Management of diabetic foot disease and amputation in the Irish health system: a qualitative study of patients' attitudes and experiences with health services.

BACKGROUND: Diabetes is an increasingly prevalent chronic illness that places a huge burden on the individual, the health system and society. Patients with active foot disease and lower limb amputations due to diabetes have a significant amount of interaction with the health care services. The purpose of this study was to explore the attitudes and experiences of foot care services in Ireland among people with diabetes and active foot disease or lower limb amputations. METHODS: A purposive sample of individuals who had either active foot disease or a lower limb amputation as a result of diabetes were recruited from the Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) Unit of an Irish hospital. One-to-one interviews were conducted in the POLAR unit using a semi-structured topic guide. Thematic analysis was used to identify, analyse and describe patterns within the data. RESULTS: Ten males participated in the study. Most participants expressed a need for emotional support alongside the medical management of their condition. There were substantial differences between participants with regard to the level of education and information they appeared to have received regarding their illness. There were also variations in levels of service received. Transport and medication costs were considered barriers. Having a medical card, which entitles the holder to free medical care, eased the burden of the patient's illness. A number of participants attributed some of the problems they faced with services to the health care system as a whole rather than health care professionals. CONCLUSION: Results suggest that rehabilitation services should place a strong focus on psychological as well as physical adjustment to active foot disease or lower limb amputations. The delivery of services needs to be standardised to ensure equal access to medical care and supplies among people with or at risk of lower extremity amputations. The wider social circumstances of patients should be taken into consideration by health care professionals to provide effective support while patients adjust to this potentially life changing complication. The patient's perspective should also be used to inform health service managers and health professionals on ways to improve services.

A novel video compendium of real surgical patient interactions for medical students.

Objective: To develop a novel video compendium of real surgical patient interactions as a tool for medical student education and to evaluate our institutional experience of its usefulness. Design: Prospective development of a video compendium of real surgical patient interactions. Setting: Single university affiliated hospital in Cork, Ireland. Participants: Patients with illnesses relevant to the surgery curriculum and students from an Irish medical school. Results: Videos were recorded of the clinical interaction between a consultant surgeon and patients, capturing focused history taking and/or clinical examination, with an associated set of explanatory notes. Fifty videos were developed with a tiered release to the clinical year medical students, via their virtual learning/education platform. Three hundred and eleven students responded to the questionnaire across 3-student year groups (311/585-53 %). Fifty-two percent of students did not have their clinical rotations affected by the COVID-19 pandemic. >90 % of students agreed that the videos helped history taking and clinical examination technique. >80 % of students agreed that the accompanying text slides reinforced key points and helped with understanding difficult topics. Eighty-five percent of students reported that the videos increased exposure to surgical patients and pathology. Eighty-five percent of students rated their experience as at least 4 out of 5. Conclusions: This online educational compendium bridged a gap for students with limited clinical exposure during the COVID-19 pandemic, and has become an important resource for all clinical students. Our novel engagement with real patients sets this compendium apart from resources which use actors.

Rare congenital abnormality resulting in spontaneous bilateral deep venous thrombosis and pulmonary emboli in a young healthy man.

This report describes a unique case of a healthy man in his 30s, who presented with progressive unilateral leg swelling with no common risk factors identified. Two days prior to the swelling he had developed significant abdominal pain following a treadmill exercise session. Ultrasound imaging revealed extensive deep vein thrombosis involving bilateral ileo-femoral venous systems, extending up the inferior vena cava (IVC). Further investigation using a CT venogram revealed the rare congenital anomaly of hypoplasia of the renal IVC. Successful treatment involved 48 hours of an intravenous unfractionated heparin infusion, followed by lifelong anticoagulation.

Lumbar sympathectomy can improve symptoms associated with ischaemia, vasculitis, diabetic neuropathy and hyperhidrosis affecting the lower extremities-a single-centre experience.

BACKGROUND: Lumbar sympthectomy (LS) was traditionally performed for intermittent claudication but is now eclipsed by revascularisation for that indication. However, it retains a role in the management of critical limb ischaemia and other conditions causing lower limb pain with or without ischaemia. We report the role of LS in modern surgical practice when revascularisation and pain management options have been exhausted. METHODS: A medical chart review was performed on all patients who underwent LS in our unit from 2005 to 2016 (inclusive). Symptomatology, surgical indications and patient outcomes were reported. RESULTS: Twenty-seven cases were performed in total (21 unilateral, 3 bilateral). Underlying diagnoses were as follows: PAD [59.3% (n = 16)], hyperhidrosis [18.5% (n = 5)] and equal numbers of complex regional pain syndrome, diabetic neuropathy and vasculitis [7.4% (n = 2) each]. Overall, 85.2% (n = 23) had improvement or resolution of symptoms at 1 month and 70.3% (n = 19) had persistent improvement of symptoms at 1 year. Non-PAD patients had superior outcomes with 90.9% (n = 10) reporting improved symptomatology at 1 month and nearly three quarters [72.8% (n = 8)] maintaining this improvement at 1 year. Only four patients required subsequent major amputation, all in the severe PAD group. CONCLUSION: Lumbar sympathectomy can improve symptoms associated with ischaemia, vasculitis, diabetic neuropathy and hyperhidrosis. Non-PAD patients have the greatest benefit.

Two Cases of Popliteal Cystic Adventitial Disease Treated With Excision and Primary Bypass Graft: A Review of the Literature.

Cystic adventitial disease (CAD) is a rare vascular pathology which predominantly affects peripheral vessels of young otherwise healthy males. Much debate exists regarding its exact etiology. It is characterized by a collection of mucinous material within the adventitial wall layer of the affected vessel, resulting in arterial stenosis and rapidly progressive calf claudication. Treatment is primarily surgical, although radiological interventions have been reported. Its rarity makes evidence-based surgical or radiological management difficult. With this in mind, we report two cases of popliteal artery CAD treated successfully with primary excision and bypass grafting. We analyzed all literature published on CAD since first reported in 1947 and we propose an algorithm for appropriate management pathways.

Massive carotid artery aneurysm presenting as an oropharyngeal swelling in a young woman.

A 28-year-old woman presented to the emergency department with a 5-day history of a sore throat and a pharyngeal swelling that increased in size. The patient was previously investigated for Marfan's syndrome after episodes of bilateral spontaneous pneumothoraces but did not meet the criteria for diagnosis. Examination revealed a large pulsatile lesion in the oropharynx. CT angiography revealed an internal carotid artery aneurysm. The patient underwent a successful urgent open repair of the aneurysm with a primary arterio-arterial anastomosis without a patch. Histopathology of the aneurysmal sac revealed cystic medial degeneration.

Upper gastrointestinal obstruction secondary to aortoduodenal syndrome owing to a noninflammatory abdominal aortic aneurysm.

Aortoduodenal syndrome is a rare complication of an abdominal aortic aneurysm wherein the aneurysm sac obstructs the patient's duodenum. It presents with the symptoms of an upper gastrointestinal tract obstruction and requires surgical intervention to relieve it. Previously, gastric bypass surgery was advocated, but now aortic replacement is the mainstay of treatment. We report a case of a 67-year-old woman whose aortoduodenal syndrome was successfully managed and review the literature on this topic.

The effect of aspirin on blood loss and transfusion requirements in patients with femoral neck fractures.

Although it is widely accepted that aspirin will increase the risk of intra- and post-operative bleeding, clinical studies have not consistently supported this assumption. We aimed to assess the effect of pre-operative aspirin on blood loss and transfusion requirements in patients undergoing emergency fixation of femoral neck fractures. A prospective case-control study was undertaken in patients presenting with femoral neck fractures. Parameters recorded included intra-operative blood loss, post-operative blood loss, transfusion requirements and peri-operative reduction in haemoglobin concentration. Of 89 patients presenting with femoral neck fractures 32 were on long-term aspirin therapy. Pre-operative aspirin ingestion did not significantly affect peri-operative blood loss, or change in haemoglobin concentration or haematocrit. However those patients taking aspirin pre-operatively had a significantly lower haemoglobin concentration and haematocrit and were more likely to be anaemic at presentation than those who were not receiving aspirin. Patients taking aspirin were also more likely to receive blood transfusion post-operatively.

Antiseptic wick: does it reduce the incidence of wound infection following appendectomy?

The role of prophylactic antibiotics is well established for contaminated wounds, but the use of antiseptic wound wicks is controversial. The aim of this work was to study the potential use of wound wicks to reduce the rate of infection following appendectomy. This prospective randomized controlled clinical trial was conducted at a university hospital in the department of surgery. The subjects were patients undergoing appendectomy for definite acute appendicitis. They were randomized by computer to primary subcuticular wound closure or use of an antiseptic wound wick. For the latter, ribbon gauze soaked in povidone-iodine was placed between interrupted nylon skin sutures. Wicks were soaked daily and removed on the fourth postoperative day. All patients received antibiotic prophylaxis. They were reviewed while in hospital and 4 weeks following operation for evidence of wound infection. The main outcome measures were wound infection, wound discomfort, and cosmetic result. The overall wound infection rate was 8.6% (15/174). In patients with wound wicks it was 11.6% (10/86) compared to 5.6% (5/88) in those whose wounds were closed by subcuticular sutures (p = NS). We concluded that the use of wound wicks was not associated with decreased wound infection rates following appendectomy. Subcuticular closure is therefore appropriate in view of its greater convenience and safety.