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Biomedical subjects

K R Poskitt

Publications and source records attributed to K R Poskitt.

At least 19 recordsLinked to original sources
PubMed2007

The Ulcerated Leg Severity Assessment score for prediction of venous leg ulcer healing.

BACKGROUND: The aim of the study was to create a reliable scoring system for the prediction of venous ulcer healing in patients treated with compression. METHODS: A prospective baseline study to identify risk factors for venous ulcer healing was undertaken between March 1999 and August 2001. All patients were treated with multilayer compression. A number of variables were related to 24-week healing rates. A Cox regression model was used to identify risk factors that predicted ulcer healing, from which a scoring system was developed and validated prospectively between February 2004 and March 2005. RESULTS: In the baseline study of 229 patients, patient age, ulcer chronicity and venous refill time (VRT) of 20 s or less were identified as risk factors. Using these factors and hazard ratios from the Cox regression analysis, the following formula was devised: Ulcerated Leg Severity Assessment (ULSA) score=age+chronicity-50 (when VRT is greater than 20 s). Patients with an ULSA score of 50 or less had higher 24-week ulcer healing rates than those with higher scores in both the baseline study (P<0.001, log rank test) and the validation study performed in 86 patients (P=0.007, log rank test). CONCLUSION: The ULSA score may help to identify patients with venous ulcers unlikely to respond to conventional treatment who could be offered alternative therapy.

Adult↗
PubMed2005

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes.

BACKGROUND: The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration. METHODS: Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg. RESULTS: Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3-48) to 15 (4-48) s 1 year after surgery (P < 0.001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery. CONCLUSION: Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common.

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PubMed2005

The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration.

OBJECTIVES: Previous studies have suggested that perforating vein incompetence is reduced by surgery to superficial veins. This study analysed the effect in a randomised clinical trial. DESIGN: Retrospective analysis of duplex data. METHODS: Patients in this study were part of the ESCHAR randomised controlled trial. All patients had chronic venous leg ulceration with superficial venous reflux. Patients were treated with compression bandaging alone or compression plus superficial venous surgery. Legs were assessed using colour venous duplex prior to treatment and at 3 and 12 months. RESULTS: Of 500 patients recruited to the ESCHAR trial, 261 were included in this study. One hundred and forty six of 261 legs were treated with compression alone and 115/261 underwent compression and superficial venous surgery. In the compression group, more legs had incompetent perforators at 12 months (77/131) compared to baseline (61/146, p =0.010, Wilcoxon Signed Ranks test for paired data in 131 legs). Following surgery, significantly fewer legs had incompetent calf perforators (59/115 vs 44/104 at 12 months, p =0.001, Wilcoxon Signed Ranks test for paired data in 104 legs). In addition, significantly fewer legs in the compression and surgery group developed new perforator incompetence in comparison to the group treated with compression alone (12/104 vs 36/131, p =0.003, Chi-Squared test). CONCLUSION: Surgical correction of superficial reflux may abolish incompetence in some calf perforators and offer protection against developing new perforator incompetence.

Bandages↗
PubMed2005

Risk factors for delayed healing and recurrence of chronic venous leg ulcers--an analysis of 1324 legs.

OBJECTIVE: Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ulcer healing and recurrence. METHODS: Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model. RESULTS: A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan-Meier life table analysis). Patient age (p <0.001, HR per year 0.989, 95% CI 0.984-0.995) and ulcer chronicity (p =0.019, HR per month 0.996, 95% CI 0.993-0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time (p <0.001, HR per week 1.016, 95% CI 1.007-1.026) and superficial venous reflux not treated with surgery (p =0.015, HR 2.218, 95% CI 1.166-4.218) were independent risk factors for ulcer recurrence. CONCLUSIONS: Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.

Age Factors↗
PubMed2005

How to approach major surgery where patients refuse blood transfusion (including Jehovah's Witnesses).

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.

Advance Directives↗
PubMed2004

Late survival after elective repair of aortic aneurysms detected by screening.

BACKGROUND: The aim of this study was to examine whether there was any survival advantage in men following elective repair of an abdominal aortic aneurysm (AAA) detected by ultrasound screening compared to those with an AAA detected incidentally. METHODS: A total of 424 men underwent elective AAA repair between 1990 and 1998; 181 were detected in an aneurysm screening programme and 243 were diagnosed incidentally. Follow-up survival data were collected until 2003 (minimum 5 years) and survival curves were compared using regression analysis. RESULTS: The postoperative 30-day mortality rate was significantly lower in men whose aneurysms were detected by screening (4.4%), compared with those detected incidentally (9.0%). Similarly, 5-year survival (78% vs. 65%) and 10-year survival rates (63% vs. 40%) were better after repair of a screen-detected AAA (p<0.0003 at all time intervals, by log rank testing). Multivariate analysis showed that this was largely due to the older age of men who had repair of an incidental AAA (71.2 vs. 67.1 years). CONCLUSION: Men who had elective repair of an AAA detected by screening had a better late survival rate than men whose aneurysm was discovered incidentally because they were younger at the time of surgery.

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PubMed2003

Recommendations for screening intervals for small aortic aneurysms.

BACKGROUND: The aim was to determine the optimum rescreening interval for small abdominal aortic aneurysms (AAAs). METHODS: Data from 12 years of population screening of 65-year-old men were analysed and 1121 small AAAs (less than 4.0 cm in initial diameter) were divided into groups: group 1 (2.6-2.9 cm; n = 625), group 2 (3.0-3.4 cm; n = 330) and group 3 (3.5-3.9 cm; n = 166). Expansion rate and the cumulative proportions to expand to over 5.5 cm, or require surgery, or rupture were calculated. RESULTS: Expansion rate was related to initial aortic diameter: 0.09 cm per year in group 1, 0.16 cm per year in group 2 and 0.32 cm per year in group 3 (P < 0.001). Aneurysms in 2.4 per cent of patients in group 1 exceeded a diameter of 5.5 cm or required surgery within 5 years; there were no ruptures. In group 2, no aorta exceeded 5.5 cm but at 3 years 2.1 per cent had reached 5.5 cm and 2.9 per cent had required surgery. The rupture rate at 3 years was zero. In group 3, the aneurysm diameter exceeded 5.5 cm in 1.2 per cent of patients, but no patient required surgery or experienced rupture within 1 year; at 2 years 10.5 per cent of aneurysms had exceeded 5.5 cm in diameter or required surgery and 1.4 per cent had ruptured. CONCLUSION: The appropriate rescreening interval can be determined by initial aortic diameter in screened 65-year-old men. AAAs of initial diameter 2.6-2.9 cm should be rescanned at 5 years, those of 3.0-3.4 cm at 3 years and those of 3.5-3.9 cm at 1 year.

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PubMed2002

Audit of attendance rates for an infra-inguinal graft surveillance programme--how complete is your graft surveillance?

Much has been written on the subject of graft surveillance following infra-inguinal bypass graft surgery, but surprisingly little information exists on actual attendance rates for such programmes. The aim of this study was to calculate the attendance rate for graft surveillance at the vascular unit in Cheltenham. All patients who entered the graft surveillance programme following an infra-inguinal graft procedure over a 5-year period were included in the study. Partial and complete surveillance attendance rates were calculated for each year in the study period. Both rates were seen to rise over the 5-year period, from 31% to 78% and 0 to 38%, respectively. These attendance rates were much lower than were expected. Vascular units relying on such graft surveillance programmes should evaluate their own 'surveillance rates'.

Ambulatory Care↗
PubMed2001

A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men.

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered 'normal' and no follow-up is arranged. The aim of this study was to ascertain if men with 'normal' aortic diameters at age 65 years ever develop a clinically significant aneurysm. METHODS: A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated. RESULTS: Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval. CONCLUSION: A single, 'normal' ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men.

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PubMed2000

Population screening reduces mortality rate from aortic aneurysm in men.

BACKGROUND: Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population. METHODS: Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages. RESULTS: The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population. CONCLUSION: Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population.

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PubMed2000

Influence of a specialized leg ulcer service on management and outcome.

BACKGROUND: The organization of leg ulcer care is poorly defined in the community. This study assessed the overall influence of a specialized community service on management and outcome of chronic leg ulcers, irrespective of aetiology. METHODS: Assessment and outcome of ulcers were compared in patient samples (n = 200) from East and West Gloucestershire, before and after the introduction of specialized clinics into East Gloucestershire. In clinics, vascular disease was routinely assessed by duplex scanning and determination of the ankle : brachial pressure index. RESULTS: There was no coordinated community structure for the care of patients with leg ulcers before the service was introduced, and 74 and 67 per cent of limbs in East and West Gloucestershire respectively had aetiology undiagnosed. After introduction of the clinics, the 12-week healing rate increased from 12 to 22 per cent in East Gloucestershire (P = 0. 05) and to 47 per cent in the specialized East Gloucestershire clinics (P < 0.001). The 12-month recurrence rate decreased from 50 to 41 per cent in East Gloucestershire and to 17 per cent in the East clinics (P < 0.001). The West Gloucestershire control showed no significant changes. CONCLUSION: A specialized leg ulcer service with defined protocols provides an improved management structure for treating patients with leg ulcers in the community. Accurate diagnosis of chronic leg ulcers and improved outcome may be achieved within this specialized service.

Ambulatory Care↗
PubMed2000

A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally.

OBJECTIVE: to compare predicted and actual mortality rates, using POSSUM scoring, after elective repair of abdominal aortic aneurysms (AAAs) detected from the Gloucestershire Aneurysm Screening Programme and those discovered incidentally. METHODS: a sample of 276 men undergoing elective AAA repair in Gloucestershire between 1991 and 1998 was studied. AAAs were either detected from the screening programme or were discovered incidentally and referred from other sources. Mortality data relating to these patients have been recorded prospectively. POSSUM scoring was performed retrospectively from patients>> notes in both groups and related to outcome (30 day and in-hospital mortality). POSSUM and P-POSSUM methodology were used to compare observed and predicted mortality rates. RESULTS: in the 276 men who had elective AAA repair, the overall mortality rate was 7%. Mortality was lower in screen-detected AAAs (3/111, 3%) than AAAs discovered incidentally (16/175, 9%) (p=0.05). Preoperative physiology scores were significantly lower in men with a screen-detected AAA (median 19, range 13-29 versus 21, 12-41, p<0.001). POSSUM operative scores were similar between the groups. Actual versus predicted death ratios in the sample group were more accurate using POSSUM (ratio 0.93) than P-POSSUM (2.38) analysis. CONCLUSIONS: men with a screen-detected AAA had a lower mortality rate after elective repair than in those detected incidentally; lower preoperative physiology scores suggested they were fitter (as well as younger). In this study POSSUM analysis more accurately predicted outcome than P-POSSUM.

Age Distribution↗
PubMed2000

Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers.

OBJECTIVES: surgical correction of isolated superficial venous reflux in ulcerated legs may reduce short term recurrence rates but the longer term benefits are unknown. DESIGN: prospective non-randomised cohort study. METHODS: consecutive patients with chronic leg ulcers were prospectively assessed at a one-stop clinic over a 4-year period from July 1995 to July 1999. All patients with ankle brachial pressure indices (ABPI)50.85 were initially treated with weekly four-layer bandaging. Venous duplex studies in all ulcerated legs assessed venous reflux pattern with surgery being offered to all those with isolated superficial reflux, of whom 56% accepted. Patients were advised to wear class two elastic compression stockings after healing. RESULTS: 766 legs in 669 patients were assessed. Six hundred and thirty-three legs had an ABPI50.85, 236 (39%) demonstrating isolated superficial venous reflux. Surgery was performed on 131 of these legs. Twelve and 24 week healing rates were 50% and 72% for operated legs and 62% and 74% for non-operated legs (p=0.67; Kaplan-Meier life table analysis). Recurrence rates at 1, 2 and 3 years were 14%, 20% and 26% for operated legs and 28%, 30% and 44% for non-operated legs (p=0.03; Kaplan-Meier life table analysis). CONCLUSION: surgical correction of superficial venous reflux in legs with chronic leg ulceration may reduce ulcer recurrence rate at 1, 2 and 3 years.

Adult↗
PubMed1998

The diagnosis and management of mixed arterial/venous leg ulcers in community-based clinics.

OBJECTIVES: To assess a management protocol for mixed arterial/venous leg ulcers in a community service. DESIGN: Two-year prospective study of outcome with intention of assessing limbs with mixed arterial/venous ulcers when managed by a new protocol. METHOD: Limbs were assessed for venous reflux by duplex and arterial insufficiency by ankle-brachial pressure index (ABPI) and defined into three categories: ABPI > 0.85, 0.5 > ABPI < or = 0.85 (moderate), ABPI < or = 0.5 (severe). Four-layer compression was applied to limbs with normal arteries. Modified compression was applied to limbs with venous and moderate arterial disease with treatment failure triggering arterial imaging and revascularisation. Limbs with venous and severe arterial disease were investigated for revascularisation. RESULTS: Of 267 consecutive limbs, 221 had pure chronic venous ulcers and 46 had mixed arterial/venous ulcers with 33 having moderate and 13 having severe arterial disease. Thirty-six week healing rates for chronic venous, moderate arterial/venous and severe arterial/venous ulcers were 70%, 64% and 23%, respectively. CONCLUSION: Limbs with mixed moderate arterial/venous ulcers achieved rates comparable with venous ulcers with this protocol although nurse-led surveillance was required. Limbs with mixed severe arterial/venous ulcers healed slowly despite an aggressive approach to correct arterial disease.

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