Prevalence and risk factors for proximal deep vein thrombosis at admission in patients with traumatic fractures: a multicenter retrospective study.

Objective: This study aimed to determine the associated risk factors for proximal deep vein thrombosis (DVT) in patients with lower extremity and pelvic-acetabular fractures. Methods: The medical records of 4,056 patients with lower extremity and pelvic-acetabular fractures were retrospectively reviewed. The patients were classified into proximal or non-proximal DVT groups. Logistic regression models were used to determine the independent risk variables for proximal DVT. The predictive value of the related risk factors was further analyzed using receiver operating characteristic curves. Results: The prevalence of proximal DVT was 3.16%. Sex, body mass index (BMI), fracture site, injury mechanism, diabetes, coronary heart disease (CHD), injury-to-admission interval, hematocrit, platelet counts, and D-dimer levels differed significantly between the two groups. BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT. CHD decreased the risk of proximal DVT. The platelet and D-dimer had high negative predictive value for predicting proximal DVT formation, with cut-off values of 174 × 109/L and 2.18 mg/L, respectively. Conclusion: BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT in patients with lower extremity and pelvic-acetabular fractures. Platelet count and D-dimer level were effective indicators for excluding proximal DVT occurrence. CHD decreased the risk of proximal DVT.

Musculoskeletal disorders of the upper and lower limb: Prevalence among patients in Eastern province, Saudi Arabia.

OBJECTIVES: To determine the prevalence of upper and lower limb musculoskeletal (MSK) disorders among adult patients referred to physical therapy. METHODS: Data were retrospectively analyzed from electronic health records of patients referred to physical therapy between April 2021 and April 2023. MSK disorders were categorized based on the affected body region (upper or lower limb). RESULTS: A total of 11,243 patients were referred to physical therapy, of whom 4,156 (37%) had MSK disorders. The 4 most commonly affected regions were the knee (27.7%), followed by the shoulder (26.9%), the ankle/foot (14.9%), and the wrist/hand (11.8%). Within each region, the most prevalent disorders were as follows: knee (arthritis [26.5%], sprain/strain [20.1%], pain [10.1%]); shoulder (pain [20.2%], rotator cuff-related syndrome [18.5%], adhesive capsulitis [8.5%]); ankle/foot (sprain/strain [23.3%], fracture [14.3%], pain [8.9%]); and wrist/hand (fracture [24.1%], pain [8.9%], sprain/strain [7.6%]). Cramer's V analysis revealed a strong association between age and the region of MSK disorders (Cramer's V=0.234, p<0.001) and between patient sex and the region of MSK disorders (Cramer's V=0.189, p<0.001). CONCLUSION: This study demonstrates the prevalence of upper and lower limb MSK disorders among adult patients referred to physical therapy. Further research involving larger, representative samples is warranted to fully understand the prevalence and risk factors of MSK disorders in Saudi Arabia.

Effect of veno-arterial extracorporeal membrane oxygenation lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk.

PURPOSE: This study aimed to investigate the effects of lower-extremity cannulation on the intra-arterial hemodynamic environment, oxygen content, blood damage, and thrombosis risk under different levels of veno-arterial (V-A) ECMO support. METHODS: Computational fluid dynamics methods were used to investigate the effects of different levels of ECMO support (ECMO flow ratios supplying oxygen-rich blood 100-40 %). Flow rates and oxygen content in each arterial branch were used to determine organ perfusion. A new thrombosis model considering platelet activation and deposition was proposed to determine the platelet activation and thrombosis risk at different levels of ECMO support. A red blood cell damage model was used to explore the risk of hemolysis. RESULTS: Our study found that partial recovery of cardiac function improved the intra-arterial hemodynamic environment, with reduced impingement of the intra-arterial flow field by high-velocity blood flow from the cannula, a flow rate per unit time into each arterial branch closer to physiological levels, and improved perfusion in the lower extremities. Partial recovery of cardiac function helps reduce intra-arterial high shear stress and residence time, thereby reducing blood damage. The overall level of hemolysis and platelet activation in the aorta decreased with the gradual recovery of cardiac contraction function. The areas at high risk of thrombosis under V-A ECMO femoral cannulation support were the aortic root and the area distal to the cannula, which moved to the descending aorta when cardiac function recovered to 40-60 %. However, with the recovery of cardiac contraction function, hypoxic blood pumped by the heart is insufficient in supplying oxygen to the front of the aortic arch, which may result in upper extremity hypoxia. CONCLUSION: We developed a thrombosis risk prediction model applicable to ECMO cannulation and validated the model accuracy using clinical data. Partial recovery of cardiac function contributed to an improvement in the aortic hemodynamic environment and a reduction in the risk of blood damage; however, there is a potential risk of insufficient perfusion of oxygen-rich blood to organs.

Sex Differences in Mortality Risk after the First Hospitalisation due to Lower Extremity Peripheral Arterial Disease.

OBJECTIVE: Lower extremity peripheral arterial disease (PAD) is a severe condition that increases the risk of major adverse cardiovascular events, major adverse limb events, and all cause mortality. This study aimed to investigate the mortality risk among females and males hospitalised for the first time due to lower extremity PAD. METHODS: Three cohorts of patients who were admitted for the first time due to lower extremity PAD in 2007 - 2010, 2011 - 2014, and 2015 - 2018 were constructed. For the 2007 - 2010 and 2011 - 2014 cohorts, the 28 day, one year, and five year mortality were calculated, assessing survival time from date of hospital admission until date of death, end of study period, or censoring. For the 2015 - 2018 cohort, only 28 day and one year mortality were investigated due to lack of follow up data. Mortality of these cohorts was compared with the general population using standardised mortality rates (SMRs), and the risk of mortality between sexes was evaluated using Cox proportional hazards models. Cox models were adjusted for age, cardiovascular disease, and diabetes mellitus to account for potential confounding factors. RESULTS: In total, 7 950, 9 670, and 13 522 patients were included in the 2007 - 2010, 2011 - 2014, and 2015 - 2018 cohorts, respectively. Over 60% of individuals in each cohort were male. Mortality rates at 28 day and one year remained stable across all cohorts, while the five year mortality rate increased both for males and females in the 2011 - 2014 cohort. The SMRs both of females and males with PAD were significantly higher than in the general population. Multivariable regression analyses found no significant differences in mortality risk between sexes at 28 days and one year. However, the five year mortality risk was lower in females, with a hazard ratio of 0.89 (95% confidence interval [CI] 0.83 - 0.97) in the 2007 - 2010 cohort and 0.88 (95% CI 0.82 - 0.94) in the 2011 - 2014 cohort. CONCLUSION: The five year mortality risk has increased, and females face a lower mortality risk than males. Lower extremity PAD still carries unfavourable long term consequences compared with the general population.

CORRELATION OF NEUTROPHIL-LYMPHOCYTE RATIO (NLR) AND PLATELET-LYMPHOCYTE RATIO (PLR) WITH COMPLICATIONS AND POSTOPERATIVE SURVIVAL IN SURGERY FOR BONE METASTASIS OF THE APPENDICULAR SKELETON / CORRELAÇÃO DO NEUTROPHIL-LYMPHOCYTE RATIO (NLR) E PLATELET-LYMPHOCYTE RATIO (PLR) COM COMPLICAÇÕES E SOBREVIDA PÓS-OPERATÓRIAS NA CIRURGIA PARA METÁSTASE ÓSSEA DO ESQUELETO APENDICULAR

Introduction: Bone metastasis is the most common malignant neoplasm of the skeleton, and surgical decision-making depends on multiple factors, including postoperative complications and life expectancy. The identification of new prognostic factors can assist in decision making. Objective: In long bones metastases, to analyze the incidence of complications and postoperative survival up to 1 year, correlating them with NLR and PLR. Method: Review of 160 medical records of patients who underwent surgery for bone metastasis in the appendicular skeleton. In addition to epidemiological characteristics, NLR and PLR values were determined, correlating them with survival and complications. Result: Women represented 64.5% with a primary breast tumor in 62.6%; the proximal femur was the most affected; median survival was 13.2 months and in 1 year 34.7%. Tumor resection with endoprosthesis was more common. The post-surgical complication rate was 10% and the average time for post-operative complications to occur was 27.9 days (0-140). An association between the neutrophil variable and postoperative complications was found (p=0.04). For every 100 more units of neutrophils there was a 1% increase in the chances of post-surgical complications. Mean NLR and PLR values were, respectively, 5.3 (0.2-30.7) and 199.7 (32.1-676.7). Patients with NLR NLR ≥ 2 (p<0,001) showed a decrease in survival from 92,3% to 62,5% at the 3rd month, and from 61,5% to 31,3% at 1 year. Those with PLR ≥209 (p<0.001) showed a decrease in survival from 69% to 59.3% at the 3rd month, and from 40.2% to 25.9% at 1 year. Conclusion: There was no positive association between NLR and PLR with postoperative complications, but strongly yes with survival from the 3rd month after surgery.

Introdução: Metástase óssea é a neoplasia maligna mais comum do esqueleto, e a tomada de decisão cirúrgica depende de múltiplos fatores, incluindo as complicações pós-operatórias e a expectativa de vida. A identificação de novos fatores prognósticos pode auxiliar na tomada de decisão. Objetivo: Analisar em metástases de ossos longos, a incidência de complicações e sobrevida pós-operatórias até 1 ano correlacionando-as com NLR e PLR. Método: Revisão de 160 prontuários de operados por metástase óssea no esqueleto apendicular. Além de características epidemiológicas, foram determinados os valores de NLR e PLR correlacionando-os com sobrevida e complicações. Resultado: Mulheres representaram 64,5% com tumor primário na mama em 62,6%; o fêmur proximal foi o mais acometido; sobrevida média foi 13,2 meses e a de 1 ano 34,7%; ressecção tumoral com endoprótese foi mais comum. A taxa de complicação pós-cirúrgicas foi de 10% e o tempo médio para a ocorrência de complicações pós-operatórias foi de 27,9 dias (0-140). Foi encontrada associação da variável neutrófilos com a complicação pós-operatória (p=0,04). A cada 100 unidades a mais de neutrófilos houve aumento de 1% nas chances de complicações pós-cirúrgicas. Valores médios do NLR e PLR foram, respectivamente, 5,3 (0,2-30,7) e 199,7 (32,1-676,7).  Os pacientes com NLR ≥ 2 (p<0,001) apresentaram diminuição na sobrevida de 92,3% para 62,5% no 3° mês e de 61,5% para 31,3% em 1 ano. Aqueles com PLR ≥209 (p<0,001) apresentaram diminuição na sobrevida de 69% para 59,3% no 3° mês, e de 40,2% para 25,9% em 1 ano. Conclusão: Não foi verificada associação positiva entre o NLR e o PLR com complicações pós-operatórias, mas com sobrevida fortemente sim, a partir do 3° mês de pós-operatório.

CAN NEUTROPHIL-LYMPHOCYTE RATIO (NLR) AND PLATELET-LYMPHOCYTE RATIO (PLR) BE PROGNOSTIC INDICATORS FOR OPERATIVE COMPLICATIONS AND SURVIVAL IN BONE METASTASES? / NEUTROPHIL-LYMPHOCYTE RATIO (NLR) E PLATELET-LYMPHOCYTE RATIO (PLR) PODEM SER INDICADORES DE PROGNÓSTICO PARA COMPLICAÇÕES OPERATÓRIAS E SOBREVIDA EM METÁSTASES ÓSSEAS?

Introduction: In general, inflammation stimulates the production and release of neutrophils and, at the same time, decreases the production of lymphocytes. Lymphopenia reflects that cell-mediated immunity is impaired, while neutrophilia represents a response to systemic inflammation in these cancers. Objective: To review the incidence of complications and postoperative survival rates in patients with bone metastases in long bones, correlating them with markers NLR and PLR. Method: Narrative review carried out collecting information published on virtual platforms in Portuguese and English, initially carried out by searching for descriptors related to the topic, which were: "lower extremity, surgery, metastasis, epidemiology, postoperative complications, neutrophils, lymphocytes, platelets". The extension incorporated AND or OR, by title and/or summary, and full reading of the texts most related to the topic. Result: 21 articles were included. Conclusion: The higher both the NLR and PLR are associated with lower survival in patients with bone metastases when undergoing surgical treatment, especially after 3 months postoperatively. However, there is still no confirmation that they signal any outcome, favorable or not, in relation to postoperative complications.

Introdução : De um modo geral, a inflamação estimula a produção e liberação de neutrófilos e, ao mesmo tempo, diminui a produção de linfócitos. A linfopenia reflete que a imunidade mediada pelas células é prejudicada, enquanto a neutrofilia representa resposta à inflamação sistêmica nesses cânceres. Objetivo : Revisar nos pacientes com metástase óssea em ossos ao longo da incidência de complicações e taxas de sobrevida pós-operatória correlacionando-as com os marcadores NLR e PLR. Método : Revisão narrativa feita colhendo informações publicadas em plataformas virtuais em português e inglês inicialmente realizada por busca dos descritores relacionados ao tema que foram: "extremidade inferior, cirurgia, metástase, epidemiologia, complicações pós-operatórias, neutrófilos, linfócitos, plaquetas" e seus equivalentes em inglês " extremidade inferior, cirurgia, metástase, epidemiologia, sobrevivência, complicações, neutrófilos, linfócitos, plaquetas sanguíneas ". A extensão incorporou AND ou OR, pelo título e/ou resumo, e leitura na íntegra dos textos mais relacionados ao tema.  Resultado : Foram incluídos 21 artigos. Conclusão : Quanto maiores, tanto o NLR quanto o PLR estão associados à menor sobrevida em pacientes com MO quando submetidos ao tratamento cirúrgico, especialmente após 3 meses de pós-operatório. Contudo, ainda não há confirmação de que eles sinalizam algum estágio, positivo ou não, em relação às complicações pós-operatórias.

Hemoglobin concentration and blood shift during dry static apnea in elite breath hold divers.

Introduction: Elite breath-hold divers (BHD) enduring apneas of more than 5 min are characterized by tolerance to arterial blood oxygen levels of 4.3 kPa and low oxygen-consumption in their hearts and skeletal muscles, similar to adult seals. Adult seals possess an adaptive higher hemoglobin-concentration and Bohr effect than pups, and when sedated, adult seals demonstrate a blood shift from the spleen towards the brain, lungs, and heart during apnea. We hypothesized these observations to be similar in human BHD. Therefore, we measured hemoglobin- and 2,3-biphosphoglycerate-concentrations in BHD (n = 11) and matched controls (n = 11) at rest, while myocardial mass, spleen and lower extremity volumes were assessed at rest and during apnea in BHD. Methods and results: After 4 min of apnea, left ventricular myocardial mass (LVMM) determined by 15O-H2O-PET/CT (n = 6) and cardiac MRI (n = 6), was unaltered compared to rest. During maximum apnea (∼6 min), lower extremity volume assessed by DXA-scan revealed a ∼268 mL decrease, and spleen volume, assessed by ultrasonography, decreased ∼102 mL. Compared to age, BMI and VO2max matched controls (n = 11), BHD had similar spleen sizes and 2,3- biphosphoglycerate-concentrations, but higher total hemoglobin-concentrations. Conclusion: Our results indicate: 1) Apnea training in BHD may increase hemoglobin concentration as an oxygen conserving adaptation similar to adult diving mammals. 2) The blood shift during dry apnea in BHD is 162% more from the lower extremities than from the spleen. 3) In contrast to the previous theory of the blood shift demonstrated in sedated adult seals, blood shift is not towards the heart during dry apnea in humans.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Motor polyradiculoneuropathy as an unusual presentation of neurobrucellosis: a case report and literature review.

Brucellosis, a zoonotic disease caused by Brucella species, poses a significant global health concern. Among its diverse clinical manifestations, neurobrucellosis remains an infrequent yet debilitating complication. Here, we present a rare case of neurobrucellosis with unusual presentations in a 45-year-old woman. The patient's clinical course included progressive lower extremity weakness, muscle wasting, and double vision, prompting a comprehensive diagnostic evaluation. Notable findings included polyneuropathy, elevated brucella agglutination titers in both cerebrospinal fluid and blood, abnormal EMG-NCV tests, and resolving symptoms with antibiotic therapy. The clinical presentation, diagnostic challenges, and differentiation from other neurological conditions are discussed. This case underscores the importance of considering neurobrucellosis in regions where brucellosis is prevalent and highlights this rare neurological complication's distinctive clinical and radiological features. Early recognition and appropriate treatment are crucial to mitigate the significant morbidity associated with neurobrucellosis.

Are Functional Performance Test Scores Better When Compared to Baseline or Contralateral Limb Scores Following LE Injury in Adolescent Athletes?

Background: Functional performance tests (FPT) have been used with athletes following an injury to determine readiness to return-to-play (RTP), usually using limb symmetry indices to the contralateral limb or a baseline score. There is not a consensus as to which criterion scores are best compared. Hypothesis/Purpose: This study aimed to compare common functional performance test scores from injured athletes at the time of release to RTP to both preseason baseline scores and to the contralateral limb. It was hypothesized that using baseline scores for comparison would be more responsive to residual deficits following injury than using the contralateral limb. Study Design: Prospective longitudinal cohort study. Methods: High school athletes (n=395) from all varsity sports completed a battery of FPTs including the Y-Balance Test (YBT), single limb hop tests and T-Test for agility (TT) during their preseason to establish baseline data. Injured athletes (n=19) were re-tested using all FTP's again at the time of RTP. Paired t-tests were used to detect if significant (p\<0.05) residual deficits were present at time of RTP when compared to baseline and to contralateral scores on FPTs. Results: Differences in YBT scores were found in the anterior direction only (p=0.021) when comparing RTP to preseason, but there were no differences when compared to RTP data for the contralateral limb. Differences were detected with the single leg hop test (p = 0.001) when comparing the RTP to preseason and were also detected in both the single leg hop (p= 0.001) and triple hop (p=0.018) when compared to the contralateral limb. Differences in TT scores were detected when comparing RTP to preseason for cutting first with both the unaffected (p = 0.019) and affected (p = 0.014) limbs. Conclusions: The YBT in the anterior direction and the TT are better able to detect residual deficits when comparing RTP to preseason scores. Hop tests are better able to detect deficits when compared to the contralateral limb. These results could make preseason testing more efficient when creating a reference for determining RTP readiness following lower extremity injury.

Prediction model of deep vein thrombosis risk after lower extremity orthopedic surgery.

Purpose: This investigation was conceived to engineer and appraise a pioneering clinical nomogram, crafted to bridge the extant chasm in literature regarding the postoperative risk stratification for deep vein thrombosis (DVT) in the aftermath of lower extremity orthopedic procedures. This novel tool offers a sophisticated and discerning algorithm for risk prediction, heretofore unmet by existing methodologies. Methods: In this retrospective observational study, clinical records of hospitalized patients who underwent lower extremity orthopedic surgery were collected at the Wuxi TCM Hospital Affiliated to the Nanjing University of Chinese Medicine between Jan 2017 and Oct 2019. The univariate and multivariate analysis with the backward stepwise method was applied to select features for the predictive nomogram. The performance of the nomogram was evaluated with respect to its discriminant capability, calibration ability, and clinical utility. Result: A total of 5773 in-hospital patients were eligible for the study, with the incidence of deep vein thrombosis being approximately 1 % in this population. Among 31 variables included, 5 of them were identified to be the predictive features in the nomogram, including age, mean corpuscular hemoglobin concentration (MCHC), D-dimer, platelet distribution width (PDW), and thrombin time (TT). The area under the receiver operating characteristic (ROC) curve in the training and validation cohort was 85.9 % (95%CI: 79.96 %-90.04 %) and 85.7 % (95%CI: 78.96 %-90.69 %), respectively. Both the calibration curves and decision curve analysis demonstrated the overall satisfactory performance of the model. Conclusion: Our groundbreaking nomogram is distinguished by its unparalleled accuracy in discriminative and calibrating functions, complemented by its tangible clinical applicability. This innovative instrument is set to empower clinicians with a robust framework for the accurate forecasting of postoperative DVT, thus facilitating the crafting of bespoke and prompt therapeutic strategies, aligning with the rigorous standards upheld by the most esteemed biomedical journals.

Livedoid Vasculopathy with Severe Debilitating Neuropathy in a Prior Professional Athlete.

Livedoid vasculopathy (LV) can be a challenging diagnosis with an interesting pathophysiology. LV is an uncommon diagnosis that can be easily mistaken for more common skin conditions, especially in a person of color who may be underrepresented in pathology images used in medical education. LV has an average of five years from initial presentation to diagnosis, possibly due to providers not having it on their differential for lower extremity ulcerations. Prolonged time to diagnosis can potentially lead to life-changing complications. We present a case of a former professional sprinter who became debilitated by neuropathy secondary to complications from LV. He was seen multiple times and had an extensive work-up exploring a broad differential including autoimmune etiologies, hypercoagulable disorders, neuropathies, and other vascular disorders before reaching the diagnosis. This case emphasizes the importance of early diagnosis and treatment with a multidisciplinary team to help prevent the progression of these symptoms. We break down an extensive work-up that involves a multidisciplinary team including dermatology, hematology, neurology, rheumatology, and vascular surgery. This case will also highlight examples of LV in a patient with a dark skin complexion, which can be challenging to find in current literature. We additionally show images that demonstrate many of the classic pathologic findings associated with LV and how those can help lead to the diagnosis along with detailed descriptions of those findings. Classic physical exam findings including atrophic blanche and lower extremity ulcerations are highlighted. We also review LV's history, diagnosis, and treatment to help readers achieve a better understanding of the disease.

The association between lower extremity function and cardiovascular diseases risk in older Chinese adults: Longitudinal evidence from a nationwide cohort.

BACKGROUND: Older adults in China are at a high risk of cardiovascular diseases (CVD), and impaired lower extremity function (LEF) is commonly observed in this demographic. This study aimed at assessing the association between LEF and CVD, thus providing valuable insights for clinical practice and public health policies. METHODS: A sample of 4,636 individuals was included from the China Health and Retirement Longitudinal Study (CHARLS) dataset. Logistic regression and cox proportional hazard regression model was utilized to study the association between LEF and CVD incidence. Cross-lagged panel models were utilized to investigate the potential causal association between LEF and CVD over time. RESULTS: Poor LEF was significantly associated with a higher risk of CVD in the total population [OR (95 % CI): 1.62 (1.27-2.05), P < 0.001]. Individuals with poor LEF demonstrated an increased risk of developing CVD [HR (95 % CI): 1.11 (1.02-1.23), P < 0.05], particularly stroke, compared to those with good LEF. And those with poor LEF had higher risks for heart disease [1.21 (1.00-1.45), P < 0.05] and stroke [1.98 (1.47-2.67), P < 0.001]. CONCLUSION: The results suggest the potential usefulness of the Short Physical Performance Battery (SPPB) for classifying stroke risk in older Chinese adults, which also suggested that preventing and/or improving LEF may be beneficial for reducing stroke incidence and promoting healthy aging for older adults.

Polyvascular Disease is Common in Patients Undergoing Carotid Endarterectomy and Lower Extremity Bypass and is Associated With Worse Outcomes.

INTRODUCTION: Polyvascular disease is strongly associated with increased risk of cardiovascular morbidity and mortality. However, its prevalence in patients undergoing carotid and lower extremity surgical revascularization and its impact on outcomes are unknown. METHODS: The Vascular Quality Initiative was queried for carotid endarterectomy (CEA) or infrainguinal lower extremity bypass (LEB), 2013-2019. Polyvascular disease was defined as presence of atherosclerotic occlusive disease in > 1 arterial bed: carotid, coronary, and infrainguinal. Primary outcomes were: (1) composite perioperative myocardial infarction (MI) or death and (2) 5-year survival. Patient characteristics and perioperative outcomes were evaluated using chi-square test and multivariable logistic regression. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards multivariable models. RESULTS: Polyvascular disease was identified in 47% of CEA (39% 2 arterial beds, 7.6% 3 arterial beds; n = 93,736) and 47% of LEB (41% 2 arterial beds, 5.7% 3 arterial beds; n=25,223). For both CEA and LEB, patients with polyvascular disease had more comorbidities including hypertension, congestive heart disease, chronic obstructive pulmonary disease, smoking, diabetes mellitus, and end-stage renal disease (P<0.0001). Perioperative MI/death rates increased with increasing number of vascular beds affected following CEA (0.9% 1 bed vs 1.5% 2 beds vs 2.7% 3 beds, P<0.001) and LEB (2.2% 1 bed vs 5.3% 2 beds vs 6.6% 3 beds, P<0.001). Polyvascular disease was independently associated with perioperative MI/death after CEA (OR 1.59 (95% CI 1.40-1.81), P<.0001) and LEB (OR 1.78 (95% CI 1.52-2.08), P<.0001). Five-year survival was decreased in patients with polyvascular disease after CEA (82% 3 beds vs 88% 2 beds vs 92% 1 bed, P<0.01) and LEB (72% 3 beds vs 75% 2 beds vs 84% 1 bed, P<0.01) in a dose-dependent manner, with the lowest 5 year survival observed in those with 3 arterial beds involved. Polyvascular disease was independently associated with five-year mortality following CEA (HR 1.33 (95% CI 1.24-1.40), P=0.0001) and LEB (HR 1.30 (95% CI 1.20-1.41), P=0.0001). CONCLUSION: Polyvascular disease is common in patients undergoing CEA and LEB and is associated with higher risk of perioperative MI/death and decreased long-term survival. Following revascularization, polyvascular disease patients may be considered for more aggressive cardioprotective medications and closer follow up.

Real World Application of WIfI Scores in Peripheral Arterial Disease Patients.

OBJECTIVE: The Society for Vascular Surgery wound, ischemia, and foot infection (WIfI) classification system aims to risk stratify patients with chronic limb threatening ischemia (CLTI), predicting both amputation rates and the need for revascularization. However, real-world utilization of the system and whether it accurately predicts outcomes following open revascularization and peripheral interventions is unclear. Therefore, we sought to determine the adoption of the WIfI classification system within a contemporary statewide collaborative as well as the impact of patient factor, and WIfI risk assessment on short- and long-term outcomes. METHODS: Using data from a large statewide collaborative, we identified patients with CLTI undergoing open surgical revascularization or peripheral vascular intervention (PVI) between 2016 - 2022. The primary exposure was preoperative clinical WIfI stage. Patients were categorized according to the SVS Lower Extremity Threatened Limb Classification System into clinical WIfI stages1, 2, 3, or 4. The primary outcomes were 30-day and 1-year amputation and mortality. Multivariable logistic regression was performed to estimate the association of WIfI stage on post-revascularization outcomes. RESULTS: In the cohort of 17,417 patients, 83.4% (n=14,529) had WIfI stage documented. Peripheral vascular interventions (PVIs) were performed on 57.6% of patients, and 42.4% underwent an open surgical revascularization (OSR). 49.5% of patients were classified as stage 1, 19.3% stage 2, 12.8% stage 3 and 18.3% of patients met stage 4 criteria. Stage 3 and 4 patients had higher rates of diabetes, congestive heart failure, and renal failure, and were less likely to be current or former smokers. One-half of stage 3 patients underwent OSR, while stage 1 patients were most likely to have received a PVI (64%). As WIfI stage increased from 1 to 4, 1-year mortality increased from 12% to 21% (p<0.001), 30-day amputation rates increased from 5% to 38% (p<0.001), and 1-year amputation rates increased from 15% to 55% (p<0.001). Finally, patients who did not have WIfI scores classified had significantly higher 30-day and 1-year mortality, as well as higher 30-day and 1-year amputation rates. CONCLUSION: The Society for Vascular Surgery WIfI clinical stage is significantly associated with 1-year amputation rates in patients with CLTI following lower extremity revascularization. As nearly 55% of stage 4 patients require a major amputation within one year of intervention, this study supports use of the WIfI classification system in clinical decision making for patients with CLTI.

Pericapsular nerve group (PENG) block: what have we learned in the last 5 years?

This educational article discusses the current understanding of the pericaspular nerve group block (PENG) of the hip regarding its mechanism of action and spread patterns, as well as plausible explanations for postblock quadriceps weakness. Finally, we will discuss the recent evidence of PENG block as an analgesic block in hip fractures and in different hip surgeries.

Anesthesia for the Patient Undergoing Foot and Ankle Surgery.

Modern anesthetic management for foot and ankle surgery includes a variety of anesthesia techniques including general anesthesia, neuraxial anesthesia, or MAC in combination with peripheral nerve blocks and/or multimodal analgesic agents. The choice of techniques should be tailored to the nature of the procedure, patient comorbidities, anesthesiologist skill level, intensity of anticipated postoperative pain, and surgeon preference.

Cognitive-motor interference during walking with modified leg mechanics: a dual-task walking study.

Background: The use of mobile exoskeletons as assistive walking devices has the potential to affect the biomechanics of the musculoskeletal system due to their weight and restricted range of motion. This may result in physical and cognitive load for the user. Understanding how lower extremity loading affects cognitive-motor interference is crucial for the design of wearable devices, including powered exoskeletons, and the development of effective training interventions. Objective: This study aims to examine the effects of modified leg mechanics on cognitive-motor interference in dual-task walking. Gait variability, as an indicator of motor control, was analyzed to investigate its relation to cognitive task difficulty and to determine whether lower extremity loading modifies this relationship. Additionally, the impact on the gait pattern, as represented by the mean values of spatio-temporal gait parameters were investigated. Method: Fifteen healthy young adults walked on a treadmill with and without weight cuffs bilaterally attached to their thighs and shanks while performing a visual-verbal Stroop test (simple task) and a serial subtraction task (difficult task). Dependent variables include mean values and variability (coefficients of variation) of step length, step width, stride time and double support time. Additionally, secondary task performance as correct response rates and perceived workload were assessed. Results: Double support time variability decreased during dual-task walking, but not during walking with modified leg mechanics while performing the difficult secondary task. Walking with modified leg mechanics resulted in increased gait variability compared to normal walking, regardless of cognitive load. During walking with modified leg mechanics, step length, step width, and stride time increased, while double support time decreased. The secondary tasks did not affect the gait pattern. Conclusion: The interplay between an external focus of attention and competition for attentional resources may influence the variability of double support time. The findings suggest that walking with modified leg mechanics could increase cognitive-motor interference for healthy young adults in demanding dual-task situations. Therefore, it is important to analyze the underlying mechanisms of cognitive-motor interference in the context of human-exoskeleton interaction.

-A machine learning model to predict surgical site infection after surgery of lower extremity fractures.

PURPOSE: This study aimed to develop machine learning algorithms for identifying predictive factors associated with the risk of postoperative surgical site infection in patients with lower extremity fractures. METHODS: A machine learning analysis was conducted on a dataset comprising 1,579 patients who underwent surgical fixation for lower extremity fractures to create a predictive model for risk stratification of postoperative surgical site infection. We evaluated different clinical and demographic variables to train four machine learning models (neural networks, boosted generalised linear model, naïve bayes, and penalised discriminant analysis). Performance was measured by the area under the curve score, Youdon's index and Brier score. A multivariate adaptive regression splines (MARS) was used to optimise predictor selection. RESULTS: The final model consisted of five predictors. (1) Operating room time, (2) ankle region, (3) open injury, (4) body mass index, and (5) age. The best-performing machine learning algorithm demonstrated a promising predictive performance, with an area under the ROC curve, Youdon's index, and Brier score of 77.8%, 62.5%, and 5.1%-5.6%, respectively. CONCLUSION: The proposed predictive model not only assists surgeons in determining high-risk factors for surgical site infections but also empowers patients to closely monitor these factors and take proactive measures to prevent complications. Furthermore, by considering the identified predictors, this model can serve as a reference for implementing preventive measures and reducing postoperative complications, ultimately enhancing patient outcomes. However, further investigations involving larger datasets and external validations are required to confirm the reliability and applicability of our model.

Effects of Recombinant Human Granulocyte/Macrophage Colony-Stimulating Factor on Diabetic Lower Extremity Ulcers: Case Series of Nine Patients.

Background: Diabetic lower extremity ulcer, including diabetic foot ulcer (DFU) and leg ulcer, is one of the refractory complications of diabetes, the treatment of which is challenging, expensive, and lengthy. Recombinant Human Granulocyte/Macrophage Colony-stimulating Factor (rhGM-CSF) is an immunomodulatory cytokine that has been mainly applied in the treatment of hematological diseases. Clinical evidence regarding GM-CSF in the treatment of diabetic lower extremity ulcers is limited. This study is the first case series that investigates the repurpose effects of rhGM-CSF on diabetic ulcer healing in real clinical practice. Methods: Nine patients diagnosed with diabetes and refractory lower extremity ulcer (ulcer duration ≥2 weeks) were included from September 2021 to February 2023 in the Division of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Patients with Wagner grade ≥4 and SINDAD ≥5 were excluded. The included subjects were treated with rhGM-CSF plus standard of care (SOC) including glycemic control, foot care education, debridement of necrotic tissues, topical wound dressings, offloading, and infection control when necessary. The observation endpoint was complete epithelialization. Their clinical manifestations, laboratory tests, and therapeutic effects were extracted and analyzed. Results: The case series included 9 cases aged from 29 to 80 years and all the patients were male. Seven of 9 patients presented neuropathic ulcer. Only one case showed non-infected ulcer from tissue samples and one case presented ankle brachial index (ABI) <0.9. It was observed that the ulcer areas among these 9 patients gradually declined throughout the whole treatment period with the average healing velocity 0.32 ± 013 cm2/day and the mean time to complete healing 16.0 ± 3.7 days. The relative area (percentage of initial ulcer area) decreased to 66.7 ± 13.0% on average after the first treatment. Ulcers in all the 9 patients achieved complete epithelialization after 4-8 times treatments. Conclusion: The case series suggests rhGM-CSF as a promising therapeutic strategy for the treatment of diabetic ulceration. More robust data from randomized controlled trials are required to further evaluate its clinical efficacy.