Prevalence and risk factors of lower limb amputation in patients with end-stage renal failure on dialysis: a systematic review

Background: Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim: Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods: Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results: Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions: This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis

The effect of patient observation on cranial computed tomography rates in children with minor head trauma

BackgroundManagement of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.MethodsThis was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.ResultsThe cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.ConclusionsEven in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI

External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children

© 2018 The Author(s). Background: Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15. This study aims to validate these guidelines and to compare them with other CDRs. Methods: A large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT. Results: The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs. Conclusion: The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI

A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): The Australasian Paediatric Head Injury Rules Study (APHIRST)

Background: Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting.Methods/design: This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria.Discussion: This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting.Trial registration: The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)- ACTRN12614000463673 (registered 2 May 2014). © 2014 Babl et al.; licensee BioMed Central Ltd

Frosted branch angiitis in an octogenarian with infective endocarditis

Case ReportPURPOSE: To present the difficulties in diagnosing frosted branch angiitis (FBA) in an elderly person, and to present the likely immunogenic association of FBA with alpha-hemolytic streptococci. METHODS: Thorough review of the medical records of an 80-year-old white man diagnosed with FBA. Patient consent was obtained before the writing of this article. RESULTS: Our patient presented with 1 week of decreasing vision and floaters in his right eye and 3 days of floaters in his left eye. Significant medical history included a prosthetic mitral valve. Notable features on examination were bilateral retinal vascular sheathing, with retinal edema and hemorrhage. Preliminary investigations-including a transoesophageal echocardiogram-did not reveal intraocular or systemic infection, autoimmune disease, or underlying malignancy. Idiopathic FBA was unlikely given that the majority of cases had been documented in middle-aged Japanese populations. Thus, we chose to treat our patient empirically for common causes of retinal vasculitis such as viral retinitis. Interestingly, 2 weeks after the diagnosis of FBA, our patient became febrile. He was subsequently diagnosed with infective endocarditis and commenced on intravenous vancomycin (penicillin allergy). Review of his transoesophageal echocardiogram found an oscillating lesion that had been initially missed. Therefore, it is likely that our patient had blood culture-negative endocarditis at the time of presentation. This was further supported by the regression of his ocular disease with intravenous vancomycin. CONCLUSION: We hypothesize that our patient developed FBA as an immunogenic response to Streptococcus viridans and Streptococcus oralis infection. Previous associations between streptococci and FBA have been made. Notably, beta-hemolytic streptococcal antigens are known to cross-react with retinal antigens. However, the implicated pathogens in our patient were alpha-hemolytic. Alpha-hemolytic streptococcal endophthalmitis has been linked to frosted branch response before, but it has never been associated with FBA through an immunogenic pathway. Therefore, it is important to note that idiopathic FBA can be associated with infective endocarditis and alpha-hemolytic streptococcal infections. Furthermore, FBA in elderly patients needs thorough evaluation to rule out systemic causes.Neharika Sharma, Sumu Simon, Graham Fraenkel, Jagjit Gilhotr

Worldwide prevalence of lower limb amputation in renal dialysis patients: a systematic review \ud

Background/Aims: Renal dialysis has recently been identified as a risk factor for lower limb amputation (LLA) however, exact rates are not known. \ud \ud Methods: A systematic review of existing literature investigating the prevalence of LLA in subjects that had end-stage renal failure (ESRF) and were on renal dialysis was conducted. A systematic literature search using the MeSH terms 'diabetes' AND 'amputations' AND 'renal dialysis' was conducted in PUBMED, Medline, Cochrane reviews and Google Scholar database for full text articles published in English from July 2003 to July 2013. \ud \ud Results: A total of 6 full text published studies conducted worldwide were included in this systematic review, 5 of which included patients on haemodialysis alone and one on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputations in the renal failure cohort varied from 1.72% in Japan to 13.4% in Canada. Five out of the 6 studies identified presence of diabetes mellitus as the leading risk factor for amputation (p<0.05) in renal dialysis patients. Other risk factors identified were: high HbA1c, high c-reactive protein and low serum albumin. \ud \ud Conclusions: This review demonstrates high prevalence of LLAs in patients with ESRF receiving dialysis therapy. It has also identified the closely associated risk factors with the adverse outcome of amputation, the most important one being the presence of diabetes mellitus

Prevalence and risk factors of lower limb amputation amongst diabetic foot ulcer patients at the Townsville Hospital

Background/Aims: Diabetic foot ulcers (DFUs) are common amongst diabetic patients, occurring at a lifetime incidence of up to 15%. Lower limb amputation (LLA) is considered a frequent outcome, yet there is no local literature on the rates of LLA amongst DFUs patients in the diabetic population of North Queensland. The aim of this study is to find the prevalence of and risk factors for LLAs amongst DFU patients.\ud \ud Methods: A retrospective pilot study was conducted on patients attending The Townsville Hospital High Risk Foot Clinic (HRFC) between 2010- 2012. Non-parametric analysis and Chi-Square tests were performed using SPSS 20 to identify strongly associated variables with amputation.\ud \ud Results: A total of 106 subjects presented with a DFU at the HRFC during the study period, out of which (n= 43; 41%) underwent a LLA, with a male: female ratio of 1.7:1. The Indigenous subgroup comprised (n= 10; 23%) of the cohort. The mean age of amputation was 69.20 + 11.78 years, with no significant difference between the Indigenous and non-Indigenous cohorts. Diabetic retinopathy (OR 4.13 [95% CI 1.772-9.628] P = 0.001) and past history of coronary artery bypass graft surgery (CABG) (OR 4.0 [95% CI 1.094-14.624] P = 0.028) were factors strongly associated with amputation. Other variables that showed positive associations but fell short of statistical significance included Indigenous background, and history of hypertension, peripheral neuropathy and nephropathy. \ud \ud Conclusions: LLAs occurred in almost half of the DFU cohort at the HRFC, and were found to be closely linked with a history retinopathy and CABG surgery, however further prospective studies are required to confirm our findings

Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review

Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis

Infective keratitis in older patients: a 4 year review, 1998–2002

Background/aim: There are few clinical series in the literature of infective keratitis in the elderly, even though this age group constitutes a significant proportion of those affected by this condition. The authors aimed to determine the incidence and risk factors for infective keratitis in those over 60 years, the causative organisms, antibiotic susceptibilities, visual and tectonic outcome, and surgical intervention rate. Methods: A retrospective review of all patients aged 60 years and over admitted to the Sydney Eye Hospital with a diagnosis of infective keratitis, between September 1998 and December 2002. Results: 190 patients were identified with a mean age of 75.5 (SD 9.6) years (range 60–101). Local risk factors were found in 93.7%, and systemic risk factors in 27.9%. Organisms were cultured in 62.8%, and 7.9% had positive herpes simplex virus (HSV) polymerase chain reaction (PCR). Perforation or severe thinning occurred in 36% overall, but in 80% with positive HSV PCR. Acute surgical intervention was required in 43.7%, with acute penetrating keratoplasty performed in 17.9%, and 8.9% required evisceration. Mean presenting visual acuity was 1.82 (SD 1.24), equivalent to 6/300, excluding 26.3% with vision of light perception (LP) or worse. Mean final visual acuity was 1.24 (SD 1.16), equivalent to 6/100, excluding 19.5% with vision of LP or worse (p<0.0005). Conclusions: The elderly represent a distinct clinical group in the context of microbial keratitis. Predisposing factors are very common, they present with poor vision, have a high complication and surgical intervention rate, and a poor visual outcome compared to younger patients. The microbiological spectrum is similar to younger age groups, except that HSV is more common and may increase the risk of severe corneal thinning and perforation. Most bacterial isolates remain sensitive to currently available antibiotic preparations