Adoption of IWGDF guidance on prevention and management of foot problems in diabetes for local use in Iran by ADAPTE methodology: a step toward best practice.

Purpose: Adoption of international working group on the diabetic foot (IWGDF) guidance on prevention and management of foot problems in patients with diabetes was the study aim. Methods: The ADAPTE process consisted of three main phases of set-up, adoption, and finalization with overall 24 steps was used. In set- up phase, organizing committee by a multidisciplinary approach was established. In adoption phase, comprehensive search in databases and guideline resources was done. According to the inclusion criteria, the 2015IWGDF guidance was selected for adoption process. Quality, currency, content and consistency of the guidance were assessed. Also, consensus on different level of agreement for each recommendation were reported. On finalization phase, the adopted version was reviewed by the guidance developer and the final guidance for local use in Iran was disseminated. Results: The 2015 IWGDF guidance with 77 recommendations was adopted after screening of 1760 documents retrieved from Jan. 2006 to Nov. 2016. An organizing committee was established according to a multidisciplinary approach including 73 members with endocrinology, orthopedic & vascular surgery, dermatology, infectious diseases, physical medicine and rehabilitation specialties, general practitioners and nurses. This guidance obtained a good quality in all six domains of AGREE II instrument (Score ≥ 80%), good currency, content, and consistency. Also, during the third round of Delphi, the consensus on the agreement level of each recommendation were greater than 80% and 77 recommendations of the original guidance were kept in the adopted version. Conclusion: The 2015 IWGDF guidance with 77 recommendations adopted for local use in different health care settings of Iran. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-022-01121-0.

The evaluation of efficacy of atmospheric pressure plasma in diabetic ulcers healing: A randomized clinical trial.

The aim of this study is to evaluate the efficacy and safety of cold atmospheric plasma (CAP) as a novel therapy for diabetic foot ulcers. This was an investigator-blinded, randomized controlled trial of 14 weeks (6 weeks of treatment and 8 weeks of follow-up). Twenty patients with diabetic foot ulcers were divided into two groups: the control group receiving standard wound care and the plasma group, which received CAP twice a week for six consecutive weeks in addition to standard wound care. The ulcer size, amount of exudate, and wound grading were determined weekly. Cold plasma was produced by applying a high voltage (4.5 kV) and a high frequency (22 kHz) to helium gas. Exudate from wounds treated with CAP showed a significant reduction in the third week after complete treatment (p = 0.039). The wound grading of the ulcers improved by the sixth week (p = 0.019), and the sizes of ulcers significantly decreased in the plasma group at the end of the treatment period (p = 0.007). In this randomized clinical trial, CAP was an effective treatment option for diabetic foot ulcers in terms of wound surface reduction and antibacterial effects.

Primitive Neuroectodermal Tumour Invading the Inferior Vena Cava.

In the present report, we describe our experience with a 44-year-old male with abnormal retroperitoneal primitive neuroectodermal tumours (PNETs) in our hospital, who was operated on with a spindle cell neoplasm diagnosis. LEARNING POINTS: Appropriate treatment is a crucial challenge in patients with PNETs due to late referral.The differential diagnoses were malignant pheochromocytoma, paraganglioma and retroperitoneal sarcoma.Physicians should keep in mind that the patient could be simultaneously suffering from sarcoma and a retroperitoneal PNET.

Endovascular Repair of a Common Carotid Pseudoaneurysm in a Patient with Behçet's Disease: A Case Report and Review of Literature.

Behçet's disease (BD) is a multisystem inflammatory disorder. Physicians should be alerted to the possibility of BD in a patient with a carotid artery pseudoaneurysm and no clear predisposing factor such as neck trauma or surgery. Endovascular repair of carotid pseudoaneurysms is technically feasible with excellent midterm follow-up results. Administration of immunosuppressive therapy before endovascular intervention is mandatory to reduce the chance of vascular complications accompanied by BD. A 40-year-old man presented with a painful and pulsatile neck mass with 2 episodes of transient ischemic attacks. The patient also complained of recurrent urogenital ulcers and aphthous lesions together with painful rashes. Ultrasonography and computed tomography angiography revealed 2 aneurysmal dilations in the left common carotid artery at the bifurcation level. He was referred to a rheumatologist, who made the diagnosis of BD. High-dose corticosteroids and cyclophosphamide were commenced. One week later, 2 overlapping self-expanding stent grafts were deployed. The final angiogram showed no residual endoleak, and the flow of the carotid and cerebral arteries was satisfactory. The patient was discharged with no neurological complications. Follow-up ultrasonography and computed tomography angiography 6 months later showed no endoleak, as well as significant shrinkage of the aneurysm sac.

Relationship Between Preoperative 25-Hydroxy Vitamin D and Surgical Site Infection.

BACKGROUND: Surgical site infection (SSI) is one of the most important and costly complications of surgical operations. Vitamin D antimicrobial and wound healing effects have been recently shown in animal models and in laboratory settings. Furthermore, potential effects of vitamin D in mitigating nosocomial infections and SSIs have been examined at a limited scale. To our knowledge, no comprehensive study has been performed to show the relationship between preoperative level of vitamin D and incidence of SSI. The present study was designed and implemented to investigate this relationship. MATERIALS AND METHODS: We performed a prospective cross-sectional study involving 300 adult patients who were admitted to undergo surgery in our tertiary care unit from January 2016 to January 2018. Cutoff point was considered at a level of 30 (ng/mL) in defining vitamin D deficiency. The presence of any SSI was investigated and recorded at the time of discharge and at postoperative visits up to 30 d after the surgery. Cross-tabulation and bivariate and multivariate logistic regression with unadjusted and adjusted odd ratio were used to determine the association between dependent and independent variables and to identify factors associated with SSIs. RESULTS: Overall, of 300 patients who were investigated, 39% had preoperative vitamin D deficiency and 11% developed SSI. In univariate logistic regressions, 20 predictors were selected to be included in the multivariate analysis. Finally preoperative level of 25-hydroxy vitamin D, history of recent infection, preoperative and postoperative hospital length of stay, and postoperative blood transfusions were confirmed as statistically significant independent predictors of SSI. CONCLUSIONS: Preoperative 25-hydroxy vitamin D level has a strong effect on postoperative SSI. Prospective double-blinded randomized clinical trials are required to confirm such strong relationship and to settle preoperative vitamin D measurement as a standard approach to reduce postoperative complications including SSI. Preoperative patient optimization, limiting hospital length of stay, and blood transfusion are other strategies to reduce SSI.

Effects of mobilized peripheral blood stem cells on treatment of primary lower extremity lymphedema.

OBJECTIVE: Lymphedema is a chronic debilitating disease characterized by the accumulation of fluid in the extremities as a result of lymphatic system impairment. Current treatments fail to restore the functionality and structural integrity of the lymphatic vessels lost in this condition. In this study, autologous mobilized peripheral blood stem cell transplantation was used and its potential efficacy and safety were evaluated in treating this condition. METHODS: Ten patients with primary lymphedema in the lower extremity received granulocyte-colony stimulating factor subcutaneously for 4 days, to stimulate stem cell mobilization, after which 200 to 250 mL of blood was drawn from each patient and used to collect stem cells. Mobilized stem cells were counted by flow cytometry with International Society of Hematotherapy and Graft Engineering method. In two sessions, 3 weeks apart, these stem cells were injected subcutaneously in the affected limb at approximately 80 points, along the lymphatic vessels. Each patient was followed for 6 months, during which changes in the limb volume and circumference were measured. Lymphangiogenesis was evaluated by biopsy, the lymphoscintigraphic transport index was calculated using Lymphoscintigraphy, and quality of life was surveyed. RESULTS: In this study, patients received on average 9.5 ± 6.8 × 108 mononuclear cells (which divided into 2 × 106 CD34+ cells for each session) in two sessions. The volume of the lower limbs decreased in 60% of patients. One patient showed a slight increase in the volume of lower limbs and three showed no change. The average limb volume was 4469.41 ± 1760.71 cm3, which on average differed from the average initial limb volume by 232.88 ± 392.53 cm3. Quality of life was reported as slightly increased in 60% of patients. The lymphoscintigraphic transport index suggested improvement in 60% of the patients. Likewise, tissue samples showed a 60% increase in lymphatic vessels. CONCLUSIONS: Subcutaneous injection of autologous hematopoietic stem cells harvested from peripheral blood into patients with primary lower limb lymphedema is feasible, potentially effective, and without serious adverse effects. However, a larger scale study with more patients is needed to validate our results. Last, to increase the effectiveness of this treatment, the optimal dose of cells injected and the requirement for additional growth factors need further study.

Clinical outcome of thymectomy in myasthenia gravis patients: A report from Iran.

Background: Myasthenia gravis (MG) is an autoimmune disease affecting acetylcholine postsynaptic receptor of voluntary muscles. Thymectomy is done in these patients and is a mainstay in the treatment of MG; however, the long-term result of surgery is still controversial. This study dealt with the investigation of the results of thymectomy in treatment, recovery and control of the symptoms of these patients. Methods: This study was performed through a retrospective method in patients suffering from MG who underwent trans-sternal thymectomy between 2011 and 2016. We conducted thymectomy, excision of mediastinal mass and contents of tissues between the right and left phrenic nerves for all patients. Then, the effect of various variables including age, sex, time interval between onset of disease and surgery, thymus pathology and the dosage of drug on clinical response after surgery was determined using various statistical tests. Results: 47 patients including 26 men and 21 women with the mean age of 33.0 ± 4.6 years have been investigated. The mean age of patients was 36.2 and 29.7 in men and women respectively (P = 0.041). Spiral chest computed tomography (CT) scan was present in 47 patients demonstrating mediastinal mass in 40 (85.1%) patients. Also, our pathological results showed thymic cells in aortopulmonary window contents of 4 patients. According to the results, the younger age of patients at the time of surgery, shorter time between diagnosis and thymectomy, being a woman and non-thymoma pathology were along with better clinical outcomes after thymectomy. Conclusion: Our study shows better clinical results of thymectomy in patients with normal chest CT scan and normal or atrophic thymus in pathologic reports. Generally, it seems that performing thymectomy in a shorter time interval after diagnosis of MG is beneficial. Moreover, in MG patients who do not suffer from thymoma, it is along with positive results.

Extracting Instantaneous Respiratory Rate From Multiple Photoplethysmogram Respiratory-Induced Variations.

In this study, we proposed a novel method for extracting the instantaneous respiratory rate (IRR) from the pulse oximeter photoplethysmogram (PPG). The method was performed in three main steps: (1) a time-frequency transform called synchrosqueezing transform (SST) was used to extract the respiratory-induced intensity, amplitude and frequency variation signals from PPG, (2) the second SST was applied to each extracted respiratory-induced variation signal to estimate the corresponding IRR, and (3) the proposed peak-conditioned fusion method then combined the IRR estimates to calculate the final IRR. We validated the implemented method with capnography and nasal/oral airflow as the reference RR using the limits of agreement (LOA) approach. Compared to simple fusion and single respiratory-induced variation estimations, peak-conditioned fusion shows better performance. It provided a bias of 0.28 bpm with the 95% LOAs ranging from -3.62 to 4.17, validated against capnography and a bias of 0.04 bpm with the 95% LOAs ranging from -5.74 to 5.82, validated against nasal/oral airflow. This algorithm would expand the functionality of a conventional pulse oximetry beyond the measurement of heart rate and oxygen saturation to measure the respiratory rate continuously and instantly.

Evaluation of wound healing in diabetic foot ulcer using platelet-rich plasma gel: A single-arm clinical trial.

The aim of the present study was to evaluate the effectiveness of using autologous platelet-rich plasma (PRP) gel for treatment of diabetic foot ulcer (DFU) during the first 4 weeks of the treatment. In this longitudinal and single-arm trial, 100 patients were randomly selected after meeting certain inclusion and exclusion criteria; of these 100 patients, 70 (70%) were enrolled in the trial. After the primary care actions such as wound debridement, the area of each wound was calculated and recorded. The PRP therapy (2mL/cm2 of ulcers) was performed weekly until the healing time for each patient. We used one sample T-test for healing wounds and Bootstrap resampling approach for reporting confidence interval with 1000 Bootstrap samples. The p-value<0.05 were considered statistically significant. The mean (SD) of DFU duration was 19.71 weeks (4.94) for units sampling. The ratio of subjects who withdrew from the study was calculated to be 2 (2.8%). Average area of 71 ulcers in the mentioned number of cases was calculated to be 6.11cm2 (SD: 4.37). Also, the mean, median (SD) of healing time was 8.7, 8 weeks (SD: 3.93) except for 2 mentioned cases. According to one sample T-test, wound area (cm2), on average, significantly decreased to 51.9% (CI: 46.7-57.1) through the first four weeks of therapy. Furthermore, significant correlation (0.22) was not found between area of ulcers and healing duration (p-value>0.5). According to the results, PRP could be considered as a candidate treatment for non-healing DFUs as it may prevent future complications such as amputation or death in this pathological phenomenon.

Clavicular Chondrosarcoma: A Case Report and Brief Review of the Literature.

Clavicular bone tumors occur in less than 0.5 percent of bone tumors. Primary chondrosarcoma is very rare even among clavicle tumors. The main symptom is a touchable mass in 69 % of patients. Dedicated centers using FNA and cytology can reach a correct diagnosis in 94% of cases. Treatment planning is done using simple X-ray, CT-scan, shoulder MRI, chest CT-scan and whole body technetium scan. Treatment of choice for primary chondrosarcoma of clavicle is surgical resection.

Esophageal Perforation in a Patient With Kidney Transplantation.

Esophageal perforation is a rupture of the esophageal wall, caused by iatrogenesis in 56% of cases. Perforation of the esophagus remains a challenge, and its incidence has increased as the use of endoscopic procedures has become more frequent. We report a 54-year-old woman with esophageal perforation 8 days after kidney transplantation. She had received a gastrointestinal consultation prior to her transplantation. This report highlights the fact that perforation may occur after any organ transplantation, especially during the initial 2 weeks after transplantation, when mycophenolate mofetil and cyclosporine as well as and high doses of corticosteroid are administered. If there is a delay in passage and a swallowing difficulty, high doses of immunosuppressive drugs are likely to cause ulceration and perforation. Preventive strategies including intravenous steroids for the first 2 to 3 weeks and divided doses of pills should be considered for such patients.

Safety and Efficacy of Repeated Bone Marrow Mononuclear Cell Therapy in Patients with Critical Limb Ischemia in a Pilot Randomized Controlled Trial.

BACKGROUND: Critical limb ischemia is a manifestation of peripheral arterial disease characterized by insufficient arterial blood flow for maintaining tissue viability in the lower extremities. Therapeutic angiogenesis is used for peripheral arterial disease patients who are not candidates for surgical revascularization or radiological intervention. There is accumulating evidence for the beneficial impact of autologous bone marrow mononuclear cell transplantation for treatment of critical limb ischemia in humans. This study aims to investigate the safety and efficacy of repeated bone marrow mononuclear cell injections in comparison with a single bone marrow mononuclear cell injection in critical limb ischemia patients. METHODS: Patients with critical limb ischemia (n = 22) were randomized (http://clinicaltrials.gov/ct2 show/NCT01480414) to receive either a single (n = 11) or four (n = 11) intramuscular injections of bone marrow mononuclear cells as a cell therapy product. RESULTS: There were no reported adverse events during the 24-week follow-up period after cell delivery. Efficacy assessment indicated that after cell injections, there was significant improvement in Ankle-Brachial Index, Visual Analog Scale, pain-free walking distance, and Wagner stage as well as reduction in ulcer size. There was no significant difference between the two groups in terms of clinical parameters. However, by the 24th week the pain-free walking distance improved significantly in the group who received four injections of cells. CONCLUSION: Favorable clinical outcomes strongly indicate the long-term benefit of bone marrow mononuclear cell transplantation, either as one or several injections, for retrieval from critical limb ischemia. Repeated cell injections have shown increased improvement of pain-free walking distance in patients. These findings warrant further exploration in later-phase clinical trials with repeated injections.

Estimating instantaneous respiratory rate from the photoplethysmogram.

The photoplethysmogram (PPG) obtained from pulse oximetry shows the local changes of blood volume in tissues. Respiration induces variation in the PPG baseline due to the variation in venous blood return during each breathing cycle. We have proposed an algorithm based on the synchrosqueezing transform (SST) to estimate instantaneous respiratory rate (IRR) from the PPG. The SST is a combination of wavelet analysis and a reallocation method which aims to sharpen the time-frequency representation of the signal and can provide an accurate estimation of instantaneous frequency. In this application, the SST was applied to the PPG and IRR was detected as the predominant ridge in the respiratory band (0.1 Hz - 1 Hz) in the SST plane. The algorithm was tested against the Capnobase benchmark dataset that contains PPG, capnography, and expert labelled reference respiratory rate from 42 subjects. The IRR estimation accuracy was assessed using the root mean square (RMS) error and Bland-Altman plot. The median RMS error was 0.39 breaths/min for all subjects which ranged from the lowest error of 0.18 breaths/min to the highest error of 13.86 breaths/min. A Bland-Altman plot showed an agreement between the IRR obtained from PPG and reference respiratory rate with a bias of -0.32 and limits agreement of -7.72 to 7.07. Extracting IRR from PPG expands the functionality of pulse oximeters and provides additional diagnostic power to this non-invasive monitoring tool.

Pulmonary blastoma: a case report and brief review of the literature of tumor-induced hypoglycemia.

BACKGROUND: Tumor induced hypoglycemia (TIH) is a rare clinical entity that can be caused by different mechanisms such as secretion of various substances, autoimmune disorders, massive tumoral infiltration of liver, and pituitary or adrenal glands destruction by tumors. Furthermore, any type of neoplasms can cause TIH. CASE PRESENTATION: The patient presented with a case of classic biphasic pulmonary blastoma (CBPB) with hypoglycemia. Chest CT scan showed 2 huge masses in the right hemi-thorax and multiple smaller masses located in the left hemi-thorax. The patient underwent surgery, and was referred to an oncologist for adjuvant therapy. CONCLUSION: CBPB is a rare primary lung tumor with poor prognosis. They are classically large, symptomatic tumors with lymph node metastasis. Surgical resection at early stages has been more effective than other treatments; however, there is no standard treatment in unresectable cases. Adjuvant treatments have been temporarily effective.

Noninvasive Optical Monitoring of Bladder Filling to Capacity Using a Wireless Near Infrared Spectroscopy Device.

Lack of bladder fullness sensation is an issue that arises in different neurogenic conditions and in addition to influencing patients' quality of life, can result in serious kidney damage. We describe a wireless wearable sensor for detecting bladder fullness using near infrared spectroscopy (NIRS). The sensor has been tested in vitro and in vivo to verify its feasibility and is shown to be capable of detecting changes in bladder content noninvasively.

Endovascular Repair of Supra-Celiac and Abdominal Aortic Pseudo Aneurysms Concomitant with a Right Atrial Mass in a Patient with Behçet's Disease: A Case Report.

Behcet's disease is a rare immune mediated systemic vasculitis which besides it's more frequent involvement of eyes and skin, sometimes present with aortic pseudo aneurysm and more rarely cardiac inflammatory masses.A 51-year-old patient with Behçet's Disease presented with two symptomatic aortic pseudoaneurysms concomitant with a right atrial mass. Computed tomography (CT) revealed one supra-celiac and another infrarenal aortic pseudoaneurysms. Echocardiography showed a large mobile mass in the right atrium. Both pseudoaneurysms were successfully excluded simultaneously via endovascular approach with Zenith stent-grafts, and the atrial mass was surgically removed 10 days later. Post-implant CT showed successful exclusion of both pseudo-aneurysms, patency of all relevant arteries, and patient is now asymptomatic and has returned to normal lifestyle. Multiple pseudoaneurysms concomitant with a right atrial mass can be an initial manifestation of Behçet's disease. Endovascular repair can be a good treatment option for the pseudoaneurysms.

Major adverse events, six months after endovascular revascularization for critical limb ischemia in diabetic patients.

BACKGROUND: This prospective study aimed to evaluate the detailed outcomes of diabetic patients with critical limb ischemia, six months after percutaneous transluminal angioplasty and appropriate multidisciplinary wound care.  METHODS: Totally, 45 consecutive patients (50 limbs) were enrolled and then divided into two groups according to the healing of ulcers. The endpoints were ulcer healing and major adverse events including amputation, mortality, and cardiac or cerebral morbidities, during a six- month follow-up period.  RESULTS: During six months follow-up, major amputation was performed for four of 50 limbs (8.0%). A total of nine (20%) patients died and the leading cause was cardiac death (13.3 %). Also, stroke and non-fatal myocardial infarction occurred in three (6.7 %) and one (2.2 %) of the patients, respectively. Among the 29 (59.2 %) healed wounds, 22 (44.9 %) were completely closed. The patients with nonhealing wounds had a higher rate of dialysis (40% vs. 0 %, P-value < 0.001) and more ulcers with stage of D3 according to the Texas Wound Classification (60% vs. 31 %, P-value = 0.016). Other demographic, clinical, ulcer characteristics and procedural characteristics such as number and level of the treated lesions did not differ significantly between the two groups.  CONCLUSION: Based on our findings, it seems that along with current usual therapeutic routines which focus on wound healing and limb salvage, more attention should be paid to simultaneous diagnostic assessments and treatment of cardiovascular disease in this group of patients during short-term follow- up.

Analyzing the resting state functional connectivity in the human language system using near infrared spectroscopy.

We have evaluated the use of phase synchronization to identify resting state functional connectivity (RSFC) in the language system in infants using functional near infrared spectroscopy (fNIRS). We used joint probability distribution of phase between fNIRS channels with a seed channel in the language area to estimate phase relations and to identify the language system network. Our results indicate the feasibility of this method in identifying the language system. The connectivity maps are consistent with anatomical cortical connections and are also comparable to those obtained from functional magnetic resonance imaging (fMRI) functional connectivity studies. The results also indicate left hemisphere lateralization of the language network.

Wavelet-based motion artifact removal for functional near-infrared spectroscopy.

Functional near-infrared spectroscopy (fNIRS) is a powerful tool for monitoring brain functional activities. Due to its non-invasive and non-restraining nature, fNIRS has found broad applications in brain functional studies. However, for fNIRS to work well, it is important to reduce its sensitivity to motion artifacts. We propose a new wavelet-based method for removing motion artifacts from fNIRS signals. The method relies on differences between artifacts and fNIRS signal in terms of duration and amplitude and is specifically designed for spike artifacts. We assume a gaussian distribution for the wavelet coefficients corresponding to the underlying hemodynamic signal in detail levels and identify the artifact coefficients using this distribution. An input parameter controls the intensity of artifact attenuation in trade-off with the level of distortion introduced in the signal. The method only modifies wavelet coefficients in levels adaptively selected based on the degree of contamination with motion artifact. To demonstrate the feasibility of the method, we tested it on experimental fNIRS data collected from three infant subjects. Normalized mean-square error and artifact energy attenuation were used as criteria for performance evaluation. The results show 18.29 and 16.42 dB attenuation in motion artifacts energy for 700 and 830 nm wavelength signals in a total of 29 motion events with no more than -16.7 dB distortion in terms of normalized mean-square error in the artifact-free regions of the signal.

Functional connectivity analysis of cortical networks in Functional Near Infrared Spectroscopy using phase synchronization.

Functional Near Infrared Spectroscopy (fNIRS) is a non invasive functional neuroimaging method used for studying brain activity using blood oxygen level dependent (BOLD) signal. We use phase synchronization between fNIRS channels to detect functional connections between brain regions in a speech study. Data is collected from 22 neonates whose brain activity was monitored by fNIRS while being exposed to two different types of auditory stimuli. The wavelet based phase locking analysis reveals functional connections between temporal regions and most other regions in general and frontal areas in particular.