The prevalent causes of death in patients with peripheral artery disease undergoing revascularisation or amputation.

OBJECTIVE: Preventing untimely death in patients with peripheral artery disease (PAD) requires a detailed understanding of the predominant causes of death (COD). This literature review aims to describe how short- and long-term COD are reported in patients who had surgery for PAD. METHODS: A literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for articles reporting specific causes of mortality in patients who had surgery for all stages of PAD. Articles were included if they reported COD after open surgical or endovascular revascularisation, or major or minor amputation for PAD. Critical appraisals were conducted according to included study types, using the Joanna Briggs Institute tools. RESULTS: Cause of death was reported in 21 publications. Twenty were observational and one was a randomised control trial. Study size ranged from 25 to 10,505 patients. Cardiovascular disease was the most prevalent COD in perioperative periods (42.5% from 13 studies). Long-term follow-up ranged from 1 month and 7 years with 15 studies reporting cardiac related mortality as the most frequent cause of death. However, mortality from neoplasia, respiratory disease (including pneumonia and pulmonary emboli), stroke and sepsis were prevalent. Many studies were low-average quality, with few population-based observational studies. CONCLUSION: Whilst cardiovascular COD are the most prevalent reasons for mortality in patients with PAD, the proportion of patients dying from neoplasia and respiratory disease is high. Improved reporting standards for COD in studies examining PAD are needed.

Patient perspectives of quality of life in chronic limb-threatening ischemia: a qualitative study.

BACKGROUND: Quality of life (QOL) is an outcome that matters to patients with chronic limb-threatening ischemia (CLTI). However, we identified the lack of and need for a CLTI-specific QOL instrument. Our group is developing this instrument which requires a deep understanding of patient perspectives of QOL in CLTI. METHODS: Qualitative inquiry with patient and public involvement was performed in accordance with the Standards for Reporting Qualitative Research. Reflexive thematic analysis of semi-structured interviews was conducted within a constructivist-interpretivist research paradigm. Data were organized and managed in NVivo. Techniques to enhance trustworthiness included maintaining an audit trail, member checking, mentoring, and peer-debriefing. Patient and the public were consulted for feedback on codes, themes, and thematic maps. RESULTS: Thirteen participants (median age: 74 years, range: 43-90 years) with a variety of patient demographics were interviewed. Four themes were developed on QOL in CLTI: (i) 'independence as key to life satisfaction', (ii) 'change in identity when continuity is needed', (iii) 'coping with intractable disease', and (iv) 'not wanting to be alone'. Member checking with patient and public involvement confirmed the relevance and centrality of these themes to the lived experiences of patients with CLTI. CONCLUSIONS: The thematic outputs contribute important insights into what QOL truly means to patients with CLTI and what matters for their QOL. The content validity of the new CLTI-specific QOL instrument is improved by giving patients voice. This study highlights the value of qualitative inquiry and patient and public involvement in vascular surgical research.

Detection, management, and prevention of diabetes-related foot disease in the Australian context.

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

Case of Amaurosis Fugax in the Setting of a Persistent Primitive Hypoglossal Artery Requiring Carotid Endarterectomy with Regional Anesthesia.

BACKGROUND A persistent primitive hypoglossal artery (PPHA) is a rare congenital anomaly leading to persistent carotid-basilar anastomosis. This is a report of an 83-year-old man with a PPHA presenting with amaurosis fugax of the left eye requiring carotid endarterectomy under regional anesthesia. CASE REPORT An 83-year-old man presented with 2 weeks of intermittent self-resolving visual disturbances, followed by an episode of left eye amaurosis fugax. The patient had been referred to the hospital for further investigation of symptoms 1 day following the amaurosis fugax event. Carotid Doppler ultrasound demonstrated a greater than 90% stenosis of the left internal carotid artery. Computed tomography carotid and Circle of Willis angiography confirmed a mixed, ulcerated plaque and revealed a persistent left hypoglossal artery originating from the left internal carotid artery and continuing as the basilar artery. On day 3 of admission, left carotid endarterectomy was performed under conscious sedation and regional anesthesia to permit continuous monitoring of neurological status and avoid the need for intraoperative shunting. "Permissive hypertension" by targeting a systolic blood pressure of 190 to 200 mmHg was sought for the duration of clamp time. There was no deterioration of neurological function during clamping of the carotid vessels. The patient recovered well and was discharged 2 days after surgery, with no residual neurology. CONCLUSIONS This report has presented a rare case of PPHA to highlight awareness of this congenital vascular anomaly when undertaking carotid endarterectomy.

A Review of Illness Perceptions in Chronic Limb-Threatening Ischemia: Current Knowledge Gaps and a Framework for Future Studies.

BACKGROUND: The aim of this study is to review illness perceptions (IPs) in chronic limb-threatening ischemia (CLTI) patients undergoing revascularization (open surgical or endovascular), major lower extremity amputation, or conservative management. METHODS: MEDLINE, EMBASE, PsycINFO, CINAHL, WOS, and Scopus databases were searched from inception to August 20, 2021 for studies evaluating IP in CLTI according to Leventhal's common sense model (CSM). Since only 1 study was identified, a post hoc secondary literature search of MEDLINE was performed for reviews of IP in cardiovascular disease and diabetes to identify potential learning points for future research. All studies underwent narrative synthesis guided by tabulated data. RESULTS: One study and 7 reviews were included from the primary and secondary literature searches, respectively. Timeline and controllability were the main aspects of IP that predict prosthetic use in CLTI patients, more so at 6 months than 1 month. Other reviews in cardiovascular disease and diabetes identified important targets for future research: (1) factors that affect IP and whether IP can be used as an outcome measure, (2) relationship between IP and clinician-reported and patient-reported outcomes, and (3) methods to educate and change maladaptive IP. The importance of using valid and reliable measures of IP that encompass all components of Leventhal's' CSM was stressed. CONCLUSIONS: Knowledge of IP in CLTI patients is severely limited in contrast to other fields in cardiovascular disease and diabetes. This review helps to close this gap by raising awareness of IP and its importance within the vascular surgical community, and by providing a framework for future studies.

Impaired voluntary quadriceps force control following anterior cruciate ligament reconstruction: relationship with knee function.

PURPOSE: Impairments in quadriceps force control and altered quadriceps and hamstring muscle activation strategies have been observed following anterior cruciate ligament reconstruction; however, the functional implications of these impairments are unclear. This study examined the cross-sectional associations between quadriceps force control, quadriceps activation, hamstring coactivation and clinically assessed knee function following anterior cruciate ligament reconstruction with a hamstring graft. METHODS: Sixty-six patients (18 ± 3 months following surgery) and 41 uninjured individuals participated. Quadriceps force control was assessed using an isometric knee extension task. Participants cyclically increased and decreased quadriceps force at slow speeds between 5 and 30 % maximum voluntary isometric contraction matching a moving target displayed on a screen. Quadriceps activation and hamstring coactivation were assessed concurrently using surface electromyography. Knee function was assessed with the Cincinnati Knee Rating Scale and three single-leg hop tests. RESULTS: The reconstructed group completed the task with 48 % greater root-mean-square error (RMSE), indicating significantly worse quadriceps force control (p < 0.001). In a multivariable model adjusted for sex, greater RMSE and greater lateral hamstring coactivation were significantly associated with worse knee function that is greater odds of scoring <85 % on one or more knee functional assessment. CONCLUSIONS: Less-accurate quadriceps force output and greater hamstring coactivation are associated with worse knee joint function following anterior cruciate ligament reconstruction and may contribute to irregular knee joint loading and the onset or progression of knee osteoarthritis. Impairments in quadriceps force control and altered muscle activation strategies may be modifiable through neuromuscular training, and this is an area for future research. LEVEL OF EVIDENCE: Case-control study, Level III.

Diminished sub-maximal quadriceps force control in anterior cruciate ligament reconstructed patients is related to quadriceps and hamstring muscle dyskinesia.

The aim of this study was to determine the effects of anterior cruciate ligament reconstruction (ACLR) on sub-maximal quadriceps force control with respect to quadriceps and hamstring muscle activity. Thirty ACLR individuals together with 30 healthy individuals participated. With real-time visual feedback of muscle force output and electromyographic electrodes attached to the quadriceps and hamstring muscles, subjects performed an isometric knee extension task where they increased and decreased their muscle force output at 0.128Hz within a range of 5-30% maximum voluntary capacity. The ACLR group completed the task with more error and increased medial hamstring and vastus medialis activation (p<0.05). Moderate negative correlations (p<0.05) were observed between quadriceps force control and medial (Spearman's rho=-0.448, p=0.022) and lateral (Spearman's rho=-0.401, p=0.034) hamstring activation in the ACLR group. Diminished quadriceps sub-maximal force control in ACLR subjects was reflective of medial quadriceps and hamstring dyskinesia (i.e., altered muscle activity patterns and coordination deficits). Within the ACLR group however, augmented hamstring co-activation was associated with better quadriceps force control. Future studies should explore the convergent validity of quadriceps force control in ACLR patients.

A pilot investigation using global positioning systems into the outdoor activity of people with severe traumatic brain injury.

BACKGROUND: Little is known about the post-discharge outdoor activities of people who have incurred severe traumatic brain injury (TBI). This study used a body-worn global positioning system (GPS) device to determine the outdoor activity per day performed by this population. Additionally, this study examined the association that mobility, time since injury and injury severity had with levels of outdoor physical activity. FINDINGS: Seventeen people with TBI and 15 control subjects wore a GPS device for between 3-7 days to monitor their outdoor activity. Based on the individual's location and speed of movement the outdoor physical activity in minutes per day was derived. Assessments of duration of outdoor activity between groups, and the relationship that duration of outdoor activity had with results on the high-level mobility assessment tool, length of post-traumatic amnesia, and time since injury were performed. No significant (p = 0.153, effect size = 0.26) difference in time spent in outdoor physical activity was observed between the TBI (median[IQR] = 19[3-43]mins) and control (median[IQR] = 50[18-65]mins) group. Interestingly, 35% of TBI subjects performed <10 mins of outdoor activity per day compared to 13% of the control group. The TBI group also recorded three of the four highest values for outdoor physical activity. Higher levels of mobility were associated with more outdoor activity (Spearman's rho = 0.443, p = 0.038). No other significant associations were observed. CONCLUSIONS: While preliminary, our results indicate that a sub-group of people with TBI exists who restrict their outdoor activities. GPS has potential as an activity tracking tool, with implications for rehabilitation and exercise prescription.