing transition from exclusively virtual model of care back to a blended model of care; and (3) Recommended uses and implementation of virtual palliative care. CONCLUSIONS: Incorporating virtual palliative care into healthcare provider practice models (blended care models) may be the ideal model of care and standard practice moving forward beyond the COVID-19 pandemic, which has important implications toward organization and delivery of community palliative care services and funding of healthcare providers.

Acute lower limb ischemia caused by vaccine-induced immune thrombotic thrombocytopenia: focus on perioperative considerations for 2 cases.

BACKGROUND: ChAdOx1 nCoV-19 (AstraZeneca) and Ad26COV2.S (Johnson & Johnson/Janssen) adenoviral vector vaccines have been associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). Arterial thrombosis and acute limb ischemia have been described in a minority of patients with VITT. These patients usually need a revascularization, but they potentially are at a higher risk of complications. Optimal perioperative care of patients undergoing vascular surgery in acute VITT is unknown and important considerations in such context need to be described. CASES PRESENTATIONS: We report 2 cases of VITT presenting with acute limb ischemia who needed vascular surgery and we describe the multidisciplinary team decisions for specific treatment surrounding the interventions. Both patients' platelet counts initially increased after either intravenous immune globulin (IVIG) or therapeutic plasma exchange (TPE). None received platelet transfusion. They both received argatroban as an alternative to heparin for their surgery. Despite persistent positivity of anti-platelet factor 4 (PF4) antibodies and serotonin-release assay with added PF4 (PF4-SRA) in both patients, only one received a repeated dose of IVIG before the intervention. Per- and post-operative courses were both unremarkable. CONCLUSION: In spite of persistent anti-PF4 and PF4-SRA positivity in the setting of VITT, after platelet count improvement using either IVIG or TPE, vascular interventions using argatroban can show favorable courses. Use of repeated IVIG or TPE before such interventions still needs to be defined.

Development and application of an innovative approach to predicting pollutant concentrations in highway runoff.

Recognising the challenges and limitations of current methodologies to predict highway runoff concentrations, this paper presents a novel approach based on the derivation of pollutant emission factors for twelve different types of vehicle. Published emission factor data and properties of differing vehicles types are combined with annual average daily traffic volume (AADT), highway characteristics and rainfall data to determine the pollutant distributions associated with differing highway and traffic types. In this paper, the method is applied to 126 sections of highway in the Greater London Borough of Enfield (United Kingdom; UK) and results are comparable with values reported in the literature. The approach is used to identify the level of AADT predicted to result in an exceedance of environmental quality standards (EQS), with results suggesting that runoff from highways experiencing AADT values as low as 5000 may require treatment prior to discharge to receiving waters. Future scenario analyses indicate that the impact of progressively replacing petrol and diesel vehicles with electric vehicles will have negligible impact on concentrations of zinc (Zn), copper (Cu), cadmium (Cd) and total suspended solids discharging from highway environments. The approach enables identification and ranking of urban highways in terms of their pollution runoff potential and provides an important support to users in prioritising locations for the installation of sustainable drainage options in order to protect receiving water environments.

Q fever aortic infection causing an aortoduodenal fistula after endovascular aneurysm repair.

An aortoduodenal fistula is a rare complication of endovascular aortic aneurysm repair. Q fever infection is known for its vascular tropism, and arterial fistulas have been reported in association with Coxiella burnetii infections. We report the case of a 78-year-old patient who had developed an aortoduodenal fistula secondary to vascular Q fever 5 years after he had been treated with an aortic endograft. Explantation of the endograft, autogenous reconstruction using the neo-aortoiliac system procedure, and duodenal repair were performed as a curative surgical treatment of this serious vascular condition. At the 9-month follow-up examination, the patient showed no signs of recurrent vascular infection and was instructed to complete an 18-month antibiotic regimen.

How Do Evaluators Differentiate Successful From Less-Than-Successful Experiences With Collaborative Approaches to Evaluation?

OBJECTIVES: In this exploratory study, we wanted to know how evaluators differentiate collaborative approaches to evaluation (CAE) perceived to be successful from those perceived to be less-than-successful. METHOD: In an online questionnaire survey, we obtained 320 responses from evaluators who practice CAE (i.e., evaluations on which program stakeholders coproduce evaluation knowledge). Respondents identified two specific CAE projects from their own experience-one they believed to be "highly successful" and another they considered "far less successful than [they] had hoped."-and offered their comments and reflections about them. They rated the respective evaluations on 5-point opinion and frequency scales about (i) antecedent stakeholder perspectives, (ii) the purposes and justifications for collaborative inquiry, and (iii) the form such inquiry takes. FINDINGS: The results showed that successful evaluations, relative to their less-than-successful counterparts, tended to reflect higher levels of agreement among stakeholders about the focal program; higher intentionality estimates of evaluation justification and espoused purposes; and wider ranges and deeper levels of stakeholder participation. No differences were found for control of technical decision-making, and evaluators tended to lead evaluation decision making, regardless of success condition. DISCUSSION: The results are discussed in terms of implications for ongoing research on CAE.

Are white storks addicted to junk food? Impacts of landfill use on the movement and behaviour of resident white storks (Ciconia ciconia) from a partially migratory population.

BACKGROUND: The migratory patterns of animals are changing in response to global environmental change with many species forming resident populations in areas where they were once migratory. The white stork (Ciconia ciconia) was wholly migratory in Europe but recently guaranteed, year-round food from landfill sites has facilitated the establishment of resident populations in Iberia. In this study 17 resident white storks were fitted with GPS/GSM data loggers (including accelerometer) and tracked for 9.1 ± 3.7 months to quantify the extent and consistency of landfill attendance by individuals during the non-breeding and breeding seasons and to assess the influence of landfill use on daily distances travelled, percentage of GPS fixes spent foraging and non-landfill foraging ranges. RESULTS: Resident white storks used landfill more during non-breeding (20.1 % ± 2.3 of foraging GPS fixes) than during breeding (14.9 % ± 2.2). Landfill attendance declined with increasing distance between nest and landfill in both seasons. During non-breeding a large percentage of GPS fixes occurred on the nest throughout the day (27 % ± 3.0 of fixes) in the majority of tagged storks. This study provides first confirmation of year-round nest use by resident white storks. The percentage of GPS fixes on the nest was not influenced by the distance between nest and the landfill site. Storks travelled up to 48.2 km to visit landfills during non-breeding and a maximum of 28.1 km during breeding, notably further than previous estimates. Storks nesting close to landfill sites used landfill more and had smaller foraging ranges in non-landfill habitat indicating higher reliance on landfill. The majority of non-landfill foraging occurred around the nest and long distance trips were made specifically to visit landfill. CONCLUSIONS: The continuous availability of food resources on landfill has facilitated year-round nest use in white storks and is influencing their home ranges and movement behaviour. White storks rely on landfill sites for foraging especially during the non-breeding season when other food resources are scarcer and this artificial food supplementation probably facilitated the establishment of resident populations. The closure of landfills, as required by EU Landfill Directives, will likely cause dramatic impacts on white stork populations.

Government and voluntary sector differences in organizational capacity to do and use evaluation.

Research on evaluation capacity is limited although a recent survey article on integrating evaluation into the organizational culture (Cousins, Goh, Clark, & Lee, 2004) revealed that interest in the topic is increasing. While knowledge about building the capacity to do evaluation has developed considerably, less is understood about building the organizational capacity to use evaluation. This article reports on the results of a pan-Canadian survey of evaluators working in organizations (internal evaluators or organization members with evaluation responsibility) conducted in 2007. Reliability across all constructs was high. Responses from government evaluators (N=160) were compared to responses from evaluators who work in the voluntary sector (N=89). The former were found to self-identify more highly as 'evaluators' (specialists) whereas the latter tended to identify as 'managers' (non-specialists). As a result, government evaluators had significantly higher self-reported levels of evaluation knowledge (both theory and practice); and they spent more time performing evaluation functions. However, irrespective of role, voluntary sector respondents rated their organizations more favorably than did their government sector counterparts with respect to the antecedents or conditions supporting evaluation capacity, and the capacity to use evaluation. Results are discussed in terms of their implications for evaluation practice and ongoing research.

Long-term resistance to fracture and/or corrosion of the nitinol wires of the talent stent-graft: observations from a series of explanted devices.

The biodurability of the Nitinol wires used in stent-grafts retrieved from reoperations and autopsy was analyzed to assess the possible causes of fracture and/or corrosion of the stents. The Nitinol wires of six explanted devices presented a corrosion-free surface after in vivo service. The drawing lines in the control wires were still present, but neither burrs nor flakes were observed. Pits and crevices were rare, but some shallow ones were present. Some abrasions of the surfaces of the Nitinol wires were also observed. The chemical composition of the explanted devices showed the presence of organic contamination that covered the thick layer of titanium oxide before reaching the Nitinol itself. The durability of the Nitinol employed in the manufacture of the Talent stent-grafts was confirmed; the results of this study show the Nitinol to be resistant to corrosion. We have also concluded that the fractures of the Nitinol wires in two devices were unique adverse incidents caused by compression and bending related to the sharp angle of the Nitinol wires.

Fatigue and/or failure phenomena observed in the fabric of stent-grafts explanted after adverse events.

In this study, we aimed to investigate changes to the fabric of Talent stent-grafts following implantation of aortic endografts and to determine the possible causes of fatigue and/or failure of the grafts. Six devices were explanted at reoperation (N=5) and autopsy (N=1). Selected segments were assessed nondestructively by gross observation and destructively by analyzing textile characteristics and chemical properties. All of the devices showed a 4/4 twill woven fabric of monofilament polyester. These devices, explanted at reoperation and autopsy, presented different levels of fatigue and/or failure. Numerous holes were found in the fabric of two devices. The minor damage caused by the passage of the sutures through the weave to fasten the Nitinol wires did not progress significantly over time. The sutures remained relatively intact, except for some distortions. The main failure mode was the abrasion of the yarns at the apices of adjacent Nitinol stents. In two devices, this abrasion resulted in fraying of the yarns and holes in the fabric tubes. This short series of explanted devices provides evidence of damage to polyester fabric used in aortic endografts and raises questions regarding their resistance to abrasion and the risk of endoleak associated with monofilament fabric yarn.

Absence of tissue ingrowth through the textile fabric in a series of explanted clinic stent-grafts.

Using the retrieved devices from one autopsy and five reoperations, the biocompatibility of explanted Talent stent-grafts was investigated to highlight the capacity of the fabric to act as an effective scaffold to regenerate a blood conduit. The autopsy device was encapsulated both internally and externally, but the capsules did not penetrate through the fabric structure. The reoperation devices showed discrete patches of compact fibrin and irregularly scattered mural thrombi. Positive staining of α-actin, tissue plasminogen activator (tPA), urokinase (uPA), urokinase receptor (uPAR), and urokinase inhibitors (PAI 1, PAI 2, PAI 3, and protease nexin), and D-dimer was more frequently identified in the autopsy sample than in the reoperation samples. This preliminary assessment shows that the stent-graft retrieved during autopsy was better healed than those explanted at reoperation.

Detailed analysis of a series of explanted Talent AAA stent-grafts: biofunctionality assessment.

Six Talent stent-grafts were harvested at reoperations (N=5) and autopsy (N=1). The explants were observed nondestructively, including gross morphology, X-rays, CT scans and closed pressure system analysis. The Nitinol frames in three devices harvested at reoperations and another harvested at autopsy were intact. One had a stent fracture of the proximal bare stent, and one had a wire fracture of a thin proximal external supporting stent as well as a hole in the fabric just above the bifurcation. For the three devices structurally intact, reoperations were performed for a type 1A endoleak (one patient) and aorto-enteric fistulas (two patients). The healing characteristics were poor or absent. The fabric in the main body of the grafts harvested after aorto-enteric fistula was devoid of biological deposits. Two of the grafts harvested at reoperation demonstrated fabric holes of up to 4 mm 2. The device obtained at autopsy showed an almost continuous internal capsule with variable thickness. The luminal surface was smooth, but the capsule detached easily. The devices explanted at reoperations showed various levels of impaired biofunctionality associated with adverse outcomes. The stent-graft retrieved from autopsy was intact.

Transmural communication at a subcellular level may play a critical role in the fallout based-endothelialization of dacron vascular prostheses in canine.

A microporous and permeable wall is important for the healing of vascular prostheses, however, the significance of its permeability to soluble substances at subcellular level has not been demonstrated. Polyester arterial prostheses were prepared in such a way that each of them contained three segments, of which at least one segment was impervious and another segment was permeable to water but impermeable to cells. Twenty graft segments were implanted in 7 dogs as a thoraco-abdominal bypass for 2 months. The prostheses were then harvested, photographed, and treated for histological and morphological studies. The low porosity graft capped by two thrombogenic segments was fully endothelialized, proving the fallout mechanism. The striking contrast with its impermeable counterpart demonstrated that a wall permeable to small substances of subcellular level was critical for the endothelial healing. A wide range of water permeabilities did not reveal advantages of high water permeable segments over low water permeable ones. Endothelial ingrowth from anastomoses was also jeopardized in the absence of wall permeability. In conclusion, transmural communication at a subcellular level may have played a critical role in the fallout based-endothelialization of arterial prostheses in canine. This highlights the potential function of perigraft cytokines and growth factors in endothelial healing.