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Milosevic S, Strange H, Morgan M, Ambler GK, Bosanquet DC, Waldron CA, Thomas-Jones E, Harris D, Twine CP, Brookes-Howell L. Rehabilitation experiences following major lower limb amputation due to complications of vascular disease: a UK qualitative study. Disabil Rehabil 2024:1-10. [PMID: 38622944 DOI: 10.1080/09638288.2024.2329747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/08/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease. METHODS Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data. FINDINGS Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants' imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations. CONCLUSIONS Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.
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Affiliation(s)
- Sarah Milosevic
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Heather Strange
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Melanie Morgan
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Graeme K Ambler
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, United Kingdom; Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - David C Bosanquet
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, United Kingdom; Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Emma Thomas-Jones
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Christopher P Twine
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, United Kingdom; Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
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Milosevic S, Strange H, Morgan M, Ambler GK, Bosanquet DC, Waldron CA, Thomas-Jones E, Harris D, Twine CP, Brookes-Howell L. Exploring patients' experiences of analgesia after major lower limb amputation: a qualitative study. BMJ Open 2021; 11:e054618. [PMID: 34853109 PMCID: PMC8638453 DOI: 10.1136/bmjopen-2021-054618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To explore patient experiences, understanding and perceptions of analgesia following major lower limb amputation. DESIGN Qualitative interview study, conducted as part of a randomised controlled feasibility trial. SETTING Participants were recruited from two general hospitals in South Wales. PARTICIPANTS Interview participants were patients enrolled in PLACEMENT (Perineural Local Anaesthetic Catheter aftEr Major lowEr limb amputatioN Trial): a randomised controlled feasibility trial comparing the use of perineural catheter (PNC) versus standard care for postoperative pain relief following major lower limb amputation. PLACEMENT participants who completed 5-day postoperative follow-up, were able and willing to participate in a face-to-face interview, and had consented to be contacted, were eligible to take part in the qualitative study. A total of 20 interviews were conducted with 14 participants: 10 male and 4 female. METHODS Semi-structured, face-to-face interviews were conducted with participants over two time points: (1) up to 1 month and (2) at least 6 months following amputation. Interviews were audio-recorded, transcribed verbatim and analysed using a framework approach. RESULTS Interviews revealed unanticipated benefits of PNC usage for postoperative pain relief. Participants valued the localised and continuous nature of this mode of analgesia in comparison to opioids. Concerns about opioid dependence and side effects of pain relief medication were raised by participants in both treatment groups, with some reporting trying to limit their intake of analgesics. CONCLUSIONS Findings suggest routine placement of a PNC following major lower limb amputation could reduce postoperative pain, particularly for patient groups at risk of postoperative delirium. This method of analgesic delivery also has the potential to reduce preoperative anxiety, alleviate the burden of pain management and minimise opioid use. Future research could further examine the comparison between patient-controlled analgesia and continuous analgesia in relation to patient anxiety and satisfaction with pain management. TRIAL REGISTRATION NUMBER ISRCTN: 85710690; EudraCT: 2016-003544-37.
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Affiliation(s)
| | | | - Melanie Morgan
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Graeme K Ambler
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Vascular Department, North Bristol NHS Trust, Bristol, UK
| | - David C Bosanquet
- Gwent Vascular Institute, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, UK
| | | | | | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Christopher P Twine
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Vascular Department, North Bristol NHS Trust, Bristol, UK
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Ambler GK, Waldron CA, Contractor UB, Hinchliffe RJ, Twine CP. Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease. Br J Surg 2019; 107:20-32. [DOI: 10.1002/bjs.11384] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/31/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
Abstract
Background
The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta-analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research.
Methods
MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta-analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random-effects models.
Results
Twenty-eight meta-analyses were included. Thirty-three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High-quality evidence showed that antiplatelet monotherapy reduced non-fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non-fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low-quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68).
Conclusion
Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention.
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Affiliation(s)
- G K Ambler
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - C-A Waldron
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - U B Contractor
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - R J Hinchliffe
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
| | - C P Twine
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol, Bath and Weston Vascular Network, North Bristol NHS Trust, Bristol, UK
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Bosanquet DC, Ambler GK, Waldron CA, Thomas-Jones E, Brookes-Howell L, Kelson M, Pickles T, Harris D, Milosevic S, Fitzsimmons D, Saxena N, Twine CP. Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): results from a randomised controlled feasibility trial. BMJ Open 2019; 9:e029233. [PMID: 31719071 PMCID: PMC6858124 DOI: 10.1136/bmjopen-2019-029233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 08/13/2019] [Accepted: 10/16/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To determine the feasibility of undertaking a randomised controlled effectiveness trial evaluating the use of a perineural catheter (PNC) after major lower limb amputation with postoperative pain as the primary outcome. DESIGN Randomised controlled feasibility trial. SETTING Two vascular Centres in South Wales, UK. PARTICIPANTS 50 patients scheduled for major lower limb amputation (below or above knee) for complications of peripheral vascular disease. INTERVENTIONS The treatment arm received a PNC placed adjacent to the sciatic or tibial nerve at the time of surgery, with continuous infusion of levobupivacaine hydrochloride 0.125% for up to 5 days. The control arm received neither local anaesthetic nor PNC. Both arms received usual perioperative anaesthesia and postoperative analgesia. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were the proportion of eligible patients who were randomised and the proportion of recruited patients who provided primary effectiveness outcome data. Secondary outcomes were: the proportion of recruited patients reaching 2 and 6 month follow-up and supplying pain data; identification of key cost drivers; development of an economic analysis framework for a future effectiveness trial; identification of barriers to recruitment and site set-up; and identification of the best way to measure postoperative pain. RESULTS Seventy-six of 103 screened patients were deemed eligible over a 10 month period. Fifty (64.5%) of these patients were randomised, with one excluded in the perioperative period. Forty-five (91.3%) of 49 recruited patients provided enough pain scores on a 4-point verbal rating scale to allow primary effectiveness outcome evaluation. Attrition rates were high; 18 patients supplied data at 6 month follow-up. Costs were dominated by length of hospital stay. Patients and healthcare professionals reported that trial processes were acceptable. CONCLUSIONS Recruitment of patients into a trial comparing PNC use to usual care after major lower limb amputation with postoperative pain measured on a 4-point verbal rating scale is feasible. Evaluation of longer-term symptoms is difficult. TRIAL REGISTRATION NUMBER ISRCTN: 85 710 690. EudraCT: 2016-003544-37.
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Affiliation(s)
- David C Bosanquet
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
| | - Graeme K Ambler
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Mark Kelson
- Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | | | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Swansea, UK
| | - Neeraj Saxena
- Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf University Health Board, Abercynon, UK
- CUBRIC, School of Psychology, Cardiff University, Cardiff, UK
| | - Christopher P Twine
- Department of Vascular Surgery, Aneurin Bevan University Health Board, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Bosanquet DC, Ambler GK, Waldron CA, Thomas-Jones E, Brookes-Howell L, Kelson M, Harris D, Pickles T, Milosevic S, Fitzsimmons D, Saxena N, Twine CP. Major lower limb amputation audit - introduction and implementation of a multimodal perioperative pain management guideline. Br J Pain 2018; 12:257-258. [PMID: 30349700 PMCID: PMC6194973 DOI: 10.1177/2049463718800736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- David C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - Graeme K Ambler
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Mark Kelson
- Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Debbie Harris
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | | | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Swansea, UK
| | - Neeraj Saxena
- Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf Local Health Board, Llantrisant, UK
- School of Psychology, Cardiff University, Cardiff, UK
- Psychology and Therapeutic Studies, University of South Wales, Pontypridd, UK
| | - Christopher P Twine
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
- Division of Population Medicine, Cardiff University, Cardiff, UK
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Ambler GK, Bosanquet DC, Brookes-Howell L, Thomas-Jones E, Waldron CA, Edwards AGK, Twine CP. Development of a core outcome set for studies involving patients undergoing major lower limb amputation for peripheral arterial disease: study protocol for a systematic review and identification of a core outcome set using a Delphi survey. Trials 2017; 18:628. [PMID: 29284523 PMCID: PMC5747272 DOI: 10.1186/s13063-017-2358-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/21/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The development of a standardised reporting set is important to ensure that research is directed towards the most important outcomes and that data is comparable. To ensure validity, the set must be agreed by a consensus of stakeholders including patients, healthcare professionals and lay representatives. There is currently no agreed core outcome set for patients undergoing major lower limb amputation for peripheral arterial disease (PAD) for either short- or medium-term research outcomes. By developing these sets we aim to rationalise future trial outcomes, facilitate meta-analysis and improve the quality and applicability of amputation research. METHODS/DESIGN We will undertake a comprehensive systematic review of studies of patients undergoing major lower limb amputation for PAD. Data regarding all primary and secondary outcomes reported in relevant studies will be extracted and summarised as outcome domains. We will then undertake focus groups with key stakeholders (patients, carers, health and social care workers) to collect qualitative data to identify the main short- and medium-term research outcomes for patients undergoing major lower limb amputation. Results of the systematic review and focus groups will be combined to create a comprehensive list of potential key outcomes. Stakeholders (patients, researchers and health and social care workers) will then be polled to determine which of the outcomes are considered to be important in a general context using a three-phase Delphi process. After preliminary analysis, results will be presented at a face-to-face meeting of key stakeholders for discussion and voting on the final set of core outcomes. This project is being run in parallel with a feasibility trial assessing perineural catheters in patients undergoing lower limb amputation (the PLACEMENT trial). Full ethical approval has been granted for the study (Wales REC 3 reference number 16/WA/0353). DISCUSSION Core outcome sets will be developed for short- and medium-term outcomes of research involving patients undergoing major lower limb amputation for PAD. This will help with the design of future trials and facilitate meta-analyses of trial data. TRIAL REGISTRATION PROSPERO: CRD42017059329 . Registered on 30 March 2017. COMET 975 . Registered on 5 April 2017.
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Affiliation(s)
- Graeme K Ambler
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, UK.,Division of Population Medicine, Cardiff University, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - David C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Cherry-Ann Waldron
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Adrian G K Edwards
- Division of Population Medicine, Cardiff University, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Christopher P Twine
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, UK. .,Division of Population Medicine, Cardiff University, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK.
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