Upper extremity vascular injuries:Etiology,management and outcome

BACKGROUND Vascular injuries of the upper extremities are considered relatively rare injuries affecting mostly the young population.They often are complex injuries accompanied by other musculoskeletal trauma or trauma in other anatomic locations.Their management is challenging since they can lead to disabilities with major socioeconomic effects.AIM To analyze data about the mechanism of injury,the management algorithm and functional outcomes of vascular injuries of the upper extremity.METHODS One hundred and fifteen patients(96 males and 19 females)with arterial injuries of the upper extremity treated in a tertiary trauma center from January 2003 to December 2022 was conducted.Mean patients’age was 33.7 years and the mean follow up time was 7.4 years.Patients with Mangled Extremity Severity Score≥7 and Injury Severity Score≥20,previous upper limb surgery or major trauma and any neuromuscular or psychiatric disease were excluded,from the study.RESULTS A penetrating trauma was the most common cause of injury.The radial artery was the artery injured in most of the cases(37.4%)followed by the ulnar(29.5%),the brachial(12.1%)and the axillary(6%).A simultaneous injury of both of the forearm’s arteries was in 15.6%of the cases.In 93%of the cases there were other concomitant musculoskeletal injuries of the extremity.Tendon lacerations were the most common,followed by nerve injuries.The postoperative functional scores(full Disabilities of the Arm,Shoulder,and Hand and VAS)had very satisfactory values.CONCLUSION Although vascular injuries of the upper extremity are rare,they may occur in the context of major combined musculoskeletal trauma.Although a multidisciplinary approach is essential to optimize outcome,the ability of trained hand surgeons to repair all injuries in combined vascular and musculoskeletal upper extremity trauma,excluding isolated vascular injuries,ensures shorter operative times and better functional outcomes.

Th17/Treg balance and macrophage polarization ratio in lower extremity arteriosclerosis obliterans

Objective:To explore the balance of peripheral blood T helper 17 cells/regulatory T cell(Th17/Treg)ratio and the polarization ratio of M1 and M2 macrophages in lower extremity arteriosclerosis obliterans(ASO).Methods:A rat model of lower extremity ASO was established,and blood samples from patients with lower extremity ASO before and after surgery were obtained.ELISA was used to detect interleukin 6(IL-6),IL-10,and IL-17.Real-time RCR and Western blot analyses were used to detect Foxp3,IL-6,IL-10,and IL-17 expression.Moreover,flow cytometry was applied to detect the Th17/Treg ratio and M1/M2 ratio.Results:Compared with the control group,the iliac artery wall of ASO rats showed significant hyperplasia,and the concentrations of cholesterol and triglyceride were significantly increased(P<0.01),indicating the successful establishment of ASO.Moreover,the levels of IL-6 and IL-17 in ASO rats were pronouncedly increased(P<0.05),while the IL-10 level was significantly decreased(P<0.05).In addition to increased IL-6 and IL-17 levels,the mRNA and protein levels of Foxp3 and IL-10 in ASO rats were significantly decreased compared with the control group.The Th17/Treg and M1/M2 ratios in the ASO group were markedly increased(P<0.05).These alternations were also observed in ASO patients.After endovascular surgery(such as percutaneous transluminal angioplasty and arterial stenting),all these changes were significantly improved(P<0.05).Conclusions:The Th17/Treg and M1/M2 ratios were significantly increased in ASO,and surgery can effectively improve the balance of Th17/Treg,and reduce the ratio of M1/M2,and the expression of inflammatory factors.

Lower Extremity Arterial Disease in Patients with Type 2 Diabetes: Prevalence and Associated Factors at the Libreville University Hospital Center

Introduction: Lower extremity arterial disease in diabetic patients has distinct characteristics. Objectives: To study the hospital frequency of lower extremity arterial disease and identify associated factors in diabetic patients at the Libreville University Hospital Center (CHUL). Materials and Methods: This was a cross-sectional study conducted from July 1, 2023, to January 31, 2024, in the endocrinology department of the CHUL. All patients with type 2 diabetes over the age of 18 admitted to this department, regardless of the reason for hospitalization, who provided informed consent, were included. Socio-demographic data and cardiovascular risk factors were recorded. Personal and family cardiovascular history and functional symptoms were investigated. The physical examination included measuring blood pressure, heart rate, and the ankle-brachial index in all patients. Results: A total of 219 patients were included, of whom 75 had lower extremity arterial disease, representing a prevalence of 34.24%. It was compensated in 28 cases (37.33%) and decompensated in 39 patients (52%). In eight cases (10.67%), there was critical chronic ischemia. Cardiovascular risk factors associated with diabetes were physical inactivity (89.5%), hypertension (55.25%), overweight (49.77%), obesity (22.84%), and smoking (10.04%). In multivariate analysis, only hypertension (OR = 2.09;95% CI: 1.05 - 4.17;p = 0.035) and LDL cholesterol (OR = 2.75;95% CI: 1.10 - 6.85;p = 0.03) were significantly associated with lower extremity arterial disease in diabetics at the University Hospital of Libreville. Conclusion: Lower extremity arterial disease is common in diabetic patients at the University Hospital of Libreville. It is often asymptomatic, thus requiring systematic screening.[-rId11-]

Relationships between Quadriceps:Hamstring Strength Ratio and Lower Extremity Injuries in Netball Players

Background: Netball is a popular sport. Due to high impact and quick movement, there is an enormous load on the lower extremities which increases the risk for injury. Aim: The aim of this study was to investigate the relationship between the quadricep and hamstring strength and the prevalence of lower extremity injuries in netball players. Setting: Twenty-five female netball players (age: 20.8 ± 1.4 years) voluntarily participated. Methods: The Cybex Isokinetic dynamometer was used to determine concentric knee torques. Quadriceps:hamstring strength ratio was determined. Occurrence of lower extremity injuries was documented bi-weekly. Results: Medium effect sizes were noted for flexion torque:work for the left leg and for the quadriceps:hamstring ratio (≥60%) for the right leg. All the other measured variables have a small effect size. 18.75% of lower extremity injuries and ConQ:ConH of Conclusion: Injuries to the ankle and knee are especially common among netball players. Hamstring and quadriceps muscle asymmetry (>10%) were found to be a potential indicator of lower extremity injury. Contribution: This study highlights awareness on lower extremity injuries and the strength ratio between the quadriceps and hamstrings. This can aid coaches and netball players to lower the risk for injuries and thus improve individual- and team performance.

Upper extremity deep vein thrombosis:An intensivist’s perspective

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.

Observation of the effect of angiojet to treat acute lower extremity arterial embolization

BACKGROUND Through significant advances in the treatment of peripheral arterial occlusive disease,acute ischemia of the lower extremity is still associated with significant morbidity,limb threat and mortality.The two main causes of acute ischemia in lower extremities are arterial embolism and atherosclerotic arteries.Timely recognition and treatment of acute limb ischemia in emergency situations is essential in order to minimize the duration of ischemia.AIM To investigate the application effect of angiojet thrombolysis in the treatment of acute lower extremity arterial embolization.METHODS Sixty-two patients with acute lower extremity arterial embolization admitted to our hospital from May 2018 to May 2020 were selected.Among them,the observation group(twenty-eight cases)had received angiojet thrombolysis,and the control group(thirty-four cases)had received femoral artery incision and thrombectomy.After thrombus clearance,significant residual stenosis of the lumen was combined with balloon dilation and/or stent implantation.When the thrombus removal was not satisfactory,catheter-directed thrombolysis was performed.The incidence of postoperative complications,recurrence rate and recovery of the two groups were compared.RESULTS There were no significant differences in postoperative recurrence(target vessel reconstruction rate),anklebrachial index and the incidence of postoperative complications between the two groups(P>0.05);there were statistically significant differences in postoperative pain score and postoperative rehabilitation between the two groups(P<0.05).CONCLUSION The application of angiojet in the treatment of acute lower limb artery thromboembolism disease is safe and effective,minimally invasive,quicker recovery after operation,less postoperative complications,which is more suitable for the treatment of femoral popliteal arterial thromboembolism lesions.If the thrombus removal is not satisfactory,the combination of coronary artery aspiration catheter and catheterized directed thrombolysis can be used.Balloon dilation and stent implantation can be considered for obvious lumen stenosis.

New Approach to Measuring the Ankle and Toe Brachial Indices as New Markers for Early Detection of Lower Extremity Peripheral Artery Disease

Background: Lower extremity Peripheral artery disease (PAD) is caused by atherosclerosis, or Plaque buildup, that reduces the blood flow to the legs and feet. PAD affects approximately 230 million adults worldwide and is associated with an increased risk of coronary heart disease, stroke, and leg amputation. The first-line method for diagnosis of PAD is the Ankle Brachial Index (ABI), which is the ratio of ankle to brachial higher systolic pressure measured in ankles and arms. The Toe Brachial Index (TBI), which is the ratio of the toe systolic pressure to brachial higher systolic pressure measured in both arms, is considered to be an alternative to the ABI in screening for PAD. The ABI and TBI are measured on the right and left side, and the lower of these numbers is the patient’s overall ABI and TBI. Clinical studies and meta-analysis reviews have shown that the conventional ABI measurement, which uses a cuff, and handheld sphygmomanometer and continuous-wave Doppler tracings, provides an acceptable-to-high specificity level but low sensitivity when compared with vascular color Doppler ultrasound, and/or angiography methods. Another study has shown that the TBI measurement has greater sensitivity but lower specificity than the ABI when compared with vascular color Doppler ultrasound diagnostic based on waveforms. The aim of this clinical study was to evaluate the specificity and sensitivity of the VasoPad System comparing its results to the vascular color doppler ultrasound waveforms. Materials and Methods: The VasoPad System is an automated device using the pulse wave method to measure the arms and ankles dorsalis and tibial posterior artery blood pressures, the photoplethysmography second derivative (PTGSD) to estimate the toe systolic pressure, a patented photoplethysmography (PTG) index marker and volume plethysmography via cuffs during deflation. Vascular Color Doppler ultrasound can diagnose stenosis through the direct visualization of atherosclerosis or plaques and through waveform analysis. The vascular color Doppler ultrasound provides 3 waveform types. The type 1, triphasic waveform is normal blood flow and no atherosclerosis or plaque, the type 2, diphasic waveform is seen when there are atherosclerosis plaques, but normal blood flow, and the type 3, monophasic waveform reflects stenosis with diameter reduction > 50%. Results: The sum of the overall ABI and TBI VasoPad values, called Sum of Brachial Indices (SBI), gave a specificity of 88.89% and sensitivity of 100% for detecting vascular color Doppler ultrasound biphasic and monophasic waveforms versus triphasic waveforms with a cutoff ≤ 1.36 (P Conclusion: The VasoPad was useful for detecting PAD, which is fully defined as having vessel stenosis > 50% (Doppler monophasic waveforms) but also early stage of atherosclerosis plaque of the lower extremities (Doppler biphasic waveforms). The VasoPad method provided a remarkable sensitivity of 100% and a specificity level similar to those of the conventional ABI test method compared with the vascular color Doppler ultrasound. In addition to being useful to screen and detect PAD, the VasoPad offers early detection of lower extremity atherosclerosis, with normal blood flow (Doppler biphasic waveforms), which could provide greater treatment options and thus reduce the overall number of lower extremity complications.

To Explore the Relationship between Lower Extremity Vascular Sclerosis and Osteoporosis in Elderly Men with Type 2 Diabetes Mellitus

Objective: To investigate the correlation between lower extremity vascular sclerosis and osteoporosis in elderly men with type 2 diabetes mellitus. Methods: A total of 359 elderly male patients with type II diabetes hospitalized in the First Affiliated Hospital of Chongqing Medical University from January 2018 to June 2023 were retrospectively collected. According to the BMD (Bone Density Value), the patients were categorized into osteoporotic (T ≤ -2.5, n = 248) and non-osteoporotic groups (T > -2.5, n = 111). T test and Chi-square test were used to evaluate the differences in clinical data, biochemical markers and ABI between two groups. Multivariate logistic regression was used to analyze the risk factors of osteoporosis in elderly men with type 2 diabetes mellitus. Results: Compared with the non-osteoporotic group, the differences in diabetes course, systolic blood pressure, ABI, BMI, uric acid, triglyceride, and HDL in the osteoporotic group were statistically significant (P < 0.05). Logistic multivariate regression analysis showed that lower extremity vascular sclerosis was an independent risk factor for osteoporosis in elderly men with type 2 diabetes mellitus (P Conclusion: Atherosclerosis of the lower extremities in elderly men with T2DM is closely related to osteoporosis, and can lead to a decrease in bone mass, and an increase in osteoporosis.

Epidemiology of Lower Extremity Artery Disease in People Living with HIV Followed at the Departmental University Hospital Center Ouémé-Plateau in 2019

Introduction: Lower extremity artery disease (LEAD) is a serious cardiovascular disease. People living with the human immunodeficiency virus (HIV) are at risk. The aim of the study was to determine the prevalence of LEAD and identify the associated factors among people living with HIV who were followed at the departmental university hospital Ouémé-Plateau in Benin. Methods: This was a cross-sectional study. It included all HIV-infected people who were monitored at the department of medicine of the target hospital during the study period and met the inclusion criteria (followed for at least three months, aged at least 25 years, and having given their written consent to participate). Data were collected during an individual interview, followed by the measurement of parameters. The ankle brachial index ≤ 0.9 was used for the diagnosis of LEAD. Associated factors were searched through a multivariable logistic regression. Results: The prevalence of LEAD was 34.2% among 222 respondents having a mean age was 42.9 ± 10.8 years and a female predominance (77.5%). No significant association was found between the presence of LEAD and sociodemographic factors. The presence of LEAD was significantly associated with hypertension and antiretroviral therapy. Hypertensive patients had a higher risk of LEAD compared to non-hypertensive patients (OR = 1.98, 95% CI [1.04-3.83], p = 0.037). Those who were receiving second-line therapy also had a higher risk of LEAD compared to those on first-line therapy (OR = 2.95, 95% CI [1.14-7.60], p = 0.025). Conclusion: This study showed a high prevalence of LEAD especially among hypertensive patients and those who were receiving second-line antiretroviral therapy. LEAD diagnosis and management should be included in the routine care of people living with HIV in Benin.

Repetitive transcranial magnetic stimulation for lower extremity motor function in patients with stroke:a systematic review and network meta-analysis

Transcranial magnetic stimulation,a type of noninvasive brain stimulation,has become an ancillary therapy for motor function rehabilitation.Most previous studies have focused on the effects of repetitive transcranial magnetic stimulation(rTMS)on motor function in stroke patients.There have been relatively few studies on the effects of different modalities of rTMS on lower extremity motor function and corticospinal excitability in patients with stroke.The MEDLINE,Embase,Cochrane Library,ISI Science Citation Index,Physiotherapy Evidence Database,China National Knowledge Infrastructure Library,and ClinicalTrials.gov databases were searched.Parallel or crossover randomized controlled trials that addressed the effectiveness of rTMS in patients with stroke,published from inception to November 28,2019,were included.Standard pairwise meta-analysis was conducted using R version 3.6.1 with the“meta”package.Bayesian network analysis using the Markov chain Monte Carlo algorithm was conducted to investigate the effectiveness of different rTMS protocol interventions.Network meta-analysis results of 18 randomized controlled trials regarding lower extremity motor function recovery revealed that low-frequency rTMS had better efficacy in promoting lower extremity motor function recovery than sham stimulation.Network meta-analysis results of five randomized controlled trials demonstrated that highfrequency rTMS led to higher amplitudes of motor evoked potentials than low-frequency rTMS or sham stimulation.These findings suggest that rTMS can improve motor function in patients with stroke,and that low-frequency rTMS mainly affects motor function,whereas high-frequency rTMS increases the amplitudes of motor evoked potentials.More highquality randomized controlled trials are needed to validate this conclusion.The work was registered in PROSPERO(registration No.CRD42020147055)on April 28,2020.

Manual aspiration thrombectomy for acute and subacute inferior vena cava thrombosis and lower extremity deep venous thrombosis

Deep vein thrombosis(DVT), which can lead to pulmonary embolism(PE), is a major contributor to the global disease burden and is the third most common cardiovascular pathology after coronary artery disease and stroke. Venous thromboembolic disease, which encompasses the disease entities of DVT and PE, affects up to 10 million cases every year and represents a serious and potentially life-threatening condition. Standard anticoagulation therapy alone is ineffective at promoting deep venous system thrombus removal. Many patients develop postthrombotic syndrome(PTS) despite being on adequate anticoagulation therapy. Aggressive therapy for rapid thrombus removal is important to prevent the development of PTS. Besides impeding the onset of PTS, rapid clearance of the thrombus is also required in the treatment of phlegmasia cerulea dolens, an uncommon but life-threatening complication of acute DVT that can lead to arterial insufficiency, compartment syndrome, venous gangrene, and limb amputation. Manual aspiration thrombectomy(MAT) can provide rapid and effective therapy that could be compared to the open surgical thrombectomy approach with minimal risk of morbidity, mortality, or recurrence after surgery. Though many devices have been developed to date for pharmacomechanical thrombolysis, the cost of the treatment using these devices is very expensive. MAT is simple to perform, easy to learn, inexpensive, and rapid. This review will outline and dissect several studies and case reports, sourced from the Pub Med database, on the subject of the use of MAT in treating inferior vena cava thrombosis and lower extremity DVT, including in patients with compression of the iliac vein and phlegmasia cerulea dolens.

Changing paradigms in lower extremity reconstruction in war-related injuries

Background: Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage.Methods: A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications.Results: Extremity injuries account for over 60% of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage.Conclusion: Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.

Therapeutic effect of autologous concentrated growth factor on lower-extremity chronic refractory wounds:A case report

BACKGROUND Management of chronic refractory wounds is one of the toughest clinical challenges for surgeons.Because of poor blood supply,less tissue coverage,and easy exposure,the lower leg is a common site for chronic refractory wounds.The current therapeutic regimens often lead to prolonged hospital stay and higher healthcare costs.Concentrated growth factor(CGF)is a novel blood extract that contains various growth factors,platelets,and fibrins to promote wound healing process.However,there has been little research reported on the treatment of lower extremity wounds with CGF.CASE SUMMARY A 37-year-old man,without any past medical history,presented an ulcerated chronic wound on his right lower leg.The skin defect exhibited clear boundaries,with a size of 2.0 cm×3.5 cm.The depth of wound was up to the layer of deep fascia.Staphylococcus aureus was detected by bacterial culture.The final diagnosis was right lower extremity ulcers with infection.Cefathiamidine,silver sulfadiazine,and mupirocin cream were applied to control the infection.CGF gel was prepared from the patient’s blood sample,and was used to cover the wound after thorough debridement.The skin wound was successfully healed after three times of CGF treatment.CONCLUSION CGF displays an excellent wound healing promoting effect in patients with lowerextremity chronic refractory wounds.

Clinical effect of ultrasound-guided nerve block and dexmedetomidine anesthesia on lower extremity operative fracture reduction

BACKGROUND Lower extremity fractures are mainly treated by surgical reduction,but this operation is often affected by the patient’s level of agitation and the type of anesthesia used.The main treatment for lower-extremity fractures is operative reduction.However,operations can often be affected by both agitation and the degree of anesthesia.Therefore,it is of great importance to develop an effective anesthesia program to effectively ensure the progress of surgery.AIM To discuss the effect of ultrasound-guided nerve block combined with dexmedetomidine anesthesia in lower extremity fracture surgery.METHODS A total of 120 hospital patients with lower extremity fractures were selected for this retrospective study and divided into an observation group(n=60)and a control group(n=60)according to the anesthesia scheme;the control group received ultrasound-guided nerve block;the observation group was treated with dextromethomidine on the basis of the control group,and the mean arterial pressure,heart rate(HR),and blood oxygen saturation were observed in the two groups.RESULTS The mean arterial pressure of T1,T2 and T3 in the observation group were 94.40±7.10,90.84±7.21 and 91.03±6.84 mmHg,significantly higher than that of the control group(P<0.05).The observation group’s HR at T1 was 76.60±7.52 times/min,significantly lower than that of the control group(P<0.05);The observation group’s HR at T2 and T3 was 75.40±8.03 times/min and 76.64±7.11 times/min,significantly higher than that of the control group(P<0.05).The observation group’s visual analog score at 2 h,6 h and 12 h after operation was 3.55±0.87,2.84±0.65 and 2.05±0.40.the recovery time was 15.51±4.21 min,significantly lower than that of the control group(P<0.05).Six hours post-anesthesia,epinephrine and norepinephrine in the observation group were 81.10±21.19 pg/mL and 510.20±98.27 pg/mL,significantly lower than that of the control group(P<0.05),and the mini-mental state exam score of the observation group was 25.51±1.15,significantly higher than that in the control group(P<0.05).CONCLUSION Ultrasound-guided nerve block combined with dexmedetomidine has a good anesthetic effect in the operation of lower limb fractures and has little effect on the hemodynamics of patients.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees

Background: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation.Methods: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees(206 amputations) from the IranIraq war were evaluated, and a detailed questionnaire was also administered.Results: The most common level of amputation was the finger or wrist level(108, 52.4%). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis(65, 31.6%), rotator cuff injury(24, 11.7%), bicipital tendonitis(69, 33.5%), shoulder drop(42, 20.4%) and muscle atrophy(19, 9.2%). Peripheral nerve disorders included carpal tunnel syndrome in 13(6.3%) and unilateral brachial plexus injury in 1(1%). Fifty-three(51.5%) were diagnosed with facet joint syndrome at the level of the cervical spine(the most frequent site). Using a prosthesis was reported by 65(63.1%), both left and right sides. The back was the most common site of pain(71.8%).Conclusion: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Lower extremity amputations and long-term outcomes in diabetic foot ulcers:A systematic review

BACKGROUNDDiabetes mellitus causes a large majority of non-traumatic major and minoramputations globally. Patients with diabetes are clinically complex with amultifactorial association between diabetic foot ulcers (DFU) and subsequentlower extremity amputations (LEA). Few studies show the long-term outcomeswithin the cohort of DFU-associated LEA.AIMTo highlight the long-term outcomes of LEA as a result of DFU.METHODSPubMed/MEDLINE and Google Scholar were searched for key terms, “diabetes”,“foot ulcers”, “amputations” and “outcomes”. Outcomes such as mortality, reamputation,re-ulceration and functional impact were recorded. Peer-reviewedstudies with adult patients who had DFU, subsequent amputation and follow upof at least 1 year were included. Non-English language articles or studiesinvolving children were excluded.RESULTSA total of 22 publications with a total of 2334 patients were selected against theinclusion criteria for review. The weighted mean of re-amputation was 20.14%,29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively withsignificantly higher rates associated with major amputation, re-amputation andischemic cardiomyopathy.CONCLUSIONPrevious LEA, level of the LEA and patient comorbidities were significant riskfactors contributing to re-ulceration, re-amputation, mortality and depreciatedfunctional status.

Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?

BACKGROUND: Deep venous thrombosis(DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department(ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT.METHODS: This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital's electronic medical record.RESULTS: A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379(15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT.CONCLUSIONS: Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

Non-ossifying fibromas: Case series, including in uncommon upper extremity sites

AIM To investigate non-ossifying fibromas(NOFs) common fibrous bone lesions in children that occur in bones of the lower extremities.METHODS We analyzed 44 cases of NOF including 47 lesions, which were referred with a working diagnosis of neoplastic lesions. Lesions were located in the upper extremities(1 proximal humerus, 1 distal radius) and the lower extremities(25 distal femurs, 12 proximal and 4 distal tibias, and 4 proximal fibulas).RESULTS Three cases had NOFs in multiple anatomical locations(femur and fibula in 1 case, femur and tibia in 2 cases). Overall, larger lesions > 4 cm and lesion expansion at the cortex were seen in 21% and 32% of cases, respectively. Multiple lesions with bilateral symmetry in the lower extremities suggest that these NOFs were developmental bone defects. Two patients suffered from fracture and were treated without surgery, one in the radius and one in the femur. Lesions in the upper extremities(i.e., humerus of a 4-year-old female and radius of a 9-year-old male) expanded at the cortex and lesion size increased with slow ossification.CONCLUSION NOFs in the lower extremity had fewer clinical problems, regardless of their size and expansiveness. In these two upper extremity cases, the NOFs had aggressive biological features. It seems that there is a site specific difference, especially between the upper extremity and the lower extremity. Furthermore, NOFs in the radius are predisposed to fracture because of the slender structure of the radius and the susceptibility to stress.

Investigation and analysis of lower extremity arterial disease in hospitalized elderly type 2 diabetic patients

Background:The risk of lower extremity arterial disease (LEAD) is increased in diabetic patients.LEAD in diabetic patients occurs earlier and is often more severe and diffuse;however,it is largely underdiagnosed and untreated.The purposes of this study were to investigate and analyze LEAD situation of hospitalized elderly type 2 diabetic patients.Methods:The ankle-brachial index (ABI) was used to screen LEAD in hospitalized elderly type 2 diabetic patients.The patients were divided into 5 groups based on the screening results:non-LEAD group and LEAD group;the LEAD group was divided into mild stenosis group,moderate stenosis group,and severe stenosis group.Results:The percentage of patients who had LEAD was 43%.Significant difference in age,diabetes duration,peak velocity,microalbuminuria,and vibratory sensory neuropathy was observed between patients with and without LEAD;regression analysis showed that urinary albumin and vibratory sensory neuropathy were independent risk factors for LEAD.Significant difference in age,body mass index (BMI),peak velocity,urinary albumin,and high-density lipoprotein cholesterol (HDL-C) was observed between mild stenosis group,moderate stenosis group,and severe stenosis group;regression analysis showed that urinary albumin,BMI,and HDL-C were independent risk factors for accelerating vascular stenosis.Conclusions:The incidence of LEAD in hospitalized elderly type 2 diabetic patients is high;age,diabetes duration,peak velocity,BMI,urinary microalbumin,vibratory sensory neuropathy,and HDL-C are the maior risk factors for LEAD.Active control of risk factors is helpful to reduce or delay LEAD.

Effect of combining music media therapy with lower extremity exercise on elderly patients with diabetes mellitus

Objective:To evaluate the compliance with lower extremity exercise and blood circulation in the feet of elderly diabetics following a combination of music media therapy and a lower extremity exercise regimen.Method:The 72 elderly diabetic patient subjects were divided into two groups:control group(n=38)and intervention group(n=34).Both groups were exposed to the same comprehensive therapy to control glucose levels.While the control group was given the lower extremity exercise,the intervention group received the extremity exercise in addition to the music media.Result:After three months of intervention,the adherence to the lower extremity exercise regimen in the intervention group was significantly higher than that of the control group(p<0.05).Additionally,following six months of treatment,both the dorsal artery peak values and ankle-brachial indices(ABIs)showed significant differences between the control and intervention groups(p<0.05).Conclusion:Music media treatment combined with lower extremity exercise can both significantly increase the extent of exercise compliance of elderly patients suffering from diabetes mellitus,as well as improve blood circulation in their feet.