Pulmonary embolism response teams. A description of the first 36-month Australian experience.

BACKGROUND: High/intermediate-risk pulmonary embolism (PE) confers increased risk of cardiovascular morbidity and mortality. International guidelines recommend the formation of a PE response team (PERT) for PE management because of the complexity of risk stratification and emerging treatment options. However, there are currently no available Australian data regarding outcomes of PE managed through a PERT. AIMS: To analyse the clinical and outcome data of patients from an Australian centre with high/intermediate-risk PE requiring PERT-guided management. METHODS: We performed a retrospective observational study of 75 consecutive patients with high/intermediate-risk PE who had PERT involvement, between August 2018 and July 2021. We recorded clinical and interventional data at the time of PERT and assessed patient outcomes up to 30 days from PERT initiation. We used unpaired t tests to compare right to left ventricular (RV/LV) ratios by computed tomography criteria or transthoracic echocardiogram (TTE) at baseline and after interventions. RESULTS: Data were available for 74 patients. Initial computed tomography pulmonary angiography RV/LV ratio was increased at 1.65 ± 0.5 and decreased to 1.30 ± 0.29 following PERT-guided interventions (P < 0.001). TTE RV/LV ratio also decreased following PERT-guided management (1.09 ± 0.19 vs 0.93 ± 0.17; P < 0.001). 20% of patients had any bleeding complication, but two-thirds were mild, not requiring intervention. All-cause mortality was 6.8%, and all occurred within the first 7 days of admission. CONCLUSION: The PERT model is feasible in a large Australian centre in managing complex and time-critical PE. Our data demonstrate outcomes comparable with existing published international PERT data. However, successful implementation at other Australian institutions may require adequate centre-specific resource availability and the presence of multispeciality input.

Outcomes of endovascular, open surgical and autotransplantation techniques for renal artery aneurysm repair: a systematic review and meta-analysis.

BACKGROUND: Renal artery aneurysms (RAA) can be repaired with endovascular exclusion (EVR), open repair (OR), or ex-vivo repair with renal autotransplantation (ERAT). This systematic review compares repair indications, aneurysm characteristics, and complications following these interventions. METHODS: A systematic review of databases including MEDLINE, PUBMED, and EMBASE by two independent reviewers for studies from January 2000-November 2022. All studies evaluating repair indications, RAA morphology, morbidity and mortality following EVR, OR, and ERAT were included. RESULTS: A total of 38 studies were included with 1540 EVR, 2377 OR and 109 ERAT subjects. Increasing aneurysm size, or diameters >20 mm, were the most common repair indications across EVR and OR (n = 537; 48%), and ERAT (n = 23; 52%). All ERAT repairs were at or distal to renal artery bifurcations (n = 46). Meta-analyses demonstrated significantly shorter length of stay (LOS) with EVR compared to OR (mean difference -4.06, 95% confidence interval (CI) -5.69 to -2.43, P < 0.001). No significant differences were found in mean aneurysm diameter (P = 0.23), total complications (P = 0.17), and mortality (P = 0.85). Major complications (Clavien-Dindo ≥III) across studies most commonly included acute renal failure (EVR 4.9% vs. OR 7.0%). Nephrectomy was the most common major complication in ERAT (5.5%). CONCLUSIONS: Outcomes following EVR and OR of RAAs are comparable. EVR offers a shorter LOS, with no difference in morbidity or mortality. ERAT is currently only utilized for distal RAAs, however carries higher risk of infarction and nephrectomy necessitating specialized expertise or algorithms to assist appropriate selection of repair methods.

The identification and management of the profunda femoris artery as a rare source of a late type II endoleak.

Internal iliac artery aneurysms are found in 20% of abdominal aortic aneurysm cases, with a high mortality rate in the event of rupture. Type II endoleaks are a common complication after endovascular intervention. Transarterial or direct sac puncture techniques have superseded open surgical repair due to the challenging nature open surgery presents in accessing the feeding vessel(s). We describe the rare source of a late type II endoleak feeding from the profunda femoris in an 83-year-old man after fenestrated endovascular aortic aneurysm repair and concurrent embolization of the right internal iliac artery for treatment of a juxtarenal abdominal aortic aneurysm and internal iliac artery aneurysm.

Infrarenal aortic reconstruction using autologous femoral vein for a mycotic aneurysm caused by Streptococcus equi.

A common source of infection in equine, Streptococcus equi, is an uncommon pathogen in humans, rarely identified as the cause for mycotic aortic aneurysms. Typically associated with consumption of unpasteurized milk or contact with horses, S. equi can result in severe bacteremia, endocarditis and meningitis. We describe the presentation and successful management of a 69-year-old retired equestrian who underwent infrarenal aortic resection and reconstruction using autologous right femoral vein for a S. equi mycotic aneurysm.

Vascular tracheobronchial compression syndrome secondary to contained ruptured thoracic aortic aneurysm.

Vascular tracheobronchial compression syndrome is the compression of the trachea or pulmonary bronchus by a vascular structure. It is primarily a diagnosis in children and secondary to congenital vascular anomalies. In adults, vascular tracheobronchial compression syndrome can be either congenital or required with a vast majority of congenital conditions found incidentally on imaging. Acquired conditions are largely due to aortic arch aneurysms or kinking of the aorta. The case described herein illustrates the rare case of a saccular thoracic aneurysm causing compression of the left primary bronchus. Patients may have a history of gradual onset of symptoms involving both the airway and oesophagus. Vascular tracheobronchial compression syndrome may go undetected and asymptomatic throughout an individual's lifespan, however as described herein this syndrome may also be life-threatening.

A 'Speed-Dating' Model of Wound Care? Rapid, High-Volume Assessment of Patients With Diabetes in a Multidisciplinary Foot Wound Clinic.

BACKGROUND: Diabetes is a major risk factor for foot ulceration and leg amputation, but the effect of intensive glycaemic control on wound healing is unknown. While an interdisciplinary approach has been shown to be important in the management of diabetic foot ulcer (DFU), there is no standardised definition of such an interdisciplinary team. OBJECTIVE: To investigate the role of an opportunistic, rapid-access, inter-disciplinary model of diabetes care at a foot wound clinic. METHODS: A retrospective case-control study of patients with DFUs attending a diabetes foot wound clinic over a 6-month period. Outcomes in patients who were seen by a rapid-access interdisciplinary team (RAIT) consisting of an endocrinologist, diabetes educator and dietician during the standard wound care those who were not seen by this team were compared. RESULTS: Fifty-five patients were seen by the RAIT and 64 control patients were not seen by this team during their attendance of a diabetes foot wound clinic. Patients in the intervention group had non-significantly higher baseline HbA1c and a significantly larger proportion were active cigarette smokers. Both groups achieved comparable reduction in the total number of DFUs per patient (p=0.971). Patients in the intervention group had a 60.1% reduction in wound size compared to 52.4% reduction in control group (p=0.526). CONCLUSION: Our study shows that the use of a rapid-access interdisciplinary team to assess and manage patients' diabetes in a foot wound clinic is feasible. Patients with higher-risk diabetes foot wounds exposed to RAIT had comparable wound healing outcomes to lower risk patients.

Vitamin C improves healing of foot ulcers: a randomised, double-blind, placebo-controlled trial.

Chronic foot ulcers are associated with a high risk of osteomyelitis, poor quality of life, amputations and disability. Few strategies improve their healing, and amputation rates in high-risk foot services are usually over 30 %. We conducted a randomised, inactive-placebo controlled, double-blind trial of 500 mg of slow-release vitamin C in sixteen people with foot ulcers in the Foot Wound Clinic at Westmead Hospital. Nine were randomised to control and seven to vitamin C. When serum vitamin C results become available at 4 weeks, all people with deficiency were offered both vitamin C and glucosamine tablets for the next 4 weeks. Patients without baseline deficiency continued their original assigned treatment. The primary outcome was percentage ulcer healing (reduction in ulcer size) at 8 weeks. Fifty percentage of subjects had baseline vitamin C deficiency, half having undetectable levels. Healing at 8 weeks was significantly better in the vitamin C group (median 100 v. -14 %, P = 0·041). Healing without amputation occurred in all patients in the vitamin C group. In contrast, 44 % of controls had not healed their ulcer at the end of the study period. Vitamin C improved healing of foot ulcers. Further studies are needed to determine whether there is a threshold effect for serum vitamin C above which therapy is ineffective and whether there are better or lesser responding subgroups. Because of its low cost and ease of access and administration, we recommend offering vitamin C therapy to all people who have chronic foot ulcers and potentially suboptimal vitamin C intake. Trial registration number: ACTRN12617001142325.

Endovascular treatment of a large iatrogenic popliteal arteriovenous fistula.

A 40-year-old man presented with years of progressive leg swelling and venous varicosities. Lower limb computed tomography angiography and subsequent digital subtraction angiography demonstrated a large popliteal arteriovenous fistula (AVF). This was treated successfully by endovascular technique with a Viabahn stent (W. L. Gore & Associates, Flagstaff, Ariz) in the popliteal artery to exclude the AVF. AVFs of this size and chronicity are rare, and this case demonstrates a successful endovascular method of treatment.

Endovascular Management of Mycotic Pseudoaneurysm After Pancreas Transplantation: Case Report and Literature Review.

INTRODUCTION: Mycotic pseudoaneurysm is a rare complication of pancreas transplantation. Successful management relies on early diagnosis and expedient treatment comprising surgery and antibiotics. While the standard of care in recipients of pancreatic transplants is open repair of pseudoaneurysm with or without excision of the allograft, endovascular management has been reported. Endovascular repair is a less invasive treatment option with advantages of expedient control of hemorrhage, avoidance of adhesions with an open repair, and greater suitability for elderly and frail patients. MATERIAL AND METHODS: We report a case of a 40-year-old recipient of a pancreas transplant who had a mycotic pseudoaneurysm managed with endovascular repair. A systematic search of PubMed-MEDLINE, Embase, and Cochrane Library was performed of all cases of mycotic aneurysms following pancreas or kidney transplantation managed with endovascular repair. RESULTS: There were 14 cases of mycotic aneurysms in transplant recipients managed with endovascular repair in the literature. Of those who received an endovascular stent as the only initial management strategy, 6 (54.5%) required a subsequent graft excision. Four (28.6%) patients required excision of their stent due to continued sepsis. There was 1 death from unrelated causes. CONCLUSIONS: Endovascular repair was a reasonable bridging technique to further definitive surgical treatment in our case. Endovascular management may be used with caution in high-risk patients. We advocate for prolonged antibiotic therapy combined with vigilant surveillance of the clinical response, and a low threshold for allograft excision in the event of clinical deterioration.

Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians.

BACKGROUND: Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand. METHODS: A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians' management practices of patients with DFIs. RESULTS: Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely. CONCLUSIONS: Patients with DFIs represent a significant proportion of an ID clinician's caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials.

A longitudinal study of the diabetic skin and wound microbiome.

BACKGROUND: Type II diabetes is a chronic health condition which is associated with skin conditions including chronic foot ulcers and an increased incidence of skin infections. The skin microbiome is thought to play important roles in skin defence and immune functioning. Diabetes affects the skin environment, and this may perturb skin microbiome with possible implications for skin infections and wound healing. This study examines the skin and wound microbiome in type II diabetes. METHODS: Eight type II diabetic subjects with chronic foot ulcers were followed over a time course of 10 weeks, sampling from both foot skin (swabs) and wounds (swabs and debrided tissue) every two weeks. A control group of eight control subjects was also followed over 10 weeks, and skin swabs collected from the foot skin every two weeks. Samples were processed for DNA and subject to 16S rRNA gene PCR and sequencing of the V4 region. RESULTS: The diabetic skin microbiome was significantly less diverse than control skin. Community composition was also significantly different between diabetic and control skin, however the most abundant taxa were similar between groups, with differences driven by very low abundant members of the skin communities. Chronic wounds tended to be dominated by the most abundant skin Staphylococcus, while other abundant wound taxa differed by patient. No significant correlations were found between wound duration or healing status and the abundance of any particular taxa. DISCUSSION: The major difference observed in this study of the skin microbiome associated with diabetes was a significant reduction in diversity. The long-term effects of reduced diversity are not yet well understood, but are often associated with disease conditions.

Migratory large vessel vasculitis preceding acute myeloid leukemia: a case report.

BACKGROUND: Large vessel vasculitis is a rare disorder usually occurring in the context of the autoimmune conditions of giant cell arteritis and Takayasu's arteritis. Case reports have described large vessel vasculitis occurring in individuals with myelodysplastic syndrome, preceding transformation to acute myeloid leukemia. CASE PRESENTATION: A 56-year-old Afghanistan-born woman presented with fever, a tender left carotid artery, and raised inflammatory markers. Computed tomography revealed thickening of the wall of her left carotid artery. Her symptoms resolved spontaneously; however, they recurred weeks later on the contralateral side, along with abdominal pain after eating. Further imaging with computed tomography and positron emission tomography demonstrated resolution of her left carotid artery abnormality, but new wall thickening and inflammation in her right carotid artery, abdominal aorta, and superior mesenteric artery. She was diagnosed as having large vessel vasculitis, which resolved with corticosteroids and methotrexate. Five months later, she developed acute myeloid leukemia. She had no known history of myelodysplastic syndrome at the time of diagnosis with vasculitis. CONCLUSIONS: Large vessel vasculitis in older individuals presenting with atypical clinical features, such as a migratory pattern of affected vessels, vessel wall tenderness, and marked systemic inflammation, should prompt a search for underlying myelodysplasia. Clinicians should be vigilant for progression to acute myeloid leukemia.

Human classical monocytes display unbalanced M1/M2 phenotype with increased atherosclerotic risk and presence of disease.

BACKGROUND: Specific monocyte and macrophage subsets have been implicated in atherosclerosis, with intermediate monocytes proportionally elevated in cardiovascular disease and M1 macrophages abundant in unstable atherosclerotic plaques. While several studies have shown altered proportions of these subsets in atherosclerosis, studies examining functional and phenotypic subset alterations remain scarce. METHODS: We used whole blood flow cytometry to investigate the expression of M1 (CD86) and M2 (CD163) markers on monocyte subsets of atherosclerotic patients and controls. RESULTS: Atherosclerotic patients had a more inflammatory monocyte profile than controls, indicated by increased intermediate subset proportions, a higher classical monocyte CD86/CD163 ratio, and elevated serum M1-related chemokines. A more inflammatory profile appeared to correlate with atherosclerotic risk, as in controls classical monocyte CD86/CD163 ratio was negatively correlated with HDL and apolipoprotein A1, and positively correlated with interleukin-1ß. CONCLUSIONS: We conclude that monocyte subsets show functional and phenotypic changes in cardiovascular disease and such changes are likely to contribute to atherosclerotic progression.

Aspirin in venous leg ulcer study (ASPiVLU): study protocol for a randomised controlled trial.

BACKGROUND: Venous leg ulceration is a common and costly problem that is expected to worsen as the population ages. Current treatment is compression therapy; however, up to 50 % of ulcers remain unhealed after 2 years, and ulcer recurrence is common. New treatments are needed to address those wounds that are more challenging to heal. Targeting the inflammatory processes present in venous ulcers is a possible strategy. Limited evidence suggests that a daily dose of aspirin may be an effective adjunct to aid ulcer healing and reduce recurrence. The Aspirin in Venous Leg Ulcer study (ASPiVLU) will investigate whether 300-mg oral doses of aspirin improve time to healing. METHODS/DESIGN: This randomised, double-blinded, multicentre, placebo-controlled, clinical trial will recruit participants with venous leg ulcers from community settings and hospital outpatient wound clinics across Australia. Two hundred sixty-eight participants with venous leg ulcers will be randomised to receive either aspirin or placebo, in addition to compression therapy, for 24 weeks. The primary outcome is time to healing within 12 weeks. Secondary outcomes are ulcer recurrence, wound pain, quality of life and wellbeing, adherence to study medication, adherence to compression therapy, serum inflammatory markers, hospitalisations, and adverse events at 24 weeks. DISCUSSION: The ASPiVLU trial will investigate the efficacy and safety of aspirin as an adjunct to compression therapy to treat venous leg ulcers. Study completion is anticipated to occur in December 2018. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12614000293662.

Characteristics of non-diabetic foot ulcers in Western Sydney, Australia.

BACKGROUND: There are few studies investigating the characteristics, risk factors and socioeconomic status of patients with non-diabetic foot ulcers. The aim of this study was to explore the characteristics of non-diabetic foot ulcers in a large tertiary referral outpatient hospital setting in Western Sydney, Australia. METHODS: From 2011 to 2013, data from 202 patients with non-diabetic foot ulcers during their initial visit were retrospectively extracted for analysis from Westmead Hospital's Foot Wound Clinic Registry. Data including demographics, socioeconomic status and foot ulcer characteristics were recorded on a standardised data collection form. RESULTS: Demographics and physical characteristics were: 54 % male, median age 78 years [interquartile range (IQR): 64-87], median body mass index (BMI) of 23.8 kg/m(2) (IQR: 20-26.9), 35 % had loss of protective sensation and the median postcode score for socioeconomic status was 996 (IQR: 935-1034). Foot ulcer characteristics were: median cross-sectional area of 1.2 cm(2) (IQR: 0.3-5.0), 30.5 % plantar and 27 % dorsal, 22.1 % University of Texas (UT) Wound Classification for Diabetic Foot Ulcers Grade of 1C-3C (with ischaemia). CONCLUSIONS: Unlike diabetic foot ulcers, non-diabetic foot ulcers largely affected older males and females. In accordance with diabetic foot ulcer characteristics, socioeconomic status was not related to non-diabetic foot ulcers in Western Sydney. Based on the findings of this study the epidemiological pattern of non-diabetic foot ulceration and its pathogenesis requires further investigation.

Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes.

BACKGROUND: The total contact cast (TCC) is an effective intervention to reduce plantar pressure in patients with diabetes and a plantar forefoot ulcer. The walls of the TCC have been indirectly shown to bear approximately 30 % of the plantar load. A new direct method to measure inside the TCC walls with capacitance sensors has shown that the anterodistal and posterolateral-distal regions of the lower leg bear the highest load. The objective of this study was to directly measure these two regions in patients with Diabetes and a plantar forefoot ulcer to further understand the mechanism of pressure reduction in the TCC. METHODS: A TCC was applied to 17 patients with Diabetes and a plantar forefoot ulcer. TCC wall load (contact area, peak pressure and max force) at the anterodistal and posterolateral-distal regions of the lower leg were evaluated with two capacitance sensor strips measuring 90 cm(2) (pliance®, novel GmbH, Germany). Plantar load (contact area, peak pressure and max force) was measured with a capacitance sensor insole (pedar®, novel GmbH, Germany) placed inside the TCC. Both pedar® and pliance® collected data simultaneously at a sampling rate of 50Hz synchronised to heel strike. The magnitude of TCC wall load as a proportion of plantar load was calculated. The TCC walls were then removed to determine the differences in plantar loading between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of interest). RESULTS: TCC wall load was substantial. The anterodistal lower leg recorded 48 % and the posterolateral-distal lower leg recorded 34 % of plantar contact area. The anterodistal lower leg recorded 28 % and the posterolateral-distal lower leg recorded 12 % of plantar peak pressure. The anterodistal lower leg recorded 12 % and the posterolateral-distal lower leg recorded 4 % of plantar max force. There were significant differences in plantar load between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of ulcer). Contact area significantly increased by 5 % beneath the whole foot, 8 % at the midfoot and 6 % at the forefoot in the shoe-cast (p < 0.05). Peak pressure significantly increased by 8 % beneath the midfoot and 13 % at the forefoot in the shoe-cast (p < 0.05). Max force significantly increased 6 % beneath the midfoot in the (shoe-cast p < 0.05). CONCLUSION: In patients with diabetes and a plantar forefoot ulcer, the walls of the TCC bear considerable load. Reduced plantar contact area in the TCC compared to the shoe-cast suggests that the foot is suspended by the considerable load bearing capacity of the walls of the TCC which contributes mechanically to the pressure reduction and redistribution properties of the TCC.