P-P24 Optimising post-operative nutrition in patients undergoing pancreaticoduodenectomy

Abstract Background A considerable number of patients undergoing pancreaticoduodenectomy require supplemental nutrition in the postoperative period. However, there remains no national consensus on the optimal postoperative supplemental feeding modality. Furthermore, at our institution a variation in practice exists when considering post-operative entera (via the naso-jejunal (NJ)) or parenteral nutrition (PN). This study aimed to evaluate the utility of post-operative enteral or parenteral nutrition at our centre and to explore risk factors predisposing patients to post-operative nutritional deficits requiring supplementation. Methods We retrospectively analysed the electronic case records of all patients undergoing a pancreaticoduodenectomy between November 2019 and November 2020 at our HPB specialist centre. Key patient demographic data and post-operative nutritional requirements with route, length and indication for supplemental feeding as well as biochemical markers, length of stay (LoS) and complications were collected and analysed. Data were analysed via intention to treat analysis. Results 48 patients underwent a pancreaticoduodenectomy, of which 26 had an NJ tube inserted intra-operatively. 16 (33%) patients required supplemental feeding, via NJ route in 7 and PN in 9. 2 patients were intolerant to NJ feeds and progressed to PN. NJ fed patients had shorter LoS (12(10-42) vs. 28(14-63) days)(p = 0.09) compared to PN feeding. PN-related line infection or thrombosis in 4 (36%) patients. Supplemental feeding met daily kcal requirements in 13 (81%) patients, but PN was associated with greater weight loss (-5%) than NJ feeding (-3%). Significantly increasing the risk of needing supplemental nutrition: advanced age(p = 0.04), ASA≥2(p = 0.04) and anastomotic leak(p = 0.02). Conclusions In this group of patients, NJ feeding was largely well-tolerated and the majority of patients met their required daily kcal via this route. Due to the increased incidence of complications associated with PN, NJ feeding should be considered as the 1st line option for post-operative nutritional supplementation, with intra-operative insertion of an NJ tube considered for higher-risk patients.

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Pentostatin, Tacrolimus, and “Mini”-Methotrexate for Graft-Versus-Host Disease (GVHD) Prophylaxis: A Phase I/II Controlled, Randomized Study.

Blood ◽

10.1182/blood.v104.11.727.727 ◽

2004 ◽

Vol 104 (11) ◽

pp. 727-727

Author(s):

M. de Lima ◽

D. Couriel ◽

M. Munsell ◽

M. Westmoreland ◽

H. Shah ◽

...

Keyword(s):

Stem Cell ◽

Treatment Plan ◽

Randomized Study ◽

Dose Finding ◽

Control Group ◽

Hematopoietic Stem ◽

Intention To Treat ◽

Gvhd Prophylaxis ◽

Number Of Patients ◽

Risk Patients

Abstract GVHD remains a major obstacle to a successful unrelated (UD) or mismatched related (MRD) donor hematopoietic stem cell transplantation (HSCT). Pentostatin is a purine nucleoside analog that targets adenosine deaminase and leads to lymphocyte depletion, with low potential for myelosuppression. We are investigating the incorporation of pentostatin to our standard GVHD prophylaxis regimen with tacrolimus (tacro) and methotrexate (MTX). Methods: This is an adaptive randomized, dose finding study that takes into account toxicity and efficacy in a Baysean “play the winner” design. The “winner” dose moves to the phase II portion of the study. Probability of assignment to the control group was fixed at 20%. Recipients of UD and MRD are eligible; all analysis is done by intention to treat. Success was defined as being alive, engrafted, in complete remission(CR), without GVHD at study completion (100 days post HSCT). Development of grade III-IV acute (a) GVHD defined failure at any time, while grade I–II did not constitute failure if absent by day 100. This design has power 0.7 to detect a dose that has a success rate of 60% for low-risk patients (HLA matched, in CR) and 45% for high-risk patients (mismatched, not in CR). High-resolution typing was available for all donor-recipient pairs at HLA-DRB1 and -DQB1 loci, and to 83% of the pairs at HLA-A and -B loci; all patients had low-resolution -C typing. Treatment plan: tacro from day -2 (target level of 5–15 ng/ml) and MTX 5 mg/m2 on days +1, +3, +6 to all patients; day +11 was given only to the control group. Pentostatin was given on days +8, +15, +22 and +30, in treatment arms: 0.5 mg/m2, 1 mg/m2, 1.5 mg/m2, and 2 mg/m2. Results: 73 patients, median age 45 yrs (range 18–72) have been enrolled. Diagnosis were AML/MDS(n=48), ALL(n=8), CML (n=10) and NHL(n=7); 58% of the patients were not in CR at HSCT. Conditioning regimens were busulfan based(n=52), melphalan based(n=10), BEAM(n= 2), and CyTBI(n =9); 71% were ablative and 29%, reduced intensity. ATG was used in the regimen in 86% of the cases. Stem cell source: bone marrow (n=67) and peripheral blood(n=6). Donors: UD(n=67) and MRD(n=6). Proportion of patients with donor-recipient HLA mismatches was 24%, 20%, 33%, 21% and 40%, respectively for the 5 study arms; median age was similar. 85% of the intended pentostatin doses were delivered. Pentostatin did not delay engraftment. Incidence of toxicities (control vs. study arms): renal (all grade I/II)=47% vs 36%; TTP/HUS= 12% vs 9% (more severe among pentostatin patients); early relapse= 12% vs 5%; engraftment failure=6% vs 3%; delayed engraftment (>21 days): 0 vs. 5%. Probability that dose 1.5 mg/m2 is better than control is 0.9341. Pentostatin dose control group (n=17) 0.5 mg/m2 (n=10) 1 mg/m2 (n=12) 1.5 mg/m2 (n=24) 2 mg/m2 (n=10) gd II-IV aGVHD 47% 44% 63% 29% 50% gd III-IV aGVHD 20% 33% 27% 10% 10% CMV reactivation 41% 30% 33% 50% 50% bact/fungal infection 59% /12% 60% /10% 50% /18% 55% /17% 70% /10% Not evaluable n=2 n=1 n=1 n=4 n=0 Failure rate 47% 70% 33% 29% 40% Conclusions: This preliminary analysis indicates that aGVHD rate may be reduced with pentostatin 1.5 mg/m2, without interference with engraftment. Longer follow-up and larger number of patients will be needed to assess impact on survival.

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P44 Is restoration of pituitary function a realistic goal in endoscopic pituitary surgery?

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.114 ◽

2019 ◽

Vol 90 (3) ◽

pp. e36.1-e36

Author(s):

L Galloway ◽

C Hayhurst

Keyword(s):

Steroid Therapy ◽

Demographic Data ◽

Pituitary Surgery ◽

University Hospital ◽

Endocrine Function ◽

Pituitary Function ◽

Included Patient ◽

Number Of Patients ◽

Hospital Patients ◽

Patient Demographic Data

ObjectivesThe ability to restore pituitary function after endoscopic transsphenoidal surgery (ETSS) in pituitary tumours causing hypopituitarism remains unclear. This study analyses patients that required steroid replacement therapy prior to ETSS, and reviews endocrine function postoperatively.MethodsA prospectively held pituitary database was retrospectively analysed from May 2011 – July 2017 at a tertiary university hospital. Patients requiring steroids for hypopituitarism pre-operatively were included. Patient demographic data, tumour characteristics, and tumour hormonal profile were recorded.ResultsFrom a database of 156 patients, 28 (18%) were hypoadrenal pre-operatively and were included in the study. All patients underwent ETSS by a single neurosurgeon. The median age of patients was 56 years (range 17–81), whilst median follow-up was 48 months (range 6–78). 20 male patients and 8 female patients were included. All patients were established on steroid therapy preoperatively with either hydrocortisone (26 patients) or prednisolone (2 patients). 5 (18%) patients were able to stop steroid replacement postoperatively. The median time to cessation of steroid therapy was 4 months (range 2–16 months).ConclusionsRestoration of pituitary function following ETSS surgery was only successful in a small number of patients despite meticulous gland preservation. Our results suggest that restoration of function in all patients undergoing ETSS is an unrealistic goal and patients should be counselled accordingly.

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An Analysis of Dental Implants Survival and Success

Revista de Chimie ◽

10.37358/rc.18.9.6554 ◽

2018 ◽

Vol 69 (9) ◽

pp. 2465-2466

Author(s):

Iustin Olariu ◽

Roxana Radu ◽

Teodora Olariu ◽

Andrada Christine Serafim ◽

Ramona Amina Popovici ◽

...

Keyword(s):

Risk Factors ◽

Cohort Study ◽

Medical History ◽

Retrospective Cohort Study ◽

Odds Ratio ◽

Retrospective Cohort ◽

Demographic Data ◽

Kaplan Meier ◽

Number Of Patients ◽

Health Related

Osseointegration of a dental implant may encounter a variety of problems caused by various factors, as prior health-related problems, patients� habits and the technique of the implant inserting. Retrospective cohort study of 70 patients who received implants between January 2011- April 2016 in one dental unit, with Kaplan-Meier method to calculate the probability of implants�s survival at 60 months. The analysis included demographic data, age, gender, medical history, behavior risk factors, type and location of the implant. For this cohort the implants�survival for the first 6 months was 92.86% compared to the number of patients and 97.56% compared to the number of total implants performed, with a cumulative failure rate of 2.43% after 60 months. Failures were focused exclusively on posterior mandible implants, on the percentage of 6.17%, odds ratio (OR) for these failures being 16.76 (P = 0.05) compared with other localisations of implants, exclusively in men with median age of 42 years.

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Venous stent versus conventional stent for the treatment of central vein obstruction in hemodialysis patients: a retrospective study

Acta Radiologica ◽

10.1177/02841851211005163 ◽

2021 ◽

pp. 028418512110051

Author(s):

Surasit Akkakrisee ◽

Keerati Hongsakul

Keyword(s):

Endovascular Treatment ◽

Patency Rate ◽

Demographic Data ◽

Hemodialysis Patients ◽

Primary Patency ◽

Central Vein ◽

Primary Patency Rate ◽

Patient Demographic Data ◽

Upper Thoracic ◽

Vein Stenosis

Background Endovascular treatment is a first-line treatment for upper thoracic central vein obstruction (CVO). Few studies using bare venous stents (BVS) in CVO have been conducted. Purpose To evaluate the treatment performance of upper thoracic central vein stenosis between BVS and conventional bare stent (CBS) in hemodialysis patients. Methods Hemodialysis patients with upper thoracic central vein obstruction who underwent endovascular treatment at the interventional unit of our institution from 1 January 2008 to 31 December 2018 were enrolled in the present study. CBS was used to treat central vein obstruction in 43 patients and BVS in 34 patients. We compared the primary patency rates and complications between the two stent types. P values < 0.05 were considered statistically significant. Results The patient demographic data between the CBS and BVS groups were similar. The characteristics of the lesions, procedures, and complications were not significantly different between the two groups ( P > 0.05). There were no statistically significant differences of primary patency rates at three and six months between the BVS and CBS groups (94.1% vs. 86.0% and 73.5% vs. 58.1%, respectively; P > 0.05). The primary patency rate at 12 months in the BVS group was significantly higher than that in the CBS group (61.8% vs. 32.6%; P = 0.008). Conclusion Endovascular treatment of central vein obstruction with BVS provided a higher primary patency rate at 12 months than CBS.

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Predictive Factors for Patients’ Failure to Show for Initial Outpatient Physical Therapist Evaluation

Physical Therapy ◽

10.1093/ptj/pzab047 ◽

2021 ◽

Author(s):

Matthew Briggs ◽

Christine Ulses ◽

Lucas VanEtten ◽

Cody Mansfield ◽

Anthony Ganim ◽

...

Keyword(s):

Predictive Factors ◽

Employment Status ◽

Physical Therapist ◽

Demographic Data ◽

Binary Logistic Regression ◽

Final Analysis ◽

Outpatient Setting ◽

Binary Logistic Regression Model ◽

Number Of Patients ◽

Payer Source

Abstract Objective The objective of this study was to xamine primary factors which may predict patients’ failure to show at initial physical therapist evaluation in an orthopedic and sports outpatient setting. Methods A retrospective analysis of patients’ demographic data for physical therapist evaluations between January 2013 and April 2015 was performed. A binary logistic regression model was used to evaluate the odds of a no-show at evaluation. Demographic variables of age, employment status, days waited for the appointment, payer source, and distance traveled to clinic were analyzed. Independent variables were considered significant if the 95% Cis of the odds ratios did not include 1.0. Results A total of 6971 patients were included in the final analysis with 10% (n = 698) of the scheduled patients having a no-show event for their initial evaluation. The following factors increased the odds of patients having a no-show event: days to appointment (OR = 1.058; 95% CI = 1.042 to 1.074), unemployment status (OR = 1.96; 95% CI = 1.41 to 2.73), unknown employment status (OR = 3.22; 95% CI = 1.12 to 8.69), Medicaid insurance (OR = 4.87; 95% CI = 3.43 to 6.93), Medicare insurance (OR = 2.22; 95% CI = 1.10 to 4.49), unknown payer source (OR = 262.84; 95% CI = 188.72 to 366.08), and distance traveled ≥5 miles (OR = 1.31; 95% CI = 1.01 to 1.70). Female sex [OR = 0.73; 95% CI = 0.57 to 0.95) and age ≥ 40 years (OR = 0.44; 95% CI = 0.33 to 0.60) decreased the odds of a no-show event. Conclusion Results from this study indicate there may be some demographic factors that are predictive of patients failing to attend their first physical therapist visit. Impact Understanding the predictive factors and identifying potential opportunities for improvements in scheduling processes might help decrease the number of patients failing to show for their initial physical therapy appointment, with the ultimate goal of positively influencing patient outcomes.

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The effect of early versus late lipid infusion in parenteral nutrition on the biochemical and cortical auditory evoked potential parameters in preterm neonates

Egyptian Pediatric Association Gazette ◽

10.1186/s43054-019-0006-6 ◽

2019 ◽

Vol 67 (1) ◽

Author(s):

Rania Mohamed Abdou ◽

Hoda Mahmoud Ibrahim Weheiba

Keyword(s):

Weight Gain ◽

Parenteral Nutrition ◽

Biochemical Parameters ◽

Evoked Potential ◽

Demographic Data ◽

Auditory Evoked Potential ◽

Preterm Neonates ◽

Lipid Infusion ◽

Significant Difference ◽

Cortical Auditory Evoked Potential

Abstract Background As brain activity depends greatly on the functions provided by lipid membranes, dietary fat in early life can affect the developing nervous system. Despite the adoption of an early more aggressive parenteral nutrition approach with amino acid infusions still reluctance to the early use of intravenous lipids in neonates. Aim To compare the effect of delayed versus early introduction of intravenous lipid in preterm on the biochemical parameters and on brain development by the cortical auditory evoked potential (CAEP) latency and amplitude. Methods This is a comparative study included 49 neonates admitted at the ain shams university NICUs. Participants were divided into two groups: 26 in group of early lipid infusion and 23 in late lipid infusion, Demographic data, and biochemical parameters were documented during the 1st 2 weeks of life. The CAEP was performed at age of 6 months. The latency and amplitude of P1 were recorded and compared between both groups. Results In the present work we found that group of early lipid infusion had reach their full oral intake earlier with shorter duration of parenteral nutrition and length of stay. They had better weight gain and significantly better glucose level control than group of late lipid infusion. There was no significant difference in the other chemical parameters between both groups expect for the higher incidence of cholestasis in the group of late lipid infusion. At 6 months of age, the group of early lipid infusion had significantly shorter latency and amplitude of P1 than the group of late lipid infusion. Conclusion Early effective nutrition positively affect feeding tolerance and weight gain and maturation of higher brain centers brain.

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Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital

Endoscopy International Open ◽

10.1055/a-0970-8828 ◽

2019 ◽

Vol 07 (11) ◽

pp. E1386-E1392

Author(s):

Thomas Worland ◽

Oliver Cronin ◽

Benjamin Harrison ◽

Linda Alexander ◽

Nik Ding ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Surgical Procedures ◽

Colonic Polyps ◽

Tertiary Hospital ◽

Safe Alternative ◽

Intention To Treat ◽

Mucosal Resection ◽

Regional Center ◽

Financial Benefits ◽

Number Of Patients

Abstract Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 – 2008) and 9 years after its introduction (2009 – 2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P < 0.0001), and shorter average LoS (1 vs 9 days, P < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.

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Prevalence of Hyponatremia and Its Associated Morbimortality in Hospitalized Patients Receiving Parenteral Nutrition

Annals of Nutrition and Metabolism ◽

10.1159/000477675 ◽

2017 ◽

Vol 71 (1-2) ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

Emilia Gómez-Hoyos ◽

Martín Cuesta ◽

Nayade Del Prado-González ◽

Pilar Matía ◽

Natalia Pérez-Ferre ◽

...

Keyword(s):

Body Mass Index ◽

Mortality Rate ◽

Parenteral Nutrition ◽

Demographic Data ◽

Tertiary Hospital ◽

Hospital Length ◽

Hospitalized Patients ◽

Hospital Length Of Stay ◽

Control Subjects ◽

Comorbidity Index

Background: The objective of the study was to determine the prevalence of hyponatremia (HN) and its associated morbimortality in hospitalized patients receiving parenteral nutrition (PN). Methods: A retrospective study including 222 patients receiving total PN (parenteral nutrition group [PNG]) over a 7-month period in a tertiary hospital and 176 matched to 179 control subjects without PN (control subjects group [CSG]). Demographic data, Charlson Comorbidity Index (CCI), date of HN detection-(serum sodium or SNa <135 mmol/L)-intrahospital mortality, and hospital length-of-stay (LOS) were registered. In the PNG, body mass index (BMI) and SNa before, during, and after PN were recorded. Results: HN was more prevalent in the PNG: 52.8 vs. 35.8% (p = 0.001), and independent of age, gender, or CCI (OR 1.8 [95% CI 1.1-2.8], p = 0.006). In patients on PN, sustained HN (75% of all intraindividual SNa <135 mmol/L) was associated with a higher mortality rate independent of age, gender, CCI, or BMI (OR 7.38 [95% CI 1.07-50.8], p = 0.042). The absence of HN in PN patients was associated with a shorter hospital LOS (<30 days) and was independent of other comorbidities (OR 3.89 [95% CI 2.11-7.18], p = 0.001). Conclusions: HN is more prevalent in patients on PN. Sustained HN is associated with a higher intrahospital mortality rate. Absence of HN is associated with a shorter hospital LOS.

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Cement-in-cement femoral component revision

The Bone & Joint Journal ◽

10.1302/0301-620x.103b7.bjj-2020-1953.r2 ◽

2021 ◽

Vol 103-B (7) ◽

pp. 1215-1221

Author(s):

John W. Kennedy ◽

Nigel Y. B. Ng ◽

David Young ◽

Nicholas Kane ◽

Andrew G. Marsh ◽

...

Keyword(s):

Femoral Component ◽

Short Form ◽

Demographic Data ◽

Senior Author ◽

Inclusion Criteria ◽

Reliable Technique ◽

Patient Demographic Data ◽

Oxford Hip Score ◽

Component Revision

Aims Cement-in-cement revision of the femoral component represents a widely practised technique for a variety of indications in revision total hip arthroplasty. In this study, we compare the clinical and radiological outcomes of two polished tapered femoral components. Methods From our prospectively collated database, we identified all patients undergoing cement-in-cement revision from January 2005 to January 2013 who had a minimum of two years' follow-up. All cases were performed by the senior author using either an Exeter short revision stem or the C-Stem AMT high offset No. 1 prosthesis. Patients were followed-up annually with clinical and radiological assessment. Results A total of 97 patients matched the inclusion criteria (50 Exeter and 47 C-Stem AMT components). There were no significant differences between the patient demographic data in either group. Mean follow-up was 9.7 years. A significant improvement in Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-item Short-Form Survey (SF-12) scores was observed in both cohorts. Leg lengths were significantly shorter in the Exeter group, with a mean of -4 mm in this cohort compared with 0 mm in the C-Stem AMT group. One patient in the Exeter group had early evidence of radiological loosening. In total, 16 patients (15%) underwent further revision of the femoral component (seven in the C-Stem AMT group and nine in the Exeter group). No femoral components were revised for aseptic loosening. There were two cases of femoral component fracture in the Exeter group. Conclusion Our series shows promising mid-term outcomes for the cement-in-cement revision technique using either the Exeter or C-Stem AMT components. These results demonstrate that cement-in-cement revision using a double or triple taper-slip design is a safe and reliable technique when used for the correct indications. Cite this article: Bone Joint J 2021;103-B(7):1215–1221.

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Surgical and medical morbidity following failed non-traumatic partial foot amputation in diabetic patients

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000132 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

Cole Cheney ◽

John Femino

Keyword(s):

Hospital Admissions ◽

Demographic Data ◽

Time Frame ◽

Diabetic Patients ◽

Index Procedure ◽

Limb Preservation ◽

Initial Surgery ◽

Number Of Patients ◽

Partial Foot Amputation

Category: Ankle, Diabetes, Lesser Toes, Midfoot/Forefoot Introduction/Purpose: Maximal limb preservation is often the goal in choosing partial foot amputation (PFA) as a treat-ment for diabetic foot infections. Some of these patients will go on to experience multiple hospital admissions, IV antibiotic courses, surgical debridements, re-amputations and other medical compli-cations. This study describes the treatment course of these patients starting at second partial foot amputation and ending at 5 year follow-up. Methods: A retrospective cohort was built from a database of all amputation procedures performed on diabet-ic patients at the University of Iowa Department of Orthopedics from 2000 – 2015. The cohort was evaluated over time frame starting at second PFA (index procedure) and ending at 5 years after in-dex procedure. Of 264 patients who underwent partial foot amputation, 49 experienced two lower extremities PFA between January 2000 and December 2011 (cut-off used to allow minimum of 5 years post-PFA). Demographic data was recorded at index PFA and included surgical dates, laterali-ty, surgery type, diagnoses at time of initial surgery, and death date. A chart review collected in-formation on 5 year post-index PFA incidence of: non-surgical hospitalizations, antibiotic admin-istrations, total contact cast applications, and complications (such as osteomyelitis and acute renal failure). Results: Thirty-two (65%) of the second partial foot amputations (index) were ipsilateral and 17 were con-tralateral to first partial foot amputation (pre-index procedure). Eighteen (37%) of the partial foot amputation patients eventually experienced transtibial / transfemoral amputations in the 5 years fol-lowing index PFA. Eleven (22%) had at least a third partial foot amputation (and as many as 7) dur-ing study period. Sixteen (32%) patients had 17 transtibial / transfemoral amputations within 5 year time frame. 11 of the 17 (65%) TT / TF procedures were ipsilateral to index (second) PFA. Seven (17%) of the patients died. Conclusion: Maximal limb preservation may not be beneficial in all cases, particularly in the case of repeat PFAs. This cohort of repeat PFA patients demonstrated a complicated medical course with long pe-riods of hospitalization, leg immobilization in cast, and home-going antibiotics (requiring PICC). This study suggested that over a 5 year period following second PFA, patients on average experi-enced at least 31 days in TCC, 17 days hospitalized and underwent one additional amputation pro-cedure. These are likely underestimates due to follow-up or outside hospital cares. A large number of patients (18 or 37%) ultimately required higher-level amputation. There is a potential morbidity with PFA that may not be communicated to patients when making these decisions. In this cohort, the average days to second PFA was 360 days. 18 of 49 repeat PFA patients underwent tran-stibial or transfemoral amputation within 5 years of their initial PFA. The morbidity of the interim medical course over 5 years added to the poor quality of life after PFA.

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