Clinical outcomes of acute limb ischaemia caused by femoropopliteal stent thrombosis.

BACKGROUND: Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI). AIMS: We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease. METHODS: This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis. RESULTS: Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novo ALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation. CONCLUSIONS: The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.

A case report of bilateral persistent sciatic artery: Bilateral aneurysm with thromboembolism of the right lower extremity.

RATIONALE: Persistent sciatic artery (PSA) is a rare congenital vascular anomaly. The sciatic artery, which normally regresses to become the inferior gluteal artery during fetal development, persists as a direct branch of the internal iliac artery. PATIENT CONCERN: We report a 78-year-old female who was admitted due to sudden pain, numbness, and loss of sensation in the right lower limb. DIAGNOSES: Acute thromboembolism in the right leg, bilateral PSA, and bilateral aneurysm. INTERVENTIONS: After the super-selective embolization, lower limb arterial thrombolysis treatment was performed. After symptom relief, a computed tomography angiography was conducted to clarify the vascular variations. OUTCOMES: After relief of lower limb embolism, long-term antiplatelet therapy was administered. LESSONS: When performing an ultrasound examination of PSA, careful identification of the arterial anatomy, evaluation of blood flow, assessment of surrounding structures, comparison between sides, and correlation with clinical symptoms are crucial to accurately diagnose this rare vascular anomaly.

Efficacy of robot-assisted gait training on lower extremity function in subacute stroke patients: a systematic review and meta-analysis.

BACKGROUND: Robot-Assisted Gait Training (RAGT) is a novel technology widely employed in the field of neurological rehabilitation for patients with subacute stroke. However, the effectiveness of RAGT compared to conventional gait training (CGT) in improving lower extremity function remains a topic of debate. This study aimed to investigate and compare the effects of RAGT and CGT on lower extremity movement in patients with subacute stroke. METHODS: Comprehensive search was conducted across multiple databases, including PubMed, Web of Science, Cochrane Library, EBSCO, Embase, Scopus, China National Knowledge Infrastructure, Wan Fang, SinoMed and Vip Journal Integration Platform. The database retrieval was performed up until July 9, 2024. Meta-analysis was conducted using RevMan 5.4 software. RESULTS: A total of 24 RCTs were included in the analysis. The results indicate that, compared with CGT, RAGT led to significant improvements in the Fugl-Meyer Assessment for Lower Extremity [MD = 2.10, 95%CI (0.62, 3.59), P = 0.005], Functional Ambulation Category[MD = 0.44, 95%CI (0.23, 0.65), P < 0.001], Berg Balance Scale [MD = 4.55, 95%CI (3.00, 6.11), P < 0.001], Timed Up and Go test [MD = -4.05, 95%CI (-5.12, -2.98), P < 0.001], and 6-Minute Walk Test [MD = 30.66, 95%CI (22.36, 38.97), P < 0.001] for patients with subacute stroke. However, it did not show a significant effect on the 10-Meter Walk Test [MD = 0.06, 95%CI (-0.01, 0.14), P = 0.08]. CONCLUSIONS: This study provides evidence that RAGT can enhance lower extremity function, balance function, walking ability, and endurance levels compared to CGT. However, the quality of evidence for improvements in gait speed remains low.

Acute effects of lower limb wearable resistance on horizontal deceleration and change of direction biomechanics.

This study aimed to investigate the acute effects of lower limb wearable resistance on maximal horizontal deceleration biomechanics, across two different assessments. Twenty recreationally trained team sport athletes performed acceleration to deceleration assessments (ADA), and 5-0-5 change of direction (COD) tests across three load conditions (unloaded, 2% of BW, 4% of body weight (BW)), with load attached to the anterior and posterior thighs and shanks. Linear mixed effect models with participant ID as the random effect, and load condition as the fixed effect were used to study load-specific biomechanical differences in deceleration mechanics across both tests. Primary study findings indicate that for the ADA, in the 4% BW condition, participants exhibited significantly greater degrees of Avg Approach Momentum, as well as significant reductions in deceleration phase center of mass (COM) drop, and Avg Brake Step ground contact deceleration (GCD) in both the 2% BW, and 4% BW condition, compared to the unloaded condition. In the 5-0-5 tests, participants experienced significant reductions in Avg Approach Velocity, Avg deceleration (DEC), and Stopping Time in the 4% BW condition compared to the unloaded condition. Similar to the ADA test, participants also experienced significant reductions in Avg Brake Step GCD in both the 2% BW and 4% BW conditions, and significant increases in Avg Approach Momentum in the 4% BW condition, compared to the unloaded condition. Therefore, findings suggest that based on the test, and metric of interest, the addition of lower limb wearable resistance led to acute differences in maximal horizontal deceleration biomechanics. However, future investigations are warranted to further explore if the use of lower limb wearable resistance could present as an effective training tool in enhancing athlete's horizontal deceleration and change of direction performance.

Evaluation of magnetic resonance thermometry performance during MR-guided hyperthermia treatment of soft-tissue sarcomas in the lower extremities and pelvis.

INTRODUCTION: This study evaluated the performance of magnetic resonance thermometry (MRT) during deep-regional hyperthermia (HT) in pelvic and lower-extremity soft-tissue sarcomas. MATERIALS AND METHODS: 17 pelvic (45 treatments) and 16 lower-extremity (42 treatments) patients underwent standard regional HT and chemotherapy. Pairs of double-echo gradient-echo scans were acquired during the MR protocol 1.4 s apart. For each pair, precision was quantified using phase data from both echoes ('dual-echo') or only one ('single-echo') in- or excluding body fat pixels in the field drift correction region of interest. The precision of each method was compared to that of the MRT approach using a built-in clinical software tool (SigmaVision). Accuracy was assessed in three lower-extremity patients (six treatments) using interstitial temperature probes. The Jaccard coefficient quantified pretreatment motion; receiver operating characteristic analysis assessed its predictability for acceptable precision (<1 °C) during HT. RESULTS: Compared to the built-in dual-echo approach, single-echo thermometry improved the mean temporal precision from 1.32 ± 0.40 °C to 1.07 ± 0.34 °C (pelvis) and from 0.99 ± 0.28 °C to 0.76 ± 0.23 °C (lower extremities). With body fat-based field drift correction, single-echo mean accuracy improved from 1.4 °C to 1.0 °C. Pretreatment bulk motion provided excellent precision prediction with an area under the curve of 0.80-0.86 (pelvis) and 0.81-0.83 (lower extremities), compared to gastrointestinal air motion (0.52-0.58). CONCLUSION: Single-echo MRT exhibited better precision than dual-echo MRT. Body fat-based field-drift correction significantly improved MRT accuracy. Pretreatment bulk motion showed improved prediction of acceptable MRT temporal precision over gastrointestinal air motion.

Construction and validation of a predictive model for preoperative lower extremity deep vein thrombosis risk in elderly hip fracture patients: An observational study.

The aim of this study was to identify independent risk factors for preoperative lower extremity deep vein thrombosis (DVT) in elderly hip fracture patients and to construct a nomogram prediction model based on them. We collected clinical data from elderly hip fracture patients from Ya'an Hospital of Traditional Chinese Medicine (2021-2023), and used univariate and multivariate logistic regression analyses to identify independent risk factors for preoperative DVT. In this way, a nomogram prediction model was established. In addition, external validation of the model was performed by patient data from Ya'an Mingshan District Hospital of Traditional Chinese Medicine. Receiver operating characteristic curve analysis was used to calculate the area under the curve, and calibration and decision curves were plotted to assess the predictive performance of the model. Of the 223 elderly hip fracture patients, 23 (10.31%) developed DVT of the lower extremities before surgery. A total of 6 variables were identified as independent risk factors for preoperative lower extremity DVT in elderly hip fracture patients by logistic regression analysis: age > 75 years (OR = 1.932; 95% CI: 1.230-3.941), diabetes mellitus (OR = 2.139; 95% CI: 1.149-4.342), and prolonged duration of disease (OR. 2.535; 95% CI: 1.378-4.844), surgical treatment (OR = 1.564; 95% CI: 1.389-3.278), D-dimer > 0.5 mg/L (OR = 3.365; 95% CI: 1.229-7.715) fibrinogen > 4 g/L (OR = 3.473; 95% CI: 1.702-7.078). The constructed nomogram model has high accuracy in predicting the risk of preoperative DVT in elderly hip fracture patients, providing an effective tool for clinicians to identify high-risk patients and implement early intervention.

[Successful endovascular treatment of proximal deep vein thrombosis following May-Thurner syndrome]. / Uspeshnoe lechenie proksimal'nogo tromboza glubokikh ven nizhnikh konechnostei na fone sindroma Meya-Ternera endovaskulyarnymi tekhnologiyami.

We present two clinical cases of successful endovascular treatment of proximal deep vein thrombosis following May-Thurner syndrome. In the first case, 2-day regional catheter thrombolysis, percutaneous mechanical thrombectomy and venous stenting were required to restore hemodynamics in the left lower limb. In the second case, regional catheter thrombolysis continued for 3 days with subsequent thrombotic mass lysis. However, iliac vein was severely narrowed that required venous stenting. Long-term results were favorable in both cases. Venous outflow has become almost normal after endovascular treatment. The patients' ability to work has been restored.

SIMBA-A Single-Puncture Approach to Lower Limb Block.

Peripheral nerve blocks provide a safe and reliable alternative in the anesthetic management of femur fractures in elderly subpopulations associated with significant comorbidities. Single-Insertion Multiple Nerve Block Anesthesia (SIMBA) is a technique where a single needle insertion is used to block all four nerves that supply the femur shaft: the femoral nerve, obturator nerve, lateral femoral cutaneous nerve, and sciatic nerve. The authors performed this technique in 11 cardiac compromised geriatric patients with midshaft/distal femur fractures, and the surgery was conducted successfully without any significant hemodynamic change and good postoperative analgesia.

Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.

BACKGROUND: Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented. METHODS: A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure. RESULTS: In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259. CONCLUSION: A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

Outcomes of Prophylactic Inguinal Lymph Node Dissection in Malignancies of Lower Limb.

AIM: To evaluate the role of early prophylactic inguinal node dissection in patients with squamous cell cancer and melanoma of lower limb. MATERIALS AND METHODS: From 2008 to 2018, a Tertiary Care Hospital connected to a teaching institute served as the site of this retrospective observational study. Patient records were gathered with the purpose of gathering clinical, investigative, surgical, pathological and follow-up information. RESULTS: We included 33 patients in this analysis out of the 47 patients we treated ourselves between 2008 and 2018; among these 33 patients, 21 (63.63%) had palpable inguinal nodes at the time of primary presentation. All 21 patients' FNAC tests were positive for metastases, in 16 patients (76.19%). 5 patients on FNAC (23.80%) exhibited not metastases. The remaining 12 patients did not have enlarged lymph nodes at the time of their initial presentation. Patients who did not have palpable lymph node were given the option of having a modified inguinal block dissection. 8 patients with metastatic disease have nodes that are positive in histology. In addition, out of 5 patients with negative nodes 4 (80%) showed evidence of metastasis. CONCLUSION: The conclusion of this retrospective observational study is that although palpable lymph nodes in groin are unquestionably a sign that inguinal nodes should be dissected, prophylactic lymph node dissection should be still done even if nodes are not palpable or provide a negative FNAC result. Given that delayed lymphadenectomy has a significant effect on survival, delaying inguinal lymphadenectomy in non-palpable nodes could cause you to lose the battle against cancer in your lower limb. The related surgical morbidity is the only downside to prophylactic lymph node dissection. This can, however, be effectively decreased with a modified inguinal lymphadenectomy operation.

Résumé Objectif:Évaluer le rôle de la dissection prophylactique précoce du ganglion inguinal chez les patients atteints d'un cancer épidermoïde et d'un mélanome du membre inférieur.Matériels et méthodes:De 2008 à 2018, un hôpital de soins tertiaires relié à un institut d'enseignement a servi de site à cette étude observationnelle rétrospective. Les dossiers des patients ont été rassemblés dans le but de recueillir des informations cliniques, d'investigation, chirurgicales, pathologiques et de suivi.Résultats:Nous avons inclus 33 patients dans cette analyse sur les 47 patients que nous avons nous-mêmes traités entre 2008 et 2018; parmi ces 33 patients, 21 (63,63 %) avaient des ganglions inguinaux palpables au moment de la présentation primaire. Les tests FNAC des 21 patients étaient positifs pour les métastases, chez 16 patients (76,19 %). 5 patients sous FNAC (23,80%) ne présentaient pas de métastases. Les 12 patients restants ne présentaient pas d'hypertrophie des ganglions lymphatiques au moment de leur présentation initiale. Les patients qui n'avaient pas de ganglion lymphatique palpable ont eu la possibilité de subir une dissection par bloc inguinal modifié. 8 patients atteints d'une maladie métastatique ont des ganglions positifs en histologie. De plus, sur 5 patients présentant des ganglions négatifs, 4 (80 %) présentaient des signes de métastases.Conclusion:La conclusion de cette étude observationnelle rétrospective est que même si les ganglions lymphatiques palpables dans l'aine sont incontestablement un signe que les ganglions inguinaux doivent être disséqués, un curage prophylactique des ganglions lymphatiques doit toujours être effectué même si les ganglions ne sont pas palpables ou fournissent un résultat FNAC négatif. Étant donné que le retardement du curage lymphatique a un effet significatif sur la survie, retarder le curage inguinal des ganglions non palpables pourrait vous faire perdre la bataille contre le cancer du membre inférieur. La morbidité chirurgicale associée est le seul inconvénient du curage prophylactique des ganglions lymphatiques. Ceci peut cependant être efficacement réduit grâce à une opération de lymphadénectomie inguinale modifiée.

[Clinical application of iliac myocutaneous flap pedicled with deep circumflex iliac artery in repair of complex defect of lower limb with cavity].

Objective: To explore the effectiveness of iliac myocutaneous flap pedicled with deep circumflex iliac artery (DCIA) on the repair of lower limb composite defect wounds with cavity. Methods: A retrospective analysis of 7 patients with lower limb composite defect wounds treated between March 2017 and September 2020 was conducted, including 4 males and 3 females, aged 24-58 years, with a median age of 37 years. The causes of injury were machine twisting injury in 2 cases, fall from height injury in 2 cases, and traffic accident injury in 3 cases. According to Gustilo-Anderson classification, there were 1 case of type Ⅲa, 4 cases of type Ⅲb, and 2 cases of type Ⅲc (combined with anterior tibial artery rupture); according to AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 2 cases of type 42-C3, 2 cases of type 43-A2, and 3 cases of type 43-B1. The time from injury to admission ranged from 2 to 10 hours, with an average of 6 hours. Tibial bone defect and surrounding soft tissue defect with deep cavity were left after primary emergency debridement. In the second stage, according to the characteristics of the wound, the three-dimensional repair of the composite defect was designed with DCIA embedded iliac myocutaneous flap. The size of the iliac flap was 2.0 cm×2.0 cm×2.0 cm to 7.0 cm×3.0 cm×2.5 cm, and the size of the flap was 12.0 cm×8.0 cm to 21.0 cm×13.0 cm. The internal oblique muscle flap was harvested in size of 3.0 cm×2.0 cm×2.0 cm to 5.5 cm×4.0 cm×4.0 cm. The donor site was primarily closed. Results: All the flaps survived after operation, except for 1 case of partial necrosis of the flap edge, which healed after secondary skin grafting, and the donor and recipient wounds healed by first intention. All patients were followed up 16-24 months, with an average of 18 months. The broken end of the bone defect healed well, and the healing time was 8-10 months, with an average of 7.3 months. At last follow-up, the shape of the flap was satisfactory, the texture was soft, and there was no abnormal hair growth, pigmentation, and so on. Only linear scar was left in the donor site, and no complication such as abdominal hernia occurred. According to Paley fracture healing scoring system, bone healing was rated as excellent in 5 cases and good in 2 cases. The limb function was satisfactory, and full weight bearing was achieved at 12-16 months after operation. According to the lower extremity functional scale (LEFS), 6 cases were excellent and 1 case was good. Conclusion: The iliac myocutaneous flap pedicled with DCIA is flexible in design and highly free in tissue composition, which can repair the composite defect wound of lower limbs with deep cavity in a three-dimensional way, and repair the limb shape and reconstruct weight-bearing function to the greatest extent.

Neutrophil-to-lymphocyte ratio in type 2 diabetes patients combined with Lower Extremity Peripheral Artery Disease.

Objective: This study explored the utility of NLR (neutrophil-to-lymphocyte ratio) as a marker to predict Lower Extremity Peripheral Artery Disease (PAD) in the Chinese population, as well as to assess its consistency and diagnostic value with digital subtraction angiography. Methods: Patients were distributed into three groups according to the angiography in lower limb arterial: group L1, plaque with no stenosis; group L2, plaque with luminal stenosis and group L3, total vascular occlusion. Changes in the neutrophil-to-lymphocyte ratio were documented and compared among groups. Results: Compared to group L1, NLR was significantly increased in L2 (1.76 vs 2.35, p=0.037) and L3 (1.76 vs 3.60, p<0.001), with a gradual decrease in ABI (Ankle-Brachial Index, 1.11 vs 1.02 vs 0.94, p<0.001). Those older patients with higher prevalence of hypertension (p=0.002), obesity (p=0.032), or reduced high-density lipoprotein cholesterol (p=0.020) were more likely to develop PAD; higher glycosylated hemoglobin (p=0.045), low-density lipoprotein cholesterol (p=0.006), and systolic blood pressure (p<0.001) levels led to a greater tendency to suffer stenosis or even occlusion; the probability of severe stenosis (>70%) increased to 2.075 times for every 1 increase in NLR, while it was 46.8% for every 0.1 increase in ABI. The optimal NLR cut-off value to predict severe stenosis in PAD was 2.73. Receiver operating characteristic curve analysis of the inflammatory biomarkers and severe stenosis prediction displayed an area under the curve of 0.81. Conclusion: NLR could serve as a new noninvasive and accurate marker in predicting PAD.

Recurrent Neural Network Enabled Continuous Motion Estimation of Lower Limb Joints From Incomplete sEMG Signals.

Decoding continuous human motion from surface electromyography (sEMG) in advance is crucial for improving the intelligence of exoskeleton robots. However, incomplete sEMG signals are prevalent on account of unstable data transmission, sensor malfunction, and electrode sheet detachment. These non-ideal factors severely compromise the accuracy of continuous motion recognition and the reliability of clinical applications. To tackle this challenge, this paper develops a multi-task parallel learning framework for continuous motion estimation with incomplete sEMG signals. Concretely, a residual network is incorporated into a recurrent neural network to integrate the information flow of hidden states and reconstruct random and consecutive missing sEMG signals. The attention mechanism is applied for redistributing the distribution of weights. A jointly optimized loss function is devised to enable training the model for simultaneously dealing with signal anomalies/absences and multi-joint continuous motion estimation. The proposed model is implemented for estimating hip, knee, and ankle joint angles of physically competent individuals and patients during diverse exercises. Experimental results indicate that the estimation root-mean-square errors with 60% missing sEMG signals steadily converges to below 5 degrees. Even with multi-channel electrode sheet shedding, our model still demonstrates cutting-edge estimation performance, errors only marginally increase 1 degree.

Drug-eluting devices for lower limb peripheral arterial disease.

Peripheral arterial disease is the third leading cause of cardiovascular morbidity after coronary artery disease and stroke. Lower limb peripheral arterial disease commonly involves infrainguinal arteries, may impair walking ability (intermittent claudication) and may confer a significant risk of limb loss (chronic limb-threatening ischaemia), depending on the severity of ischaemia. Endovascular treatment has become the mainstay revascularisation option in both the femoropopliteal and the below-the-knee arterial segments. After crossing and preparing the lesion, treatment results in these arterial segments can be enhanced by using drug-coated devices (drug-eluting stents and drug-coated balloons) that mitigate the occurrence of restenosis. As for other medical devices, the use of drug-eluting devices is based on their demonstrated safety and efficacy profiles when applied in the distinct segments of the lower limb vasculature. In this state-of-the-art narrative review we provide an overview of the safety and efficacy of drug-coated devices when used in the femoropopliteal and below-the-knee arterial segments.

2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease: An Executive Summary.

This article is an executive summary of the Wound, Ostomy, and Continence Nurses Society's (WOCN) 2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease. It is part of the Society's Clinical Practice Guideline Series. This article presents an overview of the systematic process used to update and develop the guideline. It also lists specific recommendations from the guideline for screening and diagnosis, assessment, management, and education of patients with wounds due to lower extremity arterial disease (LEAD). Suggestions for implementing recommendations from the guideline are also summarized. The guideline is a resource for WOC nurse specialists, other nurses, and health care professionals who work with adults who have/or are at risk of wounds due to LEAD. The complete guideline includes the evidence and references supporting the recommendations, and it is available from the WOCN Society's Bookstore (www.wocn.org). Refer to the Supplemental Digital Content Appendix (available at: http://links.lww.com/JWOCN/A123) associated with this article for a complete reference list for the guideline.

Pilot development of diagnostic tools for lower limb apophyseal injuries in children and adolescents.

Introduction: Lower limb apophyseal injuries commonly occur in children and adolescents with unknown incidence and prevalence. These conditions are considered benign, but impact children and adolescents quality of life and can lead to sport withdrawal at a crucial time. The primary aim of this research was to develop self-administered tools for two of the most common apophyseal injuries. The secondary aim was to test the sensitivity and specificity of the tools. Methods: Study 1 used a three round online Delphi panel (n = 8), with expert consensus supported by robust literature. This panel developed a self-administered screening tool for calcaneal (Sever's disease) and tibial tuberosity (Osgood-Schlatter's disease) apophysitis. Study 2 tested the sensitivity and specificity of these developed tools with parents and children (n = 63) with concurrent clinical examination by a health professional. An initial sample size for Study 2 was set at 155 children however this was impacted by COVID-19 and recruitment was halted. Results: Both tools had excellent diagnostic accuracy with an area under the curve of 83% (95% confidence interval = 0.70 to 0.95) for the posterior heel (calcaneal apophysitis) tool and 93% (95% confidence interval = 0.80 to 1.00) for the anterior of knee (tibial tuberosity apophysitis) tool using the pilot data from the 63 children. Conclusions: These tools may also enhance opportunities for clinicians and health service providers with pre-clinical screening to reduce wait list time and encourage low cost, self-administered management where indicated. These findings may enable large epidemiological studies to identify populations and calculate incidence and prevalence of these conditions using self report.

A Circular Network of Coregulated L-Threonine and L-Tryptophan Metabolism Dictates Acute Lower Limb Ischemic Injury.

Lower limb ischemia is characterized by reduced arterial perfusion in the lower limbs, leading to tissue ischemia and cell death. It is primarily caused by thrombosis and the rupture of arterial plaques, resulting in damage to ischemic muscle tissues. Metabolic processes are crucial in its development. Herein we combined single-cell data with metabolomics data to explore the pathways and mechanisms influencing lower limb ischemia. We analyzed single-cell and metabolomics data. In single-cell analysis, we identified different cell subpopulations and key regulatory genes, and biological enrichment analysis was performed to understand their functions and relationships. For metabolomics, mass spectrometry and chromatography techniques were employed to analyze metabolites in clinical samples. We performed differential analysis, correlation analysis, and Mendelian randomization to determine the relationships between key metabolites and genes. Nebl, Dapl1, Igfbp4, Lef1, Klrd1, Ciita, Il17f, Cd8b1, Il17a, Cd180, Il17re, Trim7, and Slc6a19 were identified to play a crucial role in lower limb ischemia. Important metabolites included L-threonine and L-tryptophan. The metabolism of L-threonine and L-tryptophan is linked to lower limb ischemia and thrombosis. B0AT1, encoded by SLC6A19, is closely related to these metabolites and appears to play a key role in lower limb ischemia development. Our analysis revealed the roles of key genes and metabolites in lower limb ischemia. These findings enhance our understanding of the pathogenesis of lower limb ischemia and provide new insights into its prevention and treatment.