Impact of comorbidities in COPD clinical control criteria. The CLAVE study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) frequently coexists with other chronic diseases, namely comorbidities. They negatively impact prognosis, exacerbations and quality of life in COPD patients. However, no studies have been performed to explore the impact of these comorbidities on COPD clinical control criteria. RESEARCH QUESTION: Determine the relationship between individualized comorbidities and COPD clinical control criteria. STUDY DESIGN AND METHODS: Observational, multicenter, cross-sectional study performed in Spain involving 4801 patients with severe COPD (< 50 predicted forced expiratory volume in the first second [FEV1%]). Clinical control criteria were defined by the combination of COPD assessment test (CAT) scores (≤16 vs ≥17) and exacerbations in the previous three months (none vs ≥1). Binary logistic regression adjusted by age and FEV1% was performed to identify comorbidities potentially associated with the lack of control of COPD. Secondary endpoints were the relationship between individualized comorbidities with COPD assessment test and exacerbations within the last three months. RESULTS: Most frequent comorbidities were arterial hypertension (51.2%), dyslipidemia (36.0%), diabetes (24.9%), obstructive sleep apnea-hypopnea syndrome (14.9%), anxiety (14.1%), heart failure (11.6%), depression (11.8%), atrial fibrillation (11.5%), peripheral arterial vascular disease (10.4%) and ischemic heart disease (10.1%). After age and FEV1% adjustment, comorbidities related to lack of clinical control were cardiovascular diseases (heart failure, peripheral vascular disease and atrial fibrillation; p < 0.0001), psychologic disorders (anxiety and depression; all p < 0.0001), metabolic diseases (diabetes, arterial hypertension and abdominal obesity; all p < 0.001), sleep disorders (p < 0.0001), anemia (p = 0.015) and gastroesophageal reflux (p < 0.0001). These comorbidities were also related to previous exacerbations and COPD assessment test scores. INTERPRETATION: Comorbidities are frequent in patients with severe COPD, negatively impacting COPD clinical control criteria. They are related to health-related quality of life measured by the COPD assessment test. Our results suggest that comorbidities should be investigated and treated in these patients to improve their clinical control. TAKE-HOME POINTS: Study question: What is the impact of comorbidities on COPD clinical control criteria? RESULTS: Among 4801 patients with severe COPD (27.5% controlled and 72.5% uncontrolled), after adjustment by age and FEV1%, comorbidities related to lack of clinical control were cardiovascular diseases (heart failure, peripheral vascular disease and atrial fibrillation; p < 0.0001), psychologic disorders (anxiety and depression; p < 0.0001), metabolic diseases (diabetes, arterial hypertension and abdominal obesity; p < 0.001), obstructive sleep apnea-hypopnea syndrome (p < 0.0001), anaemia (p = 0.015) and gastroesophageal reflux (p < 0.0001), which were related to previous exacerbations and COPD assessment test scores. INTERPRETATION: Comorbidities are related to health-related quality of life measured by the COPD assessment test scores and history of exacerbations in the previous three months.

Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease.

OBJECTIVE: Our aim was to compare transfemoral amputation (TFA) to knee disarticulation (KD) as a reamputation level after failed transtibial amputation (TTA) in patients with peripheral vascular disease and/or diabetes. METHODS: We studied 152 patients undergoing reamputation, 86 TFA and 66 KD, after a failed TTA. The primary outcome was reamputation and reoperation, and secondary outcomes were prosthetic fitting and mortality. Logistic regression analyses were performed to identify factors associated with the outcome. RESULTS: The reamputation rate was 36% after KD and 15% after TFA ( p = 0.004). The multivariable analysis showed that TFA was associated with a significantly reduced risk of reamputation, odds ratio (OR) = 0.31 (95% confidence interval [95% CI], 0.1-0.7). The overall reoperation rate was 38% after KD and 22% after TFA ( p = 0.03). This reduction of risk for TFA was not significant in the multivariable analysis, OR = 0.49 (95% CI, 0.2-1.0). Prosthetic limb fitting was possible in 30% after KD and 19% after TFA ( p = 0.1). Previous amputation in the contralateral leg was the only factor associated with reduced ability for prosthetic fitting in the multivariable analysis, OR = 0.15 (95% CI, 0.03-0.7). Mortality at 30 d was 17% and 53% at 1 year. No independent factors affected 30-d mortality in the multivariable analysis. CONCLUSIONS: In this study, we found a significantly lower risk of reamputation after TFA compared with KD after a failed TTA. We consider TFA to be the reamputation level of choice, especially when there is a need of reducing risk of further reamputations.

Prevalence and impact of cannabis use disorder on acute ischemic stroke and subsequent mortality in elderly peripheral vascular disease patients: A population-based analysis in the USA (2016 - 2019).

BACKGROUND: Given current evidence linking peripheral atherosclerotic disease, also known as cannabis arteritis, and acute ischemic stroke (AIS) in individuals with cannabis use disorder (CUD), we investigated the frequency and implications of CUD in relation to AIS risk and outcomes among elderly patients with peripheral vascular disease (PVD). METHODS: The National Inpatient Sample (2016-2019) was used to compare geriatric patients with PVD and cannabis use disorder CUD. CUD was correlated with AIS admissions. Adjusted multivariable regression models assessed in-hospital mortality rates. RESULTS: Of 5,115,824 geriatric admissions with PVD, 50.6 % were male and 77.5 % were white. 21,405 admissions had cardiovascular and CUD co-occurrence. 19.7 % of CUD patients had diabetes mellitus (DM), compared to 33.7 % of non-CUD patients. Smoking and HTN rates were comparable between groups. Patients with CUD used more recreational drugs concurrently than those without CUD. AIS prevalence was 5.2 % in CUD patients and 4.0 % in controls (p < 0.001). In the geriatric population with PVD, the presence of CUD was found to be associated with increased odds of hospitalizations due to AIS, with an adjusted odds ratio (aOR) of 1.34 (95 % confidence interval [CI] 1.18-1.52, p < 0.001). All-cause in-hospital mortality was not statistically significant, with an aOR of 0.71 (95 %CI 0.36-1.37, p = 0.302). In our study, older patients with PVD and hypertension (aOR 1.73) had a greater risk of AIS. Intriguingly, when we analyzed AIS predictors in elderly PVD patients with concurrent tobacco use disorder, we identified a counterintuitive protective effect (aOR 0.58, 95 % CI 0.42-0.79, p < 0.001). CONCLUSIONS: Our findings indicate that among geriatric patients with PVD and concurrent CUD, there is a notable 34 % risk of AIS. Importantly, this risk persists despite controlling for other CVD risk factors and substance use. Further investigations are warranted to elucidate and validate the intriguing phenomenon known as the smoker's paradox.

Embolism from a left ventricular myxoma presenting with acute limb ischaemia.

Acute limb ischaemia (ALI) secondary to cardiac myxoma is uncommon. Embolic myxoma should be considered a differential diagnosis in young patients with ALI who do not have apparent cardiovascular risk factors. A multidisciplinary approach and comprehensive care can improve outcomes and optimise the collaborative treatment of ALI. Early referral to a hospital that can provide specialised treatment for ALI helps prevent significant tissue loss and surgical complications, such as amputation.A man in his 20s presented with bilateral ALI of both lower extremities, and an arterial duplex scan revealed a thrombus occluding all arterial segments of the bilateral lower extremities. An intracardiac mass adherent to the apical and anterior interventricular septum on two-dimensional echocardiography suggested a complex myxoma. The patient was diagnosed with ALI Rutherford category III, and bilateral hip disarticulation was performed. The patient was discharged with an anticoagulant.

Major Adverse Cardiac and Cerebrovascular Events in Geriatric Patients with Obstructive Sleep Apnea: An Inpatient Sample Analysis.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with an increased risk of major cardiac and cerebrovascular events (MACCE). However, data on the burden and predictors of MACCE in geriatric patients with OSA (G-OSA) remain limited. METHODS: Using the National Inpatient Sample from 2018, we identified G-OSA admissions (age ≥ 65 years) and divided them into non-MACCE vs. MACCE (all-cause mortality, stroke, acute myocardial infarction, and cardiac arrest). We compared the demographics and comorbidities in both cohorts and extracted the odds ratio (multivariate analysis) of MACCE and associated in-hospital mortality. RESULTS: Out of 1,141,120 geriatric obstructive sleep apnea G-OSA admissions, 9.9% (113,295) had MACCE. Males, Asians, or the Pacific Islander/Native American race, and patients from the lowest income quartile revealed a higher MACCE rate. Significant clinical predictors of MACCE in elderly OSA patients on multivariable regression analysis in decreasing odds were pulmonary circulation disease (OR 1.47, 95% CI 1.31-1.66), coagulopathy (OR 1.43, 95% CI 1.35-1.50), peripheral vascular disease (OR 1.34, 95% CI 1.28-1.40), prior sudden cardiac arrest (OR 1.34, 95% CI 1.11-1.62), prior myocardial infarction (OR 1.27, 95% CI 1.22-1.33), fluid and electrolyte imbalances (OR 1.25, 95% CI 1.20-1.29), male sex (OR 1.22, 95% CI-1.18-1.26), hyperlipidemia (OR 1.20, 95% CI 1.16-1.24), low household income (OR 1.19, CI 1.13-1.26), renal failure (OR 1.15, 95% CI 1.12-1.19), diabetes (OR 1.14, 95% CI 1.10-1.17), metastatic cancer (OR 1.14, 95% CI 1.03-1.25), and prior stroke or TIA (OR 1.12, 95% CI 1.07-1.17) (All p value < 0.05). CONCLUSIONS: This study emphasizes the significant association between obstructive sleep apnea (OSA) and major cardiac and cerebrovascular events (MACCE) in the geriatric population. Among the elderly OSA patients, a substantial 9.9% were found to have MACCE, with specific demographics like males, Asian or Pacific Islander/Native American individuals, and those from the lowest income quartile being particularly vulnerable. The study sheds light on several significant clinical predictors, with pulmonary circulation disease, coagulopathy, and peripheral vascular disease topping the list. The highlighted predictors provide valuable insights for clinicians, allowing for better risk stratification and targeted interventions in this vulnerable patient cohort. Further research is essential to validate these findings and inform how tailored therapeutic approaches for geriatric OSA patients can mitigate MACCE risk. CLINICAL IMPLICATIONS: Elderly individuals with a high risk for MACCE should undergo routine OSA screening using tools like the sensitive STOP-BANG Questionnaire. Implementing CPAP treatment can enhance cardiovascular outcomes in these patients.

Dependency-related skin lesions in the prone critical patient. Incidence study.

OBJECTIVE: To determine the incidence of dependence-related skin lesions (DRSL) in patients in prone position (PP) and to identify the predisposing factors. METHOD: Follow-up study in two polyvalent intensive care units. Patients undergoing invasive mechanical ventilation and PP with no skin lesions on admission were included. We recorded the 3 types of DRSL: (pressure ulcers [PU], moisture-associated skin damage [MASD] and friction injuries [FI]), demographic variables, diagnosis, length of stay, PP episodes, postural changes, APACHE II (Acute Physiology and Chronic Health Disease Classification System), prealbumin level on admission, body mass index (BMI), diabetes, hypertension, smoking, peripheral vascular disease (PVD), vasoactive drugs, Braden scale and mortality. Bivariate analysis: chi-square test, t-test or Mann-Whitney U test. Multivariate analysis: logistic regression. RESULTS: Forty nine patients were included and 170PP were performed.Forty-one DRSL appeared in 22 patients with a cumulative incidence of 44.9% (95%CI: 31.6-58.7). PU accounted for 63.4% (73.1% facial; 76.9% stage II), 12.2% were MASD (60% inguinal; 60% stage II) and 24.4% were FI (50% thoracic; 70% stage III). The median age of the lesion group (LG) was 66.5 [61.8-71.3] vs. 64 [43-71] years old in the non-lesion group (NLG), p=0.04. Eighty percent of the LG had PVD vs. 20% of the NLG, p=0.03. The median total hours on PP of the LG was 96.9 [56.1-149.4] vs. 38.2 [18.8-57] of the NIG, p<0.001. Multivariate analysis selected total PP hours (OR=1.03; 95%CI:1.01-1.05) and PVD (OR=8.9; 95%CI:1.3-58.9) as predisposing factors for developing DRSL. CONCLUSIONS: There is a high incidence of skin lesions related to prone decubitus dependence, mostly pressure lesions, although of low severity.The accumulated hours in probe position and peripheral vascular disease favor their development.

Impaired consciousness and unilateral limb movement due to acute limb ischemia complicated by acute cerebral infarction: A case report.

RATIONALE: The symptoms of impaired consciousness and unilateral motor impairments are a perfect scenario for cerebral infarction, and a physician can easily miss the findings of limb ischemia on the patient paralyzed side even if acute limb ischemia (ALI) occurs on that side. The purpose of this case report is to reiterate the need to suspect ALI in patients with impaired consciousness who cannot complain of symptoms such as abnormal limb paresthesia or pain. PATIENT CONCERNS: An 89-year-old woman with impaired consciousness and motor impairment of the left upper and lower extremities was transported to our hospital. DIAGNOSES: Brain magnetic resonance imaging showed a suspected cerebral infarction in the posterior circulation; contrast-enhanced computed tomography showed occlusion of the left axillary artery and left femoral artery; and ultrasonography showed occlusion of the right popliteal artery. INTERVENTIONS: Cerebral angiography was performed simultaneously with surgical thrombectomy to treat the ALI. Mechanical thrombectomy was not performed for cerebral infarction. OUTCOMES: Although motor impairment of the left upper and lower extremities persisted, the patient successfully underwent limb salvage. LESSONS: Both cerebral infarction and ALI require early diagnosis and treatment. This rare case of cerebral infarction complicated by ALI emphasizes the need to avoid missing the signs of ALI in patients with impaired consciousness.

Vascular Access-Related Distal Ischemia Requiring Intervention: Frequency, Risk Factors, and Consequences.

BACKGROUND: Distal ischemia is a rare complication in patients undergoing placement of an arteriovenous (AV) fistula or AV graft. There are limited studies on its frequency, risk factors, clinical consequences, or feasibility of subsequent access. METHODS: A prospective vascular access database from a large academic medical center was queried retrospectively to identify 1498 patients (mean age 56±15 years, 48% female patients, 73% Black patients) undergoing placement of at least one vascular access from 2011 to 2020. For patients who developed access-related distal ischemia requiring surgical intervention, we determined the frequency of distal ischemia, clinical risk factors, and subsequent outcomes. RESULTS: Severe access-related distal ischemia occurred in 28 patients (1.9%; 95% confidence interval, 1.3% to 2.7%). The frequency was 0.2% for forearm AV fistulas, 0.9% for upper arm AV fistulas, 2.4% for forearm AV grafts, 2.2% for upper arm AV grafts, and 2.8% for thigh AV grafts. Risk factors independently associated with distal ischemia included female sex (odds ratio [OR], 3.64 [95% confidence interval, 1.52 to 8.72]), peripheral vascular disease (OR, 6.28 [2.84 to 13.87]), and coronary artery disease (OR, 2.37 [1.08 to 5.23]). Surgical interventions included ligation, excision, plication (banding), and other surgical procedures. Five patients developed tissue necrosis. A subsequent AV graft was placed in 13 patients, of whom only one (8%) developed distal ischemia requiring intervention. CONCLUSIONS: Access-related distal ischemia requiring intervention was rare in this study and more common in women and patients with peripheral vascular disease or coronary artery disease. In some cases, a subsequent vascular access could be placed with a low likelihood of recurrent distal ischemia.

Clinical Characteristics of Acute Lower Extremity Ischemia Due to Left Atrial Myxoma: A Rare Case Report with Review of Literature.

Emboli caused by cardiac myxomas mostly occur in the cardiovascular or cerebrovascular systems and rarely in the lower extremity vasculature. We introduce the rare case of a patient with left atrial myxoma (LAM) whose right lower extremity (RLE) suffered from acute ischemia due to tumor fragments, along with a review of the relevant literature, and highlight the clinical characteristics of LAM. An 81-year-old female presented with acute ischemia of RLE. Color Doppler ultrasound showed no blood flow signal far from the RLE femoral artery. Computed tomography angiography showed an occlusion of the right common femoral artery. A transthoracic echocardiogram revealed a left atrial mass. Femoral artery embolectomy was performed under local anesthesia, followed by thoracotomy with tumor resection under general anesthesia on postoperative day seven. The tumor was pathologically confirmed as an atrial myxoma. A literature search of the PubMed database returned 58 cases of limb ischemia due to LAM, and the conclusions drawn from the statistical analysis were that emboli from LAM occurred most commonly in the aortoiliac and bilateral lower limb vasculature and were rarely associated with upper extremity and atrial fibrillation. Multisystem embolism is characteristic of cardiac myxoma. The removed embolus should be examined pathologically for signs of a cardiac myxoma. Lower-limb embolisms should be promptly diagnosed and treated to avoid osteofascial compartment syndrome.

Managing the Patient with Peripheral Vascular Disease before Total Knee Arthroplasty Surgery.

Peripheral vascular disease (PVD), defined as decreased arterial perfusion to the lower extremities due to atherosclerotic obstruction, is known to occur in patients undergoing total knee arthroplasty with described rates of between 2% and 4.5% PVD is of significance for patients undergoing TKA as it can increase wound healing and infection complications after TKA and is an independent risk factor for arterial complications following TKA. Our goal is to provide a comprehensive review of the pathophysiology of PVD as it relates to TKA, associated outcomes of patients undergoing TKA in the setting of PVD, diagnostic pearls, and current management strategies recommended in the published literature.

Necessity, Role, and Outcomes of Fasciotomy in Patients with Acute Limb Ischemia.

BACKGROUND: The incidence of compartment syndrome in patients with acute lower limb ischemia (ALLI) and the effects of fasciotomy on outcomes are largely undefined. This study aimed to define the incidence of compartment syndrome in patients with ALLI and to examine whether different fasciotomy strategies are associated with specific patient outcomes. METHODS: A single-center retrospective study of patients who had ALLI between April 2016 and October 2020 at a tertiary care center. Patients were categorized into groups as having received early and late therapeutic fasciotomy (TF), early prophylactic fasciotomy (PF), early exploratory fasciotomy, and no fasciotomy. Primary outcome was 30-day amputation rate. Secondary outcomes were 30-day and 1-year mortality, 1-year amputation rate, and length of stay. Groups were compared using descriptive statistics to assess the association of fasciotomy approach with outcomes. RESULTS: During the study period, 266 patients were treated for ALLI, and 62 patients (23%) underwent 66 fasciotomies. A total of 41 TF, 23 PF, and 2 exploratory fasciotomies were done. There were 58 early fasciotomies performed (88% of 66 limbs): 33 (57%) early TF, 23 (40%) PF, and 2 (3%) exploratory. There were 8 patients who developed compartment syndrome after their revascularization operation and received delayed TF (12% of 66 limbs). The total number of TF was 41, which was 15% of all ALLI patients. The mean ± SD time to fasciotomy closure was 6.7 ± 5.7 days, which did not differ between PF and TF groups. Significantly more patients in the TF group had an amputation at 30 days (11 [29%] vs. 1 [5%]; P = 0.03) and at 1 year (6 [18%] vs. 2 [9%]; P = 0.02) than those in the PF group. Length of stay was increased in both TF (16 days) and PF (19 days) patients compared to nonfasciotomy patients (10 days; P < 0.01) but did not differ between the 2 fasciotomy groups (P = 0.4). Thirty-day limb loss was highest in patients who underwent early TF (10/33, 33%), intermediate in those with delayed TF (1/8, 13%), and lowest in PF (1/23, 5%; P = 0.03). CONCLUSIONS: Approximately 15% of patients with ALLI in our cohort required a TF for compartment syndrome. Close postoperative monitoring of ALLI patients who did not undergo early fasciotomy did detect delayed compartment syndrome; however, this approach did not prevent limb loss. To optimize limb salvage, physicians treating patients with ALLI should be experienced in how to recognize and treat compartment syndrome.

Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status.

BACKGROUND: Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated. QUESTION/PURPOSE: What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty? METHODS: We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis. RESULTS: After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001). CONCLUSION: Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated. LEVEL OF EVIDENCE: Level III, therapeutic study.

Catheter Directed Thrombolysis for Not Immediately Threatening Acute Limb Ischaemia: Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis reports the outcomes of catheter directed thrombolysis (CDT) in patients with not immediately threatening (Rutherford I) acute lower limb ischaemia (ALI). DATA SOURCES: PubMed, Embase, and the Cochrane Library. REVIEW METHODS: A systematic search of PubMed, Embase, and the Cochrane Library was performed to identify observational studies and trials published between 1990 and 2022 reporting on the results of CDT in patients with Rutherford I ALI. A meta-analysis was performed using a random effects model with 95% confidence intervals (CIs). The outcomes of interests were treatment duration, angiographic success, bleeding complications, amputation and mortality rates, primary and secondary patency, and functional outcome expressed as pain free walking distance. RESULTS: Thirty-nine studies were included, comprising 1 861 patients who received CDT for not immediately threatening ALI. Funnel plots showed an indication of publication bias, and heterogeneity was substantial. Data from 5 to 13 studies were included in the meta-analysis. The pooled treatment duration was 2 days (95% CI 1 - 2), with an angiographic success rate of 80% (95% CI 73 - 86) and a 30 day freedom of amputation rate of 98% (95% CI 92 - 100). The major bleeding rate was 5% (95% CI 2 - 14), with a 30 day mortality rate of 3% (95% CI 1 - 5). The amputation free survival rate was 71% (95% CI 62 - 80) at the one year and 63% (95% CI 51 - 73) at the three year follow up. Long term patency rates were retrieved from four studies: 48% at one year (95% CI 27 - 70). No data could be retrieved on patient walking distance. CONCLUSION: Although CDT in the treatment of not immediately threatening ALI showed high angiographic success, the long term outcomes were relatively poor, with low patency and a substantial risk of major amputation. Further research is required to interpret the outcome of CDT in the context of potential confounders such as age and comorbidities.

Atypical Pyoderma Gangrenosum in the Setting of Venous and Arterial Insufficiency.

Ulcers of mixed etiology are diagnostically elusive and challenging to treat, especially when rare conditions are superimposed. Pyoderma gangrenosum (PG) is an autoinflammatory, ulcerative skin disease that is difficult to diagnose. Diagnostic criteria exist but there are no specific clinical tests to identify it. We discuss a case of PG initially diagnosed as venous ulcer in the setting of peripheral artery disease, complicated by superinfection, refractory to standard wound care, multiple surgical debridements, revascularization, negative pressure therapy, and parenteral antibiotics. Findings differentiating PG from other wound etiologies are explored, with the aim of improving clinical recognition of this condition.

Hidradenitis suppurativa and the risk of myocardial infarction, cerebrovascular accident, and peripheral vascular disease: a population-based study.

Previous studies have identified an association between myocardial infarction (MI), cerebrovascular accident (CVA), and peripheral vascular disease (PVD) in patients with hidradenitis suppurativa (HS). To evaluate the risk and prognostic outcomes of MI, CVA, and PVD in patients with HS. A population-based retrospective cohort study using the computerized database of Clalit Health Services (CHS), the largest managed care organization in Israel, was conducted to compare the incidence of MI, CVA, and PVD among patients with HS (N = 6779) with age-, sex- and ethnicity-matched control subjects (N = 33,260). Adjusted hazard ratios (HRs) were estimated by multivariate Cox regression analysis. The overall incidence rates of MI, CVA, and PVD were estimated at 2.9 (2.3-3.4), 1.3 (0.9-1.7), and 0.8 (0.6-1.1) per 1000 person-year, respectively. Patients with HS were at an increased risk of developing MI (fully-adjusted HR 1.33; 95% CI 1.04-1.68; P = 0.021), but the risk of CVA (fully-adjusted HR 0.82; 95% CI 0.59-1.14; P = 0.245) and PVD (fully-adjusted HR 1.22; 95% CI 0.80-1.87; P = 0.355) was comparable relative to controls. Compared to other patients with HS, increased risk of all-cause mortality was observed among patients with HS and comorbid MI (HR 12.56; 95% CI 7.59-20.80; P < 0.001), CVA (HR 13.33; 95% CI 7.29-24.37; P < 0.001), and PVD (HR 7.11; 95% CI 2.61-19.32; P < 0.001). Patients with HS are at an increased risk of MI, but not CVA and PVD. Awareness of these epidemiological findings is of importance for clinicians managing patients with HS.

[Acute limb ischemia : Quick review for residents in interventional radiology]. / Akuter peripherer Gefäßverschluss : Übersicht für den angehenden interventionellen Radiologen bei akuter Ischämie der unteren Extremität.

BACKGROUND: Knowledge of diagnosis and treatment of acute limb ischemia is essential to preserve limb viability and prevent irreversible damage. OBJECTIVE: A brief review of treatment options, patient selection, and management in acute limb ischemia is provided for residents in interventional radiology. METHODS: The most commonly used interventional treatment options in acute limb ischemia including case studies and recommendations are provided. RESULTS: In acute limb ischemia, the decision between therapeutic procedures (interventional or surgical) depends on the clinical stage. There are three main interventional procedures: catheter-directed thrombolysis, thromboaspiration, and mechanical thrombectomy using specialized catheters; a combination of these procedures is also possible. The decision depends on various factors, some of which are center-specific, and should therefore always be made by interdisciplinary consensus. After near-complete revascularization, the cause should be sought and eliminated. CONCLUSIONS: In a case of suspected acute limb ischemia, patients should ideally be taken to an interdisciplinary center with interventional radiology and vascular surgery. After clinical evaluation and noninvasive imaging, a decision regarding possible therapeutic options can be made.

Major Bleeding During Thrombolytic Therapy for Acute Lower Limb Ischaemia: Value of Laboratory Tests for Clinical Decision Making, 17 Years of Experience.

OBJECTIVE: Regular measurement of fibrinogen as dose guidance in catheter directed thrombolysis (CDT) for acute limb ischaemia (ALI) has recently been dropped from European guidelines based on inconsistent literature. This study aimed to determine whether low fibrinogen levels and high activated partial thromboplastin time (APTT) are associated with an increased major bleeding risk during CDT. METHODS: All consecutive patients treated with CDT for ALI in two Dutch hospitals between January 2004 and April 2021 were analysed retrospectively. Patients were treated with two dosing regimens (low dose: 50 000 IU/hour; high dose: 100 000 IU/hour) of urokinase and, after 2018, with a single low dose regimen of alteplase (rtPA) due to urokinase manufacturing problems. The incidence of major bleeding and associated APTT and fibrinogen levels were reviewed from patient charts. RESULTS: Of the 443 included cases, 277 underwent CDT with urokinase and 166 with rtPA. The incidence of major bleeding in the whole cohort was 7%. Patients with a fibrinogen levels < 1.0 g/L developed more major bleeding than those in whom the fibrinogen level did not drop below 1.0 g/L (15% vs. 6%; p = .041). Systemic heparinisation during CDT or high (> 80 seconds) APTT were not significantly associated with major bleeding. Angiographic success (47% vs. 72%; p = .003) and 30 day amputation free survival (53% vs. 82%; p < .001) were lower for cases with major bleeding. Older age (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.02 - 1.11), cardiac history (OR 3.35, 95% CI 1.39 - 8.06), high dose regimens (≥ 75 000 IU/hour urokinase; OR 2.67, 95% CI 1.18 - 6.04), and fibrinogen values < 1.0 g/L (OR 5.59, 95% CI 1.98 - 15.77) were independent predictors for major bleeding during CDT. CONCLUSION: High dose thrombolytic regimens and fibrinogen levels of ≤ 1.0 g/L are associated with more major bleeding during thrombolytic therapy. Major bleeding significantly worsened the clinical outcome. A prospective comparative study is needed to assess the benefit of monitoring fibrinogen levels.

Comorbid status in patients with osteomyelitis is associated with long-term incidence of extremity amputation.

INTRODUCTION: Osteomyelitis is associated with significant morbidity, including amputation. There are limited data on long-term amputation rates following an osteomyelitis diagnosis. We sought to determine the incidence of amputation in patients with osteomyelitis over 2 years. RESEARCH DESIGN AND METHODS: Observational cohort study of 1186 inpatients with osteomyelitis between 2004 and 2015 and stratified by osteomyelitis location status to evaluate the impact on amputation, mortality rates, readmission data, and inpatient days. RESULTS: Persons with diabetes had 3.65 times greater probability of lower extremity amputation (p<0.001), readmission (p<0.001), and longer inpatient stay (p<0.001) and had higher 2-year mortality (relative risk (RR) 1.23, p=0.0027), adjusting for risk factors. Male gender (RR 1.57, p<0.001), black race (RR 1.41, p<0.05), former smoking status (RR 1.38, p<0.01), myocardial infarction (RR 1.72, p<0.001), congestive heart failure (RR 1.56, p<0.001), peripheral vascular disease (RR 2.25, p<0.001) and renal disease (RR 1.756, p<0.001) were independently associated with amputation. Male gender (RR 1.39, p<0.01), black race (RR 1.27, p<0.05), diabetes (RR 2.77, p<0.001) and peripheral vascular disease (RR 1.59, p<0.001) had increased risk of lower, not upper, extremity amputation. CONCLUSIONS: Patients with osteomyelitis have higher rates of amputation and hospitalization. Clinicians must incorporate demographic and comorbid risk factors to protect against amputation.

The association of comorbidity with Parkinson's disease-related hospitalizations.

INTRODUCTION: Unplanned hospital admissions associated with Parkinson's disease could be partly attributable to comorbidities. METHODS: We studied nationwide claims databases and registries. Persons with newly diagnosed Parkinson's disease were identified based on the first Parkinson's disease-related reimbursement claim by a medical specialist. Comorbidities were classified based on the Charlson Comorbidity Index. We studied hospitalization admissions because of falls, psychiatric diseases, pneumonia and urinary tract infections, PD-related hospitalizations-not otherwise specified. The association between comorbidities and time-to-hospitalization was estimated using Cox proportional hazard modelling. To better understand pathways leading to hospitalizations, we performed multiple analyses on causes for hospitalizations. RESULTS: We identified 18 586 people with newly diagnosed Parkinson's disease. The hazard of hospitalization was increased in persons with peptic ulcer disease (HR 2.20, p = 0.009), chronic obstructive pulmonary disease (HR 1.61, p < 0.001), stroke (HR 1.37, p = 0.002) and peripheral vascular disease (HR 1.31, p = 0.02). In the secondary analyses, the hazard of PD-related hospitalizations-not otherwise specified (HR 3.24, p = 0.02) and pneumonia-related hospitalization (HR 2.90, p = 0.03) was increased for those with comorbid peptic ulcer disease. The hazard of fall-related hospitalization (HR 1.57, p = 0.003) and pneumonia-related hospitalization (HR 2.91, p < 0.001) was increased in persons with chronic obstructive pulmonary disease. The hazard of pneumonia-related hospitalization was increased in those with stroke (HR 1.54, p = 0.03) or peripheral vascular disease (HR 1.60, p = 0.02). The population attributable risk of comorbidity was 8.4%. CONCLUSION: Several comorbidities increase the risk of Parkinson's disease related-hospitalization indicating a need for intervention strategies targeting these comorbid disorders.

Dysbetalipoproteinemia Is Associated With Increased Risk of Coronary and Peripheral Vascular Disease.

CONTEXT: Dysbetalipoproteinemia (DBL) is a disorder in which remnant lipoproteins accumulate in the plasma due to a genetic apolipoprotein E dysfunction in conjunction with the presence of secondary metabolic factors. An increased risk of both coronary and peripheral vascular disease (PVD) has been observed in these patients in retrospective studies. OBJECTIVE: The primary objective was to compare the incidence of atherosclerotic cardiovascular disease (ASCVD) and PVD in a cohort of patients with DBL compared with normolipidemic controls. As a secondary objective, the incidence of ASCVD and PVD was compared between patients with DBL and patients with familial hypercholesterolemia (FH). METHODS: A total of 221 patients with DBL, 725 patients with FH, and 1481 normolipidemic controls were included in the study. The data were obtained by review of medical records. RESULTS: In patients with DBL, there was an overall excess risk of PVD (hazard ratio [HR] 13.58, 95% CI 4.76-38.75) and ASCVD (HR 3.55, 95% CI 2.17-5.83) (P < .0001) when compared with normolipidemic controls. When compared with patients with FH, an increased risk of PVD (HR 3.89, 95% CI 1.20-12.55, P = .02) was observed in patients with DBL. CONCLUSION: We demonstrated that the risks of ASCVD and PVD in DBL are >3-fold and >13-fold higher, respectively, than normolipidemic controls. Furthermore, the risk of PVD is ∼4-fold higher in DBL than in FH. Adequate screening of DBL is imperative to improve the clinical care of these patients by preventing the development of ASCVD.