Synovial Cyst of the extensor digitorum superficialis: A case report.

Background: A synovial cyst is a herniation of synovial tissue through a joint capsule, often mistaken for a ganglion cyst. The key distinctions are that synovial cysts have a synovial cell lining, while a ganglion cyst is delineated by dense fibrous connective tissue. Typically found near joints, synovial cysts are associated with conditions like osteoarthritis, prevalent in females aged 20 to 50. We present a rare case of a synovial cyst in the extensor digitorum superficialis of the right hand. Case summary: A 53-year-old Hispanic female visited our hand clinic due to a 3-year history of pain on the back of her right hand. At exploration, a 3 × 3 cm soft tumor was identified. Surgery revealed a clear-yellowish mass within the extensor digitorum superficialis tendon. Following the surgery, synovial cyst was confirmed by pathology and the patient was discharged without complications. Conclusion: This case highlights the rare presentation of an intratendinous synovial cyst and emphasizes the importance of a comprehensive understanding of synovial cysts in the differential diagnosis of hand tumors.

Exploring Variable Approaches in Complex Hernia Repair: A Comprehensive Literature Review.

Surgeons have long grappled with categorizing complex hernias, leading to varied interpretations and fluctuating incidence rates. Complex Abdominal Wall Reconstruction (CAWR) addresses repairs for large hernias, with defined factors including size, previous repairs, mesh placement, infections, and comorbidities. This review explores pivotal surgical techniques for complex hernia repair, starting with Preoperative Progressive Pneumoperitoneum (PPP) and progressing to innovative methods like Botulinum Toxin Type A. Mesh fixation, both open and laparoscopic, plays a crucial role, with synthetic and biological mesh options discussed. Hybrid techniques and the "sandwich" approach are proposed for intricate cases. Each technique presents advantages and limitations, emphasizing the ongoing quest for optimal outcomes.

Synthetic suture tape for medial patellofemoral ligament reconstruction is an effective treatment for complex paediatric patellofemoral instability.

PURPOSE: To assess the outcomes of medial patellofemoral ligament (MPFL) reconstruction using synthetic suture tape in paediatric patients with patellofemoral instability (PFI). METHODS: This ambispective comparative study, conducted from 2014 to 2022, included paediatric patients who underwent MPFL reconstruction with synthetic suture tape and had a minimum follow-up of 1 year. Pre- and postoperative clinical and functional outcomes, patient satisfaction and complications were assessed. RESULTS: The study comprised 22 patients (29 knees), with a median age at surgery of 14.4 years (interquartile range [IQR] 10.9-16.7) and a median follow-up of 46.5 months (24.7-66). Notably, 13 knees (44.8%) had open growth plates at the time of surgery. The cohort included patients with Down syndrome (3 patients), Ehlers-Danlos (2), arthrogryposis (1), generalized joint hypermobility (8) and previous unsuccessful PFI surgeries (8). Concomitant procedures were performed on 16 knees. Postoperatively, improvements were observed in all but one patient, who reported residual pain. There were two other complications: one suture-tape rupture and one surgical wound infection. Functional scores significantly improved: Kujala, +14 points (7-29) (p < 0.001); IKDC, +10.5 points (5.2-25.3) (p < 0.001); Tegner, +2 points (0-4) (p < 0.001); Lysholm, +15 points (0-37.5) (p < 0.001). Most patients achieved excellent outcomes by Crosby-Insall criteria (21 patients, 72.4%) and reported high satisfaction (23 patients, 79.3%). CONCLUSIONS: MPFL reconstruction using synthetic suture tape is a viable and effective treatment for paediatric patients with PFI, particularly for those with connective tissue disorders, generalized joint hypermobility or past surgical failures, significantly enhancing clinical and functional outcomes with an acceptable complication rate. LEVEL OF EVIDENCE: Level IV.

Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients.

INTRODUCTION: Identifying the complexity of palliative care needs is a key aspect of referral to specialized multidisciplinary early palliative care (EPC) teams. The PALCOM scale is an instrument consisting of five multidimensional assessment domains developed in 2018 and validated in 2023 to identify the level of complexity in patients with advanced cancer. (1) Objectives: The main objective of this study was to determine the degree of instability (likelihood of level change or death), health resource consumption and the survival of patients according to the level of palliative complexity assigned at the baseline visit during a 6-month follow-up. (2) Method: An observational, prospective, multicenter study was conducted using pooled data from the development and validation cohort of the PALCOM scale. The main outcome variables were as follows: (a) instability ratio (IR), defined as the probability of level change or death; (b) emergency department visits; (c) days of hospitalization; (d) hospital death; (e) survival. All the variables were analyzed monthly according to the level of complexity assigned at the baseline visit. (3) Results: A total of 607 patients with advanced cancer were enrolled. According to the PALCOM scale, 20% of patients were classified as low complexity, 50% as medium and 30% as high complexity. The overall IR was 45% in the low complexity group, 68% in the medium complexity group and 78% in the high complexity group (p < 0.001). No significant differences in mean monthly emergency department visits (0.2 visits/ patient/month) were observed between the different levels of complexity. The mean number of days spent in hospital per month was 1.5 in the low complexity group, 1.8 in the medium complexity group and 3.2 in the high complexity group (p < 0.001). The likelihood of in-hospital death was significantly higher in the high complexity group (29%) compared to the medium (16%) and low (8%) complexity groups (p < 0.001). Six-month survival was significantly lower in the high complexity group (24%) compared to the medium (37%) and low (57%) complexity groups (p < 0.001). CONCLUSION: According to the PALCOM scale, more complex cases are associated with greater instability and use of hospital resources and lower survival. The data also confirm that the PALCOM scale is a consistent and useful tool for describing complexity profiles, targeting referrals to the EPC and managing the intensity of shared care.

Clinical characterization and detection of subclinical atherosclerosis in subjects with extreme hyperalphalipoproteinemia. / Caracterización clínica y detección de arteriosclerosis subclínica en sujetos con hiperalfalipoproteinemia extrema.

INTRODUCTION AND OBJECTIVES: The association between HDL cholesterol (HDL-C) levels and death from cardiovascular disease follows a U-shaped pattern, increasing at the extremes. The objective of the study was to characterize a sample of subjects with extreme hyperalphalipoproteinemia (HAE). MATERIAL AND METHODS: 53 cases with HAE were recruited, 24 women (HDL-C>135mg/ dL) and 29 men (HDL-C>116mg/ dL). A detailed medical history was taken and questionnaires on adherence to the Mediterranean diet and physical activity were collected. Carotid ultrasounds were performed to detect the presence of suclinical atherosclerosis. RESULTS: The most prevalent cardiovascular risk factor (CVRF) was dyslipidemia (64%) with no significant differences between men and women, unlike hypertension (21% in women, versus 55% in men, p=0.01) and others CVRF, for example, diabetes. 7% of the series had previous cardiovascular disease, women had higher LDL cholesterol (p=0.002) and HDL-C than men (without significant differences). Plaque was detected in 53% of cases, being more prevalent in men. Patients with plaque were older, drank more alcohol and smoked more (p<0.05). CONCLUSIONS: Men had a higher prevalence of CVRF than women, except for dyslipidemia. Subclinical atherosclerosis occurred in more than half of the series. Age, alcohol consumption and smoking were independently associated with the presence of plaque, however, our data do not show a significant influence of HDL-C levels.

Exploring mitochondrial targeting: an innovative fluorescent probe reveals Nernstian potential and partitioning combination.

This study introduces a paradigm-shifting approach to optimize mitochondrial targeting. Employing a new fluorescent probe strategy, we unravel a combined influence of both Nernst potential (Ψ) and partitioning (P) contributions. Through the synthesis of new benz[e]indolinium-derived probes, our findings redefine the landscape of mitochondrial localization by optimizing the efficacy of mitochondrial probe retention in primary cortical neurons undergoing normoxia and oxygen-glucose deprivation. This methodology not only advances our understanding of subcellular dynamics, but also holds promise for transformative applications in biomedical research and therapeutic development.

Characterisation and Outcomes of Patients with Solid Organ Malignancies Admitted to the Intensive Care Unit: Mortality and Impact on Functional Status and Oncological Treatment.

BACKGROUND: Despite the increasing number of ICU admissions among patients with solid tumours, there is a lack of tools with which to identify patients who may benefit from critical support. We aim to characterize the clinical profile and outcomes of patients with solid malignancies admitted to the ICU. METHODS: Retrospective observational study of patients with cancer non-electively admitted to the ICU of the Hospital Clinic of Barcelona (Spain) between January 2019 and December 2019. Data regarding patient and neoplasm characteristics, ICU admission features and outcomes were collected from medical records. RESULTS: 97 ICU admissions of 84 patients were analysed. Lung cancer (22.6%) was the most frequent neoplasm. Most of the patients had metastatic disease (79.5%) and were receiving oncological treatment (75%). The main reason for ICU admission was respiratory failure (38%). Intra-ICU and in-hospital mortality rates were 9.4% and 24%, respectively. Mortality rates at 1, 3 and 6 months were 19.6%, 36.1% and 53.6%. Liver metastasis, gastrointestinal cancer, hypoalbuminemia, elevated basal C-reactive protein, ECOG-PS greater than 2 at ICU admission, admission from ward and an APACHE II score over 14 were related to higher mortality. Functional status was severely affected at discharge, and oncological treatment was definitively discontinued in 40% of the patients. CONCLUSION: Medium-term mortality and functional deterioration of patients with solid cancers non-electively admitted to the ICU are high. Surrogate markers of cachexia, liver metastasis and poor ECOG-PS at ICU admission are risk factors for mortality.

Is reduction necessary in overriding metaphyseal distal radius fractures in children under 11 years: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: To determine the necessity of reduction in the treatment of overriding metaphyseal distal radius fractures (DRF) in children under 11 years. METHODS: In this systematic review and meta-analysis, PubMed, Embase, and Cochrane databases were searched to retrieve studies published from inception to 2023. Two reviewers independently screened for studies with observational or randomized control design comparing two treatments for overriding metaphyseal DRF in patients under 11 years: simple casting without reduction (SC group) versus closed reduction plus casting or pin fixation (CRC/F group); with varying outcomes reported (CRD471761). The risk of bias was assessed using the ROBINS-I tool. RESULTS: Out of 3,024 screened studies, three met the inclusion criteria, 180 children (mean age 7.1 ± 0.9 years) with overriding metaphyseal DRF: SC-group (n = 79) versus CRC/F-group (n = 101). Both treatment groups achieved 100% fracture consolidation without requiring further manipulation. The SC-group showed significantly fewer complications (mean difference [MD] 0.08; 95% CI [0.01, 0.53]; I2 = 22%; P < 0.009) and trends towards better sagittal alignment (MD 5.11; 95% CI [11.92, 1.71]; I2 = 94%; P < 0.14), less reinterventions (MD 0.31; 95% CI [0.01, 8.31]; P < 0.48), and fewer patients with motion limitation at the end of follow-up (MD 0.23; 95% CI [0.03,  1.98]; P < 0.18), although these findings were not statistically significant. CONCLUSIONS: Despite a limited number of studies comparing SC versus CRC/F in overriding DRF in children under 11 years, this study suggests that anatomical reduction is not necessary. Treating these fractures with SC, even when presenting with an overriding position, leads to reduced complications, shows a trend towards fewer reinterventions, improved sagittal alignment, and less limitation in patient motion. LEVEL OF EVIDENCE: Level III, Systematic review of Level-III studies.

SEA 2024 Standards for Global Control of Vascular Risk. / Estándares de la Sociedad Española de Arteriosclerosis 2024 para el control global del riesgo vascular.

One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to the knowledge, prevention and treatment of vascular diseases, which are the leading cause of death in Spain and entail a high degree of disability and health expenditure. Atherosclerosis is a multifactorial disease and its prevention requires a global approach that takes into account the associated risk factors. This document summarises the current evidence and includes recommendations for patients with established vascular disease or at high vascular risk: it reviews the symptoms and signs to evaluate, the laboratory and imaging procedures to request routinely or in special situations, and includes the estimation of vascular risk, diagnostic criteria for entities that are vascular risk factors, and general and specific recommendations for their treatment. Finally, it presents aspects that are not usually referenced in the literature, such as the organisation of a vascular risk consultation.

Hexapod Frame Correction of Proximal Tibial Recurvatum Caused Indirectly by a Femoral Aneurysmal Bone Cyst in an Adolescent: A Case Report and Systematic Review.

CASE: A 16-year-old boy presented with a recurrent distal femur aneurysmal bone cyst accompanied by a combined sagittal knee deformity (20° of femoral antecurvatum and 26.8° of tibial recurvatum) and limb shortening. After preoperative planning, the treatment involved new intralesional curettage, phenolization, and bone allograft filling. Additional procedures included distal extension femoral osteotomy with plate fixation, and proximal tibial osteotomy with, gradually corrected through a hexapod frame. At 2-year follow-up, lower limbs exhibited normoalignment and equal length. CONCLUSION: Complex knee deformities may occur with tumoral lesions around the knee but can be effectively addressed through double osteotomy and application of a hexapod frame.

Neuroganglioma in the posterior mediastinum: an incidental discovery.

Ganglioneuroma, a rare benign neuroblastic tumor, typically arises in the posterior mediastinum, but it can be found in the anterior mediastinum and thymus. Predominantly affecting the young, these asymptomatic tumors are often discovered incidentally through imaging. In our reported case, a 44-year-old woman post-hysterectomy with persistent jaundice was diagnosed with a neuroganglioma in the right posterior mediastinum via a computed tomography (CT) scan. Thoracotomy and resection revealed a 10-cm neuroganglioma untangled from mediastinal planes. Post-surgery, chylothorax emerged, which was managed through a 5-day fasting approach. Thoracic neurogangliomas, rare and often asymptomatic, demand meticulous diagnosis, emphasizing imaging and histopathology, with postoperative vigilance for complications.

An uncommon case of right hepatic duct entering cystic duct associated to multiple complications of biliary tract disease: acute pancreatitis, hepatolithiasis, acute cholecystitis and hepatic abscess.

Anatomical variations of the biliary tree pose diagnostic and treatment challenges. While most are harmless and often discovered incidentally during procedures, some can lead to clinical issues and biliary complications, making knowledge of these variants crucial to prevent surgical mishaps. Here, we present an unusual and clinically significant case. A 61-year-old man is admitted to the hospital with epigastric pain and diagnosis of pancreatitis of biliary origin and intermediate risk of choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) reported hepatolithiasis and choledocholithiasis, whereas endoscopic retrograde cholangiopancreatography showed cystic drain of the right hepatic duct. One month later the patient presented again to the emergency room with increasing abdominal pain and a computed tomography that demonstrated the presence of hepatic abscess and acute cholecystitis. The patient underwent percutaneous drain abscess and a subtotal laparoscopic cholecystectomy. Biliary anatomical variants present challenges on the diagnostic investigations, interventional and surgical procedures, understanding the possible complications is essential.

Coxsackievirus infection induces direct pancreatic ß cell killing but poor antiviral CD8+ T cell responses.

Coxsackievirus B (CVB) infection of pancreatic ß cells is associated with ß cell autoimmunity and type 1 diabetes. We investigated how CVB affects human ß cells and anti-CVB T cell responses. ß cells were efficiently infected by CVB in vitro, down-regulated human leukocyte antigen (HLA) class I, and presented few, selected HLA-bound viral peptides. Circulating CD8+ T cells from CVB-seropositive individuals recognized a fraction of these peptides; only another subfraction was targeted by effector/memory T cells that expressed exhaustion marker PD-1. T cells recognizing a CVB epitope cross-reacted with ß cell antigen GAD. Infected ß cells, which formed filopodia to propagate infection, were more efficiently killed by CVB than by CVB-reactive T cells. Our in vitro and ex vivo data highlight limited CD8+ T cell responses to CVB, supporting the rationale for CVB vaccination trials for type 1 diabetes prevention. CD8+ T cells recognizing structural and nonstructural CVB epitopes provide biomarkers to differentially follow response to infection and vaccination.

Post-Cambrian survival of the tubicolous scalidophoran Selkirkia.

Scalidophoran worms represent common infaunal components of early and middle Cambrian Burgess Shale-type fossil biotas. Early scalidophorans resemble extant priapulids based on overall morphology, but the genus Selkirkia represents the earliest record of tube dwelling for the group. Despite its ubiquitous presence in exceptional marine deposits, whether the exclusively Cambrian occurrence of Selkirkia reflects its entire evolutionary history or is affected by taphonomic biases remains unresolved. Here, we demonstrate the post-Cambrian survival of Selkirkia based on new material from the Lower Ordovician Fezouata Shale biota of Morocco. The discovery of Selkirkia in the Fezouata Shale extends the biostratigraphic range of the genus by 25 million years and its palaeobiogeographic occurrence to the high latitudes of Gondwana, strengthens the evolutionary links between Cambrian and Ordovician Burgess Shale-type biotas and increases scalidophoran diversity for the Fezouata Shale biota otherwise consisting exclusively of the palaeoscolecid Palaeoscolex? tenensis. The tube of Selkirkia underwent negligible external change for over 40 million years, indicating a high degree of morphological stasis during the Early Palaeozoic. A tubicolous mode of life is rare among extant priapulids and expressed only in Maccabeus, which forms a delicate tube from agglutinated plant debris, unlike the macroscopic secreted cuticular tube of Selkirkia.

Post-traumatic cortical cystic lesions in children: three case reports and a systematic review of the literature.

Post-traumatic cortical cystic lesions are rare radiolucent lesions that appear as a complication of low-severity fractures in children. Their relevance lies in the fact that few cases of these lesions have been described to date, so they are little known among clinicians caring for children. Three case reports of well-circumscribed cortical lytic lesions detected at 2-4 months during the follow-up of non-displaced distal radius fractures in children aged 9, 7, and 2 years are presented. The consistent clinical history and typical radiological features allowed the accurate diagnosis of post-traumatic cortical cystic lesion, without the need for advanced imaging tests or biopsy. At 12-, 8- and 11-month follow-ups, respectively, the lesions either disappeared or decreased in size. This benign and self-limited lesion should be correctly recognized to avoid confusion with other diagnoses, advanced imaging tests or biopsies, and unnecessary parental concerns.

Penile Fracture Secondary to Gunshot Injury: A Multidisciplinary Approach and Exceptional Surgical Management in an Uncommon Case.

Penile fractures happen when the tunica albuginea is forcefully torn during intense sexual activity or vigorous masturbation. Gunshot-induced cases are extremely rare. Diagnosis, often requiring surgical exploration, poses challenges due to the condition's rarity and severity. We report a complex case of a patient with multiple gunshot wounds, highlighting the need for a multidisciplinary approach for abdominal and genitourinary regions. A 24-year-old male presented to the emergency department with multiple gunshot wounds to the anterior thoracic and abdominal walls, inguinal region, penis, and lower extremities. Despite multiple gunshot wounds, the patient maintained hemodynamic stability during physical examination. No imaging study was performed since surgical management was decided due to the presence of hematemesis. During exploratory laparotomy, a 2 cm stomach lesion was found and repaired by the general surgery team. Urology then addressed genital trauma, identifying and fixing a 1 cm tunica albuginea defect in each corpora cavernosa, achieving bilateral penile fracture repair. The patient was discharged after eight days of hospitalization, with adequate oral intake and urinating. Fifty-two days later, he persists with mild erectile dysfunction (International Index of Erectile Function-5 score: 17 points). This unique case involving a gunshot-induced penile fracture alongside abdominal and several other injuries was successfully managed through a multidisciplinary approach. As these lesions are rare, prompt treatment with standardized surgical procedures for civilian cases is crucial for optimal outcomes.

Second radioiodine treatment in patients with differentiated thyroid carcinoma: Causes and effects.

INTRODUCTION: Patients with incomplete response to initial therapy of thyroid cancer can be managed with ongoing observation or potentially additional therapies. Our aim was to assess the effect of a second radioactive iodine treatment (RAIT) and its relationship with causes and clinical variables. MATERIAL AND METHODS: Patients undergoing a second RAIT for biochemical or structural incomplete response to initial therapy of DTC were retrospectively included (n=120). They were categorised based on the American Thyroid Association (ATA) classification of response to initial therapy. Patients were reclassified in the following 6-18 months after second RAIT based on imaging findings and measurements of thyroglobulin and antithyroglobulin antibody levels. The associations of a downgrading of response category and progression-free survival (PFS), and the related variables, were evaluated. RESULTS: Sixty-six patients (55%) had a downgrading on ATA response category after second RAIT. A significant interdependence of causes for second RAIT and outcomes was found (χ2=29.400, p=0.001), with patients with neck reoperation showing a higher rate of indeterminate or excellent responses. A significant association between ATA response to second RAIT and absence of structural progression was found (χ2=44.914, p<0.001), with less structural progression in patients with downgrading on ATA response (χ2=30.914, p<0.001). There was also significant interdependence to some clinical variables, such as AJCC stage (χ2=8.460, p=0.015), ATA risk classification (χ2=10.694, p=0.005) and initial N stage (χ2=8.485, p=0.004). CONCLUSIONS: In selected cases, a second RAIT could lead to more robust responses with a potential improvement in prognosis in patients with incomplete response to initial DTC treatment.

Repeatability of swept-source optical coherence tomography angiography automated macular vessel density.

INTRODUCTION: Optical Coherence Tomography Angiography Ratio Analysis (OCTARA) is capable of visualizing inner and outer retinal vascular plexuses, choriocapillaris, and larger choroidal vasculature in vivo without contrast injection. The aim of this study was to assess the intrasession repeatability of automated vessel density measurements using Triton Swept-Source Optical Coherence Tomography Angiography (OCTA) innovative algorithm OCTARA in retinal and choroidal vasculature. METHODS: To study population between 65-90 years old with no eye diseases. For each subject measurements were performed four times. The intraclass correlation coefficient and the coefficient of variation were calculated to analyze repeatability of the OCTARA automatically generated vessel density measurements. RESULTS: A total of 35 eyes were included in the study. The intraclass correlation coefficient of the global vessel density in the superficial capillary plexus and the deep capillary plexus were 0.963 and 0.975, respectively, and the coefficient of variation were 5.4% and 4.4%, respectively. The intraclass correlation coefficient of the rest of the global measurements was indicative of good reliability with the exception of the deep choroid layer with an intraclass correlation coefficient of 0.6 indicative of moderate reliability. CONCLUSIONS: Our results proved excellent repeatability of automated vessel density measurements in the superficial and deep capillary plexus layers in our cohort using a OCTARA algorithm indicating that it may be a reliable diagnostic tool. It also showed good reliability in choriocapillary and mid choroid layer. These findings may be of value in assessing the significance of differences in capillary density measurements over time and across different settings.

Correction to "Shifting the Antibody-Drug Conjugate Paradigm: A Trastuzumab-Gold-Based Conjugate Demonstrates High Efficacy against Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer Mouse Model".

[This corrects the article DOI: 10.1021/acsptsci.3c00270.].

Outpatient Foot-Sparing Surgery Is Safe in Selected Patients with Diabetic Foot Infections.

OBJECTIVE: To determine if outpatient foot-sparing surgery for patients with diabetic foot infections (DFIs) is associated with a higher rate of treatment failure or longer healing time. METHODS: In this prospective observational study, the authors consecutively recruited a cohort of 200 patients with moderate and severe DFIs from the Diabetic Foot Unit of Hospital San Juan de Dios, Caja Costarricense de Seguro Social, San José de Costa Rica, Costa Rica from October 15, 2020 to December 15, 2021. They compared outpatients with those admitted. Cox univariate analysis was performed, with time to treatment failure and time to healing as dependent variables and outpatient management as the independent variable. RESULTS: Seventy-one patients underwent surgery on an outpatient basis (35.5%), and 129 (64.5%) were admitted. Sixty of 111 patients (54.1%) with moderate infections were treated as outpatients versus 11 of 89 (12.4%) of those with severe infections. Twelve (16.9%) of the outpatients and 26 (20.2%) of those admitted presented failure (P = .57). The Cox univariate analysis with time to failure of treatment associated with outpatient management reported a hazard ratio of 1.26 (95% CI, 0.64-2.50; P = .50), and the analysis regarding healing time reported a hazard ratio of 0.91 (95% CI, 0.66-1.25; P = .56). CONCLUSIONS: Foot-sparing surgery on an outpatient basis was safe in more than half the cases of moderate DFIs, especially in patients with osteomyelitis. This approach is not associated with treatment failure or a longer healing time. Patients with severe infections, penetrating injuries, necrosis, or high inflammatory response and those with peripheral arterial disease who require revascularizations should be admitted to the hospital.