Aims: Diabetes-related amputations are typically preceded by a diabetic foot ulcer (DFU) but models to assess the quality of care are lacking. We investigated a model to measure inpatient and outpatient quality. Methods: Cohort study among adults hospitalized with a DFU to a safety-net hospital during 2016. We measured adherence to DFU-related quality metrics based on guidelines during and 12 months following hospitalization. Inpatient metrics included ankle-brachial index measurement during or 6 months prior to hospitalization, receiving diabetes education and a wound offloading device prior to discharge. Outpatient metrics included wound care ≤30 days of discharge, in addition to hemoglobin A1c (HbA1c) ≤8%, tobacco cessation, and retention in care (≥2 clinic visits ≥90 days apart) 12 months following discharge. Results: 323 patients were included. Regarding inpatient metrics, 8% had an ankle brachial index measurement, 37% received diabetes education, and 20% received offloading prior to discharge. Regarding outpatient metrics, 33% received wound care ≤30 days of discharge. Twelve months following discharge, 34% achieved a HbA1c ≤8%, 13% quit tobacco, and 52% were retained in care. Twelve-month amputation-free survival was 71%. Conclusions: Our model demonstrated large gaps in DFU guideline-adherent care. Implementing measures to close these gaps could prevent amputations.
Background
Diabetes is the leading cause of lower extremity nontraumatic amputation globally, and diabetic foot osteomyelitis (DFO) is usually the terminal event before limb loss. Although guidelines recommend percutaneous bone biopsy (PBB) for microbiological diagnosis of DFO in several common scenarios, it is unclear how frequently PBBs yield positive cultures and whether they cause harm or improve outcomes.
Methods
We searched the PubMed, EMBASE, and Cochrane Trials databases for articles in any language published up to December 31, 2019, reporting the frequency of culture-positive PBBs. We calculated the pooled proportion of culture-positive PBBs using a random-effects meta-analysis model and reported on PBB-related adverse events, DFO outcomes, and antibiotic adjustment based on PBB culture results where available.
Results
Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%–99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%–91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported.
Conclusions
This meta-analysis suggests PBBs have a high yield of culture-positive results. However, this is an understudied topic, especially in low- and middle-income countries, and the current literature provides very limited data regarding procedure safety and impact on clinical outcomes or antibiotic management.
On March 17, 2020, Emory University School of Medicine temporarily suspended student–patient contact to minimize the risk of exposure to coronavirus disease 2019, representing an unprecedented disruption to medical education. In response, virtual electives were expeditiously created to supplement existing curricula and keep students on track for their scheduled graduation dates. The Emory University School of Medicine Department of Surgery faculty and students created the ViSEG (virtual surgical education group) to design virtual electives in eight surgical specialties for third-year medical students. All students, including those not previously enrolled in a surgical clerkship, were encouraged to enroll. Seven students chose the virtual vascular surgery elective.
Background: Abdominal aortic aneurysm (AAA) rupture is an adverse arterial remodeling event with high mortality risk. Since females have increased rupture risk with smaller AAAs (<5.5 cm), many recommend elective repair prior to 5.5 cm. Elective repair improves survival for large AAAs, but long-term benefits of endovascular aneurysm repair (EVAR) for small AAAs in females remains less understood. The objective of this study is to identify if differences in late mortality exist between females undergoing elective EVAR at our institution for small/slow-growing AAAs compared to those who meet standard criteria.
Methods: We retrospectively analyzed all patients that underwent EVAR for infrarenal AAA from 6/2009–6/2013. We excluded patients that were male, treated emergently or for iliac artery aneurysm, and that received renal/mesenteric artery stenting. Patients did not meet anatomic criteria if preoperative AAA diameter was <5.5 cm or enlarged <0.5 cm over 6 months. Late mortality was assessed from the Social Security Death Index.
Results: 36/162 (22.2%) elective EVAR patients were female (mean follow-up 37.2 months). 20 (55.6%) patients met AAA size/growth criteria while 16 (44.4%) did not meet criteria. Despite comparable demographics, comorbidities, and complications, patients that did not meet criteria had higher late mortality (37.5% vs. 5%; P= .03) with a trend towards increased reoperation rate (25% vs. 5%; P= .48). Meeting size/growth criteria decreased odds of late death (OR .09; 95% CI 0.01–0.83).
Conclusion: There is increased late mortality in females receiving elective EVAR at our institution for small/slow-growing AAAs. This late mortality may limit the benefits of EVAR for this population.
Background
Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first‐line therapy, although patient adoption remains low. Home‐based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low‐resource settings, remains unknown.
Methods
Smart Step is a pilot randomized trial of smartphone‐enabled HBET vs walking advice in patients with symptomatic PAD in an inner‐city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone‐based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6‐minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year.
Results
A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants.
Conclusions
The potential significance of this trial will be to provide preliminary evidence of a home‐based, “mobile‐first” approach for delivering a structured exercise rehabilitation program. Smartphone‐enabled HBET can be potentially more accessible than center‐based programs, and if proven effective, may have a potential widespread public health benefit.