Functional outcome in a contemporary series of major lower extremity amputations.

PURPOSE: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

Smoking cessation counseling: a missed opportunity for general surgery trainees.

PURPOSE: The purpose of this study was to evaluate and compare the attitudes, practices, technique utilizations, and barrier perceptions of smoking cessation counseling (SCC) in general surgery (GS) and primary care (PC) residents. METHODS: One hundred house staff officers (45 GC and 55 PC residents, consisting of internal medicine and family medicine disciplines) were randomly surveyed. chi(2) and t tests were used for comparative analysis where appropriate. The National Cancer Institute's recommendation that physicians follow the "four A's" for SCC (Ask, Advise, Assist, and Arrange follow-up) was examined with respect to compliance by surgical and medical residents. RESULTS: Fewer GS than PC residents thought physicians were responsible for SCC (64% versus 85%; P <.02), and fewer felt well prepared to counsel their patients (38% versus 58%; P <.05). Nevertheless, about 85% of both groups reported a higher inclination to provide SCC to patients who expressed an interest for cessation. Although many GC residents Ask (89% GS versus 100% PC residents; P <.03) and Advise (64% versus 89%; P <.003) new patients about smoking, they did so less frequently than PC residents. GC residents used fewer SCC techniques than did PC residents (3.96 versus 6.00; P <.001) and Arranged fewer follow-up visits for SCC (7% versus 44%; P <.001). Postgraduate year did not correlate with SCC in either GS or PC residents. Residents from both groups perceived time constraints, lack of patient desire, and poor patient compliance to be the main barriers in SCC. CONCLUSION: In this study, many GC residents agreed that physicians were responsible for SCC, but few followed through by arranging SCC follow-up visits compared with their PC resident counterparts. Behavior does not appear to change as residents mature, despite greater exposure to smoking-related diseases. In every dimension of SCC studied, GS residents played a less assertive role when compared with PC residents. GC residents should be more proactive in SCC because the diseases they treat are often related to cigarette smoking.