Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Venous thromboembolism prophylaxis in acute medical admissions to a university teaching hospital

The objective of this study was to assess appropriate thromboprophylaxis prescription rates in a university hospital and to re-audit after a series of interventions. The notes of all acute medical patient admissions over a 4-week period were assessed for VTE risk factors and prescription of thromboprophylaxis. Subsequently, a series of hospital wide interventions including educational initiatives and a new drug prescription chart were introduced. 2 years post intervention the audit was repeated. Pre-intervention, 104 of 265 (39%) "at risk" patients were prescribed appropriate thromboprophylaxis. Post intervention the prescription rate increased to 108 of 188 (57%) "at risk patients". The results of the pre- intervention audit are consistent with the published literature. While there was a significant increase in prescription rates post intervention, over 40% of "at risk" patients still did not receive thromboprophylaxis highlighting the challenge in attempting to close the gap between guidelines and actual practice.

Extensively drug-resistant tuberculosis: first report of a case in Ireland

Extensively drug-resistant tuberculosis (XDR-TB) is an emerging global threat. Between 2002 and 2007 sixteen countries in the European Union (EU) reported at least one case of XDR-TB [1]. Infection is characterised by alarming mortality rates in both HIV and non-HIV populations.

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.