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Brousseau-Foley M, Blanchette V, Houle J, Trudeau F. Developing an interprofessional decision support tool for diabetic foot ulcers management in primary care within the family medicine group model: a Delphi study in Canada. BMC PRIMARY CARE 2024; 25:123. [PMID: 38643081 PMCID: PMC11031884 DOI: 10.1186/s12875-024-02387-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/12/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Primary care professionals encounter difficulties coordinating the continuum of care between primary care providers and second-line specialists and adhere to practice guidelines pertaining to diabetic foot ulcers management. Family medicine groups are providing primary care services aimed to improve access, interdisciplinary care, coordination and quality of health services, and reduce emergency department visits. Most professionals working in family medicine groups are primary care physicians and registered nurses. The aim of this study was to develop and validate an interprofessional decision support tool to guide the management of diabetic foot ulcers for primary care professionals working within the family medicine group model. METHODS A one-page decision tool developed by the research team was validated by an expert panel using a three-round Delphi protocol held between December 2019 and August 2021. The tool includes 43 individual actions and a care pathway from initial presentation to secondary prevention. Data collection was realized with both paper and electronic questionnaires, and answers were compiled in an electronic spreadsheet. Data was analyzed with use of descriptive statistics, and consensus for each item was defined as ≥ 80% agreement. RESULTS Experts from 12 pre-identified professions of the diabetic foot ulcer interdisciplinary care team were included, 39 participants out of the 59 invited to first round (66.1%), 34 out of 39 for second (87.2%) and 22 out of 34 for third (64.7%) rounds. All items included in the final version of the decision support tool reached consensus and were deemed clear, relevant and feasible. One or more professionals were identified to be responsible for every action to be taken. CONCLUSIONS This study provided a comprehensive decision support tool to guide primary care professionals in the management of diabetic foot ulcers. Implementation and evaluation in the clinical setting will need to be undertaken in the future.
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Affiliation(s)
- Magali Brousseau-Foley
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Boul. Des Forges, Trois-Rivières, Québec, 3351G8Z 4M3, Canada.
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie et du Centre-du-Québec (CIUSSS-MCQ) affiliated to Université de Montréal, Department of Family and Emergency Medicine, Faculty of Medicine, 731 Rue Ste-Julie, Trois-Rivières, Québec, G9A 1Y1, Canada.
| | - Virginie Blanchette
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Boul. Des Forges, Trois-Rivières, Québec, 3351G8Z 4M3, Canada
- VITAM - Research Centre on Sustainable Health, 2480 Chemin de la Canardière, Québec, QC, G1J 2G1, Canada
| | - Julie Houle
- Department of Nursing, Université du Québec à Trois-Rivières, 3351, Boul. Des Forges, Trois-Rivières, Québec, G8Z 4M3, Canada
| | - François Trudeau
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Boul. Des Forges, Trois-Rivières, Québec, 3351G8Z 4M3, Canada
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Blanchette V, Patry J, Brousseau-Foley M, Todkar S, Libier S, Leclerc AM, Armstrong DG, Tremblay MC. Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens. Front Endocrinol (Lausanne) 2023; 14:1177020. [PMID: 37645408 PMCID: PMC10461566 DOI: 10.3389/fendo.2023.1177020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens. Methods A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR). Results Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA. Discussion This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare. Conclusion Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting. Systematic review registration Open Science Framework https://osf.io/j9pu7, identifier j9pu7.
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Affiliation(s)
- Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Jérôme Patry
- Centre de Recherche du Centre Intégré de Santé et Services Sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
| | - Magali Brousseau-Foley
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Faculty of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie et du Centre-du-Québec Affiliated with Université de Montréal, Trois-Rivières Family Medicine University Clinic, Trois-Rivières, QC, Canada
| | - Shweta Todkar
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Solène Libier
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Anne-Marie Leclerc
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Marie-Claude Tremblay
- VITAM-Centre de Recherche en Santé Durable, Québec, QC, Canada
- Faculty of Medicine, Family and Emergency Medicine Department, Université Laval, Québec, QC, Canada
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Nkonge KM, Nkonge DK, Nkonge TN. Screening for diabetic peripheral neuropathy in resource-limited settings. Diabetol Metab Syndr 2023; 15:55. [PMID: 36945043 PMCID: PMC10031885 DOI: 10.1186/s13098-023-01032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/15/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Diabetic neuropathy is the most common microvascular complication of diabetes mellitus and a major risk factor for diabetes-related lower-extremity complications. Diffuse neuropathy is the most frequently encountered pattern of neurological dysfunction and presents clinically as distal symmetrical sensorimotor polyneuropathy. Due to the increasing public health significance of diabetes mellitus and its complications, screening for diabetic peripheral neuropathy is essential. Consequently, a review of the principles that guide screening practices, especially in resource-limited clinical settings, is urgently needed. MAIN BODY Numerous evidence-based assessments are used to detect diabetic peripheral neuropathy. In accordance with current guideline recommendations from the American Diabetes Association, International Diabetes Federation, International Working Group on the Diabetic Foot, and National Institute for Health and Care Excellence, a screening algorithm for diabetic peripheral neuropathy based on multiphasic clinical assessment, stratification according to risk of developing diabetic foot syndrome, individualized treatment, and scheduled follow-up is suggested for use in resource-limited settings. CONCLUSIONS Screening for diabetic peripheral neuropathy in resource-limited settings requires a practical and comprehensive approach in order to promptly identify affected individuals. The principles of screening for diabetic peripheral neuropathy are: multiphasic approach, risk stratification, individualized treatment, and scheduled follow-up. Regular screening for diabetes-related foot disease using simple clinical assessments may improve patient outcomes.
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de Mestral C, Hussain MA, Austin PC, Forbes TL, Sivaswamy A, Kayssi A, Salata K, Wijeysundera HC, Verma S, Al-Omran M. Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study. CMAJ Open 2020; 8:E659-E666. [PMID: 33109531 PMCID: PMC7595755 DOI: 10.9778/cmajo.20200048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The care necessary to prevent amputation from diabetes and peripheral artery disease (PAD) remains disjointed in many jurisdictions. To help inform integrated regional care, this study explores the correlation between regional health care services and rates of lower extremity amputation. METHODS This ecological study included 14 administrative health regions in Ontario, Canada. All diabetes- or PAD-related major (above ankle) amputations (Apr. 1, 2007, to Mar. 31, 2017) were identified among residents 40 years of age and older. For each region, age-and sex-adjusted amputation rates were calculated as well as per capita counts of key health providers (podiatrists and chiropodists, as well as surgeons) and health care utilization among study patients in the year before the first major amputation (physician visits, publicly funded podiatry visits, emergency department visits, hospital admissions, home care nursing, minor amputation, limb revascularization). RESULTS A total of 11 658 patients with major amputation were identified (of whom 79.2% had diabetes and 96.5% had PAD). There was wide regional variation in amputation rates: 2.53 to 11.77 per 100 000 person-quarters. At a regional level, the proportion of study patients who received revascularization showed the strongest negative correlation with amputation rates. The regional proportion of study patients who saw a vascular surgeon showed the strongest negative correlation with amputation rates, relative to other health provider visits. Other measures of health care utilization among patients correlated poorly with regional amputation rates, as did the regional provider counts. The results were similar when we restricted the analysis to diabetes-related amputations. INTERPRETATION Amputation rates related to diabetes and PAD vary widely across Ontario. Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts.
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Affiliation(s)
- Charles de Mestral
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.
| | - Mohamad A Hussain
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Peter C Austin
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Thomas L Forbes
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Atul Sivaswamy
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Ahmed Kayssi
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Konrad Salata
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Harindra C Wijeysundera
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Subodh Verma
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
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Hussain MA, Al-Omran M, Salata K, Sivaswamy A, Forbes TL, Sattar N, Aljabri B, Kayssi A, Verma S, de Mestral C. Population-based secular trends in lower-extremity amputation for diabetes and peripheral artery disease. CMAJ 2020; 191:E955-E961. [PMID: 31481423 DOI: 10.1503/cmaj.190134] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both. METHODS We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time. RESULTS A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both. INTERPRETATION Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.
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Affiliation(s)
- Mohamad A Hussain
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Mohammed Al-Omran
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Konrad Salata
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Atul Sivaswamy
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Thomas L Forbes
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Naveed Sattar
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Badr Aljabri
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Ahmed Kayssi
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Subodh Verma
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Charles de Mestral
- Divisions of Vascular Surgery (Hussain, Al-Omran, Salata, de Mestral) and Cardiac Surgery (Verma), St. Michael's Hospital; Li Ka Shing Knowledge Institute of St. Michael's Hospital (Al-Omran, Verma, de Mestral); Department of Surgery (Hussain, Salata, Forbes, Kayssi), University of Toronto; Diabetes Action Canada (Hussain, Al-Omran, Salata, Forbes, Kayssi), Toronto, Ont.; King Saud University-Li Ka Shing Collaborative Research Program (Aljabri, Verma) and Department of Surgery (Aljabri), King Saud University, Riyadh, Kingdom of Saudi Arabia; ICES (Sivaswamy, de Mestral); Division of Vascular Surgery (Forbes), Peter Munk Cardiac Centre, University Health Network, Toronto, Ont.; Institute of Cardiovascular and Medical Sciences (Sattar), University of Glasgow, Glasgow, Scotland, United Kingdom; Division of Vascular Surgery (Kayssi), Sunnybrook Health Sciences Centre, Toronto, Ont.
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