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.

Parent and emergency physician comfort with a system of on-line emergency-focused medical summaries for infants with significant cardiac disease.

Surveys were developed and administered to assess parental comfort with emergency care for children with special health care needs (CSHCN) with cardiac disease and the impact of a web-based database of emergency-focused clinical summaries (emergency information forms-EIF) called Midwest Emergency Medical Services for Children Information System (MEMSCIS) on parental attitudes regarding emergency care of their CSHCN. We hypothesized that MEMSCIS would improve the parent and provider outlook regarding emergencies of young children with heart disease in a randomized controlled trial. Children under age 2 were enrolled in MEMSCIS by study nurses associated with pediatric cardiac centers in a metropolitan area. Parents were surveyed at enrollment and 1 year on a 5-Point Likert Scale. Validity and reliability of the survey were evaluated. Study nurses formulated the emergency-focused summaries with cardiologists. One-hundred-seventy parent subjects, 94 study and 76 control, were surveyed at baseline and 1 year. Parents felt that hospital personnel were well-prepared for emergencies of their children and this improved from baseline 4.07 ± 1.03 to 1 year 4.24 ± 1.04 in study parents who had an EIF for their child and participated in the program (p = 0.0114) but not control parents. Parents perceived an improved comfort level by pre-hospital (p = 0.0256) and hospital (p = 0.0031) emergency personnel related to the MEMSCIS program. The MEMSCIS Program with its emergency-focused web-based clinical summary improved comfort levels for study parents. We speculate that the program facilitated normalization for parents even if the EIF was not used in an emergency during the study. The MEMSCIS program helps to prepare the family and the emergency system for care of CSHCN outside of the medical home.

Contemporary diagnosis and management of hypercholesterolemia in elderly acute myocardial infarction patients: a population-based study.

There are limited data regarding the diagnosis and treatment of hypercholesterolemia in elderly patients with acute myocardial infarction (AMI). The authors describe the in-hospital and discharge prescription patterns of lipid-lowering agents in patients hospitalized with an AMI, and identify factors associated with low rates of utilization of these therapies. The authors analyzed the Minnesota Heart Survey, a population-based surveillance project that retrospectively abstracted the medical records of patients hospitalized with AMI in 2001-2002 from 21 hospitals in the Minneapolis-St Paul metropolitan area. They identified 2773 patients 30 years and older with an AMI. The mean total cholesterol was 175+/-45 mg/dL, the mean low-density lipoprotein cholesterol was 104+/-38 mg/dL, and the mean high-density lipoprotein cholesterol was 44+/-14 mg/dL. Statins were prescribed at discharge to 74.6%, 63.2%, and 38.5% of patients younger than 65, 65-74, and 75 years and older, respectively (P<.0001). The utilization of statins was highly correlated with the administration of other standard AMI therapies-aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and reperfusion therapy-and was more prevalent among patients undergoing percutaneous coronary intervention than among those undergoing coronary artery bypass surgery. Elderly patients remain less likely to receive lipid-lowering therapy following an AMI. Greater attention is required to ensure that elderly AMI patients without contraindications are appropriately treated with lipid-lowering therapy.

Use of nonprescription medications for perceived cardiovascular health.

BACKGROUND: Nonprescription products (over-the-counter drugs; vitamins/minerals; and nonvitamin, nonmineral supplements) are promoted or advertised for cardiovascular health. The extent of nonprescription products used specifically for perceived cardiovascular health (NONRX-CVH) is unknown. This study aimed to (1) determine prevalence and types of nonprescription medications used for NONRX-CVH, (2) compare the demographics of NONRX-CVH users to persons using nonprescription medications in general, and (3) determine the prevalence of use of NONRX-CVH among those taking a prescription medication for a cardiovascular reason. METHODS: A cross-sectional survey comprised the probability sample of 3128 adults in the Minneapolis-St. Paul area in the 2000-2002 Minnesota Heart Survey. Trained interviewers collected medication information from participants using a structured medication inventory approach. RESULTS: Analysis in 2005 shows that 10% of participants (n=315) self-reported taking one or more nonprescription medications in the past 2 weeks for a perceived cardiovascular health purpose. Among these individuals, prevalence of use of vitamin/mineral supplements, nonvitamin/nonmineral supplements, and over-the-counter products for a cardiovascular purpose was 37.5%, 21.3%, and 54.6%, respectively. Popular NONRX-CVHs were aspirin (52.1%), vitamin E (24.4%), garlic (9.8%), and omega-3/fish oils/fatty acids (3.8%). NONRX-CVH users were older than general nonprescription users (p<0.001). Of 613 people using a prescription drug for cardiovascular reasons, 135 (22%) reported using one or more NONRX-CVH medications. CONCLUSIONS: Use of NONRX-CVHs, especially aspirin, vitamin E, and herbals, is common, and older patients may use aspirin or dietary supplements for this purpose. Physicians having patients with cardiovascular disease should ask about nonprescription medication usage, as some NONRX-CVHs may be inappropriate.

Surgical treatment of obstructive sleep apnea.

THE PRIMARY TREATMENT for obstructive sleep apnea (OSA) has been continuous positive airway pressure (CPAP) therapy, but the minimum acceptable number of hours of nightly CPAP use remains unclear. INTEGRATED SOFT TISSUE and bone surgery may be a viable alternative for patients who have rejected CPAP as a treatment option. Formal sleep testing has shown that surgery and CPAP therapy are equally successful at resolving OSA. REPEAT SLEEP TESTING conducted several years after patients have undergone combined soft tissue and bone surgery has demonstrated consistent and reliable surgical results. Patients with OSA should be offered surgery as an alternative to life-long CPAP treatment or as an option when CPAP therapy has not been successful.

Comparison of treatment and outcomes for patients with acute myocardial infarction in Minneapolis/St. Paul, Minnesota, and Göteborg, Sweden.

BACKGROUND: Treatment of acute myocardial infarction (AMI) is changing, and differences in medical practice are observed within and between countries on the basis of local practice patterns and available technology. These differing approaches provide an opportunity to evaluate medical practice and outcomes at the population level. The primary aim of this study was to compare medical care in patients hospitalized with AMI in 2 large cities in Sweden and the United States. A secondary aim was to compare medical outcomes. METHODS: All resident patients (age range, 30-74 years) hospitalized with AMI in Göteborg, Sweden (1995-1996), and a representative population-based sample of all patients with AMI in Minneapolis/St. Paul, Minn (1995). RESULTS: Patients with AMI in Göteborg (GB) were older than patients in Minneapolis/St. Paul (MSP), but fewer patients in GB had a prior history of cardiovascular disease. During the AMI admission, coronary angiography, percutaneous coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) were performed twice as frequently in MSP than in GB. Echocardiogram and exercise testing were more frequently performed in GB. During hospitalization, beta-blockers were more frequently prescribed in GB, whereas calcium channel blockers, long- and short-acting nitrates, intravenous nitroglycerine, digitalis, aspirin, oral anticoagulants, heparin, and lidocaine were significantly more common in MSP. Thrombolysis, acute PTCA, ACE inhibitors, and diuretics were similar. Reinfarction was higher in men in GB (4% vs 1%, P <.009) and women in GB (3% vs 1%, P = not significant). On discharge, beta-blockers and diuretics were prescribed significantly more often in GB, whereas calcium channel blockers, nitrates, and digitalis were prescribed more often in MSP. Aspirin and ACE inhibitors had similar usage rates. Despite these diagnostic and treatment contrasts, there were no differences in mortality rate at 30 days or after 3 years of follow-up after risk-adjusting for patient baseline differences. CONCLUSION: Comparing patients hospitalized with AMI in MSP and GB, we found marked differences in medical care, with invasive strategies more likely to be used in MSP. This may be the result of historical practice patterns, the healthcare system, and healthcare financing differences. Despite these differences, short- or long-term mortality rates were identical.

Trends in the trans-fatty acid composition of the diet in a metropolitan area: the Minnesota Heart Survey.

OBJECTIVE: In this study, we examine trends in dietary intake of trans-fatty acids from 1980-1982 to 1995-1997 using data collected as part of the Minnesota Heart Survey (MHS). DESIGN: The MHS is an ongoing observational epidemiologic study among independent cross-sectional probability samples of adults. Twenty-four-hour dietary recalls were collected on a subset of participants. To obtain trans-fatty acid intake estimates, the dietary recall records were recalculated using the University of Minnesota Nutrition Coordinating Center Food and Nutrient Database. Subjects/setting The survey population included noninstitutionalized adults aged 25 to 74 years residing in the Minneapolis-St. Paul, MN, metropolitan area. Statistical analysis Mean intake estimates were generated for each survey, and a generalized linear mixed model was used to test the null hypothesis of no difference in the age-adjusted sex-specific means between 1980-1982, 1985-1987, 1990-1992, and 1995-1997. RESULTS: Downward trends in dietary intake of trans-fatty acids were found between 1980-1982 and 1995-1997. For example, for men mean intake of total trans-fatty acids declined from 8.3 g per day in 1980-1982 to 6.2 g per day in 1995-1997 (P<.001). Represented as a percentage of energy, similar declines were seen with mean intake of total trans-fatty acids decreasing from 3.0% of total energy in 1980-1982 to 2.2% of total energy in 1995-1997 (P<.001). APPLICATIONS/CONCLUSIONS: It seems that intake of trans-fatty acids is on the decline. Consideration should be given to additional changes in the food supply and consumer food choices that may result in further reduction in consumption of trans-fatty acids.

Correlates of breast-feeding in a rural population.

OBJECTIVES: To examine the associations of education and employment with breast-feeding initiation and duration in rural mothers, in the context of environmental, social, and intrapersonal factors. METHODS: Data from a telephone survey of 414 mothers from rural Minnesota were examined with regression analyses. RESULTS: Education and employment had individual and interactive effects of breast-feeding practices. Women with higher educations and those who were not employed full-time were more likely to initiate and maintain a longer duration of breast-feeding. CONCLUSIONS: Rural women with less than college educations and who work full-time may need the most support for initiating and maintaining breast-feeding.

Self-reported vulvar pain characteristics and their association with clinically confirmed vestibulodynia.

OBJECTIVE: We evaluated a series of questions pertaining to vulvar pain symptoms to determine their association with a localized vulvodynia (vestibulodynia) diagnosis in women from the general population. METHODS: A sample of 12,435 women completed a self-administered screening questionnaire for the presence of specific types and characteristics of vulvar pain lasting 3 months or longer. Sensitivity, specificity, and predictive values were calculated for each cross-classification of vulvar pain type and characteristic, using as the gold standard 121 subjects with a clinically confirmed vestibulodynia diagnosis. RESULTS: Relative to women with clinically confirmed vestibulodynia, 83% reported >10 episodes of pain on contact at the time of tampon insertion, intercourse, or pelvic examination, and 83% also reported pain on contact that limited or prevented sexual intercourse. These strong associations with a vestibulodynia diagnosis were not observed with respect to women who reported vulvar pain symptoms of burning or knifelike pain, or vulvar pain characteristics of continuous versus intermittent pain, or provoked versus spontaneous pain. CONCLUSIONS: Our findings suggest that a small number of symptoms may be suitable for identifying a large proportion of women suffering from vestibulodynia which may be ideal for the development of an effective screening test in the future. However, we also recognize that a large proportion of women experiencing vulvar pain symptoms will not meet the diagnostic criteria for vestibulodynia. Thus, implementing such a screening procedure as part of a routine examination or testing would require a subsequent pelvic examination to confirm a vestibulodynia diagnosis and to rule out other known explanations for vulvar pain.

Treatment of common hip fractures.

OBJECTIVES: To conduct a systematic review and synthesize the evidence for the effects of surgical treatments for subcapital and intertrochanteric/subtrochanteric hip fractures on patient-focused outcomes for elderly patients. DATA SOURCES: MEDLINE, Cochrane databases, Scirus, and ClinicalTrials.gov, and expert consultants. We also manually searched reference lists from relevant systematic reviews. REVIEW METHODS: High quality quasi-experimental design studies were used to examine relationships between patient characteristics, type of fracture, and patient outcomes. Randomized controlled trials were used to examine relationships between type of surgical treatment and patient outcomes. Patient mortality was examined with Forest plots. Narrative analysis was used for pain, quality of life (QoL), and functional outcomes due to inconsistently measured and reported outcomes. RESULTS: Mortality does not appear to differ by device class, or by devices within a class. Nor, on the whole, do pain, functioning, and QoL. Some internal fixation devices may confer earlier return to functioning over others for some patients, but such gains are very short lived. Very limited results suggest that subcapital hip fracture patients with total hip replacements have improved patient outcomes over internal fixation, but it is unclear whether these results would continue to hold if the analyses included the full complement of relevant covariates. Age, gender, prefracture functioning, and cognitive impairment appear to be related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Again, however, the observational literature does not include the full complement of potential covariates and it is uncertain if these results would hold. CONCLUSIONS: Several factors limit our ability to definitively answer the key questions posed in this study using the existing literature. Limited perspectives lead to incomplete sets of independent variables included in analyses. Specific populations are poorly defined and separated for comparative study. Fractures with widely varying biomechanical problems are often lumped together. Outcome variables are inconsistently measured and reported, making it very difficult to aggregate or even compare results. If future high quality trials continue to support the evidence that differences in devices are short term at best, within the first few weeks to few months of recovery, policy implications involve establishing the value of a shorter recovery relative to the cost of the new device. As the literature generally focuses on community dwelling elderly patients, more attention needs to be directed toward understanding implications of surgical treatment choices for the nursing home population.

Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy.

Video-assisted thoracoscopic surgery (VATS) for lobectomy has been touted to provide superior outcomes, compared with thoracotomy, for patients with early-stage non-small-cell lung cancer (NSCLC). However, supporting data are limited to case series and small observational studies. We hypothesized that a systematic review of the literature would enable a more objective evaluation of the evidence in order to determine the potential superiority of the VATS approach, compared with thoracotomy, in terms of short-term morbidity and long-term survival. To identify relevant articles for inclusion in our analysis, we performed a systematic review of the MEDLINE database. We looked for randomized controlled trials, observational studies, and case series that reported outcomes after VATS or thoracotomy lobectomy for NSCLC. For statistical testing, we used a two-sided approach (alpha = 0.05) under the hypothesis that VATS lobectomy is superior to thoracotomy lobectomy. We screened 17,923 studies. After independent review of the abstracts by 2 reviewers, we included 39 studies (only one randomized controlled trial) in our analysis. In aggregate, these 39 studies involved 3256 thoracotomy and 3114 VATS patients. The characteristics of the two groups were not significantly different. Compared with thoracotomy, VATS lobectomy was associated with shorter chest tube duration, shorter length of hospital stay, and improved survival (at 4 years after resection), all statistically significant. Compared with lobectomy performed by thoracotomy, VATS lobectomy for patients with early-stage NSCLC is appears to favor lower morbidity and improved survival rates.

The influence of a history of diabetes on treatment and outcome in acute myocardial infarction, during two time periods and in two different countries.

AIMS: The aim of this study was to investigate the influence of diabetes on treatment and outcome in acute myocardial infarction (AMI), during two time periods, in two countries, and to assess whether this influence has changed over the past decades. METHODS: Patients, aged 30 to 74, with a diagnosis of AMI in two urban areas--Göteborg, Sweden and Minneapolis-St. Paul, Minnesota, USA--hospitalized during 1990-1991 and 1995-1996 were included. The primary endpoint was 7-year all-cause mortality. RESULTS: The study included 3824 patients, 734 (19%) had diabetes. Age-adjusted in-hospital mortality of diabetic patients was nearly twofold higher compared with non-diabetic patients (9.8% vs. 5.0%, p<0.05). Between 1990-1991 and 1995-1996 in-hospital mortality declined for both diabetic (11.9% vs. 7.6%, p=0.07) and non-diabetic (6.3% vs. 3.6%, p=0.002) patients. A history of diabetes was associated with nearly twofold higher long-term mortality rate (48.5% vs. 26%, p<0.05). Seven-year mortality was reduced between 1990-1991 and 1995-1996 in both diabetic (51.6% vs. 45.2%, p=0.13) and non-diabetic patients (29.3% vs. 22.1%, p<0.0001) (The results did not reach statistical significance for diabetic patients, due to smaller sample size.) During their hospital stay, diabetic patients received significantly less aspirin, beta-blockers and thrombolysis. After adjustment, a history of diabetes remained significantly associated with 7-year mortality following AMI, doubling the hazard of death (hazard ratio (HR)=2.11; 95% confidence interval (CI): 1.80-2.46). CONCLUSION: A history of diabetes is associated with nearly twofold higher long-term mortality rate and is independently associated with 7-year mortality following AMI. Short- and long-term mortality decreased from 1990 to 1995 in both non-diabetic and diabetic patients. Underutilization of evidence-based treatments contributes to the remaining increased mortality in diabetic patients with acute coronary disease.

Trends in blood pressure, hypertension control, and stroke mortality: the Minnesota Heart Survey.

OBJECTIVE: The study's objective was to determine population trends in blood pressure, hypertension prevalence, hypertension control, and stroke mortality. METHODS: We performed population-based surveys of 2906 to 5630 adults from 1980 to 1982, 1985 to 1987, 1990 to 1992, 1995 to 1997, and 2000 to 2002, and stroke mortality from 1980 to 2002, in the Minneapolis/St Paul, Minn metropolitan area (2.63 million population according to the 2000 census). Randomly selected resident adults aged 25 to 74 years (n = 21773) were each screened once. The main outcome measures were standardized measures of blood pressure, treatment and control of hypertension, and stroke mortality rates. RESULTS: The mean systolic blood pressure adjusted for age decreased in men (-1.5 mm Hg [95% confidence interval -0.3 to -2.7], P <.01) and women (-1.8 mm Hg [95% confidence interval -0.5 to -3.0], P <.001) from 1980 to 1982 and 2000 to 2002. The mean diastolic blood pressure was unchanged for men (0 mm Hg) and women (-0.4 mm Hg, not significant). The proportion of the population taking antihypertensive medications decreased in the 1990s but returned to 1980s levels from 2000 to 2002. The use of other methods to decrease blood pressure (diet, exercise, and weight loss) peaked in the 1990 to 1992 survey and then decreased. Proportions of hypertensive patients in the aware, treated, and/or controlled categories leveled in the 1980s and 1990s, but improved substantially from 1995 to 1997 and 2000 to 2002 with blood pressure controlled at the less than 140 and/or 90 mm Hg criteria in 44% of the men and 55% of the women. Population mortality trends for stroke paralleled those for hypertension control. CONCLUSIONS: Population data beginning in 1980 to 1982 from the Minnesota Heart Survey indicate a leveling in the detection and control of hypertension in the 1990s followed by improvement from 2000 to 2002.