Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot.

BACKGROUND: One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital. METHODS: We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared. RESULTS: A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001). CONCLUSIONS: The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Life-threating upper gastrointestinal bleeding due to a primary aorto-jejunal fistula.

INTRODUCTION: Primary aorto-enteric fistula (AEF) is an uncommon life-threating condition. Only 4% of them involve the jejunum or ileum and its mortality ranges from 33 to 85%. PRESENTATION OF CASE: A 54-year-old female was admitted to the Emergency Department with syncope and hematemesis. The esophagogastroduodenoscopy found a pulsatile vessel in the second portion of the duodenum. A computed tomography scan showed an AEF with an infrarenal aortic aneurysm and iliac artery thrombosis. During surgery, an infrarenal aortic aneurysm complicated with an aorto-jejunal fistula was found. An axilo-bifemoral bypass, open repair of the aneurysm and segmental small bowel resection with primary suture of the jejunal defect were performed. DISCUSSION: Depending on previous aortic grafting, AEF can be classified as primary or secondary. Primary AEF is usually caused by an untreated abdominal aortic aneurysm, commonly presenting an infectious etiology. The main clinical sign is a "herald" hemorrhage. The EGD is considered as the first step in diagnosing AEF. The treatment of choice for AEF is emergent surgery. Use of broad-spectrum antibiotics is mandatory in the postoperative period to avoid fistula recurrence. CONCLUSION: AEF is a rare entity with a high mortality. High clinical suspicion is essential to make a correct diagnosis, which is crucial for the prognosis of these patients, such is the case of our patient. If hemodynamic stability is achieved, it allows to employ surgical strategies in which extra-abdominal bypass is performed before fistula is treated.

Incidence and timing of hypotension after transcervical carotid artery stenting: correlation with postoperative complications.

OBJECTIVES: To assess the incidence and timing of hypotension after carotid artery stenting (CAS) and its correlation with postoperative complications. BACKGROUND: CAS-associated postoperative hypotension has been linked to surgical morbidity and mortality, especially to stroke and cardiac complications. METHODS: Ninety-seven consecutive patients undergoing transcervical CAS were monitored for at least 12 hr after operation. Hypotension was defined as systolic blood pressure < 90 mm Hg. Patients were divided into three groups: normal blood pressure and early (≤6 hr) and late (>6 hr) hypotension. Complications were recorded. RESULTS: Hypotension occurred in 34% of the patients (early hypotension in 63% of them). Hypotension was recorded in 21.6% of patients during surgery and in 21.6%, 15.5%, and 1.0% at 6, 12, and 24 hr postoperatively. Bradycardia occurred in 26.8% during operation and in 25.8%, 13.4%, and 10.3% at 6, 12, and 24 hr after surgery. Intraoperative bradycardia (P = 0.01) and hypotension (P = 0.02) were predictors of postoperative hypotension. The overall rate of complications was 5% without differences between the study groups. The mean length of stay was 3, 3.6, and 2.8 days in the normotensive, early hypotension, and late hypotension groups, respectively. CONCLUSIONS: Most postoperative hypotension episodes occurred within the first 6 hr, and more than one-third between the 6 and 12 hr post-procedure. All patients with late hypotension were asymptomatic. There was no difference in complications between the study groups. In patients undergoing ambulatory CAS, hemodynamic monitoring in the postoperative period is particularly important during the first 12 hr.

Relationship between plasma homocysteine and the morphological and immunohistochemical study of carotid plaques in patients with carotid stenosis over 70%.

BACKGROUND: Several clinical and epidemiological studies describe hyperhomocysteinemia as an independent cardiovascular risk factor. Implication of cellular immunity in atherosclerosis also seems clear. This study aimed to analyze the association among plasma hyperhomocysteinemia, neurological clinical events, and the morphology and immunocytology of carotid plaques in patients with carotid stenosis >70% receiving surgical treatment. METHODS: Sixty-two patients with carotid stenosis >70% receiving surgical treatment were studied; 58% had a history of stroke in the ipsilateral carotid territory. Plasma homocysteine concentrations were determined by considering pathological values >12.4 µmol/L. Histopathological (stable and unstable plaques) and immunohistochemical (macrophages, T lymphocytes, and active T lymphocytes counts) studies were performed. Hyperhomocysteinemia prevalence was calculated in this population, as were the possible relationships between homocysteine plasma concentrations, and the carotid plaque type and the cell types in it. The relationship between this risk factor and the presence of a neurological event relating to carotid stenosis was also investigated. RESULTS: Hyperhomocysteinemia prevalence was 43.5%, with a mean value of 11.8 µmol/L (median; range = 2-41.8 µmol/L). No significant differences were found between homocysteine levels and the plaque's morphological characteristics, or between the cell types analyzed. Elevated concentrations of homocysteine were not significantly higher in patients with a history of stroke. CONCLUSION: The present study confirms high hyperhomocysteinemia prevalence in patients with extracranial cerebrovascular disease, although no relationship between plaque complication phenomena and this cardiovascular risk factor was observed.

The genetic manipulation of medicinal and aromatic plants.

Medicinal and aromatic plants have always been intimately linked with human health and culture. Plant-derived medicines constitute a substantial component of present day human healthcare systems in industrialized as well as developing countries. They are products of plant secondary metabolism and are involved in many other aspects of a plant's interaction with its immediate environment. The genetic manipulation of plants together with the establishment of in vitro plant regeneration systems facilitates efforts to engineer secondary product metabolic pathways. Advances in the cloning of genes involved in relevant pathways, the development of high throughput screening systems for chemical and biological activity, genomics tools and resources, and the recognition of a higher order of regulation of secondary plant metabolism operating at the whole plant level facilitate strategies for the effective manipulation of secondary products in plants. Here, we discuss advances in engineering metabolic pathways for specific classes of compounds in medicinal and aromatic plants and we identify remaining constraints and future prospects in the field. In particular we focus on indole, tropane, nicotine, isoquinoline alcaloids, monoterpenoids such as menthol and related compounds, diterpenoids such as taxol, sequiterpenoids such as artemisinin and aromatic amino acids.