Macrovascular Complications in Patients with Diabetes Mellitus: Incidence and Impact on Survival in Kazakhstan

Background and aim: Diabetic patients are at an increased risk for the development of macrovascular complications such as acute myocardial infarction (AMI), stroke and lower-limb amputations (LLA). This study aimed to explore a. the incidence of hospital admission for macrovascular complications (AMI, stroke, and LLA); b. to assess the impact of hospital admission on survival in a large population with diabetes mellitus living in Kazakhstan.

Materials and methods: Retrospective observational study using a nationwide anonymized electronic database of 98.469 hospitalized diabetic patients from Kazakhstan between November 2013 and December 2019. The incidence of hospital admissions for AMI, stroke and LLA were obtained to calculate their all-time cumulative incidence, and survival rate at follow-up.

Results: The all-time cumulative incidence of hospital admissions was 1.30% for AMI, 1.94% for stroke and 2.94% for LLA. The incidence of macrovascular complications was statistically significantly higher in males compared to females (p-value<0.05). 29.03% of diabetic patients with AMI, 25.16% with stroke and 29.80% with LLA died during the follow-up period. Individuals with AMI had 3.58 (95% CI 3.20; 4.01) times, with stroke 3.86 (95% CI 3.52; 4.24) times and with LLA 3.63 (95% CI 3.38; 3.88) times higher hazard of 6-year death compared to diabetic patients free of these complications. The stratified survival analysis by sex indicated the lower survival in women than in men, and the lower survival in older age groups.

Conclusion: The results from this study shows that cumulative incidence of AMI and stroke among diabetic patients admitted in the hospitals in Kazakhstan between 2013-2019 years was similar to the estimates from other countries, but the incidence of LLA was significantly higher in Kazakhstan. Patients with diabetes mellitus (DM) in Kazakhstan are at high risk of excess mortality if they suffer from macro-vascular complications. More research is required to explore the reasons for the high incidence of those complications, in order to propose systematic solutions for lowering the incidence and improve survival.

Surgical management and outcomes of late-presenting acute limb ischaemia at 2 referral hospitals in Addis Ababa, Ethiopia: A 1-year prospective study

Objective: The study was performed to show the overall perspective of surgical management for acute limb ischemia specific to Ethiopian population.
Methods: A prospective planned cohort study was conducted to analyze the socio-demography, clinical presentation, causes of limb ischemia, and outcomes of surgical intervention, and variables associated with complications of acute limb ischemia.
Results:A total of 102 patients were operated upon. The male to female ratio was 2:1; the mean age of presentation was 54±17 years. Patients presented after an average of 9±4.8 days of symptom onset. The type of procedures performed were, thrombectomy 51(47.2%), primary amputation 24(22.2%), bypass or interposition vascular grafts 10(9.2%), embolectomy 10(9.2%), primary vascular repair 7(6.4%), and femoro-femoral graft 6(5.5%). Local and systemic complications occurred in 35.3% and 17.6% respectively. Amputation after re-vascularization surgery was seen in 32.4%. A 30-day total amputation & mortality rate was 52.9% and 9.8% respectively. Clinical variables found to have a statistical significant association (P<0.05) with complications were age ≥ 60 years, late presentation (≥ 9days), patients with hypertensive disease and previous myocardial infarction.
Conclusions: Optimizing co-morbidities, timely detection and treating immediately on arrival could potentially play a key role in improving surgical outcomes of acute limb ischemia.

Surgical Clip Ligation of Anterior Communicating Artery Aneurysm in a Resource-Limited Setting

Anterior communicating artery (ACOM) aneurysm clipping with intraoperative measures to ensure total occlusion and avoid ischemic complications is standard in countries such as the United States. However, alternatives need to be considered in resource-limited settings. The clipping of an unruptured, superiorly projecting ACOM aneurysm in a resource-limited setting is presented and special nuances that optimize safety are described. Careful surgical technique, meticulous identification of relevant anatomy, post-ligation inspection of the aneurysm and adjacent vessels, and possibly needle puncture of the aneurysm dome are critical to achieve favorable results.

Epidemiology of Surgical Amputations in Tamale Teaching Hospital, Ghana

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. This was a retrospective descriptive study. We analyzed case files of 112 patients who underwent surgical amputations
between 2011 and 2017. Demographics, site of amputation, indication for amputation, and outcomes were
retrieved from case files. Descriptive statistics were used to report the means and frequencies. Associations
between variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean age of the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limb amputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalent indication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days (range 5 to 120). Surgical site infection (17.9%) was the main complication. In our study setting, there is thus far limited capability for proper management of diabetes mellitus, which needs to be improved. There is also an urgent need for multidisciplinary foot care teams that will help patients receive comprehensive care to reduce complications from diabetes and other vasculopathies

Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Starting and Operating a Public Cardiac Catheterization Laboratory in a Low Resource Setting: The Eight-Year Story of the Uganda Heart Institute Catheter Laboratory

Background: Low- and-middle-income-countries (LMICs) currently bear 80% of the world’s cardiovascular disease (CVD) mortality burden. The same countries are underequipped to handle the disease burden due to critical shortage of resources. Functional cardiac catheterization laboratories (cath labs) are central in the diagnosis and management of CVDs. Yet, most LMICs, including Uganda, fall remarkably below the minimum recommended standards of cath lab:population ratio due to a host of factors including the start-up and recurring costs.

Objectives: To review the performance, challenges and solutions employed, lessons learned, and projections for the future for a single cath lab that has been serving the Ugandan population of 40 million people in the past eight years.

Methods: A retrospective review of the Uganda Heart Institute cath lab clinical database from 15 February 2012 to 31 December 2019 was performed.

Results: In the initial two years, this cath lab was dependent on skills transfer camps by visiting expert teams, but currently, Ugandan resident specialists independently operate this lab. 3,542 adult and pediatric procedures were conducted in 8 years, including coronary angiograms and percutaneous coronary interventions, device implantations, valvuloplasties, and cardiac defect closures, among others. There was a consistent expansion of the spectrum of procedures conducted in this cath lab each year. The initial lack of technical expertise and sourcing for equipment, as well as the continual need for sundries present(ed) major roadblocks. Government support and leveraging existing multi-level collaborations has provided a platform for several solutions. Sustainability of cath lab services remains a significant challenge especially in relation to the high cost of sundries and other consumables amidst a limited budget.

Conclusion: A practical example of how centers in LMIC can set up and sustain a public cardiac catheterization laboratory is presented. Government support, research, and training collaborations, if present, become invaluable leverage opportunities.

Long-term mortality after lower extremity amputation: A retrospective study at a second-level government hospital in Cape Town, South Africa

Long-term mortality after lower extremity amputation (LEA) is not well reported in low- and middle-income countries. The primary aim of this study was to report 30-day and one-year mortality after LEA in South Africa. The secondary objective was to report risk factors for one-year mortality.
This was a retrospective study of patients undergoing LEA at New Somerset Hospital, a second-level government facility in Cape Town, South Africa from October 1, 2015 to October 31, 2016. A medical record review was undertaken to identify co-morbidities, operation details, and perioperative mortality rate. Outcome status was defined as alive, dead, or lost to follow-up. Outcomes at 30 days and one-year were reported.
There were 152 patients; 90 (59%) males and the median age was 60 years. Co-morbidities were available for 137 (90%). One hundred and eight (79%) had peripheral vascular disease and 91 (66%) had diabetes mellitus. Fifty-three (35%) had more than one LEA on the same or contralateral limb. There were 183 LEAs in 152 patients. The most common LEA was above knee amputation (n=104, 57%) followed by below-knee amputation (n=36, 20%). At 30 days, 102 (67%) of 152 were traced and 12 (12%) were dead. At one year, 86 (57%) were traced and 37 (43%) were dead.
At this second-level South African hospital, 43% of patients undergoing LEA were dead after one year. In resource-constrained settings, mortality data are necessary when considering resource allocation for LEA and essential surgical care packages.

Placing equity at the core of vascular surgery research

Debus et al have performed a comprehensive longitudinal analysis of vascular surgery publications in 15 major international journals during a 10-year period. Their results confirm previous findings suggesting a dominance of high-income country authors and institutions, especially articles in English, a trend that maintains academic power imbalances, whereby barriers for non-English-speaking and low- and middle-income countries (LMICs) authors are upheld.

Essential Vascular Surgical Care in Low and Middle Income Countries: Towards the Tipping Point

We read with great interest Prendes et al.’ s commentary on lower limb revascularisation in low and middle income countries (LMICs). It has become increasingly apparent that the burden of vascular diseases disproportionally affects vulnerable and LMIC populations as a result of the epidemiological transition away from infectious diseases and towards non-communicable diseases, as a result of the rise in smoking, air pollution, obesity, diabetes, and trauma. Access to emergency and essential vascular surgical care, however, is grossly lacking in LMICs.

An Endovascular Surgery Experience in Far-Forward Military Healthcare-A Case Series

Introduction: The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care.

Materials and methods: We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom.

Results: A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale.

Conclusions: Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.