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It is estimated that around 347 million people in the world are diagnosed with diabetes mellitus. 1 Indian is one of the country with very high prevalence of diabetes in the world which is predicted to increase to 120.9 million by 2030. 2 It is estimated that approximately 23.6 million people in United States have diabetes mellitus. 3 It is predicted that 1 in 3 American adults will have diabetes by 2050. 4 Diabetes affect 3% of the UK population. 5 Diabetic foot is one of the most common and distressing complication of diabetes. This devastating complication has major medical, social and economic consequences. 5 Around 15% of diabetic patients will develop foot ulcer during their life time. 6 Around 6% of hospital admission in people who have diabetes are related to foot ulcers. 7 Every year 5% of the patients with diabetes will develop a foot ulcers. 5 Foot ulcers are known to carry a 25% risk of major amputation. Diabetic foot ulceration is known to precede amputation in 85% of the cases. 8 Around 40% of the patients presenting to hospital with diabetic foot will require some form of amputation. 9 In ABSTRACT Background: Aim of current study was to analyse major amputation occurring in patients with diabetic foot complication through the new principle and practice of diabetic foot. Methods: A 5 year retrospective study was done in a single surgical unit in department of surgery of St John's medical college, Bangalore, India. Results: 26 patients were included in this study. 76.9% of the patients who underwent major amputation had type 1 diabetic foot complications. Infected ulcers were the most common cause for major amputation. Most patients who underwent major amputation had a score ranging from 16-20. 11.54% of the patients who underwent major amputation had osteomyelitis with type 3C diabetic foot osteomyelitis being most common. Conclusions: This unique study for the first time utilizes the new Amit Jain's principle and practice of diabetic foot to study major amputation in diabetic foot. Majority of the patients who undergo major amputation in India has type 1 diabetic foot complication. Most of the patients undergoing major amputation belongs to the high risk category for major amputation.

Staged hybrid TAAA repair, using a combination of proximal TEVAR with open distal repair, can be performed using established endovascular skills and technology coupled with traditional open aortic surgical techniques, with low surgical morbidity and mortality. In the midterm, staged hybrid TAAA repair was associated favorable survival, aortic remodeling, and freedom from reintervention.

AimsChronic kidney disease (CKD) is prevalent and is associated with increased cardiovascular morbidity and mortality. The interaction between diastolic dysfunction (DD) and CKD in subjects with preserved systolic function is not well defined. This study sought to determine the association between renal function and DD in subjects with preserved ejection fraction.Methods and resultsThrough the Rochester Epidemiology Project, subjects who underwent echocardiography over 2 years with EF ≥50% were identified and the clinical data were obtained. Glomerular filtration rate (GFR) was estimated using the modification of diet in renal disease equation. Linear regression was used to test for association of GFR and DD. DD was defined as follows: Grade 2 or pseudonormal pattern (0.75 < E/A ≤ 1.5, E/e′ ≥ 10, DT > 140 ms, ΔE/A ≥ 0.5, and PV S < D) or Grade 3+ or restrictive pattern (E/A > 1.5, E/e′ ≥ 10, DT < 140 ms, and PV S < D). Cox regression was used to assess correlation of GFR and DD with time‐to‐event outcomes. A total of 2056 patients were identified. There was significant correlation between worsening GFR and degree of DD assessed by echo Doppler E/e′ ratio (P = 0.005), left ventricular mass index (P = 0.004), and right ventricular systolic pressure (P = 0.01). Worsening GFR was associated with increased mortality, development of heart failure, and hospitalization (P < 0.001). Within each GFR group, abnormal DD was associated with a higher risk of the clinical outcomes. No interaction between GFR and DD was noted, suggesting an increased risk of events associated with abnormal DD across ranges of GFR.ConclusionsWorsening GFR was associated with a greater degree of diastolic dysfunction and adverse clinical outcomes. Within each GFR group, the presence of DD was associated with increased morbidity and mortality. Further studies are warranted to determine if improving DD in patients with CKD will benefit clinical outcomes.

Objective Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAA) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. The purpose of this study was to evaluate the outcomes and healthcare associated value of this new method compared to traditional open repair over 10 years. Methods A prospectively collected database was used to identify all patients with extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, post-operative outcomes, and incidence of major adverse events (MAE = renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This is multiplied by a constant to set the value of open TAAA repair to 100. Results A total of 113 consecutive patients underwent extent II TAAA repairs, of which 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (p>0.05). The hybrid group had shorter operative time (255 vs 306 minutes; p=0.01), shorter postoperative length of stay (LOS) (10.1 vs 13.3 days; p=0.02), as well as reduced blood loss (1300 vs 2600 mL; p=0.01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0%vs 51.1%, p=0.03) there was no difference in renal failure (8.0% vs 4.5%, p=0.84) The incidence of MAE was lower in the staged hybrid group (20.0% vs 48.9%; p=0.01), without a difference in hospital mortality (4.0 vs 3.4%, p=0.89). Median total cost was higher in the hybrid group ($112,920 vs $72,037, p=0.003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. Conclusions The 20% major adverse event rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared to open repair, with a relative reduction of over 50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher healthcare related value compared to standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair resulting in a good value investment from a resource utilization perspective.