Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

[Chronic obstructive pulmonary disease: sense of coherence and family support versus anxiety and depression]

Chronic Obstructive Pulmonary Disease (COPD) is mainly related to smoking habit and is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Worldwide and in Greece, COPD constitutes a major epidemiological issue. Incidence of depression and anxiety is high in the COPD population. Most studies on depression and anxiety in COPD deal with factors that are positively correlated with both of these comorbidities. The aim of our study was to assess whether two variables, sense of coherence (SOC) and perception of family support (FS), are negatively correlated with depressive and anxiety symptoms in outpatients with COPD. According to Aaron Antonovsky, sense of coherence refers to the ability of individuals to make sense of and manage events. Studies in other diseases suggest that sense of family support has a significant impact on the course and outcome of the disease, yet a limited number of reports across literature addresses the role of family support in COPD patients. In our present study one hundred twenty two (98 men and 24 women) outpatients with pure COPD were included. Age and years of education were recorded. Severity of COPD was assessed with spirometry before and after bronchodilation. All patients replied to self- administered questionnaires on depression (Beck Depression Inventory, BDI), anxiety (Spielberger State-Trait Anxiety Scale, STAI), family support (Family Support Scale, FSS-13) and sense of coherence (Sense of Coherence Scale, SOC). According to our results the mean BDI depression score was 11.65 (SD 7.35), mean trait anxiety score was 40.69 (SD 11.19), mean SOC score was 54.62 (SD 7.40) and mean FS score was 64.58 (SD 11.63). Women patients had higher anxiety scores and lower sense of family support compared to men. Significant negative correlations were evidenced between depression and sense of coherence as well as between anxiety and family support. Step-wise multiple linear regression analysis verified the results and quantified the aforementioned correlations. Notably, raising scores in sense of family support by one point reduces anxiety scores by 0.14 points, and increasing sense of coherence scores by one point reduces depression scores by 0.21 points. In sum, our study confirms the presence of high levels of anxiety and depressive symptoms in COPD patients, with females being in a more disadvantaged position as they tend to have higher levels of both. Sense of coherence and family support are both protective psychological factors against the risk of developing anxiety and depressive symptoms in these patients.

Comorbidity of substance use and psychiatric disorders among inpatients of a General Hospital Psychiatric Unit

Introduction

In substance – related disorders comorbidity refers to any preexisting or following psychological or psychiatric condition that influence the course and prognosis of a patient.

Objectives

To determine the extent of comorbid substance use and psychiatric disorders among hospitalized in a General Hospital Psychiatric Unit patients and reveal the implications of treatment in such a unit.

Method

All patients hospitalized during a year, were included in the study. Demographics, final diagnosis, substance of use and means of admission (voluntary or involuntary) were recorded.

Results

7.4% of the total of 339 inpatients met the diagnostic criteria of comorbid substance use disorders. Eleven of them were diagnosed with alcohol use disorder comorbidity, 7 with illicit drug use comorbidity and 7 with both legal and illicit drug use comorbidity. Among inpatients with comorbid use disorders male patients had a significantly higher percentage versus females (x2 p < 0.05). Mean age of inpatients with comorbidity was significantly less than the mean age of the sample (t-test p < 0.05). Duration of hospitalization for inpatients with comorbidity was 15.16 ± 12.4 days versus 21.2 ± 18.4 days for the rest of patients (t-test p < 0.05). Concerning the way of admission, 72% of inpatients with comorbid use disorders were involuntary admitted (x2 p < 0.05).

Conclusion

Concerning age, sex and means of admission patients with a psychiatric disorder and substance use disorder comorbidity seem to vary from the rest of inpatients. These parameters are probably associated with serious difficulties in therapeutic compliance and with increased hazard.

Chorionic DNA analysis for the prenatal diagnosis of familial hypercholesterolaemia

Prenatal diagnosis for familial hypercholesterolaemia (FH) was performed by using restriction fragment length polymorphisms (RFLPs) of the LDL receptor gene on chorionic villi DNA taken during the 10th week of pregnancy. Both parents were FH heterozygotes and had previously had a healthy son and an FH homozygous son. Two RFLPs were informative in this family and revealed that the fetus was unaffected by FH. At birth the child was found to have an LDL cholesterol level of 30 mg/dl and a normal LDL receptor activity in cultured umbilical cord fibroblasts. RFLP analysis on chorionic villi DNA is highly recommended for all heterozygous FH couples in whom the LDL receptor gene mutation/s is/are still to be characterized.

Autoimmune thrombocytopenic purpura in pregnancy: maternal risk factors predictive of neonatal thrombocytopenia

Pregnancy in ATP women is not unusual. The problem of this association concerns the possibility of disease transmission to the fetus due to the crossing of maternal antiplatelet antibodies through the placenta. Maternal risk factors predictive of neonatal thrombocytopenia, can be identified as follows: severe thrombocytopenia, previous splenectomy, high titre of PA-IgG and/or SPB-IgG. In 63 pregnancies in ATP patients, we have evaluated whether the above maternal risk factors, considered in the third trimester, can provide useful criteria for the prediction of neonatal thrombocytopenia. In the third trimester, the distribution of maternal risk factors was as follows: 0 in 7 cases, 1 in 27 cases, 2 in 15 cases, 3 in 12 cases, 4 in 2 cases. From a statistical evaluation, the neonatal platelet values and the maternal risk factors seem inversely correlated (r -0.437; p = 0.0005). In particular, neonatal and maternal platelet count correlated positively (r = 0.249; p = 0.025); moreover, neonatal platelet count correlated negatively with Splenectomy (r = -0.209; p = 0.05), PA-IgG (r = -0.401; p < 0.0005) and SPB-IgG (r = -0.338; p < 0.005). We tried to apply a multiple regression model for all the above parameters which appears statistically significant (p = 0.001); the variability was about 30%. This regression model could be validated if applied to a larger number of cases, and it could represent an alternative to the invasive methods used for the diagnosis of neonatal thrombocytopenia.

Carrier detection and prenatal diagnosis in haemophilia A and B

Sixty probable carriers of haemophilia from 25 families were studied by using coagulation phenotype and DNA analysis: 33 with haemophilia A and 27 with haemophilia B. Coagulation phenotype was based on factor VIII/IX assay and DNA analysis on the examination of restriction fragment length polymorphisms (RFLPs) within and closely linked to factor VIII or IX: 3 RFLP for factor VIII and 3 for factor IX. The comparison between the coagulation phenotype and RFLP analysis showed the misclassification of 15 females (6 for haemophilia A and 9 for haemophilia B). Four prenatal haemophilia A diagnosis were made by DNA analysis of chorionic villi, taken with a transcervical trophoblastic biopsy, between the 18th and the 11th week.

Influence of maternal metabolic control and insulin antibodies on neonatal complications and B cell function in infants of diabetic mothers

Circulating insulin antibodies at birth and the degree of maternal metabolic control were measured in 68 infants of insulin-treated diabetic mothers. Their correlation with neonatal B cell function and with the clinical features of the infants was evaluated in order to better understand their influence on fetal outcome. Maternal metabolic control was assessed on the basis of blood glucose levels, glycosuria and the occurrence of hypoglycemia and/or ketonuria. All infants were clinically evaluated for gestational age, macrosomia, hypoglycemia, hyperbilirubinemia, hypocalcemia, and respiratory distress syndrome. Cord blood plasma glucose, C peptide, and IgG insulin antibodies were also measured. It was shown that poor maternal metabolic control was associated with a higher prevalence of fetal morbidity as well as with signs of B cell hyperfunction. Also the presence of circulating insulin antibodies correlated well with higher C peptide levels and with several neonatal complications. B cell hyperfunction, indicated by high C peptide levels in the infants of diabetic mothers, may possibly play a causal role in the pathogenesis of fetal morbidity. In conclusion, a good fetal outcome in insulin-treated diabetic pregnancies was associated with and may have depended upon: (1) good maternal metabolic control, and (2) absence or low levels of circulating insulin antibodies.

Humoral and cellular immune abnormalities in neonates of diabetic mothers: any pathological role?

Insulin antibodies, insulin complexes, T-cell subsets and T-cells bearing surface antigens indicating early activation were studied in 35 and 24 infants of diabetic and of normal mothers respectively, which were compared with normal adult control subjects. Anti-insulin antibodies were evaluated using a modified version of Andersen's method, insulin complexes were assessed by a method developed by us; total T cells, helper/inducer and cytotoxic/suppressor T lymphocytes, and early activated T lymphocytes were determined using the monoclonal antibodies OKT3, OKT4, OKT8 and 4F2 respectively. The presence of insulin antibodies was correlated to macrosomia, hypoglycaemia and respiratory distress syndrome. Insulin-anti-insulin complexes were found in some of the neonates and were likely to have been formed by maternal antibodies and insulin from the neonate. Modifications of T-cell subsets were found in the neonates both of diabetic and of normal mothers. --Despite the presence of these immune abnormalities in some infants of diabetic mothers, the clinical onset of diabetes was not diagnosed in any of the cases studied. Nevertheless, the immunological abnormalities in neonates of diabetic mothers have short-term pathogenetic effects which raises the question of their possible long-term effect.

Immunology in diabetic pregnancy: activated T cells in diabetic mothers and neonates

Lymphocytes bearing surface antigens indicating early and full activation have been evaluated, in addition to T cell subsets, in blood samples from diabetic pregnant patients, neonates from diabetic mothers and control groups. The type of diabetes and the trimester of pregnancy were taken into account. Monoclonal antibodies were used to enumerate total T cells, helper/inducer, cytotoxic/suppressor Tlymphocytes and activated mononuclear cells using antibodies binding lymphocyte surface antigens as markers of early lymphocyte activation, and MHC Class II surface antigens as markers of late activation. A decrease in T-helper cells during the third trimester of pregnancy in Type 1 (insulin-dependent) and gestational diabetic patients (p less than 0.02) and a decrease in T-suppressor cells in Type 2 (non-insulin-dependent) diabetic pregnant patients during the third trimester (p less than 0.01) were observed in relation to normal values. As in normal pregnancy, 4F2-positive cells were increased in 48% of diabetic pregnant patients during the second and third trimesters of gestation. Class II-positive cells were increased in almost 60% of Type 1 and gestational diabetic patients during the last trimester of pregnancy in comparison with normal pregnant women and control subjects. A decrease in T-helper cells (p less than 0.02) and a clear increase in 4F2-positive cells (p less than 0.001) and Class II-positive lymphocytes (p less than 0.005) were observed in the infants of diabetic mothers in comparison with control subjects. The maternal cellular immune system, actively altered in pregnancy, is fully activated in a number of Type 1 and gestational diabetic pregnant patients. Activated lymphocytes are even found in the neonates of diabetic mothers, but these do not trigger the events leading to the onset of diabetes in the short term.

Activated T cells in normal pregnant women and neonates

The phenotyping of T-cell subsets and T cells at different stages of activation was performed using a panel of monoclonal antibodies in samples from normal pregnant women at different stages of gestation and in the cord blood of neonates. The data obtained from pregnant women showed a slight decrease in the total number of T cells at the beginning of pregnancy, whereas there was a clear increase in 4F2-positive lymphocytes after a few months of gestation. No significant increase in Class II-positive lymphocytes was observed in normal pregnant women in comparison with adult healthy women. The data from neonates revealed a clear decrease of OKT3- and OKT4-positive cells and an increase of 4F2-positive cells in comparison with control subjects. These data indicate that alerted, but not fully activated, lymphocytes are present in the circulation of both the mother, after the first months of pregnancy, and the neonate. This finding reinforces the concept that during pregnancy there is an activation of certain immune components rather than a general depression of the immune system.

Endocrine pancreatic function in insulin-dependent diabetic pregnant women

In order to better understand the role of A- and B-cell function in diabetic pregnancy, we studied four groups of pregnant women at week 34-36 of gestation. Seventeen were healthy controls (C), 24 had gestational diabetes (GD), 16 had type 2 diabetes (NIDD) and 37 had type 1 diabetes (IDD). At times -20, 0, 20, 30, 45, 60, 90 and 120 min from the beginning of a 30 min infusion of 30 g of arginine intravenously, plasma glucose, glucagon (IRG) and C-peptide (CPR) were measured. Plasma glucose was higher in diabetic than in control subjects. IRG values were also higher in the GD and the NIDD women. CPR values were similar to, or slightly higher than control values in the GD and the NIDD and were much lower in the IDD women. All three variables increased during the arginine infusion in all groups, with the exception that CPR remained unchanged in the IDD. The CPR/IRG molar ratio was similar in control, GD and NIDD women; in the IDD, it was much smaller than in the other groups and was not affected by arginine. In all the diabetic patients, IRG was negatively correlated with the maternal weight gain and in the IDD IRG was positively correlated with the increase in the insulin need and with the CPR levels. In conclusion diabetes appeared to enhance the A-cell function also in pregnancy, possibly impairing the 'facilitated anabolism' and stressing the 'accelerated starvation' which are typical of normal pregnancy. Glucagon was confirmed as one possible determinant of the insulin resistance seen in diabetic pregnancy.

Gastro-entero-pancreatic hormones in amniotic fluid from normal and diabetic pregnant women

Clinical applications of analyses of hormones in amniotic fluid (AF) have recently been increased. In diabetic pregnancy, determinations of insulin and C-peptide in AF have been suggested as good indicators of the status of the foetus. We have investigated the pancreatic alpha and beta cell function by measuring insulin (IRI), C-peptide (CPR), glucagon (IRG), somatostatin (SLI), and gastric inhibitory polypeptide (GIP) in amniotic fluid collected during basal conditions or 2 h after an arginine test in 92 diabetic and 32 non-diabetic pregnant women. During basal conditions, in diabetic pregnant women, IRI, CPR and the insulin: glucagon molar ratio (I/G) were all significantly higher while amniotic fluid-IRG was significantly lower than in the controls. After arginine stimulation, IRI increased in AF of the diabetic pregnant women but not in AF of the controls while no differences were observed in AF-GIP and AF-SLI concentrations. Higher IRI and CPR, as well as lower IRG values were significantly related to poor maternal metabolic control. The occurrence of neonatal morbidity including macrosomia was significantly associated with increased AF, IRI and CPR concentrations after an arginine challenge and these factors were the most sensitive predictors of neonatal morbidity in infants of diabetic mothers. Increased AF glucose concentrations and I/G ratios were related to neonatal hypoglycaemia; jaundice and respiratory distress syndrome were associated to low concentrations of SF-IRG.

Developmental aspects of the offspring of diabetic mothers

This study examined the effect of some maternal factors on the pre- and postnatal development of a group of infants of diabetic mothers (IDMs). Body weight, length and head circumference were measured at birth and at 3, 6, 12, 24, 36, and 48 months of age. No differences were observed in pre- and postterm growth when IDMs were subdivided according to the maternal White class or pregnancy complications. Poor metabolic control during pregnancy resulted in excessive and abnormal prenatal growth; the fetal weight increased progressively during the last 3 weeks of gestation, while little or no increase was observed in fetal length or the head circumference which at 37 weeks both were already higher than (length) or similar to (head circumference) those of normal babies at term. Children of mothers with poor metabolic control during pregnancy showed significantly higher values for weight and weight/height ratio in infancy than children of well controlled mothers. Female offspring contributed most to the differences.

Treatment of diabetic pregnant women with monocomponent insulins

Very little immunological research has been undertaken in pregnant diabetic women in relation to insulin therapy. We investigated the relations between treatment with insulins of varied immunogenic character and the presence of immune factors such as insulin antibodies, immune complexes and insulin antiinsulin complexes as well as some maternal and neonatal complications of diabetic pregnancy. 128 insulin treated diabetic pregnant women and 121 of their newborns were included in the study. The incidence of insulin antibodies, immune complexes and insulin antiinsulin complexes was lower in patients treated with highly purified insulins than in those treated with conventional insulins. The insulin antibody levels were significantly related to the occurrence of maternal and neonatal morbidity. The presence of insulin antiinsulin complexes in the cord blood of infants of diabetic mothers was related to the presence of these complexes in their mothers. Our results seem to indicate that the use of highly purified insulin could favour the outcome of diabetic pregnancy.

Relationship between ultrasound findings in pregnancy and neonatal morbidity

In 142 diabetic pregnancies fetal biparietal diameter (BPD), transverse abdominal diameter (TAD) and abdominal circumference (AC) were estimated by means of serial ultrasound examinations. An accurate evaluation of fetal growth was obtained in 85% of the cases. AC was found to have the highest degree of reliability in predicting macrosomia (71%) followed by TAD (60%) and BPD (17%). Placental morphology was estimated at the last scanning before delivery in 85 of the patients. In pregnancies resulting in macrosomic infants the placental maturation seemed to be retarded. In 26 patients a third trimester amniocentesis was performed. A mature (grade III) placenta was always associated with a lecithin-sphingomyelin (L/S) ratio greater than 2, indicating fetal lung maturity but there was no constant relation between placental maturity and the L/S ratio. In conclusion, ultrasound examination during diabetic pregnancy offers valuable information concerning the prenatal diagnosis of macrosomia and could serve as a guidance in the determination of the optimal time and route of delivery. The grading of placental maturity might help to identify fetuses at risk, but further studies in this area are needed before final conclusions can be drawn.

First trimester monitoring of a pregnancy at risk for glucose phosphate isomerase deficiency

First trimester prenatal diagnosis was offered to the mother of a child affected by severe haemolytic anaemia due to glucose phosphate isomerase (GPI) deficiency. The mutant enzyme was characterized by an increased thermal lability. Both parents had 50 per cent normal red cell GPI activity. We have shown that the homozygous and heterozygous genotypes can be clearly distinguished from each other and controls by combinations of the measurement of enzyme activity and enzyme thermal lability. Examination of trophoblast cells obtained at 9 weeks of gestation led to the diagnosis of a GPI heterozygous fetus. The result was confirmed by analysis on uncultured and cultured amniotic fluid cells sampled at 16 weeks and by red blood cell studies of the healthy newborn. Prenatal diagnosis of GPI deficiency is indicated in families with previous cases resulting in severe haemolysis and mainly with the conservative view of arranging appropriate therapeutic measures for affected fetuses.

Sera from diabetic pregnant women contain reduced titres of inhibiting factors on killer cell activity

The presence of Fc-receptor-blocking factors in the sera of normal and insulin-dependent diabetic pregnant women was investigated by means of an antibody-dependent cell-mediated cytotoxicity assay. Sera from normal pregnant women induced a significant depression of antibody dependent cell-mediated cytotoxicity when compared with sera from normal and diabetic non-pregnant women (p less than 0.0001; p less than 0.002, respectively). The effect of sera from diabetic pregnant women, however, was not different from that observed with sera from normal and diabetic non-pregnant women. Thus, we confirm the presence of Fc-receptor-blocking factors in the sera of normal pregnant women. The higher cytotoxicity levels measured in the presence of sera from pregnant women with insulin-dependent diabetes suggests that the titres of such factors are reduced in this condition.

Familial paracentric inversion of chromosome 15 (q15q24)

A paracentric inversion of chromosome 15 was observed in the father of two infants who died 29 days and 24 hours, respectively, after birth. The same inversion was found in two sisters of the proband.

Prenatal prediction of duplication 10q24 leads to qter by gene dosage of GOT1 on uncultured amniotic cells

Glutamic-oxaloacetic transaminase (GOT1) gene dosage studies were performed on uncultured amniotic cells from a fetus at risk for duplication/deficiency of 10q24 leads to qter, due to maternal translocation t(9;10)(p24;q24). Previous investigations in the same pedigree had shown triplex dosage effect of GOT1 on red blood cells of a 10q24 leads to qter trisomic fetus monitored by midtrimester amniocentesis. In the present pregnancy, the GOT1 activity of amniotic cells exhibited a triplex gene dosage, suggesting duplication of region 10q24 leads to qter in the fetus. The biochemical prediction was confirmed two weeks later by cytogenetic analysis.

Decrease of thyroid antibodies during pregnancy

The behavior of serum anti-thyroglobulin (Abs-Tg) and antimicrosomal antibodies (Abs-Mc) was examined during and after normal pregnancies. The antibodies titer decreases as pregnancy progresses; they cross the placenta and are present in the fetal serum. Infants' thyroid function is not affected by this transplacentar transfer. The Abs-Tg titer increases again after delivery.