Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories

BACKGROUND

Pacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region.

METHODS

A cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks.

RESULTS

Seven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development.

CONCLUSION

Despite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

Australian evidence-based guidelines for the prevention and management of diabetes-related foot disease: a guideline summary

INTRODUCTION

Diabetes-related foot disease (DFD) - foot ulcers, infection, ischaemia - is a leading cause of hospitalisation, disability, and health care costs in Australia. The previous 2011 Australian guideline for DFD was outdated. We developed new Australian evidence-based guidelines for DFD by systematically adapting suitable international guidelines to the Australian context using the ADAPTE and GRADE approaches recommended by the NHMRC.

MAIN RECOMMENDATIONS

This article summarises the most relevant of the 98 recommendations made across six new guidelines for the general medical audience, including: prevention - screening, education, self-care, footwear, and treatments to prevent DFD; classification - classifications systems for ulcers, infection, ischaemia and auditing; peripheral artery disease (PAD) - examinations and imaging for diagnosis, severity classification, and treatments; infection - examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments; offloading - pressure offloading treatments for different ulcer types and locations; and wound healing - debridement, wound dressing selection principles and wound treatments for non-healing ulcers.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE

For people without DFD, key changes include using a new risk stratification system for screening, categorising risk and managing people at increased risk of DFD. For those categorised at increased risk of DFD, more specific self-monitoring, footwear prescription, surgical treatments, and activity management practices to prevent DFD have been recommended. For people with DFD, key changes include using new ulcer, infection and PAD classification systems for assessing, documenting and communicating DFD severity. These systems also inform more specific PAD, infection, pressure offloading, and wound healing management recommendations to resolve DFD.

Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

Background

Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD.

Methods

We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6–8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel’s and international guideline’s judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies.

Results

We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/

Conclusion

New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00533-8.

Incidence and causes of early unplanned readmission after hospitalisation with peripheral arterial disease in Australia and New Zealand

OBJECTIVE

To evaluate the characteristics and predictors of unplanned readmission within 30 days of hospitalisation for the treatment of peripheral arterial disease (PAD) in Australia and New Zealand.

DESIGN

Analysis of hospitalisations data in the Admitted Patient Collection for each Australian state and territory and the New Zealand National Minimum Dataset (Hospital Events).

SETTING

All public and 80% of private hospitals in Australia and New Zealand.

PARTICIPANTS

Adults (18 years or older) hospitalised with a primary or conditional secondary diagnosis of PAD during 1 January 2010 - 31 December 2015.

MAIN OUTCOME MEASURE

Rate of unplanned readmission (any cause) within 30 days of hospitalisation with PAD.

RESULTS

Of 104 979 admissions included in our analysis (mean patient age, 73.7 years; SD, 12.4 years), 9765 were followed by at least one unplanned readmission within 30 days of discharge (9.3%): 3395 within one week (34.8%) and 7828 within three weeks (80.2%). The most frequent readmission primary diagnoses were atherosclerosis (1477, 15.3%), type 2 diabetes (1057, 10.8%), and "complications of procedures not elsewhere classified" (963, 9.9%). Readmission was more frequent after acute (4830 of 26 304, 18.4%) than elective PAD hospitalisations (4935 of 78 675, 6.3%), but the readmission characteristics were similar. Factors associated with greater likelihood of readmission included acute PAD hospitalisations (odds ratio [OR], 2.04; 95% CI, 1.96-2.17), surgical intervention during the PAD hospitalisation (OR, 1.74; 95% CI, 1.64-1.84), and chronic limb-threatening ischaemia (OR, 1.55; 95% CI, 1.47-1.63).

CONCLUSION

Unplanned readmissions within 30 days of hospitalisation for PAD are often for potentially preventable reasons. Their number should be reduced to improve clinical outcomes for people with PAD.

Update of a Model to Predict Outcomes after Endovascular Aneurysm Repair

BACKGROUND

Risk assessment models must be continuously validated and updated to ensure that predictions remain valid. Here, the Endovascular Aneurysm Repair Risk Assessment Model, developed in 2008, is updated and improved.

METHODS

We used prospectively collected data from Australian patients who underwent elective endovascular aneurysm repair between 2009 and 2013 (n = 695). Data were provided by treating surgeons and the National Death Index. Key outcomes were early and midterm survival, early complications (endoleak, operative, and graft-related) and late complications (endoleak and graft-related). Multinomial logistic regression determined which preoperative variables best predicted each outcome. Area under Receiver Operating Characteristic curve (AUROC), model P-value and internal validation statistics were used to select the best model.

RESULTS

Ten preoperative variables were included in the modeling for 10 key outcomes. The most valid outcomes with AUROC>0.7 were 1- and 3-year survival, 30 and 90-day mortality, early and late endoleak (types I, III and IV) and type II endoleak (with an increase in sac size ≥5 mm). The 10 preoperative variables that contributed to outcome models were self-reported fitness, American Society of Anesthesiologists physical status score, history of stroke/transient ischemic attack, age, aneurysm angle, infrarenal neck length, white cell count, respiratory assessment, diabetes and statin therapy. Fitness alone statistically significantly predicted 30 and 90-day deaths better than any other preoperative variable; achieving high AUROCs (0.78 and 0.80), and high odds ratios (12.8 [95% CI: 1.5-110.4] and 18.1 [95% CI: 2.2-149]).

CONCLUSIONS

An updated interactive predictive model of outcomes after endovascular aneurysm repair has been created. Many of the variables used in the 2008 model continued to be significant, however, new variables including fitness and respiratory assessment, improved the model. The new model uses variables routinely collected preoperatively, and hence can better support surgeon-patient discussions prior to operation. Informing patients of potential risks or likely outcomes following elective surgery can assist with preoperative shared decision-making.

Supporting surgeons in patient-centred complex decision-making: a qualitative analysis of the impact of a perioperative physician clinic

OBJECTIVE

Patients with comorbidities can be referred to a physician-led high-risk clinic for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood. The aims of this study were to understand the factors that influence a surgeon's decision to refer a patient to the clinic, and how the clinic impacts on the management of complex patients.

DESIGN

Qualitative study using theoretical thematic analysis to analyse transcribed semi-structured interviews.

SETTING

Interviews were held in either the surgical consultant's private office or a quiet office/room in the hospital ward.

PARTICIPANTS

Seven surgical consultants who were eligible to refer patients to the clinic.

RESULTS

When discussing the factors that influence a referral to the clinic, all participants initially described the optimisation of comorbidities and would then discuss with examples the challenges with managing complex patients and communicating the risks involved with having surgery. When discussing the role of the clinic, two related subthemes were dominant and focused on the management of risk in complex patients. The participants valued the involvement of the clinic in the decision-making and communication of risks to the patient.

CONCLUSIONS

The integration of the high-risk clinic in this study appears to offer additional value in supporting the decision-making process for the surgical team and patient beyond the clinical outcomes. The factors that influence a surgeon's decision to refer a patient to the clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases.

Effectiveness of preoperative medical consultations by internal medicine physicians: a systematic review

OBJECTIVE

Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery.

DESIGN

Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017.

SETTING

Elective surgery.

STUDY SELECTION

Randomised controlled trials and non-randomised comparative studies conducted in adults.

OUTCOME MEASURES

Length of hospital stay, perioperative morbidity and mortality, costs and quality of life.

RESULTS

The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies.

CONCLUSION

Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients.

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair

BACKGROUND

Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self-reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms.

METHODS

Data were extracted from a trial database. All patients were assigned a fitness level (A (fit) or B (unfit)) based on their self-reported ability to walk briskly for 1 km or climb two flights of stairs. Fitness was used to stratify ASA III patients, with fitter patients assigned ASA IIIA and less fit patients ASA IIIB. Outcomes assessed included survival, reinterventions, endoleak, all early and late complications and early operative complications.

RESULTS

A combined ASA/fitness scale (II, IIIA, IIIB and IV) correlated with 1- and 3-year survival (1-year P = 0.001, 3-year P = 0.001) and early and late complications (P = 0.001 and P = 0.05). On its own, ASA predicted early complications (P = 0.0004) and survival (1-year P = 0.01, 3-year P = 0.01). Fitness alone was predictive for survival (1-year P = 0.001, 3-year P = 0.001) and late complications (P = 0.009).

CONCLUSION

This study shows that even a superficial assessment of fitness is reflected in surgical outcomes, with fitter ASA III patients showing survival patterns similar to ASA II patients. Physicians should be alert to differences in fitness between patients in the ASA III group, despite similarities based on preexisting severe systemic disease.

A comparison of propensity score-based approaches to health service evaluation: a case study of a preoperative physician-led clinic for high-risk surgical patients

RATIONALE, AIMS AND OBJECTIVES

A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design.

METHOD

Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding.

RESULTS

Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts.

CONCLUSIONS

The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations.

Long-term follow-up of last autogenous option arm vein bypass

BACKGROUND

The superiority of autogenous conduits in infrainguinal bypass surgery is well established. At our institution, arm vein is utilized as the last autogenous option for infrainguinal bypass surgery. The aim of this study was to review the long-term outcomes of last autogenous option arm vein bypass.

METHODS

All infrainguinal arm vein bypasses performed between 1997 and 2005 by The Queen Elizabeth Hospital vascular surgeons were identified. Patency, reintervention, limb salvage and survival were calculated using the Kaplan-Meier survival estimate method.

RESULTS

Thirty-eight arm vein bypasses were performed in 35 patients. Eighty-nine per cent were performed for critical limb ischaemia. Median follow-up was 58 months (range 2-121). Twelve-month primary, assisted primary and secondary patency rates were 52%, 73% and 76%, respectively. Three-year primary, assisted primary and secondary patency rates were 32%, 61% and 63%, respectively. Five-year primary, assisted primary and secondary patency rates were 21%, 47% and 49%, respectively. Patency was superior in single compared with spliced vein grafts (P < 0.05). Limb salvage rates at 1, 3 and 5 years were 94%, 87% and 76%, respectively. Patient survival at 1, 3 and 5 years was 92%, 68% and 49%, respectively.

DISCUSSION

Infrainguinal bypass surgery with arm vein can be performed safely with favourable patency and high rates of limb salvage. Secondary interventions to maintain patency are common and we recommend a vigilant surveillance programme to identify the threatened graft.

Quality of Life of Patients With Peripheral Arterial Disease and Chronic Stable Angina

The Coronary Artery Disease in gENeral practiCE (CADENCE) study examined chronic stable angina (CSA). This further analysis examined atherosclerotic risk factors, symptomatic status, clinical management, and quality of life in patients with CSA with and without peripheral arterial disease (PAD). The CADENCE study involved 207 Australian general practitioners (GPs) recruiting 10 to 15 consecutively presenting patients with CSA (n = 2031). General practitioners completed a 2-page case report form, detailing demographic data, cardiovascular status, risk factors, and GP perception of control. Patients completed the Seattle Angina Questionnaire. Patients with coexisting CSA and PAD (17%) were more likely to be older and had more comorbidities than patients with CSA without coexisting PAD. Patients with peripheral arterial disease had a longer history of heart disease and were more likely to experience angina on a weekly basis. Patients with peripheral arterial disease had poorer quality-of-life indices.

Statins inhibit neutrophil infiltration in skeletal muscle reperfusion injury

BACKGROUND

Neutrophil infiltration is a major determinant of ischemia-reperfusion injury (IRI). Statins improve endothelial function by elevating nitric oxide synthase activity and inhibiting adhesion molecule expression and may, therefore, inhibit IRI-induced neutrophil extravasation. Although statins are protective against myocardial IRI and stroke, a role for statins in ameliorating skeletal muscle IRI has not yet been confirmed. This study, therefore, addressed the hypothesis that simvastatin would attenuate the severity of tissue damage during skeletal muscle IRI.

METHODS

Rats were administered simvastatin for 6 d before 4 h hind limb ischemia and 24 h reperfusion. Neutrophil infiltration was assessed using myeloperoxidase (MPO) assays and tissue damage by quantitative immunohistochemical analysis of collagen IV. The effect of reducing nitric oxide levels on the severity of IRI was assessed by administering the NOS inhibitor, N-Imino-L-ornithine (L-NIO), before ischemia.

RESULTS

Simvastatin significantly inhibited IRI-induced MPO activity but not collagen degradation in postischemic skeletal muscle. Inhibition of nitric oxide synthase by L-NIO markedly inhibited neutrophil infiltration and protected against IRI-induced collagen degradation. When both simvastatin and L-NIO were administered before IRI, the IRI-induced elevation in MPO activity was completely inhibited. However, paradoxically, simvastatin counteracted the protective effect of L-NIO against IRI-induced collagen IV degradation.

CONCLUSIONS

The inhibition by simvastatin of IRI-induced neutrophil infiltration in skeletal muscle suggests that statins may be a useful therapy to attenuate the severity of IRI but their precise mechanisms of action remains to be determined. Nitric oxide also plays a cytotoxic, rather than protective, role in mediating IRI in this model.

Arm Vein as a Last Autogenous Option for Infrainguinal Bypass Surgery: It is Worth the Effort

OBJECTIVES

Considerable evidence exists for the use of arm vein conduit in lower limb bypass surgery. The use of arm vein in preference to synthetic conduit as a last autogenous option was assessed for patency and limb salvage outcomes.

MATERIALS AND METHODS

A prospective database was interrogated and checked against TQEH operating theatre database to detect all infrainguinal arm vein bypasses performed between 1997 and 2005. Patency, limb salvage and survival data for 37 arm vein bypasses was calculated using the Kaplan-Meier survival estimate method.

RESULTS

There were no perioperative deaths. 30 day patency rates were 89% primary, 95% secondary and 95% limb salvage. 12 month patency rates were 56% primary, 79% secondary and 91% limb salvage. 5 year patency rates were 37% primary, 76% secondary and 91% limb salvage. There was no significant patency advantage for primary vs. "redo" grafts (p=0.54), single vessel vs. spliced conduits (p=0.33) or popliteal vs tibial outflow (p=0.80). Patient survival rate was 92% and 65% at 1 and 5 years respectively.

CONCLUSION

Lower limb bypasses using arm vein can be performed with favourable patency and limb salvage compared to synthetic conduits. However, secondary interventions are frequently required to maintain patency. We recommend a vigilant surveillance program for early identification of patency threatening disease.

Preoperative Nutritional Status Predicts the Severity of the Systemic Inflammatory Response Syndrome (SIRS) Following Major Vascular Surgery

OBJECTIVES

This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery.

DESIGN AND METHODS

Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery.

RESULTS

Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices.

CONCLUSIONS

Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.

Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts

Three patients with type I proximal endoleak after previous endovascular abdominal aortic aneurysm (AAA) repair were treated with fenestrated endovascular stent grafts. Six renal arteries, three superior mesenteric arteries, and one coeliac axis were targeted for incorporation by graft fenestration. The fenestration-renal ostium interface was secured with balloon-expandable stents and completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. All patients made an uncomplicated recovery. Fenestrated endovascular stent grafts can be used to salvage failed prior endovascular AAA repair in patients who are considered unsuitable for other endovascular or open surgical interventions.

Late reintervention for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm repair in an Australian population

OBJECTIVE

To examine late reintervention rates for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm (AAA) repair in an Australian population.

METHODS

Interrogation of a prospective computerized database identified 1256 consecutive patients (1058 men, 198 women; median age, 70 years; range, 40 to 97 years) who survived open repair of nonruptured (n = 957, group I) and ruptured (n = 299, group II) infrarenal AAA in a single institution between January 1, 1982 and December 31, 2003. Median (range) follow-up was 41 (1 to 261) months for group I and 30 (1 to 243) months for group II.

RESULTS

In group I, 33 patients (3.4%) underwent 38 late reinterventions: 20 patients (2.1%) for aortic graft-related events at a median (range) interval of 36 (1 to 94) months after the index AAA repair, with a 30-day mortality rate of 15%; and 13 patients (1.4%) for new aortoiliac disease at a median (range) interval of 33 (3 to 207) months, with 30-day mortality of 8%. In group II, 15 patients (5%) underwent 16 late reinterventions: 10 patients (3.3%) for aortic graft-related events at a median (range) interval of 5 (2 to 112) months, with a 30-day mortality of 10%; and five patients (1.7%) for new aortoiliac disease at a median (range) interval of 67 (39-105) months, with a 30-day mortality of 40%. There was no significant difference in the late reintervention rate between the groups: group I, 33 (3.4%) of 957 vs group II, 15 (5%) of 299 (P = .23). For all patients, the estimated survival at 1, 3, 5 and 10-years was 90%, 79.4%, 66.4%, and 31.6%, respectively; estimated survival free from reintervention at 1, 3, 5 and 10-years was 98.7%, 97.1%, 95.1%, and 91.9%, respectively.

CONCLUSIONS

These data demonstrate, for the first time, that open AAA repair has excellent long-term durability in an Australian population and the results compare favorably with previous reports from North America and Europe. These data represent an important benchmark for comparison of the results of endovascular AAA repair in this patient population.

Trends in the Presentation and Surgical Management of the Acute Diabetic Foot

BACKGROUND

This study examines trends in the presentation and surgical management of acute diabetic foot problems in a single institution.

METHOD

Prospective audit of all diabetic patients who had a primary procedure for critical lower limb ischaemia (CLI) and/or foot sepsis between 1st January 1990 and 31st December 2002. Primary and secondary intervention, mortality and limb salvage rate within 6 weeks of the index procedure were recorded.

RESULTS

There were 661 patients (417 men and 244 women of median age 69, range 31-99, years) with 799 affected limbs. CLI alone was present in 625 (78%) limbs, combined CLI and foot sepsis in 53 (7%) and foot sepsis alone in 121 (15%). The primary intervention was minor amputation in 323 (40%) limbs, revascularisation in 288 (36%), major amputation in 185 (23%) and sympathectomy in three limbs. Within 6 weeks, 125 (16%) limbs required secondary intervention, the peri-procedural mortality rate was 38 of 924 (4%), and the limb salvage rates for patients with CLI, combined CLI and sepsis and sepsis alone were 66, 66 and 80%, respectively. There was a significant decline in the proportion of patients presenting with CLI alone and a significant increase in the proportion presenting with combined CLI and sepsis and sepsis alone. In patients with CLI alone, there was a significant increase in the primary major amputation rate and a significant decline in the minor amputation rate with no significant change in the revascularisation rate.

CONCLUSION

There has been a progressive decline in the proportion of patients presenting with CLI alone and a greater proportion of patients presenting with an element of foot sepsis. In patients with CLI alone, the primary major amputation rate has increased at the expense of a decline in minor amputation rate.

Infra-inguinal revascularization surgical site infections: Australasian benchmark

BACKGROUND

Infra-inguinal revascularization surgery remains one of the most commonly performed major vascular procedures in contemporary practice. Surgical site infections (SSI) are a common cause of morbidity in this patient cohort and generate high rates of limb loss and mortality when vascular graft involvement occurs. An overall reduction in North American SSI has been attributed to the establishment of national benchmarks. A comparable Australasian benchmark does not exist. The purpose of the present study was to assess the methods used by Australasian vascular units to determine SSI rates and to instigate the development of an acceptable benchmark.

METHODS

A structured questionnaire pertaining to SSI after infra-inguinal revascularization surgery was sent to 26 Australasian vascular units. Data requested included the number and type of lower extremity revascularization procedures performed. Units were also asked to report the methods employed for defining and detecting wound infections and to document their SSI rate. The incidence of SSI causation by methicillin-resistant Staphylococcus aureus (MRSA) was also sought.

RESULTS

The total number of revascularizations performed annually varied from 28 to 179 between units. The SSI rates ranged from 0 to 38%. The incidence of MRSA involvement varied from <1% to 56%. The SSI surveillance methodology varied considerably between units.

CONCLUSIONS

The present study confirms the significant incidence of SSI after infra-inguinal revascularization surgery in contemporary vascular practice. Standardized definitions and surveillance protocols are required to facilitate inter- and intrahospital comparisons. A possible benchmark infection rate may be 10-20%.

Systematic review of endovenous laser treatment for varicose veins

Background

The safety and effectiveness of endovenous laser treatment (EVLT) for varicose veins are not yet fully evaluated.

Methods

Medical bibliographic databases, the internet and reference lists were searched from January 1966 to September 2004. Only case series were available for inclusion in the review.

Results

Thirteen studies met the inclusion criteria. Self-limiting features, such as pain, ecchymosis, induration and phlebitis, were commonly encountered after treatment. Deep vein thrombosis and incorrect placement of the laser in vessels were uncommon adverse events. No study has yet assessed the effectiveness of laser therapy in comparison to saphenofemoral junction ligation with saphenous vein stripping. Occlusion of the saphenous vein and abolition of venous reflux occurred in 87·9–100 per cent of limbs, with low rates of re-treatment and recanalization.

Conclusion

From the low-level evidence available it seems that EVLT benefits most patients in the short term, but rates of recanalization, re-treatment, occlusion and reflux may alter with longer follow-up. The lack of such data, in addition to the small numbers of patients in the available studies, demonstrates the need for a randomized clinical trial of EVLT versus conventional surgery.

Nitric Oxide and Skeletal Muscle Reperfusion Injury: Current Controversies (Research Review)

Nitric oxide (NO) has been implicated in a large number of disease processes, including ischemia-reperfusion injury following the restoration of oxygenated blood to previously ischemic muscle, which is a recognized significant complication of vascular surgery. Altered metabolism of NO is implicated in the endothelial dysfunction that forms part of the pathophysiology of ischemia-reperfusion injury. However, NO can demonstrate either protective or cytotoxic effects during reperfusion injury. The use of transgenic mice, either NO synthase (NOS) gene knockout animals, or animals that over-express NOS isoforms, along with direct NO measurements and NO donor or inhibitor studies, have all demonstrated a role for NO in skeletal muscle reperfusion injury. There appears to be an initial stimulation of NO production in the first 20-min of ischemia, with a gradual decline through early reperfusion and a second higher peak of NO commencing in the later stages of reperfusion. The absolute levels of NO in the reperfused tissue and its regulation by the subtle interplay with superoxide and the subsequent production of the highly toxic peroxynitrite anion, are important factors in determining whether NO, in the context of ischemia-reperfusion injury, has damaging or protective effects in the body.

LETTER TO THE EDITOR: The Other Side: Failure in Fair and Balanced Reporting

Matrix metalloproteinases (MMPs) and their tissue inhibitors play important roles in the wound-healing process. An imbalance in the expression of these molecules is thought to contribute to the failure of chronic ulcers to heal. We investigated whether a mitogenic bovine whey extract enriched with growth factors modulated the expression and activity of MMP-2 and -9, and the tissue inhibitor of MMP-2 (TIMP-2) in chronic leg ulcers. Wound fluids and biopsies were collected from chronic leg ulcer patients whose ulcers were treated topically for 4 weeks with placebo or mitogenic bovine whey extract at concentrations of 2.5, 10, and 20 mg/mL. The levels of MMP-2 and -9 in wound fluid samples was assessed by gelatin zymography and showed a decrease in active MMP-2 in the 2.5 and 10.0 mg/mL mitogenic bovine whey extract-treated ulcers compared with placebo (p<0.05). Immunohistochemical analysis of ulcer biopsies for MMP-2, -9, and TIMP-2 expression showed a reduction in the number of MMP-2-positive dermal fibroblasts in the mitogenic bovine whey extract-treated ulcers compared with pretreatment biopsies (p<0.05) that persisted over the course of the study. In contrast, a transient increase in the number of MMP-9- and TIMP-2-positive cells was observed in mitogenic bovine whey extract treated ulcer biopsies compared with pretreatment levels (p<0.05). These results show that topical application of mitogenic bovine whey extract was able to modulate the expression of MMP-2, -9, and TIMP-2 in chronic leg ulcers and that its constituent growth factors may have the potential to redress the proteolytic imbalance observed in nonhealing chronic ulcers.

Intra-abdominal packing for uncontrollable haemorrhage during ruptured abdominal aortic aneurysm repair

OBJECTIVE

Intra-abdominal packing is a valuable adjunct in patients with abdominal trauma and uncontrollable bleeding but few data exist regarding early and late outcome associated with this technique in patients with ruptured abdominal aortic aneurysm (AAA).

METHODS

Interrogation of a prospective vascular surgical database identified 23 patients (22 men; median age 69, range 59-82, years) with ruptured AAA who required intra-abdominal packing for control of coagulopathic haemorrhage after insertion of an aortic graft between January 1982 and December 2003. Co-morbidity, operative and outcome data were retrieved.

RESULTS

Haemostasis was achieved and packs were removed within 48 h in 20 patients. In those patients who had a graft inserted, the peri-operative mortality rate was 12 of 23 (52%) patients (vs. 172 of 455 (38%) patients who were not packed, NS). Three (13%) patients developed early intra-abdominal sepsis, which was universally fatal: graft-enteric fistula, intra-abdominal abscess with necrotizing fasciitis of the abdominal wound, and infected retroperitoneal haematoma. Two of 11 (18%) survivors developed late graft-related infective complications: major aortic graft infection at 6 months and symptomatic infected para-anastomotic aortic false aneurysm at 39 months. Early and late intra-abdominal infective complications were significantly more common in patients who were packed than in those who were not (packed: five of 23, 22% vs. non-packed: five of 455, 1%; p < 0.001).

CONCLUSION

These data demonstrate that intra-abdominal packing in coagulopathic patients with ruptured AAA can achieve an acceptable survival rate. However, this technique may be associated with an increased incidence of early and late intra-abdominal infective complications.

The role of statins in vascular disease

BACKGROUND

Recent publications have highlighted the benefits of statins in non-cardiac occlusive disease but also the failure of vascular surgeons to recognise and treat the risk factors for atherosclerosis, in particular hypercholesterolaemia. The aim of this review is to clarify the current experimental and clinical evidence for the use of statins in vascular disease.

METHODS

Literature compiled from an extensive search of Medline and the Cochrane database has been used for the basis of this review.

RESULTS

Experimental and clinical evidence consistently reports that statins improve endothelial dysfunction, are anti-inflammatory, anti-proliferative, anti-thrombogenic and anti-proteolytic. These effects are known to inhibit atherogenesis and improve plaque stability. Independent groups support the use of statins in the prevention of both primary and secondary cardiac events. The National Stroke association recommends their use to reduce strokes following myocardial infarction and the Heart Protection Study reports benefits in patients with non-cardiac occlusive disease.

CONCLUSIONS

There is substantial evidence advocating the use of statins in patients with clinically significant vascular disease. In the future this may evolve to include those patients at risk from neointimal hyperplasia, aneurysmal disease and ischaemia reperfusion injury.

Aortic aneurysm repair with a functioning renal transplant: therapeutic options

BACKGROUND

Aortic aneurysm repair in the presence of a functioning renal transplant carries significant risks of renal ischaemia. We describe the management of patients undergoing this treatment by using a temporary, externally sited axillofemoral bypass and discuss other treatment options.

METHODS

Three patients underwent a temporary, externally sited axillary artery to common femoral artery bypass. The aneurysm was then dissected via a transperitoneal incision. When the aneurysm was clamped, the axillofemoral graft was opened allowing retrograde perfusion to the renal transplant.

RESULTS

All three patients made a good recovery without postoperative deterioration of renal function.

CONCLUSION

Numerous methods of protecting the transplanted kidney have been described, including expeditious surgery with no renal protection or some form of temporary shunt to perfuse the donor iliac artery. Temporary insertion of an axillofemoral bypass adds 45-60 min of extra operating time if two surgeons are present. However, this technique should completely avoid transplant ischaemia and is an excellent technique for dealing with abdominal aneurysms in patients with functioning transplants.

Management practices of Australian surgeons in the treatment of venous ulcers

INTRODUCTION

Venous ulcers will affect 2% of the general population during the course of their lives causing significant morbidity. The aim of the present paper was to review assessment and treatment regimes used by surgeons throughout Australia and compare these with published guidelines.

METHODS

A structured questionnaire was sent to all general and vascular surgeons in Australia. Questions detailing practice demographics, initial treatment, investigation and surgical intervention were asked. Responses were analysed using Fisher's exact test.

RESULTS

A response rate of 36% was obtained from 1390 surgeons. This included 30% of the general surgeons and 67% of the vascular surgeons surveyed. Three hundred and seventy-one of these surgeons managed patients with venous ulcers. Vascular surgeons recorded ankle-brachial pressures (88%vs 55%; P < 0.0001) more frequently and used compression therapy more often than general surgeons (99%vs 61%; P < 0.0001). Superficial vein ablation was performed by 95% in the presence of superficial vein reflux and a normal deep system, 46% also performed this procedure in the setting of an incompetent deep system. Antibiotics were prescribed by 15% of surgeons with no evidence of infection.

CONCLUSIONS

Initially venous ulcers are well managed in Australia; however, antibiotics are overprescribed in their treatment. The current rate of compression therapy use is low for some groups of surgeons and should be improved. The failure to use compression in all cases of venous ulcers and the overprescription of antibiotics in the absence of cellulitis suggests that significant improvements can be made in the management of venous ulcers in Australia.

Up-regulation of MMP-2 and MMP-9 leads to degradation of type IV collagen during skeletal muscle reperfusion injury; protection by the MMP inhibitor, doxycycline

OBJECTIVES

to determine the role of matrix metalloproteinases, MMP-2 and MMP-9, in reperfusion injury following skeletal muscle ischaemia and whether inhibition of MMPs by doxycycline protects against tissue damage.

METHODS

rats were anaesthetised and a tourniquet applied to the proximal thigh to occlude blood flow. Four hours of ischaemia was followed by reperfusion for 0, 4, 24 or 72 h. Two further groups received doxycycline for 7 days prior to bilateral ischaemia and 24 h reperfusion. Skeletal muscle from both limbs, kidneys and lungs were harvested for zymography and immunohistochemical staining for type IV collagen.

RESULTS

upregulation of MMP-2 and MMP-9 was detected by zymography in the ischaemic leg and lung but not in the kidney. Quantitative immunohistochemical analysis showed marked degradation of type IV collagen in reperfused muscle, lung and kidney. Doxycycline-treated rats showed significant preservation of type IV collagen in skeletal muscle and a trend towards preservation in kidney and lung.

CONCLUSIONS

MMP-2 and MMP-9 are strongly upregulated in skeletal muscle ischaemia/reperfusion injury and are also upregulated in remote organs, leading to degradation of basement membranes. Inhibition of MMP activity may therefore be potentially therapeutically useful in reducing the severity of reperfusion injury.

Proximalized lateral tunnel for the bypass to the dorsalis pedis artery -- a safe way to go

BACKGROUND

Wound complications associated with bypass grafting to the dorsalis pedis artery are frequent, and threaten the viability of the bypass and the limb.

METHODS

The long saphenous vein can be tunneled from its bed down the lateral side of the anterior margin of the tibia for subsequent anastomosis with the dorsalis pedis artery.

CONCLUSION

The proximalized lateral tunnel for the bypass to the dorsalis pedis artery has the advantage of protecting the bypass graft from exposure if the patient develops wound breakdown.

Apoptotic cell death makes a minor contribution to reperfusion injury in skeletal muscle in the rat

OBJECTIVE

to determine if apoptotic cell death contributes to skeletal muscle reperfusion injury.

METHODS

leg ischaemia was induced in rats with a tourniquet and maintained for 4 h before reperfusion for 24 or 72 h. Apoptosis was assessed by morphology, in situ end labelling of DNA fragments, DNA laddering, expression of p53 mRNA and detection of caspase-3-like proteolytic activity.

RESULTS

increased caspase-3-like activity was detected in muscle following ischaemia and zero, 24 h or 72 h of reperfusion. Levels remained relatively low but with a highly significant difference in enzyme activity between the ischaemic and non-ischaemic legs (p <0.0001, Repeated Measures Analysis of Variance). Morphological examination showed considerable oedema, disruption of muscle fibres and infiltration of white cells into tissues. Muscle nuclei did not show any morphological evidence of apoptosis and were negative for DNA fragmentation, while occasional neutrophils contained fragmented DNA. Expression of p53 was not induced by ischaemia and reperfusion and DNA ladders were not detected.

CONCLUSIONS

the cells undergoing apoptosis were infiltrating neutrophils rather than muscle cells and reperfused muscle was damaged largely by an inflammatory process involving considerable oedema.

Carotid bifurcation CT angiography: assessment of interactive volume rendering

PURPOSE

The purpose of this study was to compare the accuracy of CT angiography (CTA) for the assessment of carotid bifurcation stenosis, using interactive volume rendering (VR), maximum intensity projection (MIP), and 2D transverse CT technique (t-CT).

METHOD

Nineteen consecutive patients were prospectively studied with CTA and selective digital subtraction angiography (DSA). There were 13 men and 6 women from 51 to 84 years old (mean 70 years). Results of DSA were compared with those of interactive VR, MIP, and conventional t-CT results, using North American Symptomatic Carotid Endarterectomy Trial criteria for stenosis grading.

RESULTS

There were a total of 38 carotid bifurcations studied, with 9 mild, 10 moderate, and 15 severe stenoses and 4 occlusions. Overall agreement with DSA for VR was achieved in 76%. Eighty percent of the severe stenoses were correctly predicted by VR. The overall agreement between t-CT and DSA was 89%. MIP images, when analyzed independently, showed an overall agreement with angiography of only 71%. VR was not significantly different from MIP (p = 0.60). The difference between VR and t-CT had borderline significance (p = 0.09). MIP had significantly poorer agreement with angiography than t-CT (p = 0.02).

CONCLUSION

CTA has a high degree of accuracy for the assessment of carotid artery disease compared with catheter angiography. Interactive VR increases the accuracy of diagnosing carotid stenosis and decreases the number of unsatisfactory studies as compared with MIP. Further advances in computation speeds and improvements in software may dramatically alter the future use of VR for the communication of results to clinicians; however, careful analysis of transverse sections is essential to accurate CT interpretation.

Arteriography in chronic renal failure: a case for carbon dioxide

PURPOSE

The aim of this study was to assess the utilisation of carbon dioxide arteriography, performed with a simple injection system, as the imaging technique of choice in patients with chronic renal failure.

METHODS

Patients with chronic renal impairment who required arterial imaging or intervention were recruited for carbon dioxide angiography. Demographic data were prospectively recorded and pre- and post-arteriogram renal function was quantified. Radiographic images were graded by an independent radiologist.

RESULTS

Twenty-eight patients underwent renal or aorto-femoral studies with only one failure. There were no cases of contrast-induced nephropathy. Twenty-two of the films (79%) were graded as excellent or good, four as acceptable and two were considered to be poor (non-diagnostic).

CONCLUSIONS

This study has demonstrated that carbon dioxide angiography is a safe and clinically effective procedure in patients with chronic renal failure.

A prospective randomized trial evaluating the haemodynamic role of incompetent calf perforating veins

AIM

This study was undertaken to determine the haemodynamic effect of incompetent calf perforating veins in patients with uncomplicated varicose veins and long saphenous incompetence.

METHODS

Thirty-eight limbs from 35 patients were studied. All patients had uncomplicated varicose veins with both long saphenous and calf perforator incompetence on duplex ultrasonography. Patients were randomized to have incompetent calf perforators ligated or left intact, in addition to saphenofemoral junction ligation, strip of long saphenous vein to knee and stab avulsion of any visible varicosities in the leg. Patients were assessed with air plethysmography pre-operatively and 3 months postoperatively.

RESULTS

Superficial venous surgery improved venous volume, venous filling index and ejection fraction in the patient cohort. No significant haemodynamic difference was demonstrated between the two groups of patients who were randomized.

CONCLUSIONS

At present, the results of this study do not support the use of routine perforator ligation during superficial surgery for uncomplicated varicose veins.

Deregulation of apoptosis in colorectal carcinoma: theoretical and therapeutic implications

Apoptosis, or programmed cell death, maintains the structure of the colonic crypts by providing a balance to the rate of cell proliferation. Colorectal carcinoma arises partly from a disruption in this balance in the favour of uncontrolled growth. Until recently, most research into colon cancer has focused on the molecular regulators of cell-cycle progression and proliferation, but it is now evident that apoptosis is also defective. A failure of cells to die in response to premalignant damage may allow the progression of the disease and maintain the resistance of cancer cells to cytotoxic therapy. This review outlines the importance of apoptosis in the normal colon and presents recent studies that demonstrate that induction of apoptosis is defective in colonic tumours. When the molecular regulation of apoptosis is better understood, this knowledge may lead to the earlier detection of patients at greater risk of developing colorectal carcinoma, and also to the development of more effective therapies.

Upper extremity arterial injuries: experience at the Royal Adelaide Hospital, 1969 to 1991

PURPOSE

A review of upper extremity arterial injuries managed at the Royal Adelaide Hospital between 1969 and 1991 was undertaken because the optimal management of complex upper extremity trauma, particularly in proximal injuries, remains unclear.

METHODS

Patients were identified from the computer registry of patients treated by the vascular unit at the Royal Adelaide Hospital. They were studied in three groups: (1) subclavian and axillary artery, (2) brachial artery, and (3) radial and ulnar artery injuries. The mechanism of injury, associated injuries, treatment and outcome were reviewed.

RESULTS

There were 114 patients with upper extremity arterial injuries: 28 with subclavian and axillary, 62 with brachial, and 24 with radial and ulnar artery injuries. Good upper limb function was obtained in 32% of subclavian and axillary artery injuries, 79% of brachial artery injuries, and all radial and ulnar artery injuries. Amputation was performed in 14% of the proximal injuries and 8% of the brachial artery injuries. Three deaths occurred in this study group.

CONCLUSION

Blunt proximal injuries were usually associated with neurologic, soft tissue, and bony damage, which was responsible for the poor functional outcome. Critical limb ischemia or severe hemorrhage rarely occurred. Complete brachial plexus lesions resulted in uniformly poor outcomes. More distal injuries were associated with fewer nerve and soft tissue injuries, resulting in a more satisfactory outcome.