Factores de riesgo asociados a osteomielitis por Corynebacterium striatum en pacientes con pie diabético / Risk factors associated with osteomyelitis due to Corynebacterium striatum in patients with diabetic foot

Objetivo Corynebacterium striatum (C. striatum) es un microorganismo emergente en la infección de pie diabético poco estudiado. El objetivo es evaluar los factores de riesgo (FR) relacionados con osteomielitis por C. striatum en paciente con pie diabético. Métodos Estudio casos-controles en la Unidad de Pie Diabético entre 2015 y 2021. Un número de 44 pacientes con osteomielitis por C. striatum (casos) y 44 con osteomielitis por microorganismo distinto (controles) fueron incluidos. Resultados Enfermedad arterial periférica (odds ratio [OR]: 2,8, p = 0,037), fibrilación auricular (OR: 3,7, p = 0,034), pie diabético isquémico (OR: 3,3, p = 0,020) y antibioterapia previa prolongada más de 14 días (OR: 3,4, p = 0,012) fueron FR para la osteomielitis por C. striatum. En el análisis multivariado la antibioterapia más de 14 días fue el único FR independiente (OR: 3,46; p = 0,017) para osteomielitis por C. striatum. Conclusiones La antibioterapia previa recibida durante más de 14 días es un FR independiente y estadísticamente significativo de osteomielitis por C. striatum en pacientes con pie diabético (AU)

Objective Corynebacterium striatum (CS) is an emerging micro-organism in diabetic foot infection for which there are currently few studies. The objective was to analyze the risk factors (RF) related to CS osteomyelitis in patients with diabetic foot. Methods A case–control study was conducted in the Diabetic Foot Unit between 2015 and 2021. Forty-four patients with osteomyelitis due to CS (cases) and 44 patients with osteomyelitis due a different micro-organism (controls) were included. Results Peripheral artery disease (OR: 2.8, p = 0.037), atrial fibrillation (OR: 3.7, p = 0.034), ischemic diabetic foot (OR: 3.3, p = 0.020) and previous prolonged antibiotic therapy more than 14 days (OR: 3.4, p = 0.012) were identified as RF for osteomyelitis due to CS. When performing the multivariate analysis antibiotic therapy >14 days was independent RF (OR: 3.46; p = 0.017). Conclusions Previous antibiotic therapy received more than 14 days is an independent and statistically significant RF for CS osteomyelitis in patients with diabetic foot (AU)

[Risk factors associated with osteomyelitis due to Corynebacterium striatum in patients with diabetic foot]. / Factores de riesgo asociados a osteomielitis por Corynebacterium striatum en pacientes con pie diabético.

OBJECTIVE: Corynebacterium striatum (CS) is an emerging micro-organism in diabetic foot infection for which there are currently few studies. The objective was to analyze the risk factors (RF) related to CS osteomyelitis in patients with diabetic foot. METHODS: A case-control study was conducted in the Diabetic Foot Unit between 2015 and 2021. Forty-four patients with osteomyelitis due to CS (cases) and 44 patients with osteomyelitis due a different micro-organism (controls) were included. RESULTS: Peripheral artery disease (OR: 2.8, p = 0.037), atrial fibrillation (OR: 3.7, p = 0.034), ischemic diabetic foot (OR: 3.3, p = 0.020) and previous prolonged antibiotic therapy more than 14 days (OR: 3.4, p = 0.012) were identified as RF for osteomyelitis due to CS. When performing the multivariate analysis antibiotic therapy >14 days was independent RF (OR: 3.46; p = 0.017). CONCLUSIONS: Previous antibiotic therapy received more than 14 days is an independent and statistically significant RF for CS osteomyelitis in patients with diabetic foot.

Experiencia con el uso de dalbavancina en la infección profunda de pie diabético / Experience in the use of dalbavancin in diabetic foot infection

Objetivo: Describir la experiencia clínica con dalbavancina en el tratamiento de la infección de pie diabético en una unidad multidisciplinar de un hospital de segundo nivel. Métodos: Estudio descriptivo retrospectivo de pacientes con infección de pie diabético tratados con dalbavancina en la Unidad de Pie Diabético del Hospital Universitario Fundación Alcorcón de septiembre de 2016 a diciembre de 2019. Se recogieron parámetros demográficos y comorbilidades, características de la infección y del tratamiento con dalbavancina. Se estimó la tasa de curación a los 90 días tras finalizar el tratamiento. Resultados: Un total de 23 pacientes con infección de pie diabético (osteomielitis) fueron tratados con dalbavancina; 19 eran hombres con una edad media de 65 años. Los microorganismos más frecuentemente aislados fueron Staphylococcus aureus (11) y Corynebacterium striatum (7). En 22 casos se usó dalbavancina como terapia de segunda elección, en 11 debido a toxicidad de otros antibióticos. La mediana de duración del tratamiento fue de 5 (4-7) semanas; la dosis más frecuente de dalbavancina (8 pacientes) fue de 1.000mg seguido de 500mg semanales durante 5 semanas. Tres pacientes presentaron efectos secundarios leves (náuseas y molestias gastrointestinales). A los 90 días de finalizar el tratamiento, el 87% (20) de los pacientes se curaron (IC95%: 65,2-94,52%). Conclusión: Los pacientes con osteomielitis por microorganismos grampositivos que recibieron como parte del tratamiento multidisciplinar antibioterapia con dalbavancina tuvieron una elevada tasa de curación, con una adecuada tolerancia y escasos efectos secundarios. Dalbavancina ofrece una alternativa segura en el tratamiento de la infección profunda de pie diabético.(AU)

Objective: To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital. Methods: A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate was estimated at 90 days after finishing the treatment. Results: A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000mg followed by 500mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%). Conclusion: Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.(AU)

Experience in the use of dalbavancin in diabetic foot infection.

OBJECTIVE: To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital. METHODS: A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate is estimated at 90 days after finishing the treatment. RESULTS: A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000 mg followed by 500 mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%). CONCLUSION: Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.

Symptomatic Common Carotid Free-Floating Thrombus in a COVID-19 Patient, Case Report and Literature Review.

Carotid free-floating thrombus is an uncommon entity that usually presents with neurologic symptoms. Crescendo transient ischemic attack is an accepted indication for urgent carotid endarterectomy. COVID-19 is associated with severe thromboembolic complications. We report the case of a 61-year-old man who developed, 2 weeks after the diagnosis of COVID-19, crescendo transient ischemic attack, complicating a large intraluminal floating thrombus within the right common carotid artery. A carotid thromboendarterectomy under local anesthesia, with patch closure was immediately performed without complications. We conducted a literature review to identify cases of common carotid artery thrombus related to COVID-19. Carotid free-floating thrombus in the common carotid artery is exceptional. However, since the beginning of the COVID-19 pandemic, 15 cases have been published.

Experience in the use of dalbavancin in diabetic foot infection. / Experiencia con el uso de dalbavancina en la infección profunda de pie diabético.

OBJECTIVE: To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital. METHODS: A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate was estimated at 90 days after finishing the treatment. RESULTS: A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000mg followed by 500mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%). CONCLUSION: Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.

Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial.

BACKGROUND: Diabetic foot ulcers are serious and challenging wounds associated with high risk of infection and lower-limb amputation. Ulcers are deemed neuroischaemic if peripheral neuropathy and peripheral artery disease are both present. No satisfactory treatment for neuroischaemic ulcers currently exists, and no evidence supports one particular dressing. We aimed to assess the effect of a sucrose octasulfate dressing versus a control dressing on wound closure in patients with neuroischaemic diabetic foot ulcers. METHODS: We did a randomised, double-blind clinical trial (Explorer) in 43 hospitals with specialised diabetic foot clinics in France, Spain, Italy, Germany, and the UK. Eligible participants were inpatients or outpatients aged 18 years or older with diabetes and a non-infected neuroischaemic diabetic foot ulcer greater than 1 cm2 and of grade IC or IIC (as defined by the University of Texas Diabetic Wound Classification system). We excluded patients with a severe illness that might lead to them discontinuing the trial and those who had surgical revascularisation in the month before study entry. We randomly assigned participants (1:1) via a computer-generated randomisation procedure (concealed block size two); stratified by study centre and wound area (1-5 cm2 and 5-30 cm2), to treatment with either a sucrose octasulfate wound dressing or a control dressing (the same dressing without sucrose octasulfate) for 20 weeks. Both groups otherwise received the same standard of care for a 2-week screening period before randomisation and throughout the 20-week trial. Dressings were applied by nursing staff (or by instructed relatives for some outpatients). Frequencies of dressing changes were decided by the investigator on the basis of the clinical condition of the wound. Patients were assessed 2 weeks after randomisation, then monthly until week 20 or occurrence of wound closure. The primary outcome, assessed by intention-to-treat, was proportion of patients with wound closure at week 20. This trial is registered with ClinicalTrials.gov, number NCT01717183. FINDINGS: Between March 21, 2013, and March 31, 2016, we randomly assigned 240 individuals to treatment: 126 to the sucrose octasulfate dressing and 114 to the control dressing. After 20 weeks, wound closure occurred in 60 patients (48%) in the sucrose octasulfate dressing group and 34 patients (30%) in the control dressing group (18 percentage points difference, 95% CI 5-30; adjusted odds ratio 2·60, 95% CI 1·43-4·73; p=0·002). In both groups, the most frequent adverse events were infections of the target wound: 33 wound infections in 25 (20%) patients of 126 in the sucrose octasulfate dressing group and 36 in 32 (28%) patients of 114 in the control dressing group. Minor amputations not affecting the wound site were also reported in one (1%) patient in the sucrose octasulfate dressing group and two (2%) patients in the control dressing group. Three (2%) patients assigned to the sucrose octasulfate dressing and four (4%) assigned to the control dressing died, but none of the deaths were related to treatment, procedure, wound progression, or subsequent to amputation. INTERPRETATION: A sucrose octasulfate dressing significantly improved wound closure of neuroischaemic diabetic foot ulcers without affecting safety after 20 weeks of treatment along with standard care. These findings support the use of sucrose octasulfate dressing as a local treatment for neuroischaemic diabetic foot ulcers. FUNDING: Laboratoires Urgo Medical.

Diagnóstico del paciente vascular en una única consulta. Hacia una aplicación racional de los recursos / Diagnosis of vascular patients in a single visit. Towards a rational use of resources

Introducción. En cirugía vascular el modelo tradicional de la consulta médica exigía que el enfermo visitara el centro sanitario al menos en tres ocasiones. En el modelo de consulta de alta resolución, al realizar las exploraciones complementarias, se unifican las tres consultas en una. Objetivo. Plantear el modelo de única consulta en nuestro medio y analizar sus ventajas y desventajas mediante una descripción de los recursos necesarios. Pacientes y métodos. Estudio descriptivo de la actividad de consulta externa de Angiología y Cirugía Vascular en nuestro centro durante el mes de noviembre de 2004. Resultados. Durante ese mes atendimos en consulta a 432 pacientes: 148 nuevos (34,25%) y 284 (65,74%) revisiones. Se realizó alguna prueba diagnóstica al 100% de los pacientes con patología de troncos supraaórticos (TSA), hipertensión arterial /insuficiencia renal y fístula arteriovenosa; al 83% de los enfermos con aneurisma aortoilíaco; al 56% con arteriopatía periférica; y al 41% con insuficiencia venosa. Así, las pruebas complementarias se realizaron en el 40% (59/148) de los pacientes nuevos y en el 58% (165/284) de las revisiones. En todas las consultas se informó a los enfermos del resultado del estudio y del tratamiento necesario, por lo que evitamos 302 consultas sucesivas. El tiempo medio para la realización de un Doppler de miembros inferiores fue de 6 minutos; de un eco-Doppler de TSA, de 14 minutos; de uno abdominal, 9,6 minutos; femoral, 10 minutos; arterial preoperatorio de miembros inferiores, 50 minutos; venoso, 7,4 minutos, y renal, 30 minutos. Conclusiones. La consulta de alta resolución es factible en la mayoría de nuestros pacientes y disminuye el número de revisiones por cada caso

Introduction. In vascular surgery the traditional model of medical clinics required the patient to visit the health care centre on at least three occasions. In the one-stop clinic model, on performing the complementary examinations, the three visits become just one. Aim. To propose the single visit model in our area and to analyse its advantages and disadvantages by means of a description of the resources that would be needed. Patients and methods. We conducted a descriptive study of the activity in the Angiology and Vascular Surgery outpatient department in our centre during November 2004. Results. Throughout that month 432 patients visited: 148 were new cases (34.25%) and 284 (65.74%) were checkups. Diagnostic tests were carried out in 100% of patients with pathologies involving the supra-aortic trunks (SAT), arterial hypertension/renal failure and arteriovenous fistula; in 83% of patients with aortoiliac aneurysms; 56% of those with peripheral arterial disease; and 41% of subjects with venous insufficiency. Complementary tests were performed in 40% (59/148) of new patients and in 58% (165/284) of the checkups. In all visits patients were informed of the results of the study and the treatment they would require, which avoided the need for 302 successive visits. The average time required to perform a Doppler of the lower limbs was 6 minuts; a Doppler ultrasound recording of the SAT was 14 minutes; of the abdomen, 9.6 minutes; femoral, 10 minutes; preoperative arterial of the lower limbs, 50 minutes; venous, 7.4 minutes; and renal, 30 minutes. Conclusions. The one-stop clinic is a feasible proposition with most of our patients and reduces the number of checkups required by each case

Stent carotídeo por vía transcervical con reversión de flujo / Transcervical approach to carotid stenting with flow reversal

Introducción. El stent carotídeo con protección cerebral es una alternativa al tratamiento quirúrgico convencional en los pacientes de alto riesgo. Los sistemas de protección proximal son los únicos que previenen la embolia cerebral antes de cruzar la lesión. Recientemente se ha descrito una nueva técnica de stent carotídeo mediante abordaje cervical con reversión de flujo. Presentamos nuestra experiencia inicial con este procedimiento. Pacientes y métodos. Entre octubre de 2003 y noviembre de 2004 hemos tratado a 11 pacientes de alto riesgo, 9 varones y 2 mujeres, con una media de edad de 80 años (rango: 72-83 años), de los cuales el 91% era sintomático, uno de ellos con oclusión de la carótida interna contralateral. Resultados. Todos los pacientes se intervinieron con anestesia local, sin complicaciones neurológicas ni locales. Todos presentaron buena tolerancia a la reversión del flujo, y sólo hubo una bradicardia durante la dilatación (9%) resuelta con atropina. Todos fueron dados de alta en 48 horas. Durante el seguimiento medio de 11,1 meses (rango: 6-12 meses), un paciente falleció a los 3 meses por infección respiratoria. No hubo ningún evento neurológico. También hubo un paciente con reestenosis asintomática superior al 70%. Conclusiones. El tratamiento de la estenosis carotídea puede realizarse de forma sencilla y segura mediante la implantación de un stent por abordaje cervical con reversión de flujo. Elimina la dificultad de acceso en pacientes con enfermedad aortoilíaca o anatomía desfavorable del cayado, y evita las complicaciones femorales pospunción. Mientras no dispongamos de más datos sobre la efectividad y permeabilidad a largo plazo, preferimos reservar este procedimiento para los pacientes de alto riesgo (AU)

Introduction. Carotid stenting with cerebral protection is an option for the treatment of high-risk patients. Proximal occlusion catheters have the advantage of preventing cerebral embolisms before crossing the plaque. Recently a new transcervical approach with carotid flow reversal has been introduced for carotid artery stenting. We describe our initial experience with this technique. Patients and methods. Between October 2003 and November 2004 we have stented 11 high-risk patients, 9 men and 2 women, mean age 80 years (range: 72-83 years); 91% symptomatic, one of them associated contralateral carotid artery occlusion. Results. All procedures were successfully performed under local anesthesia without neurologic or local complications. Flow reversal was well tolerated in everyone, and one patient had angioplasty-induced bradycardia (9%) treated with atropine. All patients were discharged within 48 hours. During the 11.1 mean follow up (6-12 months) one patient died because of pneumonia. There was not any neurologic event. One patient had an asymptomatic reestenosis higher than 70%. Conclusions. Treatment of carotid stenosis can be accomplished simply and safely using the transcervical carotid artery stenting with flow reversal. It eliminates the problems of access in patients with aortoiliac disease or unfavourable arch anatomy, and avoids the femoral postpuncture complications. We prefer to keep this procedure for high-risk patients until more long-term patency rates are available (AU)

Importancia de la hipercoagulabilidad en la cirugía de la isquemia crónica de extremidades inferiores / The importance of hypercoagulability in the surgery of chronic ischaemia of the lower limbs

Introducción. Se ha descrito una alta prevalencia de estados de hipercoagulabilidad en pacientes con isquemia crónica.Objetivo. Determinar la prevalencia e importancia de estados de hipercoagulabilidad en pacientes con patología oclusiva crónica de extremidades inferiores, que precisan revascularización. Pacientes y métodos. Estudio prospectivo octubre 1999-abril 2000. En 52 pacientes se determinó: antitrombina III, proteína C y S, anticuerpos anticardiolipina, plasminógeno, a2-antiplasmina y resistencia a la proteína C activada. Se registraron factores de riesgo, clínica, cirugía realizada y resultados, y se analizó su relación con alteraciones de hipercoagulabilidad. Resultados. El 6 por ciento presentaban déficit de antitrombina III; el 31 por ciento, déficit de proteína C; el 2 por ciento, déficit de proteína S; el 10 por ciento, anticuerpos anticardiolipina, y el 12 por ciento, resistencia a la proteína C activada (RPCA). El 29 por ciento de los pacientes presentaban una alteración; el 13 por ciento, más de una, y el 58 por ciento, ninguna. El 50 por ciento (3/6) de los pacientes con RPCA se trombosaron, frente al 13 por ciento (6/46) de los pacientes sin RPCA (p= 0,05). El 42 por ciento (3/7) de los pacientes con varias alteraciones se trombosaron, frente al 13 por ciento (6/45) del resto (p= 0,08). El 33 por ciento (2/6) de los pacientes con RPCA presentaron trombosis precoz, frente al 2,1 por ciento (1/46) del resto (p= 0,03). El 28 por ciento (2/7) de los pacientes con varias alteraciones presentaron trombosis precoz, frente al 2,2 por ciento (1/ 45) del resto (p= 0,04). Conclusiones. La prevalencia de estados de hipercoagulabilidad en isquémicos crónicos es elevada. Estos hallazgos inducen implicaciones terapéuticas. (AU)

Técnicas endovasculares en el sector ilíaco. Revisión sistemática / Endovascular techniques at the iliac level. A systematic review

Introducción. Las técnicas endovasculares han mostrado su utilidad en las lesiones oclusivas del sector aortoilíaco, ya que se han utilizado con éxito en lesiones progresivamente más extensas y complejas. Material y métodos. Hemos realizado una revisión sistemática de la literatura publicada en lengua inglesa en dos bases bibliográficas habituales (MEDLINE y PubMed) utilizando los términos de búsqueda `aortoilíac', `iliac artery', `percutaneous transluminal angioplasty', `stent' y `endovascular', y limitándonos a ensayos clínicos. Resultados y conclusiones. La angioplastia transluminal percutánea (ATP) simple ha ofrecido excelentes resultados, con altas tasas de éxito técnico y permeabilidades a cinco años (5385 por ciento). Los factores identificados como predictivos de peor resultado han sido: lesión oclusiva, localización en ilíaca externa, longitud superior a 5 cm, mal run-off e indicación por isquemia crítica. El uso de stents ha mostrado su utilidad en indicación selectiva, pero no existen evidencias que justifiquen su indicación primaria. Las prótesis recubiertas representan una alternativa de futuro, si bien desconocemos sus resultados a largo plazo. Los malos resultados en cuanto a permeabilidad y la alta tasa de complicaciones desacreditan el empleo de técnicas de aterectomías y láser, ahora en desuso. La fibrinólisis parece mejorar los resultados de la ATP en situaciones de isquemia aguda (AU)

Anticoagulación perioperatoria y hematoma epidural. Caso clínico / Perioperative anticoagulation and epidural hematoma. Case report

La aparición de un hematoma epidural es una complicación grave y muy poco frecuente de la anestesia epidural. Presentamos el caso de un varón de 90 años, que fue intervenido quirúrgicamente bajo anestesia epidural por cuadro de isquemia aguda en miembro inferior izquierdo. En el perioperatorio fue tratado con antiagregantes, anticoagulantes y fibrinolíticos. A las 24 horas de la cirugía, presentó hematoma epidural y paraplejía, a pesar de respetarse las pautas recomendadas respecto al uso de anticoagulación perioperatoria y anestesia locoregional. (AU)