Nonhealing Leg Ulcer as the Presentation of Sarcoidosis: A Case Report

Chronic leg ulcers (CLUs) are common, with increasing prevalence in the elderly population. Circulatory dysfunctions are responsible for 90% to 95% of all causes, while 5% to 10% of CLUs are associated with underlying chronic systemic disorders. Sarcoidosis is a complex multisystemic disease characterized by noncaseating granulomas affecting mainly the pulmonary system, with cutaneous manifestation in 25% to 30% of cases. However, ulcerative sarcoidosis (US) is a rare form of cutaneous sarcoidosis. Pyoderma gangrenosum (PG) is an uncommon, chronic inflammatory noninfectious skin disease affecting different body parts. The ulcerative form of PG is rarely reported in association with sarcoidosis.We aim to report a 44-year-old female patient with a history of hypertension and varicose veins, presenting with a CLU for more than 18 months. Ulcer tissue biopsy showed noncaseating granuloma with abscess formation suggestive of sarcoidosis; however, PG could not be ruled out. Mediastinal lymph node biopsy was consistent with sarcoidosis. The leg ulcer had complete healing within 4 months by local wound management, negative pressure wound therapy, and split-thickness skin grafting without immunosuppressive treatment to achieve wound healing.

Chronic Limb-Threatening Ischemia in Patients with Type 2 Diabetes: Revascularization Index as a Predictor for Primary Endovascular Intervention Outcome

Purpose

Chronic limb-threatening ischemia in patients with diabetes is associated with a high risk of adverse outcomes. The associated co-morbidities, the heterogeneity of foot presentation and the distribution of atherosclerotic lesions led to the emergence of multiple revascularization strategies and scoring systems to improve management outcomes. This study aimed to introduce a new index, the revascularization index (RI), and to assess its predictive value for the outcomes of primary endovascular intervention in patients with type 2 diabetes presenting with chronic limb-threatening ischemia.

Patients and Methods

A retrospective electronic medical records review was conducted for patients with type 2 diabetes presenting with chronic limb-threatening ischemia managed at King Abdullah University Hospital by primary endovascular interventions between January 2014 and August 2019. The RI was analyzed for its predictive value for the treatment outcomes.

Results

A total of 187 patients were included in this study, with a major lower limb amputation rate of 19.3%. The performance of the RI was excellent in predicting secondary revascularization (AUC = 0.80, 95% CI: 0.73-0.86, p-value < 0.001), good to predict major amputation (AUC = 0.76, 95% CI: 0.67-0.85, p-value = 0.047), and poor in predicting death (AUC = 0.46, 95% CI: 0.40-0.55, p-value = 0.398). RI of <1.21 was significantly associated with a higher risk of major lower limb amputation (HR = 5.8, 95% CI: 1.25-26.97, p-value < 0.025), and RI of < 1.3 was associated with a higher risk for secondary revascularization.

Conclusion

The RI can be used to predict major adverse lower limb events (MALE). It might be used as a guide for the extent of endovascular interventions for diabetic chronic limb-threatening ischemia with multi-level outflow atherosclerotic disease.

Chronic Contained Rupture of the Abdominal Aortic Aneurysm

Background

The most lethal complication of the abdominal aortic aneurysm (AAA) is rupture (rAAA). A triad of abdominal or back pain, a pulsating mass in the abdomen, and decrease in blood pressure is mostly diagnostic. However, this presentation may not be complete due to either an impalpable aneurysm or atypical symptoms which leads to difficulties in diagnosis and delayed management. Chronic contained rupture of AAA (CCR-AAA) is a rare but well-recognized condition. Its diagnosis may be difficult because of the atypical and chronic nature of the symptoms. The aim of this study is to investigate the incidence and to highlight the importance of this less common presentation of rAAA.

Methods

Patients who presented to King Abdullah University Hospital (KAUH) with infra-renal AAAs (elective and emergency) from January 2014 to April 2021 were prospectively collected. Patients with CCR-AAA were identified and evaluated in terms of demographic data, associated comorbidities, presentation, treatments, and outcomes.

Results

A total number of 85 patients were admitted with an infra-renal AAA. Seventeen patients (20.0%) had rAAA, of them only 5 patients (29.4%) were diagnosed with CCR-AAA. CCR-AAAs represent 5.9% of cases with AAA. CCR-AAAs were all in men, with a mean age ± SD of 73.1±8.3. Two patients (40.0%) had abdominal pain, 2 patients (40.0%) had back pain and one patient (10.0%) had no symptoms at the time of diagnosis.

Conclusion

CCR-AAA represents 5.9% of all AAA and 29.4% of rAAA. To prevent this potentially fatal condition, awareness is required especially in old males with abdominal or back pain.

Knowledge of health care workers regarding COVID-19 pandemic response plan; A study from a university affiliated hospital in Jordan

Background

The education and training of healthcare workers (HCWs) about pandemic response plans, infection control protocols (ICP), and precautions are critical for breaking the virus transmission chain. This study aimed to assess the knowledge of HCWs regarding the COVID-19 pandemic response plan and the ICP. Concomitantly, evaluating the effectiveness and impact of institutional measures, policies, and training programs.

Methods

A cross-sectional study using an electronic questionnaire was used to collect data from 267 HCWs at a University-affiliated-hospital during April 2020.

Results

In this study, 90.7% of participants were nurses and 66% were females. 60.3% of participants received specific training about caring for COVID-19 patients while at least 94.3% reviewed the pandemic response plan and ICP for COVID-19. 47.5% and 29.2% of participants provided direct care for suspected or confirmed COVID-19 patients, respectively. Between 85.7% and 100% of the participants answered all items correctly regarding the COVID-19 pandemic response plan, measures, and precautions. Furthermore, the correct answers were above 95% for each item.

Conclusion

HCWs have a high level of knowledge about the COVID-19 pandemic response plan and ICP. Training and disseminating updated plans and protocols in different methods such as an intranet and onsite training in addition to regular methods were very effective.

Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries

Introduction:

Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization.

Methods:

A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality.

Results:

Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality.

Conclusions:

Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.

The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus

AIMS

Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis.

PATIENTS AND METHODS

A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records.

RESULTS

A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%.

CONCLUSION

The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.

Endovascular Treatment for Critical Limb Ischemia in Type II Diabetes Mellitus Involving Femoropopliteal and Infrapopliteal Segments: Revascularization Strategy

Purpose

To determine if further endovascular infrapopliteal angioplasty in combination with femoropopliteal revascularization improves the clinical outcomes regarding major amputation rate, rate of secondary interventions, and mortality in diabetic type-II patients presented with critical lower limb ischemia (CLI).

Patients and Methods

This is a retrospective study in which all type-II diabetic patients with CLI at King Abdullah University Hospital between October 2015 and September 2019 were identified. Patients with concomitant femoropopliteal and infrapopliteal vessels atherosclerotic lesions (total occlusion or more than 50% stenosis) who received successful endovascular treatment were included. Patients were divided into 2 groups. Group-I included patients treated for femoropopliteal segment alone, while Group-II included patients treated for both femoropopliteal and infrapopliteal segments. The outcomes of the two groups were compared regarding major amputation rate, rate of secondary interventions, and mortality. In addition, demographic data, atherosclerotic lesions distributions and cardiovascular risk factors were also collected and analyzed.

Results

In all, 90 patients (65 males and 25 females) with a mean age of 67.5±12 years were included. In Group-I; 44 patients (48.9%) were included (36 males and 8 females) with a mean age of 67±12 years. In group-II; 46 patients (51.1%) were included (29 males and 17 females) with a mean age of 68±13 years. The major amputation rate was higher and statistically significant in Group-I (38.6% vs 17.4%, p-value = 0.034). However, the secondary interventions and the mortality rates showed no statistically significant differences (56.8% vs 39.1%, p-value = 0.139) and (22.7% vs 28.3%, p-value = 0.632), respectively.

Conclusion

Endovascular infrapopliteal angioplasty in combination with femoropopliteal revascularization in diabetic type-II patients with CLI improves the clinical outcome regarding major amputation rate. However, there were no significant differences regarding the rate of secondary interventions and the mortality rate.

Prevalence of positive COVID-19 among asymptomatic health care workers who care patients infected with the novel coronavirus: A retrospective study

Background

Limited information is available about COVID-19 infections among health care workers. Sensitive detection of COVID-19 cases in health care workers is crucial for hospital infection prevention policy, particularly for those who work with vulnerable patients. The aim of this study is to describe the prevalence of positive COVID-19 among asymptomatic health care workers who took care of patients with COVID-19 during the pandemic.

Methods

This retrospective study included all health care workers at King Abdullah University Hospital who take care of patients infected with COVID-19 patients from March 18, 2020 to April 29, 2020. They were tested for COVID-19 infection by use of real-time reverse-transcriptase rRT-PCR on samples from nasopharyngeal swabs.

Results

A total number of 370 health care workers were screened. The majority were nurses followed by physicians and other personnel. This study showed that all asymptomatic health care workers were tested negative for COVID-19Q.

Conclusion

Unexpectedly, the prevalence of positive COVID-19 among asymptomatic health care workers who take care of patients infected with the novel coronavirus was 0%. This result must be cautiously interpreted. Further studies are needed in order to find effective strategy of screening health care workers to insure a safe working environment.

•

The prevalence of positive COVID-19 among asymptomatic HCWs was 0%.

•

The result should not give us a false sense of security.

•

Improvement of surveillance and protection of HCWs is important.

Comparison of postoperative liver function between different dissection techniques during laparoscopic cholecystectomy

Aim:

In this study, we investigated and compared the effect of different types of dissector (Maryland vs Hook) on changes in liver function tests (LFTs) after laparoscopic cholecystectomy.

Patients & methods:

The enrolled patients were divided into two groups. Group A patients underwent dissection by Maryland dissecting forceps, group B by Hook dissecting instrument. LFTs were measured preoperatively and at 1 day and 1 week, postoperatively.

Results:

For both Maryland and Hook dissection, the 1-day postoperative values for total bilirubin, alanine aminotransferase and aspartate aminotransferase were significantly higher than the preoperative values. Also, there were no statistical differences between Hook and Maryland.

Conclusion:

The elevation of LFTs seems to be attributed to other factors.

Laparoscopic cholecystectomy (LC) is an alternative to laparotomy and has become the standard treatment of benign gallbladder diseases. However, it has been noted that (following LC) the serum level of certain liver function tests (LFT) raises markedly in patients who had preoperatively normal LFT. Pneumoperitoneum is the main contributing factor. This is the first study to evaluate the effect of different dissectors on alteration of LFTs after LC. As there were no statistical differences in the variation of LFTs between the Maryland and Hook, it seems that the dissector type has no effect on the alteration of LFTs.

The Effects of Laparoscopic Sleeve Gastrectomy on the Parameters of Leptin Resistance in Obesity

Obesity is a growing public health problem worldwide. Bariatric surgical procedures achieve the most sustainable and efficacious outcomes in the treatment of morbid obesity. However, little is known about the underlying molecular pathways modulated by these surgical interventions. Since leptin resistance is implicated in the pathogenesis of obesity, we herein report the effects of laparoscopic sleeve gastrectomy (LSG) on the serum levels of leptin and leptin receptor, in addition to its overall effect on leptin resistance. This was an interventional and follow-up clinical study. In the first part, patients attending the general surgery outpatient clinics at our university hospital were first stratified according to their Body-Mass Index (BMI) into cases (n = 38) with BMI ≥ 35 who were scheduled to undergo LSG, and controls (n = 75) with a normal BMI. Serum leptin and leptin receptor levels were measured by sandwich ELISA technique. A leptin resistance index was estimated by adjusting leptin to BMI ratio to leptin receptor concentration. In the second part of the study, cases who underwent LSG were followed up one year postoperatively to assess their BMI and serum leptin and leptin receptor levels. Leptin to BMI ratio was significantly higher, while serum leptin receptor was significantly lower, in obese patients compared to controls. This translated into a significantly higher leptin resistance index in obese patients. LSG resulted in a significant reduction of BMI, leptin to BMI ratio, and leptin resistance index, as it significantly increased leptin receptor levels. In conclusion, LSG showed significant decrease in leptin resistance in obese patients after one year. Further studies are needed to determine the clinical impact of this finding on LSG outcomes.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

Aim

To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).

Materials and methods

After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.

Results

A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.

Conclusion

Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.

Nutcracker Syndrome Accompanying With Superior Mesenteric Artery Syndrome: A Case Report

Purpose:

The duodenum and the left renal vein (LRV) occupy the vascular angle made by the superior mesenteric artery (SMA) and the aorta. When the angle becomes too acute, compression of either structure can occur. Although superior mesenteric artery syndrome (SMAS) and renal Nutcracker syndrome (NCS) share the same pathogenesis, concurrent development has rarely been reported.

Case report:

A 38-year-old female patient with a past history of gastrojejunostomy operated 6 years ago due to SMAS. She referred to vascular clinic with sever intermittent left-sided loin pain during the last 6 years. Computed tomography (CT)-angiogram and selective LRV angiogram with pressure gradient confirmed the diagnosis of NCS. She was treated by LRV transposition with uneventful recovery and considerable relief of symptoms.

Conclusions:

NCS accompanying with SMAS is quite unusual. A patient, who first presents with clinical evidence of SMAS, could also simultaneously or sometime thereafter present with NCS and vice versa.

Arteriovenous malformations within jejunal diverticulosis: case report and literature review

Background

Jejunal diverticula are the rarest of all small bowel diverticula. Most patients with jejunal diverticula are asymptomatic. Major complications include diverticulitis, gastrointestinal hemorrhage, intestinal obstruction and perforation. The hemorrhage has been attributed to diverticulitis with ulceration, diverticulosis associated with trauma and irritation disorder. However, only six cases reported the arteriovenous malformations within jejunal diverticulosis to be the cause of hemorrhage.

Case presentation

We present a case of arteriovenous malformations within jejunal diverticulosis in a 68-year-old male presented with lower gastrointestinal bleeding. After admission and stabilization, upper and lower endoscopies were performed without demonstrating the bleeding site. They only revealed clotted and red blood throughout the colon. Technetium-labeled red blood cell bleeding scan, endoscopic capsule, and selective angiography were performed to localize the site of bleeding without significant findings. As the clinical status of the patient deteriorated, exploratory laparotomy was performed urgently. Extensive jejunal saccular pouches were found 10 cm distal to duodenojejunal junction extending 1.6 m distally. Segmental resection was performed with side to side primary anastomosis. Microscopic examination of the specimen revealed many diverticula. He was followed up 2 years after that without complications.

Conclusion

We report yet the seventh case jejunal diverticulosis with the presence of angiodysplasia, in hope of expanding the knowledge of a rare occurrence and increasing the demand for further research about the etiology, clinical impact and treatment of such anomalies coexistence. This case also highlights the importance of considering the diagnosis of AVMs within jejunal diverticulosis in the presence of uncontrollable blood loss in the pre- or intra- operatively diagnosed jejunal diverticulosis and the urgent need for surgical intervention. In addition, the diagnostic tests should be performed close to the bleeding episode.

Risk factors attributed to failure of ultrasound-guided compression for post-cardiac catheterization femoral artery pseudoaneurysms

Background:

Femoral pseudoaneurysm is the most important access site complication following cardiac catheterization. Ultrasound-guided compression repair is a safe and effective therapeutic modality with variable failure rates and risk factors. The aim of this study was to investigate which factors were associated with a higher incidence of ultrasound-guided compression repair failure for post-cardiac catheterization femoral pseudoaneurysm.

Methods:

Data were retrospectively collected from medical records at King Abdullah University Hospital during the period from January 2011 to December 2016. A total of 42 patients with post-cardiac catheterization femoral pseudoaneurysm had attempted ultrasound-guided compression repair. Data regarding patients, procedure and aneurysm-related factors were evaluated by univariate analysis and multivariate logistic regression.

Results:

Ultrasound-guided compression repair failed in 31% of the patients. Patients with body mass index of ⩾28 kg/m², platelet count of ⩽180,000/L, time lag (age of aneurysm) of >48 h following puncture time, aneurysmal neck diameter of ⩾4 mm and communicating tract length of <8 mm were associated with higher rate of ultrasound-guided compression repair failure in the univariate analysis. In the multivariate analysis, time lag (age of aneurysm) > 48 h (odds ratio = 5.7), body mass index ⩾ 28 kg/m² (odds ratio = 7.8), neck diameter > 4 mm (odds ratio = 14.4) and tract length < 8 mm (odds ratio = 18.6) were significantly associated with ultrasound-guided compression repair failure.

Conclusion:

Ultrasound-guided compression repair for patients with post-cardiac catheterization femoral pseudoaneurysm was successful in 69% of the patients. Risk factors for failed ultrasound-guided compression repair were as follows: delayed ultrasound-guided compression repair of >48 h, body mass index ⩾ 28 kg/m², wide neck diameter > 4 mm and short aneurysmal communication tract < 8 mm.

Gender variation in symptomatic peripheral arterial occlusive disease among type-2 diabetic patients

Purpose:

Little is known about the existence of potential gender disparities in peripheral arterial occlusive disease. To our knowledge, this is the first study to analyze differences attributed to gender in type-2 diabetic patients with symptomatic peripheral arterial occlusive disease, with regard to clinical presentations, risk factors and anatomical distributions of atherosclerosis.

Patients and methods:

This study was conducted at King Abdullah University Hospital, Jordan. Medical records of all diabetic (type-2) patients who presented with symptomatic peripheral arterial occlusive disease in the period from January 2012 and November 2017 were reviewed, data were collected retrospectively. In all, 364 patients (282 males and 82 females) were involved. Criteria for diagnosis include the following Ankle-Brachial Index ⩽ 0.9 and intermittent claudication or critical limb ischemia. Risk factors for atherosclerosis (age, smoking and hypertension) and computed tomography-angiogram findings were analyzed using Statistical Package for the Social Sciences. p < 0.05 was considered statistically significant.

Results:

The mean age was higher in females than males (67.61 vs 62.61 years; p = 0.001). Females had greater prevalence of uncontrolled diabetes compared to males (HbA1c 9.07 in females vs 8.51 in males; p = 0.03). High density lipoprotein was higher in females than males (1.02 vs 0.935; p = 0.009). Females presented more with critical limb ischemia than intermittent claudication in comparison with males (p = 0.017). Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion was significantly higher in females than males (p < 0.05). However, involvement of common iliac artery with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females (p = 0.003).

Conclusions:

Clinical presentation, risk factors and anatomical distributions of atherosclerosis among type-2 diabetic patients with symptomatic peripheral arterial occlusive disease are different between males and females. When compared to males, female patients presented more with critical limb ischemia than intermittent claudication. Females showed higher age at presentation, poor control of diabetes mellitus and higher level of high density lipoprotein. Involvement of superficial femoral artery, deep femoral artery and peroneal artery in hemodynamic relevant atherosclerotic lesion were significantly higher in females than males. In contrast, common iliac artery involvement with hemodynamic relevant atherosclerotic lesion was significantly higher in males than females.

Redefined clinical spectra of diabetic foot syndrome

Purpose

The aim of this study was to present the redefined clinical spectra of diabetic foot syndrome (RCS-DFS) and determine whether the RCS-DFS can be used to predict amputations.

Patients and methods

This is a retrospective study of type 2 diabetic patients referred with DFS for management at King Abdullah University Hospital (KAUH) between January 2014 and December 2015. Data collection form and diabetic foot (DF) characteristic chart were used to document the following: demographic data, diabetes-related parameters, DF characteristics, surgical interventions and amputations. The predominant clinical presentations of DF problems (ulcer, sepsis or gangrene) were integrated with the clinical criteria for diabetic foot infection (DFI) diagnosis and classification of Infectious Diseases Association of America (IDSA)/International Working Group on Diabetic Foot (IWGDF) to redefine the clinical spectra of DFS. Related risk characteristics and amputation rate at all levels were compared between the three RCS.

Results

In this study, there were 95 (47.0%) septic DFS (SDFS) patients, 65 (32.2%) ulcerative DFS (UDFS) patients and 42 (20.8%) gangrenous DFS (GDFS) patients. Poor glycemic control (HbA1c >7.5%), hypertension, history of the same foot problems, duration of symptoms, revascularizations and ischemic severity were significantly different between the three RCS. UDFS had the highest rate of limb salvage without amputations (70.8%). GDFS had the highest rate for final toe amputations (52.4%) and major amputations (23.8%). Final minor amputation rate was around 20% for both SDFS and GDFS.

Conclusion

Redefining DFS into ulcerative, septic and gangrenous by integration of the predominant clinical presentation and the clinical criteria for DFI diagnosis and classification of IDSA/IWGDF showed significant differences in amputation rate. Therefore, it can be used clinically to categorize patients with DFS to predict amputations and to help in planning their management. Further prospective studies are suggested to validate these results.

Idiopathic true aneurysm of distal radial artery: case report

INTRODUCTION

The incidence rate of true non-traumatic radial artery aneurysms (RAAs) is low, and very few cases have been described. The majority are traumatic in origin and are iatrogenic pseudo-aneurysms following arterial cannulation. However, other rare causes such as vascular tumors, connective tissue diseases, and occupational injury have also been reported. Only eight cases were reported as idiopathic true RAA. Herein, I describe a case of true idiopathic distal RAA, which was managed by surgical repair.

CASE PRESENTATION

A 61-year-old-man with no significant medical history presented to vascular clinic with complaint of a nontraumatic mass on the volar aspect and radial side of his right wrist for 6 years. Duplex ultrasound and computed tomography angiogram revealed distal RAA. It was managed by open surgical resection with primary end-to-end anastomosis. Histopathological studies revealed true aneurysm of the distal radial artery.

CONCLUSION

True distal RAAs are an extremely rare entity. Unawareness of this condition might lead to inappropriate management with significant morbidity. Surgical management is generally indicated, but the best treatment remains controversial.

Spontaneous internal jugular vein thrombosis as primary presentation of antiphospholipid syndrome: case report

Introduction

Spontaneous and isolated internal jugular vein (IJV) thrombosis is a rare entity, and atypical localization for venous thromboembolism usually occurs after an oropharyngeal infection, cancer, central venous catheter, and ovarian hyperstimulation syndrome. This report describes a case of spontaneous IJV thrombosis leading to neck pain and swelling as a primary manifestation of antiphospholipid (Hughes) syndrome.

Case presentation

A 44-year-old male with no significant past medical history presented with a 1-week duration of right-sided painful neck swelling. Duplex ultrasound and computed tomography angiogram revealed right IJV thrombosis. Hematology studies were normal apart from positive lupus anticoagulant. The patient was managed conservatively with low molecular weight heparin, antibiotics, and close follow-up.

Conclusion

Acute spontaneous IJV thrombosis as a primary presentation of antiphospholipid syndrome is extremely uncommon. We should be aware of the possibility of this condition in the differential diagnosis and management, as long-term anticoagulation is needed.

Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome

PURPOSE

This study was conducted to determine the risk factors of major lower extremity amputations in type 2 diabetic patients referred for hospital care with diabetic foot syndrome.

PATIENTS AND METHODS

This retrospective study involved 225 type 2 diabetic patients referred for management of diabetic foot syndrome at King Abdullah University Hospital in the period between January 2014 and December 2015. A structured customized diabetic foot data collection form with diabetic foot characteristics chart was used for documentation of relevant information, which checks for age, sex, body mass index, smoking, duration of diabetes, diabetic control therapy, associated hypertension, cardiac diseases, stroke, chronic renal impairment, renal replacement therapy (hem-dialysis), and history of diabetes-related complication in both feet prior to the study period. The predictors for major lower limb amputations were compared between groups using chi-square test, and binary logistic regression was used to determine the factors associated with major amputation.

RESULTS

Twenty-seven limbs underwent major amputations with an overall rate of major amputation of 11.6%. The following predictors were found to be associated with the higher incidence of major lower limb amputations: duration of diabetes ≥15 years, HbA1c ≥8%, patients on insulin, with hypertension, cardiac diseases, chronic renal impairment, stroke, having gangrene, higher number of components, higher Wagner classification, and ischemia. However, the rate did not differ significantly between men and women.

CONCLUSION

Presentation with gangrenous tissue and poor glycemic control are the important risks and significant predictive factors for type 2 diabetes-related major lower limb amputations.

Nutcracker syndrome associated with celiacomesentric trunk anomaly: case report

Introduction

Nutcracker syndrome is a rare disease entity that is caused by entrapment of the left renal vein between the aorta and superior mesenteric artery, usually due to abnormal branching of the superior mesenteric artery from the aorta causing renal venous hypertension. The symptoms vary from asymptomatic hematuria to severe pelvic congestion. Celiacomes-enteric trunk anomaly is a rare variation of splanchnic artery anomaly that occurs when the celiac trunk and superior mesenteric arteries have a common origin from the aorta. A disease involving the rarely encountered celiacomesenteric trunk anomaly is extremely uncommon. To our knowledge, association between nutcracker syndrome and celiacomesentric trunk anomaly has not been reported in the literature.

Case presentation

A 14-year-old boy with no significant past medical history presented with a 3-year painless hematuria. CT-angiogram revealed anterior nutcracker syndrome with celiacomesenteric trunk anomaly. The patient was managed conservatively with close follow-up.

Conclusion

Nutcracker syndrome associated with celiacomesenteric trunk anomaly is extremely uncommon and is a rare cause of hematuria in children. Whether this abnormal anatomy is the cause of nutcracker syndrome or just an association should be investigated. Moreover, awareness of this anatomical variation may help in planning therapeutic options and reducing the chance of surgical iatrogenic injuries.

Spontaneous Anterior Tibial Artery Avulsion and Tibio-Peroneal Trunk Transection Resulting into a Pseudoaneurysm: A Case Report

Patient: Female, 53

Final Diagnosis: Spontaneous non-traumatic anterior tibial artery avulsion and tibio-peroneal trunk transection

Symptoms: Pain

Medication: —

Clinical Procedure: Autogenous popliteal-tibioperoneal trunk bypass

Specialty: Surgery