Salvage Protocol Research Articles

“Just Pulse it!” Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability.In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Outcome of patients with relapsed or refractory acute myeloid leukemia treated with Mito-FLAG salvage chemotherapy

PurposeCurative intended treatment is challenging in patients with relapsed or refractory acute myeloid leukemia (r/r AML) and associated with a dismal prognosis for long-term survival. Despite novel treatment options, the majority of patients are treated with chemotherapy-based regimens. Although widely used, little data exist on the combination of fludarabine, cytarabine, granulocyte colony stimulating factor (FLAG) and mitoxantrone as salvage strategy for r/r AML.Materials and methodsSixty-six patients receiving Mito-FLAG for r/r AML treated at a German tertiary care center between 2009 and 2019 were analyzed with regard to response rates, survival and safety profile.ResultsOverall response rate was 75.8% with 56.1% of patients achieving complete remission (CR) and 19.7% partial remission (PR). After a median follow-up of 54 months, median overall survival (OS) was 13 months. Patients transitioned to allogeneic hematopoietic stem cell transplantation (alloHSCT) (75.8%) showed a significant improvement in OS with a median OS of 17 (95% CI 8.5–25.4) months vs 3 (95% CI 1.7–4.3) months (p < 0.001). 30- and 60-day mortality rates for all patients after the initial cycle of Mito-FLAG were 4.5% and 7.6%, respectively.ConclusionThe Mito-FLAG salvage protocol represents an effective and feasible treatment regimen for r/r AML. Importantly, a high rate of transition to successful alloHSCT with the aim of long-term disease-free survival has been shown.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

Peripheral arterial disease in patients with renal-diabetic foot ulcers.

To describe the angiographic characteristics of peripheral arterial disease (PAD) in persons with diabetic foot ulcers (DFUs) on dialysis treatment. The study is a retrospective analysis of patients with DFUs and PAD who had been referred to our diabetic foot clinic. All patients had been managed by a pre-set limb salvage protocol including revascularisation of the affected limb. Arterial lesions (stenosis between 50-99% and occlusions) were retrospectively evaluated through angiogram analysis. According to the presence or not of dialysis, patients were divided into two patient groups: renal-diabetic foot (RDF) and diabetic foot (DF). Distribution of PAD and immediate revascularisation outcome (technical revascularisation outcome) for RDF and DF were separately reported and compared. The sample included 239 patients: mean age was 71.8 years; 72.4% were male; 87.4% had type 2 diabetes; mean diabetes duration was 21.4 years; and the mean HbA1c was 63±22mmol/mol. The RDF group compared with the DF group reported higher numbers of vessels affected (n=5±1.6 versus 3.9±1.5, respectively, p<0.0001), greater involvement of the superficial femoral artery (90.2% versus 75.8%, respectively, p=0.003), the tibial-peroneal trunk (53.7% versus 25.5%, respectively, p=0.01), the anterior tibial artery (93.9% versus 80.9%, respectively, p=0.03) and below-the-ankle (BTA) arteries (70.7% versus 35.7%, respectively, p=0.0001). The RDF group showed a higher rate of revascularisation failure in comparison to DF patients (43.9% versus 15.3%, respectively, p<0.0001). BTA arterial disease (odds ratio 9.5; 95% Confidence Interval: 3.5-25.4; p=0.0001) resulted as the only independent predictor of revascularisation failure. In this study, RDF patients showed a widespread distribution of arterial lesions with a higher involvement of foot arteries in comparison with DF patients. BTA arterial disease was found to be an independent predictor of revascularisation failure.

Nivolumab (Nivo) with Azacytidine (AZA) in Patients (pts) with Relapsed Acute Myeloid Leukemia (AML) or Frontline Elderly AML

Nivolumab (Nivo) with Azacytidine (AZA) in Patients (pts) with Relapsed Acute Myeloid Leukemia (AML) or Frontline Elderly AML

A Simple and Convenient Alternative for the Reconstruction of Lower Extremity Soft Tissue Defects due to Different Types of Etiologies: Bipedicled Flap.

Reconstruction of soft tissue defects in the lower extremity due to different etiologies can be a challenging process for surgeons. Compelling reasons for reconstruction include the anatomy of the lower extremity, limited mobility of soft tissues especially the presence of bone, tendon, and neurovascular structures under the defect, and the exposed fixation materials make these defects more complicated. Local fasciocutaneous and muscle flaps are frequently used for the reconstruction of these defects. The patients in our study were with multiple comorbidities such as diabetes mellitus, hypertension, atherosclerosis, and peripheral vascular disease. In this study, with a clinic series consisting of 42 patients (29 male and 13 female), we present a reconstruction with a bipedicled flap as a safe, simple, and efficient reconstructive modality in the treatment of lower extremity soft tissue defects. Except for 1 total flap loss, all defects were successfully reconstructed without any major complications. When reconstruction is performed with a bipedicled flap, the main neurovascular structures are not damaged, free flap and other locoregional flaps can be used as a salvage protocol.

Salvaging the Unsalvageable: Negative Pressure Wound Therapy for Severe Infection of Prosthetic Breast Reconstruction.

Background:Severe infections of implant-based breast reconstruction are challenging to treat. Traditional management is removal of the implant with a further attempt at reconstruction months later once the infection has settled. This study evaluates an alternative management protocol using negative pressure wound therapy with instillation (NPWTi).Methods:Consecutive patients with severe peri-prosthetic infection following breast reconstruction were managed using the Implant Salvage Protocol: removal of the prosthesis with application of a NPWTi dressing, changed every 3 days until a negative culture was obtained. A new prosthesis was then placed in the pocket. Data were collected on patient demographics, microbiological, hospital/operative information, and overall success of salvage. Descriptive statistics were used for analysis.Results:In total, 30 breast prostheses in 28 patients were treated for severe peri-prosthetic infection. Twenty-five (83%) implants were salvaged. Mean time from initial reconstruction surgery to presentation was 49.5 days (median 23, range 7–420). Mean hospital stay was 11.5 days (median 12.0, range 6–22), mean number of returns to the operating theater was 3.7 (median 3.0, range 2–7), and mean number of days to negative culture was 5.2 (median 4.0, range 1–14). The most common organisms were methicillin-sensitive Staphylococcus aureus (n = 9) and Serratia marcescens (n = 4). Most had a tissue expander (n = 24, 80%) or implant (n = 5, 16.7%) placed at the completion of therapy. There was no record of capsular contracture nor recurrent infection during follow-up (mean 39.4 months, range 6–74 months).Conclusion:An estimated 83% of prosthetic breast reconstructions with severe infection were successfully salvaged using NPWTi.

Characteristics and Outcome for Persons with Diabetic Foot Ulcer and No-Option Critical Limb Ischemia.

The study aimed to evaluate clinical and vascular characteristics, as well as outcomes, for diabetic persons with foot ulceration and no-option critical limb ischemia (CLI). The study group included a sample of patients admitted to our diabetic foot unit because of a new diabetic foot ulcer and CLI. All subjects were managed using a limb salvage protocol which includes lower-limb revascularization. According to whether or not the revascularization procedure was a success, patients were respectively divided into two groups: successfully treated CLI patients (ST-CLI) and no-option CLI patients (NO-CLI). Failed revascularization was considered in the case of technical recanalization failure of occluded vessels (inability to overcome the obstruction) and/or absence of arterial flow to the foot. Limb salvage, major amputation, and death after 1 year of follow-up were evaluated and compared between the two groups. Overall, 239 patients were included, 74.9% belonging to ST-CLI and 25.1% to NO-CLI. NO-CLI patients reported more cases of ischemic heart disease (80 vs. 62.1, p = 0.008), heart failure (63.3 vs. 32.4%, p < 0.0001), and end-stage renal disease (ESRD) (60 vs. 25.7%) than ST-CLI patients. In addition, more vessels were affected in the NO-CLI group (5.2 ± 1.6 vs. 4 ± 1.5, p < 0.0001), and there was more involvement of tibio-peroneal trunk (50 vs. 30.2%, p = 0.006), anterior tibial (93.3 vs. 82.7, p = 0.03), posterior tibial (93.3 vs. 73.7%, p = 0.0005), peroneal (70 vs. 48%, p = 0.002), and below-the-ankle arteries (73.3 vs. 39.1%, p < 0.0001) than ST-CLI. The 1 year outcomes for the whole population were 69.9% limb salvage, 10.9% major amputation, and 19.2% death. The outcomes for NO-CLI and ST-CLI were, respectively, as follows: limb salvage (13.8 vs. 73.4%, p < 0.0001), amputation (30 vs. 4.5%, p = 0.0001), and mortality (50 vs. 8.9%, p < 0.0001). NO-CLI patients showed a more severe pattern of peripheral arterial disease (PAD) with distal arterial lesions and worse outcomes than ST-CLI.

The evolution from the two stage to the one stage procedure for biofilm based periprosthetic joint infections (PJI)

A definitive consensus on the optimal limb salvage protocol for infected total joints does not currently exist. Popular, is the two-stage revision which calls for the use of an antibiotic loaded spacer followed by a delayed exchange. Our question is whether single-stage revisions for biofilm based infected arthroplasties results in comparable or possibly better patient outcomes as compared to those reported for two-stage revisions. We retrospectively reviewed 500 cases of one-stage revisions for periprosthetic joint infections (PJI) using dual setup with radical debridement, definitive reconstruction with antibiotic loaded cement and implantation of antibiotic calcium sulfate pellets between the years 2005–2017. The revisions included 351 total knees, 122 hips, 2 hip-femur-knees, 13 shoulders, 10 elbows, and 2 shoulder-humerus-elbows. The patient population had a mean follow-up of 60 months (range: 24 months–14 years) and mean patient age of 61 years old, consisting of 250 males and 250 females. Patient comorbidities were reviewed, classified using McPherson’s staging for PJIs, and compared to the Cierny & Mader classification system. Successful treatment was defined as a joint without recurrence of infection, for a minimum of 2 years, and limb preservation. Based on our findings, one-stage revision of PJIs demonstrates at least as good an infection eradication rate as two-stage revision: 88% vs 85% respectively.

High Response Rates and Promising Outcomes of Patients with Relapsed Ewing Sarcoma, Especially in Adolescents and Young Adults Treated on a Novel Hybrid Salvage Chemotherapy Regimen

Purpose: About 30%-35% of nonmetastatic and 60%-80% of metastatic Ewing Sarcoma (ES) will relapse post-treatment and outcomes after relapse continue to be poor over last several decades. Prognostic factors affecting survival after relapse of ES are also not robustly known. We present outcomes using a novel hybrid salvage protocol of four active chemotherapeutic agents in our cohort of patients after relapse of ES. Methods: This is a retrospective analysis of all consecutive relapsed ES patients treated with curative intent over 4 years (January 2012 to December 2015). All received 12-cycles of hybrid chemotherapy regimen with surgery/radiotherapy done after first 4 cycles. Event-free survival (EFS)/overall survival (OS) estimates were analyzed by Kaplan-Meier product-limit estimator. Cox regression analysis was performed to identify prognostic factors predicting outcome in relapsed ES. Results: Salvage regimen was given to 53/108 relapsed ES patients with the rest having opted for palliation upfront. Median age of the treated patients was 19 years (range: 4-40); male:female ratio was 2.7:1. Median time to first relapse was 18.8 months (range: 2.2-91). While 41/53 patients (77%) completed salvage therapy, 6 (11.3%) progressed and 6 (11.3%) abandoned treatment. Median follow-up of the study cohort is 31 months (range: 4-81). Of the analyzable cohort (n = 47), 30 (64%) had a second relapse or progression on salvage treatment. At last follow-up, 31 patients had died (including one due to toxicity and rest due to disease) and 16 patients were alive (14 with no active disease and 2 with disease). The 4-year EFS and OS are 28% and 37%, respectively, for the entire cohort. While adolescents and young adult patients (AYA) had a better survival (p-0.041), relapsed ES patients with shorter disease-free interval (DFI) (<24 months) had a poorer survival (p-0.004). The type of relapse (local or metastatic or combined) after primary treatment did not affect outcome after salvage therapy. Conclusions: We have used a novel hybrid chemotherapy protocol using four active agents in relapsed ES, which is well tolerated and shows promising results. Older age (≥15 years) and longer DFI (>24 months) portend better survival post-relapse. In our cohort of relapsed ES, AYAs fared better than others and type of relapse after primary treatment did not affect outcome after salvage therapy.

Prevalence, Clinical Aspects and Outcomes in a Large Cohort of Persons with Diabetic Foot Disease: Comparison between Neuropathic and Ischemic Ulcers.

This study aims to evaluate clinical and ulcer characteristics as well the outcomes of patients with diabetic foot ulcers (DFUs). The study group was composed of DFUs patients managed by a limb salvage protocol according to guidance. Clinical and ulcers findings were described, and 1-year outcomes defined as limb salvage, healing, healing time, major amputation and death were compared between neuropathic and ischemic DFUs. One thousand, one hundred and ninety-eight subjects were included; 386 (32.2%) neuropathic and 812 (67.8%) ischemic DFUs. Neuropathic patients were younger (69.5 ± 11.5 vs. 74.5 ± 11.5, p < 0.0001) and reported less cases of nephropathy (22.8 vs. 39.6%, p < 0.0001), ischemic heart disease (22.8 vs. 36.9, p = 0.0004), cerebrovascular disease (8.3 vs. 17.2%, p = 0.002), heart failure (10.1 vs. 24.7%, p = 0.0002) and end-stage-renal-disease (ESRD) (5.4 vs. 27%, p = 0.0001) than ischemic patients; they also showed less cases of large (>5 cm2) (10.3 vs. 22.9%, p = 0.0007), infected (40.4 vs. 55.7%, p = 0.0005) and deep to the bone (22.3 vs. 39.2, p = 0.0002) ulcers, as well less multiple ulcerations (21.8 vs. 32.8%, p = 0.006) than patients with ischemic DFUs. The outcomes for neuropathic and ischemic DFUs were limb salvage (98.4 vs. 82.3%, p < 0.0001), healing (97.3 vs. 79.6%, p < 0.0001), healing time (34.9 vs. 35.6 weeks, p = 0.8), major amputation (0.5 vs. 6.6%, p = 0.0001), death (1.1 vs. 11%, p < 0.0001) respectively. Revascularization failure and ESRD were independent predictors of major amputation, while heart failure and number of co-morbidities (≥5) were independent predictors of death. Ischemic DFUs patients showed more severe clinical and ulcers features as well worse outcomes than neuropathic DFUs patients.

P1044RENAL DIABETIC FOOT: DIFFERENT PATTERNS AND CHARACTERIZATION OF PERIPHERAL ARTERY DISEASE BETWEEN NON-UREMIC AND UREMIC DIABETIC PATIENTS

Abstract Background and Aims The diabetic foot (DF) was traditionally considered a local foot problem due to diabetes; however many observations support the concept that the DF is actually a part of a more complex diabetes related syndrome which includes several long-term complications and co-morbidities. In recent years, an increase in the incidence of ischemic diabetic foot ulcers (DFUs) amongst dialyzed subjects has been observed, going up from approximately 5-10% fifteen years ago to the current rate of approximately 30-35%. Today it is well recognized that end stage renal disease (ESRD) is an independent risk factor for non-healing ulcers and amputation in diabetic subjects. In clinical practice, the presence of foot problems in ESRD diabetic patients is identified as a specific entity termed “renal-diabetic foot”. The aim of this study is to describe the angiographic characteristics of peripheral arterial disease (PAD) in patients with DFUs receiving chronic dialysis treatment. Method The study group was composed of patients with DFUs and PAD who referred to our diabetic foot unit. All patients have been managed with a pre-set limb salvage protocol including revascularization of the affected limb. Arterial lesions (stenosis between 50-99% and occlusions) were retrospectively evaluated through angiogram analysis. According to the presence of dialytic treatment, patients were divided in two subgroups: renal-diabetic foot (RDF) and diabetic foot (DF). Patterns of PAD and immediate revascularization outcome (technical revascularization outcome) for RDF and DF were separately reported and compared Results The demographic and clinical characteristics were reported in Table 1.RDF reported greater number of affected vessels (n= 5±1.6 vs 3.9±1.5, p&amp;lt;0.0001), greater involvement of the superficial femoral artery (90.2 vs 75.8%, p=0.003), tibial-peroneal trunk (53.7 vs 25.5%, p=0.01), anterior tibial artery (93.9 vs 80.9%, p=0.03) and below-the-ankle arteries (70.7 vs 35.7%, p=0.0001) than DF patients. RDF showed a higher rate of revascularization failure (43.9 vs 15.3%, p&amp;lt;0.0001) in comparison to DF patients (Table 2). Below-the-ankle (BTA) arterial disease [OR 9.5 (CI 95% 3.5-25.4) p=0.0001] resulted as the only independent predictor of revascularization failure. Conclusion It was interesting to highlight that the above mentioned findings could be specifically related to the effect of renal disease on the arteries of the lower extremity because the two groups, RDF and DF, did not report any difference in terms of other traditional cardiovascular risk factors (age, smoke, arterial hypertension, dyslipidemia, diabetes duration) which could influence the characteristics of PAD. RDF patients showed a widespread distribution of arterial lesions with a higher involvement of foot arteries in comparison to DF subjects. BTA arterial disease is an independent predictor of revascularization failure.

Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. Therapeutic, III.

Use of Nevelia Dermal-Epidermal Regenerative Template in the Management of Ischemic Diabetic Foot Postsurgical Wounds.

The purpose of this cross-sectional study is evaluate the effectiveness of a dermal-epidermal substitute (DES) composed of 3-dimensional porous matrix of type 1, purified, stabilized, bovin-origin collagen (Nevelia, SYMATESE, Chaponost, France) without a subsequent skin graft in the treatment ischemic postsurgical diabetic foot ulcers. This study group was composed of a sample of consecutive diabetic patients with critical limb ischemia and postsurgical wounds. All patients received a preset limb salvage protocol including the application of the DES, but none received a skin graft. Patients were closely followed until wound healing or different outcome. The outcome measures were healing, nonhealing, major amputation, and death evaluated at 1 and 2 years of follow-up. Forty-one patients were included. The average postsurgical wound area was 69.6 ± 50 cm2. Twenty-one patients (51%) healed; 10 patients (24%) did not heal after 1 year of follow-up; however, all of them achieved a mean ulcer size reduction >50%; 7 patients (17%) were amputees; 3 patients (7.3%) died. In a later follow-up (2 years), wounds in 8 additional patients healed. Successful revascularization was an independent predictor of healing (hazard ratio = 5.1, 95% confidence interval [CI] = 2.5-14-9; P = .0001), the postsurgical ulcer size (>50 cm2) was an independent predictor of nonhealing (hazard ratio = 6.2, 95% CI = 2.1-38.4; P = .0001) while recurrence of critical limb ischemia was an independent predictor of major amputation (odds ratio = 3.4, 95% CI = 1.1-4.5; P = .002). The DES composed of type 1 bovin-origin collagen is useful in the treatment of large postsurgical diabetic foot ulcers, even when the skin graft is not a suitable therapeutic option.

Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy.

Introduction:Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN.Materials and Methods:We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality.Results:The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%.Conclusion:Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers.

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Procalcitonin Is a Prognostic Marker of Hospital Outcomes in Patients with Critical Limb Ischemia and Diabetic Foot Infection.

Aim To evaluate the prognostic role of procalcitonin (PCT) in patients with diabetic foot infection (DFI) and critical limb ischemia (CLI). Materials and Methods The study group was composed of diabetic patients with DFI and CLI. All patients were treated according to a preset limb salvage protocol which includes revascularization, wound debridement, antibiotic therapy, and offloading. Inflammatory markers, including PCT, were evaluated at admission. Only positive values of PCT, greater than 0.5 ng/ml, were considered. Hospital outcomes were categorized as limb salvage (discharge with preserved limb), major amputation (amputation above the ankle), and mortality. Results Eighty-six patients were included. The mean age was 67.3 ± 11.4 years, 80.7% were male, 95.1% had type 2 diabetes, and the mean diabetes duration was 20.5 ± 11.1 with a mean HbA1c of 67 ± 16 mmol/mol. 66/86 (76.8%) of patients had limb salvage, 7/86 (8.1%) had major amputation, and 13/86 (15.1%) died. Patients with positive PCT baseline values in comparison to those with normal values showed a lower rate of limb salvage (30.4 versus 93.6%, p = 0.0001), a higher rate of major amputation (13 versus 6.3%, p = 0.3), and a higher rate of hospital mortality (56.5 versus 0%, p < 0.0001). At the multivariate analysis of independent predictors found at univariate analysis, positive PCT was an independent predictor of major amputation [OR 3.3 (CI 95% 2.0-5.3), p = 0.0001] and mortality [OR 4.1 (CI 95% 2.2-8.3), p < 0.0001]. Discussion Positive PCT at admission increased the risk of major amputation and mortality in hospital patients with DFI and CLI.

Below-the-ankle arterial disease severely impairs the outcomes of diabetic patients with ischemic foot ulcers

AimTo evaluate the impact of below-the-ankle (BTA) arterial disease in people with ischemic diabetic foot ulcers (DFUs). MethodsPatients with ischemic DFUs treated by a pre-set limb salvage protocol including peripheral revascularization were included. They were divided in two groups according to the involvement of BTA arteries (BTA+) or not (BTA−). Not healing, minor amputation, major amputation and mortality have been evaluated as primary outcome. Revascularization failure has been evaluated as secondary outcome. ResultsThe study group was composed of 272 patients, 120 (44.1%) belonging to BTA+ group and 152 (55.9%) to BTA−. After 1 year of follow-up the outcomes for BTA+ and BTA− were respectively: not healing (40.8 vs 17.8%, p < 0.0001), minor amputation (80.8 vs 20.4%, p < 0.0001), major amputation (18.3 vs 6.6%, p = 0.002), mortality (16.7% vs 10.5%, p = 0.001). The rate of revascularization failure was respectively 38.3 vs 11.2%, p < 0.0001. At the multivariate analysis BTA arterial disease resulted an independent predictor of not healing [OR 3.5 (CI 95% 2.3–6.1) p = 0.0001], minor amputation [OR 3.1 (1.5–5.9) p < 0.0001] and revascularization failure [OR 3.5 (1.9–6.3) p = 0.0001]. BTA+ patients with successful BTA revascularization showed lower rate of not healing (37.8 vs 89.1%) p < 0.0001, minor amputation (74.3 vs 91.3%) p = 0.002 and major amputation (8.1 vs 34.8%) p = 0.0003 in comparison to patients with unsuccessful BTA revascularization. ConclusionBTA arterial disease severely impairs the outcomes of diabetics with ischemic foot ulcers. BTA revascularization reduces the rate of not healing, minor and major amputation.

To Pull or Not to Pull: Salvaging Central Line Catheters in Home Parenteral Nutrition.

Catheter-related blood stream infections (CRBSI) pose a significant risk to patients on home parenteral nutrition (HPN). Recurrent loss of catheters can lead to scarring and eventual loss of central access, a potentially fatal situation for patients dependent on HPN. In the past, the standard of care to treat these infections required catheter removal. More recently, several studies have indicated that many CRBSI can be treated without removal of the catheter. Successful treatment without removal can be achieved by intentionally following a catheter salvage protocol. We define this as a previously defined protocol to accurately diagnose CRBSI, identify the organism(s) involved, and effectively treat not only the blood stream infection, but also sterilize the catheter. For patients on HPN with CRBSI, consider attempting line salvage if the patient is not suffering from severe sepsis, other infection related complications, or certain specific infections. Success rates vary depending on the organism causing the infection and the risks; benefits and chance of success should be considered when deciding to attempt line salvage.

High transplant-related mortality associated with haematopoietic stem cell transplantation for paediatric therapy-related acute myeloid leukaemia (t-AML). A study on behalf of the United Kingdom Paediatric Blood and Bone Marrow Transplant Group.

Paediatric therapy-related acute myeloid leukaemia (t-AML) is rare and the outcome is poor. While allogeneic haematopoietic stem cell transplantation (HSCT) is generally the accepted modality of treatment, data regarding salvage chemotherapy, remission induction, conditioning regimens, transplant-related mortality and outcome is scarce. Between 2000 and2016, 36 children with t-AML were treated in seven UK paediatric HSCT centres. The most common salvage protocol for remission induction was FLAG with or without idarubicin and 28 patients were in complete morphological remission prior to BMT. Only 12 patients survived (33%). Transplant-related mortality (TRM) was the leading cause of death.