Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries

BACKGROUND

Incontinence-associated dermatitis (IAD) is a specific type of irritant contact dermatitis with different severity levels. An internationally accepted instrument to assess the severity of IAD in adults, with established diagnostic accuracy, agreement and reliability, is needed to support clinical practice and research.

OBJECTIVES

To design the Ghent Global IAD Categorization Tool (GLOBIAD) and evaluate its psychometric properties.

METHODS

The design was based on expert consultation using a three-round Delphi procedure with 34 experts from 13 countries. The instrument was tested using IAD photographs, which reflected different severity levels, in a sample of 823 healthcare professionals from 30 countries. Measures for diagnostic accuracy (sensitivity and specificity), agreement, interrater reliability (multirater Fleiss kappa) and intrarater reliability (Cohen's kappa) were assessed.

RESULTS

The GLOBIAD consists of two categories based on the presence of persistent redness (category 1) and skin loss (category 2), both of which are subdivided based on the presence of clinical signs of infection. The agreement for differentiating between category 1 and category 2 was 0·86 [95% confidence interval (CI) 0·86-0·87], with a sensitivity of 90% and a specificity of 84%. The overall agreement was 0·55 (95% CI 0·55-0·56). The Fleiss kappa for differentiating between category 1 and category 2 was 0·65 (95% CI 0·65-0·65). The overall Fleiss kappa was 0·41 (95% CI 0·41-0·41). The Cohen's kappa for differentiating between category 1 and category 2 was 0·76 (95% CI 0·75-0·77). The overall Cohen's kappa was 0·61 (95% CI 0·59-0·62).

CONCLUSIONS

The development of the GLOBIAD is a major step towards a better systematic assessment of IAD in clinical practice and research worldwide. However, further validation is needed.

Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access

This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.

Preoperative Cardiac Stress Testing in the Southern California Vascular Outcomes Improvement Collaborative

BACKGROUND

The objective of this study was to examine the use of preoperative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe).

METHODS

A retrospective review was performed on data in all modules of the So Cal VOICe from September 2012 through May 2016. PCST was defined as stress echocardiogram or nuclear stress test. A new postoperative myocardial infarction (MI) was defined as troponin elevation and/or electrocardiogram/imaging changes with or without ischemic symptoms. Only elective cases in patients with asymptomatic cardiac status were included in the study.

RESULTS

During the study period, 3,063 procedures meeting the inclusion criteria were performed in 7 registries: carotid endarterectomy (CEA), carotid artery stent, thoracic endovascular aneurysm repair, infrainguinal bypass (Infra), endovascular aneurysm repair (EVAR), suprainguinal bypass (Supra), and open abdominal aortic aneurysm repair (OAAA). PCST varied across registries from 17% in PVI to 62% in OAAA. PCST in CEA varied across 9 institutions from 10% to 79%. PCST in EVAR varied across 7 institutions from 14% to 83%. PCST in Infra varied across 4 institutions from 10% to 57%. Of the 12 patients across all registries who had a new MI, 6 had PCST, one of which was abnormal.

CONCLUSIONS

The incidence of PCST varies widely across registries and institutions in the So Cal VOICe. Despite the wide variation, the incidence of new postoperative MI is exceptionally low. Further studies should evaluate the cost-effectiveness of the PCST practices and future quality improvement efforts should focus on standardization of indications for PCST.

Atherectomy-Associated Complications in the Southern California Vascular Outcomes Improvement Collaborative

BACKGROUND

Atherectomy has become an increasingly utilized modality for the endovascular treatment of peripheral arterial occlusive disease. The objective of this study was to determine the incidence and risk factors for atherectomy-associated complications.

METHODS

A retrospective review was performed for all atherectomy procedures performed between January 2011 and December 2015 in the Southern California Vascular Outcomes Improvement Collaborative. Atherectomy was defined as laser, orbital, or excisional atherectomy. Complications were dissection, perforation, and distal embolization.

RESULTS

Seven hundred twenty-nine atherectomy procedures were performed at 7 institutions by 27 practitioners. The mean age was 73 years with 415 (57%) males. Four hundred nineteen (57%) were diabetic, 673 (92%) hypertensive, 457 (63%) smokers, and 244 (34%) had coronary artery disease. Dissection occurred in 51 (7%) procedures, embolization in 23 (3.1%), and perforation in 12 (1.6%). The mean number of lesions treated per artery was the same at 1.6 in patients with any complication and no complication (P = 0.77). The total occluded length was 7.4 cm for complications versus 7.2 cm for no complication (P = 0.73). The total treated length was 12.9 cm for complications versus 11.3 cm for no complication (P = 0.03). The incidence of complications for Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions were 13% compared to 10% for TASC A/B lesions (P = 0.05). The incidence of complications in superficial femoral/popliteal lesions was 12.9% vs. 10.4% in tibial lesions (P = 0.13). In multivariable analysis, treatment length was associated with a small increased risk of complication (odds ratio = 1.02, 95% confidence interval = 1.0-1.04).

CONCLUSIONS

Increased treatment length is associated with an increased risk of atherectomy-associated complications. Demographic factors and comorbidities were not predictors of complications.

Electron Shock Ignition of Inertial Fusion Targets

It is shown that inertial confinement fusion targets designed with low implosion velocities can be shock-ignited using laser-plasma interaction generated hot electrons (hot-e's) to obtain high energy gains. These designs are robust to multimode asymmetries and are predicted to ignite even for significantly distorted implosions. Electron shock ignition requires tens of kilojoules of hot-e's which can be produced only at a large laser facility like the National Ignition Facility, with the laser-to-hot-e conversion efficiency greater than 10% at laser intensities ∼10^{16}  W/cm^{2}.

Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis

Objectives

Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair.

Methods

The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011–July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences.

Results

The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82–2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03–5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74–3.26), P = 0.244).

Conclusion

For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.