Should Long-Term Survival in Elderly Patients Presenting with Diabetic Foot Complications Impact Treatment Decision Making?

Patients presenting with diabetic foot ulceration (DFU) and associated complications often require revascularisation. Although current evidence advocates for an open bypass first strategy if patients are expected to live more than two years, this may not be appropriate in octogenarians. We sought to investigate the survival of patients aged over 70 years presenting with complicated DFU and chronic limb threatening ischaemia (CLTI) to clarify its prognosis and guide subsequent management. A database of patients admitted into a large tertiary service over the age of 70 years with DFU and CLTI between 2014 and 2017 were included. Survival data was obtained from medical records and public obituaries through to 2020. Patients were divided into three age groups: seventies (70-79 years), eighties (80-89 years) and nineties (≥90 years). Survival was evaluated using a stratified log-rank test and Kaplan-Meier methods. A total of 323 patients were included for analysis. Survival information was available for 225 patients (69%). Mean duration of follow-up was 19 months. There were 113 deaths recorded (35%). Mean survival for patients in their seventies, eighties and nineties was 63 months (95% CI 48.8-65.5), 37 months (95% CI 27.4-44.9) and 6 months (95% CI 2.3-19.2), respectively. In patients over 70 years of age presenting with DFU and CLTI, long-term survival decreases rapidly with increasing age, especially in the octogenarians. With recent technological advances and reduced morbidity, an endovascular approach may sufficiently treat acute presentations in octogenarians while reserving an open first strategy for younger patients with better long-term survival and adequate autologous conduit.

Low Morbidity Anatomical Revascularisation for an Infected Aorto-Bifemoral Graft Using a Staged Hybrid Procedure.

A 66-year-old woman presented with a right femoral false aneurysm following an aortobifemoral bypass for lifestyle-limiting claudication. A computed tomography (CT) angiogram revealed features of complete aortobifemoral graft infection. A two-stage procedure was performed. The first hybrid stage involved the excision of only the femoral components and covered stenting of the aortic stump, along with recanalization of bilateral native iliac systems. The second stage, six weeks later, involved aortic stent and graft explant via midline laparotomy with aortic bovine pericardium patch repair (LeMaitre Vascular Inc, Burlington, Massachusetts). Follow-up imaging demonstrated no residual infection, and the patient remained without complication at the 12-month follow-up. This novel approach utilizes hybrid surgical techniques and modern bioprosthetic material to safely manage an infected aortobifemoral bypass graft.

The prescription of best medical therapy following infrainguinal bypass grafting in Australia and New Zealand: a multicentre Australasian audit.

BACKGROUND: The benefits of best medical therapy (BMT) for secondary prevention of cardiovascular events in patients with peripheral arterial disease are well established. Guidelines recommend prescription of BMT should consist of anti-platelet, statins and angiotensin-converting enzyme inhibitor or angiotensin receptor blocking therapy, with evidence this regimen reduces cardiovascular mortality following vascular surgery and improves vascular bypass graft patency. This multicentre study examines the BMT prescription on discharge after infrainguinal bypass (IIB) in Australia and New Zealand (ANZ). Primary outcome measure was discharge prescription of three BMT pharmacological agents, defined for study purposes as an anti-platelet/anti-coagulant, a lipid-lowering agent, and an anti-hypertensive medication if hypertension was diagnosed. METHODS: This study retrospectively examined discharge prescriptions and summaries of all patients discharged following IIB in five ANZ hospitals, between January 2015 and April 2018. RESULTS: A total of 688 admissions for IIB were included (76.9% male; mean age 67.8 ± 12.0). A total of 72.4% of procedures were for chronic limb ischaemia, compared to acute limb ischaemia (12.6%), and aneurysmal disease (15%). The primary outcome of adherence with complete BMT prescription occurred in 66.9% of admissions. Anti-thrombotic agents were most frequently prescribed (96.4%), followed by anti-lipidaemic agents (82.1%). Of the patients with documented hypertension, 43.8% were not prescribed an angiotensin-converting enzyme inhibitor/angiotensin receptor blocking, while 19.2% were discharged without any anti-hypertensive medications. CONCLUSION: Almost one third of patients were not prescribed complete BMT following IIB. There is potential to improve the outcomes after IIB in ANZ through a focus on risk-factor control and BMT prescription.

Helping doctors utilize the prostate-specific antigen effectively: an online randomized controlled trial (The DUPE trial).

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of an information aid (IA) on doctor's knowledge about the strengths and limitations of prostate-specific antigen/digital rectal examination (PSA/DRE) testing, and to help doctors make better and more informed decisions about prostate cancer screening. METHODS: An online randomized trial among 45 doctors in Victoria's public health-care network that fulfilled CONSORT requirements was conducted. Participants were randomized to either immediate or delayed access to an online IA, and knowledge was compared across both groups at the conclusion of the trial. RESULTS: Doctors spent a mean time of 4:04 (95% confidence interval: 0.53-7:52) reading and completing the IA. Those who read IA were more knowledgeable (mean score out of 9, 7.45 versus 5.75, P < 0.0001). Potential harms and current literature findings were better recognized, as well as having a better understanding of what is meant by the term screening. Eighty-two per cent found that IA helped them understand prostate cancer screening, and 73% found it easy to understand. CONCLUSION: The IA increased knowledge, took minimal time to complete and was found to be helpful in understanding prostate cancer screening. PRACTICAL IMPLICATIONS: The IA is an easy-to-access resource that improves knowledge regarding the strengths and limitations of the PSA/DRE test for prostate cancer screening. Doctors who are unsure how to summarize the latest evidence should be directed towards the IA.

Current medical students' understanding of Surgical Education and Training.

BACKGROUND: The current Surgical Education and Training (SET) programme in Australia and New Zealand has been implemented to streamline surgical training. As applications to the SET programme can occur as early as the 2nd post-graduate year, early preparation is vital to ensure a successful outcome in gaining a SET position. We wish to demonstrate to what degree medical students are aware of the SET structure and application requirements to determine if further assistance to future SET candidates is required. METHODS: A standardized questionnaire was delivered to students of an Australian Medical School via an online medium. Ethics approval was granted, and all surveys were completed anonymously and voluntarily. One hundred eighty-two completed surveys were received. RESULTS: Eighteen percent of surveyed participants felt they had a good understanding of the SET programme, with 82% stating they had minimal or no understanding of the programme. Fourteen percent felt they had the information needed to pursue a career in surgery. Fifty-three percent were unaware that the College outlined areas of core competencies required in their training, with 75% unable to name any core competencies. CONCLUSION: There are a large proportion of medical students potentially considering a career in surgery. However, only a small number feel that they have been adequately equipped throughout their medical course to understand the steps needed to build a strong application for SET.