Impact of rural versus urban geographic location on length of stay after carotid endarterectomy

Abstract Background: Reducing the incidence of extended length of stay (ELOS) after carotid endarterectomy (CEA), defined as LOS \u3e I day, is an important quality improvement focus of the Vascular Quality Initiative (VQI). Rural patients with geographic barriers pose a particular challenge for discharge and may have higher incidences of ELOS as a result. The purpose of this study was to examine the impact of patients’ home geographic location on ELOS after CEA. Methods: The VQI national database for CEA comprised the sample for analyses (N = 66,900). Rural-Urban Commuting Area (RUCA) codes, a validated system used to classify the nation’s census tracts according to rural and urban status, was applied to the VQI database and used to indicate patients’ home geographic location. LOS was categorized into two groups: LOS ≤ 1 day (66%) and LOS \u3e 1 day (ELOS) (34%). Multivariable logistic regression was conducted to examine the effect of geographic location on ELOS after adjustment for age, gender, race, and comorbid conditions. Results: A total of 66,900 patients were analyzed and the mean age of the sample was 70.5 ± 9.3 years (40% female). After adjustment for covariates, the urban group had increased risk for ELOS (OR = 1.20, p \u3c 0.001). Other factors that significantly increased risk for ELOS were non-White race/Latinx/Hispanic ethnicity (OR = 1.44, p \u3c 0.001) and nonelective status (OR =3.31, p \u3c 0.001). In addition, patients treated at centers with a greater percentage of urban patients had greater risk for ELOS (OR = 1.008, p \u3c 0.001). Conclusions: These analyses found that geographic location did impact LOS, but not in the hypothesized direction. Even with adjustment for comorbidities and other factors, patients from urban areas and centers with more urban patients were more likely to have ELOS after CEA. These findings suggest that other mechanisms, such as racial disparities, barriers in access to care, and disparities in support after discharge for urban patients may have a significant impact on LOS

Open retrieval management of inferior vena cava filter erosion resulting in symptomatic hydroureteronephrosis

Inferior vena cava filters are effective for the management of thromboembolic disease but can erode into adjacent organ systems in rare instances. Endovascular retrieval of eroded filters has been the preferred management for this complication. We present a case for which endovascular retrieval was not appropriate because of filter orientation and erosion into the ureter and describe successful management using open retrieval of a permanent filter with erosion into the renal collecting system requiring reconstruction. Although minimally invasive retrieval is preferred over open repair, this approach should be considered when filter erosion is not amenable to endovascular retrieval

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population