PATIENTS WITH ACUTE LOWER LIMB ISCHEMIA CONTINUE TO HAVE SIGNIFICANT MORBIDITY AND MORTALITY.

BACKGROUND: The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS: We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS: During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion 24% had embolic occlusion, and 3% due to a low-flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, one or no vessel runoff to the foot post-operatively was associated with higher 30-day limb loss. Patients with no run-off vessels post-operatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSION: Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.

Combined Resection Approaches: Decision Making for Synchronous Resection, Timing of Staged Intervention to Optimize Outcome.

Advancement in systemic and regional radiation therapy, surgical technique, and anesthesia has provided a path for increased long-term survival and potential cure for more patients with stage IV rectal cancer in recent years. When patients have resectable disease, the sequence for surgical resection is classified in three strategies: classic, simultaneous, or combined, and reversed. The classic approach consists of rectal cancer resection followed by metastatic disease at a subsequent operation. Simultaneous resection addresses both rectal and metastatic disease in a single surgery. The reversed approach treats metastatic disease first, followed by the primary tumor in several months. Simultaneous resection is appropriate for selected patients to avoid delay of definitive surgery, and reduce number of surgeries, hospital stay, and cost to the health care system. It may also improve patients' psychological effect. Multidisciplinary discussions including colorectal and liver surgeons to review patients' baseline medical conditions, tumor biology and behavior, and disease burden and distribution is imperative to guide proper patient selection for simultaneous resection and perioperative treatments.

Necessity, Role, and Outcomes of Fasciotomy in Patients with Acute Limb Ischemia.

BACKGROUND: The incidence of compartment syndrome in patients with acute lower limb ischemia (ALLI) and the effects of fasciotomy on outcomes are largely undefined. This study aimed to define the incidence of compartment syndrome in patients with ALLI and to examine whether different fasciotomy strategies are associated with specific patient outcomes. METHODS: A single-center retrospective study of patients who had ALLI between April 2016 and October 2020 at a tertiary care center. Patients were categorized into groups as having received early and late therapeutic fasciotomy (TF), early prophylactic fasciotomy (PF), early exploratory fasciotomy, and no fasciotomy. Primary outcome was 30-day amputation rate. Secondary outcomes were 30-day and 1-year mortality, 1-year amputation rate, and length of stay. Groups were compared using descriptive statistics to assess the association of fasciotomy approach with outcomes. RESULTS: During the study period, 266 patients were treated for ALLI, and 62 patients (23%) underwent 66 fasciotomies. A total of 41 TF, 23 PF, and 2 exploratory fasciotomies were done. There were 58 early fasciotomies performed (88% of 66 limbs): 33 (57%) early TF, 23 (40%) PF, and 2 (3%) exploratory. There were 8 patients who developed compartment syndrome after their revascularization operation and received delayed TF (12% of 66 limbs). The total number of TF was 41, which was 15% of all ALLI patients. The mean ± SD time to fasciotomy closure was 6.7 ± 5.7 days, which did not differ between PF and TF groups. Significantly more patients in the TF group had an amputation at 30 days (11 [29%] vs. 1 [5%]; P = 0.03) and at 1 year (6 [18%] vs. 2 [9%]; P = 0.02) than those in the PF group. Length of stay was increased in both TF (16 days) and PF (19 days) patients compared to nonfasciotomy patients (10 days; P < 0.01) but did not differ between the 2 fasciotomy groups (P = 0.4). Thirty-day limb loss was highest in patients who underwent early TF (10/33, 33%), intermediate in those with delayed TF (1/8, 13%), and lowest in PF (1/23, 5%; P = 0.03). CONCLUSIONS: Approximately 15% of patients with ALLI in our cohort required a TF for compartment syndrome. Close postoperative monitoring of ALLI patients who did not undergo early fasciotomy did detect delayed compartment syndrome; however, this approach did not prevent limb loss. To optimize limb salvage, physicians treating patients with ALLI should be experienced in how to recognize and treat compartment syndrome.

The Impact of the Medicare Access and CHIP Reauthorization Act on the Field of Ophthalmology.

PURPOSE: To analyze the impact of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on the field of ophthalmology. DESIGN: A perspective on the effects of MACRA's Quality Payment Program after analysis of the proposed rule, final rule, and commentary submitted by relevant stakeholders. RESULTS: Physicians will need to use 1 of 2 payment structures: Merit-Based Incentive Payment Systems (MIPS) or Alternative Payment Models (APMs). APMs and MIPS will focus on bundling payments and reimbursing based on "fee-for-service-plus" models, which take into account clinical outcomes, coordination of care, clinical improvement, and electronic information exchange and security. APMs have substantial advantages, with eligible participants receiving a bonus and a higher rate of annual adjustment over the program's life. For most ophthalmology practices, MIPS may be more appropriate owing to its broader applicability and the current paucity of APMs for ophthalmologists. CONCLUSION: The Quality Payment Program is a substantial improvement over the negative adjustments under the repealed Substantial Growth Rate model. Ophthalmologists will likely use the MIPS system; however, its comparatively lower reimbursements, as well as its cost, quality, and other reporting measures, may prove problematic.