The benefits of a centralized remote surveillance program for vascular patients.

OBJECTIVE: We aimed to assess the clinical and financial utility of a centralized remote surveillance program for vascular patients compared with traditional outpatient follow-up. METHODS: In 2014, the Royal Adelaide Hospital Department of Vascular Surgery introduced a centralized remote surveillance program where suitable patients were monitored by remote imaging in lieu of traditional outpatient appointments (OPAs). Surveillance imaging was performed at a site local to the patient and was reviewed centrally by a dedicated surveillance nurse. We undertook a 5-year retrospective analysis of the program's prospectively maintained database since its inception. Costs for inpatient admissions and OPAs were retrieved from hospital financial databases. The surveillance database and electronic patient records were analyzed for number and outcome of surveillance scans, interventions, and OPAs. Additional savings in travel distance, fuel costs, and CO2 emissions were also calculated. RESULTS: Over 5 years, 1262 patients underwent a mean of four scans per patient. A total of 3718 OPAs were saved, approximating 930 hours of clinic and consultant time, with associated savings of Australian (A)$1,524,900 (United States [US]$ 1,065,684) over 5 years (A$ 304,980 [US$ 213,137] per year). For every OPA avoided, each patient saved 197 km travel and A$87 (US$ 61) fuel costs, with an associated 115 kg of CO2 emissions saved. Over 5 years, this equated to savings of 248,173 km travel, A$ 110,136 (US$ 76,969) fuel costs, and 146 tons of CO2 emissions. A total of 134 surveillance-detected pathologies (10.6%) required intervention, a further 28 despite surveillance (2.2%), and three following surveillance cessation (0.2%). Subgroup analysis demonstrated that interventions despite surveillance were three times more expensive and incurred four times longer admissions than those due to surveillance. CONCLUSIONS: Remote vascular surveillance, particularly applicable in our current COVID-19 pandemic climate, is associated with quantifiable financial, clinical, patient, and environmental beneficial outcomes and can be safely delivered to populations spanning large geographical areas such as those in Australia.

Factors associated with delay to carotid endarterectomy for acute ischaemic stroke in South Australia: A multicentre retrospective cohort study.

BACKGROUND: The greatest benefits of carotid endarterectomy (CEA) accrue when performed within two weeks of acute ischaemic stroke (AIS) due to symptomatic carotid stenosis. Previous studies have identified multiple factors contributing to CEA delay. AIMS: To determine factors associated with delayed CEA in patients admitted to tertiary stroke centres within a major metropolitan region with AIS METHODS: In a retrospective cohort study, consecutive patients admitted to the tertiary hospitals with stroke units within South Australia (Lyell McEwin Hospital, Royal Adelaide Hospital and Flinders Medical Centre) between 2016 to 2020 were included. Univariable and multivariable logistic regression were used to identify individual factors associated with time from symptom onset to CEA of over two weeks. RESULTS: A total of 174 patients were included. The median time to CEA was 5 days (IQR 3-9.75). Delayed CEA beyond 14 days occurred in 28/174 (16%). Factors most associated with delayed CEA included presentation to a tertiary hospital without onsite Vascular Surgical Unit (OR 3.71, 95%CI 1.31-10.58), history of previous stroke (OR 3.38, 95% CI 1.11-9.84) and presenting NIHSS above 6 (OR 5.16, 95% CI 1.60-16.39). CONCLUSION: This study identified that presentation to a tertiary hospital without a Vascular Surgery Unit, history of previous stroke and presenting NIHSS above 6 were associated with delay to CEA in AIS patients in South Australia. Interventional studies aiming to improve the proportion of patients that receive CEA within 14 days are required.

Chemical Composition, Market Survey, and Safety Assessment of Blue Lotus (Nymphaea caerulea Savigny) Extracts.

Blue lotus, also known as Nymphaea caerulea (Nymphaeaceae), is a water lily found globally in lakes and rivers. With its long history of use in Egyptian culture, blue lotus has been associated with spiritual rituals and health benefits. Nowadays, blue lotus is still consumed as a tea or tincture to induce relaxation and heightened spiritual awareness. In this study, six authentic N. caerulea extracts from trusted sources and eleven commercial products were analyzed using gas chromatography-mass spectrometry (GC-MS). Authentic blue lotus extracts were produced in industrial settings. Overall, the extracts were a mixture of aliphatic hydrocarbons, aromatic alcohols, fatty acids, phenyl derivatives, diterpenoids, phytosterols, and stigmastanes. Apomorphine and nuciferine, which are responsible for psychoactive effects of the blue lotus flower, were virtually absent from the authentic blue lotus extract. Although blue lotus has a long history of use, the safety data on the plant and its extracts is limited; however, together with the analytical data, the available information does not indicate major safety concerns for the topical application of authentic blue lotus flower concrete or absolute when diluted as a fragrance ingredient.

Evaluation of Glove Performance after Decontamination.

Studies of healthcare providers doffing personal protective equipment, especially gloves, indicate that self-contamination does occur. Although generally this is not hazardous, working with particularly pathogenic organisms, such as Ebola virus and Clostridium difficile, can present a serious health risk. Decontaminating medical gloves before removal can reduce self-contamination and mitigate the spread of these types of pathogens. Also, in cases of extreme shortage, the Centers for Disease Control and Prevention (CDC) has specific recommendations for decontaminating gloves for extended use. Reuse of medical gloves is strongly discouraged by both the CDC and Food and Drug Administration. This work seeks to lay a foundation of testing to evaluate whether a decontamination method is compatible for a given glove type and material. Four potential methods of decontamination (commercial hand soap, alcohol-based hand sanitizer, commercial bleach, and quaternary ammonium solution) were tested on a variety of surgical and patient examination gloves. The method of barrier performance evaluation was ASTM D5151-19, Standard Test Method for Detection of Holes in Medical Gloves. Our results indicated that the performance of the gloves after treatment was highly dependent on the composition of the medical gloves. In general, the surgical gloves in this study performed better than the patient examination gloves, regardless of the material from which they were made. Specifically, vinyl examination gloves tended to have poorer performance. In this study, the number of gloves available to test were limited and therefore statistical significance is beyond the scope of this project.

Effect of Telmisartan on the Peak Wall Stress and Peak Wall Rupture Index of Small Abdominal Aortic Aneurysms: An Exploratory Analysis of the TEDY Trial.

OBJECTIVE: This study was an unplanned exploratory analysis of a subset of participants from the Telmisartan in the Management of Abdominal Aortic Aneurysm (TEDY) trial. It aimed to assess the efficacy of the angiotensin 1 receptor blocker telmisartan in reducing abdominal aortic aneurysm (AAA) peak wall stress (PWS) and peak wall rupture index (PWRI) among individuals with small AAAs. METHODS: Participants with AAAs measuring 35 - 49 mm in maximum diameter were randomised to receive telmisartan 40 mg or identical placebo in the TEDY trial. Participants who had computed tomography angiography performed at entry and at least one other time point during the trial (12 or 24 months) were included in the current study. Orthogonal AAA diameter, PWS, and PWRI were measured using previously validated methods. The annual change in PWS and PWRI from baseline was compared between participants allocated telmisartan or placebo using linear mixed effects models. These models were either unadjusted or adjusted for risk factors that were different in the groups at entry (p < .100) or systolic blood pressure (SBP) at one year. RESULTS: Of the 207 participants recruited to TEDY, 124 were eligible for inclusion in this study. This study included 65 and 59 participants from the telmisartan and placebo groups, respectively. The PWS and PWRI were not significantly different in the two groups at baseline. Participants allocated telmisartan had a slower annual increase in PWS (-4.19; 95% CI -8.24, -0.14 kPa/year; p = .043) and PWRI (-0.014; 95% CI -0.026, -0.001; p = .032) compared with those allocated placebo after adjusting for risk factors. After adjustment for SBP at one year, telmisartan did not significantly reduce annual increases in PWS or PWRI. CONCLUSION: The findings of this study suggest that telmisartan limits the rate of increase in PWS and PWRI of small AAAs by reducing blood pressure.

Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis.

AIMS: Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes. METHODS AND RESULTS: This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations. CONCLUSION: Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.

Use of Transmission Electron Microscopy for Analysis of Aerosol Particles and Strategies for Imaging Fragile Particles.

For over 25 years, transmission electron microscopy (TEM) has provided a method for the study of aerosol particles with sizes from below the optical diffraction limit to several microns, resolving the particles as well as smaller features. The wide use of this technique to study aerosol particles has contributed important insights about environmental aerosol particle samples and model atmospheric systems. TEM produces an image that is a 2D projection of aerosol particles that have been impacted onto grids and, through associated techniques and spectroscopies, can contribute additional information such as the determination of elemental composition, crystal structure, and 3D particle structures. Soot, mineral dust, and organic/inorganic particles have all been analyzed using TEM and spectroscopic techniques. TEM, however, has limitations that are important to understand when interpreting data including the ability of the electron beam to damage and thereby change the structure and shape of particles, especially in the case of particles composed of organic compounds and salts. In this paper, we concentrate on the breadth of studies that have used TEM as the primary analysis technique. Another focus is on common issues with TEM and cryogenic-TEM. Insights for new users on best practices for fragile particles, that is, particles that are easily susceptible to damage from the electron beam, with this technique are discussed. Tips for readers on interpreting and evaluating the quality and accuracy of TEM data in the literature are also provided and explained.

Assessment of a smartphone-based application for diabetic foot ulcer measurement.

The accurate measurement of diabetic foot ulcer (DFU) wound size is essential as the rate of wound healing is a significant prognostic indicator of the likelihood of complete wound healing. Mobile phone photography is often used for surveillance and to aid in telemedicine consultations. However, there remains no accurate and objective measurement of wound size integrated into these photos. The NDKare mobile phone application has been developed to address this need and our study evaluates its accuracy and practicality for DFU wound size assessment. The NDKare mobile phone application was evaluated for its accuracy in two- (2D) and three-dimensional (3D) wound measurement. One hundred and fifteen diabetic foot wounds were assessed for wound surface area, depth and volume accuracy in comparison to Visitrak and the WoundVue camera. Thirty five wounds had two assessors with different mobiles phones utilizing both applications to assess the reproducibility of the measurements. The 2D surface area measurements by NDKare showed excellent concordance with Visitrak and WoundVue measurements (ICC: 0.991 [95% CI: 0.988, 0.993]) and between different users (ICC: 0.98 [95% CI: 0.96, 0.99)]. The 3D NDKare measurements had good agreement for depth and fair agreement for volume with the WoundVue camera. The NDKare phone application can consistently and accurately obtain 2D measurements of diabetic foot wounds with mobile phone photography. This is a quick and readily accessible tool which can be integrated into comprehensive diabetic wound care.

Factors Associated With Key Outcomes in Diabetes Related Foot Disease: A Prospective Observational Study.

OBJECTIVE: Diabetic foot disease is a serious and common complication of diabetes mellitus. The aim of this study was to assess limb and patient factors associated with key clinical outcomes in diabetic patients with foot ulcers. METHODS: This was a prospective observational study of diabetic patients with foot wounds admitted to a major tertiary teaching hospital in South Australia or seen at associated multidisciplinary foot clinics between February 2017 and December 2018. Patient demographic and clinical data were collected, including limb status severity assessed by the WIfI system and grip strength. Participants were followed up for 12 months. The primary outcomes were major amputation, death, amputation free survival, and completion of healing of the index wound within one year. RESULTS: A total of 153 participants were recruited and outcome data were obtained for 152. Forty-two participants underwent revascularisation during the research period. Eighteen participants (11.8%) suffered major amputation of the index limb and 16 (10.5%) died during follow up. Complete wound healing was achieved in 106 (70%) participants. There was a statistically significant association between WIfI stage and major amputation (subdistribution hazard ratio [SHR] 2.75), mortality (hazard ratio [HR] 2.60), amputation free survival (odds ratio [OR] 0.32), and wound healing (SHR 0.69). There was also a statistically significant association between time to healing and grip strength (SHR 0.50), and previous amputations (major or minor) (SHR 0.57). CONCLUSION: This prospective study supports the ability of the WIfI classification system to predict one year key clinical outcomes in a diabetic population with foot ulcers. It also demonstrated that grip strength may be a useful predictor of wound healing.

Ultrafine Particles Emitted through Routine Operation of a Hairdryer.

Particulate matter is a large concern for human health. Fine and ultrafine particulate matter has been shown to negatively impact human health; for example, it causes cardiopulmonary diseases. Current regulation targets the size of the particles, but composition also impacts toxicity. Indoor sources of air pollution pose unique challenges for human health due to the potential for human exposure to high concentrations in confined spaces. In this work, six hairdryers were each operated within a plexiglass chamber, and their emissions were analyzed with transmission electron microscopy and energy-dispersive spectroscopy. All hairdryers were found to emit ultrafine iron, carbon, and copper. In addition, emissions from two hairdryers primarily contained silver nanoparticles in the ultrafine range (<100 nm). The ultrafine particle emission rates for the hairdryers that did not contain silver were measured and found to be lower than ultrafine particle emissions by gas stoves and electric burners. Based on their size, these particles can either remain in the lung or enter the bloodstream after inhalation and potentially cause long-term health effects.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits.

BACKGROUND: Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group. METHODS: This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed. RESULTS: One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%). CONCLUSIONS: The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions. LEVEL OF EVIDENCE: IV.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.

GUIDELINE SUMMARY: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Medical and lifestyle management of peripheral arterial disease.

OBJECTIVE: Peripheral arterial disease (PAD) is a global health issue associated with impaired functional capacity and elevated risk of major adverse cardiovascular events (MACEs). With changing risk factor profiles and an aging population, the burden of disease is expected to increase. This review considers evidence for the noninvasive management of PAD and makes clinical recommendations accordingly. METHODS: A comprehensive literature review was performed to examine the evidence for smoking cessation, exercise therapy, antiplatelet therapy, anticoagulant therapy, antihypertensive therapy, lipid-lowering therapy, and glycemic control in diabetes for patients with PAD. RESULTS: Nicotine replacement, bupropion, and varenicline are safe and more effective than placebo in achieving smoking abstinence. Wherever it is practical and available, supervised exercise therapy is ideal treatment for intermittent claudication. Alternatively, step-monitored exercise can increase walking performance and the participant's compliance with less staff supervision. Clopidogrel is preferable to aspirin alone for all patients. However, small studies support the use of dual antiplatelet therapy after revascularization to improve limb outcomes. More recently, the addition of low-dose rivaroxaban to aspirin alone was proven to be more effective in reducing MACEs without a significant increase in major bleeding. However, the exact role of direct oral anticoagulant therapy in the management of PAD is still being understood. Evidence is emerging for more intensive blood pressure and lipid-lowering therapy than traditional targets. Whereas research in PAD is limited, there is clinical scope for an individualized approach to these risk factors. The management of diabetes remains challenging as glycemic control has not been demonstrated to improve macrovascular outcomes. Any potential impact of glycemic control on microvascular disease needs to be weighed against the risks of hypoglycemia. Sodium-glucose cotransporter 2 inhibitors appear to reduce MACEs, although caution is advised, given the increased incidence of lower limb amputation in clinical trials of canagliflozin. CONCLUSIONS: Medical and lifestyle management of PAD should aim to improve functional outcomes and to reduce MACEs. Smoking cessation counseling or pharmacotherapy is recommended, although new strategies are needed. Whereas supervised exercise therapy is ideal, there can be barriers to clinical implementation. Other initiatives are being used as an alternative to walking-based supervised exercise therapy. More studies are required to investigate the role of intensive glycemic, blood pressure, and dyslipidemia control in patients with PAD. Overall, a multifactorial approach is recommended to alter the natural history of this condition.

Thermal Stability of Particle-Phase Monoethanolamine Salts.

The use of monoethanolamine (MEA, 2-hydroxyethanamine) for scrubbing of carbon dioxide from combustion flue gases may become the dominant technology for carbon capture in the near future. The widespread implementation of this technology will result in elevated emissions of MEA to the environment that may increase the loading and modify the properties of atmospheric aerosols. We have utilized experimental measurements together with aerosol microphysics calculations to derive thermodynamic properties of several MEA salts, potentially the dominant forms of MEA in atmospheric particles. The stability of the salts was found to depend strongly on the chemical nature of the acid counterpart. The saturation vapor pressures and vaporization enthalpies obtained in this study can be used to evaluate the role of MEA in the aerosol and haze formation, helping to assess impacts of the MEA-based carbon capture technology on air quality and climate change.

atz-1 Influences meiosis to maintain germline chromosomal stability in Caenorhabditis elegans.

Exchange of genetic information during meiosis occurs in all sexually reproducing species to produce haploid gametes from diploid cells. This process involves tight coordination of a meiotic specific cohesin complex, the synaptonemal complex, and DNA damage repair mechanisms. In this study, we describe a putative myosin heavy chain protein orthologous to human myosin 1, F28D1.2, which we named Abnormal Transition Zone (atz-1). Deletion of atz-1 results in embryonic lethality and a depleted transition zone, accompanied by reduced expression of the meiotic cohesin protein, REC-8. atz-1 mutants display disorganized and aggregated chromosomal bodies in diakinetic oocytes. In addition to this, atz-1 mutants are hypersensitive to mild inhibition of DNA damage repair, suggesting that DNA replication in atz-1 mutants is impaired. Moreover, the atz-1 mutant phenotype is germline specific and resupplying somatically expressed atz-1 does not rescue the reproductive defects associated with atz-1 mutants. Overall, our data suggest that atz-1 contributes to meiosis and maintains germline chromosomal stability.

Heterogeneous Freezing of Carbon Nanotubes: A Model System for Pore Condensation and Freezing in the Atmosphere.

Heterogeneous ice nucleation is an important mechanism for cloud formation in the upper troposphere. Recently, pores on atmospheric particles have been proposed to play a significant role in ice nucleation. To understand how ice nucleation occurs in idealized pores, we characterized the immersion freezing activity of various sizes of carbon nanotubes. Carbon nanotubes are used both as a model for pores and proxy for soot particles. We determined that carbon nanotubes with inner diameters between 2 and 3 nm exhibit the highest ice nucleation activity. Implications for the freezing behavior of porous materials and nucleation on soot particles will be discussed.