Management of diabetes-related foot disease in the outpatient setting during the COVID-19 pandemic.

The use of telephone and/or video consultation in routine management of acute diabetes-related foot disease (DFD) before the coronavirus disease 2019 (COVID-19) pandemic at a tertiary hospital is unprecedented. In March 2020, the Diabetes Feet Australia (DFA) released a national guideline to inform DFD management during the COVID-19 pandemic. The present study aimed to describe the adherence to the DFA guideline of managing acute DFD using telephone and/or video consultation at a Western Australian tertiary hospital during this period. We found >80% adherence rate to the DFA guideline and the management of active DFD using telephone and/or video consultations was feasible and acceptable in carefully selected patients.

Early Infectious Diseases Specialty Intervention Is Associated With Shorter Hospital Stays and Lower Readmission Rates: A Retrospective Cohort Study.

Background: Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods: We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results: Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions: Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.

PD-1 expression on CD8+ T cells regulates their differentiation within lung allografts and is critical for tolerance induction.

Immunological requirements for rejection and tolerance induction differ between various organs. While memory CD8+ T cells are considered a barrier to immunosuppression-mediated acceptance of most tissues and organs, tolerance induction after lung transplantation is critically dependent on central memory CD8+ T lymphocytes. Here we demonstrate that costimulation blockade-mediated tolerance after lung transplantation is dependent on programmed cell death 1 (PD-1) expression on CD8+ T cells. In the absence of PD-1 expression, CD8+ T cells form prolonged interactions with graft-infiltrating CD11c+ cells; their differentiation is skewed towards an effector memory phenotype and grafts are rejected acutely. These findings extend the notion that requirements for tolerance induction after lung transplantation differ from other organs. Thus, immunosuppressive strategies for lung transplant recipients need to be tailored based on the unique immunological properties of this organ.

The role of C4d deposition in the diagnosis of antibody-mediated rejection after lung transplantation.

Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, P = .035), there was no significant difference in the presence of other histologic findings. Despite aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but that the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may respond initially to therapy, there is a high incidence of CLAD and poor survival after AMR.

Safety, tolerability, pharmacokinetics and pharmacodynamics of AZP-531, a first-in-class analogue of unacylated ghrelin, in healthy and overweight/obese subjects and subjects with type 2 diabetes.

AIM: To explore the safety, pharmacokinetics and pharmacodynamics in humans of the unacylated ghrelin analogue AZP-531, designed to improve glycaemic control and reduce weight. METHODS: Assessments, including glucose measurements, were performed in a three-part randomized study. In Part A, healthy subjects [n = 44, age 18-50 years, body mass index (BMI) 20-28 kg/m(2) ] received a single subcutaneous dose of 0.3, 3, 15, 30, 60 or 120 µg/kg AZP-531 or placebo. In Part B, overweight/obese subjects (n = 32, age 18-65 years, BMI 28-38 kg/m(2) ) and in Part C, patients with type 2 diabetes [T2D; n = 36, age 18-65 years, BMI 20-40 kg/m(2) , glycated haemoglobin (HbA1c) 7-10%] received AZP-531 or placebo for 14 days (daily doses of 3, 15, 30 or 60 µg/kg and 15, 2 × 30 or 60 µg/kg, respectively). RESULTS: AZP-531 was well tolerated. Single- and multiple-dose pharmokinetic variables were similar. Maximum AZP-531 concentrations were typically reached at 1 h post-dose. Observed maximum concentration (Cmax ) and area under the curve were dose-proportional. The mean terminal half-life (t1/2 ) was 2-3 h. In Part B, AZP-531 doses of ≥15 µg/kg significantly improved glucose concentrations, without increasing insulin levels, suggesting an insulin-sensitizing effect. AZP-531 decreased mean body weight by 2.6 kg (vs 0.8 kg for placebo). In Part C, glucose variables improved in all groups, including placebo, suggesting a study effect in uncontrolled patients at baseline. Notwithstanding, AZP-531 60 µg/kg reduced HbA1c by 0.4% (vs 0.2% for placebo) and body weight by 2.1 kg (vs 1.3 kg for placebo). CONCLUSIONS: AZP-531 was well tolerated in this first-in-human study. Its pharmacokinetic profile, suitable for once-daily dosing, and metabolic effects support further clinical development for T2D.

Donor CD4 T Cell Diversity Determines Virus Reactivation in Patients After HLA-Matched Allogeneic Stem Cell Transplantation.

Delayed reconstitution of the T cell compartment in recipients of allogeneic stem cell grafts is associated with an increase of reactivation of latent viruses. Thereby, the transplanted T cell repertoire appears to be one of the factors that affect T cell reconstitution. Therefore, we studied the T cell receptor beta (TCRß) gene rearrangements of flow cytometry-sorted CD4(+) and CD8(+) T cells from the peripheral blood of 23 allogeneic donors before G-CSF administration and on the day of apheresis. For this purpose, TCRß rearrangements were amplified by multiplex PCR followed by high-throughput amplicon sequencing. Overall, CD4(+) T cells displayed a significantly higher TCRß diversity compared to CD8(+) T cells irrespective of G-CSF administration. In line, no significant impact of G-CSF treatment on the TCR Vß repertoire usage was found. However, correlation of the donor T cell repertoire with clinical outcomes of the recipient revealed that a higher CD4(+) TCRß diversity after G-CSF treatment is associated with lower reactivation of cytomegalovirus and Epstein-Barr virus. By contrast, no protecting correlation was observed for CD8(+) T cells. In essence, our deep TCRß analysis identifies the importance of the CD4(+) T cell compartment for the control of latent viruses after allogeneic stem cell transplantation.

Encephalitozoonosis in 2 South American Fur Seal (Arctocephalus australis) Pups.

Cerebral and disseminated encephalitozoonosis was diagnosed by histopathology, electron microscopy, and immunohistochemistry in 2 free-ranging South American fur seal pups found dead at Guafo Island (43°33'S 74°49'W) in southern Chile. In the brain, lesions were characterized by random foci of necrosis with large numbers of macrophages containing numerous microsporidial organisms within parasitophorous vacuoles. In addition, occasional histiocytes loaded with numerous mature and immature microsporidia spores consistent with Encephalitozoon sp were observed in pulmonary alveolar septa, splenic red pulp, glomerular capillaries, and proximal renal tubules by Gram and immunohistochemical stains. To our knowledge, microsporidial infection in a marine mammal species has not been previously reported.

Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs.

BACKGROUND: Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset. METHODS: We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments. RESULTS: The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, -5.5% to -1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions. CONCLUSIONS: ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections.

Hepatitis E in liver transplant recipients in the Rhône-Alpes region in France.

PURPOSE: In developed countries, hepatitis E virus (HEV) is considered an emerging pathogen, but prevalence seems highly variable according to previous European studies. As HEV can lead to chronic infections in immunosuppressed patients, it is thus essential to evaluate the prevalence and incidence of this infection. METHODS: We determined retrospectively, in a cohort of 206 pediatric and adult liver transplant recipients from the Rhône-Alpes region in France, pre-transplant anti-HEV-IgG prevalence and incidence of HEV infections during post-transplant follow-up (HEV IgG and IgM ± HEV-RNA). RESULTS: Transplantations were carried out between 2005 and 2012 and mean post-transplant follow-up was 32.8 months. Global pre-transplant prevalence of anti-HEV IgG was 29%, increasing regularly with age from 7% for children under 15 to 49% for patients older than 60. From the 142 seronegative patients before transplant, 11 seroconversions (7.7%) were observed during follow-up (incidence of 2.83 cases per 100 person-years). HEV RNA-tested at transaminases peak or randomly-was detected in only one case of seroconversion. For at least 2 HEV-seropositive patients, who had negative RNAemia before transplantation, viral RNA was detected chronically during follow-up, suggesting reinfection with HEV. CONCLUSION: Acute infections were largely more frequent than chronic infections and were asymptomatic or misdiagnosed, suggesting that liver transplant patients may not be particularly prone to developing severe HEV hepatitis. In addition, the presence of IgG anti-HEV may not protect against re-infection. Serological testing, therefore, appears to be of limited interest for the diagnosis of HEV infections in liver transplant recipients.

Changes in intracellular metabolite pools during growth of adherent MDCK cells in two different media.

In bioprocess engineering, the growth of continuous cell lines is mainly studied with respect to the changes in cell concentration, the resulting demand for substrates, and the accumulation of extracellular metabolites. The underlying metabolic process rests upon intracellular metabolite pools and their interaction with enzymes in the form of substrates, products, or allosteric effectors. Here, we quantitatively analyze time courses of 29 intracellular metabolites of adherent Madin-Darby canine kidney cells during cultivation in a serum-containing medium and a serum-free medium. The cells, which originated from the same pre-culture, showed similar overall growth behavior and only slight differences in their demand for the substrates glucose (GLC), glutamine (GLN), and glutamate (GLU). Analysis of intracellular metabolites, which mainly cover the glycolytic pathway, the citric acid cycle, and the nucleotide pools, revealed surprisingly similar dynamics for both cultivation conditions. Instead of a strong influence of the medium, we rather observed a growth phase-specific behavior in glycolysis and in the lower citric acid cycle. Furthermore, analysis of the lower part of glycolysis suggests the well-known regulation of pyruvate kinase by fructose 1,6-bisphosphate. The upper citric acid cycle (citrate, cis-aconitate, and isocitrate) is apparently uncoupled from the lower part (α-ketoglutarate, succinate, fumarate, and malate), which is in line with the characteristics of a truncated cycle. Decreased adenosine triphosphate and guanosine triphosphate pools, as well as a relatively low energy charge soon after inoculation of cells, indicate a high demand for cellular energy and the consumption of nucleotides for biosynthesis. We finally conclude that, with sufficient availability of substrates, the dynamics of GLC and GLN/GLU metabolism is influenced mainly by the cellular growth regime and regulatory function of key enzymes.

Neurologic melioidosis in an imported pigtail macaque (Macaca nemestrina).

Burkholderia pseudomallei is the cause of melioidosis in humans and other animals. Disease occurs predominately in Asia and Australia. It is rare in North America, and affected people and animals typically have a history of travel to (in human cases) or importation from (in animal cases) endemic areas. We describe the gross and histopathologic features and the microbiologic, molecular, and immunohistochemical diagnoses of a case of acute meningoencephalomyelitis and focal pneumonia caused by B. pseudomallei infection in a pigtail macaque that was imported from Indonesia to the United States for research purposes. This bacterium has been classified as a Tier 1 overlap select agent and toxin; therefore, recognition of pathologic features, along with accurate and timely confirmatory diagnostic testing, in naturally infected research animals is imperative to protect animals and personnel in the laboratory animal setting.

Development of a curative treatment within the AML-BFM studies.

The first multicenter treatment study for AML in childhood in Germany was performed from 1978 onwards. The therapy plan was designed similar to that for the acute lymphoblastic leukaemia (ALL). The drugs with the highest efficacy in AML, cytarabine cutting catara-bine and anthracyclines, were combined during induction and consolidation, followed by preventive cranial irradiation and maintenance therapy similar to that in ALL. The remission rate of the initial study was 80%, and the 5-year survival rate increased from less than 10% before 1970 to 40%. 5 subsequent trials have further increased the 5-year survival to now 70% and even 90% in the subgroup of core-binding factor leukaemias by using an intensified and optimised treatment schedule.The AML-BFM studies were the only prospective study sequence testing the benefit of cranial irradiation. Results from study -87 including the non-randomized patients showed an increased risk of CNS and/or bone marrow relapses in non-irradiated patients. Later on there was evidence that 12 Gy resulted in the same relapse rate as 18 Gy. The AML-BFM studies always used the experience from the previous study to optimize the next study. This approach was essential together with improved supportive treatment and experience of the medical staff for the step-wise and considerable increase of longterm survival within the 6 subsequent AML-BFM studies.

Key treatment questions in childhood acute lymphoblastic leukemia: results in 5 consecutive trials performed by the ALL-BFM study group from 1981 to 2000.

Between 1981 and 2000, 6 609 children (<18 years of age) were treated in 5 consecutive trials of the Berlin-Frankfurt-Münster (BFM) study group for childhood acute lymphoblastic leukemia (ALL). Patients were treated in up to 82 centers in Germany, Austria, and Switzerland. Probability of 10-year event-free survival (survival) improved from 65% (77%) in study ALL-BFM 81-78% (85%) in ALL-BFM 95. In parallel to relapse reduction, major efforts focused on reducing acute and late toxicity through advanced risk adaptation of treatment. The major findings derived from these ALL-BFM trials were as follows: 1) preventive cranial radiotherapy could be safely reduced to 12 Gy in T-ALL and high-risk ALL patients and eliminated in non-high-risk non-T-ALL patients, if it was replaced by high-dose and intrathecal methotrexate; 2) omission of delayed reintensification severely impaired outcome of low-risk patients; 3) 6 months less maintenance therapy caused an increase in systemic relapses; 4) slow response to an initial 7-day prednisone window was identified as adverse prognostic factor; 5) condensed induction therapy resulted in a significant improvement of outcome; 6) the daunorubicin dose in induction could be safely reduced in low-risk patients; 7) intensification of consolidation/reintensification treatment led to considerable improvement of outcome in high-risk patients.

Reliable Initial Trauma CT Findings of Supraclavicular Brachial Plexus Injury in Patients Sustaining Blunt Injuries.

BACKGROUND AND PURPOSE: Traumatic brachial plexus injuries are uncommon but can be debilitating. Early diagnosis is critical. Most patients undergo CT after trauma. We sought to identify correlative CT findings of supraclavicular brachial plexus injuries to discern who may require further evaluation with MR imaging and to measure multireviewer performance for their interpretations. MATERIALS AND METHODS: We identified all MR imaging examinations of the brachial plexus from our institution from January 2010 to January 2021 and included those performed for trauma. We excluded patients with penetrating or infraclavicular injuries and without preceding CTA of the neck or CT of the cervical spine. The cohort of 36 cases and 50 controls remained for analysis and were assessed for 6 findings: scalene muscle edema/enlargement, interscalene fat pad effacement, first rib fracture, cervical spine lateral mass/transverse process fracture, extra-axial cervical spinal hemorrhage, and cervical spinal cord eccentricity, forming a reference key. A resident physician and 2 neuroradiologists (blinded to the MR imaging) independently reviewed each CT scan for these findings. We measured agreement (Cohen κ) between observers and against the reference key. RESULTS: Interscalene fat pad effacement (sensitivity, specificity, 94.44%, 90.00%; OR = 130.33; P < .001) and scalene muscle edema/enlargement (sensitivity, specificity, 94.44%, 88.00%; OR = 153.00; P < .001) correlated significantly with brachial plexus injury. Agreement between observers and the key was almost perfect for those findings and fractures (pooled κ ≥ 0.84; P < .001). Agreement between observers was variable (κ = 0.48-0.97; P < .001). CONCLUSIONS: CT can accurately predict brachial plexus injuries, potentially enabling earlier definitive evaluation. High interobserver agreement suggests that findings are consistently learned and applied.

Diagnosis of invasive fungal infections in hematology and oncology--guidelines from the Infectious Diseases Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO).

Invasive fungal infections (IFIs) are a primary cause of morbidity and mortality in patients with hematological malignancies. Establishing a definite diagnosis of IFI in immunocompromised patients is particularly challenging and time consuming, but delayed initiation of antifungal treatment increases mortality. The limited overall outcome has led to the strategy of initiating either 'empirical' or 'preemptive' antifungal therapy before the final diagnosis. However, diagnostic procedures have been vastly improved in recent years. Particularly noteworthy is the introduction of newer imaging techniques and non-culture methods, including antigen-based assays, metabolite detection and molecular detection of fungal DNA from body fluid samples. Though varying widely in cancer patients, the risk of IFI is highest in those with allogeneic stem cell transplantation and those with acute leukemia. The AGIHO presents recommendations for the diagnosis of IFIs with risk-adapted screening concepts for febrile episodes in patients with haemato-oncological disorders.

Cutaneous lymphomas in European pet rabbits (Oryctolagus cuniculus).

Cutaneous lymphoma is a common skin neoplasm of pet rabbits in Europe but is rarely reported in pet rabbits in North America. These neoplasms have not been previously characterized, nor has the cause for the apparent predilection for cutaneous lymphoma in European pet rabbits compared with North American pet rabbits been investigated. In this retrospective study, the authors morphologically and immunohistochemically characterized 25 cutaneous lymphomas in European pet rabbits according to the World Health Organization classification. Tumors were classified as diffuse large B cell lymphomas, with 14 lymphomas exhibiting a centroblastic/centrocytic subtype and 11 tumors exhibiting a T cell-rich B cell subtype. To investigate a potential viral etiology of these lymphomas, 3 diffuse large B cell and 3 T cell-rich B cell lymphomas were evaluated by polymerase chain reaction for retroviral and herpesviral genes. Neither virus was detected. In contrast to other domestic animals, cutaneous lymphomas in European pet rabbits were highly pleomorphic and frequently contained multinucleated giant cells. Unexpectedly, the second most common subtype was T cell-rich B cell lymphoma, a subtype that is rare in species other than horses. Based on a limited number of samples, there was no support for a viral etiology that would explain the higher incidence of lymphoma in European pet rabbits compared with American pet rabbits. Further investigation into genetic and extrinsic factors associated with the development of these tumors is warranted.

Feline gonads exhibit tissue specific alternative splicing of oestrogen receptor alpha (ESR1).

Male felids frequently show teratospermia. At least in the domestic cat model, teratospermia is accompanied by impaired regulation of testicular apoptosis. We hypothesize that this phenomenon is caused by dysregulations in oestrogen signalling pathways. Both classical oestrogen receptors (ESR1 and 2) are expressed in species and/or tissue-specific manners and display different variants, inter alia, caused by alternative splicing. In vitro studies showed that exon deleted transcripts are translated into proteins and that some of the variants modify the effects of the full-length ERs. It has been proposed that some of the functional and morphological dysregulations, for example, during spermatogenesis, could directly derive from this phenomenon. In the present basic study, we investigated the expression pattern of ESR1 splicing variants in the gonads of domestic cats. Testicular, epididymal as well as ovarian tissue samples were collected from routine castrations. ESR1 variants were detected by means of RT-PCR using primers spanning one to three exons. We detected the variants Δ4 and Δ7 in all tissue samples investigated. Additionally, the testicular parenchyma expressed the variant Δ6 and double exon deletions of ESR1 (Δ4/6 and Δ6/7). Using an antiserum recognizing all previously identified ESR1 splicing variants, we revealed ESR1 proteins being expressed in nearly all cells of the testicular and ovarian parenchyma. ESR1 Δ6 protein, however, detected by an antiserum specifically raised against the Δ6 variant, was predominantly located in Sertoli cells. As the exon deletion variants are significantly expressed and show a distinct expression pattern, they could specifically modulate the cellular responsiveness to hormonal stimuli within the gonads.

[Which services do companies need to retain employability in their workforce?--help offered by the German Pension Insurance]. / Welche Hilfen benötigen Betriebe und Unternehmen beim Erhalt der Beschäftigungsfähigkeit ihrer Mitarbeiter--Was kann die Rentenversicherung tun?

German Pension Insurance as a provider of services in rehabilitation has reacted to demographic changes in society, both strategic and practical. The implementation of services for companies including support of company return to work management and prevention services for employees with specific health-related burdens offer the chance to identify an endangerment of earning capacity at an early stage. Workplace-orientated medical rehabilitation increases the focus on the job and the workplace in rehabilitation under the pension insurance scheme, both in selecting the right service for a client as well as in the service itself. Employers, employees and pension insurance together benefit from close cooperation.

The role of cerebral oximetry in combination with awake testing in patients undergoing carotid endarterectomy under local anaesthesia.

INTRODUCTION: The aim of this study is to analyse the role of cerebral oximetry in combination with awake testing in detecting cerebral ischaemia in patients undergoing carotid endarterectomy (CEA) under local anaesthesia (LA). METHODS: One hundred consecutive patients scheduled for CEA under LA were investigated. Regional oxygen saturation (rSO(2)) was measured with a cerebral oximeter. Cerebral ischaemia was assessed by awake testing in conjunction with rSO(2). Shunting was based solely on deterioration in conscious state assessed by awake testing. The correlation between awake testing and percentage fall in rSO(2) levels was statistically analysed. RESULTS: Patients requiring general anaesthesia were excluded from analysis (n = 17). Seven patients developed deterioration in conscious state and an immediate drop in rSO(2) ≥20% following carotid cross-clamping. Two patients requiring shunting for non-neurological reasons were excluded from analysis. Two patients had a drop in rSO(2) ≥20%, but remained conscious and were not shunted. There were no permanent neurological deficits postoperatively. Statistical analysis showed a sensitivity of 100% with a specificity of 96% yielding a positive predictive value of 81% and negative predictive value of 100% for a ≥19% drop in rSO(2). CONCLUSION: Cerebral oximetry using a cut off ≥19% drop in rSO(2) has a high sensitivity and specificity when compared with awake testing.

Distal versus ultradistal bypass grafts: amputation-free survival and patency rates in patients with critical leg ischaemia.

OBJECTIVES: Compare the outcome of distal (bypass to the crural arteries) versus ultradistal (bypass to the pedal arteries) bypasses in patients with critical leg ischaemia (CLI). DESIGN: Retrospective analysis of prospectively collected data of patients with CLI undergoing infra-popliteal bypass surgery is performed. MATERIALS AND METHODS: Patients undergoing infra-popliteal bypass at a single institution between 2004 and 2010 are included. Patency rates at 1-year and amputation-free survival at 12 and 48 months are analysed. RESULTS: Two hundred and thirty bypasses were performed in 209 consecutive patients (156 men, median age; 76 years, range; 19-96 years). One hundred and seventy nine (78%) bypass were classified as distal and 51 (22%) as ultradistal. The incidence of diabetes mellitus was significantly higher in the ultradistal group (p=0.0025). At 1-year, the distal group primary, assisted-primary and secondary patency rates were 61.7%, 83.1% and 87.4% compared to 61.9%, 87.4% and 87.4% in the ultradistal group respectively. Amputation-free survival at 12 and 48 months was 82.9% and 61.5% in the distal group compared to 83.0% and 64.9% in the ultradistal group. CONCLUSIONS: This study show that both distal and ultradistal bypass have comparable outcome regardless of the co-morbidities. The authors believe that elderly patients should be offered ultradistal bypass if indicated to avoid major amputation.