Prevalence and risk factors of lower limb amputation in patients with end-stage renal failure on dialysis: a systematic review

Background: Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim: Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods: Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results: Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions: This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis

Defining mild traumatic brain injury: How classification differs across studies when applied to a large prospective data set. A PREDICT prospective cohort study

Aims Mild traumatic brain injury (TBI) in children is a major public health issue, yet there is wide variation in the way ‘mild’ TBI is defined in the literature and in guidelines. To date no study has prospectively detailed the proportion of children presenting with mild TBI to Emergency Departments (EDs) according to these various definitions. The objective of this study was to apply published definitions of mild TBI to a large prospectively collected data set of childhood head injuries (HIs), and to determine the proportions of mild TBI when the various definitions are applied.Methods Prospective observational study of children with HIs of any severity presenting to 10 Australian/New Zealand centres. We applied 18 different definitions of mild TBI, identified through a systematic review of the literature, to children aged 3 to 16 years. We assessed the number and percentage of cases the definitions applied to when the specific inclusion and exclusion criteria were used.Results Of 20 137 children with HI of any severity, 11 907 were aged 3 to 16 years. Mean age was 8.2 years, 32% were female. 61.9% were fall related. Cranial CT rate was 12.7% and neurosurgery rate was 0.5%. Adjustments were made to some definitions to enable application to the data set: none in 7, minor in 9, substantial in 2. Percentages of the cohort covered by the definitions of ‘mild’ TBI ranged from 2.4% (284) to 98.7% (11,756) of the cohort. The median percentage of the cohort which was classed as ‘mild’ TBI using the 18 definitions investigated was 21.7% (2,589).Conclusions When applying different definitions of mild TBI to a single data set including all severities, a wide range of cases are included depending on the definition used. Clinicians and researchers need to be aware of this important variability when attempting to apply the published literature to children presenting to EDs with TBI

Diagnostic accuracy of the NEXUS II head injury clinical decision rule in children. A PREDICT prospective cohort study

Aims Clinical decision rules (CDRs) can be applied in Emergency Departments (EDs) to optimise the use of computed tomography (CT) in children with head trauma. The National Emergency X- Radiography Utilisation Study II (NEXUS II) CDR, as amended for children, has not been externally validated in a large paediatric cohort.The objective of this study was to conduct a multicentre external validation of the NEXUS II CDR in children.Methods We performed a prospective observational study of patients<18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis we assessed the performance of the NEXUS II CDR for its diagnostic accuracy (with 95% confidence intervals (CI)) in predicting clinically important intracranial injury (ICI) as identified in CT scans performed in ED.Results Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had a clinically important ICI as defined by NEXUS II. 74 (19.6%) of these patients underwent neurosurgery. Sensitivity for clinically important ICI based on the NEXUS II CDR was 373/377 (98.9%; 97.3%–99.7%) and specificity 156/1585 (9.8%; 8.4%–11.4%). Positive and negative predictive values were respectively 373/ 1802 (20.7%; 18.8%–22.6%) and 156/160 (97.5%; 93.7%–99.3%). Of the 18 147 children who did not have a CT scan 49.5% had at least one NEXUS II risk criterion.Conclusions NEXUS II had very high sensitivity when analysed with a focus on head injured patients who have had a CT performed, similar to the derivation study. With half of the unimaged patients positive for NEXUS II risk criteria the use of this CDR has the potential to increase the number of CTs

The effect of patient observation on cranial computed tomography rates in children with minor head trauma

BackgroundManagement of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma.MethodsThis was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects.ResultsThe cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI.ConclusionsEven in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate‐ and higher‐risk groups for ciTBI

A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): The Australasian Paediatric Head Injury Rules Study (APHIRST)

Background: Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting.Methods/design: This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria.Discussion: This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting.Trial registration: The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)- ACTRN12614000463673 (registered 2 May 2014). © 2014 Babl et al.; licensee BioMed Central Ltd

Prevalence and risk factors of lower limb amputation amongst diabetic foot ulcer patients at the Townsville Hospital

Background/Aims: Diabetic foot ulcers (DFUs) are common amongst diabetic patients, occurring at a lifetime incidence of up to 15%. Lower limb amputation (LLA) is considered a frequent outcome, yet there is no local literature on the rates of LLA amongst DFUs patients in the diabetic population of North Queensland. The aim of this study is to find the prevalence of and risk factors for LLAs amongst DFU patients.\ud \ud Methods: A retrospective pilot study was conducted on patients attending The Townsville Hospital High Risk Foot Clinic (HRFC) between 2010- 2012. Non-parametric analysis and Chi-Square tests were performed using SPSS 20 to identify strongly associated variables with amputation.\ud \ud Results: A total of 106 subjects presented with a DFU at the HRFC during the study period, out of which (n= 43; 41%) underwent a LLA, with a male: female ratio of 1.7:1. The Indigenous subgroup comprised (n= 10; 23%) of the cohort. The mean age of amputation was 69.20 + 11.78 years, with no significant difference between the Indigenous and non-Indigenous cohorts. Diabetic retinopathy (OR 4.13 [95% CI 1.772-9.628] P = 0.001) and past history of coronary artery bypass graft surgery (CABG) (OR 4.0 [95% CI 1.094-14.624] P = 0.028) were factors strongly associated with amputation. Other variables that showed positive associations but fell short of statistical significance included Indigenous background, and history of hypertension, peripheral neuropathy and nephropathy. \ud \ud Conclusions: LLAs occurred in almost half of the DFU cohort at the HRFC, and were found to be closely linked with a history retinopathy and CABG surgery, however further prospective studies are required to confirm our findings

Worldwide prevalence of lower limb amputation in renal dialysis patients: a systematic review \ud

Background/Aims: Renal dialysis has recently been identified as a risk factor for lower limb amputation (LLA) however, exact rates are not known. \ud \ud Methods: A systematic review of existing literature investigating the prevalence of LLA in subjects that had end-stage renal failure (ESRF) and were on renal dialysis was conducted. A systematic literature search using the MeSH terms 'diabetes' AND 'amputations' AND 'renal dialysis' was conducted in PUBMED, Medline, Cochrane reviews and Google Scholar database for full text articles published in English from July 2003 to July 2013. \ud \ud Results: A total of 6 full text published studies conducted worldwide were included in this systematic review, 5 of which included patients on haemodialysis alone and one on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputations in the renal failure cohort varied from 1.72% in Japan to 13.4% in Canada. Five out of the 6 studies identified presence of diabetes mellitus as the leading risk factor for amputation (p<0.05) in renal dialysis patients. Other risk factors identified were: high HbA1c, high c-reactive protein and low serum albumin. \ud \ud Conclusions: This review demonstrates high prevalence of LLAs in patients with ESRF receiving dialysis therapy. It has also identified the closely associated risk factors with the adverse outcome of amputation, the most important one being the presence of diabetes mellitus