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.

Observational study of the medical management of patients with peripheral artery disease

BACKGROUND

Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification.

METHODS

The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD.

RESULTS

Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained.

CONCLUSION

The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

Intestinal perforation secondary to Salmonella typhi: case report and review of the literature

The case of a young woman presenting with fever, abdominal distention, and diarrhea is presented. While hospitalized, she developed peritonitis, and a laparotomy was performed emergently. Intraoperative and pathologic examinations are highly suggestive of Salmonella typhi as an etiology for her symptoms and eventual perforation. Salmonella enteritis can be a difficult diagnosis to make, but in most cases it is a self-limited disease process. In a minority of cases, multidrug antibiotic therapy may be required secondary to an increasing prevalence of resistant strains. Patients who perforate require prompt operation to limit morbidity and mortality. Outcome is significantly improved in those patients by directed resection of the affected segment of bowel and by aggressive perioperative care.

Mucormycosis after open fracture injury

An 18-year-old woman (a former intravenous drug abuser) sustained open tibial plateau and shaft fractures, followed by cellulitis and a wound infection caused by a Rhizopus species, which is a fungus of the class Mucorales. The patient responded to surgical debridement and a prolonged course of amphotericin B. No lymphocyte abnormality or other host immune defect could be demonstrated in this patient.

Effects of tomato pomace and mixed-vegetable pomace on serum and liver cholesterol in rats

The effects of tomato pomace and mixed-vegetable pomace, vegetable processing by-products, on serum and liver cholesterol were compared against pectin, wheat bran, cellulose, and lignin. Male Sprague-Dawley rats (100 g) were fed high sucrose, semi-purified diets containing basal (0), 5% or 10% of the fiber source and either 0, 0.5% cholesterol or 0.5% cholesterol + 0.125% sodium cholate. After 28 days, there were highly significant differences (P less than 0.001) in serum and liver cholesterols due to fiber source, dietary cholesterol and the interaction. The effect of fiber source level was significant (P less than 0.05) for liver cholesterol only. Pectin groups had serum and liver cholesterol levels lower (P less than 0.05) than the others. At the 10% level, tomato pomace, wheat bran and lignin (Indulin AT) groups had serum cholesterols higher (P less than 0.05) than basal; the mixed-vegetable pomace and cellulose groups were not different from basal. Liver cholesterols of tomato pomace, mixed-vegetable pomace, wheat bran and lignin groups were not different at the 10% level, but were higher than the pectin, cellulose and basal groups (P less than 0.05). In a second experiment, serum cholesterols of rats fed pectin were lower (P less than 0.05) than for those fed cellulose or two types of lignin (Indulin AT, Reax 27).

Spontaneous corneal perforation with expulsion of the lens and retina in a premature infant

This case presents an additional ophthalmological complication in the infant under 1000 gm. The potential relationship of spontaneous corneal perforation suggests the need for extreme care in eye management in these infants.