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1.
Anand Dayama Nikolaos Tsilimparis Stephen Kolakowski Nathaniel M. Matolo Misty D. Humphries 《Journal of vascular surgery》2019,69(1):156-163.e1
Background
Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease.Methods
We reviewed the American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity revascularization database from 2012 to 2015 to identify patients with CLTI and isolated infrageniculate arterial disease who underwent primary infrageniculate bypass or endovascular intervention. We excluded patients with a history of ipsilateral revascularization and proximal interventions. The end points were major adverse limb event (MALE), major adverse cardiovascular event (MACE), amputation at 30 days, reintervention, patency, and mortality. Multivariable logistic regression was used to determine the association of a bypass-first or an endovascular-first intervention with outcomes.Results
There were 1355 CLTI patients undergoing first-time revascularization to the infrageniculate arteries (821 endovascular-first revascularizations and 534 bypass-first revascularizations) identified. There was no significant difference in adjusted rate of 30-day MALE in the bypass-first vs endovascular-first revascularization cohort (9% vs 11.2%; odds ratio [OR], 0.73; 95% confidence interval [CI], 0.50-1.08). However, the incidence of transtibial or proximal amputation was lower in the bypass-first cohort (4.3% vs 7.4%; OR, 0.60; CI, 0.36-0.98). Patients with bypass-first revascularization had higher wound complication rates (9.7% vs 3.7%; OR, 2.75; CI, 1.71-4.42) compared with patients in the endovascular-first cohort. Compared with the endovascular-first cohort, the incidence of 30-day MACE was significantly higher in bypass-first patients (6.9% vs 2.6%; adjusted OR, 3.88; CI, 2.18-6.88), and 30-day mortality rates were 3.23% vs 1.8% (adjusted OR, 2.77; CI, 1.26-6.11). There was no difference in 30-day untreated loss of patency, reintervention of treated arterial segment, readmissions, and reoperations between the two cohorts. In subgroup analysis after exclusion of dialysis patients, there was also no significant difference in MALE or amputation between the bypass-first and endovascular-first cohorts.Conclusions
CLTI patients with isolated infrageniculate arterial disease treated by a bypass-first approach have a significantly lower 30-day amputation. However, this benefit was not observed when dialysis patients were excluded. The bypass-first cohort had a higher incidence of MACE compared with an endovascular-first strategy. These results reaffirm the need for randomized controlled trials, such as the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL-2) trial and Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI), to provide level 1 evidence for the role of endovascular-first vs bypass-first revascularization strategies in the treatment of this population of challenging patients. 相似文献2.
3.
Andrew R. Hoellein MD Christopher A. Feddock MD Charles H. Griffith III MD MSPH John F. Wilson PhD Donald R. Barnett MD MSPH Pat F. Bass III MD MS T. Shawn Caudill MD MSPH 《Journal of general internal medicine》2004,19(5P2):562-565
Due to recent public debate and newly imposed resident work hour restrictions, we decided to investigate the relationship of resident call status to their ambulatory patients' satisfaction. Resident continuity clinic patients were asked to rate their level of satisfaction on a 10-point Likert-type scale. Using multiple regression approaches, these data were then assessed as a function of resident call status. We found that in 646 patient encounters, patient satisfaction scores were significantly less when the resident was postcall, 8.99 ± 1.8, than when not postcall, 9.31 ± 1.3. We herein discuss etiologies and implications of these findings for both patient care and medical education. 相似文献
4.
5.
Pat Price 《Radiotherapy and oncology》2006,78(3):233-235
6.
Flexible endoscopes are complex medical instruments that are easily damaged. In order to maintain the flexible endoscope in optimum working condition, the user must have a thorough understanding of the structure and function of the instrument. This is the fourth in a series of articles presenting an in-depth look at the care and handling of the flexible endoscope. The first three articles discussed the air-water system, the suction channel system, and the mechanical system. This article will focus specifically on the endoscopic retrograde cholangiopancreatography elevator system. 相似文献
7.
Denis O'Mullane PhD ; Helen P. Whelton PhD ; Pat Costelloe BDS David Clarke BDS ; Stephen McDermott MSc ; Jacinta McLoughlin MDS 《Journal of public health dentistry》1996,56(5):259-264
The visit of Dr. Trendley Dean to Dublin in the mid-1950s helped accelerate the decision to introduce water fluoridation as a public health measure in the prevention of caries in the Republic of Ireland. A challenge to the constitutional validity of the Health (Fluoridation of Water Supplies) Act 1960 failed and in 1964 the water supplies of Dublin city were fluoridated. Over the next seven to eight years all the major urban communities in the Republic of Ireland were fluoridated. Currently, 67 percent of the 3.5 million people in the country reside in fluoridated communities. Studies conducted over the last 20 years show that residents of fluoridated communities have better dental health than those in nonfluoridated communities—the mean dmft is lower in children and the number of natural teeth present in adults is higher. 相似文献
8.
Pat D. O'Donnell 《Neurourology and urodynamics》1989,8(5):505-511
Urinary incontinence is a serious management problem among elderly patients. The care and management of chronic care patients is more difficult in those having urinary incontinence. The level of care required is dependent on both the continence and incontinence behavior of the patient. The continence behavior in this study is presented as the time interval between episodes of involuntary urine loss. The continence interval in elderly inpatient men having severe incontinence was found to be significantly longer in patients having a larger measured cystometric bladder capacity as well as in patients having greater independence in activities of daily living. Significant variability in the continence interval was measured for each patient over a wide range of continence intervals and resulted in an irregular pattern of time between episodes of incontinence. The irregular continence intervals suggest an instability of the central nervous system sensory-motor regulatory mechanism of bladder control in the elderly. 相似文献
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10.
Mo Therese Hannah Ellen R. Gritz David K. Wellisch Pat Fobair Richard T. Hoppe Joan R. Bloom Guo-Wen Sun Anna Varghese Malcolm D. Cosgrove David Spiegel 《Psycho-oncology》1992,1(2):89-103
This study compares the effects of the cancer experience on various aspects of marital and sexual functioning (e.g., communication, emotional support, body image, sexual satisfaction and frequency) for two groups of long-term cancer survivors (testicular cancer and Hodgkin's disease) and their spouses. Comparisons between the two patient groups showed significantly more survivors of Hodgkin's disease than testicular cancer reporting the emergence of special issues and changes in the marital relationship. No differences emerged between the spouse groups on sexual functioning variables; however, spouses of survivors of Hodgkin's disease were more likely than spouses of survivors of testicular cancer to report the development of special issues and communication difficulties. A substantial proportion of both survivor groups disclosed negative changes in body image and sexual frequency. Majorities of both survivors and spouses acknowledged that the illness had drawn them closer together. When representative marital/sexual functioning variables were used to predict Family Environment Scale (FES) scores for survivors and for spouses, changes in the spouse's importance, influence of the illness on the relationship, and changes in sexual frequency emerged as significant predictors. The clinical significance of long-term changes in marital and sexual functioning for the couple and the need for therapeutic interventions are discussed. 相似文献