Predictors of operative management in diabetic foot ulcers.

BACKGROUND & AIMS: Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. METHODS: All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2 years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. RESULTS: Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p < 0.001), OR 2.19 (p < 0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p < 0.019) if osteomyelitis was present. CONCLUSIONS: Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.

Timely surgical intervention for ureteric complications ensures adequate graft function in renal transplantation: a 10-year review.

BACKGROUND: Ureteric complications can cause significant morbidity in renal and simultaneous pancreas-kidney (SPK) transplantation. This 10-year review identified transplant patients with ureteric complications necessitating surgical intervention in an Australian tertiary centre. METHODS: The hospital records were scrutinized in detail to identify all patients who underwent renal or SPK transplantation from 1 June 2009 to 31 May 2019 with subsequent surgical management of ureteric complications. A case series of patients with ureteric complications was generated and findings were analysed. RESULTS: A total of 893 renal and SPK transplants were performed over the 10-year period. Ten of these (1.12%; seven renal and three SPK) had ureteric complications. All were managed surgically. Five of the 10 had ureteric leaks (0.56%); three had ureteric strictures (0.34%), one had ureteric obstruction from extraluminal compression (0.11%) and one had both leak and stricture (0.11%). All 10 patients underwent ureteric reimplantation. Two patients required more than one operation for their ureteric complication. No graft loss or surgical mortality occurred. All 10 patients currently have functioning kidney transplants and none require maintenance dialysis. CONCLUSION: We report a low rate (1.12%) of ureteric complications in our renal and SPK transplants. Our standard practice of definitive correction by ureteric reimplantation is proving successful. The authors confirm that appropriate surgery is a viable and durable option in renal transplant patients with excellent graft outcomes.

Broad-Ranging Nutritional Deficiencies Predict Amputation in Diabetic Foot Ulcers.

Diabetic foot ulcers present across the spectrum of nonhealing wounds, be it acute or many months duration. There is developing literature highlighting that despite this group having high caloric intake, they often lack the micronutrients essential for wound healing. This study reports a retrospective cohort of patients' micro- and macro-nutritional state and its relationship to amputation. A retrospective cohort was observed over a 2-month period at one of Australia's largest tertiary referral centers for diabetic foot infection and vascular surgery. Patient information, duration of ulcer, various biochemical markers of nutrition and infection, and whether the patient required amputation were collected from scanned medical records. A cohort of 48 patients with a broad-spectrum of biochemical markers was established. Average hemoglobin A1c (HbA1c) was 8.6%. A total of 58.7% had vitamin C deficiency, including 30.4% with severe deficiency, average 22.6 L} 5.8 µmol/L; 61.5% had hypoalbuminemia, average albumin 28.7 L} 2.5 g/L. Average vitamin B12 was 294.6 L} 69.6 pmol/L; 57.9% had low vitamin D, average 46.3 L} 8.3 nmol/L. Basic screening scores for caloric intake failed to suggest this biochemical depletion. There was a 52.1% amputation rate; biochemical depletion was associated with risk of amputation with vitamin C (P < .01), albumin (P = .03), and hemoglobin (P = .01), markedly lower in patients managed with amputation than those managed conservatively. There was no relation between duration of ulceration and nutrient depletion. Patients with diabetic foot ulceration rely on multidisciplinary care to optimize their wound healing. An important but often overlooked aspect of this is nutritional state, with micronutrients being very important for the healing of complex wounds. General nutritional screening often fails to identify patients at risk of micronutrient deficiency. There is a high prevalence of vitamin deficiency in patients with diabetic foot ulcers. This presents an excellent avenue for future research to assess if aggressive nutrient replacement can improve outcomes in this cohort of patients.

Risk-Factor Profile of Living Kidney Donors: The Australia and New Zealand Dialysis and Transplant Living Kidney Donor Registry 2004-2012.

BACKGROUND: Recent literature suggests that living kidney donation may be associated with an excess risk of end-stage kidney disease and death. Efforts to maximize access to transplantation may result in acceptance of donors who do not fit within current guidelines, potentially placing them at risk of adverse long-term outcomes. METHODS: We studied the risk profile of Australian and New Zealand living kidney donors using data from the Australia and New Zealand Dialysis and Transplant Living Kidney Donor Registry over 2004 to 2012. We compared their predonation profile against national guidelines for donor acceptance. RESULTS: The analysis included 2,932 donors (mean age 48.8 ± 11.2 years, range 18-81), 58% female and 87% Caucasian. Forty (1%) had measured glomerular filtration rate less than 80 mL/min; 32 (1%) had proteinuria >300 mg/day; 589 (20%) were hypertensive; 495 (18%) obese; 9 (0.3%) were diabetic while a further 55 (2%) had impaired glucose tolerance; and 218 (7%) were current smokers. Overall 767 donors (26%) had at least one relative contraindication to donation and 268 (9%) had at least one absolute contraindication according to national guidelines. CONCLUSIONS: Divergence of current clinical practice from national guidelines has occurred. In the context of recent evidence demonstrating elevated long-term donor risk, rigorous follow-up and reporting of outcomes are now mandated to ensure safety and document any change in risk associated with such a divergence.

Post-operative risk factor control following internal carotid artery intervention.

BACKGROUND: Patients who undergo carotid surgical interventions remain at significant risk of further vascular events post-operatively. This study evaluates the level of risk factor monitoring and control being achieved post-operatively for patients who undergo carotid surgical interventions within Southern Health and investigates the significance of patient education and patient insight in this context. METHODS: The study included all patients who underwent successful carotid endarterectomy (CEA) or carotid angioplasty within Southern Health during the 5-year study period. To ascertain the objective risk factor status of participants, the most current reported measurements for the variables of blood pressure, blood lipids and glycosylated hemoglobin were obtained from the participant's usual medical attendants. To ascertain the participant's subjective perceptions of their risk factor status, participants completed a self-administered mail-out questionnaire. RESULTS: A high level of post-operative risk factor monitoring was demonstrated. Post-operative risk factor control was not as commendable. There was a significant discrepancy identified between patient perceptions of current post-operative risk factor status and the objective reality of current post-operative risk factor status. There was a moderate positive linear correlation between level of accurate patient insight into their disease (including their post-operative risk factor control) and the level of postoperative risk factor control being achieved (r = 0.51, P <0.001). CONCLUSION: Future strategy targeted at achieving optimal post-CEA and carotid angioplasty with adjuvant stenting risk factor control should consider incorporating themes that increase the level of accurate patient insight into their disease (particularly their post-operative risk factor control), for instance, patient education and effective doctor-patient communication.

Initial Australasian experience with portal-enteric drainage in simultaneous pancreas-kidney transplantation.

BACKGROUND: Pancreas-kidney transplantation is currently the most effective method to re-establish euglycaemia in insulin-dependent diabetics with associated renal failure. The standard technique employed has been bladder drainage of exocrine secretions coupled with systemic venous drainage ('systemic-bladder' (SB) drainage). The more physiological technique, enteric exocrine with portal venous drainage ('portal-enteric' (PE) drainage), has been utilized sparingly in the past as a result of fears of technical complications. This paper compares the Monash Medical Centre experience with both techniques. METHODS: A total of 68 simultaneous pancreas-kidney transplantations were performed at Monash Medical Centre from 1991 until 2004. The first 37 received SB drainage. Since March 2001, 27 have received PE drainage. This retrospective study compared the SB group (n= 37) with the PE group (n= 27), with a 2-year follow-up, examining a number of surgical outcomes. RESULTS: Two-year patient (94.3 versus 96.0%), kidney (89.2 versus 85.2%), pancreas (77.9 versus 71.4%) and event-free (73.0 versus 67.7%) survivals were all similar between the SB and PE groups, respectively. Although surgery took longer in PE subjects (4 h : 47 min ± 0:48 versus 5 h : 16 min ± 1:00; P= 0.045), less intraoperative transfusions were required (1.3 ± 1.43 versus 0.52 ± 0.90; P= 0.024). Length of hospital stay and time to insulin independence were similar. Pancreas graft thrombosis rates were similar (10.8% SB versus 7.4% PE, P= 0.497). CONCLUSIONS: PE drainage is a safe and viable method for pancreas transplantation, which can be performed with excellent outcomes. An increased rate of complications with PE drainage has not been demonstrated in this series.