Search Results
Endovascular therapy has increasingly become the initial clinical option for the treatment of lower-extremity peripheral arterial occlusive disease not only for patients with claudication but also for those with critical limb ischemia. Despite this major clinical practice paradigm shift, the outcomes of endovascular therapy for peripheral arterial disease are difficult to evaluate and compare with established surgical benchmarks because of the lack of prospective randomized trials, incomplete characterization of indications for intervention, mixing of arterial segments and extent of disease treated, the multiplicity of endovascular therapy techniques used, the exclusion of early treatment failures, crossover to open bypass during follow-up, and the frequent lack of intermediate and long-term patency and limb salvage rates in life-table format. These data limitations are especially problematic when one tries to assess the outcomes of endovascular therapy in patients with diabetes. The purpose of the present article is to succinctly review and objectively analyze available data regarding the results of endovascular therapy in patients with diabetes. (J Am Podiatr Med Assoc 100(5): 424–428, 2010)
Herpetic whitlow is a viral infection of the fingers or toes caused by the herpes simplex virus. Herpes simplex virus is a common pathogen that causes infections in any cutaneous or mucocutaneous surface, most commonly gingivostomatitis or genital herpes. However, infection of the digits is also infrequently reported. Herpetic whitlow occurs when the virus infects the distal phalanx of the fingers or toes by means of direct inoculation, causing pain, swelling, erythema, and vesicle formation. The proper diagnosis is important because the condition can mimic various other podiatric abnormalities such as paronychia, bacterial cellulitis, or even embolic disease. Improper diagnosis often leads to unnecessary work-up, antibiotic therapy, or even surgical intervention. This case will help illuminate the clinical presentation of herpetic whitlow in an atypical location, and the patient’s subsequent treatment. We present an atypical case of right hallux herpetic whitlow with delayed diagnosis and associated cellulitis. The patient was admitted after seeing multiple providers for a progressive right hallux infection that presented as a mixture of vesicular lesions and apparent cellulitis. His history was positive for biting his fingernails and toenails, and the lesions were noted to be honeycomb-like, with minimal drainage. The lesions were then deroofed and viral cultures were obtained, which were positive for herpes simplex virus type 1, thus confirming a diagnosis of herpetic whitlow. Although he remained afebrile with negative wound cultures during admission, a secondary bacterial infection could not be excluded because of his nail avulsion and surrounding cellulitis. He was discharged on oral antibiotics, antivirals, and wound care recommendations. Herpetic whitlow should be included in the differential diagnosis of pedal digital lesions that appear as vesicular or cellulitic in the pediatric population.
Background: A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations.
Methods: The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median ± SD age, 72 ± 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg.
Results: The mean ± SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 ± 5.5 weeks versus 5.5 ± 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean ± SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% ± 18.6% versus 94.9% ± 9.8% (P < .0001).
Conclusions: Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations. (J Am Podiatr Med Assoc 97(2): 95–101, 2007)
Challenges of Distal Bypass Surgery in Patients with Diabetes
Patient Selection, Techniques, and Outcomes
Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The diabetic patient with a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit and inflow/outflow artery selection, play a dominant role in determining clinical success. An adequate-caliber, good-quality great saphenous vein is the optimal graft for distal bypass in the leg. Alternative veins perform acceptably in the absence of the great saphenous vein, whereas prosthetic and other nonautogenous conduits have markedly inferior outcomes. Graft configuration (reversed, nonreversed, or in situ) seems to have little effect on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, and allow for adequate soft-tissue coverage of the graft and simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to outcomes and highlights the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery. (J Am Podiatr Med Assoc 100(5): 429–438, 2010)
Background: Multiple organizations have issued guidelines to address the prevention, diagnosis, and management of diabetic foot ulcers (DFUs) based on evidence review and expert opinion. We reviewed these guidelines to identify consensus (or lack thereof) on the nature of these recommendations, the strength of the recommendations, and the level of evidence.
Methods: Ovid, PubMed, Web of Science, Cochrane Library, and Embase were searched in October 2018 using the MESH term diabetic foot, the key word diabetic foot, and the filters guideline or practice guideline. To minimize recommendations based on older literature, guidelines published before 2012 were excluded. Articles without recommendations characterized by strength of recommendation and level of evidence related specifically to DFU were also excluded. A manual search for societal recommendations yielded no further documents. Recommendations were ultimately extracted from 12 articles. Strength of evidence and strength of recommendation were noted for each guideline recommendation using the Grading of Recommendations Assessment, Development, and Evaluation system or the Centre for Evidence-Based Medicine system. To address disparate grading systems, we mapped the perceived level of evidence and strength of recommendations onto the American Heart Association guideline classification schema.
Results: Recommendations found in two or more guidelines were collected into a clinical checklist characterized by strength of evidence and strength of recommendation. Areas for future research were identified among recommendations based on minimal evidence, areas of controversy, or areas of clinical care without recommendations.
Conclusions: Through this work we developed a multidisciplinary set of DFU guidelines stratified by strength of recommendation and quality of evidence, created a clinical checklist for busy practitioners, and identified areas for future focused research. This work should be of value to clinicians, guideline-issuing bodies, and researchers. We also formulated a method for the review and integration of guidelines issued by multiple professional bodies.
