Delphi study to reach international consensus among vascular surgeons on major arterial vascular surgical complications

BackgroundThe complications discussed with patients by surgeons prior to surgery vary, because no consensus on major complications exists. Such consensus may improve informed consent and shared decision-making. This study aimed to achieve consensus among vascular surgeons on which complications are considered major' and which minor,' following surgery for abdominal aortic aneurysm (AAA), carotid artery disease (CAD) and peripheral artery disease (PAD).MethodsComplications following vascular surgery were extracted from Cochrane reviews, national guidelines, and reporting standards. Vascular surgeons from Europe and North America rated complications as major or minor on five-point Likert scales via an electronic Delphi method. Consensus was reached if >= 80% of participants scored 1 or 2 (minor) or 4 or 5 (major).ResultsParticipants reached consensus on 9-12 major and 6-10 minor complications per disease. Myocardial infarction, stroke, renal failure and allergic reactions were considered to be major complications of all three diseases. All other major complications were treatment specific or dependent on disease severity, e.g., spinal cord ischemia, rupture following AAA repair, stroke for CAD or deep wound infection for PAD.ConclusionVascular surgeons reached international consensus on major and minor complications following AAA, CAD and PAD treatment. This consensus may be helpful in harmonizing the information patients receive and improving standardization of the informed consent procedure. Since major complications differed between diseases, consensus on disease-specific complications to be discussed with patients is necessary

Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family

Cognitive changes in cardiovascular patients following a tailored behavioral smoking cessation intervention

Background. Action aimed at changing smoking behavior to prevent cardiovascular patients from further impairing their health is advisable. Cognitive behavioral interventions can be effective in this regard since they attempt to influence cognitive determinants that presumably lead to smoking cessation. The Minimal Intervention Strategy for Cardiology patients (C-M IS) is such an intervention, tailored to the patients' readiness to change, Our aim is to investigate whether the C-MIS is successful in changing patients' cognitions such as attitudes, social influence, self-efficacy and intention to quit during a 1-year period, Methods. Smoking outpatients (N = 315) with cardiovascular disease were included, They were randomized and received either Nicotine Replacement Therapy (NRT) or NRT + C-MIS. At baseline (T I), sociodemographic and clinical characteristics were measured. Cognitions and quitting behavior were assessed at baseline and at four follow-up measurements, Results. Comparing treatments, the C-MIS did not affect pros of quitting. pros of smoking and social influence, We did find small effects of the C-MIS on intention to quit and self-efficacy, although only for higher-educated patients. Conclusion. The C-MIS appears successful in affecting intention to quit and self-efficacy abilities, but only for patients with higher education levels. Initial positive changes in cognitions may also emerge in a medical intervention. such as the provision of NRT. © 2004 Elsevier Inc. All rights reserved