Gangrene Research Articles

Lower limb ischemia cured by stimulation electrode implantation assisted with microendoscopic discectomy system: A case report

A 58-year-old male patient diagnosed with thromboangiitis obliterans (Fontaine stage IV) was recently treated with microendoscope discectomy system-assisted spinal cord stimulation electrode implantation and cured by department of vascular surgery combined with department of spinal surgery at Peking University People's Hospital. The patient suffered from cold injury to the right foot 14 years ago, which was cold, painful, numb, and then the toe was ulcerated and gangrene. Only the right foot small toe was left. The right foot skin was swollen from the toe to the proximal segment 1 year ago, accompanied by resting pain. Both pain and autologous bone marrow stem cell transplantation were ineffective. The above symptoms were aggravated three months ago, and the pain was severe. The visual analogue score was 10 points. A high amputation of the left lower extremity was performed 30 years ago due to trauma. Physical examination: the bilateral femoral artery was weak, and the right radial artery, posterior tibial artery, and dorsal artery were not touched. Buerger sign (+). Auxiliary examination: angiography of both lower extremities showed complete occlusion of the bilateral external iliac artery and its distal end. The percutaneous oxygen partial pressure was measured to be 30 mmHg on the right side of the iliac crest. The operation was performed under the local anesthesia. After X-ray positioning, the body projection of the lumbar vertebrae 1-2 lamina gap was marked. The skin had a 1.8 cm incision on the caudal side 2 cm from the mark. Then the dilators were used, and the working sleeve was tilted to the lumbar vertebrae 1-2 lamina gap. The microendoscope discectomy system was installed, the electrode was directly placed into the epidural space from the interlamina space under the microendoscope, the vascular surgeon adjusted the position of the electrode in the spinal canal under fluoroscopy, then connected the stimulator, adjusted the current until the patient had the lower limb fever, fixed electrode position, removed the microendoscope discectomy system after hemostasis under the microendoscope, used the guide needle to lead the electrode through the lumbar subcutaneous and then sutured the incision. After the operation, the electrode was connected to the temporary stimulator to stimulate for several minutes, the patient felt numbness in his lower limbs. In less than one hour, the skin temperature of the affected limb increased, and the painkiller could be stopped while sleeping. After 1 week, the skin temperature of the affected limb increased, and the percutaneous oxygen partial pressure of the foot and ankle was 36 mmHg, and the pain improved, and the score was reduced to 2 points. One month after surgery, the patient underwent permanent stimulator implantation. The pain disappeared after 3 months and half year of follow-up, and the score was reduced to 1 point. Microendoscope discectomy system-assisted spinal cord stimulation electrode implantation can complete the operation quickly, safely and effectively, and greatly reduce the number of intraoperative fluoroscopy and reduce the occurrence of complications.

Medical illustration in China: Lam Qua and his Western-style paintings

Lam Qua, a Chinese artist who painted in the Western style, was hired by American ophthalmologist and missionary Peter Parker to paint Parker’s Chinese patients. Most of Lam Qua’s paintings depict patients with rather large tumors located in various areas across the body; there are a few that are also of dermatologic interest. This contribution explores Lam Qua's paintings that depict a cutaneous horn, gangrenous necrosis, and an ulcerating tumor.

A crisis averted: the phaeochromocytoma multisystem crisis with peripheral gangrene.

A crisis averted: the phaeochromocytoma multisystem crisis with peripheral gangrene.

Amputation-free survival, limb symptom alleviation, and reintervention rates after open and endovascular revascularization of femoropopliteal lesions in patients with chronic limb-threatening ischemia

BackgroundThe optimal strategy for revascularization in chronic limb-threatening ischemia (CLTI) is not yet completely known and is still under debate. Endovascular treatment methods predominate despite limited evidence for their advantage. In this concurrent, prospective observational cohort study, we investigated outcomes after open and endovascular revascularization in the femoropopliteal segment for CLTI. MethodsBetween March 2011 and January 2015, there were 190 patients presenting with CLTI with the principal target lesion in the superficial femoral or popliteal segment who underwent endovascular intervention (n = 117) or bypass surgery (n = 73) and were observed prospectively. The choice of revascularization technique was based on international and local guidelines. All patients were observed for 2 years. The primary end point was amputation-free survival (AFS) assessed with Kaplan-Meier estimates; secondary end points included CLTI symptom alleviation rates and reintervention rates. A Cox proportional hazards regression model was used to investigate risk factors for amputation and death. ResultsAFS at 2 years was 59% in the endovascular group and 76% in the bypass group (P = .020). Kaplan-Meier survival analysis confirmed a significant difference in AFS, with mortality rate as the main driver for the observed intergroup AFS difference. In sequential multivariable regression analysis, the observed difference in AFS between the groups favored bypass surgery and remained significant after controlling for covariates of known prognostic importance (hazard ratio, 2.38; 95% confidence interval, 1.14-4.96). At 2 years, a higher proportion of patients subjected to bypass surgery remained free from ischemic rest pain, wounds, and gangrene (65% vs 45%; P = .009). The proportions of patients who underwent reintervention within 2 years were similar in the two groups (38% vs 39%; P = .90), but repeated reinterventions were more frequent in the bypass group. ConclusionsAt 2 years, bypass surgery was associated with higher AFS than endovascular intervention, a finding that could not be explained only by differences in case mix. More patients who had bypass surgery were free from CLTI symptoms at both 1 year and 2 years after revascularization. Reinterventions to maintain patency were equally common after bypass and endovascular intervention.

Improvisation in External Fixation in the Management of Open Extremity Fractures at the University of Port Harcourt Teaching Hospital

Background: External fixation is an important modality in fracture management. It is a method that utilises a combination of pins, wires, clamps and bars or rings. Clamps link a pin or wire to a rod or ring. Sometimes all the components of an external fixator may not be available and there will be need to improvise. Aim: To document the use of a synthetic cast as an improvised external fixator clamp in open fracture management. Methods: A prospective study of consecutive patients with open extremity fractures at the University of Port Harcourt Teaching Hospital, Port Harcourt from October 2012 to October 2017. A synthetic cast was utilised either partially or wholly as clamps for external fixation. The patients’ sociodemographics and information relevant to the injury were obtained. Data was analysed using SPSS version 23. Results: Twenty-eight patients were managed with improvised clamp. Ages ranged from 16 to 47 years, consisting of 18 males and 10 females. Majority resulted from road traffic crashes. There were three humeral and 25 tibial fractures with majority being in the middle third. Majority were Gustilo type IIIB. Twenty-five fractures united although two of these were malunited. One had non-union. Other complications were delayed union and pin tract infection. Two patients had below knee amputation for gangrene. Duration of hospital stay ranged from 26 to 151 days. Follow up period ranged from four to 24 months. Conclusion: Improvisation of synthetic cast for external fixator clamp is effective in acute management of open extremity fractures as well as during subsequent care.

Revascularization limb salvage in chronic limb-threatening ischemia: does open surgery still the best option in the era of endovascular therapy?

Introduction: Chronic limb-threatening ischemia (CLTI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels who suffered from diabetes mellitus type 2, and also associated with physical, as well as psychosocial, consequences such as amputation and depression. Successful revascularization decreases the major amputation rate in patients with CLTI. The efficacy of peripheral bypass grafts and percutaneous transluminal angioplasty in accomplishing limb salvage has been recognized.Case Description: A 42-year-old man came to the RSUZA emergency room with chief complaints claudication above the right thigh and continuous pain (rest pain) at the right lower extremity since 9 months ago. History of finger amputation 2nd, 3rd and 4th right foot since 10 months ago at local hospital, and now there are necrotic wounds on his toes. Patients suffered from type 2 diabetes mellitus and have bad habits such as smoking 3 packs a day all the time. Physical examination has a wound in the lower leg area of more than 10 cm x 8 cm. Right ankle-brachial index (ABI) 0.6 and left ABI 1.3. CT-angiography (CTA) shows infra inguinal type D TASC II classification. A revascularization procedure is performed to salvage the limb with the right femoro-popliteal bypass technique with graft R-SVG and debridement in the right lower leg area so that chronic right lower limb ischemia can be overcome. Systemic heparinization was given post operatively and complaints of pain in the right lower limb begin to disappear. Patient was discharged on the 5th day of treatment with good results.Conclusion: Open surgical bypass continues to be a primary treatment of choice, durable approach in a significant proportion of patients. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5mm diameter.Â

Academic thoughts and related research progress of Guarding field theory in traditional Chinese medical surgery

The Guarding field theory is a unique theoretical system of traditional Chinese medicine for the treatment of surgical diseases such as scabies, sores and gangrene. The hooping in place is the best performance of Guarding field theory. This paperreviews the research progress of Guarding field theory from the aspects of theoretical research, basic research, clinical research in recent years, which shows the connotation of this theory has been expanded. and the generalized concept of Guarding field theory refers to human's healthy Qi, and the field theory has been widely used in treating diseases likemalignant tumor, postoperative anorectal infection, refractory wound to guide clinical treatment. Key words: Surgery (TCM); Guarding field; Malignant tumor; Refractory wound; Postoperative anorectal infection; Literature review

Increase Of Death Malady And Energy Situation Of Trees Of Choosy Aspect During A Frequently Contribute Fagus Beam-Point Stance

We tend to compare the results of observations of bark death malady and defoliation of Fagus absorptive organs administrated in 1998 and 2002. A frequently managed, 53-year previous Fagus beam -point interchange Central European country was chosen as Associate in Nursing object of our analysis. it had been found that death malady had Associate in Nursing increasing trend. The degree of death malady indicated on trees of choosy aspect that area unit the most focus of interest of silvicultural managers was not up to the degree of death malady on the opposite trees within the same stance layer (trees of undiscriminating quality). The defoliation of absorptive organs wasn't influenced by Associate in Nursing increasing trend of death malady increase . it had been confirmed that the strategy of crown thinnings realized with the aim to support the trees of choosy quality, combined with healthful choice, was affordable conjointly in Fagus beam -point stances suffering from gangrene. throughout the analysis amount within the studied stance we tend to detected four tracheomycotic fungi of Nectria (Fr.) Fr. genus and 2 species of imperfect fungi of the genus Cylindrocarpon Wollenw. and fungus Nees.

Descriptive title: The body with chronic limb-threatening ischaemia: A phenomenologically derived understanding.

To explore person and family lifeworld narratives of chronic limb-threatening ischaemia (CLTI) after major amputation has been offered as a treatment option. Chronic limb-threatening ischaemia manifests as ischaemic pain, ulceration and/or gangrene and is receiving heightened attention due to the increasing health system burden from associated complex wounds and hospitalisations for repeat procedures. The patient and family impact of these manifestations is not well-reported: current studies largely seek to measure treatment outcomes. Patient-reported outcome measurements need to be developed but should be underpinned by rigorous qualitative research. Prospective, longitudinal, qualitative design using interpretive phenomenology. The journeys of 19 people with CLTI were explored via 42 semi-structured interviews with 14 patient and 13 family participants. The initial interview was conducted soon after the advice of the need for major amputation, and where amputation followed, participants were invited for a second interview 6months postprocedure. Hermeneutic phenomenological analysis was guided by Merleau-Ponty's philosophy of embodiment. People with embodied CTLI faced an existential crisis due to the catastrophic impact of creeping decay of their flesh and vascular system, relentless pain and a sense of spreading poison from gangrene, infection and drugs, which disrupted the interleaving of the physical and existential body. Consequent to the creeping decay and surgery, participants also experienced shifting body boundaries and an unreliable body. The lifeworld of the patient and family living with CTLI is irrevocably altered through the disruption of a spontaneous and reliable body. This shapes subsequent therapeutic relationships and discourse. People facing CLTI require early patient- and family-centred discussions about the possibility for major amputation and its potential to arrest the further decline of the body and to support the body's existential expression.

A Profile of 23 Indian Patients with Purpura Fulminans: A Retrospective, Descriptive Study.

Background:Purpura fulminans (PF) is a potentially fatal uncommon disorder of intravascular thrombosis and is clinically characterized by rapidly progressive hemorrhagic infarction of the skin.Objective:To describe the clinical feature and outcome of a series of patients with PF.Materials and Methods:A descriptive study based on review of case records was carried out at a tertiary care hospital in Kolkata.Results:Twenty three consecutive cases seen over a period of 8 years were studied. The age range was 4 days to 78 years (mean 35.6 years) with a male to female ratio of 1:2.8. Hemorrhagic rash was the universal presenting symptom. Other major presenting features included pneumonia (26.1%), sudden-onset shock syndrome (21.7%), and urinary tract infection (17.4%). All patients presented with retiform purpura and lesional necrosis and 8 (34.8%) patients had associated peripheral gangrene. Nineteen (82.6%) patients had sepsis and 60.9% patients had vesiculo-bullous lesion. Pneumococcus was the most common (26.1%) pathogenic organism detected. The precise cause of PF could not be detected in two (8.7%) patients. One patient (4.3%) with neonatal PF had protein C deficiency. All patients had evidence of disseminated intravascular coagulation (DIC). One patient had to undergo a below knee surgical amputation and one patient had autoamputation of the digits. Ten (43.5%) patients succumbed to their illness. Seven of the 8 patients who had peripheral gangrene had a fatal outcome.Limitations:Relatively small sample size and a referral bias were a few limitations of the present study.Conclusion:The present study emphasizes that PF is a cutaneous marker of DIC. Association of peripheral gangrene, leukopenia and neutropenia may be the reason for the high mortality rate.

Gangrene: Types, Characteristics and Treatment

Gangrene: Types, Characteristics and Treatment

A Late Presentation of Hand Pain with Skin Changes.

A middle-aged homeless man presented with ongoing left-hand pain and worsening cutaneous phalangeal color changes. On examination, digital ischemia was observed with associated dry gangrene. Doppler examination showed impaired distal arterial flow. Angiography showed irregular digital perfusion. The patient later provided vital information to secure the diagnosis without further clinical workup. This quiz discusses the presentation, differential diagnosis, and treatment of a rare clinical scenario.

Rare cecum pathologies as a cause of acute abdomen in children.

We aimed to present cecum pathologies which are the cause of acute abdomen. Between January 2015 and June 2019, patients that were operated with the diagnosis of acute abdomen and patients with the primary cecum pathologies were evaluated retrospectively. There were eight patients, five males and three females. The mean age was 7.2±2.9 years. Complaints were abdominal pain and vomiting in all patients. Physical examination was consistent with acute abdomen. In the imaging studies, the preliminary diagnosis was considered as two patients had acute appendicitis, two had invagination (one due to Meckel diverticulum and one with mesenteric cyst), two had ileus, one had perforated appendicitis, and one had cecum diverticulum. In surgery, five patients had cecum mass, one had cecum diverticulitis, one had cecum volvulus, and one had inflamed necrotic cecum. All patients underwent cecum resection and ileocolonic anastomosis. Histopathologic examination was resulted as Burkitt's lymphoma in three patients, cecum diverticulum in two, duplication of cecum in one, tuberculosis of cecum in one, and gangrenous necrosis due to volvulus in one patient. The mean follow-up period was 25 months (2 months-4 years). Follow-up was uneventful. Primary cecum pathologies are very rare. This leads to lack of standardization in treatment planning. Considering the patients with malignancy in the series, ileocolonic anastomosis with cecum resection is an adequate and appropriate treatment option in children with primary cecum pathology.

Effect of barbed wire in stump treatment during laparoscopic gangrenous appendectomy

Objective To observe the safety and efficacy of barbed wire in the treatment of root gangrene stump in laparoscopic appendectomy (LA). Methods From January 2016 to January 2018, 42 patients with gangrene in the root of the appendix treated in the First People's Hospital of Tongxiang were selected as study objects, and they were divided into observation group and control group according to the digital table.The observation group (22 cases) was treated with barbed suture, and 20 cases in the control group received body-absorbable suture.The time of suture, operation time, perioperative blood loss, postoperative hospital stay and the incidence of postoperative complications were observed. Results All patients successfully completed the operation without conversion to open surgery.No serious complications occurred during the perioperative period.The preoperative general data, intraoperative bleeding, postoperative hospital stay and postoperative complications between the two groups had no statistically significant differences (all P>0.05). But the suture time[(5.2±1.2) min vs.(7.2±2.6) min], the operation time[(40.1±6.8) min vs.(47.0±8.3 min)] in the observation group were significantly shorter than those in the control group, the differences were statistically significant(t=3.25, 2.99, all P<0.05). All 42 patients were followed up for 3-6 months, with an average follow-up time 4.6 months, without serious complications. Conclusion The barbed wire is safe and effective in the treatment of root gangrene stump in LA.It can shorten the suture time and operation time, lower the level of difficulty of laparoscopic surgery and shorten the learning curve, which is worthy of clinical application. Key words: Appendicitis; Gangrene; Laparoscopy; Barbed wire; Sutures; Suture techniques

Analysis of risk factors for appendicitis caused by incarcerated inguinal hernia in infants

Objective To investigate the risk factors for appendicitis caused by incarcerated inguinal hernia in infants. Methods The retrospective case-control study was conducted. The clinicopathological data of 371 infants with incarcerated inguinal hernia who were admitted to Wuhan Children′s Hospital of Tongji Medical College of Huazhong University of Science and Technology between January 2010 and December 2018 were collected. There were 256 males and 115 females, aged from 0 to 90 days, with an average age of 47 days. Observation indicators: (1) situations of incarcerated hernia; (2) surgical and postoperative recovery; (3) postoperative pathological examination; (4) analysis of risk factors for appendicitis caused by incarcerated inguinal hernia in infants. Measurement data with skewed distribution were described as M (range). Count data were expressed as absolute numbers. Univariate analysis was performed using the chi-square test. Multivariate analysis was performed using the Logistic regression model. Results (1) Situations of incarcerated hernia: of the 371 infants, 264 had bowel incarceration, 102 had ovarian incarceration, 2 had both bilateral ovarian and bowel incarceration, 1 had bilateral ovarian and womb incarcerated into one side, and 2 had Meckel′s diverticulums incarceration. Among the 264 infants with bowel incarceration, 29 had Amyand′s hernia, including 18 of ileocecal incarceration (3 with appendicitis) and 11 of pure appendix incarceration (10 with appendicitis). (2) Surgical and postoperative recovery: of the 29 infants with Amyand′s hernia, 10 underwent laparoscopic hernia sac high ligation and 19 underwent inguinal explorations, relaxation of hernia ring and then hernia sac high ligation. One infant undergoing laparoscopic hernia sac high ligation had pure appendix incarceration. It showed that chorda at the blind end of appendix was connected with the bottom of hernia sac intraoperatively. There was no obvious inflammation in the appendix. Chorda was released, and the appendix was reset into the abdominal cavity. One infant was resected appendix because of its inflammation after ileocecal reduction. Twelve infants undergoing inguinal explorations, relaxation of hernia ring and then hernia sac high ligation had appendicitis (2 of ileocecal incarceration and 10 of pure appendix incarceration), and received appendectomy and hernia sac high ligation. One infant of ileocecal incarceration had postoperative intestinal adhesion, and was found local adhesion and stenosis after abdominal re-exploration. The infant underwent ileocecoectomy followed by ileum-ascending colon anastomosis. All infants recovered well after operation. (3) Postoperative pathological examination: 13 of 29 Amyand′s hernia infants had appendictis, 4 of which were confirmed as appendix suppuration by pathological examination, 2 were appendix suppuration and perforation, and 2 were gangrene. (4) Analysis of risk factors for appendicitis caused by incarcerated inguinal hernia. Results of univariate analysis showed that age, local swelling and erythema of the hemiscrotum, intestinal obstruction, and incarceration location were related factors for the appendicitis caused by incarcerated inguinal hernia (χ2=10.598, 15.603, 9.732, 3.866, P<0.05). Multivariate analysis showed that age less than 28 days, local swelling and erythema of the hemiscrotum, no obvious obstruction were the independant risk factors for appendicitis caused by incarcerated inguinal hernia (odds ratio: 4.537, 35.506, 34.565, 95% confidence interval: 1.014-20.296, 6.447-195.552, 6.370-187.546, P<0.05). Conclusion Age less than 28 days, local swelling and erythema of the hemiscrotum, and no obvious obstruction are independent risk factors for appendicitis caused by incarcerated inguinal hernia. Key words: Hernia; Incarcerated inguinal hernia; Amyand′s hernia; Appendicitis; Neonate; Risk factors

Comparative analysis of different doses of abdominal enhanced CT in the diagnosis of acute appendicitis

Objective To study and compare the diagnostic value of computed tomography(CT) with different doses in acute appendicitis. Methods A total of 90 suspected acute appendicitis patients were selected from January 1, 2015 to December 31, 2017 in the First People's Hospital of Yongkang.Low dose abdominal enhanced CT and standard dose abdominal enhanced CT were performed on patients.The image quality, radiation dose, diagnostic results of different dose abdominal enhanced CT were compared, and the consistency between low dose, standard dose abdominal enhanced CT and pathological diagnosis was analyzed.According to the pathological diagnosis, the patients with acute appendicitis were divided into simple appendicitis, suppurative appendicitis and gangrenous appendicitis. Results There was no statistically significant difference in image quality between low dose and standard dose abdominal enhanced CT(67.78% vs.74.44%, χ2=0.974, P>0.05), but the radiation dose of low dose abdominal enhanced CT [(9.28±3.05) mGy] was lower than that of standard dose [(21.34±7.86)mGy](t=13.570, P 0.05). Through consistency test analysis, it was found that in the diagnosis of acute appendicitis, there was a good consistency between the diagnosis results of low dose and standard dose abdominal enhanced CT and the pathological diagnosis results(Kappa=0.713, 0.782). The diagnostic coincidence rates of low dose abdominal enhanced CT in simple appendicitis, suppurative appendicitis and gangrenous appendicitis were 86.67%, 91.30%, 93.75%, respectively, and there were no statistically significant differences compared with the standard dose (93.33%, 95.65%, 100.00%; χ2=0.741, 0.357, 1.032, all P>0.05). Conclusion The accuracy, sensitivity and specificity of low dose abdominal enhanced CT in the diagnosis of acute appendicitis are comparable to those of standard dose abdominal enhanced CT, but low dose CT can reduce the radiation dose and is more safe. Key words: Appendicitis; Diagnosis; Tomography, X-ray computed; Radiation dosage; Sensitivity; Specificity

Clinical value of abdominal ultrasound in the diagnosis of acute appendicitis

Objective To investigate the clinical value of abdominal ultrasound in the diagnosis of acute appendicitis. Methods From March 2015 to April 2017, 60 patients with acute appendicitis admitted to Hangzhou Hospital of Zhejiang Medical Hospital Health Care Group were selected in this study.All patients were diagnosed by abdominal ultrasound and performed surgical treatment.The clinical value of abdominal ultrasound in the diagnosis of acute appendicitis was analyzed. Results The diagnostic rate of acute simple appendicitis was 94%(33/35). The diagnostic rate of acute gangrene perforated appendicitis was 87%(7/8). The diagnostic rate of abscess classification around the appendix was 100%(5/5). The diagnosis of abdominal gray-scale ultrasound examination was consistent with the results of surgical pathological diagnosis, with an accuracy rate of 93%(56/60). Conclusion In the diagnosis of acute appendicitis, abdominal gray-scale ultrasound examination is a direct, simple, safe and accurate method, which is worthy of extensive promotion and application. Key words: Abdominal gray-scale ultrasound; Acute appendicitis; Clinical value; Ultrasound; Abscess around the appendix; Diagnosis; Diagnosis; Appendicitis; Surgical pathology

English

English

Trans-ileostomy management to Dieulafoy's lesion.

A 64‐year‐old male patient was admitted to our level 1 trauma centre following a high‐speed motorbike crash with thoracic spine, abdominal, bilateral upper and lower extremities injuries. On admission, the trauma series computed tomography (CT) scan did not suggest any acute bowel pathology; however, 24 hours later whilst in theatre for re‐washout of the lower extremity wound and increasing ionotropic requirement, we decided to do a laparotomy. Intraoperative findings were suggestive of ischaemic necrosis of the colon and majority of small bowel. He underwent a subtotal colectomy, along with small bowel resection – the proximal jejunum (100 cm from duodeno‐jejunal junction) and most of the ileum, sparing 20 cm of distal ileum. After 24 hours, as physiology improved, re‐look laparotomy with hand‐sewn jejuno‐ileal anastomosis and end ileostomy was carried out. Histology suggested gangrenous infarction and wall necrosis, and no evidence of embolus or thrombus. Post‐operatively, on day 21, he developed selective trans‐stomal bleeding requiring blood products to maintain haemodynamic stability. Further resection of small bowel was not an option as the patient and the next of kin declined surgery due to reluctance of being on lifelong total parenteral nutrition. Upper gastrointestinal (GI) endoscopy was negative and CT with angiography and delayed venous phase suggested extravasation of contrast (Fig. 1). Interventional radiology managed this with selective coils to the bleeding vessel to avoid ischaemia of the small bowel segment. Unfortunately, 48 h later, he developed further bleeding. At this time, we proceeded to trans‐stomal enteroscopy where a Dieulafoy's lesion (DL) was found 50 cm from the stoma (Fig. 2). Two clips were successfully placed over the DL, no further bleeds were noted and his haemodynamics improved (Fig. 3).

Correlations of the Mechanisms Involved in Diabetes Mellitus, Peripheral Arterial Disease and Gangrene Leading to Amputations-a Retrospective Study Over the Non-traumatic Amputations Performed in the Emergency Clinical County Hospital of Arad Between 2014- 2018

Diabetes mellitus (DM) is, undoubtedly, an important risk factor of peripheral artery disease (PAD), leading to increased and severe complications, as well as for primary or associated dermatological lesions, all of which leading to radical therapeutic measures, as amputations are. DM and its complications have an important effect on life expectancy and quality of life, which can be quantified using disability-adjusted life year (DALY) as universal metric that allows researchers and policymakers to compare very different populations and health conditions across time. In the last five years these medical conditions have had a detrimental effect on the whole Arad County society, with a magnitude of premature deaths (YLL ) of 1,779 years and a value for Years Lost due to Disability (YLD) of 20,795, DALY reaching 22,574. These figures have to change completely the existent DM control measures for better protection of patients� health and improving their quality of life.