Research Spotlight

Squiers, J.J., Thatcher, J.E., Bastawros, D.S., Applewhite, A.J., Baxter, R.D., Yi, F., Quan, P., Yu, S., DiMaio, J.M. and Gable, D.R. (2022). “Machine learning analysis of multispectral imaging and clinical risk factors to predict amputation wound healing.” J Vasc Surg 75(1): 279-285.

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OBJECTIVE: Prediction of amputation wound healing is challenging due to the multifactorial nature of critical limb ischemia and lack of objective assessment tools. Up to one-third of amputations require revision to a more proximal level within 1 year. We tested a novel wound imaging system to predict amputation wound healing at initial evaluation. METHODS: Patients planned to undergo amputation due to critical limb ischemia were prospectively enrolled. Clinicians evaluated the patients in traditional fashion, and all clinical decisions for amputation level were determined by the clinician’s judgement. Multispectral images of the lower extremity were obtained preoperatively using a novel wound imaging system. Clinicians were blinded to the machine analysis. A standardized wound healing assessment was performed on postoperative day 30 by physical exam to determine whether the amputation site achieved complete healing. If operative revision or higher level of amputation was required, this was undertaken based solely upon the provider’s clinical judgement. A machine learning algorithm combining the multispectral imaging data with patient clinical risk factors was trained and tested using cross-validation to measure the wound imaging system’s accuracy of predicting amputation wound healing. RESULTS: A total of 22 patients undergoing 25 amputations (10 toe, five transmetatarsal, eight below-knee, and two above-knee amputations) were enrolled. Eleven amputations (44%) were non-healing after 30 days. The machine learning algorithm had 91% sensitivity and 86% specificity for prediction of non-healing amputation sites (area under curve, 0.89). CONCLUSIONS: This pilot study suggests that a machine learning algorithm combining multispectral wound imaging with patient clinical risk factors may improve prediction of amputation wound healing and therefore decrease the need for reoperation and incidence of delayed healing. We propose that this, in turn, may offer significant cost savings to the patient and health system in addition to decreasing length of stay for patients.

Shazadeh Safavi, K., Janney, C., Shazadeh Safavi, P., Kunzler, D., Jupiter, D. and Panchbhavi, V. (2021). “Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review.” Prim Care Diabetes Dec 7;S1751-9918(21)00216-3. [Epub ahead of print].

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AIMS: Differentiating Charcot neuropathic osteoarthropathy (CN) from infection is challenging. The diagnosis of CN is often missed or delayed, resulting in inappropriate and delayed treatment. We hypothesized that the misdiagnosis of CN results in inappropriate antibiotic prescriptions and explore the sequelae of unnecessary antibiotic use. METHODS: A retrospective review of patient electronic medical records from January 2010 to December 2017 was conducted for those diagnosed with CN after being referred to an orthopaedic foot and ankle specialist. RESULTS: Our review showed 58 of 103 (56%) patients received antibiotics on the date, or within the next 7 days, of referral to foot and ankle orthopaedic specialist. The antibiotic of choice given on referral were as follows: Sulfamethoxazole/Trimethoprim 18 of 58 (31%), doxycycline 13 of 58 (22%), clindamycin 13 of 58 (22%), cephalexin 9 of 58 (16%), minocycline 5 of 58 (9%). CONCLUSION: Missed diagnoses for CN are common and result in complications stemming from inappropriate treatment, delays in appropriate therapy, and may accelerate antibiotic resistance. Misdiagnosis of CN contributes to the inappropriate use of prescription antibiotics.

Shaked, O., Demetris, J., Levitsky, J., Feng, S., Loza, B.L., Punch, J., Reyes, J., Klintmalm, G., Jackson, W., DesMarais, M., Sayre, P., Shaked, A. and Reddy, K.R. (2022). “Impact of Donor and Recipient Clinical Characteristics and Hepatic Histology on Steatosis/Fibrosis Following Liver Transplantation.” Transplantation 106(1): 106-116.

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BACKGROUND: Deceased donor and recipient predictors of posttransplant steatosis/steatohepatitis and fibrosis are not well known. Our aim was to evaluate the prevalence and assess donor and recipient predictors of steatosis, steatohepatitis, and fibrosis in liver transplantation recipients. METHODS: Using the immune tolerance network A-WISH multicenter study (NCT00135694), donor and recipient demographic and clinical features were collected. Liver biopsies were taken from the donor liver at transplant, and from recipients per protocol and for-cause (ie, abnormal transaminases and to rule out rejection) and were interpreted by a central pathologist. RESULTS: One hundred eighty-three paired donor/recipients liver biopsies at the time of transplant and posttransplant follow-up (median time 582 d; average time to last biopsies was 704 d [SD ± 402 d]) were analyzed. Donor steatosis did not influence recipient steatosis or fibrosis. Ten of 183 recipients had steatohepatitis on the last biopsy. Recipient body mass index at the time of liver biopsy was the most influential factor associated with posttransplant steatosis. Both donor and recipient metabolic syndrome features were not associated with graft steatosis. Untreated hepatitis C viral (HCV) infection was the most influential factor associated with the development of allograft fibrosis. CONCLUSIONS: In a large experience evaluating paired donor and recipient characteristics, recipient body mass index at the time of liver biopsy was most significantly associated with posttransplant steatosis. Untreated HCV etiology influenced graft fibrosis. Thus relative to untreated HCV, hepatic fibrosis in those with steatosis/steatohepatitis is less common though long-term follow-up is needed to determine the course of posttransplant fibrosis. Emphasis on recipient weight control is essential.

Sensi, B., Khan, J., Warusavitarne, J., Nardi, A., Spinelli, A., Zaghiyan, K., Panis, Y., Sampietro, G., Fichera, A., Garcia-Granero, E., Espin-Basany, E., Konishi, T., Siragusa, L., Stefan, S., Bellato, V., Carvello, M., Adams, E., Frontali, A., Artigue, M., Frasson, M., Marti-Gallostra, M., Pellino, G. and Sica, G.S. (2021). “Long-term oncological outcome of segmental versus extended colectomy for colorectal cancer in Crohn’s disease: results from an international multicentre study.” J Crohns Colitis Dec 13;jjab215. [Epub ahead of print].

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BACKGROUND AND AIMS: Crohn’s Disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s Disease recommend pan-proctocolectomy. Aim of this study was to evaluate oncologic outcomes of a less invasive surgical approach. METHODS: Retrospective database analysis of Crohn’s disease patients with colorectal cancer undergoing surgery at selected European and U.S. tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy: total colectomy and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer and major postoperative complications. RESULTS: Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older (p= 0.0429), had less extensive colitis (p = 0.0002) and no pre-operatively identified synchronous lesions (p = 0.0109).Median follow up was 43 (31-62) months. There was no difference in unadjusted progression-free survival (p = 0.2570) nor in overall survival (p = 0.4191) between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score and AJCC staging, confirmed no difference for progression-free survival (HR 1.00 p = 0.9993) or overall survival (HR 0.77 p = 0.6654). Synchronous and metachronous cancers incidence was 9% and 1.5% respectively. Perioperative mortality was nil and major complications were comparable (7.58% vs 6.06% p = 0.9998). CONCLUSIONS: Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

Scherer, N.V. and Bista, D. (2022). “Management of asymptomatic severe hypertriglyceridemia.” Proc (Bayl Univ Med Cent) 35(1): 58-59.

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Severe hypertriglyceridemia is an urgent presentation that requires acute treatment. We present a rare case that could not be controlled by medical management and required plasmapheresis.