Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia.

OBJECTIVE: Investigate the relationship of frailty and severity of chronic limb-threatening ischaemia (CLTI), and their comparative associations with one-year outcomes, in patients presenting to a vascular limb salvage (VaLS) clinic. METHODS: This retrospective cohort study utilised data collected from a prospectively maintained VaLS clinic database. Patients aged ≥50 presenting to the VaLS clinic with CLTI between February 2018 and April 2019 were included. Frailty was measured using the Clinical Frailty Scale (CFS) and limb threat severity by the Wound, Ischaemia, and foot Infection (WIfI) score. Excessive polypharmacy was defined as ≥10 medications. Anticholinergic burden (ACB) score and Charlson comorbidity index (CCI) were calculated for all patients. The primary outcome measure was a composite endpoint of death or amputation at one-year. Associations with outcome were assessed using Cox regression and reported as hazards ratios (HR) with 95% confidence intervals (CI). RESULTS: A total of 198 patients were included, with CFS scores available for 190 patients. 98 patients (52%) were frail (CFS ≥5). 127 patients (67%) initially underwent endovascular revascularisation. Excessive polypharmacy was common (55 patients; 28%). Frailty was associated with increased WIfI stage (P = 0.025) as well as age, female sex, CCI score, number of medications, excessive polypharmacy but not ACB score. Frail patients were more frequently managed non-operatively (P = 0.017). Frailty (HR 1.91; 95% CI 1.09, 3.34; P = 0.024) and WIfI stage 4 (HR 3.29; 95%CI 1.23, 8.80; P = 0.018) were associated with death or amputation on univariable analysis. WIfI stage 4 (HR 2.80; 95%CI 1.04, 7.57; P = 0.042) and CCI score (HR 1.21; 95%CI 1.03, 1.41; P = 0.015), but not frailty (HR 1.25; 95%CI 0.67, 2.33; P = 0.474), were independently associated with death or amputation on multivariable analysis. CONCLUSIONS: Frailty is highly prevalent among CLTI patients and related to severity of limb threat. The CFS may be a useful adjunct to patient risk assessment in CLTI.

Academic ability and teamworking in medical students.

BACKGROUND: Teamworking is an essential skill for a doctor to develop in order to work effectively, and is required in the UK as part of the General Medical Council (GMC) Good Medical Practice guidance. Assessment of teamwork may be difficult, however, with medical school assessments being more commonly focused on knowledge and individual skills. We aim to explore the link between academic ability as measured at final medical examinations and teamworking. METHODS: All final-year medical students were asked to attend a simulation session in an immersive 22-bed simulated ward, which used a combination of patient simulators and high-fidelity manikin simulators, with nursing and telephone support. Students were split into separate groups stratified by performance in final-year assessments or in groups with mixed performance. Students were observed in real time by faculty staff and assessed with the individual Teamwork Observation and Feedback Tool (iTOFT), around which the debriefing was centred. Assessment of teamwork may be difficult RESULTS: The performance of 119 students in simulation was assessed, and groups with a mix of academic performance showed significantly greater teamworking ability as measured with the iTOFT as compared with those stratified by performance (p = 0.045). Final assessment at medical school was shown to be a poor predictor of teamworking ability: those who performed best at assessment seemed to underperform in teamworking. DISCUSSION: The simulated-ward learning activity received positive feedback, although the mix of patient simulators and high-fidelity manikins proved a challenge to some students. Medical school assessments appear to be inadequate in the assessment of teamworking ability, with change needed in future to ensure that this and other non-technical skills are assessed.