Plasma and tissue concentrations of 2 g prophylactic cefazolin prior to lower extremity surgery.

Surgical site infections (SSIs) are among the most clinically relevant complications and the use of prophylactic cefazolin is common practice. However, the knowledge about the pharmacological aspects of prophylactic cefazolin in the lower extremities remains limited. In this prospective cohort, a sub-study of the WIFI-2 randomized controlled trial, adults between 18 and 75 years of age who were scheduled for implant removal below the level of the knee and randomized for cefazolin, was included. A maximum of two venous plasma, target-site plasma, and target-site tissue samples were taken during surgery. The primary outcomes were the cefazolin concentrations in venous plasma, target-site plasma, and target-site tissue. A total of 27 patients [median (interquartile range) age, 42 (29-59) years; 17 (63%) male] with 138 samples were included in the study. A minimum of 6 weeks follow-up was available for all patients. The mean (SD) venous plasma, target-site plasma, and target-site tissue concentrations were 36 (13) µg/mL, 29 (13) µg/mL, and 28 (13) µg/g, respectively, and the cefazolin concentrations between the different locations of surgery did not differ significantly in both target-site plasma and target-site tissue (P = 0.822 and P = 0.840). In conclusion, 2 g of prophylactic cefazolin demonstrates adequacy in maintaining coverage for a duration of at least 80 minutes of surgery below the level of the knee, significantly surpassing the MIC90 required to combat the most prevalent microorganisms. This study represents the first of its kind to assess cefazolin concentrations in the lower extremities by examining both plasma and tissue samples in this magnitude.

Current outcomes following upper and lower extremity arterial trauma from the National Trauma Data Bank.

OBJECTIVE: The modern treatments of trauma have changed in recent years. We aim to evaluate the factors associated with limb salvage and mortality after extremity arterial trauma, especially with respect to the type of conduit used in revascularization. METHODS: The National Trauma Data Bank was queried to identify patients with upper and lower extremity (UE and LE) arterial injuries between 2016 and 2020. The patients were stratified by the types of arterial repair. The primary outcome was in-hospital mortality. RESULTS: 8780 patients were found with 5054 (58%) UE and 3726 (42%) LE injuries. Eighty-three percent were men, and the mean age was 34 ± 15 years. Penetrating mechanism was the predominant mode of injury in both UEs and LEs (73% and 67%, respectively) with a mean injury severity score of 14 ± 8. For UEs, the majority underwent primary repair (67%, P < .001), whereas the remainder received either a bypass (20%) or interposition graft (12%). However, LEs were more likely to receive a bypass (52%, P < .00001) than primary repair or interposition graft (34% and 14%, respectively). Compared with the extremely low rates of amputation and mortality among UE patients (2% for both), LE injuries were more likely to result in both amputation (10%, P < .001) and death (6%, P < .001). Notably, compared with primary repair, the use of a prosthetic conduit was associated with a 6.7-fold increase in the risk of amputation in UE and a 2.4-fold increase in LE (P < .0001 for both). Synthetic bypasses were associated with a nearly 3-fold increase in return to the operating room (OR) in UE bypasses (P < .05) and a 2.4-fold increase in return to the OR in LE bypasses (P < .0001). CONCLUSIONS: In recent years, most extremity vascular trauma was due to penetrating injury with a substantial burden of morbidity and mortality. However, both limb salvage rates and survival rates have remained high. Overall, LE injuries more often led to amputation and mortality than UE injuries. The most frequently used bypass conduit was vein, which was associated with less risk of unplanned return to the OR and limb loss, corroborating current practice guidelines for extremity arterial trauma.

Dedifferentiated liposarcoma of the extremities: a Korean multi-center study of 107 cases.

BACKGROUND: Dedifferentiated liposarcoma of the extremities (DDL-E) is rare in comparison to that of the retroperitoneum. Its clinical features and surgical principle for resection margins at the dedifferentiated and the well-differentiated components are yet to be elucidated. METHODS: This retrospective multi-center study examined patients diagnosed with DDL-E from August 2004 to May 2023 at 5 sarcoma centers. Clinical features, oncologic outcomes, and prognostic factors were analyzed. RESULTS: A total of 107 patients were reviewed. The 5-year local recurrence free survival (LRFS), metastasis-free survival (MFS) and disease specific survival (DSS) were 84.7%, 78.6%, and 87.8%, respectively. Other primary malignancies and extrapulmonary metastasis were observed in 27 and 4 patients, respectively. The independent risk factor for local recurrence was R1/2 margin at the dedifferentiated component of the tumor. Metastasis was associated with tumor size in univariate analysis. The independent risk factor for DSS was tumor grade. Previous unplanned excision, de novo presentation, tumor depth, absence of the well-differentiated component, infiltrative border, R1/2 margin at the well-differentiated component were not associated with oncologic outcomes. CONCLUSIONS: This is the largest study examining DDL-E to-date. Localized DDL-E has low potential for metastasis and carries an excellent prognosis. Other primary malignancy and extrapulmonary metastasis are more frequent in DDL-E, thus close monitoring of other sites during follow-up is recommended. While wide resection margin is the standard surgical approach for DDL-E, further investigation into moderated wide resection margin at the well-differentiated component is warranted.

Mohs micrographic surgery in the surgical treatment paradigm of melanoma in situ and invasive melanoma: A clinical review of treatment efficacy and ongoing controversies.

Mohs Micrographic Surgery (MMS) for treatment of melanoma offers several advantages over wide local excision (WLE), including complete histologic margin evaluation, same-day resection and closure, and sparing of healthy tissue in critical anatomic sites. Recently, a large volume of clinical data demonstrating efficacy in MMS treatment of melanoma was published, leading to emerging patient safety considerations of incurred treatment costs, risk of tumor upstaging, and failure of care coordination for sentinel lymph node biopsy (SLNB). MMS offers a safe, effective, and value-based treatment for both melanoma in situ (MIS) and invasive melanoma (IM), particularly with immunohistochemistry use on frozen sections. Compared to wide local excision, MMS treatment demonstrates similar or improved outcomes for local tumor recurrence, melanoma-specific survival, and overall survival at long-term follow-up. Tumor upstaging risk is low, and if present, alteration to clinical management is minimal. Discussion of SLNB for eligible head and neck IM cases should be done prior to MMS. Though challenging, successful multidisciplinary coordination of SLNB with MMS has been demonstrated. Herein, we provide a detailed clinical review of evidence for MMS treatment of cutaneous melanoma and offer recommendations to address current controversies surrounding the evolving paradigm of surgical management for both MIS and invasive melanoma (IM).

A pilot study of p53 immunohistochemistry in atypical squamous lesions, using a vulvar scoring system.

BACKGROUND: Histopathologic overlap between cutaneous squamous cell carcinoma (cSCC) and its indolent mimics likely leads to the overdiagnosis of cSCC. OBJECTIVE: To perform a pilot study of the p53 immunohistochemical scoring system developed on vulvar squamous lesions in cSCC. METHODS: The consistency and reliability of p53 immunostaining using a scoring system developed on vulvar cases, as compared with TP53 genomic sequencing, was studied in an initial cohort of 28 cutaneous cases. p53 labeling was further assessed in an additional 63 cases of atypical squamous lesions, including 20 atypical squamous lesions classified by the authors as benign, 22 cases diagnosed as cSCC without high-risk features, and 21 cases of high-risk cSCC (cSCC-HR). RESULTS: The concordance of p53 labeling and TP53 sequencing was 82.1%. Four positive patterns of p53 mutation were identified: basal, parabasal/diffuse, null, and cytoplasmic. p53 positivity in atypical, benign squamous lesions (10%) was significantly lower than that of low-risk cSCC (63.6%, p = 0.0004) or cSCC-HR (90.5%, p < 0.0001). p53 positivity in low-risk cSCC versus cSCC-HR was not statistically significant (p = 0.07). CONCLUSION: p53 Labeling may be a helpful biomarker to support the diagnosis of cSCC and distinguish cSCC from atypical but benign mimics.

CT angiography of the lower limbs: combining small field of view with large matrix size and iterative reconstruction further improves image quality of below-the-knee arteries.

BACKGROUND: Image quality and diagnostic accuracy in computed tomography angiography (CTA) reach their limits in imaging of below-the-knee vessels. PURPOSE: To evaluate whether image quality in CTA of lower limbs is further improvable by combining side-separate reconstruction with a larger matrix size and whether resulting noise can be compromised with iterative reconstruction (IR). MATERIAL AND METHODS: From CTA of the lower extremities of 26 patients (5 women, 21 men; mean age = 68.5 ± 10.3 years), the lower legs were reconstructed side-separately with different reconstruction algorithms and matrix sizes including filtered back projection (FBP) with a 512 × 512 matrix, FBP with a 1024 × 1024 matrix, IR (SAFIRE) with a 512 × 512 matrix, and IR (SAFIRE) with a 1024 × 1024 matrix. A total of 208 CT series were evaluated. Subjective image quality was assessed by two readers using a 5-point Likert scale. Image noise was assessed by measuring signal-to-noise and contrast-to-noise ratios. RESULTS: Subjective image quality was rated significantly higher when using a 1024 × 1024 matrix (P < 0.001) and could further be increased with IR. Vessel sharpness was rated significantly better with a larger matrix (P < 0.001). Visible and measured image noise was significantly higher with a 1024 × 1024 matrix but could be reduced by using IR (P < 0.001), even to a level below FBP with a 512 × 512 matrix while reconstructing with a larger matrix (P < 0.001). CONCLUSION: Image quality, image noise, and vessel sharpness can be further improved in CTA of the lower extremities with side-separate reconstruction using a 1024 × 1024 matrix size and IR.

Foot and lower leg pain in children and adults with cerebral palsy: a population-based register study on 5,122 individuals.

BACKGROUND: Pain is common in individuals with cerebral palsy (CP) and the most reported pain site is the foot/lower leg. We analyzed the prevalence of pain in the foot/lower leg and the associations with age, sex, gross motor function, and clinical findings in individuals with CP. METHOD: This was a cross-sectional register-study, based on data reported to the Swedish Cerebral Palsy Follow-up Program (CPUP). All participants in CPUP, four years-of-age or older, were included. Pearson chi-square tests and logistic regression were used to analyze the prevalence and degree of pain in the foot/lower leg. RESULTS: In total, 5,122 individuals were included from the CPUP database: 58% were males and 66% were under 18 years-of-age. Overall, 1,077 (21%) reported pain in the foot/lower leg. The odds ratios (ORs) of pain were higher in females (OR 1.31, 95% confidence interval (CI) 1.13-1.53), individuals who could ambulate (Gross Motor Function Classification System Level I (OR 1.84, CI 1.32-2.57) and II (OR 2.01, CI 1.46-2.79) compared to level V), and in individuals with decreased range of motion of the ankle (dorsiflexion 1-10 degrees (OR 1.43, CI 1.13-1.83) and ≤ 0 degrees (OR 1.46, CI 1.10-1.93) compared to ≥ 20 degrees). With increasing age the OR of pain increased (OR 1.02, CI 1.01-1.03) as well as the reported pain intensity (p < 0.001). CONCLUSIONS: Pain in the foot and lower leg appears to be a significant problem in individuals with CP, particularly in those who walk. As with pain in general in this population, both pain intensity and frequency increase with age. The odds of pain in the foot and lower leg were increased in individuals with limited dorsiflexion of the ankle. Given the cross-sectional design causality cannot be inferred and it is unknown if pain causes decreased range of motion of the ankle or if decreased range of motion causes pain. Further research is needed on causal pathways and importantly on prevention.

Predictive factors for iliac vein compression syndrome in patients with varicose veins.

OBJECTIVE: This study aimed to identify predictors of iliac vein compression syndrome (IVCS) in patients with varicose veins and to evaluate the necessity of routine lower extremity venography for preoperative assessment of these patients. METHODS: A retrospective analysis was conducted on data from 1165 patients with lower-limb varicose veins who underwent preoperative venography at Wuhan Union Hospital, Tongji Medical College, China, between January 2019 and September 2023. Logistic regression analyses identified factors associated with concurrent IVCS, and a nomogram was constructed based on these findings. RESULTS: Out of 1165 patients, 75 (6.4%) had IVCS according to venography and 769 had iliac vein ultrasound and found 2 (0.17%) positives. Multivariate analysis revealed the independent predictive value of left-sided involvement (odds ratio (OR) = 3.22, 95% confidence interval (CI): 1.24-8.33, p = 0.016), history of deep vein thrombosis (DVT) in the affected limb (OR = 3.11, 95% CI: 1.21-8.00, p = 0.018), pain (OR = 2.24, 95% CI: 1.17-4.26, p = 0.014), and positive results on iliac vein ultrasound (OR = 25.56, 95% CI: 2.10-311.26, p = 0.011) for the presence of IVCS in patients with lower-limb varicose veins. A nomogram incorporating these predictors demonstrated moderate predictive ability (AUV = 0.689, 95% CI: 0.607-0.771), with good calibration upon validation. CONCLUSIONS: Patients with left lower extremity varicose veins, pain symptoms, history of DVT in the affected limb, and positive iliac vein ultrasound findings are at a higher risk of concurrent IVCS. Patients with varicose veins who have the aforementioned risk factors may need to undergo preoperative angiography.

A systematic review and meta-analysis of the relative safety and efficacy of treating lower extremity deep vein thrombosis via pharmacomechanical thrombectomy and catheter-directed thrombolysis.

OBJECTIVE: To evaluate the safety and efficacy of pharmacomechanical thrombectomy and catheter-directed thrombolysis (CDT) as approaches to treating deep venous thrombosis of lower extremities (LEDVT). METHODS: The PubMed, Web of Science, Wanfang, Embase, Chinese Science and Technology Journal, Cochrane, and China National Knowledge Infrastructure (CNKI) databases were systematically searched for relevant articles published through October 2023, after which appropriate inclusion and exclusion criteria were used to screen out relevant articles. Review Manager 5.4.1 was used to extract key data from these studies, and pooled analyses were conducted based on mead difference (MD) or odds ratio (OR) values and corresponding 95% confidence interval (CI). Study quality was assessed with the Newcastle-Ottawa scale. TRIAL REGISTRATION: This study has been registered at INPLASY.COM (No. INPLASY2023100075). RESULTS: In total, 31 relevant studies enrolling 2413 patients were included in this meta-analysis, with 1184 and 1229 patients in the AngioJet and CDT groups, respectively. These analyses revealed that the AngioJet group exhibited significantly higher rates of early postoperative deep vein patency (MD = 7.73, 95% CI (3.29, 12.17), p = .0006) and affected limb symptom improvement (MD = 6.31, 95% CI (1.82,10.80), p = .006) relative to the CDT group, whereas no differences in grade II or III thrombus clearance rates (OR = 1.30, 95% CI (0.95, 1.77), p = .10) or changes in thigh circumference before and after treatment (MD = 0.01, 95% CI (-0.80, 0.83), p = .97) were observed. The AngioJet group also exhibited lower urokinase doses (MD = -145.33, 95% CI (-164.28,126.38), p < .00001), shorter thrombolysis time (MD = -2.35, 95% CI(-2.80, -1.90), p < .00001), a less prolonged hospital stay (MD = -3.13, 95% CI(-3.81, -2.45), p < .00001), lower rates of PTS incidence (OR = 0.56, 95% CI(0.36, 0.88), p = .01), and reduced complication rates (OR = 0.51, 95% CI(0.31, 0.83), p = .0007). CONCLUSION: Studies published to date suggest that relative to CDT treatment, pharmacomechanical thrombectomy is associated with improved thrombus clearance, fewer complications, and lower complication rates in LEDVT patients, underscoring the safety and efficacy of this therapeutic strategy.

Rare deep vein thrombosis in pregnancy and puerperium 3 case series; upper extremities vein thrombosis, ovarian vein thrombosis, portal and superior mesenteric vein thrombosis.

Pregnancy induces a hypercoagulable state, elevating thrombosis risk by 5-6 times compared to non-pregnant conditions. Predominantly affecting the left lower extremity due to anatomical and hematological factors, deep vein thrombosis can escalate into pulmonary embolism, impacting mortality. The authors aim to report rare incidents of thrombosis beyond the norm, including upper extremity vein thrombosis, right ovarian vein thrombosis, and portal vein and superior mesenteric vein thrombosis, highlighting their significance. Obstetricians should be mindful that thrombosis can occur not only in the lower extremities but also in other areas. Especially when symptoms such as fever unresponsive to antibiotics, atypical pain, and an abnormally high C-reactive protein level are present. Considering the possibility of a rare thrombosis is crucial. Understanding these less common thrombotic events during pregnancy and the postpartum period can contribute to the improvement of timely diagnosis and management strategies.

Meta-analysis of the quantitative assessment of lower extremity motor function in elderly individuals based on objective detection.

OBJECTIVE: To avoid deviation caused by the traditional scale method, the present study explored the accuracy, advantages, and disadvantages of different objective detection methods in evaluating lower extremity motor function in elderly individuals. METHODS: Studies on lower extremity motor function assessment in elderly individuals published in the PubMed, Web of Science, Cochrane Library and EMBASE databases in the past five years were searched. The methodological quality of the included trials was assessed using RevMan 5.4.1 and Stata, followed by statistical analyses. RESULTS: In total, 19 randomized controlled trials with a total of 2626 participants, were included. The results of the meta-analysis showed that inertial measurement units (IMUs), motion sensors, 3D motion capture systems, and observational gait analysis had statistical significance in evaluating the changes in step velocity and step length of lower extremity movement in elderly individuals (P < 0.00001), which can be used as a standardized basis for the assessment of motor function in elderly individuals. Subgroup analysis showed that there was significant heterogeneity in the assessment of step velocity [SMD=-0.98, 95%CI(-1.23, -0.72), I2 = 91.3%, P < 0.00001] and step length [SMD=-1.40, 95%CI(-1.77, -1.02), I2 = 86.4%, P < 0.00001] in elderly individuals. However, the sensors (I2 = 9%, I2 = 0%) and 3D motion capture systems (I2 = 0%) showed low heterogeneity in terms of step velocity and step length. The sensitivity analysis and publication bias test demonstrated that the results were stable and reliable. CONCLUSION: observational gait analysis, motion sensors, 3D motion capture systems, and IMUs, as evaluation means, play a certain role in evaluating the characteristic parameters of step velocity and step length in lower extremity motor function of elderly individuals, which has good accuracy and clinical value in preventing motor injury. However, the high heterogeneity of observational gait analysis and IMUs suggested that different evaluation methods use different calculation formulas and indicators, resulting in the failure to obtain standardized indicators in clinical applications. Thus, multimodal quantitative evaluation should be integrated.

Effect of intranasal sufentanil on acute post-traumatic pain in the emergency department: a randomised controlled trial.

BACKGROUND: Intranasal sufentanil is a potent opioid which can be used in patients with traumatic injuries presenting to the ED. Although previous studies have demonstrated the superiority of intranasal sufentanil over intravenous morphine in terms of pain relief, its clinical superiority in patients with traumatic injuries receiving adequate multimodal analgesia with acetaminophen and non-steroidal anti-inflammatory drugs is uncertain. We compared pain relief offered by intranasal sufentanil with that offered by oral and intravenous opioids in patients with acute traumatic injuries also receiving a specified regimen of non-opioid treatment. METHODS: In this single-centre, open-label, parallel-group, randomised controlled superiority trial conducted between January 2020 and February 2022, trauma patients presenting to the ED with a pain score of ≥7 on a visual analogue scale (VAS) were randomised to receive either intranasal sufentanil or other oral/intravenous opioids alongside oral/intravenous acetaminophen and non-steroidal anti-inflammatory drugs. The primary outcome was reduction in VAS score 15-20 min after randomisation. RESULTS: An intention-to-treat analysis included 170 out of 205 patients screened for inclusion. The intranasal sufentanil group (83 patients) showed a significantly greater reduction in pain when compared with the oral/intravenous opioid group (87 patients) 15-20 min after randomisation (reduction in VAS score 3.0 (IQR 1.7-5.0) vs 1.5 (IQR 0.9-3.0); p<0.001). Similarly, a greater reduction in pain was observed in the intranasal sufentanil group 60 min after randomisation (5.0 (IQR 3.0-7.0) vs 3.0 (IQR 2.0-5.3); p<0.001). However, side effects were more frequent in the intervention group (71.1% vs 23%; p<0.001). CONCLUSIONS: Intranasal sufentanil was associated with more effective pain relief than oral/intravenous opioids in patients with traumatic injuries treated with coanalgesia. Intranasal sufentanil could be considered for the management of pain in patients with traumatic injuries associated with severe pain. TRIAL REGISTRATION NUMBER: NCT04137198.

The Effect of Maternal Lower Limb Compression on Amniotic Fluid Index, Uteroplacental Perfusion, and Fetal Blood Flow in Isolated Oligohydramnios.

INTRODUCTION: The aim of this study was to examine the efficacy of pneumatic compression of the maternal lower extremities in increasing the amniotic fluid index (AFI) in pregnancies complicated by isolated oligohydramnios. METHODS: Women with isolated oligohydramnios (AFI <5 cm) at 32-41 weeks of pregnancy were connected to a sequential compression device for 60 min. Prior and after the application, AFI and the pulsatility index (PI) of a number of arteries were measured. RESULTS: The median (interquartile range) maternal age of the 21 women included was 29 years (26.50-32.00), the median parity was 1 (1-2), and the median gestational age at intervention was 37.60 weeks (37.00-39.40). The median AFI increased after the application from 4.00 (3.62-4.50) to 6.08 cm (4.90-7.03) (p < 0.001). The median PI of the fetal renal artery decreased from 2.30 (2.01-2.88) to 2.26 (1.68-2.71) (p = 0.01). The hourly fetal urine production did not increase. Changes were not significant in the PI of the umbilical artery, the middle cerebral artery, and the bilateral uterine arteries. CONCLUSION: Short-term activation of pneumatic compression on maternal lower extremities could increase the AFI in women with isolated oligohydramnios.

Technological Features of Immersive Virtual Reality Systems for Upper Limb Stroke Rehabilitation: A Systematic Review.

Stroke is the second most common cause of death worldwide, and it greatly impacts the quality of life for survivors by causing impairments in their upper limbs. Due to the difficulties in accessing rehabilitation services, immersive virtual reality (IVR) is an interesting approach to improve the availability of rehabilitation services. This systematic review evaluates the technological characteristics of IVR systems used in the rehabilitation of upper limb stroke patients. Twenty-five publications were included. Various technical aspects such as game engines, programming languages, headsets, platforms, game genres, and technical evaluation were extracted from these papers. Unity 3D and C# are the primary tools for creating IVR apps, while the Oculus Quest (Meta Platforms Technologies, Menlo Park, CA, USA) is the most often used headset. The majority of systems are created specifically for rehabilitation purposes rather than being readily available for purchase (i.e., commercial games). The analysis also highlights key areas for future research, such as game assessment, the combination of hardware and software, and the potential integration incorporation of biofeedback sensors. The study highlights the significance of technological progress in improving the effectiveness and user-friendliness of IVR. It calls for additional research to fully exploit IVR's potential in enhancing stroke rehabilitation results.

Integrated Wearable System for Monitoring Skeletal Muscle Force of Lower Extremities.

Continuous monitoring of lower extremity muscles is necessary, as the muscles support many human daily activities, such as maintaining balance, standing, walking, running, and jumping. However, conventional electromyography and physiological cross-sectional area methods inherently encounter obstacles when acquiring precise and real-time data pertaining to human bodies, with a notable lack of consideration for user comfort. Benefitting from the fast development of various fabric-based sensors, this paper addresses these current issues by designing an integrated smart compression stocking system, which includes compression garments, fabric-embedded capacitive pressure sensors, an edge control unit, a user mobile application, and cloud backend. The pipeline architecture design and component selection are discussed in detail to illustrate a comprehensive user-centered STIMES design. Twelve healthy young individuals were recruited for clinical experiments to perform maximum voluntary isometric ankle plantarflexion contractions. All data were simultaneously collected through the integrated smart compression stocking system and a muscle force measurement system (Humac NORM, software version HUMAC2015). The obtained correlation coefficients above 0.92 indicated high linear relationships between the muscle torque and the proposed system readout. Two-way ANOVA analysis further stressed that different ankle angles (p = 0.055) had more important effects on the results than different subjects (p = 0.290). Hence, the integrated smart compression stocking system can be used to monitor the muscle force of the lower extremities in isometric mode.

Comparison of the Pre-Established and Finally Selected Treatment Strategies for Endovascular Treatment in Femoropopliteal Artery Lesions.

This study aimed to compare lower limb events associated with preplanned and finally selected treatment strategies-the validity and usefulness of the physician-chosen strategy were verified.We examined the data of 1003 patients in the registry of multicenter endovascular treatment for superficial femoral and popliteal artery disease study and prospectively enrolled patients who underwent endovascular treatment (EVT) of the femoropopliteal (FP) artery between February 2017 and June 2018 from 67 Japanese institutes. The outcome measures were major adverse limb events (MALE) and target vessel revascularization.The EVT strategies were classified into balloon angioplasty-alone (37.3%), primary stenting (26.7%), and provisional stenting (36.0%) groups. In the initial strategy analysis for the balloon angioplasty-alone, primary stenting, and provisional stenting groups, two-year rates of freedom from MALE (95% confidence interval) were 0.680 (0.620-0.732), 0.754 (0.688-0.808), and 0.798 (0.746-0.840), respectively. Additionally, the rate of MALE was significantly higher among patients in the balloon angioplasty-alone group than among those in the primary or provisional stenting groups in the initial strategy analysis (P = 0.007). Changes in treatment strategy were more frequent in the primary stenting group than in the other groups. Furthermore, the rate of MALE did not significantly differ among the three groups in the final strategy analysis (P = 0.56).Limb outcomes for the final applied strategy did not differ among the three strategies. Additionally, the physician's selection bias was mostly appropriate in the EVT of the FP artery.

Peripheral warming for prevention of hypothermia in small dogs during soft tissue surgery: A randomized controlled trial.

OBJECTIVE: To evaluate the effects of wrapping the extremities of small dogs with table leg covers to prevent hypothermia during anesthesia. STUDY DESIGN: Randomized parallel-group study. ANIMALS: A total of 60 adult dogs with a body mass <15 kg anesthetized for soft tissue surgery. METHODS: Dogs were randomly assigned to one of two groups. The control group received routine intraoperative thermal support, while the limb-wrapping group had their peripheral limbs covered with table leg covers up to the mid-metacarpal/metatarsal region, in addition to routine thermal support. Rectal temperature during anesthesia was recorded and compared between the two groups. Data analyses were performed using Student's t-test for rectal temperature, Fisher's exact test for hypothermia incidence and analysis of covariance for the effect of limb-wrapping while taking other factors into account. RESULTS: Thirty dogs were included per group. Rectal temperature did not differ between the groups at the time of intubation, but it was significantly higher in the limb-wrapping group (36.7 ± 1.0 °C) than in the control group (35.9 ± 0.8 °C) at the end of surgery (p = 0.003). The mean difference was 0.81 °C (95% confidence interval of mean difference 0.33-1.29 °C). The incidence of hypothermia (<37.0 °C) was significantly lower in the limb-wrapping group than in the control group (19/30 versus 28/30 dogs, respectively; p = 0.010). CONCLUSIONS: For dogs with body masses <15 kg, limb-wrapping with table leg covers slowed the reduction in intraoperative rectal temperature. Limb-wrapping is inexpensive and easy to perform, making it a practical method for minimizing hypothermia during anesthesia in small dogs undergoing soft tissue surgery. CLINICAL RELEVANCE: Peripheral warming with table leg covers has the potential to reduce hypothermia during soft tissue surgery in small dogs.

Cardiovascular Effectiveness and Safety of Antidiabetic Drugs in Patients with Type 2 Diabetes and Peripheral Artery Disease: Systematic Review.

Peripheral artery disease (PAD) is an atherosclerotic condition commonly complicating type 2 diabetes (T2D), leading to poor quality of life and increased risk of major adverse lower-limb (MALE) and cardiovascular (CV) events (MACE). Therapeutic management of PAD in T2D patients is much more arduous, often due to bilateral, multi-vessel, and distal vascular involvement, in addition to increased systemic polyvascular atherosclerotic burden. On the other hand, the pathophysiological link between PAD and T2D is very complex, involving mechanisms such as endothelial dysfunction and increased subclinical inflammation in addition to chronic hyperglycemia. Therefore, the clinical approach should not ignore vascular protection with the aim of reducing limb and overall CV events besides a mere glucose-lowering effect. However, the choice of the best medications in this setting is challenging due to low-grade evidence or lacking targeted studies in PAD patients. The present review highlighted the strong relationship between T2D and PAD, focusing on the best treatment strategy to reduce CV risk and prevent PAD occurrence and worsening in patients with T2D. The Medline databases were searched for studies including T2D and PAD up to June 2024 and reporting the CV effectiveness and safety of the most used glucose-lowering agents, with no restriction on PAD definition, study design, or country. The main outcomes considered were MACE-including nonfatal acute myocardial infarction, nonfatal stroke, and CV death-and MALE-defined as lower-limb complications, amputations, or need for revascularization. To the best of our current knowledge, GLP-1 receptor agonists and SGLT2 inhibitors represent the best choice to reduce CV risk in T2D and PAD settings, but a personalized approach should be considered. GLP-1 receptor agonists should be preferred in subjects with prevalent atherosclerotic burden and a history of previous MALE, while SGLT2 inhibitors should be used in those with heart failure if overall CV benefits outweigh the risk of lower-limb complications.

Fish Arrow Injuries to the Extremities: A Case Series.

Fishing as a hobby is fairly popular among youth in hilly and mountainous areas of the world. Hence, injuries to extremities are also common by fishing equipment, especially in untrained people using indigenous equipment. The mechanism of injury is that of penetrating trauma. There is a paucity of literature regarding fishing equipment injury to extremities. In this article, we have presented a case series of fishing arrow injuries presented to us in the Department of Plastic and Reconstructive Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India. Most of these injuries were treated under the wide-awake local anesthesia no tourniquet technique which has revolutionized the management of extremity injuries. Also, special precautions regarding the prevention of further tissue injury by arrow hooks while retrieving the arrows have been highlighted.

[Endovascular treatment of deep vein thrombosis of the upper extremities]. / Endovaskulyarnoe lechenie trombozov glubokikh ven verkhnikh konechnostei.

OBJECTIVE: To improve the results of treatment of deep vein thrombosis of the upper extremities sing endovascular technologies. MATERIAL AND METHODS: We analyzed safety and effectiveness of treatment in 24 patients with deep vein thrombosis of the upper extremities. All ones were divided into 2 homogeneous groups by 12 people each. In the first group, conventional anticoagulation was performed. In the second group, we used additional regional catheter thrombolysis with alteplase and, if necessary, venous stenting or balloon angioplasty for residual stenosis. Patients received apixaban at baseline and throughout 6 postoperative months. After 12 months, we performed ultrasound and clinical examination to identify deep vein patency and venous outflow disorders. Vein recanalization was evaluated as follows: <50% - minimal, 50-99% - partial, 100% - complete. The quality of life of patients was studied using the SF-36 questionnaire. RESULTS: In the first group, we observed complete vein recanalization in 25% of cases, partial - in 33%, minimal - in 41% of cases; in the second group - 83.3% and 16.7% of patients, respectively. In the first group, clinical manifestations of venous outflow disorders were absent in 25% of patients, mild disorders - 25%, moderate - 8.3%, severe - 41.7% of patients. In the second group, venous outflow was not impaired in 83.7% of patients, mild violations occurred in 16.7% of patients. In the first group, physical health was equal to 44.2±1.7 scores, psychological health - 49.3±2.3 scores; in the second group - 69.3±5.7 and 71.3±5.4 scores, respectively. CONCLUSION: Endovascular treatment improved postoperative outcomes.