The Edinburgh Claudication Questionnaire (ECQ) was developed to help identify peripheral arterial disease (PAD) in the general population but has not been validated against diagnostic arterial imaging methods such as Duplex Vascular Ultrasound Scanning (DUS). In the present study, we assessed the accuracy of the ECQ for diagnosis using DUS. As part of a National Institute of Health Research funded project looking at novel diagnostic methods, 250 patients were studied from 15 general practices across North East England from May 2015 and November 2016. Practices identified those with a PAD diagnosis from their registers as well as age- and sex-matched controls. All the ECQs were recorded by a vascular specialist nurse. Duplex vascular ultrasound scanning was used as a reference standard for the diagnosis of occlusive PAD. The ECQ had a sensitivity of 52.5% (95% CI: 42.3%-62.5%), specificity of 87.1% (95% CI: 80.6%-92.0%), positive likelihood ratio of 4.06 (95% CI: 2.57-6.42), and negative likelihood ratio of 0.55 (95% CI: 0.44-0.68) compared with reference standard DUS. The ECQ has relatively poor overall diagnostic test accuracy in isolation. It may be helpful in ruling out PAD or as a supplementary test to improve diagnosis of symptomatic disease in General Practice.
Background: Approximately 20% of the UK population aged 55 to 75 years have evidence of peripheral arterial disease (PAD). PAD affects quality of life and life expectancy if not appropriately diagnosed and managed. At risk patients require accurate diagnosis to ensure optimal treatment to slow disease progression and minimize adverse outcomes. Aim: To assess the accuracy of general practice (GP) registration of the diagnosis of peripheral arterial disease (PAD). Design and Setting: An observational analytic case-control study. As part of a National Institute for Health Research–funded (ISRCTN13301188) project assessing novel diagnostic methods set in GP practice. Methods: A total of 125 patients registered as having PAD and 125 age- and sex-matched controls were recruited from 15 general practices across North East England. The register was then assessed for accuracy of diagnosis. Duplex vascular ultrasound scanning (DUS) undertaken by vascular scientists was used as the gold standard reference for PAD. Results: The PAD register had a sensitivity of 86% (95% CI 77%-92%) and specificity of 74% (95% CI 67%-81%) when compared with DUS. The positive predictive value, however, was 69.6% (95% CI 63%-75%) and negative predictive value 88.8% (95% CI 82%-92%). The overall diagnostic effectiveness of the PAD register was 79.2% (95% CI 73%-84%). Conclusion: This analysis indicates that while PAD is detected with reasonable sensitivity in primary care, many patients registered with a diagnosis of PAD lacked DUS-proven disease. Improved approaches to the objective diagnosis of PAD may improve diagnosis and management of PAD in primary care.
Introduction Approximately 5000 major lower-limb amputations (MLLA) for PAD occur per-annum in the UK with clinical outcomes being poor for this high-risk cohort of patients. Existing evidence suggests that anaemic surgical patients have an increased 30-day mortality, but this has not been explored in the context of MLLA. Recent prioritization processes suggested that MLLAs are a target area for research into outcome improvement. This cohort study evaluates the impact of anaemia on the outcome of MLLA to understand if optimization might improve outcomes. Methods All PAD patients undergoing MLLA during 2015–2018 at a tertiary vascular centre were reviewed. Patients were stratified into groups; non-anaemia (>12 g/dL), mild-anaemia (12-10 g/dL) and severe-anaemia (<10 g/dL) by pre-operative haemoglobin (Hb). Primary outcome was overall survival by Kaplan–Meier. Secondary outcomes included length of stay (LOS), post-operative blood-transfusion, surgical-site infection (SSI) and myocardial infarction (MI). Cox-proportional-hazard and receiver-operator characteristics (ROC) analyses were conducted. Results 345 patients were followed up over (mean) 23 months. 105 were non-anaemic, 111 mildly anaemic and 129 severely anaemic. Patients with severe-anaemia had a higher incidence of heart and renal failure ( p = 0.003) than those with non- or mild-anaemia. Overall survival worsened significantly with increasing anaemia ( p = 0.001). LOS was significantly longer in mild-anaemia which is 26 (16–43) days, ( p = 0.006) and severe-anaemia of 28 days (17–40), ( p < 0.001) compared to non-anaemia of 18 (10–30) days. Post-operative blood-transfusion (RBC) was required more frequently in 70.5% of severely anaemic patients ( p < 0.001), compared to mildly anaemic (24.3%) and non-anaemic (7.6%) patients, with those receiving RBCs having a significantly worse survival. There was no difference in MI, SSI or wound dehiscence. Anaemia was significantly associated with mortality; (HR 1.7 (1.04–2.78), p = 0.03). A minimum-Hb of 10.4 g/L (by ROC) was identified as a cutoff Hb for an increased risk of mortality. Conclusion Pre-operative anaemia is associated with worse outcome following MLLA, with increasing severity of anaemia associated with increasing mortality and RBC transfusion being potentially detrimental. More work is required to prospectively evaluate this relationship in this complex and multi-morbid cohort of patients.
Introduction: Anaemia in elective open general and cardiovascular surgery has been shown to have a detrimental impact on clinical outcomes and survival. Endovascular aortic repair (EVAR) is the mainstay for the management of complex aortic aneurysms. The relationship to pre-operative haemoglobin (Hb) and anaemia in standard EVAR is associated with a higher mortality. The role of Hb in fenestrated endovascular aortic repair (FEVAR) has not been specifically evaluated. This tertiary centre study explores the impact of anaemia on FEVAR outcomes. Methods: A prospectively populated database of all FEVAR's performed between 2010 and 2018 were analysed. Anaemia was defined as a pre-operative haemoglobin (Hb) of less than 120g/dL for women and < 130g/dL for men as per WHO guidelines. Pre-, intra-and post-operative metrics were analysed to understand if anaemia impacted on clinical outcome. Comparative statistics and regression analyses were performed. Results: Some 130 patients who underwent FEVAR were included. Mean follow-up was 3.7(2.2) years. 38 patients were anaemic with an average Hb of 112(13)g/dL. 95 patients were not anaemic with a Hb of 145(12)g/dL. At baseline groups were comparable for age, AAA diameter, BMI and gender ratio. The anaemic group patients had a lower eGFR (64.1(23.2) vs. 70.9(18.8) mL/min/1.73m 2) (P¼0.022). Intra-operatively the anaemic patients had a longer procedural time of 242(103) minutes vs. 195.4(88) minutes (P¼0.009). There was no difference in the number of fenestrations (P¼0.696). Post-operatively the anaemic group patients had a greater number of cardiac events (4 vs. 2, P¼0.037). Renal function (eGFR) was lower at day 3 and day 7 in the anaemic group (P¼0.23 and 0.027) but this became similar by 3 months (P¼0.517). There was a significantly longer hospital stay in the anaemic patients of 9.2(7.1) versus 6.3(6.8) days (P¼0.001). Overall mortality at the end of follow-up was higher in the anaemic group with 40% deceased compared to 21% in the non-anaemic group (P¼0.041). An increase in Hb by 1g/dL increased the odds of survival by 18.4% (OR 0.816). Conclusion: The presence of anaemia significantly increases the rate of cardiac complications, duration of hospital stay and overall mortality rate following FEVAR for complex aortic repair. This is associated with a poorer renal function. Optimization of pre-operative Hb may lead to improvements in clinical outcomes for those undergoing FEVAR and a study is underway to evaluate this.
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