Page 6 - Vasoclick emagazine Issue2

Four major factors associated with a
improved by revascularization in patients with
significantly shorter OS
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ischemic infection. Thus, timely management of
6
ischemic wound and early access to vascular
Major amputation(s) during hospitaliza-
6.673;
tion
(P<0.001;
HR
CI
surgery for limb salvage in diabetic patients is
2.836–15.700)
strongly recommended.
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Wound ischemia: due to an infected
ulcer [(vs. non-ischemic wound; P=0.046;
e) Infection
b) The LRINEC-score
a) Patient characteristics
HR 1.598; CI 1.008–2.532)
1) Indicative of severe infection, high CRP
Overall 324 patients were enrolled (237 males,
The LRINEC -score had no effect on the OS or
Age: over 67 years (P<0.001; HR 1.055;
levels were found to be associated with a
87 females; mean age, 66.8 years, SD 12.8)
AFS.
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CI 1.035–1.076)
worse AFS.
with 404 periods of hospitalization.
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2) AFS was also associated with a deep wound
Impaired renal functions: eGFR under
Materials and methods
The Laboratory Risk Indicator for Necrotizing
60 ml/min (P<0.001; HR 0.989; CI
(penetrating to the bone or joint) and high
Fasciitis score (LRINEC score):
The retrospective cohort study enrolled adult
0.982–0.995)
blood leukocytes.
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It is a sensitive scoring system to identify
patients presenting with acute DFI at the
3) Long-lasting and multiple foot ulcers were
necrotizing fasciitis and distinguish it from other
Tampere University Hospital during 2010
also associated with a worse outcome as
soft tissue infections. An LRINEC score of >8
-2014.
8
6,7
acute infection can undergo a minor amputation
reported previously.
2, 6
has been found to be sensitive for patients with
to restrict the infection, and this way a major
diabetes.
was
9
information
patient-related
Following
amputation can be avoided, saving both limb and
c) Survival of patients with DFI
The study therefore emphasized on the

collected from the hospital records:
life of the patient.
The present study showed that survival of
importance of early detection and treatment of
The present study assessed the utility of LRINEC
Patient demographics (age and gender)
patients after a DFI was poor within one-year
the infection for diabetic foot ulcers.
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score to diagnose severe DFI and a poor
Registered diagnoses (ischemic heart disease,
d) Effect of revascularization
(81.2%), and almost 50% of patients died within
prognosis. LRINEC score with a cutoff of >8 was
chronic obstructive pulmonary disease, con-
The AFS was greatly reduced in patients with
5-years after a DFI. The risk of death was almost
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f) Hypertension
chosen to identify necrotizing fasciitis.
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gestive heart failure and dyslipidemia, microbi-
ischemic wounds. 16.1% of the cases had
six-fold after the infection among patients that
The study demonstrated that use of a
ological and clinical chemistry findings, surgi-
revascularization within 1 month of admission
underwent
hypertensive medication was associated with an
A specialist in plastic surgery staged the wounds
cal revisions and amputations, open and endo-
and in most cases within 1 week.
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infections but treated without amputation. After
increased AFS, however the observation requires
according to the University of Texas Staging
vascular revascularization procedures, wound

a 5-year follow-up, only 1 of 12 patients (8.3%)
further validation.
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System for Diabetic Foot Ulcers (UT scale).
6,10
status, and the length of hospital stay).
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or
(open
Revascularization
procedure
survived.
6

endovascular) had no effect on survival of
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A Summary of Guidelines for the Treatment of Cancer-Associated Thrombosis amputation than those with Therefore, a diabetes patient presenting with an patients, however, AFS was significantly
CASSINI trial showed that rivaroxaban (10 mg Duration of anticoagulation for CAT:
Conclusion 7) LaaksoM, Kiiski J, KarppelinM, HelminenM, Kaartinen I. once daily) is associated with a lower Owing to the lack of randomized clinical studies
Pathogens causing diabetic foot infection and the Practice Guidelines
Patients with DFI have high morbidity and reliability of the superficial culture. Surg Infect. 2020. doi: incidence of recurrent VTEs and major to investigate different durations of
poor survival outcomes despite advanced 10.1089/sur.2020.072. A Summary of Guidelines for the Treatment of Cancer-Associated Thrombosis bleeding in high-risk ambulatory patients with anticoagulation in cancer patients, the optimal

treatment resources. 8) Wong C-H, Khin L-W, Heng K-S, Tan K-C, Low C-O. The Endorsed by: Dr. Narendranath Meda, Chief and Consultant Vascular and Endovascular Surgeon, cancer as well as lower rates of duration of treatment remains elusive. Based on
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LRINEC (Laboratory Risk Indicator for Necrotizing KIMS Hospital, Secunderabad
High CRP levels are associated with a Fasciitis) score: a tool for distinguishing necrotizing discontinuation due to adverse events. 13 existing evidence, patients with active cancer
reduced AFS. fasciitis from other soft tissue infections. Crit Care Med. Background and metastatic cancer undergoing therapy are
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2004; 32:1535–41. doi:
Ischemic infections in deep wounds with 10.1097/01.CCM.0000129486.35458.7D Venous thromboembolism (VTE) is a common type of cancer-associated thrombosis (CAT) in A growing body of clinical and real-world data posed to high risk of recurrent VTE. According to
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high CRP levels suggest severity of the 9)Tan JH, Koh BTH, Hong CC, Lim SH, Liang S, Chan GEH, patients with cancer and the second leading cause of death in patients receiving active continues to support the use of rivaroxaban different guidelines, the duration of
disease and must be prevented early. 6 et al. A comparison of necrotising fasciitis in diabetics chemotherapy. Cancer patients with VTE have a ten-fold higher risk of death compared to VTE for the treatment of CAT based on its safety anticoagulation may range from 3-6 months. 3,7,8
and non-diabetics: a review of 127 patients. Bone Joint J.
A major amputation is a strong predictor of (2016) 98-B:1563–8. doi: patients without cancer. Thus, the prevention and treatment of VTE is a vital part of cancer and efficacy 9, 13 . The COSIMO study using a The guidelines emphasized that the duration of
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10.1302/0301-620X.98B11.37526
death in patients with DFI. management and several guidelines have been published to facilitate it. Recently, Streiff et al reviewed non-interventional approach demonstrated therapy should be routinely evaluated based on
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Thus, early identification and treatments of 10) Lavery LA, Armstrong DG, Harkless LB. Classification the latest versions of some widely recognized evidence-based guidelines for CAT management and that patients with CAT who switched from the patient’s clinical profile, risks and benefits of
of diabetic foot wounds. J Foot Ankle Surg. 1996; 35:528–
DFI are critical to improve both the AFS and 31. doi: 10.1016/S1067-2516(96)80125-6 compared their methodologies and recommendations. The studied guidelines for VTE treatment in LMWH, fondaparinux, or VKA therapy to therapy, and patient preferences. 2
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OS. patients with CAT were from the American Society of Clinical Oncology (ASCO) , the International rivaroxaban experienced an improvement in
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Society of Thrombosis and Hemostasis (ISTH) , the International Initiative on Thrombosis in Cancer treatment satisfaction in reducing Overall, the recently published guidelines are
4,5
References: (ITAC) , the National Comprehensive Cancer Network (NCCN) , and the Spanish Society of Medical patient-reported anticoagulation burden. 14 consistent in their recommendations for CAT
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1) Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Oncology (SEOM). 8 management as summarized in table 1. They
Padula WV, Bus SA. Five year mortality and direct costs of In line with these findings, rivaroxaban has provide unanimous advice to reassess the
care for people with diabetic foot complications are
comparable to cancer. J Foot Ankle Res. 2020;13:16. doi: been recommended for the treatment of CAT duration of therapy depending on the patient’s
10.1186/s13047-020-00383-2 Guideline recommendations for treat- Rivaroxaban for treatment of CAT: across all the international guidelines for
ment of cancer-associated thrombosis: Rivaroxaban was the first DOAC approved by clinical condition and preferences, as well as the
2) Ndosi M, Wright-Hughes A, Brown S, Backhouse M, cancer patients, having a low risk of bleeding risks/benefits of the therapy. 2
Lipsky BA, Bhogal M, et al. Prognosis of the infected All the guidelines are consistent in the US Food and Drug Administration (FDA)
diabetic foot ulcer: a 12-month prospective observational and no drug-drug interactions. 2
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study. Diabet Med. 2018; 35:78–88. doi: recommending direct oral anticoagulants for the treatment of VTE in 2012. Though, the
10.1111/dme.13537 initial approval did not selectively address
(DOAC) in their treatment for CAT. DOACs and
3) Huang Y-Y, Lin C-W, Yang H-M, Hung S-Y, Chen I-W. low-molecular-weight heparin (LMWH) are the cancer patients with CAT, the EINSTEIN and
Survival and associated risk factors in patients with
diabetes and amputations caused by infectious foot agents of choice for long-term therapy (over EINSTEIN-PE trials that led to the approval
gangrene. J Foot Ankle Res. 2018; 11:1. doi: included ~5.6% of cancer patients in the
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10.1186/s13047-017-0243-0 Vitamin K antagonist (VKA)) . Guidelines,
however, recommend cautious use of DOACs in rivaroxaban treatment arm. 9,10,11
4) Raspovic KM, Wukich DK. Self-reported quality of life
and diabetic foot infections. J Foot Ankle Surg. 2014; patients with gastrointestinal (GI) and
53:716–9. doi: 10.1053/j.jfas.2014.06.011 SELECT-D, the first randomized comparison
gastro-urinary (GU) malignancies until more
5) Peters EJ, Childs MR, Wunderlich RP, Harkless LB, evidence is available. Inferior vena cava (IVC) of rivaroxaban (15mg twice daily for 3 weeks,
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Armstrong DG, Lavery LA. Functional status of persons
with diabetesrelated lower-extremity amputations. filters can be offered in case the anticoagulation then 20 mg once daily for a total of 6 months)
Diabetes Care. 2000; 24:1799-804. doi: versus dalteparin (200 IU/kg daily during
10.2337/diacare.24.10.1799 is contraindicated or if there is progressive
thrombosis despite optimal anticoagulation. The month 1, then 150 IU/kg daily for months 2-6)
6) Vuorlaakso M, Kiiski J, Salonen T, Karppelin M,
Helminen M, Kaartinen I. Major Amputation Profoundly filter should be retrieved once the for the treatment of CAT in cancer patients,
Increases Mortality in Patients With Diabetic Foot showed non-inferior efficacy and safety of
Infection. Front Surg. 2021;8:655902. Published 2021 Apr anticoagulation is safe to resume. 2
30.doi:10.3389/fsurg.2021.655902 rivaroxaban compared to LMWH. 12