Outcomes Among Patients With Chronic Critical Limb Ischemia With No Revascularization Option And Deep Vein Arterialization As A Novel Revascularization Approach: A Systematic Review And Meta-Analysis

Objective: To quantify the 6- and 12-month amputation-free survival (AFS) in patients with “no-option” Rutherford category 5/6 critical limb ischemia (CLI) in current clinical practice and to characterize outcomes and methods for deep vein arterialization as a possible means for revascularization in patients who are not candidates for conventional surgical or endovascular revascularization. We also sought to determine if there was any trend in amputation-free survival before and after 2003 which was the year of publication for the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Background: The natural history of patients with Rutherford category 5/6 CLI who are not candidates for revascularization is not well-known. Deep vein arterialization, or arterial shunting of blood to the deep veins, may offer a potential revascularization option for this select patient population. Methods: Data Sources and Study Selection Natural History of “no-option” Rutherford category 5/6 CLI: 6- and 12-month AFS A systematic review was performed according to PRISMA guidelines. Two pre-specified literature searches were conducted via Ovid utilizing the following databases: MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews (CDSR). For the first literature search, we identified studies reporting AFS in patients with non-revascularizable Rutherford Category 5 or 6 CLI (or any symptomatic/ischemic equivalent) at a minimum follow-up of 6 months. Studies that included a subset of patients with less severe disease (Rutherford Category ≤4) were included. An exploratory search had determined that nearly all studies also included Ruther category 4 patients. As such, a supplemental search was conducted to identify hazard ratios for amputation-free survival or its components between patients (regardless of revascularization status) with more severe (Rutherford Category 5/6), compared with less severe (Rutherford Category ≤4) disease to inform appropriate risk adjustment due to limited available outcome data in high risk patients. For the supplemental search, we selected studies of Rutherford category 4, 5, or 6 patients that reported hazard ratios (HR) for outcomes (AFS, all-cause mortality, or major amputation) between high-risk (Rutherford 5/6) and lower-risk (Rutherford 4) patients. Deep Vein Arterialization A separate (third) systematic review was conducted via Ovid utilizing the following databases: MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews (CDSR). We identified prospective, randomized clinical trials as well as retrospective studies utilizing surgical or percutaneous deep vein arterialization (DVA) for revascularization of lower-extremity peripheral vascular disease. Data Extraction and Synthesis: Natural History of “no-option” Rutherford category 5/6 CLI: 6- and 12-month AFS Data was extracted from relevant articles in duplicate. Extracted information included qualifying CLI criteria, baseline demographics, enrollment dates, and proportion of patients with each Rutherford classification [(3) severe claudication; (4) ischemic rest pain; (5) minor tissue loss; or 6 (major tissue loss)]or Fontaine stage [(IIa) mild claudication; (IIb) moderate severe claudication; (III) ischemic rest pain with or without minor tissue loss; (IV) ulceration or gangrene], and 6- and 12- month endpoints of interest (major amputation, defined as any amputation performed above the level of the ankle, all-cause mortality, and amputation-free survival). Risk of bias of individual studies was assessed with the Cochrane Risk of Bias tool. Objective criteria such as the ability to complete standard treadmill exercise testing, ankle pressures before and after exercise, metatarsal peripheral vascular resistance, and toe pressures were used to impute the Rutherford categories of a study population if they were not directly reported. For studies that included a subset of lower-risk patients (Rutherford class ≤4), an adjustment factor was developed and applied to the observed rates to better reflect outcomes in the population of interest. An adjustment factor for AFS rates was calculated from the reported HRs by log transforming the HR, calculating the weighted average of the log HR, and inverting back to the arithmetic scale. The adjustment factor was then applied to the observed AFS rates in the applicable studies of no-option CLI patients according to the proportion of high-risk (Rutherford category 5/6) and low-risk (Rutherford category ≤4) patients in each study to arrive at an adjusted AFS rate Deep Vein Arterialization Data was extracted from relevant articles in duplicate for studies of deep vein arterialization in patients with CLI (Rutherford class 4 or higher or Fontaine stage III or higher). Extracted information included baseline patient demographics (Rutherford classification or Fontaine stage and comorbidities), peri-procedural outcomes (technical success rate, mortality, and complications within 30 days of procedure), medium-term outcomes (survival, limb salvage rate, cumulative patency, and mean follow-up time). Main Outcomes and Measures: Natural History of “no-option” Rutherford category 5/6 CLI: 6- and 12-month AFS Amputation-free survival (a composite of major amputation, defined as any amputation performed above the level of the ankle, and all-cause mortality) at 6- and 12-months in patients with Rutherford class 5 or 6 CLI and no revascularization options. Due to a scarcity of evidence, we collected HRs for any outcome (n=1 AFS; N=1 death; and N=1 major amputation). Deep Vein Arterialization Technical success, peri-procedural (within 30 days of procedure) mortality and complications, and postprocedural (\u3e30 days postprocedure) survival, limb salvage, and cumulative patency. Results: Natural History of “no-option” Rutherford category 5/6 CLI: 6- and 12-month AFS The meta-analytic adjustment factor for AFS rate at 6- and 12-months between Rutherford 4 patients and Rutherford 5/6 patients was 2.18. A total of 36 studies meeting the selection criteria reported AFS at 6 and/or 12 months; the meta-analytic average AFS rates were 56.5% and 49.8%, respectively. An analysis by time of enrollment determined that AFS was significantly higher at 6 and 12 months in studies enrolling patients after 2003 versus before 2003; therefore, analyses were limited to the recent (after 2003) cohort. The unadjusted meta-analytic average AFS rates at 6 and 12 months were 60.0% (n=23 publications; 1238 patients; 67.5% average Rutherford 5/6) and 56.1% (n=19 studies; 1161 patients; 57.7% average Rutherford 5/6), respectively. The risk-adjusted estimated AFS rates were 43.6% (95% CI, 33.7 – 53.5) at 6 months (n=16 publications, 826 patients; 67.5% average Rutherford 5/6) and 36.8 (95% CI, 19.6-54.1) at 12 months (n=12 publications, 659 patients; 57.7% Rutherford 5/6) in no-option Rutherford category 5 or 6 CLI patients. Deep Vein Arterialization A total of 16 studies were identified reporting results for surgical DVA while 5 studies were identified reporting results for percutaneous (endovascular) DVA. We collected baseline patient comorbidities, Rutherford classification, Fontaine stage, peri-procedural outcomes (technical success, mortality, and complications) and medium-term outcomes (survival, limb salvage, cumulative patency). The average proportions of comorbidities in the surgical deep vein arterialization studies were 73% for diabetes, 60% for hypertension, 38% for hyperlipidemia, 54% for coronary artery disease, 28% for chronic renal disease, and 45% for current smokers. The average technical success rate for surgical deep vein arterialization was 81% with an average periprocedural (\u3c30 \u3edays) mortality of 2.4% and an average complication (\u3c30 \u3edays) rate of 25%. The average technical success rate for percutaneous deep vein arterialization was 93% with an average periprocedural (\u3c30 \u3edays) mortality of 0% and an average periprocedural (\u3c30 \u3edays) complication rate of 16%. Conclusions and Relevance: Approximately half of all patients with advanced critical limb ischemia who are not candidates for current revascularization approaches will die or require major amputation within 1 year. These outcomes have not changed significantly in recent years, and alternative treatments that can address this high-risk population are urgently needed. Percutaneous deep vein arterialization is a promising technique for revascularization in patients with no other treatment options

PHYTOCHEMICAL SCREENING AND ANTIMICROBIAL ACTIVITY OF PORTULACA QUADRIFIDA LINN.

Objective: The objective of the study was to investigate in vitro antimicrobial activity against enterotoxigenic Escherichia coli and Bacillus subtilis and preliminary phytochemical screening of the leaves of Portulaca quadrifida (Linn.). Methods: The solvent extract such as petroleum ether, methanol, and water on the leaves of P. quadrifida (Linn) was prepared by Soxhlet extraction (continuous hot percolation method). These solvent extracts were screened for antimicrobial activity against enterotoxigenic E. coli and B. subtilis at various concentrations and were measured by observing zone of inhibition in mm by disc diffusion method (cup plate method). Results: The preliminary phytochemical screening revealed the flavonoids, fats, and oils in all extracts. Similarly, the presence of alkaloids and tannins was obtained in the petroleum ether and methanolic extracts, while the presence of glycosides was obtained in the methanolic and water extracts. Further, proteins and sterols were found in petroleum extracts. The results of antimicrobial activity shown that methanolic extracts of the plant leaf showed good antimicrobial activity and petroleum ether and water extract showed similar activity but less antimicrobial activity than methanolic extract. The antimicrobial activities of extracts were compared with standard antibiotic such as chloramphenicol. Conclusion: P. quadrifida (Linn.) has broad-spectrum antimicrobial activity and a potential source of new classes of antibiotics that could be useful for infectious disease chemotherapy and control. The phytochemical analysis of the crude extracts of this plant indicates the presence of major phytoconstituents which may have been responsible for the observed antimicrobial property. &nbsp

Investigating the Impact of Proximity and Visual Conation Modes on Enhancing Engagement with Public Large Interactive Displays

Deployment of large interactive displays (LIDs) to public spaces has provided new ways for passersby to gain information. This medium plays the role of transmitter for information visualizations designed to communicate certain messages or provide specific digital experiences. However, prior research has shown that these forms of interactive surfaces are often highly underutilized, even unnoticed, when installed in public spaces. When LIDs are unnoticed, or fail to sufficiently engage passersby, the intended message(s) cannot be transmitted or perceived successfully. To mitigate this problem, this research leverages empirical and theoretical frameworks from the field of Communication Studies, and from the subfield of Symbol Interaction as well as various message functions. Accordingly, we generated several animated visual cues to examine the impact of proximity and conation (persuasion) modes. We also ran a field study to evaluate the interface design. Through implementing of the data analysis, we learned that animation effects are useful assets in order to obviate the conative function of communication (persuade passersby to become engaged with the LID). Our findings emphasize that self-revealing systems design may encourage the user to become engaged with the LID. It was also revealed that randomized animated visual effects had more impact on the passersby touch behaviour

Increasing Passersby Engagement with Public Large Interactive Displays: A Study of Proxemics and Conation

This is the author’s version of the work. It is posted here by permission of ACM for your personal use. Not for redistribution. The definitive version was published in the Proceedings of the 2018 International Conference on Human Factors on Computing Systems on the ACM Digital Library at https://dx.doi.org/10.1145/3279778.3279789Prior research has shown that large interactive displays de- ployed in public spaces are often underutilized, or even un- noticed, phenomena connected to ‘interaction’ and ‘display blindness’, respectively. To better understand how designers can mitigate these issues, we conducted a field experiment that compared how different visual cues impacted engagement with a public display. The deployed interfaces were designed to progressively reveal more information about the display and entice interaction through the use of visual content designed to evoke direct or indirect conation (the mental faculty related to purpose or will to perform an action), and different ani- mation triggers (random or proxemic). Our results show that random triggers were more effective than proxemic triggers at overcoming display and interaction blindness. Our study of conation – the first we are aware of – found that “conceptual” visuals designed to evoke indirect conation were also useful in attracting people’s attention.Natural Sciences and Engineering Research Council of Canad

The impact of diagnostic criteria for gestational diabetes mellitus on adverse maternal outcomes : a systematic review and meta-analysis

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Effect of Different Types of Diagnostic Criteria for Gestational Diabetes Mellitus on Adverse Neonatal Outcomes : A Systematic Review, Meta-Analysis, and Meta-Regression

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