Single-Institution Learning Curve for Management of Mega-Fistulae Revision.

BACKGROUND: Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. METHODS: A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. RESULTS: We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient.  Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. CONCLUSIONS: Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

A Novel Angiography Scoring System Predicts Improvement After Isolated Common Femoral Endarterectomy With Profundaplasty.

BACKGROUND: Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). METHODS: A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, between-group t-tests, Pearson correlations, and linear regression were used. RESULTS: Clinical Outcomes 88% of patients (n = 22) had clinical improvement at 30 days; the remaining 12% of patients (n = 3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 ± 0.21 at 30 days, and by 0.06 ± 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of ≥2.6 was strongly associated with 6-month clinical improvement (64% of those ≥ 2.6 improved, versus 15% of those <2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r = 0.73, P = 0.01) and 6 months (r = 0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of ≥1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. CONCLUSIONS: This institutional angiography scoring system successfully predicts clinical improvement following CFEP.  Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months. Future validation studies will investigate these outcomes in a larger population, and over a longer period.

A systematic review of physical and psychological health and wellbeing of older women in Sub-Saharan Africa.

BACKGROUND: Sub-Saharan Africa (SSA) has the fastest growing proportion of older adults in the world, the majority of whom are women. Global health agendas, however, continue to deprioritise older women's health issues, including the incidence of and mortality from non-communicable disease (NCDs). This is the first systematic review to address the health, wellbeing and healthcare utilization of older SSA women. METHODS: Studies with primary analysis of health, wellbeing and/or healthcare utilization outcomes for women over the age of 50 from SSA countries were included. Databases searched include EMBASE, Scopus and Psycinfo. FINDINGS: About 26 studies from six SSA countries met inclusion criteria. Studies regarding NCDs predominated (n = 12), followed by healthcare utilization (n = 4), disability (n = 4), wellbeing (n = 2), depression (n = 2) and HIV (n = 2). Every study indicated significantly lower self-rated health and wellbeing, higher rates of depression, hypertension, obesity, disability or weakness for women compared with men. The studies also indicated that older women use healthcare more often, and choose public over private facilities more often. INTERPRETATION: The studies in the review had large, diverse samples. This review demonstrates the need for more gender-specific studies to better understand the unique challenges older women face in managing NCDs in particular.

Self-Reported Versus Performance-Based Assessments of a Simple Mobility Task Among Older Adults in the Emergency Department.

STUDY OBJECTIVE: Accurate information about the mobility of independently living older adults is essential in determining whether they may be safely discharged home from the emergency department (ED). We assess the accuracy of self-reported ability to complete a simple mobility task among older ED patients. METHODS: This was a cross-sectional study of cognitively intact patients aged 65 years and older who were neither nursing home residents nor critically ill, conducted in 2 academic EDs. Consenting participants were asked whether they could get out of bed, walk 10 feet, turn around, and get back in bed without assistance, and if not, whether they could perform this task with a cane, walker, or assistance. Each participant was then asked to perform the task and was provided with a mobility device or assistance as needed. RESULTS: Of 272 patients who met eligibility criteria and answered the physical task question, 161 (59%) said they could do the task unassisted, 45 (17%) said they could do it with a cane or walker, 21 (8%) said they could do it with assistance, and 45 (17%) said they would be unable to do it even with assistance. Among those who said they could do the task either with or without assistance and who were subsequently willing to attempt the task (N=172), discrepancies between self-reported ability and actual performance were common. Of those who said they could perform the task without assistance, 12% required some assistance or were unable to complete the task. Of those who said they could perform the task with a cane or walker, 48% required either assistance or were unable to perform the task. Of those who said they could perform the task with assistance, 24% were unable to perform the task even with assistance. CONCLUSION: In this sample of older adults receiving care in the ED, the accuracy of their self-reported ability to perform a simple mobility task was poor, particularly for those who reported some need for assistance. For older adults being considered for discharge who report a need for assistance with mobility, direct observation of the patient's mobility by a member of the emergency care team should be considered.

Barriers to the Development and Sustainability of Bone Banking Programs in Low- and Middle-Income Countries: A Systematic Review.

Purpose: The number of bone allograft transplantations required in low- and middle-income countries (LMICs) is growing very quickly. No previous study has investigated the challenges clinical banks face to sustain operations or meet this demand. The purpose of this study was to conduct a systematic review of the barriers to implementation and sustainability of clinical bone tissue banks in LMICs. Barriers identified in clinical bone banking can shed light on strategies for overcoming obstacles in other biobanking programs. Methods: A systematic review protocol was registered with PROSPERO under identification number CRD42019136045. LMIC was defined using World Bank criteria. A search strategy targeting PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the World Health Organization (WHO) Global Health Library was used. Studies from the inception of bone banking until June 4, 2019, that discussed an identifiable barrier to bone banking were included. Study quality was assessed using The Critical Appraisals Skills Programme (CASP) Qualitative Checklist. Results: Of studies identified, 33 studies were included in the final analysis. Based on the full-text review, the primary barriers identified were lack of regulation, low donor rates, and insufficient training and staffing. CASP analysis performed on the 24 qualitative articles showed an average of 3.6 qualitative measurements met. Conclusions: As international organizations such as the International Atomic Energy Agency (IAEA) restructure their participation in global bone banking regulation, these barriers such as lack of regulation, low donor rates, and insufficient training and staffing could pose a challenge to meeting the rising demand for bone transplantation in LMICs. Articles with higher quality evidence are needed to better define barriers and propose evidence-based solutions.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone.

INTRODUCTION: The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS: Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS: From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION: The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study.

INTRODUCTION: Increasing advance care planning (ACP) among older adults is a national priority. Documentation of ACP in the electronic health record (EHR) is particularly important during emergency care. OBJECTIVE: We sought to characterize completion and availability of ACP among a subset of older patients at an academic emergency department (ED) with an integrated EHR. METHODS: In this cross-sectional study, patients were eligible if aged ≥80 years or aged 65-79 with ≥1 indicator of high risk for short-term mortality. Patient-reported completion of ACP and availability of ACP documentation in the EHR were assessed. RESULTS: Among study patients (n = 104), 59% reported completing some form of ACP: living will 52%, heathcare power of attorney 54%, do not resuscitate 38%, and medical orders for scope of treatment or physician orders for life-sustaining treatment 6%. Whites were more likely to report having some form of ACP than minorities (66% vs. 37%, p < 0.01), as were patients aged ≥80 years than those aged 65-79 (79% vs. 44%, p < 0.01). Only 13% of all patients had either a current code status or any other current ACP documentation in the EHR. Among patients whose primary care provider uses the same EHR system as the study ED, only 19% had a current code status or any other ACP documentation in the EHR. CONCLUSION: In a sample of older ED patients likely to benefit from ACP, few patients had documented end-of-life care preferences in the EHR.

A Prospective Evaluation of Shared Decision-making Regarding Analgesics Selection for Older Emergency Department Patients With Acute Musculoskeletal Pain.

OBJECTIVES: Musculoskeletal pain is a common reason for emergency department (ED) visit by older adults. Outpatient pain management following ED visits in this population is challenging as a result of contraindications to, and side effects from, available therapies. Shared decision-making (SDM) between patients and emergency physicians may improve patient experiences and health outcomes. Among older ED patients with acute musculoskeletal pain, we sought to characterize their desire for involvement in the selection of outpatient analgesics. We also sought to assess the impact of SDM on change in pain at 1 week, patient satisfaction, and side effects. METHODS: This was a prospective study of adults aged 60 years and older presenting to the ED with acute musculoskeletal pain. Participants' desire to contribute to outpatient analgesic selection was assessed by phone within 24 hours of ED discharge using the Control Preferences Scale and categorized as active, collaborative, or passive. The extent to which SDM occurred in the ED was also assessed within 24 hours of discharge using the 9-item Shared Decision Making Questionnaire, and scores were subsequently grouped into tertiles of low, middle, and high SDM. The primary outcome was change in pain severity between the ED visit and 1 week. Secondary outcomes included satisfaction regarding the decision about how to treat pain at home, satisfaction with the pain medication itself, and side effects. RESULTS: Desire of participants (N = 94) to contribute to the decision regarding selection of outpatient analgesics varied: 16% active (i.e., make the final decision themselves), 37% collaborative (i.e., share decision with provider), and 47% passive (i.e., let the doctor make the final decision). The percentage of patients who desired an active role in the decision was higher for patients who were college educated versus those who were not college educated (28% vs. 11%; difference 17%, 95% confidence interval [CI] = 0% to 35%), received care from a nurse practitioner versus a resident or an attending physician (32% vs. 9%; difference 23%, 95% CI = 4% to 42%), or received care from a female versus a male provider (24% vs. 5%; difference 19%, 95% = CI 5% to 32%). After potential confounders were adjusted for, the mean decrease in pain severity from the ED visit to 1-week follow-up was not significantly different across tertiles of SDM (p = 0.06). Higher SDM scores were associated with greater satisfaction with the discharge pain medications (p = 0.006). SDM was not associated with the class of analgesic received. CONCLUSIONS: In this sample of older adults with acute musculoskeletal pain, the reported desire of patients to contribute to decisions regarding analgesics varied based on both patient and provider characteristics. SDM was not significantly related to pain reduction in the first week or type of pain medication received, but was associated with greater patient satisfaction.

Willingness and Ability of Older Adults in the Emergency Department to Provide Clinical Information Using a Tablet Computer.

OBJECTIVES: To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions. DESIGN: Prospective, ED-based cross-sectional study. SETTING: Two U.S. academic EDs. PARTICIPANTS: Individuals aged 65 and older. MEASUREMENTS: As part of screening for another study, potential study participants were asked whether they would be willing to use a tablet computer to answer eight questions instead of answering questions orally. A custom user interface optimized for older adults was used. Trained research assistants observed study participants as they used the tablets. Ability to use the tablet was assessed based on need for assistance and number of questions answered correctly. RESULTS: Of 365 individuals approached, 248 (68%) were willing to answer screening questions, 121 of these (49%) were willing to use a tablet computer; of these, 91 (75%) were able to answer at least six questions correctly, and 35 (29%) did not require assistance. Only 14 (12%) were able to answer all eight questions correctly without assistance. Individuals aged 65 to 74 and those reporting use of a touchscreen device at least weekly were more likely to be willing and able to use the tablet computer. Of individuals with no or mild cognitive impairment, the percentage willing to use the tablet was 45%, and the percentage answering all questions correctly was 32%. CONCLUSION: Approximately half of this sample of older adults in the ED was willing to provide information using a tablet computer, but only a small minority of these were able to enter all information correctly without assistance. Tablet computers may provide an efficient means of collecting clinical information from some older adults in the ED, but at present, it will be ineffective for a significant portion of this population.