Inter-observer agreement of the Wagner, University of Texas and PEDIS classification systems for the diabetic foot syndrome.

BACKGROUND: The aim of this cohort study was to assess the inter-observer agreement of three diabetic foot classification systems: the Wagner, the University of Texas and the PEDIS. METHODS: We included 250 consecutive patients diagnosed of diabetic foot syndrome in 2009-2013. Wound scores were recorded at admission and a reevaluation was performed simultaneously or 24h later by a different evaluator. Demographical, laboratory data and associated risk factors were obtained from the patients' medical records. RESULTS: The Kappa coefficient showed a moderate inter-observer agreement between the first evaluation and the reevaluation for Wagner scale (Kappa=0.55; 95% CI: 0.507-0.593), University of Texas scale (Kappa=0.513; 95% CI: 0.463-0.563) and for PEDIS scale (Kappa=0.574; 95% CI: 0.522-0.626). CONCLUSIONS: This moderate agreement shows that these scales should not be used alone for management decisions regarding diabetic foot syndrome and should, therefore, be integrated with other clinical data to ensure an adequate handover.

Endovascular Treatment of Complex Carotid-Jugular Fistula.

Inadvertent complications of jugular vein catheterization are not uncommon, however, a persistent symptomatic carotid-jugular fistula has been rarely reported. A 72-year-old male with infected surgical wound after coxofemoral disarticulation for sarcoma presented with symptoms of acute right heart failure. A fistula between the right common carotid artery (CCA) and the internal jugular vein was demonstrated on Doppler ultrasound and confirmed on computed tomography angiogram. Catheterization of the right CCA seemed not possible using a conventional femoral approach due to the tortuosity and elongation of the brachiocephalic artery. A small incision in the right temporal area was used to access the superficial temporal artery and a wire was advanced retrograde into the aorta where it was snared from below, allowing for successful treatment of the fistula with a covered stent. This alternative technique may facilitate safe and stable carotid artery stenting even in patients with a severely tortuous access route due to atherosclerotic disease.

Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores / Evaluation of the tissue diffusion capacity of antibiotics in lower limb ischaemia

INTRODUCCIÓN: El objetivo principal del estudio ha sido valorar si la penetración de antibióticos se ve influenciada por la perfusión tisular disminuida en pacientes con isquemia de miembros, reduciendo la concentración alcanzada en tejidos por debajo de los puntos de corte (breakpoints) de la concentración mínima inhibitoria (CMI) de los antimicrobianos utilizados para diferentes patógenos. MÉTODOS: Estudio prospectivo. Se incluyeron candidatos a amputación mayor con isquemia crítica de miembro inferior e infección en tratamiento antibiótico. Se determinaron 3 niveles de perfusión en el miembro inferior, midiendo la presión transcutánea de oxígeno (TcPO2). Se extrajo una muestra de sangre de vía central así como biopsias de piel, músculo y hueso de cada uno de los niveles de perfusión. Se determinó la concentración del antibiótico mediante HPLC. RESULTADOS: El número total de casos es de 61 (46 pacientes): 6 clindamicina, 9 vancomicina, 8 linezolid, 18 levofloxacino, 9 ceftazidima y 11 meropenem. Se encuentran diferencias estadísticamente significativas entre todos los niveles de TcPO2 (ANOVA, p = 0,000). La concentración en piel de vancomicina, levofloxacino y ceftazidima depende del nivel de perfusión. Vancomicina y levofloxacino difunden peor en hueso que en el resto de tejidos. La concentración de ceftazidima no supera el punto de corte de Pseudomonas aeruginosa en tejidos isquémicos. CONCLUSIONES: Linezolid y meropenem difunden en todos los tejidos independientemente de la perfusión, alcanzando concentraciones superiores a la CMI de los microrganismos diana, asegurando su efectividad en tejidos isquémicos

INTRODUCTION: The aim of the study was to assess whether the penetration of antibiotics is affected by decreased tissue perfusion in patients with limb ischaemia, thus reducing its concentration in tissues below the minimum inhibitory concentration (MIC) breakpoints of antibiotics for different microorganisms. METHODS: rospective study. Candidates for major amputation with critical lower limb ischaemia and an infection on antibiotic treatment, were included. Three levels of perfusion in the lower limb were determined by measuring the transcutaneous oxygen pressure (TcPO2). A central line blood specimen, as well as biopsies of the skin, muscle, and bone, were taken at each perfusion level. The antibiotic concentration was determined using HPLC. RESULTS: The total number of cases was 61 (46 patients): 6 clindamycin, 9 vancomycin, 8 linezolid, 18 levofloxacin, 9 ceftazidime, and 11 meropenem. Statistically significant differences were found in TcPO2 at all levels (ANOVA, P=.000). The vancomycin, levofloxacin and ceftazidime skin concentration depends on perfusion. Vancomycin and levofloxacin diffusion in bone is worse than in other tissues. Ceftazidime concentration does not exceed the MIC breakpoint of Pseudomonas aeruginosa in ischaemic tissues. CONCLUSIONS: Meropenem and linezolid diffuse in all tissues, regardless of perfusion, reaching concentrations above the MIC of the target microorganisms, ensuring its effectiveness in ischaemic tissues

[Evaluation of the tissue diffusion capacity of antibiotics in lower limb ischaemia]. / Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores.

INTRODUCTION: The aim of the study was to assess whether the penetration of antibiotics is affected by decreased tissue perfusion in patients with limb ischaemia, thus reducing its concentration in tissues below the minimum inhibitory concentration (MIC) breakpoints of antibiotics for different microorganisms. METHODS: Prospective study. Candidates for major amputation with critical lower limb ischaemia and an infection on antibiotic treatment, were included. Three levels of perfusion in the lower limb were determined by measuring the transcutaneous oxygen pressure (TcPO2). A central line blood specimen, as well as biopsies of the skin, muscle, and bone, were taken at each perfusion level. The antibiotic concentration was determined using HPLC. RESULTS: The total number of cases was 61 (46 patients): 6 clindamycin, 9 vancomycin, 8 linezolid, 18 levofloxacin, 9 ceftazidime, and 11 meropenem. Statistically significant differences were found in TcPO2 at all levels (ANOVA, P=.000). The vancomycin, levofloxacin and ceftazidime skin concentration depends on perfusion. Vancomycin and levofloxacin diffusion in bone is worse than in other tissues. Ceftazidime concentration does not exceed the MIC breakpoint of Pseudomonas aeruginosa in ischaemic tissues. CONCLUSIONS: Meropenem and linezolid diffuse in all tissues, regardless of perfusion, reaching concentrations above the MIC of the target microorganisms, ensuring its effectiveness in ischaemic tissues.

Clinical and health costs impact of progress in diagnosis and treatment in venous thromboembolic disease: evolution in 15 years.

BACKGROUND: The therapeutic and diagnostic approach in deep vein thrombosis (DVT) has changed enormously in the last two decades with the introduction of ultrasound, low-molecular-weight heparin (LMWH), and premature motion. The aim of this study is to evaluate these changes and analyze their clinical and economic aspects. METHODS: We registered all inpatients with a diagnosis of DVT during 1994 (n=110) and 2009 (n=75) and their sociodemographic and clinical features in a descriptive observational design. We performed a comparison of diagnostic techniques, length of stay, inpatient complications, and costs thus derived for both series, based on 2009 prices, so that we could get comparable results. RESULTS: Ninety-one percent of inpatients in 1994 were diagnosed by venography, whereas, in 2009, the diagnosis was based on clinical features, D-dimer, and ultrasound in 100% of patients. Inpatient treatment went from 7% LMWH in 1994 to 96% in 2009, and as outpatient from 82% acenocumarol to 90.6% LMWH. Complications decreased by 13.3%. Length of stay was 2.7 higher in 1994. Globally, the cost per patient decreased by 63.39%, based primarily on reduced length of stay. CONCLUSIONS: The current diagnostic and therapeutic approach in DVT allows for effective treatment, fewer complications, and a drastic reduction in inpatient costs.