Squamous cell carcinoma arising in a below-knee stump of a patient with chronic lymphocytic leukemia.

We report a case of localized squamous cell carcinoma arising in the ulceration at the site of a below-knee amputation in a patient with chronic lymphocytic leukemia on treatment with ibrutinib. The patient underwent local excision of the skin and soft tissue with histopathology showing a small focus of well-differentiated squamous cell carcinoma in the specimen. This case highlights the importance of clinical evaluation and histopathological review for underlying malignancy in the setting of amputation stump ulceration.

Association between Insurance Status and Outcomes of Hospitalizations for Necrotizing Soft Tissue Infections.

Background: Lack of insurance is associated with poorer outcomes in hospitalized patients. However, few studies have explored this association in hospitalizations for necrotizing soft tissue infections (NSTIs). This study examined the impact of insurance status on the outcome of NSTI admissions. Methods: All adult hospitalizations for necrotizing fasciitis, gas gangrene, and Fournier gangrene between 2016 and 2018 were examined using the Nationwide Inpatient Sample database. Insurance status was categorized as insured (including Medicare, Medicaid, and Private, including Health maintenance organization (HMO) or uninsured (Self-pay). Outcome measures included mortality rates, limb loss, length of hospital stay, prolonged hospital stay, and critical care admissions. Statistical analysis included weighted sample analysis, chi-square tests, multivariate regression analysis, and negative binomial regression modeling. Results: Approximately 29,705 adult hospitalizations for NSTIs were analyzed. Of these, 57.4% (17,065) were due to necrotizing fasciitis, 22% (6,545) to gas gangrene, and 20.5% (6,095) to Fournier gangrene. Approximately 9.7% (2,875) were uninsured, whereas 70% (26,780) had insurance coverage. Among the insured, Medicare covered 39.6% (10,605), Medicaid 29% (7,775), and private insurance 31.4% (8,400). After adjustments, Medicare insurance was associated with greater odds of mortality (adjusted odds ratio [aOR]: 1.81; 95% confidence interval [CI]: 1.33-2.47; p = 0.001). Medicaid insurance was associated with increased odds of amputation (aOR: 1.81; 95% CI: 1.33-2.47; p < 0.001), whereas private insurance was associated with lower odds of amputation (aOR: 0.70; 95% CI: 0.51-0.97; p = 0.030). Medicaid insurance was associated with greater odds of prolonged hospital stay (aOR: 1.34; 95% CI: 1.09-1.64; p < 0.001). No significant association was observed between the lack of insurance or self-pay and the odds of primary or secondary outcomes. Conclusion: Medicare insurance was correlated with greater odds of mortality, whereas Medicaid insurance was associated with increased odds of amputation and longer hospital stay. Uninsured status was not associated with significant differences in NSTI outcomes.

One-year follow-up of amputation as a curative treatment for body integrity dysphoria: A case report.

Key Clinical Message: Elective amputation as a treatment for Body Integrity Identity Disorder (BIID) or Body Integrity Dysphoria (BID) where noninvasive treatments prove ineffective and the patient's distress is substantial, may permit long-term remission of symptoms at follow-up. Abstract: We present the one-year follow-up post-surgery of an ambidextrous male who sought elective amputation of his left hand's fourth and fifth fingers after an unsuccessful trial of psychotherapy and pharmacotherapy for Body Integrity Dysphoria. He had no psychiatric comorbidities. At one-year follow-up, his dysphoria was still in remission. He exhibited full adaptation in his social and occupational life, demonstrating increased ease in hand use compared to pre-amputation. He reported sleeping well, happiness, good health and continued acceptance by friends and family. This one-year post-surgery follow-up, at 22 years old, underscores the efficacy of amputation as a curative treatment, high patient satisfaction, and the quality of life gained through the procedure.

Neuropsychiatric drugs and a neurophysiological marker as predictors of health-related quality of life in patients with phantom limb pain.

OBJECTIVE: To explore the relationship between sociodemographic, clinical, and neurophysiological variables and health-related quality of life (HR-QOL) of patients with phantom limb pain. METHODS: This is a cross-sectional analysis of a previous clinical trial. Univariate and multivariate linear and logistic regression analyses were used to model the predictors of HR-QOL. We utilized a sequential modeling approach with increasing adjustment levels, controlling for age and sex, and other relevant clinical variables (time since amputation, level of amputation, and pain). HR-QOL was assessed by the SF-36 Health Survey and its eight subdomains. RESULTS: We analyzed baseline data from 92 patients with lower-limb amputations. They were mostly male (63%), 45.2 ± 15.6 years, with a mean time since amputation of 82.7 ± 122.4 months, and an overall SF-36 score of 55.9 ± 21.5. We found an association between intracortical facilitation in the affected hemisphere (ICF), gabapentin usage, and HR-QOL. ICF is a predictor of better HRQOL, whereas gabapentin usage was associated with a poorer HR-QOL, with the main model explaining 13.4% of the variance in the outcome. For the SF-36 subdomains, ICF was also a positive predictor for social functioning, bodily pain, and vitality, while medication usage was associated with lower scores in mental health, general health perception, bodily pain, and vitality. CONCLUSION: We found firsthand two new independent predictors of HR-QOL in individuals with PLP, namely, the neurophysiological metric ICF and gabapentin usage. These results highlight the role of the motor cortex excitability in the HR-QOL and stress the need for treatments that favor the neuroplastic adaptation after amputation, for which ICF may be used as a possible marker.

Utilizing the Frailty Index to Predict Long-term Mortality in Patients Undergoing Major Lower Extremity Amputation.

The 5-factor modified Frailty Index (mFI-5) is a risk-stratification tool utilized to predict complications and mortality following major lower extremity (LE) amputation. However, its prognostic value for long-term mortality is unknown. The study aim was to assess whether a high mFI-5 score relates to long-term mortality following major LE amputation for chronic wounds. Patients ≥60 years who underwent major LE amputation from 2017 to 2021 were retrospectively reviewed. Data regarding demographics, comorbidities, perioperative factors, amputation type, and postoperative complications was collected and mFI-5 was calculated. Survival analysis was performed with Kaplan-Meier curves and differences were assessed with Log-Rank test. A total of 172 patients were identified. Mean age was 70.7 ± 8.0 years. Median time to ambulation was 3.7 months (IQR 4.0). By final follow-up of 17.5 ± 15.9 months, ambulatory rate was 51.7% (n=89), overall mortality 36.0% (n=62), one-year mortality 14.0% (n=24), and three-year mortality 27.9% (n=48). Patients with an mFI-5 of ≥4 (26.7%, n=46) compared with patients with mFI-5 <4 (73.3%, n=126) had a higher rate of prolonged postoperative LOS (34.8% vs. 19.8%, p=0.042), overall mortality (52.2% vs. 30.2%, p=0.008), one-year mortality (23.9% vs. 10.3%, p=0.023), and three-year mortality (45.7% vs. 21.4%, p=0.002). Multivariate analysis demonstrated mFI-5 was an independent predictor of three-year mortality (OR 2.35, p=0.043). At a threshold ≥4, the mFI-5 demonstrated utility in predicting long-term mortality. The value of this prognostic indicator is in its preoperative application of assessing risk of mortality, which should be utilized in conjunction with other measures.

Attenuation of acute postoperative pain and opioid requirement with the use of magnesium sulfate in patients undergoing limb amputations.

OBJECTIVE: To compare the effects of magnesium sulphate on the total dose of intravenous morphine consumption postoperatively following limb amputations along with rescue analgesia requirement, pain scores and side effects. METHODS: This prospective, triple-blinded, randomised controlled study was conducted from October 2021 to May 2022 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised of patients scheduled for limb amputations. They were randomised into 2 equal groups. The anaesthesia protocol was uniform for all patients. Intervention group A was administered 30mg/kg loading dose and 10mg/kg/hr maintenance dose of magnesium sulphate intravenously, while patients in control group B received the same amount of plain isotonic saline. Morphine consumption, including that used for rescue analgesia and patient-controlled analgesia, was measured for 24 hours postoperatively. Numeric rating scale was used for the evaluation of postoperative pain in both groups at 15min, 1h, 2h, at discharge from the post-anaesthesia care unit and at 12h and 24h in the ward. Data was analysed using SPSS 23. RESULTS: Of the 24 patients enrolled, the study was completed by 20(83.33%). There were 10(50%) patients in group A; 8(40%) males and 2(20%) females with mean age 24.8±14.14 years and mean surgery time 130.5±47.86 minutes. There were 10(50%) patients in group B; 8(40%) males and 2(20%) females with mean age 23.2±7.4 years and mean surgery time 117±23.85 minutes (p>0.05). Total morphine used over 24 hours in group A was 16±3.1 mg compared to 29.6±11.2 mg in group B (p<0.05). The time for first use of patient-controlled analgesia after arriving in the postanaesthesia care unit was significantly delayed in group A (72.2±24.95 minutes) compared to that in group B (25±26.68 minutes) (p<0.05). Pain scores were significantly higher in the group B at 15min compared to group A (p<0.05), but not at the rest of the time points (p>0.05). CONCLUSIONS: Intravenous magnesium sulphate proved to be effective in lowering postoperative opioid requirement following limb amputations.

Positioning the Bariatric Amputee: A Case Report.

Traumatic lower limb amputation has been identified as a major risk factor for obesity and metabolic diseases. Surgery in amputees with obesity poses significant complexities with physical and logistical issues of positioning and ergonomics. A 64-year-old gentleman with a history bilateral above knee amputation, obesity, type 2 diabetes mellitus, and obstructive sleep apnea was worked up for bariatric surgery. Due to his amputations, it was unknown whether this would be safe or feasible. In order to ensure this, the patient was brought to the operating room more than a week in advance to trial positioning. The patient was able to be positioned in reverse Trendelenburg with straps across his lower chest and his proximal thighs. Despite obesity being a prevalent and increasing issue facing lower limb amputees, there was relative paucity of literature on the topic. The successful use of this strategy to position a bilateral amputee could be mirrored in future cases.

Longitudinal Alterations in the Control of Lateral Center of Mass Movement During Walking in a Patient With Unilateral Transtibial Amputation: A Case Study.

This study assessed longitudinal changes in the control of the center of mass (CoM) in the lateral direction through gait reacquisition in an individual with unilateral transtibial amputation (UTTA). We examined a male patient with UTTA who could walk on a parallel bar. The marker trajectories and ground reaction forces were measured every two weeks (total: four times) using an optical motion capture system and force plates. After two measurements, the samples were collected without a parallel bar. Subsequently, we evaluated the CoM movement and its segmental coordination through uncontrolled manifold (UCM) analysis. After the second measurement, the walking speed and step length increased. The lateral CoM movements gradually increased toward the prosthetic side until the third measurement. In the fourth measurement, the CoM movement towards the prosthetic side was the smallest and closest to the intact side at the end of the stance phase. In addition, segmental coordination improved significantly. Enhanced gait performance delayed the improvement of segmental coordination for CoM movement in the lateral direction.

Evaluation of the Transfemoral Bone-Implant Interface Properties Using Vibration Analysis.

Evaluating the bone-implant interface (BII) properties of osseointegrated transfemoral (TFA) implants is important for early failure detection and prescribing loads during rehabilitation. The objective of this work is to derive and validate a 1D finite element (FE) model of the Osseointegrated Prosthetic Limb (OPL) TFA system that can: (1) model its dynamic behaviour and (2) extract the BII properties. The model was validated by: (1) comparing the 1D FE formulation to the analytical and 3D FE solutions for a simplified cylinder, (2) comparing the vibration modes of the actual TFA geometry using 1D and 3D FE models, and (3) evaluating the BII properties for three extreme conditions (LOW, INTERMEDIATE, and HIGH) generated using 3D FE and experimental (where the implant was embedded, using different adhesives, in synthetic femurs) signals for additional validation. The modes predicted by the 1D FE model converged to the analytical and the 3D FE solutions for the cylinder. The 1D model also matched the 3D FE solution with a maximum frequency difference of 2.02% for the TFA geometry. Finally, the 1D model extracted the BII stiffness and the system's damping properties for the three conditions generated using the 3D FE simulations and the experimental INTERMEDIATE and HIGH signals. The agreement between the 1D FE and the 3D FE solutions for the TFA geometry indicates that the 1D model captures the system's dynamic behaviour. Distinguishing between the different BII conditions demonstrates the 1D model's potential use for the non-invasive clinical evaluation of the TFA BII properties.

Immersive Virtual Reality in Orthopedic Hand Therapy.

Emerging advances in immersive virtual reality incorporating optical hand-tracking present promising potential for application in orthopedic hand therapy. The system is designed to analyze hand movements, enabling users to "use" their hands virtually in any fabricated setting. This article, supplemented with videos, examines practical applications of immersive virtual reality in routine hand therapy and provides a scientific presentation of the interaction of immersive virtual reality with our physiological and neurological systems. Indications for immersive virtual reality use, critical evaluations and recommendations are comprehensively discussed. Immersive virtual reality has the potential to evolve into a standard treatment modality in orthopedic hand therapy.

Risk of limb amputation and bone fractures with sodium glucose cotransporter-2 inhibitors: a network meta-analysis and meta-regression.

BACKGROUND: Sodium glucose cotransporter-2 inhibitors (SGLT2is) have gained immense attention for a variety of indications. Limb amputations (LA) and fractures were reported in clinical trials. This network meta-analysis and meta-regression were carried out to quantify the risks of these events. RESEARCH DESIGN AND METHODS: Randomized clinical trials evaluating SGLT2is and reporting patients developing LA/fracture were included. Odds ratios (OR) with 95% confidence intervals (95% CI) were the effect estimates. Sub-group analyses and meta-regression analysis were carried out. RESULTS: Ninety articles were included (LA: 36 studies; 96522 participants and fracture: 66 studies; 102,862 participants). An increased risk of LA (OR: 1.2; 95% CI: 1.1, 1.3) was observed. Amongst SGLT2is, canagliflozin was associated with increased risk of LA (OR: 1.6, 95% CI: 1.1, 2.4) while dapagliflozin with fracture (OR: 1.1, 95% CI: 1, 1.2). Sub-group analysis revealed increased risk of LA with an OR of 1.3 among those in the age group of > 40 to < 65, body-mass index of > 30 kg/m2, HbA1c category of > 7%, duration of diabetes of > 10 years, type 2 diabetes, and an OR of 1.2 for SGLT2is administration of > 6 months. CONCLUSIONS: SGLT2is were observed with an increased risk of LA. High- risk categories were identified for which precautions should be recommended in the standard treatment guidelines. PROTOCOL REGISTRATION: Open Science Framework (https://osf.io/5fwyk).

Interleg coordination in free-walking bug Erthesina fullo (Hemiptera: Pentatomidae).

Insects can adapt their walking patterns to complex and varied environments and retain the ability to walk even after significant changes in their physical attributes, such as amputation. Although the interleg coordination of intact insects has been widely described in previous studies, the adaptive walking patterns in free-walking insects with amputation of 1 or more legs are still unclear. The pentatomid bug Erthesina fullo exhibits a tripod gait, when walking freely on horizontal substrates, like many other insects. In this study, amputations were performed on this species to investigate changes in interleg coordination. The walking parameters were analyzed, such as the locations of touchdown and liftoff, cycle period, walking speed, and head displacement of intact and amputated insects. The results show that E. fullo displays adaptive interleg coordination in response to amputations. With 1 amputated leg, bugs changed to a 3-unit gait, whereas with 2 amputated legs they employed a wave gait. These data are helpful in exploring the motion mode control in walking insects and provide the theoretical basis for the gait control strategy of robots, when leg failure occurs.

Limb salvage versus amputation: Experience of a young patient at a university hospital.

Decision-making regarding limb amputation represents a significant clinical challenge, especially when the initial evaluation does not coincide with the criteria established in scales used worldwide, as is the case of the MESS scale. This article presents the case of a 24-year-old female patient who was transferred to a university hospital after a road traffic accident with severe and large lesions in the left lower limb. Despite a poor initial prognosis and in-hospital complications, including multiple surgical procedures and foot drop, a favorable recovery was achieved with complete anatomical salvage of the limb at risk. The multidisciplinary approach and intensive rehabilitation were instrumental in achieving a satisfactory functional recovery. This case highlights the importance of considering factors beyond amputation scale scores, as well as the need for comprehensive care to improve outcomes in patients with complex extremity injuries.

Bone mineral density in osseointegration implant surgery: A review of current studies (Review).

Osseointegration implant (OI) surgery is the latest rehabilitation technology for amputees, where a bone-anchored implant obviates the limitations of traditional socket prostheses. The bone mineral density (BMD) in the periprosthetic and other anatomical regions can be used to assess bone remodelling following OI surgery. Currently, limited studies have used BMD measurements in reporting post-operative OI outcomes and the association between the maintenance of BMD and implant efficacy has remained elusive. This review captured and analysed all studies that have reported the BMD as an objective outcome measure in patients with trans-femoral or trans-tibial OI. The PubMed, Medline, Scopus and Web of Science databases were searched using the terms 'amputation', 'osseointegration' and 'bone mineral density'. A total of 6 studies involving human participants were included for analysis. All studies used dual X-ray absorptiometry and/or X-rays for measuring BMD. Rehabilitation of trans-femoral or trans-tibial amputation using OI may help restore healthy BMD by enabling physiological bone loading. However, there is a low correlation between the BMD around the OI and the success of OI surgery or the risk of periprosthetic fractures. This review summarises the current evidence on BMD assessment in OI for lower limb amputee rehabilitation. Despite the great variability in the results, the available evidence suggests that OI may help restore BMD following surgery. The limited evidence calls for further investigation, as well as the development of a standard BMD measurement protocol.

The incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers: A meta-analysis.

This study analysed the incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers. This study systematically searched both Chinese and English databases, including CNKI, Wanfang, VIP, PubMed, EMBASE and Web of Science, to identify cohort studies related to lower extremity amputation and associated risk factors in patients with diabetic foot ulcers up to October 2023. The patients were stratified based on whether they underwent lower extremity amputation, and relevant data, including basic information, patient characteristics, complications, comorbidities and pertinent laboratory test data, were extracted from the included studies. The literature quality assessment in this study utilized the Newcastle-Ottawa Scale to screen for high-quality literature, resulting in the inclusion of 16 cohort studies, all of which were of at least moderate quality. Meta-analysis of outcome indicators was conducted using the Stata 14.0 software. The results indicate that the overall amputation rate of lower extremities in patients with diabetic foot ulcers is 31% (0.25, 0.38). Among the 16 variables evaluated, gender (male), smoking history, body mass index (BMI), hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels were found to be correlated with the occurrence of lower extremity amputation in patients with diabetic foot ulcers. However, no significant correlation was observed between age, diabetes type, duration of diabetes, stroke, glycosylated haemoglobin, creatinine and total cholesterol levels and lower extremity amputation in patients with diabetic foot ulcers. This meta-analysis indicates that the overall amputation rate in patients with diabetic foot ulcers is 31%. Factors such as gender (male), smoking history, high BMI, hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels are identified as significant risk factors for lower extremity amputation in diabetic foot ulcer patients. These findings suggest that attention should be focused on these risk factors in patients with diabetic foot ulcers to reduce the risk of lower extremity amputation. Therefore, preventive and intervention measures targeting these risk factors are of significant importance in clinical practice. (Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42024497538]).

[Fillet flap transfer as alternative to conventional lower limb amputation]. / Filetlappentransfer als Alternative zu konventionellen Amputationen der unteren Extremität.

BACKGROUND: The fitting of a prosthesis after lower limb amputation is associated with several challenges. Skeletal stump-prosthesis interfaces and selective nerve transfer can partially overcome these but are also associated with new impairments that emphasize the necessity of innovative approaches. The concept of so-called spare part surgery with the use of fillet flaps could play an important role in this respect. OBJECTIVE: An overview of the classical prosthesis-associated discomforts, advantages and disadvantages of treatment strategies and presentation of alternative surgical concepts. MATERIAL AND METHODS: A selective literature search was carried out considering the experiences of the authors and perspectives with respect to the advantages and disadvantages of the surgical treatment options. Furthermore, a clinical case is presented. RESULTS AND CONCLUSION: The transfer of the sole of the foot as a fillet flap to the weight-bearing region of the amputation stump offers a number of benefits, such as creating a fully weight-bearing stump, prevention of neuralgia, preserved sensation and conservation of the body image. As long as the calcaneal region is not impaired, this technique can be performed in amputations below as well as above the knee. The question of whether parts of the bone should be included in the transfer must be individually evaluated for each patient. This approach enables optimization of the residual limb stump for the subsequent fitting of a prosthesis for the patient.

A case series study in new restorative surgery in thumb amputation: The Adiposofaciocutaneous flap technique for distal thumb amputation replantation.

Thumb distal amputation refers to the loss of a portion of the thumb at or near the tip, which can be caused by various injuries such as crush injuries, lacerations, or avulsions. Several surgical methods can be used to repair thumb distal amputations, including composite graft, flap reconstruction, replantation, and amputation revision. In this case report, we describe a successful surgical procedure performed on three healthy men (19, 26, and 44 years old) who suffered a sharp amputation of their left and right hands thumb. In one case initial fixation of the amputated part was performed by a general orthopedic surgeon as a composite graft, two other cases were referred us without any procedure. The procedure involved irrigation and minimal debridement and deepithelializing the amputated part and fixation it with one or two 1.5 mm steinman pins and repairing the nail bed with7/0 absorbable sutures. An adiposofaciocutaneous flap from the index finger was used to cover the pulp of the thumb and the nail bed, while a full-thickness grafts from the same wrist in one case and medial part of ipsilateral arm in others were used to repair the defect on the dorsal side of the index finger. The wound was dressed, and the sutures were removed after two weeks. The base of the flap was detached from the index finger after three weeks, and the kwires were removed after six weeks. The flap and graft were successfully taken, except for a small part of the tip of the thumb. Two years after the operation, in two patients and 3 months in whom was operated recently, all the patient's thumbs had a reasonable shape and length with minimal nail deformity. The use of an index finger based adiposofaciocutaneous flap and full-thickness graft in these cases allowed for successful reconstruction of the thumb and, improving both function and appearance.

The modified albumin-bilirubin (ALBI) grade reflect the fate of limb prognosis in patients with chronic limb threatening ischemia.

OBJECTIVE: To examine the influence of liver function on patients with chronic limb-threatening ischemia (CLTI), we classified patients with CLTI after revascularization according to their modified ALBI grades. METHODS: We retrospectively analyzed single-center data of patients who underwent revascularization for CLTI between 2015 and 2020. Patients were classified with modified albumin-bilirubin (ALBI) grades 1, 2a, and 2b & 3 according to the ALBI score, which was calculated based on serum albumin and total bilirubin levels. The endpoints were the two-year amputation-free survival (AFS) and one-year wound healing rates. RESULTS: We included 190 limbs in 148 patients, and 50, 54, and 86 cases were assigned as grade 1, 2a, and 2b & 3, respectively. The two-year AFS rates for the grade 1, 2a, and 2b & 3 groups were 79 ± 6%, 66% ± 7%, and 45 ± 6%, respectively (P < 0.01). One-year cumulative wound healing rates for grade 1, 2a, and 2b & 3 groups were 68 ± 7%, 69% ± 6%, and 48% ± 5%, respectively (P = 0.01). Multivariate Cox proportional hazard analyses identified age (≥75 years), dependent ambulatory status, and modified ALBI grades 2b & 3 compared with grades 1 and 2a as significant independent predictors of AFS. The dependent ambulatory status and WIfI stage 4 were significant negative predictors of wound healing. CONCLUSIONS: Many patients with CLTI had high modified ALBI grades and impaired liver function classified as modified ALBI grade 2b or 3 is a robust negative predictor of amputation-free survival.

Regional anesthesia is associated with improved mortality and morbidity in patients with congestive heart failure undergoing lower extremity amputation.

OBJECTIVE: While existing literature reports variable results of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing lower extremity amputation (LEA), the effect of RA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this vulnerable population. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005-2022, all patients receiving LEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. The association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis. RESULTS: A total of 5,831 patients (4,779 undergoing GA, 1,052 undergoing RA) with a diagnosis of CHF undergoing LEA were identified. On multivariable logistic regression analysis, RA was associated with lower mortality (aOR 0.79, 95% CI 0.65-0.97), pneumonia (aOR 0.76, 95% CI 0.58-0.99), septic shock (aOR 0.64, 95% CI 0.47-0.88), post-operative blood transfusion (aOR 0.82, 95% CI 0.70-0.97), and 30-day readmission (aOR 0.79, 95% CI 0.64-0.97). CONCLUSION: This study demonstrates that RA for LEA in patients with CHF is associated with decreased morbidity and mortality compared to GA. While further research is needed to confirm this association, RA should be at least considered in CHF patients undergoing LEA when feasible.

Incretin-based therapy and the risk of diabetic foot ulcers and related events.

AIM: To investigate the effect of dipeptidyl peptidase-4 inhibitors (DPP4-Is) and glucagon-like peptide-1 receptor agonists (GLP1-RAs) on diabetic foot ulcer (DFU) and DFU-related outcomes (lower limb amputation [LLA], DFU-related hospitalization and mortality). METHODS: We performed a cohort study with data from the Clinical Practice Research Datalink Aurum database with linkage to hospital data. We included people with type 2 diabetes starting treatment with metformin. Then we propensity score matched new users of DPP4-Is and sulphonylureas (N = 98 770), and new users of GLP1-RAs and insulin (N = 25 422). Cox proportional hazards models estimated the hazard ratios (HRs) for the outcomes. RESULTS: We observed a lower risk of DFU with both DPP4-I use versus sulphonylurea use (HR 0.88, 95% confidence interval [CI]: 0.79-0.97) and GLP1-RA use versus insulin use (HR 0.44, 95% CI: 0.32-0.60) for short-term exposure (≤ 400 days) and HR 0.74 (95% CI: 0.60-0.92) for long-term exposure (>400 days). Furthermore, the risks of hospitalization and mortality were lower with both DPP4-I use and GLP1-RA use. The risk of LLA was lower with GLP1-RA use. The results remained consistent across several sensitivity analyses. CONCLUSIONS: Incretin-based therapy was associated with a lower risk of DFU and DFU-related outcomes. This suggests benefits for the use of this treatment in people at risk of DFU.