Prevalence of Peripheral Arterial Disease in Diabetic Foot Ulcer Patients and its Impact in Limb Salvage

Diabetic foot ulcer syndrome is a common complication of diabetes mellitus. Three main factors contribute to it: neuropathy, vasculopathy, and infection. This study was conducted to evaluate the prevalence of peripheral arterial disease (PAD) in diabetic foot ulcer patients and its impact on limb salvage as an outcome. This prospective cross-sectional study included 392 cases, who were divided according to the presence of PAD into 2 groups; patients with PAD were labeled as PAD +ve (172 cases) and those without PAD were labeled as PAD -ve (22 cases). All cases were clinically assessed, and routine laboratory examinations were ordered. Moreover, duplex ultrasound was done for suspected cases of having PAD by examination. Computed tomography angiography was ordered for patients who are in need of a revascularization procedure. Cases were managed by debridement and/or revascularization. After that, these cases were assessed clinically and radiologically for vascularity and infection and the possibility for amputation was evaluated. Infection was classified using Wagner Classification System, and revascularization was decided according to the TASC II system. The incidence of PAD in cases with diabetic foot ulcer syndrome was 43.87%. No difference was detected between the 2 groups regarding age and gender (P > .05). The prevalence of smoking, hemodialysis, ischemic heart disease (IHD), and hypertension was more significantly higher in cases with PAD (P < .05). Revascularization procedures were only performed in cases that had documented severe PAD or chronic limb-threatening ischemia in addition to foot ulcer and/or infection. With regard to limb salvage, it was more significantly performed in cases without PAD (82.3% vs 48.3% in PAD cases; P < .001). Male gender, smoking, ankle-brachial pressure index, hemodialysis, IHD, neuropathy, HbA1C, PAD, and high Wagner classification were predictors of limb amputation (P < .05). PAD is associated with worse outcomes in diabetic foot ulcer patients. Not only does it constitute a great number among diabetic foot ulcer patients, but it also has a negative impact on limb salvage.

Surgery Is the Last Resort for Huge Scrotal Lymphedema: A Series of Challenging Cases

We aim to provide our surgical techniques, and outcomes of functional scrotal reduction procedures with complete preservation of the genitourinary original anatomy in a simple way without using complicated skin grafting or skin advancement flaps in Patients with huge and long-standing scrotal lymphedema 18 patients ages ranged from 14-65 with a median of 30 years. Functional scrotal and penoscrotal reduction was attained in all cases, without distortion of the genitourinary anatomy and without the need for advancement, rotational or free flaps, maximal scrotal diameter was reduced from median of 61[48-92] cms to a median of 25[21–29] cms (P<0.0001) and remained almost unchanged at the end of the follow up period 26[22-34] cms (P<0.0001). Sexual performance and voiding capacity were improved in all patients, testicular vascularity was unaffected and the Glasgow Benefit Inventory (GBI) for the quality of life showed marked enhancement in the total 55.5[50–72], general 55.5[50–72], social 100[50–100] and physical 16.6[16–33] points subscales. According to our experience, surgery remains the gold standard treatment for management of huge scrotal lymphedema, successful preservation of the genitourinary functions can be attained despite the size in most cases with excellent cosmoses.

Trans-pedal access for endovascular revascularization in complex infra-popliteal lesions in critically ischemic limb: A cohort study

Background

critical limb ischemia is one of the most challenging cases we face nowadays with high risk for amputation, retrograde trans-pedal angioplasty offers an alternative technique after failure of traditional ante-grade angioplasty.

Patients and Methods

96 patients underwent trans-pedal or trans-tibial retrograde angioplasty after failure of the traditional ante-grade angioplasty with the aid of US, 21-gauge needle and 0.018 wire through sheath-less approach as a last chance for revascularization.

Results

clinical success or improvement in 77 cases (80.2%), and in other 19 cases (19.8%) there was no clinical success or improvement. The technical success was achieved in 81 cases with percentage of (84.4%), and not achieved in 15 cases (15.6%) only.

Conclusions

Retrograde Trans-pedal angioplasty is an efficient, safe, and practical procedure with a high technical success and a relatively minimal procedural adverse effect.

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retrograde trans-pedal angioplasty offers an alternative technique after failure of traditional ante-grade angioplasty.

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Retrograde Trans-pedal angioplasty is an efficient, safe, and practical procedure

Outcomes of periarterial sympathectomy in patients with digital ischemia

INTRODUCTION

Digital ischemia with subsequent severe pain and tissue loss is often difficult to treat, with no obvious guidelines or strong evidence in the literature to support a specific treatment modality. Patients who fail medical treatment remain with very limited surgical options due to the difficulty of any intervention in this "no man's land" area of the hand, as described since 1918. Extended distal periarterial sympathectomy is reported as an effective treatment option since the eighties of last century. The procedure entails large incisions and major technical difficulties. In this study, we describe a less invasive approach with very promising results and equally high success rates.

MATERIALS AND METHODS

This was a prospective study. All patients with severe digital ischemia manifesting with bluish discoloration, ulceration, and/or dry gangrene who failed medical treatment underwent distal periarterial sympathectomy for the radial and ulnar arteries, with added digital sympathectomy in very severe cases. Primary endpoints were ulcer healing and improvement in pain scores assessed by Visual Analog Scale pain scoring system. Secondary endpoints included complications and amputation rates.

RESULTS

This study recruited 17 patients between January 2019 and January 2020. The mean follow-up was 14.6 months. The mean age was 33.71 (±SD 13.14) years. 41% were males. 59% suffered from vasculitis, 35% of patients had dry gangrene, and 71% had ulcers. Periarterial radial and ulnar sympathectomy was performed for all cases, with digital sympathectomy for 12 fingers. We had 50% complete ulcer healing within 1 month (p = 0.031), and 100% were completely healed at 6 months (p < 0.001). Pain scores showed significant reductions at 1 (p = 0.001) and 6 months (p < 0.001) of follow-up.

CONCLUSION

Distal periarterial sympathectomy demonstrates high success rates in terms of pain relief and ulcer healing in severe digital ischemia.

Conversion of Arterio-Venous Access of Hemodialysis to Arterio-Arterial Access for Treatment of Venous hypertension with Central Venous Occlusion

This report describes conversion of arterio-venous graft or fistula to arterio-arterial vascular access as a new surgical treatment option for central venous occlusion. It starts with control of the axillary vein and the synthetic graft or superficialized vein proximally, the suture line of venous anastomosis is closed and end-to-side anastomosis of the synthetic graft or vein to the brachial artery (BA) is done, then ligation of the BA distal to the anastomosis is done. Now the blood flow is directed through synthetic graft or vein from proximal to distal BA that can be used as arterio-arterial vascular access for hemodialysis.

Helicobacter pylori infection in patients with metabolic syndrome, with or without nonalcoholic fatty liver disease

Background

Helicobacter pylori (HP) infection is considered a risk factor of GIT diseases, e.g., gastric and duodenal ulcers and gastric carcinomas. It is transmitted through feco/oral route and can be diagnosed by many methods, e.g., stool antigen test (SAT). Metabolic syndrome (MET S) is considered a circle of metabolic derangements that can cause some complications as ischemic changes and heart diseases. Metabolic syndrome may also cause nonalcoholic fatty liver disease (NAFLD) resulting in liver fibrosis, cirrhosis, and HCC.

Results

The study included 300 subjects recruited from Obesity Clinic and Diabetes & Endocrinology Unit, Specialized Medical Hospital, Mansoura University. Two hundred of metabolic syndrome patients were subdivided into two groups according to the presence or absence of NAFLD, in addition to 100 subjects not having metabolic syndrome and served as control group. We found that HP infection is more frequent in MET S with NAFLD patients (73%) than in MET S without NAFLD (47%) with (P value < 0.001) emphasizing that HP infection increases the risk of NAFLD development in patients with MET S.

The study proved that HP infection is associated with increased degree of fibrosis significantly (P value < 0.001) with progression to marked fibrosis which may complicate with NASH with over all predictive value of 75% especially in patients with hyperglycemia.

Conclusions

Our findings show that a circle of metabolic abnormalities seems to be attributed to HP infection in MET S patients increasing the risk of fatty liver and progression to marked fibrosis especially with coexistent hyperglycemia, dyslipidemia, and upper body obesity.

Diagnosis and early eradication of HP infection will help in decreasing metabolic disturbances and possibility of NAFLD, and protect against marked fibrosis progression.

Shear wave elastography of the tibial nerve in healthy subjects

The purpose of this study is to investigate sonoelastographic features of the tibial nerve.The study included 72 tibial nerves in 36 healthy subjects. High resolution ultrasound and Shear wave elastography were used to evaluate the tibial nerve. Cross sectional area and stiffness were measured.The mean cross sectional area of the tibial nerve was 13.4 mm2. The mean shear elastic modulus of the tibial nerve in the short axis was 23.3 kPa. The mean shear elastic modulus of the tibial nerve in long axis was 26.1 kPa. The tibial nerve elastic modulus also showed no correlation with cross sectional area neither in the long axis nor short axis. Age, height, weight, and body mass index showed no correlation with tibial nerve elastic modulus in short or long axes.The elastic modulus of the tibial nerve has been determined in healthy subjects and can serve as a reference for future assessment of polyneuropathy.

Gene polymorphism of transforming growth factor-β1 in Egyptian patients with type 2 diabetes and diabetic nephropathy

Role of the transforming growth factor-β1 (TGF-β1) gene polymorphisms located at codons 10 and 25 in the genetic predisposition to type 2 diabetes (T2D) and in diabetic nephropathy (DN) in Egyptian patients was investigated. A case control study was done for 99 unrelated Egyptian patients with T2D (50 DN(-) and 49 DN(+)) and 98 age- and sex-matched healthy controls. TGF-β1 T869C (codon 10) and G915C (codon 25) polymorphism detection was done by amplification refractory mutation system method. DN(+) patients were younger, with higher body mass index, serum triglycerides, serum creatinine, and lower serum albumin than those in DN(-) patients. Moderate and bad grades of diabetic control were associated with DN (P < 0.001). The TGF-β1 (T869C) C allele, TC and TC + CC genotypes were significantly higher in patients; the T allele and TT genotype were significantly higher in controls (Pc < 0.001). The TGF-β1 TC genotype was associated with DN (Pc < 0.05). Non-significant differences were detected between T2D patients and controls in the frequencies of TGF-β1 (G915C) alleles and genotypes. In conclusion, these preliminary data showed that the TGF-β1 codon 10 C allele, and C allele-containing genotypes may be susceptible, and T allele/TT genotype may be protective factors for T2D and DN(+) complications.