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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The unique multidisciplinarity of diabetes-related foot disease. Diabetes Metab Res Rev 2024; 40:e3804. [PMID: 38616492 DOI: 10.1002/dmrr.3804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Few diseases globally require treatment from so many different disciplines as diabetes-related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence-based treatment in diabetes-related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews, all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes-related foot disease.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Fran Game
- Research and Development Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- Cross I&D, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Univ-lille, Tourcoing, France
| | - Nicolaas C Schaper
- Division Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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Chuter V, Charles J, Fitridge R. Delivering Equitable Access to Diabetes Foot Care Services. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00256-9. [PMID: 38490357 DOI: 10.1016/j.ejvs.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, NSW, Australia
| | - James Charles
- First Peoples Health Unit, Griffith University, Gold Coast, Australia
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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van Netten JJ, Bus SA, Apelqvist J, Chen P, Chuter V, Fitridge R, Game F, Hinchliffe RJ, Lazzarini PA, Mills J, Monteiro-Soares M, Peters EJG, Raspovic KM, Senneville E, Wukich DK, Schaper NC. Definitions and criteria for diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3654. [PMID: 37186781 DOI: 10.1002/dmrr.3654] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
Multiple disciplines are involved in the management of diabetes-related foot disease and a common vocabulary is essential for clear communication. Based on the systematic reviews of the literature that form the basis of the International Working Group on the Diabetic Foot (IWGDF) Guidelines, the IWGDF has developed a set of definitions and criteria for diabetes-related foot disease. This document describes the 2023 update of these definitions and criteria. We suggest these definitions be used consistently in both clinical practice and research, to facilitate clear communication with people with diabetes-related foot disease and between professionals around the world.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Pam Chen
- Joondalup Health Campus, Ramsay Healthcare, Sydney, Australia
- Faculty of Health, University of Tasmania, Hobart, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Sydney, Australia
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
| | - Joseph Mills
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas, USA
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Edgar J G Peters
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, the Netherlands
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing Univ-lille, Tourcoing, France
| | - Dane K Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3657. [PMID: 37243927 DOI: 10.1002/dmrr.3657] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/29/2023]
Abstract
Diabetes-related foot disease results in a major global burden for patients and the healthcare system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetes-related foot disease since 1999. In 2023, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In addition, a new guideline on acute Charcot neuro-osteoarthropathy was created. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification and management of diabetes-related foot disease based on the seven IWGDF Guidelines. We also describe the organisational levels to successfully prevent and treat diabetes-related foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of healthcare professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower-extremity amputations. The burden of foot disease and amputations is increasing at a rapid rate, and comparatively more so in middle to lower income countries. These guidelines also assist in defining standards of prevention and care in these countries. In conclusion, we hope that these updated practical guidelines continue to serve as a reference document to aid healthcare providers in reducing the global burden of diabetes-related foot disease.
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Affiliation(s)
- Nicolaas C Schaper
- Division Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing; Univ-lille, Lille, France
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Bus SA, Monteiro-Soares M, Game F, van Netten JJ, Apelqvist J, Fitridge R, Senneville E, Schaper NC. Standards for the development and methodology of the 2023 IWGDF guidelines. Diabetes Metab Res Rev 2024; 40:e3656. [PMID: 37179482 DOI: 10.1002/dmrr.3656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
AIMS Diabetes-related foot disease is a major source of patient burden and societal costs. Investing in evidence-based international guidelines on diabetes-related foot disease is important to reduce this burden and costs, provided the guidelines are focused on outcomes important to key stakeholders and are evidence-based and properly implemented. MATERIALS AND METHODS The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2023 updates were made using the Grading of Recommendations Assessment Development and Evaluation evidence-to-decision framework. This concerns formulating relevant clinical questions and important outcomes, conducting systematic reviews of the literature and meta-analyses where appropriate, completing summary of judgement tables, and writing recommendations that are specific, unambiguous and actionable, along with their transparent rationale. RESULTS We herein describe the development of the 2023 IWGDF Guidelines on the prevention and management of diabetes-related foot disease, which consists of seven chapters, each prepared by a separate working group of international experts. These chapters provide guidelines related to diabetes-related foot disease on prevention; classification of diabetes-related foot ulcer, offloading, peripheral artery disease, infection, wound healing interventions, and active Charcot neuro-osteoarthropathy. Based on these seven guidelines, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. CONCLUSIONS We believe that the adoption and implementation of the 2023 IWGDF guidelines by healthcare providers, public health agencies, and policymakers will improve the prevention and management of diabetes-related foot disease, and subsequently reduce the worldwide patient and societal burden caused by this disease.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing, France
- Univ-lille, Lille, France
| | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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Chuter V, Schaper N, Hinchliffe R, Mills J, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, David R, van den Berg JC, Venermo M, Fitridge R. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3701. [PMID: 37493206 DOI: 10.1002/dmrr.3701] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes-related foot ulcer (DFU). Determining performance of non-invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non-invasive bedside tests for PAD to predict DFU healing, healing post-minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene. METHODS A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non-invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6-month follow-up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle-brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe-brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2 ) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post-minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non-healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10). CONCLUSIONS Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post-revascularisation bedside testing, and heterogenous subpopulations.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St. Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries MD, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2024; 40:e3700. [PMID: 37539634 DOI: 10.1002/dmrr.3700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is associated with an increased likelihood of delayed or non-healing of a diabetes-related foot ulcer, gangrene, and amputation. The selection of the most effective surgical technique for revascularisation of the lower limb in this population is challenging and there is a lack of conclusive evidence to support the choice of intervention. This systematic review aimed to determine, in people with diabetes and tissue loss, if direct revascularisation is superior to indirect revascularisation and if endovascular revascularisation is superior to open revascularisation for the outcomes of wound healing, minor or major amputation, and adverse events including mortality. METHODS Title and abstract searches of Medline, Embase, PubMed, and EBSCO were conducted from 1980 to 30th November 2022. Cohort and case-control studies and randomised controlled trials reporting comparative outcomes of direct (angiosome) revascularisation (DR) and indirect revascularisation (IR) or the comparative outcomes of endovascular revascularisation and open or hybrid revascularisation for the outcomes of healing, minor amputation, and major amputation in people with diabetes, PAD and tissue loss (including foot ulcer and/or gangrene) were eligible. Methodological quality was assessed using the Cochrane risk-of-bias tool for randomised trials, the ROBINS-I tool for non-randomised studies, and Newcastle-Ottawa Scale for observational and cohort studies where details regarding the allocation to intervention groups were not provided. RESULTS From a total 7086 abstracts retrieved, 26 studies met the inclusion criteria for the comparison of direct angiosome revascularisation (DR) and indirect revascularisation (IR), and 11 studies met the inclusion criteria for the comparison of endovascular and open revascularisation. One study was included in both comparisons. Of the included studies, 35 were observational (31 retrospective and 4 prospective cohorts) and 1 was a randomised controlled trial. Cohort study quality was variable and generally low, with common sources of bias related to heterogeneous participant populations and interventions and lack of reporting of or adjusting for confounding factors. The randomised controlled trial had a low risk of bias. For studies of DR and IR, results were variable, and it is uncertain if one technique is superior to the other for healing, prevention of minor or major amputation, or mortality. However, the majority of studies reported that a greater proportion of participants receiving DR healed compared with IR, and that IR with collaterals may have similar outcomes to DR for wound healing. For patients with diabetes, infrainguinal PAD, and an adequate great saphenous vein available for use as a bypass conduit who were deemed suitable for either surgical procedure, an open revascularisation first approach was superior to endovascular therapy to prevent a major adverse limb event or death (Hazard Ratio: 0.72; 95% CI 0.61-0.86). For other studies of open and endovascular approaches, there was generally no difference in outcomes between the interventions. CONCLUSIONS The majority of available evidence for the effectiveness of DR and IR and open and endovascular revascularisation for wound healing and prevention of minor and major amputation and adverse events including mortality in people with diabetes, PAD and tissue loss is inconclusive, and the certainty of evidence is very low. Data from one high quality randomised controlled trial supports the use of open over endovascular revascularisation to prevent a major limb event and death in people with diabetes, infrainguinal disease and tissue loss who have an adequate great saphenous vein available and who are deemed suitable for either approach.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine at the Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3683. [PMID: 37477087 DOI: 10.1002/dmrr.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
As a progressive disease process, early diagnosis and ongoing monitoring and treatment of lower limb peripheral artery disease (PAD) is critical to reduce the risk of diabetes-related foot ulcer (DFU) development, non-healing of wounds, infection and amputation, in addition to cardiovascular complications. There are a variety of non-invasive tests available to diagnose PAD at the bedside, but there is no consensus as to the most diagnostically accurate of these bedside investigations or their reliability for use as a method of ongoing monitoring. Therefore, the aim of this systematic review was to first determine the diagnostic accuracy of non-invasive bedside tests for identifying PAD compared to an imaging reference test and second to determine the intra- and inter-rater reliability of non-invasive bedside tests in adults with diabetes. A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective and retrospective investigations of the diagnostic accuracy of bedside testing in people with diabetes using an imaging reference standard and reliability studies of bedside testing techniques conducted in people with diabetes were eligible. Included studies of diagnostic accuracy were required to report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) which were the primary endpoints. The quality appraisal was conducted using the Quality Assessment of Diagnostic Accuracy Studies and Quality Appraisal of Reliability quality appraisal tools. From a total of 8517 abstracts retrieved, 40 studies met the inclusion criteria for the diagnostic accuracy component of the review and seven studies met the inclusion criteria for the reliability component of the review. Most studies investigated the diagnostic accuracy of ankle -brachial index (ABI) (N = 38). In people with and without DFU, PLRs ranged from 1.69 to 19.9 and NLRs from 0.29 to 0.84 indicating an ABI <0.9 increases the likelihood of disease (but the extent of the increase ranges from a small to large amount) and an ABI within the normal range (≥0.90 and <1.3) does not exclude PAD. For toe-brachial index (TBI), a threshold of <0.70 has a moderate ability to rule PAD in and out; however, this is based on limited evidence. Similarly, a small number of studies indicate that one or more monophasic Doppler waveforms in the pedal arteries is associated with the presence of PAD, whereas tri- or biphasic waveform suggests that PAD is less likely. Several forms of bedside testing may also be useful as adjunct tests and 7 studies were identified that investigated the reliability of bedside tests including ABI, toe pressure, TBI, transcutaneous oxygen pressure (TcPO2 ) and pulse palpation. Inter-rater reliability was poor for pulse palpation and moderate for TcPO2. The ABI, toe pressure and TBI may have good inter- and intra-rater reliability, but margins of error are wide, requiring a large change in the measurement for it to be considered a true change rather than error. There is currently no single bedside test or a combination of bedside tests that has been shown to have superior diagnostic accuracy for PAD in people with diabetes with or without DFU. However, an ABI <0.9 or >1.3, TBI of <0.70, and absent or monophasic pedal Doppler waveforms are useful to identify the presence of disease. The ability of the tests to exclude disease is variable and although reliability may be acceptable, evidence of error in the measurements means test results that are within normal limits should be considered with caution and in the context of other vascular assessment findings (e.g., pedal pulse palpation and clinical signs) and progress of DFU healing.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco (UCSF) Medical Centre, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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10
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Hon K, Nobels F, Senneville É, Uckay I, Maas M, Fitridge R. Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds. Diabetes Metab Res Rev 2024; 40:e3737. [PMID: 37855302 DOI: 10.1002/dmrr.3737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.
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Affiliation(s)
- Kay Hon
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Frank Nobels
- Department of Internal Medicine-Endocrinology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Éric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Ilker Uckay
- Balgrist University Hospital, Zurich, Switzerland
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AUMC), Amsterdam, the Netherlands
| | - Robert Fitridge
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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11
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Thurston B, Fitridge R. Intervention for Aortic Rupture After Prior Abdominal Aortic Aneurysm Repair: Is EVAR the Best Approach? Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00113-8. [PMID: 38311049 DOI: 10.1016/j.ejvs.2024.01.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Benjamin Thurston
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia.
| | - Robert Fitridge
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia; Discipline of Surgery, University of Adelaide, Adelaide, Australia
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12
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Graham K, Fitzpatrick K, Agius J, Loughry C, Ong E, McMillan N, Gunn K, Fitridge R. A qualitative exploration of the experiences of Aboriginal and Torres Strait Islander people using a real-time video-based telehealth service for diabetes-related foot disease. Rural Remote Health 2024; 24:7970. [PMID: 38413381 DOI: 10.22605/rrh7970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
INTRODUCTION Diabetes-related foot disease (DFD) is one of the most prevalent causes of global hospitalisation and morbidity, and it accounts for up to 75% of lower-extremity amputations globally. The 5-year mortality rate following any amputation ranges from 53% to 100%. Early identification of wounds and multidisciplinary management can reduce amputation rates by 39-56%. Rural and remote communities and Indigenous populations are disproportionately affected by DFD. This is reflected in amputation rates, which are much higher for Indigenous than for non-Indigenous Australians and for those in very remote areas than for those in major cities or inner regional areas. The large geographical spread of the population in Australia is a substantial barrier for those providing or accessing health services, particularly multidisciplinary and specialist services, which undoubtedly contributes to poorer DFD outcomes in rural and remote communities. METHODS A real-time, video-based telehealth service for DFD management was established at the Royal Adelaide Hospital Vascular Services clinic to improve access to specialist services for rural and remote Aboriginal and Torres Strait Islander communities. An exploratory qualitative study that utilised one-on-one, semi-structured interviews was conducted with 11 participants who identified as Aboriginal and who had participated in the telehealth foot service. Interviews were transcribed, de-identified and analysed using thematic analysis, using an inductive approach. RESULTS Four interrelated themes emerged. 'Practical benefits of staying home' describes the reduced burden of travel and advantages of having local healthcare providers and support people at consultations. 'Access to specialists and facilities' highlights how some participants felt that there was a lack of appropriate facilities in their area and appreciated the improved access telehealth provided. 'Feeling reassured that a specialist has seen their feet' reflects the positive impact on wellbeing that participants experienced when their feet were seen by specialist health staff. 'Facilitates communication' describes how participants felt included in consultations and how seeing a person on screen assisted conversation. CONCLUSION The advantages of real-time, video-based telehealth go beyond reduced travel burden and improved access to specialist care. This model of care may facilitate relationship-building, patient wellbeing, and feelings of trust and safety for Aboriginal and Torres Strait Islander DFD patients.
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Affiliation(s)
- Kristin Graham
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA 5000, Australia
| | - Katrina Fitzpatrick
- Department of Podiatry, Central Adelaide Local Health Network, Adelaide, SA, Australia; and Watto Purrunna Aboriginal Health Service, Port Adelaide, SA, Australia
| | - Joseph Agius
- Department of Podiatry, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Cathy Loughry
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA 5000, Australia; and Department of Podiatry, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Emilee Ong
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA 5000, Australia
| | - Neil McMillan
- Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, Woodville South, SA, Australia; and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Kate Gunn
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA 5000, Australia
| | - Robert Fitridge
- Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, Woodville South, SA, Australia; and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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13
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Scierka LE, Peri-Okonny PA, Romain G, Cleman J, Spertus JA, Fitridge R, Secemsky E, Patel MR, Gosch KL, Mena-Hurtado C, Smolderen KG. Psychosocial and socioeconomic factors are most predictive of health status in patients with claudication. J Vasc Surg 2024:S0741-5214(24)00081-8. [PMID: 38266885 DOI: 10.1016/j.jvs.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND As a key treatment goal for patients with symptomatic peripheral artery disease (PAD), improving health status has also become an important end point for clinical trials and performance-based care. An understanding of patient factors associated with 1-year PAD health status is lacking in patients with PAD. METHODS The health status of 1073 consecutive patients with symptomatic PAD in the international multicenter PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry was measured at baseline and 1 year with the Peripheral Artery Questionnaire (PAQ). The association of 47 patient characteristics with 1-year PAQ scores was assessed using a random forest algorithm. Variables of clinical significance were retained and included in a hierarchical multivariable linear regression model predicting 1-year PAQ summary scores. RESULTS The mean age of patients was 67.7 ± 9.3 years, and 37% were female. Variables with the highest importance ranking in predicting 1-year PAQ summary score were baseline PAQ summary score, Patient Health Questionnaire-8 depression score, Generalized Anxiety Disorder-2 anxiety score, new onset symptom presentation, insurance status, current or prior diagnosis of depression, low social support, initial invasive treatment, duration of symptoms, and race. The addition of 19 clinical variables in an extended model marginally improved the explained variance in 1-year health status (from R2 0.312 to 0.335). CONCLUSIONS Patients' 1-year PAD-specific health status, as measured by the PAQ, can be predicted from 10 mostly psychosocial and socioeconomic patient characteristics including depression, anxiety, insurance status, social support, and symptoms. These characteristics should be validated and tested in other PAD cohorts so that this model can inform risk adjustment and prediction of PAD health status in comparative effectiveness research and performance-based care.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Poghni A Peri-Okonny
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Gaelle Romain
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Departments of Biomedical and Health Informatics and Internal Medicine, Section of Cardiovascular Disease, University of Missouri-Kansas City, Kansas City, MO
| | - Robert Fitridge
- Vascular Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Eric Secemsky
- Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiology, Department of Internal Medicine, Yale University, New Haven, CT; Department of Psychiatry, Section of Psychology, Yale University, New Haven, CT.
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14
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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15
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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The International Working Group on the Diabetic Foot: Stories and Numbers Behind Three Decades of Evidence-Based Guidelines for the Management of Diabetes-Related Foot Disease. Diabetes Ther 2024; 15:19-31. [PMID: 37971638 PMCID: PMC10786793 DOI: 10.1007/s13300-023-01510-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
Foot disease is a devastating complication of diabetes. For almost 3 decades, the mission of the International Working Group on the Diabetic Foot (IWGDF) is to produce evidence-based guidelines to inform health care providers worldwide on strategies for the prevention and management of diabetes-related foot disease. In this publication, we aim to better inform the reader about 'the story behind' the IWGDF Guidelines and thus facilitate improved uptake of the recommendations described in the guidelines. The first IWGDF Guidelines were published in 1999, and these have been successfully updated every 4 years since. With each update, IWGDF has improved the methodological rigour and extended the topics covered. This has been possible thanks to the involvement of > 100 experts from > 60 countries, all voluntarily dedicating their time. We estimate that the 2023 update of the IWGDF Guidelines required a total 10 years of full-time work, which would have cost 2 million euros if the voluntary work had been financially compensated. The IWGDF Guidelines are not only published in English but also translated to support local implementation. Currently available translations serve 2.9 billion people globally in their native language. As an independent and multidisciplinary organisation, IWGDF hopes that the 2023 update will continue to stimulate clinicians from all different disciplines to deliver the best care possible for these patients, will motivate researchers to undertake the high-quality trials needed to deliver the new evidence to advance the field further, and collectively will support people with diabetes-related foot disease to minimize their disease burdens.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Vascular and Endovascular Surgery Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health-Lisbon, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine, Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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16
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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17
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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18
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Graham K, Siatis CM, Gunn KM, Ong E, Loughry C, McMillan N, Fitridge R. The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration. J Foot Ankle Res 2023; 16:47. [PMID: 37553572 PMCID: PMC10410775 DOI: 10.1186/s13047-023-00645-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/14/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Diabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD. METHODS This exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed. RESULTS Participants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. 'Patients have reduced travel burden' included that telehealth enabled Indigenous patients to stay on country. 'Patients had increased psychosocial support' covered the benefits of having health professionals who knew the patient present in consults. 'Improved access' incorporated how telehealth improved interprofessional relationship building and communication. 'Technological and equipment challenges' highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,'Lack of service communication to rural health professionals', highlighted the need for communication around service details. CONCLUSION Telehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.
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Affiliation(s)
- Kristin Graham
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA, 5000, Australia.
| | - Christie Marie Siatis
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
| | - Kate M Gunn
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
| | - Emilee Ong
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
| | - Cathy Loughry
- Allied Health and Human Performance, The University of South Australia, North Terrace, Adelaide, SA, 5000, Australia
- Department of Podiatry, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Neil McMillan
- Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, Woodville South, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Robert Fitridge
- Basil Hetzel Institute for Translational Health Research, Central Adelaide Local Health Network, Woodville South, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, 5000, Australia
- Vascular and Endovascular Surgery Service, Royal Adelaide Hospital, Adelaide, Australia
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19
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Lee J, Mashayamombe M, Walsh TP, Kuang BKP, Pena GN, Vreugde S, Cooksley C, Carda-Diéguez M, Mira A, Jesudason D, Fitridge R, Zilm PS, Dawson J, Kidd SP. The bacteriology of diabetic foot ulcers and infections and incidence of Staphylococcus aureus Small Colony Variants. J Med Microbiol 2023; 72. [PMID: 37326607 DOI: 10.1099/jmm.0.001716] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Introduction. Uninfected diabetes-related foot ulcer (DFU) progression to diabetes-related foot infection (DFI) is a prevalent complication for patients with diabetes. DFI often progresses to osteomyelitis (DFI-OM). Active (growing) Staphylococcus aureus is the most common pathogen in these infections. There is relapse in 40-60 % of cases even when the initial treatment at the DFI stage apparently clears infection.Hypothesis. S. aureus adopts the quasi-dormant Small Colony Variant (SCV) state during DFU and consequently infection, and when present in DFI cases also permits survival in non-diseased tissues as a reservoir to cause relapse.Aim. The aim of this study was to investigate the bacterial factors that facilitate persistent infections.Methodology. People with diabetes were recruited from two tertiary hospitals. Clinical and bacterial data was taken from 153 patients with diabetes (51 from a control group with no ulcer or infection) and samples taken from 102 patients with foot complications to identify bacterial species and their variant colony types, and then compare the bacterial composition in those with uninfected DFU, DFI and those with DFI-OM, of whom samples were taken both from wounds (DFI-OM/W) and bone (DFI-OM/B). Intracellular, extracellular and proximal 'healthy' bone were examined.Results. S. aureus was identified as the most prevalent pathogen in diabetes-related foot pathologies (25 % of all samples). For patients where disease progressed from DFU to DFI-OM, S. aureus was isolated as a diversity of colony types, with increasing numbers of SCVs present. Intracellular (bone) SCVs were found, and even within uninfected bone SCVs were present. Wounds of 24 % of patients with uninfected DFU contained active S. aureus. All patients with a DFI with a wound but not bone infection had previously had S. aureus isolated from an infection (including amputation), representing a relapse.Conclusion. The presence of S. aureus SCVs in recalcitrant pathologies highlights their importance in persistent infections through the colonization of reservoirs, such as bone. The survival of these cells in intracellular bone is an important clinical finding supporting in vitro data. Also, there seems to be a link between the genetics of S. aureus found in deeper infections compared to those only found in DFU.
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Affiliation(s)
- James Lee
- Department of Molecular and Biomedical Sciences, School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Research Centre for Infectious Disease (RCID), University of Adelaide, Adelaide, South Australia, Australia
- Australian Centre for Antimicrobial Resistance Ecology (ACARE), University of Adelaide, Adelaide, South Australia, Australia
| | - Matipaishe Mashayamombe
- Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tom P Walsh
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
| | - Beatrice K P Kuang
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Guilherme N Pena
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah Vreugde
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Clare Cooksley
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Miguel Carda-Diéguez
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, Valencia, Province of Valencia, Spain
| | - Alex Mira
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, Valencia, Province of Valencia, Spain
| | - David Jesudason
- Endocrinology Unit, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Robert Fitridge
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter S Zilm
- Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph Dawson
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen P Kidd
- Department of Molecular and Biomedical Sciences, School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Research Centre for Infectious Disease (RCID), University of Adelaide, Adelaide, South Australia, Australia
- Australian Centre for Antimicrobial Resistance Ecology (ACARE), University of Adelaide, Adelaide, South Australia, Australia
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20
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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21
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Mashayamombe M, Carda-Diéguez M, Mira A, Fitridge R, Zilm PS, Kidd SP. Subpopulations in Strains of Staphylococcus aureus Provide Antibiotic Tolerance. Antibiotics (Basel) 2023; 12:antibiotics12020406. [PMID: 36830316 PMCID: PMC9952555 DOI: 10.3390/antibiotics12020406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
The ability of Staphylococcus aureus to colonise different niches across the human body is linked to an adaptable metabolic capability, as well as its ability to persist within specific tissues despite adverse conditions. In many cases, as S. aureus proliferates within an anatomical niche, there is an associated pathology. The immune response, together with medical interventions such as antibiotics, often removes the S. aureus cells that are causing this disease. However, a common issue in S. aureus infections is a relapse of disease. Within infected tissue, S. aureus exists as a population of cells, and it adopts a diversity of cell types. In evolutionary biology, the concept of "bet-hedging" has established that even in positive conditions, there are members that arise within a population that would be present as non-beneficial, but if those conditions change, these traits could allow survival. For S. aureus, some of these cells within an infection have a reduced fitness, are not rapidly proliferating or are the cause of an active host response and disease, but these do remain even after the disease seems to have been cleared. This is true for persistence against immune responses but also as a continual presence in spite of antibiotic treatment. We propose that the constant arousal of suboptimal populations at any timepoint is a key strategy for S. aureus long-term infection and survival. Thus, understanding the molecular basis for this feature could be instrumental to combat persistent infections.
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Affiliation(s)
- Matipaishe Mashayamombe
- Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Discipline of Surgery, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Adelaide, SA 5000, Australia
| | - Miguel Carda-Diéguez
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, 46020 Valencia, Spain
| | - Alex Mira
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, 46020 Valencia, Spain
- School of Health and Welfare, Jönköping University, 551 11 Jönköping, Sweden
| | - Robert Fitridge
- Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Discipline of Surgery, Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Basil Hetzel Institute for Translational Research, The Queen Elizabeth Hospital, Adelaide, SA 5000, Australia
| | - Peter S. Zilm
- Adelaide Dental School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Stephen P. Kidd
- Department of Molecular and Biomedical Sciences, School of Biological Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
- Research Centre for Infectious Disease, The University of Adelaide, Adelaide, SA 5005, Australia
- Australian Centre for Antimicrobial Resistance Ecology (ACARE), The University of Adelaide, Adelaide, SA 5005, Australia
- Correspondence:
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22
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Chuter V, Quigley F, Tosenovsky P, Ritter JC, Charles J, Cheney J, Fitridge R. Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:51. [PMID: 35787293 PMCID: PMC9254685 DOI: 10.1186/s13047-022-00550-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/06/2022] [Indexed: 11/20/2022] Open
Abstract
Background Peripheral artery disease (PAD) is implicated in up to 50% of diabetes-related foot ulcers (DFU) and significantly contributes to morbidity and mortality in this population. An evidence-based guideline that is relevant to the national context including consideration of the unique geographical and health care system differences between Australia and other countries, and delivery of culturally safe care to First Nations people, is urgently required to improve outcomes for patients with PAD and DFU in Australia. We aimed to identify and adapt current international guidelines for diagnosis and management of patients with PAD and DFU to develop an updated Australian guideline. Methods Using a panel of national content experts and the National Health and Medical Research Council procedures, the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines were adapted to the Australian context. The guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were applied to the IWGDF guideline for PAD by the expert panel. Recommendations were then adopted, adapted or excluded, and specific considerations for implementation, population subgroups, monitoring and future research in Australia were developed with accompanying clinical pathways provided to support guideline implementation. Results Of the 17 recommendations from the IWGDF Guideline on diagnosis, prognosis and management of PAD in patients with diabetes with and without foot ulcers, 16 were adopted for the Australian guideline and one recommendation was adapted due to the original recommendation lacking feasibility in the Australian context. In Australia we recommend all people with diabetes and DFU undergo clinical assessment for PAD with accompanying bedside testing. Further vascular imaging and possible need for revascularisation should be considered for all patients with non-healing DFU irrespective of bedside results. All centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively, including implementation of intensive cardiovascular risk management. Conclusions A guideline containing 17 recommendations for the diagnosis and management of PAD for Australian patients with DFU was developed with accompanying clinical pathways. As part of the adaptation of the IWGDF guideline to the Australian context, recommendations are supported by considerations for implementation, monitoring, and future research priorities, and in relation to specific subgroups including Aboriginal and Torres Strait Islander people, and geographically remote people. This manuscript has been published online in full with the authorisation of Diabetes Feet Australia and can be found on the Diabetes Feet Australia website: https://www.diabetesfeetaustralia.org/new-guidelines/. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00550-7.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia. .,Discipline of Podiatry, University of Newcastle, Ourimbah, Australia.
| | | | - Patrik Tosenovsky
- Department of Vascular & Endovascular Surgery, Royal Perth Hospital, Wellington Street, Perth, Australia
| | - Jens Carsten Ritter
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia.,Curtin University, School of Medicine, Perth, Australia
| | - James Charles
- First Peoples Health Unit, Griffith University, Gold Coast, Australia
| | | | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia.,Vascular and Endovascular Service, Central Adelaide Local Health Network, Adelaide, Australia
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23
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Aitken SJ, Allard B, Altaf N, Atkinson N, Aziz O, Battersby R, Benson R, Chambers JL, Charlton G, Coleman C, Dawson JA, Dean A, Dhal BS, Fitridge R, Gan J, Hanna J, Hattam AT, Hein M, Hon K, Khoo S, Kilby J, Kuang B, Leong KW, Lim E, Liu JWN, McClure DN, Mehta S, Moss JL, Muller J, Musicki K, Nandhra S, Papanikolas MJ, Pineda FP, Pond F, Ravintharan N, Richards T, Saeed H, Selvaraj CN, Singh G, Sivakumaran Y, Stavert BM, Suthers E, Tang R, Varley VC, Vasudevan TM, Vo UG, Wagner T, Wang J, Wong J. Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation. ANZ J Surg 2022; 92:2305-2311. [PMID: 35674397 PMCID: PMC9347445 DOI: 10.1111/ans.17810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes. METHODS The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail. RESULTS Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity. CONCLUSION Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.
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Affiliation(s)
| | - Sarah J Aitken
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | | | | | - Omar Aziz
- Nepean Hospital, Sydney, NSW, Australia
| | | | - Ruth Benson
- Vascular and Endovascular Research Network, Birmingham, UK
| | | | | | | | | | | | | | | | - John Gan
- Port Macquarie Base Hospital, Port Macquarie, NSW, Australia
| | | | | | | | - Kay Hon
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Samantha Khoo
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Joseph Kilby
- University Hospital Geelong, Geelong, VIC, Australia
| | | | | | - Eunice Lim
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Ju-Wei N Liu
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | - Shreya Mehta
- Concord Repatriation General Hospital, Sydney, NSW, Australia
| | | | | | | | - Sandip Nandhra
- Vascular and Endovascular Research Network, Birmingham, UK
| | | | | | | | | | | | - Hani Saeed
- Western Health, Melbourne, VIC, Australia
| | | | | | | | | | | | | | | | | | - Uyen G Vo
- Fiona Stanley Hospital, Perth, WA, Australia
| | | | - Judy Wang
- University Hospital Geelong, Geelong, VIC, Australia
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24
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Angraal S, Hejjaji V, Tang Y, Gosch KL, Patel MR, Heyligers J, White CJ, Tutein Nolthenius R, Mena-Hurtado C, Aronow HD, Moneta GL, Fitridge R, Soukas PA, Abbott JD, Secemsky EA, Spertus JA, Smolderen KG. One-Year Health Status Outcomes Following Early Invasive and Noninvasive Treatment in Symptomatic Peripheral Artery Disease. Circ Cardiovasc Interv 2022; 15:e011506. [PMID: 35579010 DOI: 10.1161/circinterventions.121.011506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lifestyle changes and medications are recommended as the first line of treatment for claudication, with revascularization considered for treatment-resistant symptoms, based on patients' preferences. Real-world evidence comparing health status outcomes of early invasive with noninvasive management strategies is lacking. METHODS In the international multicenter prospective observational PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry, disease-specific health status was assessed by the Peripheral Artery Questionnaire in patients with new-onset or worsening claudication at presentation and 3, 6, and 12 months later. One-year health status trajectories were compared by early revascularization versus noninvasive management on a propensity-matched sample using hierarchical generalized linear models for repeated measures adjusted for baseline health status. RESULTS In a propensity-matched sample of 1000 patients (67.4±9.3 years, 62.8% male, and 82.4% White), 297 (29.7%) underwent early revascularization and 703 (70.3%) were managed noninvasively. Over 1 year of follow-up, patients who underwent early invasive management reported significantly higher health status than patients managed noninvasively (interaction term for time and treatment strategy; P<0.001 for all Peripheral Artery Questionnaire domains). The average 1-year change in Peripheral Artery Questionnaire summary scores was 30.8±25.2 in those undergoing early invasive, compared with 16.7±23.4 in those treated noninvasively (P<0.001). CONCLUSIONS Patients with claudication undergoing early invasive treatment had greater health status improvements over the course of 1 year than those treated noninvasively. These data can be used to support shared decision-making with patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01419080.
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Affiliation(s)
- Suveen Angraal
- Department of Internal Medicine, University of Missouri Kansas City School of Medicine (S.A.)
| | - Vittal Hejjaji
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Yuanyuan Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO (Y.T., K.L.G.)
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.R.P.)
| | - Jan Heyligers
- Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands (J.H.)
| | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland, AU, and Ochsner Health, New Orleans, LA (C.J.W.)
| | - Rudolf Tutein Nolthenius
- Department of (vascular) Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands (R.T.N.)
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Alpert Medical School of Brown University, Providence, RI (H.D.A.)
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland (H.D.A., G.L.M.)
| | - Robert Fitridge
- Departments of Vascular Surgery, Royal Adelaide and The Queen Elizabeth Hospital, Australia (R.F.)
| | - Peter A Soukas
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (P.A.S., J.D.A.)
| | - Eric A Secemsky
- Division of Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology (E.A.S.), Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute (V.H., J.A.S.), University of Missouri-Kansas City
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (C.M.-H., K.G.S.)
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25
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Scierka LE, Mena-Hurtado C, Shishehbor MH, Spertus JA, Nagpal S, Babrowski T, Bunte MC, Politano A, Humphries M, Chung J, Kirksey L, Alabi O, Soukas P, Parikh S, Faizer R, Fitridge R, Provance J, Romain G, McMillan N, Stone N, Scott K, Fuss C, Pacheco CM, Gosch K, Harper-Brooks A, Smolderen KG. The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale. Int J Cardiol Heart Vasc 2022; 39:100971. [PMID: 35198727 PMCID: PMC8850321 DOI: 10.1016/j.ijcha.2022.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.
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Affiliation(s)
- Lindsey E. Scierka
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Carlos Mena-Hurtado
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Mehdi H. Shishehbor
- Case Western University School of Medicine/Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Sameer Nagpal
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | | | - Matthew C. Bunte
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Amani Politano
- Oregon Health & Science University, Portland, OR, United States
| | | | - Jayer Chung
- Baylor College of Medicine, Houston, TX, United States
| | - Lee Kirksey
- Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Sahil Parikh
- Columbia University – Presbyterian, New York, NY, United States
| | - Rumi Faizer
- University of Minnesota, Minneapolis, MN, United States
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Jeremy Provance
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Gaëlle Romain
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Neil McMillan
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christine Fuss
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christina M. Pacheco
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Avis Harper-Brooks
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Kim G. Smolderen
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
- Yale University, Department of Psychiatry, New Haven, CT, United States
- Corresponding author at: 789 Howard Avenue, New Haven, CT 06519, United States.
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Fernando S, Salagaras T, Schwarz N, Sandeman L, Tan JTM, Xie J, Zareh J, Jensen K, Williamson A, Dimasi C, Chhay P, Toledo-Flores D, Long A, Manavis J, Worthington M, Fitridge R, Di Bartolo BA, Bursill CA, Nicholls SJ, Proud CG, Psaltis PJ. Eukaryotic elongation factor 2 kinase regulates foam cell formation via translation of CD36. FASEB J 2022; 36:e22154. [PMID: 35032419 DOI: 10.1096/fj.202101034r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/14/2021] [Accepted: 12/27/2021] [Indexed: 11/11/2022]
Abstract
Eukaryotic elongation factor 2 kinase (eEF2K) is an atypical protein kinase that controls protein synthesis in cells under stress. Although well studied in cancer, less is known about its roles in chronic inflammatory diseases. Here, we examined its regulation of macrophage cholesterol handling in the context of atherosclerosis. eEF2K mRNA expression and protein activity were upregulated in murine bone marrow-derived macrophages (BMDMs) exposed to oxidized low-density lipoprotein cholesterol (oxLDL). When incubated with oxLDL, BMDMs from eEF2K knockout (Eef2k-/- ) mice formed fewer Oil Red O+ foam cells than Eef2k+/+ BMDMs (12.5% ± 2.3% vs. 32.3% ± 2.0%, p < .01). Treatment with a selective eEF2K inhibitor, JAN-384, also decreased foam cell formation for C57BL/6J BMDMs and human monocyte-derived macrophages. Disabling eEF2K selectively decreased protein expression of the CD36 cholesterol uptake receptor, mediated by a reduction in the proportion of translationally active Cd36 mRNA. Eef2k-/- mice bred onto the Ldlr-/- background developed aortic sinus atherosclerotic plaques that were 30% smaller than Eef2k+/+ -Ldlr-/- mice after 16 weeks of high cholesterol diet (p < .05). Although accompanied by a reduction in plaque CD36+ staining (p < .05) and lower CD36 expression in circulating monocytes (p < .01), this was not associated with reduced lipid content in plaques as measured by oil red O staining. Finally, EEF2K and CD36 mRNA levels were higher in blood mononuclear cells from patients with coronary artery disease and recent myocardial infarction compared to healthy controls without coronary artery disease. These results reveal a new role for eEF2K in translationally regulating CD36 expression and foam cell formation in macrophages. Further studies are required to explore therapeutic targeting of eEF2K in atherosclerosis.
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Affiliation(s)
- Sanuja Fernando
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Thalia Salagaras
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Nisha Schwarz
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Lauren Sandeman
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Joanne T M Tan
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jianling Xie
- Lifelong Health in Nutrition and Metabolism, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jonar Zareh
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Kirk Jensen
- Lifelong Health in Nutrition and Metabolism, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Anna Williamson
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Catherine Dimasi
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Pich Chhay
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Deborah Toledo-Flores
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Aaron Long
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jim Manavis
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Michael Worthington
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Belinda A Di Bartolo
- The Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Christina A Bursill
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen J Nicholls
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Monash Cardiovascular Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Christopher G Proud
- Lifelong Health in Nutrition and Metabolism, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
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Kota A, Subramaniam P, Fitridge R. John anderson – Pioneer of complex aortic endovascular repair in Australia. Indian J Vasc Endovasc Surg 2022. [DOI: 10.4103/ijves.ijves_31_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kuang B, Pena G, Cowled P, Fitridge R, Greenwood J, Wagstaff M, Dawson J. Use of Biodegradable Temporising Matrix (BTM) in the reconstruction of diabetic foot wounds: A pilot study. Scars Burn Heal 2022; 8:20595131221122272. [PMID: 36157311 PMCID: PMC9500262 DOI: 10.1177/20595131221122272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Complex diabetes-related foot wounds are at high risk of infection and subsequent major amputation unless healed expediently. Biodegradable Temporising Matrix (BTM) is a synthetic matrix that facilitates the organisation of the extracellular matrix, resulting in a neodermis layer over these difficult-to-heal areas. The aim of this study was to evaluate the efficacy of using BTM in the reconstruction of challenging diabetic foot wounds. Methods Eighteen patients with complex diabetic foot wounds (exposed tendon, fascia, joint, bone), or chronic ulcers at high shear stress locations had BTM applied. Indications for BTM application were high shear stress location (66.6%), exposed bone (16.6%), exposed fascia (5.6%), exposed tendon (5.6%) and chronic non-healing wound (5.6%). The time to complete healing, infection rate and incidence of subsequent wound breakdown was analysed. Discussion Thirteen of 18 patients completed the BTM treatment regime with all these patients achieving complete wound healing at a median time of 13 weeks. One patient had partial treatment with BTM and four patients were withdrawn from the study following BTM application. The rate of infection and re-ulceration were both 15.4%. Conclusion This is the first prospective cohort pilot study evaluating the use of BTM for complex diabetic foot wounds. BTM demonstrates potential in healing uninfected, non-ischaemic diabetic foot wounds with exposed deep structures and chronic wounds subject to high shear stress. The re-ulceration and infection rates were relatively low for this high-risk population. BTM may also offer promise as an alternative to free flaps. Lay Summary The prevalence of diabetes and its complications, including foot ulcers and wounds, have significantly increased worldwide over the last 40 years. Increasingly patients are admitted to hospital for antibiotics, debridements and subsequent amputations from these wounds. Complex diabetes-associated wounds are those at highest risk of these complications or necessitating more extensive, complex operations such as free flaps. These wounds may have exposed deep structures, be at risk of high shear stress or be chronic non-healing wounds. Temporisers are a type of material which integrates into the wound and promotes in-growth of tissue, ideal for healing over these difficult to heal areas. Biodegradable Temporising Matrix (BTM) is a synthetic temporising matrix which has demonstrated positive outcomes in facilitating healing in burns and plastics wounds, but its effectiveness in diabetic foot wounds has not yet been proven. This is the first prospective cohort pilot study evaluating the use of BTM for complex diabetic foot wounds. BTM demonstrates potential in healing uninfected, non-ischaemic complex diabetic foot wounds and potentially avoiding more complex operations.
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Affiliation(s)
- Beatrice Kuang
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia
| | - Guilherme Pena
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia
| | - John Greenwood
- Adult Burn Service, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Marcus Wagstaff
- Adult Burn Service, Royal Adelaide Hospital, Adelaide, SA, Australia.,Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Joseph Dawson
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia.,Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, SA, Australia
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Carson-Chahhoud KV, Smith BJ, Peters MJ, Brinn MP, Ameer F, Singh K, Fitridge R, Litt J, Edwards D, Koblar SA, Jannes J, Veale AJ, Goldsworthy S, Hnin K, Esterman AJ. Correction: Two-year efficacy of varenicline tartrate and counselling for inpatient smoking cessation (STOP study): A randomized controlled clinical trial. PLoS One 2021; 16:e0262188. [PMID: 34969062 PMCID: PMC8717977 DOI: 10.1371/journal.pone.0262188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0231095.].
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Hart O, Jansen S, Fitridge R, Khashram M. Protocol for a prospective observational study: the Australia and New Zealand Diabetic and Ischaemic Foot Outcomes Study (ANZ-DIFOS). BMJ Open 2021; 11:e050833. [PMID: 34475182 PMCID: PMC8413961 DOI: 10.1136/bmjopen-2021-050833] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/19/2021] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Diabetic foot disease is a common condition globally and is over-represented in indigenous populations. The propensity for patients with diabetic foot disease to undergo minor or major limb amputation is a concern. Diabetic foot disease and lower limb amputation are debilitating for patients and have a substantial financial impact on health services. The purpose of this multicentre study is to prospectively report the presentation, management and outcomes of diabetic foot disease, to validate existing scoring systems and assess long term outcomes for these patients particularly in relation to major limb amputation. METHODS AND ANALYSIS This is a multisite, international, prospective observational study, being undertaken at Waikato Hospital, New Zealand (NZ); Sir Charles Gairdner Hospital, the Royal Adelaide Hospital and the Queen Elizabeth Hospital, Australia. Consecutive participants with diabetic foot disease that meet inclusion criteria and agree to participate will be recruited from multidisciplinary team diabetic foot clinic, vascular clinic, dialysis and admission to hospital. Follow-up of participants will occur at 1, 3, 6 and 12 months. At recruitment and follow-up reviews, information about service details, demographic and clinical history, wound data and discharge information will be recorded. The primary outcomes are the time to wound healing, major amputation, overall mortality and amputation-free survival at 12 months. This study started in NZ in August 2020 and will commence in Australian sites in early 2021. ETHICS AND DISSEMINATION New Zealand Central Health and Disability Ethics Committee (20/CEN/122), Waikato DHB Research Department (RDO020044), Quality Improvement HoD Sir Charles Gairdner Hospital (39715) and the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (13928). Results will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12621000337875).
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Affiliation(s)
- Odette Hart
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Shirley Jansen
- Curtain Medical School, Curtin University, Perth, Western Australia, Australia
- Surgery Division, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular Surgery, Royal Adelaide and Queen Elizabeth Hospitals, Adelaide, South Australia, Australia
| | - Manar Khashram
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
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31
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Mohan IV, Khashram M, Fitridge R. Vascular Surgery in Australia and New Zealand (Australasia). Eur J Vasc Endovasc Surg 2021; 62:338-339. [PMID: 34294507 DOI: 10.1016/j.ejvs.2021.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Irwin V Mohan
- Westmead Hospital, University of Sydney, Sydney, Australia.
| | - Manar Khashram
- Waikato Hospital & Senior Lecturer, University of Auckland, Auckland, New Zealand
| | - Robert Fitridge
- Vascular Surgeon Royal Adelaide Hospital and Discipline of Surgery, University of Adelaide, Adelaide, Australia
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32
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Lotfollahi Z, Dawson J, Fitridge R, Bursill C. The Anti-inflammatory and Proangiogenic Properties of High-Density Lipoproteins: An Emerging Role in Diabetic Wound Healing. Adv Wound Care (New Rochelle) 2021; 10:370-380. [PMID: 33176621 DOI: 10.1089/wound.2020.1308] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Significance: Prolonged inflammation and impaired angiogenesis are the two principal factors that prevent successful wound healing, which is exacerbated in people with diabetes. There is a significant need for new wound healing treatments that target both these factors simultaneously. This review discusses the emerging evidence that high-density lipoproteins (HDL) have pleiotropic wound healing benefits. Recent Advances: Numerous in vitro and in vivo studies have demonstrated the anti-inflammatory and proangiogenic effects of HDL. In endothelial cells, HDL mediate these effects through interaction with the scavenger receptor SR-BI, which activates the PI3K/Akt pathway, causing a decrease in inflammatory protein production and an increase in proangiogenic growth factors. In macrophages, HDL inhibit inflammation through suppression of the nuclear factor kappa B activation pathway. This review details the molecular disturbances that cause impaired wound healing in diabetes with a particular focus on inflammation and angiogenesis and the pathways in which HDL provide benefit. Critical Issues: Diabetic foot ulcers (DFUs) impose a major public health challenge worldwide. It is estimated that 20% patients with DFUs require amputation, which is accompanied by a significant social and economic burden. To date, there are no therapeutic agents with pleiotropic effects that actively improve wound healing, highlighting a therapeutic void for this complex disease.
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Affiliation(s)
- Zahra Lotfollahi
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, Australia
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, Australia
| | - Joseph Dawson
- Discipline of Surgery, and The University of Adelaide, Adelaide, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Robert Fitridge
- Discipline of Surgery, and The University of Adelaide, Adelaide, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Christina Bursill
- Vascular Research Centre, South Australian Health and Medical Research Institute, Adelaide, Australia
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, Australia
- ARC Centre of Excellence for Nanoscale BioPhotonics (CNBP), The University of Adelaide, Adelaide, Australia
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33
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Thomas HM, Ahangar P, Fitridge R, Kirby GTS, Mills SJ, Cowin AJ. Plasma-polymerized pericyte patches improve healing of murine wounds through increased angiogenesis and reduced inflammation. Regen Biomater 2021; 8:rbab024. [PMID: 34221447 PMCID: PMC8242226 DOI: 10.1093/rb/rbab024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/13/2021] [Accepted: 05/10/2021] [Indexed: 12/15/2022] Open
Abstract
Pericytes have the potential to be developed as a cell therapy for the treatment of wounds; however, the efficacy of any cell therapy relies on the successful delivery of intact and functioning cells. Here, the effect of delivering pericytes on wound repair was assessed alongside the development of a surface-functionalized pericyte patch. Plasma polymerization (PP) was used to functionalize the surface of silicone patches with heptylamine (HA) or acrylic acid (AA) monomers. Human pericytes were subsequently delivered to murine excisional wounds by intradermal injection or using the pericyte-laden patches and the comparative effects on wound healing, inflammation and revascularization determined. The AA surface provided the superior transfer of the cells to de-epidermized dermis. Excisional murine wounds treated either with pericytes injected directly into the wound or with the pericyte-laden AA patches showed improved healing with decreased neutrophil infiltration and reduced numbers of macrophages in the wounds. Pericyte delivery also enhanced angiogenesis through a mechanism independent of VEGF signalling. Pericytes, when delivered to wounds, improved healing responses by dampening inflammation and promoting angiogenesis. Delivery of pericytes using PP-AA-functionalized patches was equally as effective as direct injection of pericytes into wounds. Pericyte-functionalized dressings may therefore be a clinically relevant approach for the treatment of wounds.
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Affiliation(s)
- Hannah M Thomas
- Future Industries Institute, University of South Australia, Mawson Lakes SA 5095, Australia.,Cell Therapy Manufacturing Cooperative Research Centre, Adelaide SA 5000, Australia
| | - Parinaz Ahangar
- Future Industries Institute, University of South Australia, Mawson Lakes SA 5095, Australia.,Cell Therapy Manufacturing Cooperative Research Centre, Adelaide SA 5000, Australia
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide SA 5005, Australia
| | - Giles T S Kirby
- Future Industries Institute, University of South Australia, Mawson Lakes SA 5095, Australia
| | - Stuart J Mills
- Future Industries Institute, University of South Australia, Mawson Lakes SA 5095, Australia.,Cell Therapy Manufacturing Cooperative Research Centre, Adelaide SA 5000, Australia
| | - Allison J Cowin
- Future Industries Institute, University of South Australia, Mawson Lakes SA 5095, Australia.,Cell Therapy Manufacturing Cooperative Research Centre, Adelaide SA 5000, Australia
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34
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Pena G, Kuang B, Edwards S, Cowled P, Dawson J, Fitridge R. Factors Associated With Key Outcomes in Diabetes Related Foot Disease: A Prospective Observational Study. Eur J Vasc Endovasc Surg 2021; 62:233-240. [PMID: 34024706 DOI: 10.1016/j.ejvs.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/29/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Diabetic foot disease is a serious and common complication of diabetes mellitus. The aim of this study was to assess limb and patient factors associated with key clinical outcomes in diabetic patients with foot ulcers. METHODS This was a prospective observational study of diabetic patients with foot wounds admitted to a major tertiary teaching hospital in South Australia or seen at associated multidisciplinary foot clinics between February 2017 and December 2018. Patient demographic and clinical data were collected, including limb status severity assessed by the WIfI system and grip strength. Participants were followed up for 12 months. The primary outcomes were major amputation, death, amputation free survival, and completion of healing of the index wound within one year. RESULTS A total of 153 participants were recruited and outcome data were obtained for 152. Forty-two participants underwent revascularisation during the research period. Eighteen participants (11.8%) suffered major amputation of the index limb and 16 (10.5%) died during follow up. Complete wound healing was achieved in 106 (70%) participants. There was a statistically significant association between WIfI stage and major amputation (subdistribution hazard ratio [SHR] 2.75), mortality (hazard ratio [HR] 2.60), amputation free survival (odds ratio [OR] 0.32), and wound healing (SHR 0.69). There was also a statistically significant association between time to healing and grip strength (SHR 0.50), and previous amputations (major or minor) (SHR 0.57). CONCLUSION This prospective study supports the ability of the WIfI classification system to predict one year key clinical outcomes in a diabetic population with foot ulcers. It also demonstrated that grip strength may be a useful predictor of wound healing.
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Affiliation(s)
- Guilherme Pena
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia.
| | - Beatrice Kuang
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Joseph Dawson
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia; Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
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35
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Derbas LA, Patel KK, Muskula PR, Wang J, Gosch K, Fitridge R, Spertus JA, Smolderen KG. Variability in utilization of diagnostic imaging tests in patients with symptomatic peripheral artery disease. Int J Cardiol 2021; 330:200-206. [PMID: 33581177 DOI: 10.1016/j.ijcard.2021.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 12/20/2020] [Accepted: 02/05/2021] [Indexed: 01/09/2023]
Abstract
AIM Imaging can help guide management in peripheral arterial disease (PAD) with symptoms refractory to medical treatment. However, there are no set guidelines to determine when physicians should seek further imaging in patients with PAD for the assessment of new, persistent or worsening symptoms. This study describes the rates and variability in non-invasive and invasive imaging for patients presenting to vascular specialty clinics for symptomatic PAD. METHODS Patients (n=1,275) with a new PAD diagnosis or exacerbation of PAD symptoms were enrolled from 16 vascular clinics. Hierarchical logistic regression models were used to estimate the referral rates for 1) non-invasive and 2) invasive imaging tests, after adjusting for patient demographics, disease characteristics, PAQ summary score, PAD performance measures and country. Median Odds Ratios (MOR) were calculated to examine the variability across sites and providers. RESULTS Mean ABI was 0.67 ± 0.19. There were 690 (54.1%) patients who had imaging, of which 62 (9.0%) had invasive imaging. Imaging rates ranged from 8.6% to 98.6% across sites. The MOR for use of imaging for site was 3.36 (p < 0.001) and provider 3.49 (p < 0.001). The variability was explained primarily by (R2 = 29%) country followed by patient-level factors, provider and lastly site (R2 = 17%, 14%, and 13%, respectively). CONCLUSION There is wide variation in the use of imaging for patients presenting with new onset or recent exacerbations of their PAD. Country, followed by provider and site, were most strongly associated with this variability after adjusting for patient characteristics.
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Affiliation(s)
| | - Krishna K Patel
- University of Missouri Kansas City, Kansas City, MO, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Jingyan Wang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Robert Fitridge
- The University of Adelaide, The Queen Elizabeth Hospital, Woodville, Australia
| | - John A Spertus
- University of Missouri Kansas City, Kansas City, MO, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Kim G Smolderen
- Yale School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, Cardiovascular Medicine Section, New Haven, CT, USA.
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Kuang B, Pena G, Szpak Z, Edwards S, Battersby R, Cowled P, Dawson J, Fitridge R. Assessment of a smartphone-based application for diabetic foot ulcer measurement. Wound Repair Regen 2021; 29:460-465. [PMID: 33657252 DOI: 10.1111/wrr.12905] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/19/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
The accurate measurement of diabetic foot ulcer (DFU) wound size is essential as the rate of wound healing is a significant prognostic indicator of the likelihood of complete wound healing. Mobile phone photography is often used for surveillance and to aid in telemedicine consultations. However, there remains no accurate and objective measurement of wound size integrated into these photos. The NDKare mobile phone application has been developed to address this need and our study evaluates its accuracy and practicality for DFU wound size assessment. The NDKare mobile phone application was evaluated for its accuracy in two- (2D) and three-dimensional (3D) wound measurement. One hundred and fifteen diabetic foot wounds were assessed for wound surface area, depth and volume accuracy in comparison to Visitrak and the WoundVue camera. Thirty five wounds had two assessors with different mobiles phones utilizing both applications to assess the reproducibility of the measurements. The 2D surface area measurements by NDKare showed excellent concordance with Visitrak and WoundVue measurements (ICC: 0.991 [95% CI: 0.988, 0.993]) and between different users (ICC: 0.98 [95% CI: 0.96, 0.99)]. The 3D NDKare measurements had good agreement for depth and fair agreement for volume with the WoundVue camera. The NDKare phone application can consistently and accurately obtain 2D measurements of diabetic foot wounds with mobile phone photography. This is a quick and readily accessible tool which can be integrated into comprehensive diabetic wound care.
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Affiliation(s)
- Beatrice Kuang
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Guilherme Pena
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Zygmunt Szpak
- Australian Institute for Machine Learning, The University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ruth Battersby
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Division of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Joseph Dawson
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia.,Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia.,Division of Surgery, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
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Parvar SL, Ngo L, Dawson J, Nicholls SJ, Fitridge R, Psaltis PJ, Ranasinghe I. Long-term outcomes following endovascular and surgical revascularization for peripheral artery disease: a propensity score-matched analysis. Eur Heart J 2021; 43:32-40. [PMID: 33624819 DOI: 10.1093/eurheartj/ehab116] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/26/2021] [Accepted: 02/14/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Peripheral artery disease (PAD) revascularization can be performed by either endovascular or open surgical approach. Despite increasing use of endovascular revascularization, it is still uncertain which strategy yields better long-term outcomes. METHODS AND RESULTS This retrospective cohort study evaluated patients hospitalized with PAD in Australia and New Zealand who underwent either endovascular or surgical revascularization between 2008 and 2015, and compared procedures using a propensity score-matched analysis. Hybrid interventions were excluded. The primary endpoint was mortality or major adverse limb events (MALE), defined as a composite endpoint of acute limb ischaemia, urgent surgical or endovascular reintervention, or major amputation, up to 8 years post-hospitalization using time-to-event analyses 75 189 patients fulfilled eligibility (15 239 surgery and 59 950 endovascular), from whom 14 339 matched pairs (mean ± SD age 71 ± 12 years, 73% male) with good covariate balance were identified. Endovascular revascularization was associated with an increase in combined MALE or mortality [hazard ratio (HR) 1.13, 95% confidence interval (CI): 1.09-1.17, P < 0.001]. There was a similar risk of MALE (HR 1.04, 95% CI: 0.99-1.10, P = 0.15), and all-cause urgent rehospitalizations (HR 1.01, 95% CI: 0.98-1.04, P = 0.57), but higher mortality (HR 1.16, 95% CI: 1.11-1.21, P < 0.001) when endovascular repair was compared to surgery. In subgroup analysis, these findings were consistent for both claudication and chronic limb-threatening ischaemia presentations. CONCLUSION Although the long-term risk of MALE was comparable for both approaches, enduring advantages of surgical revascularization included lower long-term mortality. This is at odds with some prior PAD studies and highlights contention in this space.
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Affiliation(s)
- Saman L Parvar
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Linh Ngo
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Joseph Dawson
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Vascular & Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, VIC, Australia
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Vascular & Endovascular Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Isuru Ranasinghe
- School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
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Golledge J, Pinchbeck J, Tomee SM, Rowbotham SE, Singh TP, Moxon JV, Jenkins JS, Lindeman JH, Dalman RL, McDonnell L, Fitridge R, Morris DR. Efficacy of Telmisartan to Slow Growth of Small Abdominal Aortic Aneurysms: A Randomized Clinical Trial. JAMA Cardiol 2020; 5:1374-1381. [PMID: 32845283 DOI: 10.1001/jamacardio.2020.3524] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Currently there is no drug therapy for abdominal aortic aneurysm (AAA). Objective To test the efficacy of the angiotensin receptor blocker telmisartan in slowing AAA growth in the Telmisartan in the Management of Abdominal Aortic Aneurysm (TEDY) trial. Design, Setting, and Participants A randomized, double-blind, placebo-controlled trial recruited participants between September 6, 2011, and October 5, 2016, to evaluate the efficacy of telmisartan treatment in patients with AAA. Participants with 35- to 49-mm AAAs recruited from Australia, the Netherlands, and the US were randomized 1:1 to receive telmisartan, 40 mg, or identical placebo. Analyses were conducted according to intention-to-treat principles. Final follow-up was conducted on October 11, 2018, and data analysis was performed between June and November 2019. Intervention Telmisartan, 40 mg, or identical placebo. Main Outcomes and Measures The primary outcome of the difference in AAA growth, assessed on core imaging laboratory-read ultrasonographic scanning, was tested with linear mixed-effects models. Other outcomes included effects on blood pressure, computed tomographic (CT)-measured AAA diameter and volume, time to AAA-related events (AAA repair or mortality due to AAA rupture), and health-related quality of life. Results Of 300 intended participants, 210 were enrolled and randomized to receive telmisartan (n = 107) or placebo (n = 103). Of patients included in the intention-to-treat analysis (telmisartan: n = 106, placebo: n = 101), 183 were men (88%); mean (SD) age was 73.5 (7.9) years. At 1 year, participants receiving telmisartan had mean lower systolic (8.9; 95% CI, 4.1-13.8 mm Hg; P < .001) and diastolic (7.0; 4.3-9.8 mm Hg; P < .001) blood pressure levels compared with participants receiving placebo. A total of 188 participants (91%) received at least 2 ultrasonographic scans and 133 participants (64%) had at least 2 CT scans. There was no significant difference in ultrasonographic-assessed AAA growth rates among those assigned telmisartan (1.68 mm/y) or placebo (1.78 mm/y): mean difference, -0.11 mm/y (95% CI, -0.60 to 0.38 mm/y; P = .66). Telmisartan had no significant effects on AAA growth assessed by CT-measured AAA diameter (mean difference, -0.01 mm/y; 95% CI, -0.02 to 0.01 mm/y; P = .23) or volume (mean difference, -0.02 cm3/y; 95% CI, -0.04 to 0.00 cm3/y; P = .11), AAA-related events (relative risk, 1.35; 95% CI, 0.54-3.35; P = .52), or health-related quality of life (mean difference in physical component score at 24 months, 0.4; 95% CI, 0.4-0.4; P = .80). Hypotensive symptoms (eg, syncope) were twice as common among participants receiving telmisartan compared with placebo (28 [26%] vs 13 [13%]; P = .02), but overall adverse event rates were otherwise similar for both groups. Conclusions and Relevance This underpowered study did not show a treatment effect for telmisartan on small AAA growth. Future trials will need to ensure adequate sample size and duration of follow-up. Trial Registrations anzctr.org.au Identifier: ACTRN12611000931976; ClinicalTrials.gov Identifier: NCT01683084.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Jenna Pinchbeck
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Stephanie M Tomee
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Sophie E Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Joseph V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Australian Institute of Tropical Health and Medicine, Townsville, Queensland, Australia
| | - Jason S Jenkins
- Department of Vascular Surgery, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jan H Lindeman
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Ronald L Dalman
- Department of Surgery, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Lori McDonnell
- Department of Surgery, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Dylan R Morris
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
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Pena G, Kuang B, Szpak Z, Cowled P, Dawson J, Fitridge R. Evaluation of a Novel Three-Dimensional Wound Measurement Device for Assessment of Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2020; 9:623-631. [PMID: 33095125 DOI: 10.1089/wound.2019.0965] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: The initial wound measurement and regular monitoring of diabetic foot ulcers (DFU) is critical to assess treatment response. There is no standardized, universally accepted, quick, reliable, and quantitative assessment method to characterize DFU. To address this need, a novel topographic imaging system has been developed. Our study aims at assessing the reliability and practicality of the WoundVue® camera technology in the assessment of DFU. Approach: The WoundVue system is a prototype device. It consists of two infrared cameras and an infrared projector, and it is able to produce a three-dimensional (3D) reconstruction of the wound structure. Fifty-seven diabetic foot wounds from patients seen in a multidisciplinary foot clinic were photographed from two different angles and distances by using the WoundVue camera. Wound area, volume, and maximum depth were measured for assessment of reliability. Thirty-one of these wounds also had area calculated by using the established Visitrak™ system, and a correlation between the area obtained by using both systems was assessed. Results: WoundVue images analysis showed excellent agreement for area (intraclass correlation coefficient [ICC]: 0.995), volume (ICC: 0.988), and maximum depth (ICC: 0.984). Good agreement was found for area measurement by using the WoundVue camera and Visitrak system (ICC: 0.842). The average percentage differences between measures obtained by using the WoundVue from different angles for assessment of different sizes and shapes of wounds were 2.9% (95% confidence interval [CI]: 0.3-5.4), 12.9% (95% CI: 9.6-35.7), and 6.2% (95% CI: 2.3-14.7) for area, maximum depth, and volume, respectively. Innovation: This is the first human trial evaluating this novel 3D wound measurement device. Conclusion: The WoundVue system is capable of recreating a 3D model of DFU and produces consistent data. Digital images are ideal for monitoring wounds over time, and the WoundVue camera has the potential to be a valuable adjunct in diabetic foot wound care.
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Affiliation(s)
- Guilherme Pena
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Beatrice Kuang
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Zygmunt Szpak
- School of Computer Science, Australian Institute for Machine Learning, The University of Adelaide, Adelaide, South Australia, Australia
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph Dawson
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
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40
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Thomas HM, Ahangar P, Hofma BR, Strudwick XL, Fitridge R, Mills SJ, Cowin AJ. Attenuation of Flightless I Increases Human Pericyte Proliferation, Migration and Angiogenic Functions and Improves Healing in Murine Diabetic Wounds. Int J Mol Sci 2020; 21:ijms21165599. [PMID: 32764293 PMCID: PMC7460558 DOI: 10.3390/ijms21165599] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 12/14/2022] Open
Abstract
Pericytes are peri-vascular mural cells which have an important role in the homeostatic regulation of inflammatory and angiogenic processes. Flightless I (Flii) is a cytoskeletal protein involved in regulating cellular functions, but its involvement in pericyte activities during wound healing is unknown. Exacerbated inflammation and reduced angiogenesis are hallmarks of impaired diabetic healing responses, and strategies aimed at regulating these processes are vital for improving healing outcomes. To determine the effect of altering Flii expression on pericyte function, in vitro and in vivo studies were performed to assess the effect on healing, inflammation and angiogenesis in diabetic wounds. Here, we demonstrated that human diabetic wounds display upregulated expression of the Flii protein in conjunction with a depletion in the number of platelet derived growth factor receptor β (PDGFRβ) +/ neural glial antigen 2 (NG2) + pericytes present in the dermis. Human pericytes were found to be positive for Flii and attenuating its expression in vitro through siRNA knockdown led to enhanced proliferation, migration and angiogenic functions. Genetic knockdown of Flii in a streptozotocin-induced murine model of diabetes led to increased numbers of pericytes within the wound. This was associated with dampened inflammation, an increased rate of angiogenic repair and improved wound healing. Our findings show that Flii expression directly impacts pericyte functions, including proliferation, motility and angiogenic responses. This suggests that Flii regulation of pericyte function may be in part responsible for the changes in pericyte-related processes observed in diabetic wounds.
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Affiliation(s)
- Hannah M Thomas
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Parinaz Ahangar
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Benjamin R Hofma
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Xanthe L Strudwick
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, Australia;
| | - Stuart J Mills
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Allison J Cowin
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Correspondence: ; Tel.: +61-883-025-018
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Kifelew LG, Warner MS, Morales S, Vaughan L, Woodman R, Fitridge R, Mitchell JG, Speck P. Efficacy of phage cocktail AB-SA01 therapy in diabetic mouse wound infections caused by multidrug-resistant Staphylococcus aureus. BMC Microbiol 2020; 20:204. [PMID: 32646376 PMCID: PMC7346408 DOI: 10.1186/s12866-020-01891-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/01/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Diabetic foot ulcer (DFU) is a serious complication of diabetes mellitus. Antibiotic-resistant Staphylococcus aureus is frequently isolated from DFU infections. Bacteriophages (phages) represent an alternative or adjunct treatment to antibiotic therapy. Here we describe the efficacy of AB-SA01, a cocktail of three S. aureus Myoviridae phages, made to current good manufacturing practice (cGMP) standards, and which has undergone two phase I clinical trials, in treatment of multidrug-resistant (MDR) S. aureus infections. RESULTS Wounds of saline-treated mice showed no healing, but expanded and became inflamed, ulcerated, and suppurating. In contrast, AB-SA01 treatment decreased the bacterial load with efficacy similar or superior to vancomycin treatment. At the end of the treatment period, there was a significant decrease (p < 0.001) in bacterial load and wound size in infected phage- and vancomycin-treated groups compared with infected saline-treated mice. In phage-treated mice, wound healing was seen similar to vancomycin treatment. No mortality was recorded associated with infections, and post-mortem examinations did not show any evident pathological lesions other than the skin wounds. No adverse effects related to the application of phages were observed. CONCLUSION Topical application of phage cocktail AB-SA01 is effective, as shown by bacterial load reduction and wound closure, in the treatment of diabetic wound infections caused by MDR S. aureus. Our results suggest that topical phage cocktail treatment may be effective in treating antibiotic-resistant S. aureus DFU infections.
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Affiliation(s)
- Legesse Garedew Kifelew
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia. .,St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
| | - Morgyn S Warner
- Infectious Diseases Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Faculty of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra Morales
- AmpliPhi Biosciences Corporation, Sydney, New South Wales, Australia
| | - Lewis Vaughan
- Research Development and Support, Flinders University, Adelaide, South Australia, Australia
| | - Richard Woodman
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - James G Mitchell
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Peter Speck
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Corrigendum to "Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischaemia" [Eur J Vasc Endovasc Surg 58 (1S) (2019) 1-109>]. Eur J Vasc Endovasc Surg 2020; 60:158-159. [PMID: 32622518 DOI: 10.1016/j.ejvs.2020.04.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospital of Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Centre, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, USA
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Angraal S, Hejjaji V, Derbas L, Patel MR, Heyligers J, White CJ, Tutein Nolthenius R, Mena-hurtado C, Aronow HD, Hiatt WR, Moneta GL, Fitridge R, Soukas P, Abbott JD, Spertus J, Smolderen KG. Abstract 24: Health Status Differences Between Early Invasive and Non Invasive Treatment Strategies in Patients With Peripheral Artery Disease: Insights From Portrait Registry. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In patients with symptomatic peripheral artery disease (PAD), a key treatment goal is to improve their health status; their symptoms, function, and quality of life (QoL). While medical therapy with lifestyle changes is recommended in all, revascularization can be a consideration to alleviate PAD symptoms. We sought to compare the real-world impact of either treatment strategy on patients’ health status improvement.
Methods:
Patients with new or worsening PAD symptoms (Rutherford category 1-3), from 10 U.S. specialty vascular clinics between 2011-2015, who either underwent early revascularization (using stent, angioplasty or surgery within 3 months of enrolment) or medical management alone (statin, aspirin, cilostazol, supervised exercise therapy, risk factor (diabetes, hypertension) management) were identified from the Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry. The Peripheral Artery Questionnaire (PAQ) was used to assess patients’ disease-specific health status at enrollment and at 3, 6 and 12 months of follow up. The differences in PAQ overall summary scores, and each subdomain, were compared using an adjusted generalized linear model for repeated measures (Figure 1).
Results:
Among 797 patients (mean age of 68.6 years, 58.1% male), 226 underwent early revascularization and 571 were managed medically. At baseline, patients in the revascularization vs. medical management cohort had lower PAQ summary scores (mean ± SD; 42.6 ± 20.7 vs. 48.5 ± 22.3, P<0.001) and QoL scores (43.4 ± 23.9 vs. 50.4 ± 26.4, P<0.001). Over 1 year of follow-up, patients who underwent revascularization reported significantly higher health status over time than patients managed medically without revascularization (P <0.001 for all PAQ sub-domains; Figure 1).
Conclusion:
Patients with PAD who received early revascularization had worse health status at baseline, but they reported a greater degree of improvement over 1 year of follow-up when compared to patients managed medically without revascularization. Summarizing real-world health status benefits following a PAD diagnosis is critical to help guide preference-sensitive decisions on PAD management.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Peter Soukas
- Lifespan Cardiovascular Institute, Rhode Island Hosp, Providence, RI
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Carson-Chahhoud KV, Smith BJ, Peters MJ, Brinn MP, Ameer F, Singh K, Fitridge R, Koblar SA, Jannes J, Veale AJ, Goldsworthy S, Hnin K, Esterman AJ. Two-year efficacy of varenicline tartrate and counselling for inpatient smoking cessation (STOP study): A randomized controlled clinical trial. PLoS One 2020; 15:e0231095. [PMID: 32348306 PMCID: PMC7190140 DOI: 10.1371/journal.pone.0231095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/15/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Varenicline tartrate is superior for smoking cessation to other tobacco cessation therapies by 52 weeks, in the outpatient setting. We aimed to evaluate the long-term (104 week) efficacy following a standard course of inpatient-initiated varenicline tartrate plus Quitline-counselling compared to Quitline-counselling alone. METHODS Adult patients (n = 392, 20-75 years) admitted with a smoking-related illnesses to one of three hospitals, were randomised to receive either 12-weeks of varenicline tartrate (titrated from 0.5mg daily to 1mg twice-daily) plus Quitline-counselling, (n = 196) or Quitline-counselling alone, (n = 196), with continuous abstinence from smoking assessed at 104 weeks. RESULTS A total of 1959 potential participants were screened for eligibility between August 2008 and December 2011. The proportion of participants who remained continuously abstinent (intention-to-treat) at 104 weeks were significantly greater in the varenicline tartrate plus counselling arm (29.2% n = 56) compared to counselling alone (18.8% n = 36; p = 0.02; odds ratio 1.78; 95%CI 1.10 to 2.86, p = 0.02). Twenty-two deaths occurred during the 104 week study (n = 10 for varenicline tartrate plus counselling and n = 12 for Quitline-counselling alone). All of these participants had known or developed underlying co-morbidities. CONCLUSIONS This is the first study to examine the efficacy and safety of varenicline tartrate over 104 weeks within any setting. Varenicline tartrate plus Quitline-counselling was found to be an effective opportunistic treatment when initiated for inpatient smokers who had been admitted with tobacco-related disease.
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Affiliation(s)
- Kristin V. Carson-Chahhoud
- Australian Centre for Precision Health, School of Health Sciences, The University of South Australia, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Brian J. Smith
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J. Peters
- Thoracic Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Malcolm P. Brinn
- Australian Centre for Precision Health, School of Health Sciences, The University of South Australia, Adelaide, South Australia, Australia
| | - Faisal Ameer
- Respiratory Medicine, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Kuljit Singh
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Robert Fitridge
- Division of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Simon A. Koblar
- Stroke Research Programme, University of Adelaide, Adelaide, South Australia, Australia
| | - Jim Jannes
- Stroke Research Programme, University of Adelaide, Adelaide, South Australia, Australia
- Stroke Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Antony J. Veale
- Respiratory Medicine Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Sharon Goldsworthy
- Pharmacy Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Khin Hnin
- Department of Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Adrian J. Esterman
- School of Nursing and Midwifery, The University of South Australia, Adelaide, South Australia, Australia
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Pham C, Lizarondo L, Karnon J, Aromataris E, Munn Z, Gibb C, Fitridge R, Maddern G. Strategies for implementing shared decision making in elective surgery by health care practitioners: A systematic review. J Eval Clin Pract 2020; 26:582-601. [PMID: 31490593 DOI: 10.1111/jep.13282] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES To summarize relevant international scientific evidence on strategies aimed at facilitating or improving health care practitioners' adoption of shared decision making in elective surgery. The review evaluated the effectiveness of these strategies and described the characteristics of identified strategies. METHOD A systematic search of the literature was conducted up to March 2019. The review included interventions that targeted patients, health care practitioners, or health systems/organizations. Main outcomes were measures of decision process and decision outcomes. Two independent reviewers conducted study selection, assessed methodological quality and extracted data. RESULTS Fifteen randomized controlled trials, one pseudo-randomized controlled trial, and four quasi-experimental studies were included in this review. The heterogeneity of interventions and the variability of outcomes used to measure the impact of these interventions precluded meta-analysis. All of the interventions included an educational component regarding the medical condition of interest and available treatment options and a supportive component to encourage patients to ask questions and involve themselves in the decision making. Published evidence on shared decision-making interventions in elective surgery is most prevalent in the breast cancer/endocrine and urology specialties, with most studies targeting their shared decision-making interventions at the patient population. The use of multiple media components within an intervention including interactive video appeared to improve patient satisfaction with the shared decision-making process. CONCLUSIONS The use of well-developed educational information provided through interactive multimedia, computer or DVD based, may enhance the decision-making process. The evidence suggests that such multimedia can be used prior to the surgical consultation, presenting medical and surgical information relevant to the upcoming consultation. A decision and communication aid also appears to be an effective method to support the surgeon in patient participation and involvement in the decision-making process.
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Affiliation(s)
- Clarabelle Pham
- College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, SA, Australia.,School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Lucylynn Lizarondo
- The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Jonathan Karnon
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Edoardo Aromataris
- The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Zachary Munn
- The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Catherine Gibb
- Discipline of Surgery, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Robert Fitridge
- Discipline of Surgery, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Guy Maddern
- Discipline of Surgery, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3277. [PMID: 32176448 DOI: 10.1002/dmrr.3277] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023]
Abstract
The accurate identification of peripheral artery disease (PAD) in patients with diabetes and foot ulceration is important, in order to inform timely management and to plan intervention including revascularisation. A variety of non-invasive tests are available to diagnose PAD at the bedside, but there is no consensus as to the most useful test, or the accuracy of these bedside investigations when compared to reference imaging tests such as magnetic resonance angiography, computed tomography angiography, digital subtraction angiography or colour duplex ultrasound. Members of the International Working Group of the Diabetic Foot updated our previous systematic review, to include all eligible studies published between 1980 and 2018. Some 15 380 titles were screened, resulting in 15 eligible studies (comprising 1563 patients, of which >80% in each study had diabetes) that evaluated an index bedside test for PAD against a reference imaging test. The primary endpoints were positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We found that the most commonly evaluated test parameter was ankle brachial index (ABI) <0.9, which may be useful to suggest the presence of PAD (PLR 6.5) but an ABI value between 0.9 and 1.3 does not rule out PAD (NLR 0.31). A toe brachial index >0.75 makes the diagnosis of PAD less likely (NLR 0.14-0.24), whereas pulse oximetry may be used to suggest the presence of PAD (if toe saturation < 2% lower than finger saturation; PLR 17.23-30) or render PAD less likely (NLR 0.2-0.27). We found that the presence of triphasic tibial waveforms has the best performance value for excluding a diagnosis of PAD (NLR 0.09-0.28), but was evaluated in only two studies. In addition, we found that beside clinical examination (including palpation of foot pulses) cannot reliably exclude PAD (NLR 0.75), as evaluated in one study. Overall, the quality of data is generally poor and there is insufficient evidence to recommend one bedside test over another. While there have been six additional publications in the last 4 years that met our inclusion criteria, more robust evidence is required to achieve consensus on the most useful non-invasive bedside test to diagnose PAD.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation, University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki University Hospital, Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Seattle, Washington
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3278. [PMID: 32176442 DOI: 10.1002/dmrr.3278] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 11/10/2022]
Abstract
Clinical outcomes of patients with diabetes, foot ulceration, and peripheral artery disease (PAD) are difficult to predict. The prediction of important clinical outcomes, such as wound healing and major amputation, would be a valuable tool to help guide management and target interventions for limb salvage. Despite the existence of a number of classification tools, no consensus exists as to the most useful bedside tests with which to predict outcome. We here present an updated systematic review from the International Working Group of the Diabetic Foot, comprising 15 studies published between 1980 and 2018 describing almost 6800 patients with diabetes and foot ulceration. Clinical examination findings as well as six non-invasive bedside tests were evaluated for their ability to predict wound healing and amputation. The most useful tests to inform on the probability of healing were skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO2 ≥ 25 mmHg. With these thresholds, all of these tests increased the probability of healing by greater than 25% in at least one study. To predict major amputation, the most useful tests were ankle pressure < 50 mmHg, ABI < 0.5, toe pressure < 30 mmHg, and TcPO2 < 25 mmHg, which increased the probability of major amputation by greater than 25%. These indicative values may be used as a guide when deciding which patients are at highest risk for poor outcomes and should therefore be evaluated for revascularization at an early stage. However, this should always be considered within the wider context of important co-existing factors such as infection, wound characteristics, and other comorbidities.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
| | - Konstantinos Katsanos
- Department of Interventional Radiology, Patras University Hospital School of Medicine, Patras, Greece
| | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Department of Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Garguilo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, Vega de Ceniga M, Veller M, Vermassen F, Wang J, Wang S. Corrigendum to ‘Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia’ [European Journal of Vascular & Endovascular Surgery 58/1S (2019) 1–109]. Eur J Vasc Endovasc Surg 2020; 59:492-493. [DOI: 10.1016/j.ejvs.2019.11.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3276. [PMID: 31958217 DOI: 10.1002/dmrr.3276] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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Affiliation(s)
| | - Rachael O Forsythe
- British Heart Foundation/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, AZ
| | - Sigrid Nikol
- Department of Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Hinchliffe RJ, Schaper NC. Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3279. [PMID: 32176439 DOI: 10.1002/dmrr.3279] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/16/2022]
Abstract
In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13 000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2 years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30 days, 10% vs 9% at 1 year and 13% vs 9% at 2 years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30 day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2 years and 47% (39-71%) at 5 years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre-Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Department of Veterans Affairs, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon P Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Washington, Seattle
| | | | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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