Background: We sought to determine the frequency of toenail onychomycosis in diabetic patients, to identify the causative agents, and to evaluate the epidemiologic risk factors.
Methods: Data regarding patients’ diabetic characteristics were recorded by the attending internal medicine clinician. Clinical examinations of patients’ toenails were performed by a dermatologist, and specimens were collected from the nails to establish the onycomycotic abnormality. All of the specimens were analyzed by direct microscopy and culture.
Results: Of 321 patients with type 2 diabetes mellitus, clinical onychomycosis was diagnosed in 162; 41 of those diagnoses were confirmed mycologically. Of the isolated fungi, 23 were yeasts and 18 were dermatophytes. Significant correlations were found between the frequency of onychomycosis and retinopathy, neuropathy, obesity, family history, and duration of diabetes. However, no correlation was found with sex, age, educational level, occupation, area of residence, levels of hemoglobin A1c and fasting blood glucose, and nephropathy. The most frequently isolated agents from clinical specimens were yeasts.
Conclusions: Long-term control of glycemia to prevent chronic complications and obesity and to promote education about the importance of foot and nail care should be essential components in preventing onychomycosis and its potential complications, such as secondary foot lesions, in patients with diabetes mellitus. (J Am Podiatr Med Assoc 101(1): 49–54, 2011)
Background: Since the implementation of highly active antiretroviral therapy (HAART), the life expectancy of patients with human immunodeficiency virus (HIV) has significantly increased. This is likely to cause changes in podiatric medical manifestations, such as plantar verrucae, in this population.
Methods: Attendees at a San Francisco street fair in 2008 provided information about HIV status and the presence of verrucae via a survey. A total of 504 surveys were analyzed and compared with 1995 data, before HAART implementation. We examined if there was a statistically significant change in the increased likelihood of plantar verrucae in HIV-positive patients from 1995 to 2008. Then we examined the likelihood of HIV-positive patients (compared to HIV-negative patients) presenting with plantar verrucae in 2008, by using logistic regression, and controlling for age, sex, and race/ethnicity.
Results: Patients with HIV infection were 5.2 times more likely to present with plantar verrucae compared to patients without HIV infection in 2008 (95% confidence interval, 2.5–11.0, P < .0001) and 10.0 times more likely in 1995 (95% confidence interval, 3.4–29.0, P < .0001). This decrease in likelihood over time was not statistically significantly different (P = .33). Logistic regression analysis controlling for the covariates of age, race, and sex showed that patients with HIV in 2008 were 4.5 times more likely to present with verrucae compared to patients without HIV (95% confidence interval, 2.1–9.9, P = .0002).
Conclusions: Patients with HIV infection in 2008 are still significantly more likely to present with plantar verrucae after controlling for age, race, and sex. This increased likelihood has not changed significantly across time. Because HAART has increased the life expectancy of patients with HIV, this group of patients with plantar verrucae will continue to represent a significant population in the practice of podiatric medicine. (J Am Podiatr Med Assoc 101(1): 35–40, 2011)
Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.
Diabetic foot infections tend to lead to amputation. Partial first-ray resections are used to help salvage the foot and maintain bipedal ambulation. Losing the first metatarsophalangeal joint has biomechanical consequences that lead to further foot deformities and result in more proximal amputations of the ipsilateral limb, such as a transmetatarsal amputation.
We reviewed 48 patients (32 male and 16 female; mean age = 62.44) who underwent 50 partial first-ray resections between April 1, 2003, and July 31, 2009. These partial first-ray resections were done at various levels of the first metatarsal. We hypothesize that partial first-ray resections that require further bone resection will lead to poor biomechanics that can result in further amputation.
We found that out of 50 partial first-ray resections, 24 cases required further surgical intervention, 12 of which were a transmetatarsal amputation (TMA) (mean time between partial first-ray resection and TMA = 282.08 days). Forty-eight percent of patients did not require further surgical intervention and were considered a success.
Partial first-ray resections are not highly successful. Our study found a higher success rate compared to a previous study done by Cohen et al in 1991. Partial first-ray amputations can be a good initial procedure to salvage the foot and prolong a patient’s bipedal ambulatory status, thereby lowering the patient’s morbidity and mortality. (J Am Podiatr Med Assoc 102(5): 412–416, 2012)
Patients suffering from chronic kidney disease are at greater risk of perioperative and postoperative complications. There is no systematic review study demonstrating whether total joint arthroplasty can be safely performed in patients with chronic kidney disease.
A literature search was performed in the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and Cochrane Library databases for information from the earliest date of data collection to September of 2018. Studies comparing the perioperative and postoperative outcomes of no–chronic kidney dysfunction (CKD) patients with those of CKD patients were included. Statistical heterogeneity was quantitatively evaluated by means of the χ2 test, with significance set at P < .10 or I2 > 50%.
Three articles consisting of 38,209 patients were included (35,363 no-CKD patients and 2,846 CKD patients). The results showed that CKD was related to a greater increase in postoperative infection rate, deep vein thrombosis, readmission, and mortality (P < .1). No differences in length of surgery, length of stay, pulmonary embolism, or revision were observed (P > .10).
Compared with no-CKD patients, CKD patients demonstrated an increased risk of perioperative and postoperative complications.
Charcot's neuroarthropathy (CN) treatment is still controversial, and the results are controversial. Owing to patient comorbidities, surgical intervention carries a high risk of complications. Thus, foreseeing the possible results of planned treatment is crucial. We retrospectively evaluated the Charcot Reconstruction Preoperative Prognostic Score (CRPPS) in patients with surgically treated CN.
Twenty-two feet of 20 patients were included in the study. Two groups were formed according to their CRPPS. Twelve patients with values less than 4 were defined as group A, and eight patients with values of 4 or greater were defined as group B. Mean follow-up was 61 months (range, 5–131 months). Groups were compared according to American Orthopaedic Foot and Ankle Society (AOFAS) scores, Foot and Ankle Disability Index (FADI) scores, and complication rates.
Group A and B mean AOFAS scores were 76.83 (range, 71–85) and 70.5 (range, 20–85), respectively. All of the patients were improved according to AOFAS and FADI scores, but no correlation was found with the CRPPS. None of the group A patients required additional intervention, but five patients in group B underwent revision surgery. No amputations were performed.
The CRPPS is focused on feasibility. The data needed to fill the scoring system is easily obtainable from medical records even retrospectively, and the score is helpful to predict a patient's outcome after CN-related surgery. Herein, CRPPS values of 4 or greater were related to high complication rates and lower functional outcomes.
Nitric oxide is an endogenous gas released by endothelial cells that induces vasodilatation and plays other important roles in the wound-healing process. Nitroglycerin preparations are liberators of nitric oxide. Podiatric physicians have used nitroglycerin paste and patches on patients in an attempt to increase perfusion to the foot. However, the drug’s efficacy seems to be largely anecdotal. A prospective, randomized, placebo-controlled, double-blind study was conducted to investigate the efficacy of a nitroglycerin patch in locally increasing perfusion to the foot. Twenty-two healthy subjects were randomly assigned to either a drug group (nitroglycerin patch, 0.2 mg/h) or a placebo group (adhesive patch without active ingredient). The patch was applied to the plantar arch of the foot. Objective and subjective measures were then used to detect changes in perfusion to the foot after a 2-hour experimental period. The objective measures, cutaneous thermometry and photoplethysmography, found no significant measurable difference in perfusion to the foot between the drug and placebo groups (P > .05). A subjective questionnaire used to assess changes in temperature or sensation detected by the subject yielded similar results. Thus a nitroglycerin patch dose of 0.2 mg/h showed no measurable ability to increase perfusion to the foot. Further research is needed to validate the indications for this therapy. (J Am Podiatr Med Assoc 96(4): 318–322, 2006)
Diabetic foot infections (DFIs) are the most common cause of hospitalization for patients with diabetes. Studies have shown diabetic patients have high readmission rates. It is important to identify variables that contribute to readmission. This study aimed to investigate clinical variables associated with 30-day hospital readmission in patients with DFI.
We conducted a retrospective study of adults admitted to the hospital for DFI between July 1, 2012, and July 1, 2015. We identified patients by International Classification of Diseases, Ninth Revision codes and randomly selected 35% of medical records for review. Patients were excluded if they did not have a DFI by review, were pregnant, or were incarcerated. The primary outcome was 30-day readmission. Data collected included baseline demographics, medical comorbidities, substance abuse, homelessness, tobacco use, and laboratory and surgical pathology data. Univariate and multivariate logistic regression models were used to identify independent predictors.
Of 140 included patients, 106 (76%) were male. Median age was 55 years and length of stay (LOS) was 7 days. In univariate analysis, 31 patients (22%) were readmitted in the 30 days after the index hospitalization. Factors associated with readmission included treatment failure, elevated C-reactive protein level, and hospital LOS (P < .05). In multivariate analyses, LOS and treatment failure were independent predictors of readmission.
The 30-day readmission rate for patients with DFI is high. Treatment failure, C-reactive protein, and LOS are independently associated with readmission. More work is needed to determine reasons for readmission so that appropriate measures can be taken before discharge.
A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient’s evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis. (J Am Podiatr Med Assoc 97(2): 151–155, 2007)
This article presents a series of case reports to describe the technique of ankle joint manipulation and its effects on common problems of the foot and ankle. The relationship between motion and pain is described, as are the effects of muscular inhibition on the presence of joint restriction and their association with pain in various joints remote to the ankle joint. (J Am Podiatr Med Assoc 94(4): 395–399, 2004)