Search Results
This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls. Patients who underwent a fifth metatarsal head resection healed significantly faster (mean ± SD, 5.8 ± 2.9 versus 8.7 ± 4.3 weeks). Patients were much less likely to reulcerate during the period of evaluation in the surgical group (4.5% versus 27.8%). The results of this study suggest that fifth metatarsal head resection is a potentially effective treatment in patients at high risk of ulceration and reulceration. (J Am Podiatr Med Assoc 95(4): 353–356, 2005)
Maggot debridement therapy is rapidly increasing in popularity at major diabetic foot and wound care centers worldwide. However, we are unaware of specific guidelines on the short-term storage of larvae. We sought to evaluate differences in maggot motility over time in larvae refrigerated versus those stored at room temperature. We also introduce a simple surrogate method for evaluating maggot vitality that may be useful for in vivo studies if validated in future works. We randomly selected ten larvae from the same shipment at ten different times in 9 days. Larvae were placed on a translucent acetate grid, and their total excursion in 30 sec was measured. This was converted into a Maggot Motility Index. In the refrigerated group, the index remained at or above 40 mm/min for approximately 60 hours from baseline, when there was a significant decrease. This same phenomenon occurred during the first 12 hours in the nonrefrigerated group. There were significant differences in motility between refrigerated and nonrefrigerated larvae immediately after baseline until day 8. Larvae are more practical for repeated clinical use if kept refrigerated between applications. (J Am Podiatr Med Assoc 94(4): 353–355, 2004)
Background:
Diabetic foot care management is directed at patients with a history of complications, especially those with rising levels of hemoglobin A1c, and those who have had diabetes for several years. The aim of this study was to cross-culturally adapt a French-language version of the Diabetic Foot Self-care Questionnaire of the University of Malaga (DFSQ-UMA) for use in France.
Methods:
Cross-cultural adaptation was performed according to relevant international guidelines (International Society for Pharmacoeconomics and Outcomes Research), and the factor structure was determined. Internal consistency was measured using the Cronbach α. Item-total and inter-item correlations were assessed.
Results:
The French data set comprised 146 patients. The mean ± SD patient age was 62.60 ± 15.47 years. There were 47 women and 99 men. The structure matrix (with three factors) was tested by confirmatory factor analysis. The 16-item questionnaire had a Cronbach α of 0.92. The mean value for inter-item correlations was 0.48 (range, 0.17–0.86). The rotated solution revealed a three-factor structure that accounted for 48.10% of the variance observed. A significant inverse correlation was observed between questionnaire scores and hemoglobin A1c levels (r = –0.17; P < .01).
Conclusions:
This study validates the French-language version of the DFSQ-UMA, which can be used as a self-reported outcome measure for French-speaking patients in France.
The aim of this study was to evaluate whether high plantar foot pressures can be predicted from measurements of plantar soft-tissue thickness in the forefoot of diabetic patients with neuropathy. A total of 157 diabetic patients with neuropathy and at least one palpable foot pulse but without a history of foot ulceration were invited to participate in the study. Plantar tissue thickness was measured bilaterally at each metatarsal head, with patients standing on the same standardized platform. Plantar pressures were measured during barefoot walking using the optical pedobarograph. Receiver operating characteristic analysis was used to determine the plantar tissue thickness predictive of elevated peak plantar pressure. Tissue thickness cutoff values of 11.05, 7.85, 6.65, 6.55, and 5.05 mm for metatarsal heads 1 through 5, respectively, predict plantar pressure at each respective site greater than 700 kPa, with sensitivity between 73% and 97% and specificity between 52% and 84%. When tissue thickness was used to predict pressure greater than 1,000 kPa, similar results were observed, indicating that high pressure at different levels could be predicted from similar tissue thickness cutoff values. The results of the study indicate that high plantar pressure can be predicted from plantar tissue thickness with high sensitivity and specificity. (J Am Podiatr Med Assoc 94(1): 39-42, 2004)
Background:
There is an increased prevalence of foot ulceration in patients with diabetes, leading to hospitalization. Early wound closure is necessary to prevent further infections and, ultimately, lower-limb amputations. There is no current evidence stating that an elevated preoperative hemoglobin A1c (HbA1c) level is a contraindication to skin grafting. The purpose of this review was to determine whether elevated HbA1c levels are a contraindication to the application of skin grafts in diabetic patients.
Methods:
A retrospective review was performed of 53 consecutive patients who underwent split-thickness skin graft application to the lower extremity between January 1, 2012, and December 31, 2015. A uniform surgical technique was used across all of the patients. A comparison of HbA1c levels between failed and healed skin grafts was reviewed.
Results:
Of 43 surgical sites (41 patients) that met the inclusion criteria, 27 healed with greater than 90% graft take and 16 had a skin graft that failed. There was no statistically significant difference in HbA1c levels in the group that healed a skin graft compared with the group in which skin graft failed to adhere.
Conclusions:
Preliminary data suggest that an elevated HbA1c level is not a contraindication to application of a skin graft. The benefits of early wound closure outweigh the risks of skin graft application in patients with diabetes.
Background
The skin on human feet presents unique environments for the proliferation of potentially pathogenic commensals. This study examined microflora changes on healthy intact skin under a semiocclusive dressing on the medial longitudinal arch of the foot to determine changes in growth, distribution, and frequency of microflora under the dressing.
Methods
Nine human participants wore a low-adherent, absorbent, semiocclusive dressing on the medial longitudinal arch of the left foot for 2 weeks. An identical location on the right foot was swabbed and used as a control. Each foot was swabbed at baseline, week 1, and week 2. The swabs were cultured for 48 hours. Visual identification, Gram staining, DNase test agar, and a latex slide agglutination test were used to identify genera and species.
Results
Microflora growth was categorized as scant (0–10 colony-forming units [CFU]), light (11–50 CFU), moderate (51–100 CFU), or heavy (>100 CFU). Scant and light growth decreased and moderate and heavy growth increased under the dressing compared with the control. Seven different genera of bacteria were identified. Coagulase-negative Staphylococcus spp appeared most frequently, followed by
Conclusions
Changes in microflora distribution, frequency, and growth were found under the dressing, supporting historical studies. Microflora changes were identified as an increase in bioburden and reduction in diversity. The application of similar methods, using more sophisticated identification and analysis techniques and a variety of dressings, could lead to a better understanding of bacterial and fungal growth under dressings, informing better dressing selection to assist the healing process of wounds and prevent infection.
Background
Persons with diabetes have a higher incidence of fractures compared with persons without diabetes. However, there is little published information concerning the deleterious effect of late-stage diabetes on fracture healing. There are no studies using animal models that evaluate the effect of advanced diabetes on fracture healing. The purpose of our study was to evaluate cytokine expression, specifically macrophage inflammatory protein 1 (MIP-1) and vascular endothelial growth factor, in fracture healing in a type 2 diabetes rat model.
Methods
We evaluated biomarker expression after femur fracture using a rat model. The two groups consisted of 24 Zucker diabetic rats (study group) and 12 Zucker lean rats (control group). An independent reviewer was used to assess delayed union. We evaluated serum samples 2, 4, 7, and 14 days after surgery for MIP-1, vascular endothelial growth factor, leptin, and other cytokine levels.
Results
At 3 weeks, Kaplan-Meier estimates showed that 45.8% of femur fractures in Zucker diabetic rats had healed, whereas 81.8% of those in Zucker lean rats had healed (P = .02). A logistic regression model to predict fast healing that included the three cytokines and diabetes status showed that the only factor achieving significance was MIP-1α. Vascular endothelial growth factor was the only biomarker to show significance compared with delayed healing.
Conclusions
These results confirm significant differences in biomarker expression between diabetic and nondiabetic rats during bone healing. The key factors for bone healing may appear early in the healing process, whereas differences in diabetes versus nondiabetes are seen later in the healing process. Increased levels of MIP-1α were associated with the likelihood of delayed healing.
Background:
Partial foot amputations (PFAs) are often indicated for the treatment of severe infection, osteomyelitis, and critical limb ischemia, which consequently leads to irreversible necrosis. Many patients who undergo PFAs have concomitant comorbidities and generally present with a severe acute manifestation of the condition, such as gangrenous changes, systemic infection, or debilitating pain, which would then require emergency amputation on an inpatient basis.
Methods:
The purpose of this study was to track the recent prevalence of PFAs and to investigate the current demographic trends of the physicians managing and performing PFAs, specifically regarding medical degree and specialty. Doctors of podiatric medicine are striving to achieve parity with their allopathic and osteopathic surgical counterparts and become a more prominent part of the multidisciplinary approach to limb salvage and emergency surgical treatment. This study evaluated 4 years (2009–2012) of PFA data from the Pennsylvania state inpatient database in the two most populated areas of Pennsylvania: Philadelphia and Allegheny counties. Statistics on medical schools were obtained directly from the accrediting bodies of allopathic, osteopathic, and podiatric medical schools. The goal of this study was to evaluate the general trends of patients undergoing a PFA and to quantify the upswing of podiatric surgeons intervening in the surgical care of these patients.
Results:
The number of partial foot amputations in the United States rose from 2006 to 2012. Podiatric surgeons performed 46% of theses procedures for residents of Philadelphia County from 2009 to 2012. In Allegheny County podiatric physicians performed 42% of these procedures during the same time frame.
Conclusions:
Partial foot amputations are increasing over time. Podiatric Surgeons perform a significant share of these operations. This share is increasing in the most populated areas of Pennsylvania.
Background: We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections. It is widely believed that soft-tissue cultures are adequate in the determination of causative bacteria in patients with diabetic foot osteomyelitis. The culture results of specimens taken concurrently from soft-tissue and bone infections show that the former does not predict the latter with sufficient reliability. We sought to determine the similarity of pathogens isolated from soft tissue and bone in patients with diabetic foot infections.
Methods: Forty-five patients with diabetic foot infections were enrolled in the study. Patients had to have clinically suspected foot lesions of grade 3 or higher on the Wagner classification system. In patients with clinically suspected osteomyelitis, magnetic resonance imaging, scintigraphy, or histopathologic examination were performed. Bone and deep soft tissue specimens were obtained from all patients by open surgical procedures under aseptic conditions during debridement or amputation. The specimens were compared only with the other specimens taken from the same patients.
Results: The results of bone and soft-tissue cultures were identical in 49% (n = 22) of cases. In 11% (n = 5) of cases there were no common pathogens. In 29% (n = 13) of cases there were more pathogens in the soft-tissue specimens; these microorganisms included microbes isolated from bone cultures. In four patients (9%) with culture-positive soft-tissue specimens, bone culture specimens remained sterile. In one patient (2%) with culture-positive bone specimen, soft-tissue specimen remained sterile.
Conclusion: Culture specimens should be obtained from both the bone and the overlying deep soft tissue in patients with suspected osteomyelitis whose clinical conditions are suitable. The decision to administer antibiotic therapy should depend on these results. (J Am Podiatr Med Assoc 98(4): 290–295, 2008)
Background
Diabetic foot infection (DFI) is a serious, difficult-to-treat infection, especially when caused by methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin has been the standard treatment for MRSA infection, but lower response rates in MRSA skin infections have been reported. This analysis assessed the outcome and safety of daptomycin therapy in patients with a DFI caused by MRSA.
Methods
Using the Cubicin Outcomes Registry and Experience and the European Cubicin Outcomes Registry and Experience (2006–2009), 79 patients with MRSA DFI were identified and included in this analysis.
Results
In the 74 evaluable patients, daptomycin was administered at a median dose of 4.8 mg/kg primarily every 24 hours (85.1%) and for a median of 15.0 days. Overall, 77.0% of the patients (57 of 74) received initial therapy with activity against MRSA; however, of patients receiving daptomycin as second-line therapy (n = 31), only 45.2% were treated with an antibiotic agent active against MRSA. The overall clinical success and treatment failure rates were 89.2% and 10.8%, respectively. Success with daptomycin therapy was higher in patients who had surgery and in those whose initial therapy was daptomycin. Eleven patients had 14 adverse events, two of which were possibly related to daptomycin use and led to discontinuation.
Conclusions
In a large real-world cohort of patients with MRSA DFI, daptomycin therapy was shown to be generally well tolerated and effective. The use of an anti-MRSA antibiotic agent should be considered when implementing first-line antibiotic drug therapy for DFI in countries where MRSA is common to avoid inappropriate empirical treatment and potential negative effects on outcomes.
