Outcomes of a Multidisciplinary Vascular Practice: 12-Month Amputation-Free Survival and Beyond in Patients With Chronic Limb-Threatening Ischemia.

OBJECTIVE: There is great variability in the treatment of chronic limb-threatening ischemia, including the practice paradigm, vascular provider specialty, devices utilized, and experience with advanced open and/or endovascular treatments, among other factors. Our unique practice consists of patient-centered, clinically oriented Interventional Radiologists and Vascular Surgeons, with treatments being performed in Office Interventional Suites (OIS), Ambulatory surgery center (ASC), and hospital inpatient/outpatient settings. We evaluate our results, centered on major amputation rates while comparing case complexity and rates with previously published data. METHODS: A retrospective review was performed of all Rutherford 4, 5, and 6 patients who underwent treatment in our practice from 2015 to 2021. Baseline patient characteristics, complexity of lesions, and major amputation rates were collected. Patients with more complex diseases or requiring re-interventions were openly discussed in multidisciplinary fashion to determine the group's approach to revascularization. Limb salvage, clinically driven target lesion revascularization (TLR), repeat interventions, length of follow-up, and mortality were assessed. RESULTS: Treatment was performed in 829 limbs in 351 females and 478 males, with chronic limb-threatening ischemia. Of the 829 cases, 541 cases had at least 1 chronic total occlusion (CTO), including 115 limbs with 2 CTOs and 24 limbs with 3 CTOs with 63.5% of cases requiring multilevel intervention. One year mortality rate was 6.2% with a major lower extremity amputation rate of 2.3% with a mean length of follow-up of 22.3 months. One-year freedom from clinically driven TLR rate was 78.7% with repeat intervention in 163 cases within 12 months. Over the course of the study, within the femoropopliteal stent subset, there was a significant increase in time to reintervention when newer stent technologies were utilized such as woven nitinol and drug-eluting technology (p=0.03). The overall 1-year amputation-free survival (AFS) was 91.5. CONCLUSIONS: Multidisciplinary approach with surgical and endovascular treatment may provide patients with the best chance of AFS. CLINICAL IMPACT: Real world practice of critical limb-threatening ischemia in a multidisciplinary practice demonstrates favorable outcomes for patients with the best reported one year major amputation free survival in a population this large. A strong clinical practice based on close routine follow up and arterial duplex monitoring is a major contributing factor, as well as utilization of the latest technology in drug eluting stents and drug coated balloons for best patient outcomes. We hope this study provides other practices with a guideline for establishing or modifying their practice to attain the best procedural and clinical outcomes.

Mental health service users experiences of medication discontinuation: a systematic review of qualitative studies.

BACKGROUND: The use of psychotropic medication is often the first line of treatment for people with mental distress. However, many service users discontinue their prescribed medication, and little is known about their experiences or the reasons why they choose to stop taking medication. AIM: The aim of this review is to synthesize research literature focused on the experiences of people who decided to discontinue taking medication for their mental health problem. METHODS: A systematic review of qualitative studies was conducted. Data bases were searched for qualitative research which explored participants' motivations for discontinuing medication and their experiences of the process. RESULTS: Six themes were identified: (1) Taking medications: a loss of autonomy, (2) Discontinuing medication: a thought-out process, (3) Factors influencing the decision to discontinue medication, (4) Discontinuing medication: experiences of the process, (5) Outcomes of discontinuing medication, (6) Managing mental distress in the absence of medication. CONCLUSION: Service providers need to be aware that for some service user's psychotropic medication is not deemed a suitable treatment approach. Those who wish to discontinue medication need to be supported in the context of positive, therapeutic risk where their mental and physical health can be monitored and the likelihood of success increased.

Deciding to discontinue prescribed psychotropic medication: A qualitative study of service users' experiences.

Many mental health service users decide to discontinue their psychotropic medication at some stage in the treatment process; however, few studies have captured these experiences. This study aimed to explore people's experiences of coming off medication. A qualitative descriptive design and individual interviews with 23 people who experienced coming off medication were employed. COREQ checklist was used. Data were analysed using inductive and deductive approaches and six major themes were developed. Findings suggest that while medication was useful for many in the short-term, the adverse effects had significant impact and contributed to the decision to come off medication. Participants also reported being driven by a questioning of the biomedical model of treatment and the belief that there were other strategies to manage their distress. Mixed experiences of support from healthcare professionals for the medication cessation process were reported. The discontinuation process was often difficult resulting in changes in mood and behaviour which for many culminated in relapse of distress, rehospitalization and return to medication. To support the process of coming off and staying off medication, participants identified a range of useful strategies but particularly highlighted the importance of peer support. Findings from this study demonstrate the importance of mental health nurses having a collaborative discussion with service users which may support safer decision-making and lessen the risk of people discontinuing medication abruptly. Finding also indicates a need for robust studies that develop and test interventions to support people who wish to discontinue psychotropic medications.

Predictors of recovery following allogeneic CD34+-selected cell infusion without conditioning to correct poor graft function.

Poor graft function is a serious complication following allogeneic hematopoietic stem cell transplantation. Infusion of CD34+-selected stem cells without pre-conditioning has been used to correct poor graft function, but predictors of recovery are unclear. We report the outcome of 62 consecutive patients who had primary or secondary poor graft function who underwent a CD34+-selected stem cell infusion from the same donor without further conditioning. Forty-seven of 62 patients showed hematological improvement and became permanently transfusion and growth factor-independent. In multivariate analysis, parameters significantly associated with recovery were shared CMV seronegative status for recipient/donor, the absence of active infection and matched recipient/donor sex. Recovery was similar in patients with mixed and full donor chimerism. Five -year overall survival was 74.4% (95% CI 59-89) in patients demonstrating complete recovery, 16.7% (95% CI 3-46) in patients with partial recovery and 22.2% (CI 95% 5-47) in patients with no response. In patients with count recovery, those with poor graft function in 1-2 lineages had superior 5-year overall survival (93.8%, 95% CI 82-99) than those with tri-lineage failure (53%, 95% CI 34-88). New strategies including cytokine or agonist support, or second transplant need to be investigated in patients who do not recover.

How to deal with calcium in the superficial femoral artery.

Despite the continuous evolution of endovascular therapy, severe calcification remains a major issue for the minimally invasive treatment of superficial femoral artery (SFA) disease. The presence of calcium might negatively affect both the crossing of peripheral lesions and outcomes of all available treatment modalities and is therefore associated with unfavorable acute and long-term results. This manuscript summarizes the challenges raised from severe calcified atherosclerotic lesions and presents the outcomes of the various endovascular modalities in the treatment of calcified SFA disease.

UK consensus statement on the use of plerixafor to facilitate autologous peripheral blood stem cell collection to support high-dose chemoradiotherapy for patients with malignancy.

Plerixafor is a CXC chemokine receptor (CXCR4) antagonist that mobilizes stem cells in the peripheral blood. It is indicated (in combination with granulocyte-colony stimulating factor [G-CSF]) to enhance the harvest of adequate quantities of cluster differentiation (CD) 34+ cells for autologous transplantation in patients with lymphoma or multiple myeloma whose cells mobilize poorly. Strategies for use include delayed re-mobilization after a failed mobilization attempt with G-CSF, and rescue or pre-emptive mobilization in patients in whom mobilization with G-CSF is likely to fail. Pre-emptive use has the advantage that it avoids the need to re-schedule the transplant procedure, with its attendant inconvenience, quality-of-life issues for the patient and cost of additional admissions to the transplant unit. UK experience from 2 major centers suggests that pre-emptive plerixafor is associated with an incremental drug cost of less than £2000 when averaged over all patients undergoing peripheral blood stem cell (PBSC) transplant. A CD34+ cell count of <15 µl-1 at the time of recovery after chemomobilization or after four days of G-CSF treatment, or an apheresis yield of <1 × 106 CD34+ cells/kg on the first day of apheresis, could be used to predict the need for pre-emptive plerixafor.

But is it science?

Early years science education is not science, but a curricular construction designed to induct young children into a range of ideas and practices related to the natural world. While inquiry-based learning is an important approach to this, it is not of itself unique to science and there are a range of logico-mathematical constructions that come closer to the essence of science. In this paper we discuss just three: empirical question-asking, transgressive play, and good thinking. The challenge, of course is to induct early years practitioners to a different way of shaping early science.

ANCA-negative Granulomatosis with Polyangiitis: A Difficult Diagnosis.

Granulomatosis with polyangitiis (GPA) is a systemic small and medium vessel vasculitis, commonly associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Presenting signs and symptoms in GPA are varied and patients may present with constitutional, non-specific symptoms, which can delay the diagnosis. Tissue biopsy of the site of active disease can confirm the diagnosis of GPA, in which necrotising granulomatous inflammation is seen. However, surrogate markers may be used for diagnosis without a tissue biopsy. They include upper and lower airway symptoms, signs of glomerulonephritis and a positive ANCA. However, approximately 10-20% of patients with GPA are ANCA negative, allowing for the diagnosis to be overlooked, particularly in those patients with non-specific findings. The reason for the absence of ANCAs is unclear. LEARNING POINTS: A case of granulomatosis with polyangitiis presenting with non-specific findings is described.Some 10% of cases are ANCA negative.When a vasculitis is suspected, a negative ANCA does not exclude the diagnosis of GPA, so further investigations (i.e. tissue biopsy) should be considered.

A survey of pedagogical approaches and quality mechanisms used in education programs for mental health professionals.

The provision of high-quality education and training that is responsive, relevant, accessible and evidence based is critical if the vision for quality mental health services presented in recent policy initiatives in Ireland is to be fulfilled. This paper reports the findings related to pedagogical approaches and quality assurance mechanisms utilized within mental health education. The study involved canvassing all Higher Education Institutions in Ireland. A total of 227 courses in 31 educational institutes were identified and 149 questionnaires were returned from 129 Course Coordinators. Various quality processes were identified in existing programs; however, formal feedback from service providers, service users and carers was seldom reported. Ongoing evaluation and quality assurance strategies are a key element of governance and there is a need to develop strategies that explore the impact of education programs on mental health education and health outcomes. Recommendations are made in terms of future interprofessional mental health education and practice.

Personal Construct Theory and constructivist drug education.

In recent years drug education has come under scrutiny. Research has found that drug education is having minimal impact. Questions have been raised as to the appropriateness of theories underpinning drug education programmes as well as the aims and purpose of programmes. As such, there is a call for new approaches. This paper explores the potential of a personal construct approach to drug education. Personal Construct Theory (PCT) has been used to understand drug use and treatment as well as an approach to education and training. Although generally thought of as an individualistic approach, there are also social, interpersonal as well as educational aspects to the theory. In this paper, we argue that drug education needs to remove itself from the political and moral arena and ground itself in a theory that relates to young people and drug use in today's society. In so doing it should aim to facilitate and educate young people in making informed and healthy choices. PCT offers one such approach.

Pragmatic language interpretation after closed head injury: relationship to executive functioning.

INTRODUCTION: Closed head injury is associated with impairment in a range of executive skills, and with everyday difficulties in social interactions. Comprehension of pragmatic language plays an important role in social interactions. The present study was designed to examine performance on a task involving pragmatic judgement in people who had suffered closed head injury (CHI), and the relationship between this and any impairments in executive skills. METHODS: Participants with CHI were compared to a matched healthy control group on a pragmatic inference task consisting of a series of brief vignettes. Participants made judgements about alternative responses in relation to social appropriateness/skill, and carried out several nonsocial executive tasks thought to play a role in pragmatic judgement. RESULTS: The CHI group was poorer than the control group on the pragmatic measure, showing less discrimination than the control group between direct, literal interpretations and correct, indirect interpretations. They also performed more poorly on the nonsocial executive measures. Regression analysis showed an association between pragmatic performance and one of the executive tasks, a measure of inhibition. CONCLUSIONS: More work is needed to explore further the nature of any relationship between pragmatic judgement and executive skills.