Interobserver Reliability of Three Validated Scoring Systems in the Assessment of Diabetic Foot Ulcers

Scoring systems for diabetic foot ulcers may be used for clinical purposes, research or audit, to help assess disease severity, plan management, and even predict outcomes. While many have been validated in study populations, little is known about their interobserver reliability. This prospective study aimed to evaluate interobserver reliability of 3 scoring systems for diabetic foot ulceration. After sharp debridement, diabetic foot ulcers were classified by a multidisciplinary pool of trained observers, using the PEDIS (Perfusion, Extent, Depth, Infection, Sensation), SINBAD (Site, Ischemia, Neuropathy, Bacterial infection, Depth), and University of Texas (UT) wound classification systems. Interobserver reliability was assessed using intraclass correlations (0 = no agreement; 1 = complete agreement). Thirty-seven patients (78.4% male) were assessed by a pool of 12 observers. Single observer reliability was slight to moderate for all scoring systems (UT 0.53; SINBAD 0.44; PEDIS 0.23-0.42), but multiple observer reliability was almost perfect (UT 0.94; SINBAD 0.91; PEDIS 0.80-0.90). The worst agreement for single observers was when scoring infection (SINBAD 0.28; PEDIS 0.28), ischemia (SINBAD 0.26; PEDIS 0.23), or both (UT 0.25); however, this improved to almost perfect agreement for multiple observers (infection: 0.83; ischemia: 0.80-0.82; both: 0.81). These classification systems may be reliably used by multiple observers, for example, when conducting research and audit. However, they demonstrate only slight to moderate reliability when used by a single observer on an individual subject and may therefore be less helpful in the clinical setting, when documenting ulcer characteristics or communicating between colleagues. </jats:p

String figures as mathematics?

PARIS7-Bibliothèque centrale (751132105) / SudocSudocFranceF

Prosthetic axillary-axillary arteriovenous straight access (necklace graft) for difficult hemodialysis patients: A prospective single-center experience

BackgroundIt is not uncommon for all usual upper limb autogenous access sites to fail, often in patients for whom neither peritoneal dialysis nor transplantation is an appropriate option. Axillary-axillary arteriovenous bypass grafts could be used as the last option before a thigh autogenous access even in case of unilateral central venous stenosis or obstruction. We describe our experience with this procedure in a series of patients.MethodsA consecutive series of 18 patients for whom all possible arm accesses had failed and neither peritoneal dialysis nor transplantation was possible underwent a necklace graft formation over a 2.5-year period. All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (PTFE, Gore-Tex Intering Vascular Graft, W. L. Gore and Associates, Inc, Flagstaff, Ariz) anastomosed end to side the axillary artery and contralateral vein, and tunneled straight in the subcutaneous space before the sternum. All patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and dialysis adequacy were reviewed. They also had at the same time a transonic assessment where graft flows and recirculation rates were measured. In case of low flow (<600 mL/min) or drop of 20% between two measurements or recirculation >5% a fistulogram was obtained, and an intervention was performed to restore patency.ResultsWe operated on 10 males and 8 females; mean age was 55.1 years. The primary patency was 83% and 72.2%, and the secondary patency was 94.4% and 88.9% at 6 months and 1 year, respectively. Five successful surgical revisions were carried out for four clotted grafts and one post dialysis rupture. One surgical revision for thrombosis failed and one local infection lead to thrombosis and was not amenable to surgical revision. Three patients died of causes unrelated to their vascular access during the study period.ConclusionThe reasonable patency and minimal complications associated with these bypasses show that they are a valid option for complex patients. We advocate the use of this bypass in patients with exhaustion of all access possibilities in both arms with a patent superior vena cava, subclavian, and brachiocephalic veins. We also indicate it in case of unilateral central venous stenosis or obstruction with complete exhaustion of all other access possibilities on the contralateral side