Endovascular reconstruction of popliteal and infrapopliteal arteries for limb salvage and wound healing in patients with critical limb ischemia – A retrospective analysis

BackgroundAdvancement in endovascular techniques has led to rapid growth in endovascular revascularization, and it has emerged as a treatment for critical limb ischemia (CLI). Clinical effectiveness of revascularization has been frequently judged by vessel patency and limb salvage, but there is paucity of reports on outcomes of the wound. We present a retrospective analysis of immediate angiographic and 3-month clinical outcome of patients who underwent endovascular reconstruction of popliteal and infrapopliteal arteries for CLI.MethodsAll patients who underwent endovascular reconstruction of popliteal and/or infrapopliteal arteries for CLI and >70% stenosis on digital subtraction angiography between March 2010 and November 2014 and had a clinical follow-up of at least 3 months were selected for analysis.Results34 patients underwent endovascular reconstruction. 9 patients (26%) underwent only POBA and remaining 25 (74%) underwent additional stenting. 13 patients (38%) had multiple segmental revascularization. 24 patients (71%) had successful vessel recanalization. Linear flow to foot in at least one artery could be achieved in 20 patients (59%) post revascularization. Successful wound healing occurred in 11 (35%) patients with an additional 7 (21%) patients showing clinical improvement in their wounds. Limb salvage was achieved in 33 patients (97%) at 3-month follow-up.ConclusionEndovascular revascularization of popliteal and infrapopliteal arteries is a feasible, safe, and effective procedure for the treatment of CLI. Normal inflow and outflow with at least one of the three infrapopliteal vessels being patent is essential for adequate healing of chronic ulcers and prevention of major amputation.     

Leishmaniasis of the lip diagnosed by lymph node aspiration and treated with a combination of oral ketaconazole and intralesional sodium stibogluconate

A 26-year-old male who presented to the dermatology OPD with complaints of a swelling on his lip of 6 months' duration was on examination found to have a solitary ulcerated nodule over the lip and an enlarged submental lymph node. Skin smear and biopsy from the lesion did not yield the diagnosis. Needle aspiration from the draining lymph node revealed the diagnostic Leishman-Donovan bodies. The patient responded to treatment with a combination of oral ketoconazole and intralesional sodium stibogluconate. We report this case because of both the unusual location of the lesion and the unusual method of diagnosis and treatment.     

A Comprehensive Study of Tumor Necrosis Factor-Alpha Genetic Polymorphisms,its Expression in Skin and Relation to Histopathological Features in Psoriasis

Background:

Tumor necrosis factor-alpha (TNFα) is an important inflammatory mediator in psoriasis and several genetic polymorphisms of this cytokine have been reported. Majority of studies have focused on the increased G– A polymorphism at the –308 position in psoriasis. There has been no comprehensive study evaluating the genetic polymorphisms, TNFα expression in the skin and histopathology. We are undertaking this study to outline TNFα genetic polymorphisms, its skin expression and histopathological correlation to help determine its role at the genetic and protein level.

Materials and Methods

112 patients of psoriasis and 243 healthy controls were included in this prospective study. 5 ml of peripheral blood was collected to study the TNFα genetic polymorphisms by polymerase chain reaction and restriction fragment length polymorphism analysis. Histopathological analysis of biopsies from the 112 patients were done using visual analogue scale and correlated with the findings. 61 of these cases were analyzed for TNFα expression by immunohistochemistry. The results of study were statistically analyzed using SPSS 13.0 statistical package program.

Results:

A strong association of TNFα –308 G/A polymorphism in psoriasis cases was detected. The A allele of the TNFα –308 G/A polymorphism occurs rarely in the Indian population, however there is an over representation of this allele in psoriatic patients. There was no association seen between TNFα genotype and histopathological severity of psoriasis.

Conclusion:

The study emphasized the central role of TNFα in the pathogenesis of psoriasis. TNFα genotyping may be helpful in identifying subjects in whom anti-TNFα therapeutic strategies may be tried.     

Translation and validation of chronic liver disease questionnaire (CLDQ) in Tamil language

Background

Chronic liver disease questionnaire (CLDQ), a self-administered quality-of-life (QOL) instrument for chronic liver disease (CLD) patients, was originally developed in English language. We aimed to translate and validate CLDQ in Tamil language (CLDQ-T).

Methods

CLDQ-T, prepared by two forward and two backward independent translations by four bilingual (Tamil and English) persons, and repeated iterative modifications, was validated in adult, native-Tamil patients with CLD. CLDQ-T was re-tested in some patients 2 weeks later. Convergent validity was assessed using Spearman’s correlation, and discriminant validity by comparison with World Health Organization’s brief QOL tool (WHOQOL-BREF). Reliability was assessed through internal consistency (Cronbach’s alpha) and test-retest reliability (intra-class correlation). Cutoff used for statistical significance was p<0.05.

Results

The study included 126 patients (age: mean [SD] 46 years [12.5]; male 104; cause: alcohol 42%, HBV 25%, HCV 4%, cryptogenic 29%; CTP class A 47%, B 37%, and C 16%). In convergent validity, all domains except the “abdominal domain” showed significant correlation between CLDQ-T and WHOQOL-BREF. Patients with severe disease had lower scores for all domains of CLDQ-T except the “abdominal” domain, but not for any of the domains for WHOQOL-BREF. Overall Cronbach’s alpha was 0.942, and more than 0.7 for all the individual domains except the “activity” domain. On retesting in 44 (35%) patients, intraclass correlation coefficient was 0.879 for the overall CLDQ-T score and >0.700 for individual domains.

Conclusion

CLDQ-T was easily understood and showed good performance characteristics in assessing QOL in Tamil-speaking patients with CLD.

     

Primary Hepatic Burkitt Lymphoma Presenting with Acute Liver Failure

Introduction

We report the first case of immunophenotypically confirmed primary hepatic Burkitt lymphoma presenting with acute liver failure. The patient survived following an aggressive diagnostic approach followed by emergent chemotherapy.

Discussion

Data from the primary hepatic non-Hodgkin lymphoma literature show a survival rate of 87% at 5 years with combination regimens of chemotherapy. However, mortality rate in this population is 85% in patients with acute liver failure.

Conclusion

Primary hepatic Burkitt lymphoma may respond well to emergent chemotherapy even in the setting of acute liver failure.     

Invasive fungal infection following chemotherapy for acute myeloid leukaemia—Experience from a developing country

The incidence of invasive fungal infections (IFI) is believed to be higher in patients with acute myeloid leukaemia (AML) undergoing chemotherapy in non‐HEPA‐filtered rooms. The aim of this study is to review the incidence of IFI in a large cohort of patients with AML treated at a single centre in India. Two hundred and twenty‐two patients with AML treated with either induction chemotherapy or salvage chemotherapy between 2008 and 2013 were studied retrospectively. IFI was defined as per the revised EORTC‐MSG criteria. Data on type of chemotherapy, prophylactic strategies, engraftment (ANC>500), the presence of IFI and survival were collected. IFI was diagnosed in 86 patients (38.7%) with proven IFI in 12 (5.4%). Use of posaconazole prophylaxis (P=.001) was the only factor associated with reduced incidence of IFI. Survival in patients with proven IFI was lower than those without proven IFI, but not statistically significant (59.4% vs 78.5%; P=.139). There is a high incidence of IFI during induction chemotherapy for acute myeloid leukaemia in developing countries. Posaconazole prophylaxis was associated with a significantly lower incidence of IFI. Optimal yet cost‐effective strategies for prevention and early diagnosis of IFI are required to improve survival in patients undergoing chemotherapy for AML.