The objective of this study was to investigate if the insurance status of patients impacted the treatment options and prognosis in acute limbischemia (ALI). A retrospective chart review was performed at a single university tertiary care center using ICD-9 codes for the diagnosis and pro- cedure for ALI from January 2000 to January 2011. A total of 96 patients were diagnosed with ALI, comprising of 66 males and 30 females with a mean age of 56 years (range was 19 - 80 years). Time to presentation and prognosis (rate and level of amputation) were analyzed using insurance status as the independent variable. Patients covered under commercial insurance were compared to patients with Medicare and Medicaid and to patients without any insurance coverage. Statistical analysis was performed using the proportion z test to evaluate differences among the groups in- vestigated. A “p” value of ≤0.05 was considered significant. In this study, ALI occurred more com- monly in African Americans (p = 0.0029) and in patients without insurance coverage regardless of race (p = 0.0034). Chronic obstructive pulmonary disease (COPD), hypertension (HTN), and acute renal failure (ARF) were significantly higher in the uninsured group, compared to the insured group (p = 0.0005, 0.0055, and 0.0034, respectively). The time to hospital admission was signifi- cantly longer in uninsured patients compared to the insured group (p = 0.0449). The rates of ma- jor amputation above the ankle were 46% in patients with commercial insurance, 62% in the government insurance (Medicare and Medicaid) group, and 51% in the uninsured group. There was no significant difference in major versus minor amputation in patients with commercial in- surances. However, the rates of major amputation were significantly higher than the rates of mi- nor amputation in both Medicare and Medicaid and uninsured patients (p = 0.005, and <0.0001, respectively). With respect to acute lowerlimbischemia, African Americans presented more fre- quently and were more likely to be uninsured. The incidences of COPD, HTN, and ARF were signif- icantly higher in uninsured patients. The majority of the amputations in Medicare and Medicaid
Purpose: Metabolic syndrome (MS) is a clinical condition that shares many com- mon characteristics with diabetes. However, unlike diabetes, the usefulness of MS as a prognostic entity in peripheral arterial disease is uncertain. This study evaluat- ed the prognostic usefulness of MS in critical lowerlimbischemia (CLI) patients. Materials and Methods: We compared the 2-year clinical outcomes in 101 con- secutive CLI patients (66±14 years; 78% men) with 118 affected limbs treated with percutaneous transluminal angioplasty (PTA) according to the presence of MS and diabetes. Results: The number of MS patients was 53 (52%), of which 45 (85%) had diabetes. During a 2-year follow-up, the incidence of clinical outcomes, including reintervention, major amputation, minor amputation, and survival, was not significantly different between MS and non-MS patients; however, the inci- dence of minor amputation was significantly higher in diabetic than in non-diabet- ic patients (42% vs. 17%; p=0.011). Cox regression analysis for the 2-year prima- ry patency demonstrated no association between MS and 2-year primary patency [hazard ratio (HR), 1.02; 95% confidence interval (CI), 0.45-2.30; p=0.961], where- as there was a significant association between diabetes and 2-year primary patency (HR, 2.81; 95% CI, 1.02-7.72; p=0.046). Kaplan-Meier analysis revealed no sig- nificant difference in the 2-year primary patency between MS and non-MS pa- tients; however, the 2-year primary patency was lower in diabetic than in non-dia- betic patients (p=0.038). Conclusion: As a prognostic concept, MS might conceal the adverse impact of diabetes on the prognosis of CLI patients treated with PTA.
Background: There are still many unresolved problems that reduce frequency of clinical and technical success of angioplasty of lowerlimb arteries. One of such problems is impact of the arterial pedal arch revascularization on the clinical result of angioplasty in patients with IV class critical lowerlimbischemia according to Pokrovsky-Fontaine classification. Material and methods: The results of treatment of 98 patients with peripheral arterial disease (PAD), complicated by critical lowerlimbischemia of IV class according to Pokrovsky-Fontaine classification were analyzed in the early postoperative period and 1 year later after the completed angioplasty. Patients were divided into two comparable groups: the first group-the patients with the arterial pedal arch revascularization, the second group – the patients whom it had been impossible to revascularize the arterial arch. Results: “Good result” in patients of the first group in the early postoperative period and one year later was 23.1% and 22.7% respectively. In the patients of the second group-9.2% and 5.6%. The both group patients avoided amputations in the early postoperative period, but one year later 53.3% of the second group patients with the “unsatisfactory result” underwent amputation. Conclusions: According to the results, the arterial pedal arch revascularization influences on the clinical results and decreases the quantity of amputations in patients with purulent-necrotic changes in the lowerlimb.
Various imaging techniques are used in the diagnosis of lower extremity arterial occlusive disease (LEOD). The usual are duplex scan ultrasonography and conventional angiography. The gold standard conventional angiography is responsible for complications in 1 to 2% of patients. For this reason non invasive techniques have been recently developed. 5
Initial broad-spectrum antibiotics in addition to Pre and postoperative debridement and minor amputations (toe/s or trans metatarsal without affecting the pedal arch) for patients presenting with wet gangrene/ necrotic tissue or sloughs in the wound bedand, this was done in both groups. The wounds were subsequently reassessed for possibility of limb salvage.Cardiac,pulmonary,renal,and glycemic status were optimized preoperatively with the assistance of the concerned specialist physicians.
by the overgrowth of gut microbial flora [6,8]. In view of the slow rate of enzymatic breakdown, it is a very sensi- tive early marker of the ischemic process (where the lac- tate levels may be subject to several factors including ischemia-related hepatic dysfunction) [6-8]. Our approach recommends that a consistent fall in lactate during this interim period may represent the ischemia as resolving. One can therefore perform a delayed repair of the proximal aortic dissection  providing a decreased intra-operative risk to the patient. Individuals with persistently high lactate levels may then require a revascularization procedure at that time rather than delaying intervention in anticipation of clinical signs. Differentiating between bowel ischemia and lowerlimbischemia in the absence of clinical signs and a raised lactate can be based on radiological imaging.
Although the number of hospitalisations due to vascular disease (obstructive carotid disease, deep venous thrombo- sis, chronic venous insufficiency, acute lowerlimbischemia, peripheral arterial disease, abdominal and peripheral artery aneurysms, and vascular trauma) decreased over a period of six years (19 267 in 2009 to 14 381 in 2014), hospitalisa- tion levels for PAD remained relatively stable, with a ten- dency to increase from 4102 in 2009 to 4428 in 2015, with a slight decrease in 2016 to 3893.
Critical limbischemia (CLI) is estimated to develop in 500 to 1000 individuals per million per year . Nowadays, chronic lowerlimbischemia treatment is based on pharmacotherapy and inva- sive techniques. However, results from these tra- ditional treatment procedures are unsatisfactory, especially in severely ill patients suffering from critical ischemia. The latest scientific discoveries have brought about a completely new era of lowerlimbischemia treatment. These new methods of treatment including modern stent construction, coating stents with substances attenuating epi- thelial hyperplasia and preventing restenosis, new drugs, and, raising the greatest hopes, using genes encoding proteins to affect disease process (gene therapy) and administering multipotential bone marrow cells (cell therapy) [2–8]. It seems that intramuscular injections of angiogenic cytokine genes may be a supplement or even an alterna- tive to conventional treatment. The purpose of the treatment is to induce collateral small blood ves- sel formation, which become bypasses around the blocked arteries [9–11].
Extension of primary lung tumors into the left atrium via pulmonary veins is a well-documented phenomenon. Peripheral arterial embolism and cerebral embolism originating from a primary lung neoplasm are rare events. We report a case of simultaneous acute bilateral lowerlimbischemia, bilateral renal infarction, splenic infarction and cerebral infarction as a result of multiple emboli originating from primary lung malignancy invasion of the left atrium. An emergent embolectomy revealed pathologic features of the extracted thrombus that were identical to the pulmonary neoplasm.
Delayed reperfusion of acute occlusive limbischemia causes local and systemic serious conse- quences and is the main cause of morbidity and mortality in these patients. The aim of this study was to examine the outcome and risk factors of reperfusion injury in such cases. Patients and Me- thods: Retrospective review of all cases presented, to King Fahd Hospital of University, with acute occlusive limbischemia more than 12 hours was performed between June 2004 and November 2012. Grades of ischemia, extremities, co-morbidities, morbidities and mortality were recorded. Results: During the study period, 92 patients were included, 47 (51%) were embolic and the rest was thrombotic. On admission, 15 patients had grade III ischemia, 68 had grade IIb, 8 had grade IIa and 1 had grade I. Four patients died (4.3%) and 15 (16%) patients had amputation. The risk fac- tors of amputation were age (p = 0.031), extremity (lowerlimb 21% vs. Upper limb 0%, p = 0.019), cause of ischemia (thrombotic 24% vs. embolic 8.5%, p = 0.049) and grade of ischemia (p = 0.001). Conclusion: Delayed reperfusion of acute occlusive ischemia carries acceptable morbidity and mortality and could be performed even in irreversible ischemia. The risk factors of amputation are age, lowerlimbischemia, thrombosis and grade III ischemia.
the lesion through the distal venous circulation by means of a completely percutaneous arterialization of the venous bed (Figure 4) in patients not treatable by conventional or alterna- tive endovascular techniques due to long calcific occlusions of PTa and poor or absent runoff. In these case series, 33% of patients underwent BTK amputation at 6 months after the procedure, while 66% had limb salvage. Although further investigations enrolling larger patient populations are needed, these data should be considered very encouraging in dialyzed patients affected by CLI in relation to the high risk of major amputation historically recorded in this complex subset of patients. Even if the earliest theories about the arterialization of the peripheral venous bed were developed more than one century ago, 80 the mechanisms that may justify the benefits
The parents attributed all this to a trivial fall while playing in school, 2 days after which the symptoms started appearing. There was no loss of consciousness before or after the fall. h/o numbness involving both feet, no dysesthesia. No h/o breathing difficulty. No h/s/o upper limb weakness. No h/s/o raised ICT in the form of ABSTRACT
In the present study, out of 107 cases of snake bite, age group commonly involved is 50 years and above, most affected being agricultural labourer, maximum fatality occurred at winter and during activity. Lowerlimb is the commonest site involved and majority of cases received antisnake venom, eventhough bite to ASV time is more. Among the local findings, local pain and swelling predominated. Histopathological study of kidney revealed that tubular lesions (acute focal tubular necrosis) predominant in Viperine bites, tubular (diffuse ATN) and interstitial changes (severe inflammation ) in Krait bite and glomerular (congested capillary loop) and interstitial (severe inflammation) changes in Cobra bite.
3 instrument to detect blood flow to the lower extremities and a blood pressure cuff at the arm. Using these devices together the blood pressure in the posterior tibial artery is compared to the blood pressure in the brachial artery. The results from the test are reported as a ratio between the lower leg and upper arm. Atherosclerotic plaques in peripheral arteries will cause decreased blood flow in the lower extremities. A healthy ABPI is in the range of 0.9-1.3 indicating that the blood pressure between the legs and arms is roughly the same. ABPI ratios between 0.4 and 0.9 are indicative of moderate PAD and values below 0.4 suggest severe PAD.
Actuators are the device that provide motion for the exoskeleton and hence support the wearer’s limb motion. It takes the command from the controller and provides motion according to the requirement at a certain instant. Electrical Actuator is one of the most popular choices due to its clean and silent operation as well as lower power consumption than others . Some of the electrical actuators used by previous studies include DC Servomotor, Linear Actuator and Series Elastic Actuator.
The Beighton score is the most widely used tool for identifying GJH and plays a significant role in the diagnosis of hEDS [6, 12]. Despite its utility as a simple epidemiological clinical tool, the Beighton score is domi- nated by tests of the upper extremity, with knee exten- sion being the only lowerlimb specific inclusion . In addition it does not include several body sites that are commonly and symptomatically hypermobile, such as the hips, ankles, and first metatarsophalangeal joints . Consequently, the Beighton score may not validly iden- tify generalised hypermobility when it presents predom- inantly in the lower limbs [13, 14].
using evidence published by National Institute for Health and Care Excellence, Cochrane library, systematic reviews and randomised control trials (levels I and II). Only evidence published in the English language over the past 10 years was inlcuded. A question was confirmed as a genuine uncertainty if it could not be answered using the literature- search method described above. Several topic experts in various fields were consulted to finalise the decisions. The full list of questions submitted through the initial survey can be found on the web (http://www. jla. nihr. ac. uk/ priority- setting- partnerships/ Paediatric- lower- limb- surgery/ downloads/ Paediactric- Lower- Limb- Surgery- PSP- final- data- sheet. pdf).
Methods: Veins to be treated are identified and marked. Intra arterial accidental injection should be avoided. Preparations to manage anaphylaxis should be ready. Needles of syringes containing 0.5ml sclerosant introduced into veins and position confirmed. Limb is elevated and veins are emptied. Sclerosant injected and compression applied compression maintained for 3 weeks. Exercise advised during this period to avoid deep vein thrombosis. Complications
The Great majority of bilateral lowerlimb amputees today are the elderly who lose their limbs secondary to Diabetes and Vascular disease between the ages of 55 and 95 years. The challenge of rehabilitating these patients is frequently complicated by the presence of other illnesses. Chronological age alone should not determine whether an amputee is a prosthetic candidate.