Observed impact of skin substitutes in lower extremity diabetic ulcers: lessons from the Medicare Database (2015–2018)

2021 ◽  
Vol 30 (Sup7) ◽  
pp. S5-S16
Author(s):  
David G Armstrong ◽  
William H Tettelbach ◽  
Thomas J Chang ◽  
Julie L De Jong ◽  
Paul M Glat ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Hospital Readmission ◽  
Hospital Readmissions ◽  
Skin Substitutes ◽  
Diabetic Ulcers ◽  
Matched Group ◽  
Ed Visits ◽  
Group 2 ◽  
Medicare Database ◽  
Group 1

Objective: To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. Method: The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analyse people receiving care for a LEDU treated with AT or NAT (propensity-matched Group 1). Analysis included major and minor amputations, emergency department (ED) visits and hospital readmissions. In addition, AT following parameters for use (FPFU) was compared with AT not FPFU (propensity-matched Group 2). A paired t-test was used for comparisons of the two groups. For comparisons of three groups, the Kruskal–Wallis test was used. A Bonferroni correction was performed when multiple comparisons were calculated. Results: There were 9,738,760 patients with a diagnosis of diabetes, of whom 909,813 had a LEDU. In propensity-matched Group 1 (12,676 episodes per cohort), AT patients had statistically fewer minor amputations (p=0.0367), major amputations (p<0.0001), ED visits (p<0.0001), and readmissions (p<0.0001) compared with NAT patients. In propensity-matched Group 2 (1131 episodes per cohort), AT FPFU patients had fewer minor amputations (p=0.002) than those in the AT not FPFU group. Conclusion: AT for the management of LEDUs was associated with significant reductions in major and minor amputation, ED use, and hospital readmission compared with LEDUs managed with NAT. Clinics should implement AT in accordance with the highlighted parameters for use to improve outcomes and reduce costs.

scholarly journals Effects of Change in 6-Minute Walking Distance on Hospital Readmissions and Emergency Department Visits in Patients with Pulmonary Arterial Hypertension

2021 ◽  
Author(s):  
Yong-Gon Seo ◽  
SuKi Oh ◽  
MiJa Jang ◽  
Ho-Young Kim ◽  
Sung-A Chang ◽  
...  
Keyword(s):  
Hospital Readmission ◽  
Hospital Readmissions ◽  
Walking Distance ◽  
Change Rate ◽  
Significant Difference ◽  
Pulmonary Arterial ◽  
Ed Visits ◽  
Hospital Visits ◽  
Group 2 ◽  
Group 1

Abstract Pulmonary arterial hypertension (PAH) is a rare disease and its prognostic factor includes reduction of 6-min walking distance (6MWD). Thus, the study aimed to confirm the correlation between different change rate of 6MWD and hospital readmission and emergency department (ED) visits in patients with PAH. 139 patients were divided into three groups according to change rate of 6MWD; group 1 (≥15%, n = 54), group 2 (15%<change≥0%, n = 47)), group 3 (<0%, n = 38). The hospital readmission, ED visits, and hospital visits were compared between the three groups. A significant difference in hospital readmission was observed between the groups (P = 0.0113), with group 1 showing higher frequency of hospital readmissions than group 2 (P = 0.0261). A significant difference in the hospital visits was observed between the three groups (P = 0.0024). A positive correlation was observed between hospital readmission (r = 0.21861, P = 0.0097) and hospital visit (r = 0.35877, P < 0.0001). A weak negative correlation was observed between the ED visit and change rate in 6MWD (r = −0.25299, P = 0.0027).This study showed that the positive change rate in 6MWD may relate to the reduction in the ED visits in patients with PAH.

Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation?

2019 ◽  
Vol 17 (4) ◽  
pp. 354-364
Author(s):  
Hassan Al-Thani ◽  
Moamena El-Matbouly ◽  
Maryam Al-Sulaiti ◽  
Noora Al-Thani ◽  
Mohammad Asim ◽  
...  
Keyword(s):  
Glycemic Control ◽  
Lower Extremity ◽  
Hazard Ratio ◽  
Lower Extremity Amputation ◽  
Group 4 ◽  
Group 3 ◽  
Group 5 ◽  
Group 2 ◽  
Extremity Amputation ◽  
Group 1

Background: We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA). Methods: A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively. Results: The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control. Conclusion: The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.

Relationship of triglyceride–glucose index with chronic limb-threatening ischemia in lower extremity peripheral artery disease

Vascular ◽  
2021 ◽  
pp. 170853812110183
Author(s):  
Arda Aybars Pala ◽  
Yusuf Salim Urcun
Keyword(s):  
Lower Extremity ◽  
High Density Lipoprotein ◽  
Peripheral Artery Disease ◽  
Density Lipoprotein ◽  
Peripheral Artery ◽  
Tyg Index ◽  
Triglyceride Glucose Index ◽  
Group 2 ◽  
Artery Disease ◽  
Group 1

Objectives Triglyceride-glucose index (TyG index), which is defined as the simple and novel marker of insulin resistance, is becoming increasingly important as a promising predictive marker for atherosclerotic diseases. Chronic limb-threatening ischemia is defined as the most advanced stage of the lower extremity peripheral artery disease, whose main cause is atherosclerosis and is associated in this respect with amputation, impaired quality of life, and mortality. The main purpose of the present study was to investigate the relation between the calculated TyG index values and chronic limb-threatening ischemia development. Methods A total of 296 patients who were diagnosed with lower extremity peripheral artery disease in our outpatient clinic between October 2018 and October 2020 were included in this study retrospectively. Two groups were formed by clinically staging the patients according to Rutherford Classification. Patients who did not develop chronic limb-threatening ischemia were classified as “Group 1” ( n = 224) and those who developed were classified as “Group 2” ( n = 72). Results The mean TyG index values that were calculated in Group 2 were significantly higher than in Group 1 (9.27 ± 0.31 vs. 9.00 ± 0.34, p < 0.001). In the multivariate logistic regression analysis conducted to determine the predictors of chronic limb-threatening ischemia development, C-reactive protein (OR [Odds Ratio]: 1.220, 95% CI [confidence interval]: 1.092–1.363, p < 0.001), high-density lipoprotein cholesterol (OR: 0.775, 95% CI: 0.715–0.839, p < 0.001) and TyG index (OR: 5.796, 95% CI: 2.050–16.382, p = 0.001) were identified as independent predictors. Receiver operating characteristic analysis revealed that the cut-off value of TyG index was 9.13 (area under the curve: 0.721, p < 0.001) with 70.8% sensitivity and 65.2% specificity. The TyG index was significantly correlated with Rutherford category, high-density lipoprotein cholesterol and mean platelet volume. Conclusions Chronic limb-threatening ischemia development may be predicted with the TyG index value, which is calculated easily from routine biochemical parameters, in patients diagnosed with lower extremity peripheral artery disease.

scholarly journals Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

2020 ◽  
Vol 17 (8) ◽  
pp. 2925 ◽  
Author(s):  
Hai Mai Ba ◽  
Youn-Jung Son ◽  
Kyounghoon Lee ◽  
Bo-Hwan Kim
Keyword(s):  
Heart Failure ◽  
Hospital Readmission ◽  
Transitional Care ◽  
Hospital Readmissions ◽  
Recovery Period ◽  
Functional Decline ◽  
Integrative Review ◽  
Patients With Heart Failure ◽  
Ed Visits ◽  
The Common

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in complex comorbidities. Hospital readmissions for HF, including emergency department (ED) visits, are considered preventable. Majority of the patients with HF are often discharged early in the recovery period with inadequate self-care instructions. To address these issues, transitional care interventions have been implemented with the common objective of reducing the rate of hospital readmission, including ED visits. However, there is a lack of evidence regarding the benefits and adverse effects of transitional care interventions on clinical outcomes and patient-related outcomes of patients with HF. This integrative review aims to identify the components of transitional care interventions and the effectiveness of these interventions in improving health outcomes of patients with HF. Five databases were searched from January 2000 to December 2019, and 25 articles were included.

scholarly journals Shortening of the First Ray After First Tarsometatarsal Joint Fusion: A Cadaveric Comparison Between Curettage Versus Planal Resection

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0042
Author(s):  
Calvin J. Rushing ◽  
Bryon J. McKenna ◽  
Travis M. Langan ◽  
Patrick E. Bull ◽  
Christopher F. Hyer ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Anatomic Study ◽  
Joint Preparation ◽  
Joint Fusion ◽  
Tarsometatarsal Joint ◽  
First Ray ◽  
Group 2 ◽  
Preparation Techniques ◽  
Digital Caliper ◽  
Group 1

Category: Bunion; Midfoot/Forefoot; Other Introduction/Purpose: Potential shortening of the first ray is an important consideration when performing a first tarsometatarsal (TMTJ) fusion. However, no previous study has sought to directly quantify the resultant shortening after TMTJ fusion. The purpose of the present anatomic study was to directly assess and compare shortening of the first ray using two joint preparation techniques (curettage, planal resection) for first TMTJ fusion. Methods: Ten pairs of matched lower extremity cadaver specimens were divided into two groups. Preoperative length assessments were performed at the first TMTJ dorsally and plantarly using a digital caliper. In Group 1, joint preparation for first TMTJ fusion was performed with curettage, whereas specimens in Group 2 underwent planal resection. Post-operative length assessments were repeated. All data was analyzed using two-tailed Students t-tests. Results: Mean shortening of the first ray following curettage was 1.1 (range, 0.3 to 2.0) mm dorsally and 1.6 (range, 0.6 to 3.7) mm plantarly; while mean shortening following planal resection was 4.5 (range, 2.7 to 7.9) mm dorsally and 4.6 (range, 2.4 to 8.9) mm plantarly. The measured differences were statistically significant (p <0.001, p=0.001). Conclusion: Both curettage and planal resection resulted in shortening of the first ray after first TMTJ fusion. Planal resection resulted in significantly more shortening, which was also more variable. Surgeons performing first TMTJ fusions may consider curettage over planal resection to mitigate the risk of painful postoperative transfer metatarsalgia.

scholarly journals Evaluating the effectiveness of a lower extremity venous phantom on developing ultrasound examination skills and confidence

Ultrasound ◽  
2020 ◽  
pp. 1742271X2095077
Author(s):  
Carol Mitchell ◽  
Pazee L Xiong ◽  
Benjamin L Cox ◽  
Maame A Adoe ◽  
Michelle M Cordio ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Teaching Methods ◽  
Ultrasound Examination ◽  
Human Volunteer ◽  
Confidence Levels ◽  
Significant Difference ◽  
Ultrasound Phantom ◽  
Group 2 ◽  
Didactic Lecture ◽  
Group 1

Introduction The aims of this study were: (1) Determine the effect on student ultrasound scanning skills using a lower extremity venous ultrasound phantom in addition to standard teaching methods of didactic lecture and scanning live volunteers and (2) Determine the effect of using a lower extremity venous ultrasound phantom in addition to standard teaching methods of didactic lecture and scanning live volunteers on student confidence levels in performing the lower extremity venous ultrasound examination. Methods Participants were first year diagnostic medical sonography students with minimal scanning experience ( n = 11), which were randomized into two groups. Group 1 ( n = 5) received the standard didactic lecture and attended a scan lab assessment where they performed a lower extremity venous examination on a human volunteer. Group 2 ( n = 6) received the standard didactic lecture, performed three scheduled scanning sessions on an anatomic lower extremity venous phantom with flow and then attended the same scan lab assessment as Group 1, where they performed a lower extremity venous examination on a human volunteer. Results Scan lab assessments on day 4 of the study demonstrated a significant difference in scanning performance ( p = 0.019) between the two groups. Post scan lab assessment confidence scores also demonstrated a significant difference between how participants in each group scored their confidence levels ( p = 0.0260), especially in the ability to image calf veins. Conclusions This study suggests anatomical phantoms can be used to develop scanning skills and build confidence in ultrasound imaging of the lower extremity venous structures.

Abstract T P382: Urgent Primary Care Physician Follow up is Associated with Reduced Stroke Readmission after Acute Ischemic Stroke Hospitalization

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
William Neil ◽  
Jane Rosete ◽  
Jennifer Seibel ◽  
David Buccigrossi ◽  
Kerry Forde ◽  
...  
Keyword(s):  
Heart Failure ◽  
Primary Care ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Hospital Readmission ◽  
Care Physician ◽  
Stroke Patients ◽  
Group 2 ◽  
Group 1

Introduction: Readmission after acute ischemic stroke is common and costly, with an average rate of 14.8% within 30 days of discharge1. In 2010, as part of a hospital performance improvement strategy, ischemic stroke patients who were discharged to home had an urgent (within 7 days) appointment with Primary Care Physician (PCP) scheduled. We compared 30-day readmission rates for those who kept and did not keep their appointment. Methods: Data from an electronic medical record system was retrospectively evaluated. The cohort included all patients with hospital admission for ICD 9 diagnosis of ischemic stroke (433, 434, 435) during the years 2010 - 2013. Only those with a discharge disposition of home were included. Group 1 included patients discharged to home who kept follow up appointment. Group 2 included those who did not keep their scheduled appointment. Significant predictors of readmission such as age, heart failure, diabetes, LACE score were compared. Fisher’s Exact test was used for categorical variables. Results: A total of 349 ischemic stroke patients were discharged to home during the study period. Of these, 250 had appointments scheduled, and 167 (66.8%) kept these appointments (Group 1). The average age was 69.2 and 68.3 with average LACE of 9.7 and 9.5 for groups 1 and 2 respectively. There was no significant difference in rates of diabetes or heart failure between groups. There were 7 (3.6%) readmissions in group 1 and 19 of 83 (22.9%) in group 2. Five patients were readmitted prior to appointment time in group 2, so were not entered into final calculation; this left readmission rate of 14/83 (16%); p =0.004. Conclusion: Urgent follow up with PCP may prevent hospital readmission in those with mild strokes. Reverse causation, from missing appointment due to hospital readmission did not account for these results. Although NIHSS was not compared, our cohort consisted of those with mild symptoms, given home disposition. Further study is needed to determine which elements of the PCP follow up visit are most effective in reducing hospital readmission. Reference: 1. Lichtman, JH. Leifheit-Limson, EC. Predictors of Hospital Readmission after Stroke: A Systematic Review Stroke. 2010; 41(11): 2525-2533.

THROMBOSIS IN PATIENTS WITH HEPARIN-INDUCED THROMBOCYTOPENIA

1987 ◽  
Author(s):  
C M Chesney ◽  
R H Lands
Keyword(s):  
Platelet Count ◽  
Lower Extremity ◽  
Serotonin Release ◽  
Positive Test ◽  
Additional Patient ◽  
Heparin Group ◽  
Prophylactic Measure ◽  
Heparin Induced Thrombocytopenia ◽  
Group 2 ◽  
Group 1

Heparin induced thrombocytopenia was studied in a 2000 bed teaching hospital with 21,000 admissions annually. Approximately 25% (5250 patients) received some form of heparin therapy (lV,SC, catheter flushes). In l6 months 21 patients(<0.4%) developed well-documented thrombocytopenia while receiving therapeutic bovine lung heparin(IV). In 12 cases thrombocytopenia appeared to be directly related to heparin (Group 1). In 9 cases additional disease processes were also present (Group 2). While on heparin 5 patients in Group 1 (42%) developed new thrombotic episodes including pulmonary embolus, transient ischemic attack, stroke, lower extremity embolus, and myocardial infarction. None of these complications resulted in death. All patients were tested by a sensitive and specific lUC-serotonin release method for detecting heparin-induced thrombocytopenia (Blood 67:27, 1986). The test was positive in 10/12 patients (83%) in Group 1 and only 4/9 (44%) in Group 2. All 5 patients with thrombosis had a positive test. In all 21 cases heparin was discontinued. Platelet count began to improve in 1-9 days and eventually returned to normal in all Group 1 patients and the 4 Group 2 patients with positive test. An additional patient not included in Group 1 or 2 received minidose heparin(8000 units SC q8h) as a prophylactic measure following cholcystectomy. Ten days later while still receiving heparin she developed a cold, pulseless right lower extremity. Test for heparin associated platelet antibody was strongly positive despite platelet count of 200,000 per ul. However review of medical record revealed platelet count of 433,000 the preceding day. Therefore the drop represents a decrease in platelet count of 54%. Embolectomy of the right femoral-popliteal system revealed white platelet thrombus. Heparin was discontinued.The results presented here demonstrate that the l4C-serotonin release test is sensitive and specific for heparin induced thrombocytopenia. Well documented heparin induced thrombocytopenia occurs infrequently. However, thrombosis is not rare in these patients and may occur in the absence of absolute thrombocytopenia. Increased awareness of this entity and more accurate diagnosis may result in decreased mortality and morbidity.

Implementation of a Postoperative Outpatient Care Pathway for Delayed Hyponatremia Following Transsphenoidal Surgery

Neurosurgery ◽  
2017 ◽  
Vol 82 (1) ◽  
pp. 110-117 ◽  
Author(s):  
Michael A Bohl ◽  
Shahjehan Ahmad ◽  
William L White ◽  
Andrew S Little
Keyword(s):  
Transsphenoidal Surgery ◽  
Care Pathway ◽  
Hospital Readmissions ◽  
Treated Group ◽  
Routine Screening ◽  
Readmission Rates ◽  
Severe Hyponatremia ◽  
Group 2 ◽  
The Impact ◽  
Group 1

Abstract BACKGROUND After transsphenoidal surgery, delayed hyponatremia (DH) is the leading cause of 30-d unplanned hospital readmissions. OBJECTIVE To determine the impact of a DH care pathway on 30-d readmissions after transsphenoidal surgery. METHODS Data from before and after DH care pathway implementation were retrospectively reviewed. Patient demographics and clinical characteristics were compared. Readmission causes, clinical pathway failures, sodium trends, and symptoms were evaluated. RESULTS Before the DH care pathway implementation, 229 (55%) patients were treated (group 1); afterward, 188 (45%) were treated (group 2). Baseline characteristics were equivalent between groups, except for glucocorticoid supplementation, which was higher in group 2. The incidence of detected DH was significantly lower in group 1 (16/229, 7%) than group 2 (29/188, 15%) (P = .006) likely due to the impact of routine screening in group 2. Ten group 1 patients (4%) were readmitted for hyponatremia and 6 (3%) were managed as outpatients. Eleven group 2 patients (6%) were readmitted and 17 (9%) were managed as outpatients. Readmission rates between groups were similar (P = .49). Patients readmitted with severe hyponatremia experienced symptoms ≥24 h before presentation. The protocol failed to prevent readmission because outpatient management for mild or moderate DH (n = 4) failed, sodium levels precipitously declined after normal screening (n = 3), and severe hyponatremia developed after scheduled screenings were missed (n = 3). CONCLUSION Although more DH patients were identified after care pathway implementation, readmission rates were not reduced and clinical outcomes were not changed. Because DH onset timing varies, some patients have highly acute presentation, and most readmitted patients develop symptoms before reaching their sodium nadir, close symptom monitoring may be a reasonable alternative to routine screening.

In-vivo evaluation of the effect of cyanoacrylate on prosthetic vascular graft infection – does cyanoacrylate increase the severity of infection?

VASA ◽  
2020 ◽  
Vol 49 (4) ◽  
pp. 281-284
Author(s):  
Atıf Yolgosteren ◽  
Gencehan Kumtepe ◽  
Melda Payaslioglu ◽  
Cuneyt Ozakin
Keyword(s):  
Vascular Graft ◽  
Graft Infection ◽  
Vascular Graft Infection ◽  
Group 4 ◽  
Significant Difference ◽  
Group 3 ◽  
Group 2 ◽  
Prosthetic Vascular Graft Infection ◽  
Group 1

Summary. Background: Prosthetic vascular graft infection (PVGI) is a complication with high mortality. Cyanoacrylate (CA) is an adhesive which has been used in a number of surgical procedures. In this in-vivo study, we aimed to evaluate the relationship between PVGI and CA. Materials and methods: Thirty-two rats were equally divided into four groups. Pouch was formed on back of rats until deep fascia. In group 1, vascular graft with polyethyleneterephthalate (PET) was placed into pouch. In group 2, MRSA strain with a density of 1 ml 0.5 MacFarland was injected into pouch. In group 3, 1 cm 2 vascular graft with PET piece was placed into pouch and MRSA strain with a density of 1 ml 0.5 MacFarland was injected. In group 4, 1 cm 2 vascular graft with PET piece impregnated with N-butyl cyanoacrylate-based adhesive was placed and MRSA strain with a density of 1 ml 0.5 MacFarland was injected. All rats were scarified in 96th hour, culture samples were taken where intervention was performed and were evaluated microbiologically. Bacteria reproducing in each group were numerically evaluated based on colony-forming unit (CFU/ml) and compared by taking their average. Results: MRSA reproduction of 0 CFU/ml in group 1, of 1410 CFU/ml in group 2, of 180 200 CFU/ml in group 3 and of 625 300 CFU/ml in group 4 was present. A statistically significant difference was present between group 1 and group 4 (p < 0.01), between group 2 and group 4 (p < 0.01), between group 3 and group 4 (p < 0.05). In terms of reproduction, no statistically significant difference was found in group 1, group 2, group 3 in themselves. Conclusions: We observed that the rate of infection increased in the cyanoacyrylate group where cyanoacrylate was used. We think that surgeon should be more careful in using CA in vascular surgery.

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