Patient Characteristics and Clinical Outcomes of Type 1 Versus Type 2 Myocardial Infarction.

BACKGROUND: Type 2 myocardial infarction (MI) patients may have different characteristics and outcomes when compared with type 1 MI. OBJECTIVES: The purpose of this study was to compare patients with type 1 MI to those with type 2 MI in the United States. METHODS: Using the Nationwide Readmissions Database, MI patients were categorized over the 3 months following the introduction of an International Classification of Diseases-10th Revision code specific for type 2 MI. Baseline characteristics and inpatient and post-discharge outcomes among both cohorts were compared. RESULTS: There were 216,657 patients with type 1 MI, 37,765 patients with type 2 MI, and 1,525 patients with both type 1 and 2 MI. Patients with type 2 MI were older (71 years vs. 69 years; p < 0.001), were more likely to be women (47.3% vs. 40%; p < 0.001), and had higher prevalence of heart failure (27.9% vs. 10.9%; p < 0.001), kidney disease (35.7% vs. 25.7%; p < 0.001), and atrial fibrillation (31% vs. 21%; p < 0.001). Rates of coronary angiography (10.9% vs. 57.3%; p < 0.001), percutaneous coronary intervention (1.7% vs. 38.5%; p < 0.001), and coronary artery bypass grafting (0.4% vs. 7.8%; p < 0.001) were lower among type 2 MI patients. Patients with type 2 MI had lower risk of in-hospital mortality (adjusted odds ratio: 0.57 [95% confidence interval: 0.54 to 0.60]) and 30-day MI readmission (adjusted odds ratio: 0.46 [95% confidence interval: 0.35 to 0.59]). There was no difference in risk of 30-day all-cause or heart failure readmission. CONCLUSIONS: Patients with type 2 MI have a unique cardiovascular phenotype when compared with type 1 MI, and are managed in a heterogenous manner. Validated management strategies for type 2 MI are needed.

Epidemiology of major lower extremity amputations in individuals with diabetes in Austria, 2014-2017: A retrospective analysis of health insurance database.

AIMS: To describe the incidence, mortality, and trend of major lower extremity amputations (LEA) and to assess risk factors of all-cause mortality after major LEA in individuals with diabetes. METHODS: Procedure codes of major LEA were extracted from the Austrian Health Insurance database (N = 507,180) during 2014-2017 to estimate crude and age-standardized rates per 100,000 population. Short- (30-day, 90-day) and long-term (1-year, 5-year) all-cause mortality after major LEA was estimated from the date of amputation till the date of death. RESULTS: The age-standardized rate of major LEA was 6.44 with an insignificant annual change of 3% (p = 0.825) from 2014 to 2017. Cumulative 30-day mortality was 13.5%, 90-day 22.0%, 1-year 34.4%, and 5-year 66.7%. Age, male sex, above-knee amputation, Charlson index, and heart failure were significantly associated with both short- and long-term mortality. Cancer, dementia, heart failure, peripheral vascular disease, and renal disease were associated with long-term mortality. CONCLUSIONS: The rate of major LEA in individuals with diabetes remained stable during 2014-2017 in Austria. Short- and long-term mortality rates were considerably high after major LEA. Old age, male sex, above-knee amputations, and Charlson Index were significant predictors of both short- and long-term mortality and comorbidities were significant predictors of long-term mortality only.

Peripheral vascular disease in women: Are we analyzing the costs correctly?

Women treated with a peripheral vascular intervention, on average, have more comorbidities and cost more per hospital admission than women treated with a percutaneous coronary intervention. The impact of critical limb ischemia on these results is likely significant, but not available in these data. Physicians need to be more aware of the differences in the risks and manifestations of cardiovascular disease in women.

Evolving Indications for Lower Limb Amputations in South Africa Offer Opportunities for Health System Improvement.

BACKGROUND: Rapid urbanization and westernization have precipitated dramatic changes in the profile and prevalence of surgical diseases in sub-Saharan Africa. Disease of lifestyle is now common. We aimed to review our experience with lower-limb amputations at our surgical service in South Africa. METHODS: A single-center retrospective review of a prospectively collected database was performed of all patients who underwent a lower limb amputation. Inferential and descriptive statistics were performed. Patient demographics, indication, type of amputation, and management were reviewed. The primary outcome was 30-day in-patient mortality rate. RESULTS: Over a 5-year period (2013-2018), 348 patients underwent lower limb amputations. The median age was 61.5 years. 53.7% were diabetic and 56.3% were hypertensive. 53.2% had associated peripheral vascular disease and 8% preexisting cardiac disease. 30.7% smoked. Guillotine below-knee amputation was frequently performed (44.5% of amputations). 16.1% of these patients required a further operation. The in-hospital mortality rate was 8%. Underlying renal disease was an independent risk factor for mortality (p = 0.004). CONCLUSION: Currently, the most common indications for LLA in South Africa are diabetes mellitus and atherosclerosis. This reflects the changing pattern of disease in the country. There is a major problem with access to health care in rural areas in South Africa with significant delays in getting patients to tertiary units for evaluation by specialists. Foot care and prevention at a primary health care level is also lacking. Global improvements in the healthcare system are needed to improve LLA rates in South Africa.

Experiencia de trabajo en cirugía vascular en Ecuador / Experiences working in vascular surgeries in Ecuador

Introducción: Las enfermedades vasculares periféricas comprenden un variado número de entidades nosológicas que afectan a los sistema arterial (excluidos los vasos del corazón, e intracraneales) y venolinfáticos del organismo. Objetivo: Describir las características de los pacientes que necesitaron ser atendidos por un cirujano vascular por presentar algún tipo de enfermedad vascular periférica. Métodos: Estudio descriptivo realizado en el total de pacientes atendidos por consulta externa y hospitalizados en el Servicio de Cirugía Vascular del Instituto Ecuatoriano de Seguridad Social; Hospital Manuel Ignacio Montero Valdivieso. El período de estudio fue de dos años (septiembre de 2014 a octubre de 2016). Se tuvieron en cuenta las siguientes enfermedades vasculares periféricas: enfermedades vasculares periféricas, insuficiencia venosa crónica, pie diabético, trombosis venosa profunda y trombosis arterial aguda Los resultados se expresaron en trabajo con las frecuencias absolutas y relativas. Resultados: La insuficiencia venosa crónica fue la causa más frecuente de hospitalización y consulta externa. Se encontró un predominio del sexo femenino. La úlcera del pie diabético se ubicó en orden decreciente de frecuencia entre las enfermedades consideradas. El desbridamiento quirúrgico o limpieza quirúrgica fue el procedimiento más empleado. La amputación mayor se realizó en todos los pacientes que tuvieron una trombosis arterial aguda de extremidades inferiores. Conclusiones: Se describen las características de los pacientes atendidos por el cirujano vascular en Ecuador, así como las enfermedades vasculares periféricas más frecuentes atendidas que son motivo de consulta externa y de hospitalización(AU)

Introduction: Peripheral vascular diseases include a varied number of nosologic entities that affect the arterial (excluding heart and intracranial vessels) and venolymphatic systems of the organism. Objective: To characterize patients who needed to be treated by a vascular surgeon after presenting some type of peripheral vascular disease. Method: A descriptive and prospective study was carried out in all the patients treated by external consultation and to the patients hospitalized in the service of Vascular surgery of the Ecuadorian Institute of Social Security and Manuel Ignacio Montero Valdivieso Hospital. The study lasted two years ( from September 2014 to October 2016). The following peripheral vascular diseases were taken into account: peripheral vascular diseases, chronic venous insufficiency, diabetic foot, deep-vein thrombosis and acute arterial thrombosis. The results were expressed in this paper with absolute and relative frequencies. Results: Chronic venous failure was the most frequent cause of hospitalization and outpatient consultation. A prevalence of female sex was found. The diabetic foot ulcer was observed in a decreasing order of frequency. Surgical debridement and/or surgical cleaning were the most used procedures. Major amputations were performed in all patients who had an acute arterial thrombosis of the lower limbs. Conclusions: It was possible to characterize the patients treated by the vascular surgeon in Ecuador, as well as the most frequent peripheral vascular diseases attended that needed outpatient consultation and hospitalization(AU)

Risk assessment of vascular disorders by a supplementary hand-arm vascular weighting of hand-transmitted vibration.

PURPOSE: To provide an updated epidemiological validation for a supplementary method for assessing the risk of vascular disorders from hand-transmitted vibration. METHODS: The occurrence of vibration-induced white finger (VWF) in the vibration-exposed workers of the Italian cohort of the EU VIBRISKS study was related to measures of daily vibration exposure expressed in terms of r.m.s. acceleration magnitude normalised to an 8-h day, frequency weighted according to either the frequency weighting Wh defined in international standard ISO 5349-1:2001 [Ah(8) in ms- 2] or the hand-arm vascular frequency weighting Wp proposed in the ISO technical report (TR) 18570:2017 [Ap(8) in ms- 2]. To estimate a threshold value for vascular hand-arm vibration risk, the Wp-weighted vibration exposure value Ep,d (in ms- 1.5) was calculated according to the ISO/TR document. The difference in the predictions of VWF between the exposure measures calculated with the frequency weightings Wh or Wp was investigated by means of logistic modelling. RESULTS: Measures of daily vibration exposure constructed with the frequency weighting Wp [Ap(8) and Ep,d], which gives more importance to intermediate- and high-frequency vibration, were better predictors of the occurrence of VWF in the vibration-exposed workers than the metric derived from the conventional ISO frequency weighting Wh [Ah(8)]. There was some epidemiological evidence for a threshold value of Ep,d for the onset of VWF in the vibration-exposed workers. CONCLUSIONS: Measures of daily vibration exposure evaluated with the vascular weighting Wp performed better for the predictions of VWF than those obtained with the frequency weighting Wh recommended in ISO 5349-1.

Estimating State-Level Health Burden of Diabetes: Diabetes-Attributable Fractions for Diabetes Complications.

INTRODUCTION: Limited information is available on the health burden of diabetes at the state level. This study estimated state-specific attributable fractions and the number of cases attributable to diabetes for diabetes-related complications. METHODS: For each state, diabetes-attributable fractions for nine diabetes complications were estimated: three self-reported complications from the 2013 Behavioral Risk Factor Surveillance System, hospitalizations with three complications from 2011 to 2014 State Inpatient Databases, and three complications from 2013 Medicare data. Attributable fractions were calculated using RR and diabetes prevalence and the total number of cases using attributable fractions and total number of complications. Adjusted RR of each complication for people with and without diabetes by age and sex was estimated using a generalized linear model. Analyses were conducted in 2015-2016. RESULTS: Median state-level diabetes-attributable fractions for self-reported complications were 0.14 (range, 0.10-0.19) for mobility limitations; 0.13 (range, 0.04-0.21) for limitations in instrumental activities of daily living; and 0.12 (range, 0.06-0.20) for severe visual impairment or blindness. Median state-level diabetes-attributable fractions for diabetes-associated hospitalizations were 0.19 (range, 0.08-0.24) for congestive heart failure; 0.08 (range, 0.02-0.16) for myocardial infarction; and 0.62 (range, 0.46-0.73) for lower extremity amputations. Median state-level diabetes-attributable fractions for complications among Medicare beneficiaries were 0.17 (range, 0.14-0.23) for coronary heart disease; 0.28 (range, 0.24-0.33) for chronic kidney disease; and 0.22 (range, 0.08-0.32) for peripheral vascular disease. CONCLUSIONS: Diabetes carries a significant health burden, and results vary across states. Efforts to prevent or delay diabetes or to improve diabetes management could reduce the health burden because of diabetes.

No Disparity in Outcomes Between Surgical Clipping and Endovascular Coiling After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (SAH) can be treated with either endovascular coiling or surgical clipping. The International Subarachnoid Aneurysm Trial (ISAT) found that endovascular coiling provided lower mortality rates at 1-year follow-up, starting a trend toward the endovascular treatment approach for SAH. Subsequently, specific procedural indications have driven an approach to SAH management involving a patient-specific procedural choice. The present study evaluates whether specific indications for these procedures have eliminated the differences in risk-adjusted mortality and in-hospital complications from SAH in a large nationally representative set of hospitalizations from 2013 to 2014. METHODS: All cases of nontraumatic subarachnoid hemorrhage were queried from the National Inpatient Sample using codes from the International Classification of Diseases, 9th edition. These patients were assigned to cohorts based on whether they were treated by surgical clipping or by endovascular coiling. Subsequent univariate and multivariate analyses were used to characterize and compare demographics, in-hospital complications, and total charges between the 2 groups. RESULTS: In 2013 to 2014, 6555 patients hospitalized for SAH underwent surgical clipping and 15,350 underwent endovascular coiling. The patients undergoing coiling were older (55.3 vs. 54.1, P = 0.02) and had lower severity scores (3.24 vs. 3.44, P < 0.0001); however, they had higher average risk of mortality scores (2.96 vs. 2.44, P < 0.0001) and longer lengths of stay (19.0 vs. 17.8 days, P = 0.009) than did those undergoing surgical clipping. Multivariate logistic regression analysis comparing clipping to coiling showed no differences in rates of complication (odds ratio [OR]: 0.87; 95% confidence interval [CI]: 0.67-1.13), death (OR: 0.78; 95% CI: 0.57-1.05), or total charges (-$3282, 95% CI: -$8376-$14,941) between both cohorts. CONCLUSIONS: Concerns about overzealous use of endovascular coiling in treating SAH after the ISAT stemmed from a lag in condition-specific indications. The allure of endovascular coiling stems from its noninvasiveness and initial results; however, in the years after ISAT, evaluation of SAH conditions led to more patient-specific indications for SAH. The results presented here suggest that more rigorous procedural selection has allowed for an optimization of outcomes for the 2 procedures.

Comparison of Outcomes of Transfemoral Versus Transapical Approach for Transcatheter Aortic Valve Implantation.

Post hoc analyses of clinical trials have shown superior outcomes for a transfemoral (TF) compared with a transapical (TA) approach for transcatheter aortic valve implantation (TAVI). There are few contemporary data on utilization and outcomes of TF versus TA TAVI in real-world patient populations. Using the National Inpatient Sample 2011 to 2014, we identified TF-TAVI and TA-TAVI procedures using ICD-9 procedure codes 35.05 and 35.06, respectively. A propensity-matched cohort of TF and TA TAVI procedures balanced on 23 baseline characteristics was assembled. Outcomes included in-hospital mortality, acute kidney injury (AKI), AKI requiring dialysis (AKI-D) and postoperative stroke. A total of 7,973 TAVI procedures representative of 39,745 procedures nationally were included in the study. Of these, 80.2% were performed using a TF approach while 19.8% used a TA approach. Patients in the TF-TAVI group were older (mean age 81.7 vs 80.4 years, p < 0.001), with a higher prevalence of heart failure (12.7% vs 7.6%, p < 0.001) and lower prevalence of peripheral vascular disease (28.0% vs 35.5%, p < 0.001) compared with the TA-TAVI group. In 1,576 propensity-matched pairs of TF-TAVI and TA-TAVI procedures, TF-TAVI was associated with significantly lower in-hospital mortality (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.42 to 0.88, p = 0.01), lower rates of AKI (0.53, 95% CI 0.44 to 0.63, p < 0.001), similar rates of AKI-D (OR 0.77, 95% CI 0.44 to 1.38, p = 0.38) and postoperative stroke (OR 1.19, 95% CI 0.67 to 2.10, p = 0.56) compared with TA-TAVI. In conclusion, TF-TAVI is associated with lower rates of in-hospital mortality and AKI compared with TA-TAVI. A TF approach should be preferred over a TA approach for TAVI whenever possible.

Mental health visits and low socio-economic status in adolescence are associated with complications of Type 1 diabetes in early adulthood: a population-based cohort study.

AIM: To determine the association of mental health visits and socio-economic status in late adolescence with the risk of mortality and acute and chronic diabetes complications in early adulthood. METHODS: We conducted a population-based cohort study of individuals in Ontario, Canada, who had their 20th birthday between January 1999 and March 2015 and a diagnosis of diabetes prior to their 15th birthday, using linked administrative databases (n=8491). The main outcome was death; other outcomes were hypoglycaemia or hyperglycaemia-related hospitalizations and emergency department visits and chronic diabetes complications (dialysis, ophthalmological and macrovascular complications). RESULTS: Over the course of 59 361 person-years there were 127 deaths.. Low socio-economic status and mental health visits were both associated with a higher risk of death [hazard ratio 2.03, (95% CI 1.13 to 3.64) and 2.45 (95% CI 1.71 to 3.51), respectively]. Those with the lowest socio-economic status and a mental health visit had a higher rate of diabetes-related hospitalizations (rate ratio 4.84, 95% CI 3.64 to 6.44) and emergency department visits (rate ratio 3.15, 95% CI 1.79 to 5.54). Low socio-economic status and mental health visits were both associated with an increased risk of any chronic complication [hazard ratio 1.54 (95% CI 1.21 to 1.96) and 1.57 (95% CI 1.35 to 1.81), respectively]. CONCLUSION: We identified significant socio-economic and mental health disparities in the risk of death and acute and chronic complications in early adulthood for people with childhood-onset diabetes. Targeted interventions to prevent adverse events for these adolescents at highest risk should be evaluated.

Patient-Related Risk Factors for Infection Following Open Carpal Tunnel Release: An Analysis of Over 450,000 Medicare Patients.

PURPOSE: To establish the rate of postoperative infection after open carpal tunnel release (CTR) on a national level using an administrative database and define relevant patient-related risk factors associated with its occurrence. METHODS: The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files retrospectively from 2005 to 2012 for patients undergoing open CTR using Current Procedural Terminology code 64721. Postoperative infection within 90 days of surgery was assessed using both International Classification of Diseases, Ninth Revision codes for diagnoses of postoperative infection or pyogenic arthritis of the wrist and Current Procedural Terminology codes for procedures for these indications, including either open or arthroscopic irrigation and debridement. We used a multivariable binomial logistic regression model that allows for assessment of the independent effect of a variable while controlling for remaining variables to evaluate which patient demographics and medical comorbidities were associated with an increased risk for postoperative infection. Adjusted odds ratios and 95% confidence intervals were calculated for each risk factor, with P < .05 considered statistically significant. RESULTS: A total of 454,987 patients met all inclusion and exclusion criteria. Of these patients, 1,466 developed a postoperative infection, corresponding to an infection rate of 0.32%. Independent positive risk factors for infection included younger age, male sex, obesity (body mass index of 30 to 40), morbid obesity (body mass index greater than 40), tobacco use, alcohol use, and numerous medical comorbidities including diabetes, inflammatory arthritis, peripheral vascular disease, chronic liver disease, chronic kidney disease, chronic lung disease, and depression. CONCLUSIONS: The current study reinforced conventional wisdom regarding the the overall low infection rate after CTR and revealed numerous patient-related risk factors that are independently associated with an increased risk of infection after open CTR in patients enrolled in Medicare. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Socioeconomic Status as a Predictor of Mortality in Patients Admitted With Atrial Fibrillation.

Lower socioeconomic status (SES) is associated with a higher risk of cardiovascular disease. However, the association between SES and mortality in patients with atrial fibrillation (AF) is not clear. We examined whether SES predicts all-cause mortality in patients hospitalized with AF. This is a retrospective study of patients aged >18 years, admitted with a primary diagnosis of AF to Montefiore Medical Center between 2000 and 2010. Multivariable logistic regression models were used to determine predictors of survival adjusted for age, gender, heart failure, diabetes mellitus, chronic kidney disease, previous myocardial infraction, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, and SES. SES was determined using the New York City Department of Health Standardized Score (a log composite score of household income, value of housing units, net rental income, household occupations, and educational level). The cohort was divided into quartiles based on SES score, with Q4 the highest and Q1 the lowest SES score. There were 4,503 patients identified with a mean follow up of 4.5 years in the following SES quartiles: Q1 (n = 1,132), Q2 (n = 1,119), Q3 (n = 1,126), and Q4 (n = 1,126). The unadjusted mortality varied across quartiles (Q1 to Q4), 54%, 58%, 56%, and 59%, respectively (p = 0.004). After controlling for other variables in the multivariable analysis, patients with the lowest SES (Q1) had a significantly higher mortality than patients in the quartile with the highest (Q4) SES (odds ratio 1.3, CI 1.1 to 1.5). In conclusion, patients admitted to the hospital with AF have varying mortality based on their SES. After controlling for co-morbidities, patients with AF and lower SES scores had higher mortality. Further research studies are warranted to study this risk of increased mortality in AF population.

Rates and Outcomes of Parathyroidectomy for Secondary Hyperparathyroidism in the United States.

BACKGROUND AND OBJECTIVES: Secondary hyperparathyroidism is common among patients with ESRD. Although medical therapy for secondary hyperparathyroidism has changed dramatically over the last decade, rates of parathyroidectomy for secondary hyperparathyroidism across the United States population are unknown. We examined temporal trends in rates of parathyroidectomy, in-hospital mortality, length of hospital stay, and costs of hospitalization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Using the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, a representative national database on hospital stay regardless of age and payer in the United States, we identified parathyroidectomies for secondary hyperparathyroidism from 2002 to 2011. Data from the US Renal Data System reports were used to calculate the rate of parathyroidectomy. RESULTS: We identified 32,971 parathyroidectomies for secondary hyperparathyroidism between 2002 and 2011. The overall rate of parathyroidectomy was approximately 5.4/1000 patients (95% confidence interval [95% CI], 5.0/1000 to 6.0/1000). The rate decreased from 2003 (7.9/1000 patients; 95% CI, 6.2/1000 to 9.6/1000), reached a nadir in 2005 (3.3/1000 patients; 95% CI, 2.6/1000 to 4.0/1000), increased again through 2006 (5.4/1000 patients; 95% CI, 4.4/1000 to 6.4/1000), and remained stable since that time. Rates of in-hospital mortality decreased from 1.7% (95% CI, 0.8% to 2.6%) in 2002 to 0.8% (95% CI, 0.1% to 1.6%) in 2011 (P for trend <0.001). In-hospital mortality rates were significantly higher in patients with heart failure (odds ratio [OR], 4.23; 95% CI, 2.59 to 6.91) and peripheral vascular disease (OR, 4.59; 95% CI, 2.75 to 7.65) and lower among patients with prior kidney transplantation (OR, 0.20; 95% CI, 0.06 to 0.65). CONCLUSIONS: Despite the use of multiple medical therapies, rates of parathyroidectomy of secondary hyperparathyroidism have not declined in recent years.

Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries.

BACKGROUND: This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified. METHODS: Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described. RESULTS: From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage. CONCLUSION: Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease.

BACKGROUND & AIMS: Non-invasive lower limb vascular assessment in people at risk of peripheral arterial disease (PAD) including those with diabetes is crucial. There is evidence that standard assessment techniques such as the ankle-brachial index (ABI) may be less effective in people with diabetes. However there is limited evidence for other frequently used tests including continuous wave Doppler (CWD), and the toe-brachial index (TBI). The aim of this study was to determine the sensitivity and specificity of, ABI, CWD and TBI in a population with, and without diabetes. METHODS: Participants with and without diabetes who met current guidelines for vascular screening were recruited, and CWD waveforms, an ABI and a TBI were obtained from the right lower limb. Diagnostic accuracy was determined using colour duplex ultrasound (CFDU). Receiver operating characteristic curves were calculated. RESULTS: 117 participants were recruited, seventy-two with diabetes and forty-five without diabetes. CWD had the highest sensitivity in people with diabetes (74%) and without (84%). CWD also had the highest specificity in people with diabetes (74%) and without (84%) compared to both TBI and ABI. In participants with diabetes, the ABI was a poor test, area under the curve: 0.58 (p=0.27). CONCLUSIONS: CWD waveform is more likely to detect significant PAD compared to ABI and TBI in people with and without diabetes.

Policy evaluation in diabetes prevention and treatment using a population-based macro simulation model: the MICADO model.

AIMS: To test a simulation model, the MICADO model, for estimating the long-term effects of interventions in people with and without diabetes. METHODS: The MICADO model includes micro- and macrovascular diseases in relation to their risk factors. The strengths of this model are its population scope and the possibility to assess parameter uncertainty using probabilistic sensitivity analyses. Outcomes include incidence and prevalence of complications, quality of life, costs and cost-effectiveness. We externally validated MICADO's estimates of micro- and macrovascular complications in a Dutch cohort with diabetes (n = 498,400) by comparing these estimates with national and international empirical data. RESULTS: For the annual number of people undergoing amputations, MICADO's estimate was 592 (95% interquantile range 291-842), which compared well with the registered number of people with diabetes-related amputations in the Netherlands (728). The incidence of end-stage renal disease estimated using the MICADO model was 247 people (95% interquartile range 120-363), which was also similar to the registered incidence in the Netherlands (277 people). MICADO performed well in the validation of macrovascular outcomes of population-based cohorts, while it had more difficulty in reflecting a highly selected trial population. CONCLUSIONS: Validation by comparison with independent empirical data showed that the MICADO model simulates the natural course of diabetes and its micro- and macrovascular complications well. As a population-based model, MICADO can be applied for projections as well as scenario analyses to evaluate the long-term (cost-)effectiveness of population-level interventions targeting diabetes and its complications in the Netherlands or similar countries.

Comorbidity ascertainment from the ESRD Medical Evidence Report and Medicare claims around dialysis initiation: a comparison using US Renal Data System data.

BACKGROUND: The end-stage renal disease Medical Evidence Report serves as a source of comorbid condition data for risk adjustment of quality metrics. We sought to compare comorbid condition data in the Medical Evidence Report around dialysis therapy initiation with diagnosis codes in Medicare claims. STUDY DESIGN: Observational cohort study using US Renal Data System data. SETTING & PARTICIPANTS: Medicare-enrolled elderly (≥66 years) patients who initiated maintenance dialysis therapy July 1 to December 31, 2007, 2008, or 2009. INDEX TESTS: 12 comorbid conditions ascertained from claims during the 6 months before dialysis therapy initiation, the Medical Evidence Report, and claims during the 3 months after dialysis therapy initiation. REFERENCE TEST: None. RESULTS: Comorbid condition prevalence according to claims before dialysis therapy initiation generally exceeded prevalence according to the Medical Evidence Report. The κ statistics for comorbid condition designations other than diabetes ranged from 0.06 to 0.43. Discordance of designations was associated with age, race, sex, and end-stage renal disease Network. During 23,930 patient-years of follow-up from 4 to 12 months after dialysis therapy initiation (8,930 deaths), designations from claims during the 3 months after initiation better discriminated risk of death than designations from the Medical Evidence Report (C statistics of 0.674 vs 0.616). Between the Medical Evidence Report and claims, standardized mortality ratios changed by >10% for more than half the dialysis facilities. LIMITATIONS: Neither the Medical Evidence Report nor diagnosis codes in claims constitute a gold standard of comorbid condition data; results may not apply to nonelderly patients or patients without Medicare coverage. CONCLUSIONS: Discordance of comorbid condition designations from the Medical Evidence Report and claims around dialysis therapy initiation was substantial and significantly associated with patient characteristics, including location. These patterns may engender bias in risk-adjusted quality metrics. In lieu of the Medical Evidence Report, claims during the 3 months after dialysis therapy initiation may constitute a useful source of comorbid condition data.

The imperative to prevent diabetes complications: a broadening spectrum and an increasing burden despite improved outcomes.

Diabetes mellitus and its complications are common; the complications are, of themselves, a major reason to manage diabetes. Recent data from Australia and similar developed health care systems overseas indicate that morbidity and mortality outcomes relating to diabetes complications are improving. However, these benefits are offset by increasing numbers of people diagnosed with diabetes, resulting in an increased disease burden with significant health care implications. Thus the imperative to prevent diabetes and diabetes complications has never been greater. Furthermore, the recognised spectrum of diabetes complications is broadening, especially complications relating to lipid levels, insulin resistance and the metabolic syndrome. Clinicians now need to be aware of both traditional complications (eg, nephropathy and cardiovascular disease) and non-traditional complications (eg, polycystic ovary syndrome, non-alcoholic fatty liver disease, some cancers and eating disorders). Complications outcomes could be further improved by decreasing the evidence-treatment gap - for example, by increasing personalisation of care in managing diabetes complications.