Editor's Choice - Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia.

OBJECTIVE: The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). METHODS: This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. RESULTS: After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p < .001). Subintimal angioplasty (47.1% vs. 29.9%; p = .019) and pedal-plantar loop technique (18.4% vs. 0%; p < .001) were more frequent in the PAR group. At the one year follow up, the PAR group showed greater freedom from major amputation (96.3% vs. 84.2%; p = .009). The wound healing rate, overall survival, major adverse limb event, and freedom from re-intervention did not differ significantly between the two groups. However, the patient subgroup with successful PAR showed a higher wound healing rate than the non-PAR group (76.0% vs. 67.0%; p = .031). In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068-2.290; p = .022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% confidence interval [CI] 0.471-0.923; p = .015), C reactive protein >3 mg/dL (HR 0.591, 95% CI 0.386-0.904; p = .015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431-0.916; p = .016) were associated with impaired wound healing. CONCLUSION: Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.

The role of the dermatologist in Raynaud's phenomenon: a clinical challenge.

Raynaud's phenomenon (RP) is a functional vascular disorder involving extremities. In his practice, the dermatologist may frequently encounter RP which affects mainly women and is categorized into a primary benign form and a secondary form associated with different diseases (infections, drugs, autoimmune and vascular conditions, haematologic, rheumatologic and endocrinologic disorders). Still today, the differential diagnosis is a clinical challenge. Therefore, a careful history and a physical examination, together with laboratory tests and nailfold capillaroscopy, is mandatory. RP is generally benign, but a scheduled follow-up for primary RP patients should be established, due to risk of evolution to secondary RP. A combination of conservative measures and medications can help in the management of RP. The importance of avoiding all potential physical, chemical and emotional triggers, as well as quitting smoking, should be strongly suggested to the patient. As first-line treatment, dihydropyridine calcium channel blockers should be used. If this approach is not sufficient, prostacyclin derivatives, phosphodiesterases inhibitors and endothelin receptor antagonists can be considered as second-line treatment. In cases of acute ischaemia, nifedipine and intravenous prostanoids are helpful. In refractory cases, botulinum injections have shown a significant benefit. The approach to the RP patients requires therefore a coordinated care of specialists together with the primary care physician.

Severe vascular complications in patients affected by systemic sclerosis cyclically treated with iloprost.

The objective of this study was to evaluate the incidence of the most severe vascular complications, such as pulmonary arterial hypertension, scleroderma renal crisis, and digital necrosis requiring amputation, in a monocentric group of systemic sclerosis (SSc) patients cyclically treated with intravenous iloprost. We reviewed the record-charts of 115 patients affected by SSc (18 men and 97 women, mean age 58.9.1 ± 14.2 years) regularly receiving iloprost for at least 3 years; the mean duration of the treatment was 98.8 ± 37.5 months (a total of 946.8 years of therapy). Demographic and clinical features were recorded. None of the patients died of SSc-associated vascular complications. After iloprost administration digital gangrene requiring amputation developed in 2 patients who had concomitant peripheral arterial disease (a total of 3 episodes; annual incidence of 0.31 for 100 years of iloprost therapy). Four patients were diagnosed with pulmonary arterial hypertension during iloprost treatment (annual incidence of 0.42 for 100 years of drug therapy); in none of the cases did the complication show a progressive course. No cases of scleroderma renal crisis were observed. With the limits of an observational study and in the absence of a control group, our experience suggests that prolonged cyclic iloprost therapy may limit the incidence/progression of severe digital and visceral SSc-vasculopathy.

[The possibilities of laser Doppler flowmetry for the estimation of the intestine resection volume by the acute mesenteric ischemia].

The results of the surgical treatment of the acute mesenteric ischemia in 2 groups of patients were comparatively analyzed. The control group (n=52) experienced the traditional way and criteria of detecting the volume of intestinal resection (color and peristaltic activity, arterial pulsation). For the main group (n=57) the intraoperative estimation of the intestinal viability was performed with the help of laser Doppler flowmetry. As a result, the postoperative intestinal gangrene rate was 9.1% among patients of the main group, whereas the complication was registered among 48.6% of the control group. The main group of patients demonstrated the overall lower rate of postoperative complications in comparison with the control group: 67.6 and 40.9% (p=0.01), respectively. The same picture was for the lethality rate: 76.9 and 52.6% (p=0.03), respectively.

Fuzzy Models of Choice of Prevention Schemes for the Occurrence and Development of Gangrene of the Lower Extremities.

The study focuses on the choice of prevention schemes of the appearance and recurrence of gangrene of the lower extremities, depending on any of the degrees of confidence that the patient will have gangrene or will experience its relapse. The degree of confidence is determined using the fuzzy logic of decision making on the relevant membership functions. For each of the selected classes, an appropriate prevention scheme has been developed, the effectiveness of which was tested using the theory of measuring latent variables and the synthesis of mathematical models of their choice depending on the degree of risk of the occurrence and recurrence of lower extremities gangrene. Model statistical tests showed that compared with traditional prevention schemes the use of the proposed models can increase the rate of positive results in the absence of lower extremities gangrene and reduce the possibility of relapse (recurrent changes by 42%, risk of amputation by 35%).

Nitroglycerin patch use in digital ischemia secondary to sepsis: a case report.

Sepsis results in intense disturbances in homoeostasis and is responsible for considerable morbidity and mortality in early infancy. Owing to insufficiency on part of infant to develop adequate inflammatory response to localize the infection, they usually progress to disseminated systemic infection, pneumonia and/or meningitis. We present the case of a 26 weeks preterm boy with acute digital ischemia in right index finger progressing to impending gangrene as a manifestation of septicemia. Use of topical nitroglycerin patch with meticulous monitoring successfully alleviated the impending peripheral gangrene without any adverse effects.

Does time to antibiotic initiation and surgery have an impact on acute appendicitis results? / ¿Influye el tiempo hasta el inicio de la antibioterapia y la intervención en los resultados de la apendicitis aguda?

OBJECTIVE: Time to treatment initiation is a key element to be considered in infectious pathologies such as acute appendicitis (AA). There are few articles in the literature analyzing the relationship between early pre-surgical antibiotic treatment initiation and complication occurrence in AA. Our objective is to analyze such influence and the effects of late treatment initiation. MATERIALS AND METHODS: A retrospective, observational study was carried out in children undergoing surgery for AA between 2017 and 2018. Demographic variables, time to antibiotic treatment initiation, time to surgery, and postoperative complications were analyzed. RESULTS: 592 patients with a median 12-month follow-up were included in the study. Antibiotic treatment initiation in the first 8 hours following diagnosis prevents complications [OR 0.24 (95% CI: 0.07-0.80)] and dramatically reduces the occurrence of intra-abdominal abscess from 25.0% to 5.5% (p=0.03). Antibiotic treatment initiation in the first 4 hours following diagnosis significantly reduced wound infection rate in non-overweight patients [2.9% vs. 13.6%; OR 0.19 (95% CI: 0.045-0.793); p=0.042]. Surgery within the first 24 hours following diagnosis reduced the proportion of advanced AA (gangrenous appendicitis and peritonitis) from 100% to 38.6% (p=0.023). CONCLUSIONS: Antibiotic treatment initiation in the first 4 hours following AA prevented the occurrence of post-surgical complications, especially in non-overweight patients. An adequate clinical approach and an early assessment by the pediatric surgeon are key to reduce the morbidity associated with AA.

OBJETIVO: El tiempo hasta el inicio del tratamiento es un elemento fundamental a considerar en patologías infecciosas como la apendicitis aguda (AA). Existen escasos artículos en la literatura que analicen la relación entre el inicio precoz de la antibioterapia prequirúrgica y el desarrollo de complicaciones en la AA. Nuestro objetivo es analizar dicha influencia y el efecto de su retraso. MATERIAL Y METODOS: Se realizó un estudio observacional retrospectivo en niños intervenidos de AA entre 2017-2018. Se analizaron variables demográficas, tiempo transcurrido hasta el inicio de la antibioterapia, tiempo hasta la cirugía y complicaciones postoperatorias. RESULTADOS: Se incluyeron 592 pacientes con mediana de seguimiento de 12 meses. El inicio de la antibioterapia en las primeras 8 horas tras el diagnóstico previene la aparición de complicaciones [OR 0,24 (IC95% 0,07-0,80)], disminuyendo significativamente el porcentaje de aparición de abscesos intraabdominales del 25,0 al 5,5% (p= 0,03). El inicio de la antibioterapia en las primeras 4 horas tras el diagnóstico disminuyó significativamente la tasa de infección de herida en pacientes sin sobrepeso [2,9 vs. 13,6%; OR 0,19 (IC95% 0,045-0,793); p= 0,042]. La intervención quirúrgica en las primeras 24 horas tras el diagnóstico disminuyó la proporción de AA evolucionada (gangrenada y peritonitis) del 100 al 38,6% (p= 0,023). CONCLUSIONES: El inicio de la antibioterapia en las primeras 4 horas tras el diagnóstico de AA previno el desarrollo de complicaciones postquirúrgicas, sobre todo en pacientes sin sobrepeso. Una orientación clínica adecuada y valoración precoz por el cirujano pediátrico son un elemento clave para disminuir la morbilidad asociada a la AA.

Acute arterial embolism of the lower extremities: impact of 24-hour duration on the outcome of management.

OBJECTIVE: Determine the impact of 24-hour duration of arterial embolism on the outcomes of management. MATERIAL AND METHOD: A prospective study of 91 patients with acute arterial embolism of the lower extremities was carried out. RESULTS: Among the 91 patients, 31(34.1%) were with early acute embolism(< 24 hours) and 60 (65.9%) were with late acute embolism (> 24 hours). Extensive limb gangrene was more common in patients with late acute embolism (26.7% versus 3.2%, p = 0.009). Subsequently, primary major amputation was higher in those patients (20% versus 3.2%, p = 0.05). In early acute embolism, surgical embolectomy was only the primary treatment of revascularization (87.1%) whereas in late acute embolism, there were varying modalities of revascularization (68.3%) in addition to surgical embolectomy. The successful revascularization after the initial surgical embolectomy was significantly higher in patients with early acute embolism (92.6% versus 43.9%, p < 0.001). Patients with late acute embolism had a higher tendency of undergoing major amputation after revascularization (24.4% versus 7.4%, p = 0.106). Successful outcome was higher in patients with early acute embolism (83.9% versus 58.3%, p = 0.014). CONCLUSION: The 24- hour duration of arterial embolism may be a crucial factor influencing the outcome in the management of this disease.

Gangrenous dermatitis in chickens and turkeys.

Gangrenous dermatitis (GD) is a disease of chickens and turkeys that causes severe economic losses in the poultry industry worldwide. Clostridium septicum, Clostridium perfringens type A, and occasionally Clostridium sordellii are considered the main causes of GD, although Staphylococcus aureus and other aerobic bacteria may also be involved in some cases of the disease. GD has become one of the most significant diseases of commercial turkeys in the United States. Several infectious and/or environmental immunosuppressive factors can predispose to GD. Skin lesions are considered to be the main portal of entry of the microorganism(s) involved. GD is characterized by acute onset of mortality associated with gross skin and subcutaneous tissue lesions consisting of variable amounts of serosanguineous exudate together with emphysema and hemorrhages. The underlying skeletal muscle can also be involved. Ulceration of the epidermis may be also noticed in cases complicated with S. aureus. Microscopically, necrosis of the epidermis and dermis, and subcutaneous edema and emphysema are commonly observed. Gram-positive rods can be identified within the subcutis and skeletal muscles, usually associated with minimal inflammatory infiltrate. A presumptive diagnosis of GD can be made based on history, clinical signs, and gross anatomic and microscopic lesions. However, confirmation should be based on demonstration of the causative agents by culture, PCR, immunohistochemistry, and/or fluorescent antibody tests.

Incarcerated umbilical hernia in children.

BACKGROUND: Umbilical hernia is common in children. Complications from umbilical hernias are thought to be rare and the natural history is spontaneous closure within 5 years. PATIENTS AND METHODS: A retrospective analysis was performed of the medical records of a series of 23 children who presented with incarcerated umbilical hernias at our institution over an 8-year period. RESULTS: Fifty-two children with umbilical hernias were seen in the hospital over the period. Twenty-three (44.2%) had incarceration. Seventeen (32.7%) had acute incarceration while 6 (11.5%) had recurrent incarceration. There were 16 girls and 7 boys. The ages of the children with acute incarceration ranged from 3 weeks to 12 years (median 4 years), while the ages of those with recurrent incarceration ranged from 3-15 years (median 8.5 years). Incarceration occurred in hernias of more than 1.5 cm in diameter (in those whose defect size was measured). Twenty-one children (15 with acute and all six with recurrent incarceration) underwent repair of the umbilical hernia using standard methods. The parents of two children with acute incarceration declined surgery after spontaneous reduction of the hernia in one and taxis in the other. One boy had gangrenous bowel containing Meckel's diverticulum inside the sac, for which bowel resection with end-to-end anastomosis was done. Operation led to disappearance of pain in all 6 children with recurrent incarceration. Superficial wound infection occurred in one child. There was no mortality. CONCLUSION: Incarcerated umbilical hernia is not as uncommon as thought. Active observation of children with umbilical hernia is necessary to prevent morbidity from incarceration.

The prevention of traditional bone setter's gangrene.

A two-year retrospective survey in southern Ethiopia revealed that 49 amputations had been performed, 25 of which were for gangrene following tight splintage applied by traditional bone setters. The aim of this study was to determine if it was possible to reduce this incidence of gangrene by offering one-day instructional courses to bone setters. In ten separate one-day courses 112 tradition healers attended. In addition, two-day courses were given to local health assistants, who also received written instructions for the safe care of fractures. A two-year prospective study revealed a marked reduction in amputations, from 49 to 25, with only seven rather than 25 being required for gangrene. We found that it is possible to educate traditional healers so that fewer gangrenous limbs require to be amputated.

Successful intravenous regional sympathetic blockade (Bier's Block) with guanethidine and lidocaine in a patient with advanced Buerger's Disease (thromboangiitis obliterans)--a case report.

A 65-year-old man, a heavy smoker with Buerger's disease (thromboangiitis obliterans), presented to this department with persistent severe ischemic rest pain at the fingers of his right hand, not responding to oral treatment with vasodilators and analgesics. Critical blood flow was discovered in the middle, ring, and little finger, with ischemic ulcerations apparent in the fingertips of these 3 fingers. The distal phalanx of the little finger had been amputated 6 months before because of gangrenous necrosis. In an attempt to avoid further disabling amputations, the patient received 3 series of Bier's block sessions with guanethidine and lidocaine according to a specific protocol. Marked increase in finger blood flow was induced even after the first series, and complete disappearance of both fingertip ulcerations and ischemic rest pain was achieved. No side effects were observed. The above-described method in a patient with advanced Buerger's disease resulted in excellent pain relief and full restoration of both blood flow and function of the affected fingers.

Lower-extremity amputation in people with diabetes. Epidemiology and prevention.

The age-adjusted rate of lower-extremity amputation (LEA) in the diabetic population is approximately 15 times that of the nondiabetic population. Over 50,000 LEAs were performed on individuals with diabetes in the United States in 1985. Among individuals with diabetes, peripheral neuropathy and peripheral vascular disease (PVD) are major predisposing factors for LEA. Lack of adequate foot care and infection are additional risk factors. Several large clinical centers have experienced a 44-85% reduction in the rate of amputations among individuals with diabetes after the implementation of improved foot-care programs. Programs to reduce amputations among people with diabetes in primary-care settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and follow-up; provide patient education; and, when necessary, refer patients to specialists, including health-care professionals for diagnostic and therapeutic interventions and shoe fitters for proper footwear. Programs should monitor and evaluate their activities and outcomes. Many issues related to the etiology and prevention of LEAs require further research.

Management and causes of acute large-bowel obstruction.

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

Traumatic dislocation of the knee joint.

The results in thirty-three of fifty-three traumatic dislocations of the knee followed for more than one year confirmed our conclusion, made in 1971, that early repair of all torn ligaments gives the best results, and that the vascular status following this injury must be observed carefully since vascular repair or thrombectomy within eight hours of injury gives the best chance of preventing gangrene of the leg. The twenty associated fractures in these thirty-three patients were treated successfully with conventional methods, except for three displaced fractures of the medial tibial plateau in which closed reduction failed and internal fixation was required.

Occlusion of femoropopliteal bypasses (Biografts).

In a series of 225 femoropopliteal bypasses with a Biograft (1978-1983) there were 57 failures due to occlusion of the graft. The main cause was progressive atherosclerotic disease. Inflow obstruction occurred 12 times and outflow obstruction 27 times. Biograft-related causes were kinking of the graft in 7 and distal anastomotic stenosis in 11 cases. Forty nine of the 57 failures were submitted to reoperation. Inflow obstructions were corrected easily. Outflow obstructions were corrected with a jump graft in most of the above-knee cases. Outflow obstructions in the below-knee cases were difficult to correct. Thrombectomy and endarterectomy were successful on a few occasions. After occlusion of the Biograft due to kinking, a simple thrombectomy was always sufficient. Stenosis of the distal anastomosis made a patch angioplasty necessary. The 49 reoperations were initially successful in 38 patients (77%). Major amputation of the leg after an unsuccessful reintervention was necessary in 5 cases.

[New experimental documents on circulatory reversal by arteriovenous fistula in ischemia of the extremities]. / Nouveaux documents expérimentaux sur l'inversion circulatoire par fistule artério-veineuse dans l'ischémie du membre.

The beneficial effects of circulatory reversal by lateral a.-v. fistula was confirmed in 20 hind limbs of dogs made ischaemic by Collagen embolisation. Although not done in the experiments presented here, rupture of the distal venous valves is advisable. The peripheral circulation was studied by measurement of venous pressures and by angiography. Retrograde infusions, with proximal tourniquet, confirmed reversal of flow veins to arteries. Return routes to the heart remain unknown.