Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease.

OBJECTIVE: Prior studies have described risk factors associated with amputation in patients with concomitant diabetes and peripheral arterial disease (DM/PAD). However, the association between the severity and extent of tissue loss type and amputation risk remains less well-described. We aimed to quantify the role of different tissue loss types in amputation risk among patients with DM/PAD, in the context of demographic, preventive, and socioeconomic factors. METHODS: Applying International Classification of Diseases (ICD)-9 and ICD-10 codes to Medicare claims data (2007-2019), we identified all patients with continuous fee-for-service Medicare coverage diagnosed with DM/PAD. Eight tissue loss categories were established using ICD-9 and ICD-10 diagnosis codes, ranging from lymphadenitis (least severe) to gangrene (most severe). We created a Cox proportional hazards model to quantify associations between tissue loss type and 1- and 5-year amputation risk, adjusting for age, race/ethnicity, sex, rurality, income, comorbidities, and preventive factors. Regional variation in DM/PAD rates and risk-adjusted amputation rates was examined at the hospital referral region level. RESULTS: We identified 12,257,174 patients with DM/PAD (48% male, 76% White, 10% prior myocardial infarction, 30% chronic kidney disease). Although 2.2 million patients (18%) had some form of tissue loss, 10.0 million patients (82%) did not. The 1-year crude amputation rate (major and minor) was 6.4% in patients with tissue loss, and 0.4% in patients without tissue loss. Among patients with tissue loss, the 1-year any amputation rate varied from 0.89% for patients with lymphadenitis to 26% for patients with gangrene. The 1-year amputation risk varied from two-fold for patients with lymphadenitis (adjusted hazard ratio, 1.96; 95% confidence interval, 1.43-2.69) to 29-fold for patients with gangrene (adjusted hazard ratio, 28.7; 95% confidence interval, 28.1-29.3), compared with patients without tissue loss. No other demographic variable including age, sex, race, or region incurred a hazard ratio for 1- or 5-year amputation risk higher than the least severe tissue loss category. Results were similar across minor and major amputation, and 1- and 5-year amputation outcomes. At a regional level, higher DM/PAD rates were inversely correlated with risk-adjusted 5-year amputation rates (R2 = 0.43). CONCLUSIONS: Among 12 million patients with DM/PAD, the most significant predictor of amputation was the presence and extent of tissue loss, with an association greater in effect size than any other factor studied. Tissue loss could be used in awareness campaigns as a simple marker of high-risk patients. Patients with any type of tissue loss require expedited wound care, revascularization as appropriate, and infection management to avoid amputation. Establishing systems of care to provide these interventions in regions with high amputation rates may prove beneficial for these populations.

Hurricanes enhance coral connectivity but also superspread coral diseases.

Climate change poses an existential threat to coral reefs. A warmer and more acidic ocean weakens coral ecosystems and increases the intensity of hurricanes. The wind-wave-current interactions during a hurricane deeply change the ocean circulation patterns and hence potentially affect the dispersal of coral larvae and coral disease agents. Here, we modeled the impact of major hurricane Irma (September 2017) on coral larval and stony coral tissue loss disease (SCTLD) connectivity in Florida's Coral Reef. We coupled high-resolution coastal ocean circulation and wave models to simulate the dispersal of virtual coral larvae and disease agents between thousands of reefs. While being a brief event, our results suggest the passage of hurricane Irma strongly increased the probability of long-distance exchanges while reducing larval supply. It created new connections that could promote coral resilience but also probably accelerated the spread of SCTLD by about a month. As they become more intense, hurricanes' double-edged effect will become increasingly pronounced, contributing to increased variability in transport patterns and an accelerated rate of change within coral reef ecosystems.

Scrotal reconstruction after Fournier's Gangrene using the superficial circumflex iliac artery perforator (SCIP) propeller flap: A case report.

INTRODUCTION: Fournier's gangrene, a rare infectious condition affecting the external genitalia, often requires aggressive medical-surgical interventions, resulting in variable scrotal tissue loss. Despite numerous proposed reconstruction techniques, achieving a consensus on the most effective approach that balances aesthetics and function remains elusive. This case report presents a one-year follow-up on scrotal reconstruction using a pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) propeller flap. CASE REPORT: A 56-year-old patient with significant scrotal tissue loss due to Fournier's gangrene underwent scrotal reconstruction using a pedicled SCIP propeller flap. Optimal placement was ensured through a subcutaneous tunnel, with a thin thigh skin graft applied to cover the penile skin defect. DISCUSSION: The SCIP flap is distinguished by its thin and pliable characteristics, rapid harvesting and featuring a discreet donor site. It stands as a compelling alternative to skin grafts, providing advantages in sensory restoration, color congruence, and resilience against tension. Considering the thickness of the reconstruction helps both in recovering testicular function and improving the appearance by restoring the natural contour. CONCLUSION: The utilization of the pedicled SCIP propeller flap for scrotal tissue loss resulting from Fournier's gangrene has demonstrated both aesthetic and functional success, underscoring its potential as an effective reconstructive option.

First report of yellow-banded tissue loss disease on coral reefs outside the Arabian/Persian Gulf.

Coral disease is a major cause of coral reef degradation, yet many diseases remain understudied. Yellow-banded tissue loss disease (YBTLD) has a distinct gross lesion morphology and to date has only been reported from the Arabian/Persian Gulf; little else is known about the ecology of the disease. We report on the first occurrence of YBTLD outside of the Arabian/Persian Gulf at 2 sites (Laku Point, Narara Reef) within the Gulf of Kachchh (GoK) located on the northwest coast of India. At Narara Reef, YBTLD was observed at 12 out of 24 transects with an average prevalence of 4.7 ± 1.3%. At Laku Point, YBTLD was observed at 19 out of 24 transects with an average prevalence of 5.4 ± 1%. Four out of 15 coral genera within transects had signs of YBTLD and included Goniopora, Dipsastraea, Lobophyllia, and Turbinaria. Lobophyllia and Turbinaria had the highest susceptibility to the disease, with prevalence significantly higher than expected based on their abundance on the reefs. The distribution and prevalence of YBTLD in the GoK was higher than in coral reefs in the Arabian/Persian Gulf. The GoK is an extreme environment for coral reefs with both natural stressors (high salinities, strong, seasonal storm activities, and extreme tides) and anthropogenic pollutants from industrial, mining, agricultural, and domestic activities. These poor environmental conditions may help explain the high occurrence of YBTLD on GoK reefs.

Rapid prototyping for quantifying belief weights of competing hypotheses about emergent diseases.

Emerging diseases can have devastating consequences for wildlife and require a rapid response. A critical first step towards developing appropriate management is identifying the etiology of the disease, which can be difficult to determine, particularly early in emergence. Gathering and synthesizing existing information about potential disease causes, by leveraging expert knowledge or relevant existing studies, provides a principled approach to quickly inform decision-making and management efforts. Additionally, updating the current state of knowledge as more information becomes available over time can reduce scientific uncertainty and lead to substantial improvement in the decision-making process and the application of management actions that incorporate and adapt to newly acquired scientific understanding. Here we present a rapid prototyping method for quantifying belief weights for competing hypotheses about the etiology of disease using a combination of formal expert elicitation and Bayesian hierarchical modeling. We illustrate the application of this approach for investigating the etiology of stony coral tissue loss disease (SCTLD) and discuss the opportunities and challenges of this approach for addressing emergent diseases. Lastly, we detail how our work may apply to other pressing management or conservation problems that require quick responses. We found the rapid prototyping methods to be an efficient and rapid means to narrow down the number of potential hypotheses, synthesize current understanding, and help prioritize future studies and experiments. This approach is rapid by providing a snapshot assessment of the current state of knowledge. It can also be updated periodically (e.g., annually) to assess changes in belief weights over time as scientific understanding increases. Synthesis and applications: The rapid prototyping approaches demonstrated here can be used to combine knowledge from multiple experts and/or studies to help with fast decision-making needed for urgent conservation issues including emerging diseases and other management problems that require rapid responses. These approaches can also be used to adjust belief weights over time as studies and expert knowledge accumulate and can be a helpful tool for adapting management decisions.

Meshed dermal regeneration template for traumatic periocular tissue loss in the young population.

The IntegraⓇ Dermal Regeneration Template (DRT) is a bioengineered dermal substitute that is becoming increasingly popular in the field of reconstruction. Its unique properties allow for immediate wound closure while providing a scaffold for tissue regeneration. Currently, it is commonly used to treat burns, ulcers, and complex wounds. In the setting of traumatic periocular tissue loss, only two prior reports have been published on its use for primary reconstruction. We present our institution's experience with a series of four young patients who received primary reconstruction with IntegraⓇ DRT as a full-thickness skin substitute for their large traumatic periorbital skin defects.

Evaluation of Tissue Perfusion by Wound Blush and 2D Color-Coded Digital Subtraction Angiography During Endovascular Intervention and Its Impact on Limb Salvage in Critical Limb Ischemia.

PURPOSE: Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI. MATERIALS AND METHODS: 198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow). RESULTS: 176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001). CONCLUSIONS: WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.

OPTIMIZING DISTRACTION OSTEOSYNTHESIS IN PATIENT WITH THE TIBIAL SEGMENT TISSUE LOSS AFTER FRACTURES.

OBJECTIVE: The aim: Improving treatment outcomes in patients with segment tibial bone tissue loss after fractures by improving the ring fixators technology. PATIENTS AND METHODS: Materials and methods: The study includes the data of 77 patients. The patients were distributed between two groups: the main and control one, using random numbers table. The inclusion criteria were: patients' consent, their age over 18 years, tissue inflammation episodes, fibular defects 4-5cm in size and disseminated scar lesions. RF was applied with the proposed improvements. Finally, a semi-rigid external fusion system Softcast / Scotchcast was used to prevent deformation of the regenerate and create optimal conditions for fusion of fragments. RESULTS: Results: The following results were obtained for the Modified Functional Evaluation System by Karlstrom-Olerud: positive treatment outcomes in the main group made up 97.1%, and 92.9% in the control one. Though, the specific gravity of good and excellent outcomes in the main group was 82.8%, while in the comparison group - just 45.2. CONCLUSION: Conclusions: Along with considerable positive advantages of the "Ilizarov's" apparatus, some disadvantages have been noted. Elimination of the drawbacks is stipulated for the practical needs, which requires further scientific study.

Comparison of single-stage and delayed gastrocnemius flap procedures for soft-tissue defects of the knee and proximal tibia.

PURPOSE: Gastrocnemius flaps provide reliable reconstructive solutions to soft-tissue loss of the knee and proximal tibia following orthopedic procedures. While this technique has been used and studied, little is known about its prophylactic application. Single-stage and delayed approaches were compared with respect to the timing of débridement, complications, and relationship between microorganisms and complications. METHODS: Gastrocnemius flaps for soft-tissue defects of the knee joint were retrospectively reviewed. Success of the flap procedure was defined as a healed soft-tissue envelope, no evidence of infection, a good blood supply to the flap, and adherence of the flap to its bed. Independent sample t test was used to compare the corresponding parameters (level of statistical significance was 0.05). RESULTS: Of 43 flaps (43 patients), 18 were performed during a single-stage procedure along with the orthopedic procedure and 25 were delayed. Success of the single-stage (100%) and delayed flaps (88%) was not significantly different (p = 0.083). Complication rate did not differ significantly for single-stage (11%) and delayed flaps (24%) (p = 0.272). We were unable to establish a relationship between complications and microorganisms. CONCLUSION: Results indicate both approaches are reliable. Single-stage gastrocnemius flaps may eliminate the need for a second surgery. LEVEL OF EVIDENCE: Level III (Therapeutic, Retrospective cohort).

Trends, factors, and disparities associated with length of stay after lower extremity bypass for tissue loss.

OBJECTIVE: The objective of this study was to determine predictors of increased length of stay (LOS) in patients who underwent lower extremity bypass for tissue loss. METHODS: Using 2011 to 2016 National Surgical Quality Improvement Program vascular targeted databases, we compared demographics, comorbidities, procedural characteristics, and 30-day outcomes of patients who had expected LOS vs extended LOS (>75th percentile, 9 days) after nonemergent lower extremity bypass for tissue loss. We also compared factors associated with short LOS (<25th percentile, 4 days) and extended LOS (>75th percentile, 9 days) vs the interquartile range of LOS (4-9 days). Yearly trends and independent predictors were determined by linear and logistic regression. This study was exempt from Institutional Review Board approval. RESULTS: In 4964 analyzed patients, there were no significant yearly trends or changes in LOS in the recent 5 years (P > .05). Overall 30-day mortality, major amputation, and reintervention rates were 1.6%, 4.5%, and 4.8%, respectively, also with no significant yearly trends (all P > .05). On univariate analysis, nonwhite race, dependent functional status, transfers, dialysis, congestive heart failure, hypertension, beta blockers, distal bypass targets, and extended operative time were associated with extended LOS (P < .05). Extended LOS was also associated with higher rates of 30-day major adverse limb and cardiac events, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility but lower 30-day readmission rates. After adjustment for covariates, the independent factors for extended LOS included dialysis, beta blockers, prolonged operative time, reintervention, major amputation, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility (P < .05). On the other hand, multivariable analysis showed that patients with expected LOS were significantly more likely to have been of white race or readmitted postoperatively (P < .05). CONCLUSIONS: From 2011 to 2016, there were no significant changes in LOS. Efforts to decrease LOS without increasing readmission rates while focusing on some of the identified factors, including preventable postoperative complications and pre-existing socioeconomic factors, may improve the overall vascular care of these challenging patients.