Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis.

Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.

Systematic review of interventions to increase the use of arteriovenous fistulae and grafts in incident haemodialysis patients.

BACKGROUND: Patients who commence haemodialysis (HD) through arteriovenous fistulae and grafts (AVF/G) have improved survival compared to those who do so by venous lines. OBJECTIVES: This systematic review aims to assimilate the evidence for any strategy which increases the proportion of HD patients starting dialysis through AVF/G. DATA SOURCES: Medline, Embase, Cochrane Central and Scopus. STUDY ELIGIBILITY, PARTICIPANTS AND INTERVENTIONS: English language studies comparing any educational, clinical or service organisation intervention for adult patients with end stage renal failure and reporting incident AVF/G use. STUDY APPRAISAL AND SYNTHESIS: Two reviewers assessed studies for eligibility independently. Outcome data was extracted and reported as relative risk. Reporting was performed with reference to the PRISMA statement. RESULTS: Of 1272 studies, 6 were eligible for inclusion. Studies varied in design and intervention. Formal meta-analysis was not appropriate. One randomised controlled trial and two cohort studies assessed the role of a renal access coordinator. Two cohort studies assessed the implementation of qualitive initiative programmes and one cohort study assessed a national, structured education programme. Results between studies were contradictory with some reporting improvements in incident AVF/G use and some no significant difference. Quality was generally low. CONCLUSIONS: It is not possible to reach firm conclusions nor make strategic recommendations. A comprehensive package of care which educates and identifies patients approaching dialysis in a timely manner may improve incident AVF/G use. An unbiased, robust comparison of different strategies for timing AVF/G referral is required.

Plantar shear stress in the diabetic foot: A systematic review and meta-analysis.

AIMS: Diabetic foot ulceration (DFU) is a multifactorial process involving undetected, repetitive trauma resulting in inflammation and tissue breakdown. Shear stress forms a major part of plantar load, the aim of this review is to determine whether elevated shear stress results in ulceration. METHODS: A systematic review of the Ovid Medline, EMBASE, CINAHL and Cochrane library databases was performed. Studies involving patients with diabetes who underwent plantar shear stress assessment were included. The primary outcome was plantar shear stress in patients with diabetes who had a current/previous DFU compared with those with no prior ulceration. Meta-analysis was performed comparing shear stress between those with a current or previous DFU and those without, and those with diabetes and healthy controls. RESULTS: The search strategy identified 1461 potentially relevant articles, 16 studies met the inclusion criteria, involving a total of 597 patients. Comparing shear stress between the current/previous DFU group and those without: Standardised mean difference (SMD) 0.62 (95% CI -0.01 to 1.25), in favour of greater shear stress within the DFU group, p = 0.05. Comparing shear stress between people with diabetes and healthy controls: 0.36 (95% CI -0.31 to 1.03), in favour of greater shear stress within the diabetes group, p = 0.29. CONCLUSION: This review suggests that that patients with diabetes and a history of ulceration exhibit greater shear stress than their ulcer-free counterparts. This strengthens the premise that development of systems to measure shear stress may be helpful in DFU prediction and prevention.

Use of Omniflow® II in Infected Vascular Grafts with Femoral Anastomotic Dehiscence.

BACKGROUND: Vascular graft infection with anastomotic dehiscence requires immediate surgical intervention to preserve life and limb. We present our experience of using the Omniflow® II biosynthetic vascular prosthesis (LeMaitre Vascular) in the emergency repair of vascular graft dehiscence at the femoral anastomosis. METHODS: A retrospective review of consecutive patients presenting with femoral anastomotic dehiscence in a single centre was conducted. All patients were revascularized using an in situ Omniflow II graft. Patient demographics, affected graft type, microbiology, and antibiotic regimes were documented. Primary outcome measures were limb salvage, patency rates, and mortality. RESULTS: Five patients presented with acute femoral false aneurysm and four of five with significant hemorrhage. Infected grafts included one aortobifemoral, two femoral crossover, one axillobifemoral, and one infrainguinal reversed vein graft. All were revascularized with an in situ Omniflow II graft following the excision of the infected graft material. The median followup was 50 months. Limb salvage was achieved in 8 of 9 threatened limbs, and none required further intervention for re-infection. One graft occluded at 5 months. Two of five patients died during followup (one at 12 months, one at 50 months). CONCLUSIONS: Omniflow II provides a useful "off-the-shelf" conduit for the urgent revascularization of infected femoral dehiscence.

"Take-home" box trainers are an effective alternative to virtual reality simulators.

BACKGROUND: Practice on virtual reality simulators (VRSs) has been shown to improve surgical performance. However, VRSs are expensive and usually housed in surgical skills centers that may be inaccessible at times convenient for surgical trainees to practice. Conversely, box trainers (BT) are inexpensive and can be used anywhere at anytime. This study assesses "take-home" BTs as an alternative to VRS. METHODS: After baseline assessments (two simulated laparoscopic cholecystectomies, one on a VRS and one on a BT), 25 surgical trainees were randomized to two groups. Trainees were asked to practice three basic laparoscopic tasks for 6 wk (BT group using a "take-home" box trainer; VR group using VRS in clinical skills centers). After the practice period, all performed two laparoscopic cholecystectomy, one on a VRS and one on a BT; (i.e., posttraining assessment). VRS provided metrics (total time [TT], number of movements instrument tip path length), and expert video assessment of cholecystectomy in a BT (Global Operative Assessment of Laparoscopic Skills [GOALS] score) were recorded. Performance during pretraining and posttraining assessment was compared. RESULTS: The BT group showed a significant improvement for all VRS metrics (P = 0.008) and the efficiency category of GOALS score (P = 0.03). Only TT improved in the VRS group, and none of the GOALS categories demonstrated a statistically significant improvement after training. Finally, the improvement in VRS metrics in the BT group was significantly greater than in the VR group (TT P = 0.005, number of movements P = 0.042, path length P = 0.031), although there were no differences in the GOALS scores between the groups. CONCLUSIONS: This study suggests that a basic "take-home" BT is a suitable alternative to VRS.

Clinical and Preclinical Use of LOX-1-Specific Antibodies in Diagnostics and Therapeutics.

Lectin-like oxidized low-density lipoprotein receptor-1 (SR-E1, LOX-1, OLR1) was first discovered as a vascular receptor for modified lipoprotein particles nearly 20 years ago. Since then, in vitro and in vivo studies have demonstrated an association between LOX-1, a soluble form (sLOX-1) and a number of diseases including atherosclerosis, arthritis, hypertension and pre-eclampsia. However, converting such discoveries into tools and drugs for routine clinical use is dependent on translational preclinical and clinical studies but such studies have only begun to emerge in the past decade. In this review, we identify the key clinical applications and corresponding criteria that need to be addressed for the effective use of LOX-1-related probes and molecules for patient benefit in different disease states.

Ward-based, nurse-led, outpatient chest tube management: analysis of impact, cost-effectiveness and patient safety.

OBJECTIVES: Prolonged drainage and air leaks are recognized complications of elective and acute thoracic surgery and carry significant burden on inpatient stay and outpatient resources. Since 2007, we have run a ward-based, nurse-led clinic for patients discharged with a chest drain in situ. The aim of this study is to assess its cost-effectiveness and safety. METHODS: We present a retrospective review of the activity of the clinic for a period of 12 months (November 2009-10). An analysis of the gathered data is performed, focusing specifically on the duration of chest tube indwelling, the indications, complications and cost efficiency. RESULTS: The nurse-led clinic was housed in the thoracic ward with no additional fixed costs. Seventy-four patients were reviewed (53 males, 21 females, mean age of 59) and subsequently discharged from the clinic in this time period, accounting for 149 care episodes. Thirty-three (45%) of the patients underwent a video-assisted thoracoscopic surgery procedure, 35 (47%) of them a thoracotomy and 7 (9%) had a bedside chest tube insertion. Following hospital discharge, the chest tubes were removed after a median of 14 days (range 1-82 days). Fifty-eight percent of the patients were reviewed because of a prolonged air leak, 26% for persistent fluid drainage and 16% due to prolonged drainage following evacuation of empyemas. For the care episodes analysed, we estimate that the clinic has generated an income of €24,899 for the department. Hourly staffing costs for the service are significantly lower compared with those of the traditional outpatient clinic: €15 vs. €114. CONCLUSIONS: Our results show that a dedicated chest tube monitoring clinic is a safe and efficient alternative to formal outpatient clinic review. It can lead to shorter hospital stays and is cost effective.