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Pseudomonas aeruginosa
An Uncommon Cause of Diabetic Foot Infection
Background
Pseudomonas aeruginosa has traditionally been considered a common pathogen in diabetic foot infection (DFI), yet the 2012 Infectious Diseases Society of America guideline for DFI states that “empiric therapy directed at P aeruginosa is usually unnecessary.” The objective of this study was to evaluate the frequency of P aeruginosa isolated from bone or tissue cultures from patients with DFI.
Methods
This study is a cross-sectional survey of diabetic patients presenting with a foot infection to an urban county hospital between July 1, 2012, and December 31, 2013. All of the patients had at least one debridement procedure during which tissue or bone cultures from operative or bedside debridements were obtained. The χ2 test and the t test of means were used to determine relationships between variables and the frequency of P aeruginosa in culture.
Results
The median number of bacteria isolated from DFI was two. Streptococcus spp and Staphylococcus aureus were the most commonly isolated organisms; P aeruginosa was isolated in only five of 112 patients (4.5%). The presence of P aeruginosa was not associated with the patient's age, glycosylated hemoglobin level, tobacco abuse, the presence of osteomyelitis, a prescription for antibiotic drugs in the preceding 3 months, or the type of operative procedure.
Conclusions
Pseudomonas aeruginosa was an infrequent isolate from DFI in this urban, underserved diabetic population. The presence of P aeruginosa was not associated with any measured risk factors. By introducing a clinical practice guideline, we hope to discourage frontline providers from using routine antipseudomonal antibiotic drugs for DFI.
Evaluating Iatrogenic Complications of the Total-Contact Cast
An 8-Year Retrospective Review at Cleveland Clinic
Background: Total-contact casting is an effective method to treat various pathologic abnormalities in patients with diabetic neuropathy, but its use is frequently associated with iatrogenic complications.
Methods: The largest retrospective review to date of iatrogenic complications of total-contact casts was conducted over an 8-year period at Cleveland Clinic.
Results: In the past 8 years, 23% of patients developed complications, and the most common complication was a new heel ulcer formation. Of these complications, 92.1% resolved, 6.4% were lost to follow-up, and 1.4% resulted in a partial foot amputation. Mean cast duration was 10.3 days for patients who developed a total-contact cast iatrogenic complication. The most common indication for the use of a total-contact cast was a neuropathic foot ulceration.
Conclusions: The results of this study support the use of total-contact casting in the insensate patient with diabetes. However, adequate staff training in total-contact cast application is recommended to reduce complications.
A prospective study was performed to examine the performance of bone scintigraphy in the earliest stage of soft-tissue foot ulceration with potential risk for progression to osteomyelitis. Twenty-three podiatry clinic patients with new or recurrent foot ulcers but negative plain film radiographs of the foot underwent 24 (one patient was studied twice) multiphase bone scans (flow, blood pool, and 3- and 24-hour delayed images) that were visually scored for severity of increased uptake on a scale of 0 to 3+, with 0 indicating normal and 3+ indicating severe. Twenty-one scans (88%) showed abnormal uptake on at least one phase, with 17 (71%) having increased bone uptake on late images. Ulcer healing without complications occurred in 20 cases (83%), whereas 4 cases had adverse outcomes, 3 requiring surgical resection for failure to heal and 1 having radiographic progression to frank osteomyelitis. All three patients whose bone scans showed severe abnormal uptake had an adverse clinical outcome. (J Am Podiatr Med Assoc 93(2): 91-96, 2003)
Diabetic foot complications are costly and often recurrent. The use of diabetic footwear has been shown to be effective in reducing the incidence of diabetic foot ulcerations. For diabetic footwear to be most effective, it must be worn at least 60% of the time. All reported rates of compliance fall well short of this level. The style and appearance of the shoe have been commonly blamed for this poor compliance. This study evaluates patients’ motivations and perceptions regarding diabetic footwear. A patient’s decision to use diabetic footwear is based on the perceived value of the shoe and not on the patient’s previous history of foot complications or the aesthetics of diabetic footwear. (J Am Podiatr Med Assoc 93(6): 485-491, 2003)
Background:
Diabetes is a major chronic disease with high morbidity and mortality. Diabetic preventive care services are essential in the management and outcome of the disease. More than other preventive diabetic care services, preventive care of diabetic retinopathy has been emphasized and recommended by practitioners and insurance companies. We investigated the status of preventive care in the diabetic population.
Methods:
Information was collected from 420 outpatients aged 30 to 80 years. The patients were divided into two groups: those with well-controlled blood sugar levels (hemoglobin A1c [HbA1c] level ≤7%) and those with uncontrolled blood sugar levels (HbA1c level >7%).
Results:
Data analysis indicated that for both groups, 93% of the participants were seen for diabetic eye care at least once and 78% were getting an annual eye examination regularly. In the controlled and uncontrolled blood sugar groups, 26% and 32% of patients, respectively, had ever seen a nephrologist and 38% and 49%, respectively, had ever seen a cardiologist. In the controlled and uncontrolled blood sugar groups, 32% and 38% of patients, respectively, had visited a podiatric physician. For statistical analysis and comparison of results between the two groups, we applied the χ2 test and calculated 95% confidence intervals. There were some significant differences regarding the complications of diabetes mellitus and preventive care.
Conclusions:
There is a need for greater engagement by podiatric physicians and health-care providers to promote regular visits for the diabetic population to podiatric medical clinics.
Background:
Accurate representation of the insole geometry is crucial for the development and performance evaluation of foot orthoses designed to redistribute plantar pressure, especially for diabetic patients.
Methods:
Considering the limitations in the type of equipment and space available in clinical practices, this study adopted a simple portable three-dimensional (3-D) desktop scanner to evaluate the 3-D geometry of an orthotic insole and the corresponding deformities after the insole has been worn. The shape of the insole structure along horizontal cross sections is defined with 3-D scanning and image processing. Accompanied by an in-shoe pressure measurement system, plantar pressure distribution in four foot regions (hallux, metatarsal heads, midfoot, and heel) is analyzed and evaluated for insole deformity.
Results:
Insole deformities are quantified across the four foot regions. The hallux region tends to show the greatest changes in shape geometry (17%–50%) compared with the other foot regions after 2 months of insole wear. As a result of insole deformities, plantar peak pressures change considerably (–4.3% to +69.5%) during the course of treatment.
Conclusions:
Changes in shape geometry of the insoles could be objectively quantified with 3-D scanning techniques and image processing. This investigation finds that, in general, the design of orthotic insoles may not be adequate for diabetic individuals with similar foot problems. The drastic changes in the insole shape geometry and cross-sectional areas during orthotic treatment may reduce insole fit and conformity. An inadequate insole design may also affect plantar pressure reduction. The approach proposed herein, therefore, allows for objective quantification of insole shape geometry, which results in effective and optimal orthotic treatment.
Background:
Dialysis therapy is associated with an increased incidence of lower-extremity wounds and amputations. We compared the incidence of foot ulcers and amputations before and after the start of dialysis.
Methods:
We evaluated 150 consecutive diabetic patients receiving dialysis and compared the incidence of foot complications 30 months before and after initiation of hemodialysis. We used claims data for diabetes, ulceration, and dialysis and abstracted medical records to verify diagnoses and dates of ulcers and amputations. We compared initial and cumulative ulcer/amputation incidence to account for multiple events in the same person over time. We used the same formula to determine the incidence rate difference and 95% confidence intervals (CIs) to compare new ulcers and amputations during the study.
Results:
There was no significant difference in the incidence of first foot ulcers before (91.7 per 1,000 patient-years; 95% CI, 73.7–112.3 per 1,000 patient-years) and after (82.7; 95% CI, 65.7–102.3) the start of hemodialysis. The incidence of cumulative ulcers was significantly higher before (304.0 per 1,000 patient-years; 95% CI, 270.8–340.2) compared with after (210.7 per 1,000 patient-years; 95% CI, 183.0–240.9) dialysis. There was no difference in the incidence of first amputation before (29.3 per 1,000 patient-years; 95% CI, 1 9.4–41.7 per 1,000 patient-years) and after (37.3 per 1,000 patient-years; 95% CI, 19.4–41.7 per 1,000 patient-years) dialysis or in the cumulative incidence of amputations before (61.3 per 1,000 patient-years; 95% CI, 46.7–8.4 per 1,000 patient-years) and after (58.7 per 1,000 patient-years; 95% CI, 44.5–75.5 per 1,000 patient-years) dialysis.
Conclusions:
There was no increase in the incidence of ulcers or amputations after beginning hemodialysis.
The efficacy of concentrated autologous platelet-derived growth factors in the healing and closure of chronic lower-extremity wounds was evaluated in 24 patients with 33 lower-extremity wounds treated previously for at least 6 months using traditional methods. Surgical wound debridement was performed to convert chronic ulcers into acute wounds. Concentrated autologous platelet-derived growth factors and thrombin were applied to the wound bases and protected with a nonadhering compression dressing that remained intact for 7 days. Wounds were evaluated and the concentrate was reapplied every 2 weeks. Wound closure and complete epithelialization was achieved in 20 wounds. Seventy-five percent or greater wound closure was obtained in three wounds, 50% to 74% closure in three wounds, and 25% to 49% closure in two wounds. Five wounds displayed no improvement. Mean time to complete closure was 11.15 weeks. The application of concentrated autologous platelet-derived growth factors and thrombin resulted in substantial wound healing and wound-diameter reduction. This technique constitutes a safe and effective treatment option and avoids lengthy treatment periods that increase the potential for infection. (J Am Podiatr Med Assoc 96(6): 482–488, 2006)
Background: A study was conducted to compare the accuracy, reliability, and essential features of nine commercially available handheld infrared thermometers used to manage the neuropathic foot.
Methods: The thermometers were compared using two temperature-control sources simulating physiologic conditions found in a foot-care clinic. With each control source independently set, temperature difference ranges of 0°, 2°, 4°, and 6° C were randomly sampled and analyzed for each thermometer by two testers. The order of testing was randomly assigned for testers and instruments.
Results: There were differences in mean temperature change among thermometers (P < .001) and between testers (P = .0247). Differences in mean temperature change among instruments (<0.5°C), although small, could affect interpretation of skin temperature if temperature comparisons are made using two different instruments. The difference in temperature change between testers (0.06°C) was not large enough to affect decisions in clinical practice. Instrument response time, distance-to-spot ratio, sensor diameter, display resolution, emissivity, and cost were compared.
Conclusions: The low-cost, general-use infrared thermometers used in this study showed good accuracy, reliability, and performance and are appropriate for use in a foot-care clinic. (J Am Podiatr Med Assoc 97(5): 360–365, 2007)
Validation of the Basic Foot Screening Checklist
A Population Screening Tool for Identifying Foot Ulcer Risk in People with Diabetes Mellitus
Background: We sought to evaluate the validity, reliability, and predictive value of the Basic Foot Screening Checklist.
Methods: Five hundred patients with type 2 diabetes mellitus and impaired glucose tolerance were screened by a generalist foot screener and a specialist podiatric physician to determine the sensitivity and specificity of the Basic Foot Screening Checklist. One hundred twelve of the 500 participants had their feet screened by two foot screeners to determine reliability.
Results: The sensitivity of the screening tool was 0.54 (95% confidence interval, 0.50–0.58), and the specificity was 0.77 (95% confidence interval, 0.73–0.81), with a positive predictive value of 0.82 (95% confidence interval, 0.79–0.85). Overall, the reliability of the tool was poor (κ = 0.35; 95% confidence interval, 0.17–0.53).
Conclusions: The validity and reliability of the Basic Foot Screening Checklist was poor despite the finding that generalist foot screeners performed individual tests with good sensitivity and specificity. This inconsistency was likely attributable to the inability of screeners to adequately interpret the test findings and form accurate risk classification outcomes. (J Am Podiatr Med Assoc 99(4): 339–347, 2009)
