It is well established and accepted that fungi are a major contributing factor in nail dystrophy. It has also been recognized that bacteria play a crucial role in onycholysis. However, the bacteria and fungi that can be grown on culture media in the laboratory are only a small fraction of the total diversity that exists in nature. Contemporary studies have revealed that fungi and bacteria often form physically and metabolically interdependent consortia that harbor properties and pathogenicity distinct from those of their individual components. Metagenomic DNA “shotgun” sequencing has proved useful in determining microbial etiology in clinical samples, effective for not only bacteria but also fungi, archaea, and viruses.
Thirty-nine consecutive nail and subungual debris samples with suspected onychomycosis were sent for laboratory analysis using three examination techniques: DNA sequencing, polymerase chain reaction analysis, and standard fungal culture. The nail plate and surrounding areas were disinfected with an ethyl alcohol swab before nail sampling. Samples from 16 patients were analyzed for suspected onychomycosis with DNA sequencing, searching a database of 25,000 known pathogens. These results were compared with 15 real-time polymerase chain reaction screening assays and eight fungal cultures sampled with the same methods.
The DNA sequencing detected 32 species of bacteria and 28 species of fungi: 50% were solely bacterial, 6.3% were solely fungal, and 43.7% were mixed communities of bacteria and fungi.
Toenails tested with DNA sequencing demonstrated the presence of both bacteria and fungi in many samples. Further work is required to fully investigate its relevance to nail pathology and treatment.
Diabetic foot ulcer (DFU) is a serious health problem. Major amputation increases the risk of mortality in patients with DFU; therefore, treatment methods other than major amputation come to the fore for these patients. Graft applications create an appropriate environment for the reproduction of epithelial cells. Similarly, epidermal growth factor (EGF) also stimulates epithelization and increases epidermis formation. In this study, we aimed to compare patients with DFU treated with EGF and those treated with a split-thickness skin graft.
Patients who were treated for DFU in the general surgery clinic were included in the study. The patients were evaluated retrospectively according to their demographic characteristics, wound characteristics, duration of treatment, and treatment modalities.
There were 26 patients in the EGF group and 21 patients in the graft group. The mean duration of treatment was 7 weeks (4-8 weeks) in the EGF group and 5.3 weeks (4-8 weeks) in the graft group (P < .05). In the EGF group, wound healing could not be achieved in one patient during the study period. In the graft group, no recovery was achieved in three patients (14.2%) in the donor site. Graft loss was detected in four patients (19%), and partial graft loss was observed in three patients (14.2%). The DFU of these patients were on the soles (85.7%). These patients have multiple comorbidities.
EGF application may be preferred to avoid graft complications in the graft area and the donor site, especially in elderly patients with multiple comorbidities and wounds on the soles.
Background: Prediction of amputation would aid clinicians in the management of diabetic foot infections. We aimed to assess the predictive value of baseline and post-treatment levels of acute phase reactants in the outcome of patients with diabetic foot infections.
Methods: We collected data prospectively during minimum follow-up of 6 months in patients with infected diabetic foot ulcers hospitalized in Dokuz Eylul University Hospital between January 1, 2003, and January 1, 2008. After excluding patients who did not attend the hospital for follow-up visits regularly (n = 36), we analyzed data from 165 foot ulcer episodes.
Results: Limb ischemia and osteomyelitis were much more frequent in patients who underwent amputation. Wagner grade, which assesses ulcer depth and the presence of osteomyelitis or gangrene, was higher in patients who needed amputation. Ulcer size was slightly larger in the amputation group. Baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, white blood cell counts, and platelet counts were significantly elevated in patients who underwent amputation. Albumin levels were significantly suppressed in the amputation group. Univariate analysis showed that a 1-SD increase in baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, and white blood cell counts and a 1-SD decrease in post-treatment albumin levels were significantly associated with increased risk of amputation. Post-treatment C-reactive protein level was strongly associated with amputation risk.
Conclusions: Circulating levels of acute phase reactants were associated with amputation risk in diabetic foot infections. (J Am Podiatr Med Assoc 101(1): 1–6, 2011)
Background: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon.
Methods: We evaluated the incidence of infection and other wound complications, such as suture reactions, scar revision, hematoma, incisional neuromas, and granuloma formation.
Results: A total of 219 surgical cases were available for review (140 males and 70 females; mean ± SD age at the time of surgery, 46.5 ± 12.6 years; age range, 16–75 years). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, for a total complication rate of 10.0%. Six patients had more than one complication; therefore, the percentage of patients with complications was 7.3%. There were no hematomas. Seven patients had additional surgery after their wound complications; some had simple granuloma excision, and one necessitated a flap. Patients with risk factors such as diabetes mellitus, smoking, and rheumatoid arthritis necessitating corticosteroid therapy were more likely to have a wound complication (Fisher exact test, P = .03).
Conclusions: Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed manner. Absorbable and nonabsorbable sutures can be implicated. (J Am Podiatr Med Assoc 98(2): 95–101, 2008)
Sixty-two patients were treated for single or multiple warts by intralesional injection of bleomycin sulfate (1.5 U/mL) and then were observed for 6 months. The dose varied according to the size of the lesion and ranged from 0.25 to 1.0 mL per injection per lesion, up to a maximum dose of 3 mL. The total cure rate was 87% after one or two injections. Twelve of the 62 patients required a second injection. (J Am Podiatr Med Assoc 96(3): 220–225, 2006)
An Assessment of Intralesional Epidermal Growth Factor for Treating Diabetic Foot Wounds
The First Experiences in Turkey
Intralesional epidermal growth factor (EGF) has been available as a medication in Turkey since 2012. We present the results of our experience using intralesional EGF in Turkey for patients with diabetic foot wounds.
A total of 174 patients from 25 Turkish medical centers were evaluated for this retrospective study. We recorded the data on enrolled individuals on custom-designed patient follow-up forms. Patients received intralesional injections of 75 μg of EGF three times per week and were monitored daily for adverse reactions to treatment. Patients were followed up for varying periods after termination of EGF treatments.
Median treatment duration was 4 weeks, and median frequency of EGF administration was 12 doses. Complete response (granulation tissue >75% or wound closure) was observed in 116 patients (66.7%). Wounds closed with only EGF administration in 81 patients (46.6%) and in conjunction with various surgical interventions after EGF administration in 65 patients (37.3%). Overall, 146 of the wounds (83.9%) were closed at the end of therapy. Five patients (2.9%) required major amputation. Adverse effects were reported in 97 patients (55.7%).
In patients with diabetic foot ulcer who received standard care, additional intralesional EGF application after infection control provided high healing rates with low amputation rates.
Vancomycin is a common treatment option for skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus (MRSA). Given the increasing prevalence of MRSA, vancomycin is widely used as empirical therapy. In patients with lower-limb infections, antimicrobial penetration is often reduced because of decreased vascular perfusion. In this study, we evaluated the tissue concentrations of vancomycin in hospitalized patients with lower-limb infections.
An in vivo microdialysis catheter was inserted near the margin of the wound and was perfused with lactated Ringer's solution. Tissue and serum samples were obtained after steady state for one dosing interval. Tissue concentrations were corrected for percentage of in vivo recovery using the retrodialysis technique.
Nine patients were enrolled (mean ± SD: age, 54 ± 19 years; weight, 105.6 ± 31.5 kg). Patients received a mean of 12.8 mg/kg of vancomycin every 12 hours (n = 7), every 8 hours (n = 1), or every 24 hours (n = 1). Mean ± SD steady-state trough vancomycin concentrations in serum and tissue were 11.1 ± 3.3 and 6.0 ± 2.6 μg/mL. The mean ± SD 24-hour free drug areas under the curve for serum and wound were 283.7 ± 89.4 and 232.8 ± 75.7 μg*h/mL, respectively. The mean ± SD tissue penetration ratio was 0.8 ± 0.2.
These data suggest that against MRSA with minimum inhibitory concentrations of 1 μg/mL or less, vancomycin achieved blood pharmacodynamic targets required for the likelihood of success. Reduced concentrations may contribute to poor outcomes and the development of resistance. As other literature suggests, alternative agents may be needed when the pathogen of interest has a minimum inhibitory concentration greater than 1 μg/mL.
Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds.
Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected.
There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P 30 = .818; 82.2% versus 80.9%, P 60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P 30 = .902; 1.2 cm2 versus 1.1 cm2, P 60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group.
Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.
The objective of this study was to evaluate the effectiveness of the surgical method of arc resection of soft-tissue nail fold combined with a shaped dressing for ingrown toenails. The surgical method involved the excision of nail fold granulation tissue and partial or total nail avulsion with preservation of its matrix. This surgical approach was applied to 20 consecutive patients (age range, 11–30 years) admitted to the hospital from January 1, 2014, to December 31, 2015. For assessment of the method, the operative technique, dressing change, and postoperative wound healing were recorded by photography. Finally, we evaluated the therapeutic effects by calculating the recurrence rate and nail groove expansion rate. Twenty patients with 38 surgical sites in 26 toes were analyzed; there was no recurrence at 3, 6, and 12 months. There was a statistically significant difference in the groove expansion rate at different time points. We measured the wound distance on postoperative day 1 compared with the day of healing and found that the method of shaped dressing could expand the nail groove by more than 50% (P ≤ .05). The mean ± SD recovery time was 15.1 ± 2.4 days. Arc resection of the nail folds for ingrown toenails coupled with preservation of its matrix minimizes trauma and is easy to manipulate. Applying a shaped dressing after the operation further reduces the risk of recurrence and ensures enough growth space for the toenails.
The surgical records of three podiatric physicians were reviewed to identify all chevron-type osteotomies performed during 2000–2001 for the correction of bunion deformity, and complications were reviewed for each. In the 95 cases identified, 15 complications occurred in 12 patients. Of these 15 complications, 4 were soft-tissue infections (4 patients), 4 were cases of painful hardware (3 patients), 4 were cases of second metatarsal head pain (2 patients), 2 were cases of cystic changes initially interpreted as osteomyelitis but later determined to be degenerative changes (2 patients), and 1 was a case of stiff toe (1 patient). There were no cases of avascular necrosis, hallux varus, or recurrence. (J Am Podiatr Med Assoc 93(6): 499-502, 2003)