An Assessment of the Potential Benefits of Video Consultation in the Emergency Department: Mixed Methods Study.

BACKGROUND: District general hospital emergency departments may refer patients to a tertiary center depending on the information available to a generalist clinician in discussion with a specialist team. If there is uncertainty, the lowest-risk strategy is often to transfer the patient. Video consultation allowing the specialist team to see and talk to the patient and local clinician while still in the emergency department could improve decision-making for patient transfer. OBJECTIVE: The aim of this study is to assess the potential benefit of real-time video consultation between remote specialists and emergency department patients and clinicians across all specialties. METHODS: Detailed patient data were collected prospectively for 6 months (between January 16, 2012, and July 15, 2012) on all patients presenting to a district general hospital emergency department who required input from a specialist team at the nearest tertiary care center. These patients were discussed retrospectively with the specialist teams to determine whether videoconferencing could have benefited their management. The logistics for the use of videoconferencing were explored. RESULTS: A total of 18,799 patients were seen in the emergency department during the study period. Among the 18,799 patients, 413 referrals (2.2%) were made to the tertiary center specialist teams. A review of the patients transferred indicated that 193 (46.7%) of the 413 patients who were referred might have benefited from video consultation (193/18,799, 1% of all patients). If the specialist team could be accessed via videoconferencing only while a senior member was available in the hospital (8:00 AM-10:00 PM), then a maximum of 5 patients per week across all specialties would use the equipment. If 24-hour specialist access was available, this would increase to 7 patients per week. CONCLUSIONS: In regions where there is direct transportation of patients by ambulance to specialist centers and there is a regional picture archiving and communication system in place, video consultation between emergency department patients and specialists has limited potential to improve patient management.

Quantification of carotid plaque lipid content with magnetic resonance T2 mapping in patients undergoing carotid endarterectomy.

BACKGROUND AND PURPOSE: Techniques to stratify subgroups of patients with asymptomatic carotid artery disease are urgently needed to guide decisions on optimal treatment. Reliance on estimates of % luminal stenosis has not been effective, perhaps because that approach entirely disregards potentially important information on the pathological process in the wall of the artery. METHODS: Since plaque lipid is a key determinant of plaque behaviour we used a newly validated, high-sensitivity T2-mapping MR technique for a systematic survey of the quantity and distribution of plaque lipid in patients undergoing endarterectomy. Lipid percentage was quantified in 50 carotid endarterectomy patients. Lipid distribution was tested, using two imaging indices (contribution of the largest lipid deposit towards total lipid (LLD %) and a newly-developed LAI 'lipid aggregation index'). RESULTS: The bifurcation contained maximal lipid volume. Lipid percentage was higher in symptomatic vs. asymptomatic patients with degree of stenosis (DS ≥ 50%) and in the total cohort (P = 0.013 and P = 0.005, respectively). Both LLD % and LAI was higher in symptomatic patients (P = 0.028 and P = 0.018, respectively), suggesting that for a given plaque lipid volume, coalesced deposits were more likely to be associated with symptomatic events. There was no correlation between plaque volume or lipid content and degree of luminal stenosis measured on ultrasound duplex (r = -0.09, P = 0.53 and r = -0.05, P = 0.75), respectively. However, there was a strong correlation in lipid between left and right carotid arteries (r = 0.5, P <0.0001, respectively). CONCLUSIONS: Plaque lipid content and distribution is associated with symptomatic status of the carotid plaque. Importantly, plaque lipid content was not related to the degree of luminal stenosis assessed by ultrasound. Determination of plaque lipid content may prove useful for stratification of asymptomatic patients, including selection of optimal invasive treatments.

Quantification of Lipid-Rich Core in Carotid Atherosclerosis Using Magnetic Resonance T2 Mapping: Relation to Clinical Presentation.

OBJECTIVES: The aim of this study was to: 1) provide tissue validation of quantitative T2 mapping to measure plaque lipid content; and 2) investigate whether this technique could discern differences in plaque characteristics between symptom-related and non-symptom-related carotid plaques. BACKGROUND: Noninvasive plaque lipid quantification is appealing both for stratification in treatment selection and as a possible predictor of future plaque rupture. However, current cardiovascular magnetic resonance (CMR) methods are insensitive, require a coalesced mass of lipid core, and rely on multicontrast acquisition with contrast media and extensive post-processing. METHODS: Patients scheduled for carotid endarterectomy were recruited for 3-T carotid CMR before surgery. Lipid area was derived from segmented T2 maps and compared directly to plaque lipid defined by histology. RESULTS: Lipid area (%) on T2 mapping and histology showed excellent correlation, both by individual slices (R = 0.85, p < 0.001) and plaque average (R = 0.83, p < 0.001). Lipid area (%) on T2 maps was significantly higher in symptomatic compared with asymptomatic plaques (31.5 ± 3.7% vs. 15.8 ± 3.1%; p = 0.005) despite similar degrees of carotid stenosis and only modest difference in plaque volume (128.0 ± 6.0 mm3 symptomatic vs. 105.6 ± 9.4 mm3 asymptomatic; p = 0.04). Receiver-operating characteristic analysis showed that T2 mapping has a good ability to discriminate between symptomatic and asymptomatic plaques with 67% sensitivity and 91% specificity (area under the curve: 0.79; p = 0.012). CONCLUSIONS: CMR T2 mapping distinguishes different plaque components and accurately quantifies plaque lipid content noninvasively. Compared with asymptomatic plaques, greater lipid content was found in symptomatic plaques despite similar degree of luminal stenosis and only modest difference in plaque volumes. This new technique may find a role in determining optimum treatment (e.g., providing an indication for intensive lipid lowering or by informing decisions of stents vs. surgery).

Population-Based Study of Incidence, Risk Factors, Outcome, and Prognosis of Ischemic Peripheral Arterial Events: Implications for Prevention.

BACKGROUND: There are few published data on the incidence and long-term outcomes of critical limb ischemia, acute limb ischemia, or acute visceral ischemia with which to inform health service planning, to monitor prevention, and to enable risk prediction. METHODS AND RESULTS: In a prospective population-based study (Oxfordshire, UK; 2002-2012), we determined the incidence and outcome of all acute peripheral arterial events in a population of 92,728. Risk factors were assessed by comparison with the underlying population. A total of 510 acute events occurred in 386 patients requiring 803 interventions. Two hundred twenty-one patients (59.3%) were ≥75 years of age, and 98 (26.3%) were ≥85 years old. Two hundred thirty patients (62.3%) were independent before the event, but 270 (73.4%) were dead or dependent at the 6-month follow-up, and 328 (88.9%) were dead or dependent at 5 years. The 30-day survival was lowest for patients with acute visceral ischemia (28.2%) compared with acute limb ischemia (75.3%) and critical limb ischemia (92.6%; P<0.001). Risk factors (all P<0.001) were hypertension (age- and sex-adjusted risk ratio, 2.75; 95% confidence interval, 1.95-3.90), smoking (adjusted risk ratio, 2.14; 95% confidence interval, 1.37-3.34), and diabetes mellitus (adjusted risk ratio, 3.01; 95% confidence interval, 1.69-5.35), particularly for critical limb ischemia (adjusted risk ratio, 5.96; 95% confidence interval, 3.15-11.26). Two hundred eighty-eight patients (77.2%) had known previous cardiovascular disease, and 361 (96.8%) had vascular risk factors, but only 203 (54.4%) were on an antiplatelet and only 166 (44.5%) were on a statin. Although 260 patients (69.7%) were taking antihypertensives, 42.9% of all blood pressures recorded during the 5 years before the event were >140/90 mm Hg. Of 88 patients (23.6%) with incident cardioembolic events, 62 had known atrial fibrillation (diagnosed before the event), of whom only 14.5% were anticoagulated despite 82.3% having a CHA2DS2VASC score ≥2 without contraindications. CONCLUSIONS: The clinical burden of peripheral arterial events is substantial. Although the vast majority of patients have known vascular disease in other territories and multiple treatable risk factors, premorbid control is poor.

Between a rock and a hard place.

The authors present the case of a patient who presented with acute coronary syndrome requiring percutaneous coronary intervention. He was incidentally diagnosed with a large abdominal abdominal aortic aneurysm which developed acute inflammatory features with rapid sac expansion and imminent rupture. This short report aims to highlight several dilemma that confronted us during the management of this patient.

Should we train the trainers? Results of a randomized trial.

BACKGROUND: The development of efficient training methods in surgery is increasingly important. The effectiveness of training trainers is unclear. This study was designed to determine the effect on their trainees' performance of instructing trainers in a specific cognitive training method. STUDY DESIGN: Ten trainers from a university teaching hospital were randomized to train novices on a one-to-one basis in a simulated procedure using either a four-step cognitive method or their own unspecified method. Thirty trainees were randomly assigned to either a cognitive or standard trainer. After training, trainees were assessed on performing the procedure using a task-specific checklist, a global rating scale, and time taken to complete the procedure. RESULTS: Trainees who were trained using the specific cognitive method completed the procedure in a faster time (mean 331 seconds [SD 37 seconds] versus 426 seconds [SD 66 seconds]) and with higher global rating scores (mean 23.25 seconds [SD 3.7 seconds] versus 20.5 seconds [SD 4.5 seconds]) compared with those taught by a standard method. CONCLUSIONS: Instructing trainers in a cognitive training method results in a significant improvement in training outcomes.

Endogenous heparin activity is decreased in peripheral arterial occlusive disease.

BACKGROUND: Naturally occurring heparin-like activity in the form of endogenous heparin and heparin sulfate proteoglycans has been shown in normal human plasma. Exogenous low-dose heparin improves pain-free walking distance and maximum walking distance in peripheral arterial occlusive disease (PAOD). Is reduced endogenous heparin activity responsible for some of the problems found in PAOD? This study compared heparin-like activity in patients with PAOD with that in healthy subjects and explored its relationship to disease severity. METHODS: In part 1, native and heparinase-modified thromboelastography was performed on peripheral venous blood samples in three groups of patients to measure heparin-like anticoagulant activity. Group 1: 15 control subjects (median age, 60 years; range, 49-74 years; ankle-brachial pressure index [ABPI] >0.9); group 2: 14 patients with intermittent claudication (median age, 66 years; range, 56-80; ABPI, 0.69 [SD, 0.09]); group 3: 14 patients with rest pain (median age, 67.5 years; range, 54-84 years; ABPI, 0.45 [SD, 0.08]). In part 2, heparin equivalent to that in normal plasma was added to blood samples from 15 patients with short-distance claudication (n = 4) or rest pain (n = 11), and baseline (without heparinase) thromboelastography was performed to exclude lack of antithrombin as a cause of diminished heparin-like activity. RESULTS: In part 1, all patients with PAOD had a significant increase in coagulability compared with controls. Heparinase-modified thromboelastography in controls showed a significant decrease in the latent period between placing the sample in the analyser, where it is recalcified, to the initial fibrin formation (DeltaR time; P = .002) compared with native TEG, confirming endogenous heparin-like activity. Using DeltaR time as a measure of heparin-like activity, a significant reduction was found in patients with claudication (0.33 minutes; 95% confidence interval [CI], 0.004-0.65; P = .02) and in those with rest pain (0.25 minutes; 95% CI, -0.02 to 0.52; P = .02) compared with that in controls (0.78 minutes; 95% CI, 0.39-1.16). The DeltaR time also correlated with the ABPI (r = 0.35, P = .02), suggesting declining heparin-like activity with increasing ischemia. In part 2, exogenous heparin restored the thromboelastography in PAOD patients to normal, suggesting that lack of endogenous heparin-like compounds rather than reduced antithrombin levels was responsible for changes in coagulation. CONCLUSION: Patients with PAOD have reduced endogenous heparin-like activity that correlates with disease severity.

Informed prognosis [corrected] after abdominal aortic aneurysm repair using predictive modeling techniques [corrected].

OBJECTIVE: To identify the best method for the prediction of postoperative mortality in individual abdominal aortic aneurysm surgery (AAA) patients by comparing statistical modelling with artificial neural networks' (ANN) and clinicians' estimates. METHODS: An observational multicenter study was conducted of prospectively collected postoperative Acute Physiology and Chronic Health Evaluation II data for a 9-year period from 24 intensive care units (ICU) in the Thames region of the United Kingdom. The study cohort consisted of 1205 elective and 546 emergency AAA patients. Four independent physiologic variables-age, acute physiology score, emergency operation, and chronic health evaluation-were used to develop multiple regression and ANN models to predict in-hospital mortality. The models were developed on 75% of the patient population and their validity tested on the remaining 25%. The results from these two models were compared with the observed outcome and clinicians' estimates by using measures of calibration, discrimination, and subgroup analysis. RESULTS: Observed in-hospital mortality for elective surgery was 9.3% (95% confidence interval [CI], 7.7% to 11.1%) and for emergency surgery, 46.7% (95% CI, 42.5 to 51.0%). The ANN and the statistical models were both more accurate than the clinicians' predictions. Only the statistical model was internally valid, however, when applied to the validation set of observations, as evidenced by calibration (Hosmer-Lemeshow C statistic, 14.97; P = .060), discrimination properties (area under receiver operating characteristic curve, 0.869; 95% CI, 0.824 to 0.913), and subgroup analysis. CONCLUSIONS: The prediction of in-hospital mortality in AAA patients by multiple regression is more accurate than clinicians' estimates or ANN modelling. Clinicians can use this statistical model as an objective adjunct to generate informed prognosis.

An e-Health approach to managing vascular surgical patients.

The objective of this study was to investigate an e-health approach to managing patients presenting with vascular-type symptoms. A pilot study of a prospective cohort of patients referred from a single general practitioner practice of 5700 patients using electronic referral, assessment by a practice nurse, and teleconferencing facilities as an adjunct to normal referral and management practice was designed and conducted. Thirty-eight patients aged 30-93 years old (median 72 years) were enrolled in the study between March 2001 and July 2004. Twelve patients had leg ulceration and 12 complained of leg pain. The remainder had a range of symptoms potentially vascular in nature. All but 1 patient had an initial teleconsultation. This initial teleconsultation lasted a median of 11 minutes (interquartile range 9 minutes (min) 59 seconds (sec)-12 min 43 sec). For 10 patients this was their only contact with the hospital. One patient had teleconsultation follow-up only, 26 patients attended the hospital for vascular laboratory studies or angiography, and 8 of these went on to have radiological and/or surgical intervention. Three patients attended the outpatient department for follow up; all other follow-ups were managed via the teleclinic. Overall, 57 standard outpatient attendances in these patients were replaced by teleconsultations. Common vascular-type symptoms can be satisfactorily evaluated across a telelink with the aid of a practice nurse and baseline patient data transmitted electronically. Decisions can be made regarding the need for further investigation and attendance in outpatient clinic can be largely eliminated.

Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test.

BACKGROUND: The Allen test is commonly used to assess collateral hand circulation before radial artery harvest for coronary artery bypass grafting. However there is no consensus as to whether an abnormal Allen test is an absolute or relative contraindication to radial artery harvesting. We assessed the safety of harvesting the radial artery using arterial duplex ultrasonography in patients with an abnormal Allen test. METHODS: Two hundred and eighty-seven consecutive patients scheduled for total arterial coronary revascularisation underwent preoperative Allen tests over a 34-month period. Patients with an abnormal Allen test underwent duplex ultrasonography preoperatively to assess the adequacy of the ulnar collateral supply and the suitability of the radial artery for harvesting. RESULTS: Two hundred and forty-four patients (85%) had a normal left Allen test and proceeded directly to radial artery harvest. Forty-three patients (15%) with an abnormal left Allen test underwent duplex ultrasonography scans and of those, 5 patients had an abnormal scan. These patients underwent scanning of the contralateral forearm. Three patients had a normal right forearm arterial duplex scan and the right radial artery was harvested. The mean diameter of the radial and ulnar arteries was not significantly different between the patients with normal and abnormal duplex ultrasonograms. There were no ischemic hand complications in this series. CONCLUSIONS: The Allen test is a quick, easy, and reliable screening test before radial artery harvesting in the majority of patients. Duplex ultrasonography predicts safe radial artery harvest in the majority of patients with an abnormal Allen test.

The effect of telemedicine on consultation time.

We have implemented an 'evidence-based referral' for primary care patients in dermatology, cardiology and peripheral vascular disease. Telemedicine clinics bring together a district nurse, patient and vascular surgeon to discuss diagnosis, management and care. During a 30-month study, a total of 30 patients participated in telemedicine clinics. The mean consultation time fell from 23 to 10 min. In parallel, the type of consultation changed from dermatology to vascular surgery. Nineteen patients participated in vascular telemedicine clinics over the last 16 months of the study. The average consultation time was 10 min (SD 1), which included discussion of the case and negotiation of its management. The average consultation time in the equivalent outpatient clinic in the same hospital for the same consultant was 15 min. The acquisition of the relevant information in primary care could lead to a reduction of 75% in outpatient clinic appointments.

A Technology-assisted approach to integrating healthcare in the community.

The fragmentary nature of healthcare provision in the United Kingdom presents particular problems for many patients with vascular disease. The management and organization of this disease are also costly for the National Health Service (NHS). Hence, so any attempt to keep hospital visits to the minimum while at the same time aiding effective treatment is to be welcomed. Information in the current NHS is stored in various places and access to it is restricted. There is no central, complete, patient record that is accessible to all healthcare professionals at the various levels of care. There is also no mechanism that allows the patient to interact with his or her local nurse and/or doctor/general practitioner (at primary-care level) involving the specialist/consultant (at secondary-care level). The concept and conduct of an ulcer care program for such patients are described in this paper. Nurse-led, this novel approach uses an innovative information technology system to bring together the isolated 'islands' of knowledge and information held by both the patient and healthcare professionals involved in their care. The technology described here combines both store and forward and real-time video. Informal feedback from patients, community nurses, doctors/general practitioners, and specialists/consultants suggests that such an approach is well received. However, we conclude with a discussion of the complexities involved in the interaction between technology and people and the implications for the management of healthcare.

Femoro-femoral arterial bypass is an effective and durable treatment for symptomatic unilateral iliac artery occlusion.

AIMS: This study was designed to determine the effectiveness of femoro-femoral arterial bypass (FFB) operation at hospital discharge and 1 year after operation, and to determine the role of long saphenous vein (LSV) as a conduit. METHODS AND RESULTS: A retrospective review was undertaken of 161 consecutive patients (median age, 66 years; range, 44-97 years) who had femoro-femoral grafts during the 12 years from July 1987 to March 1999. The indication for operation was claudication in 66 patients and critical ischaemia in 95. A synthetic graft was used in 123 patients and LSV in 38. Six patients with LSV had a previously infected synthetic graft and 2 a previously occluded synthetic graft. In-hospital operative mortality was 13 (8.1%). One year postoperatively, known mortality was 29, fifteen patients were lost to follow-up putting 1-year mortality at 18.0-27.3%. Eight of these had LSV as the conduit. At discharge from hospital, the median improvement in the ankle brachial pressure index was 0.3 (range, 0-1.0) overall, and 0.32 for patients with LSV (range 0-1.0). Among the 117 known survivors at 1 year, secondary graft patency was 107 confirmed by Doppler or duplex (91.5%) overall, and 25 (89.3%) for LSV; 100 (85.5%) maintained symptomatic improvement, 11 (9.4%) were experiencing no benefit and 6 (5.1%) were worse, of whom 2 had undergone amputation. In patients in whom LSV was used, 22 (78.8%) remained symptomatically improved, 3 (10.7%) experienced no benefit, 3 deteriorated and one had an amputation. CONCLUSIONS: One year following FFB, at least 18.0% of patients were dead. Among possible survivors to 1-year, graft patency was at least 78.8% and at least 75.8% remained clinically improved. FFB is effective in the treatment of unilateral iliac artery occlusion. LSV is as effective as a synthetic conduit.

An integrated nursing and telemedicine approach to vascular care.

We have developed a telemedicine approach to vascular care for patients being managed in primary care. District nurses visit patients in their homes. Clinical information and digital photographs can be sent by email to the vascular surgeon for assessment. Where appropriate a preliminary teleconsultation between the patient and a vascular surgeon, with the nurse in attendance, is held at the primary care centre and the management of the patient is agreed. This may include referral to surgery. Over eight months six patients with diabetes and peripheral ulcers participated in the vascular telemedicine clinic. The average consultation time was 12 min (SD 4), which included discussion of the case and negotiation of its management. Important outcomes of the new system were the ability to schedule patients for rapid referral and to have completed the management of the case during the teleconsultation.