Search Results
Background:
This study investigated the resistance of bacteria isolated from diabetic foot ulcers (DFUs) to antibiotics frequently used in the management of the diabetic foot infections, at a range of pH values (pH 6.5, 7.5, and 8.5) known to exist in DFU wound fluid. This study aimed to determine whether changes (or atypical stasis) in wound fluid pH modulate the antibiotic resistance of DFU isolates, with potential implications in relation to the suppression/eradication of bacterial infections in DFUs.
Methods:
Thirty bacterial isolates were recovered from DFU wound fluid, including Staphylococcus spp, Staphylococcus aureus, Escherichia coli, Streptococcus spp, Pseudomonas spp, and Pseudomonas aeruginosa. The resistances of these isolates to a panel of antibiotics currently used in the treatment of infected or potentially infected DFUs, ie, ciprofloxacin, amoxicillin-clavulanate, doxycycline, and piperacillin-tazobactam, at the previously mentioned pH values were determined by a modification of the Kirby-Bauer assay.
Results:
The resistance of DFU isolates to clinically relevant antibiotics was significantly affected by the pH levels in DFU wound fluid.
Conclusions:
These findings highlight the importance of a more comprehensive understanding of the conditions in DFUs to inform clinical decision making in the selection and application of antibiotics in treating these difficult-to-heal wounds. The scale of the differences in the efficacies of antibiotics at the different pH values examined is likely to be sufficient to suggest reconsideration of the antibiotics of choice in the treatment of DFU infection.
Addressing pressure reduction in the treatment of diabetic foot wounds is a critical component of therapy. The total-contact cast has proven to be the gold standard of treatment because of its ability to reduce pressure and facilitate patient adherence to the off-loading regimen. Removable cast walkers have proven to be as effective as total-contact casts in pressure reduction, but this has not translated into equivalent time to healing. A simple technique to convert the removable cast walker into a device that is not as easily detached from the lower extremity, thereby encouraging the use of this device over a 24-hour period, is presented in this article. The procedure involves wrapping the cast walker with cohesive bandage or plaster of Paris. In the authors’ opinion, this technique addresses many of the disadvantages of the total-contact cast, resulting in an adequate compromise in this aspect of care. (J Am Podiatr Med Assoc 92(7): 405-408, 2002)
Background: The selection of materials for the production of multilayer insoles for diabetic feet is a difficult task owing to the lack of technical information about these materials. Therefore, objective criteria were established for the selection of these materials.
Methods: Mechanical- and comfort-related tests for the mechanical characterization of different materials and their combinations were considered. These tests were conducted according to standardized test methods for polymeric cellular materials.
Results: Criteria for the use of cellular materials were obtained. The properties of accommodation, cushioning, and filling materials were established and the most adequate polymer nature for each of the three applications was identified. Variables that affect the properties of these material combinations were studied.
Conclusions: These test results will allow podiatrists to select insoles in a more objective way, thus achieving a more successful treatment for diabetic foot-related injuries. (J Am Podiatr Med Assoc 98(3): 229–238, 2008)
Foot pain and lower-limb neuroischemia in diabetes mellitus is common and can be debilitating and difficult to treat. We report a comparison of orthotic materials to manage foot pain in a 59-year-old man with type 1 diabetes mellitus, peripheral neuropathy, peripheral arterial disease, and a history of foot ulceration. We investigated a range of in-shoe foot orthoses for comfort and plantar pressure reduction in a cross-sectional study. The most comfortable and most effective pressure-reducing orthoses were subsequently evaluated for pain relief in a single system alternating-treatment design. After 9 weeks, foot pain was completely resolved with customized multidensity foot orthoses. The outcome of this case study suggests that customized multidensity foot orthoses may be a useful intervention to reduce foot pain and maintain function in the neuroischemic diabetic foot. (J Am Podiatr Med Assoc 98(2): 143–148, 2008)
Relation Between Popliteal-Tibial Artery Atherosclerosis and Global Glycolytic Metabolism in the Affected Diabetic Foot
A Pilot Study Using Quantitative FDG-PET
Background:
We evaluated the extent and the degree of active atherosclerosis in the popliteal-tibial arteries by quantitative techniques using [18F]-2-fluoro-2-deoxy-d-glucose–positron emission tomography (FDG-PET). An effort was made to determine whether there was a positive correlation between the level of ongoing atherosclerosis and subsequent chronic ischemia in the diabetic foot.
Methods:
A total of 115 diabetic patients were enrolled in this prospective research study and underwent lower-extremity FDG-PET and magnetic resonance imaging. We selected 36 diabetic patients with complicated diabetic foot for this analysis (11 men, 25 women; mean age, 59.5 years; age range, 36–85 years). Ten nondiabetic control participants (6 men, 4 women; mean age, 59.7 years; age range, 27–88 years) were also included for comparison. Only patients with blood glucose levels less than 200 mg/100 mL were enrolled in this study. The metabolic volumetric product (MVP), for each patient was calculated multiplying foot average maximum standard uptake value (SUVmax) by foot volume. Pearson correlation analysis between foot mean SUVmax alone and the degree of atherosclerosis and between the foot MVP and the degree of atherosclerosis was performed as measured by FDG-PET. A t test was used to assess for significant differences in foot SUVmax and foot MVP among varying degrees of atherosclerosis, using P < .05 as the criterion for statistical significance.
Results:
Foot SUVmax significantly correlated (P < .05) with the ratio of popliteal-tibial artery SUVmax to background SUV (Pearson correlation coefficient = 0.49). Foot MVP was also significantly correlated (P < .05) with the ratio of popliteal-tibial artery SUVmax to background SUV (Pearson correlation coefficient = 0.69).
Conclusions:
Using FDG-PET, one may be able to detect and quantify the degree of increased metabolic activity of early active atherosclerosis and the associated chronic tissue ischemic effects at the regional level and globally throughout the whole body during the asymptomatic phase of disease. (J Am Podiatr Med Assoc 102(3): 240–246, 2012)
Elevated plantar pressures are an important predictor of diabetic foot ulceration. The objective of this study was to determine which clinical examination variables predict high plantar pressures in diabetic feet. In a cross-sectional study of 152 male veterans with diabetes mellitus, data were collected on demographics, comorbid conditions, disease severity, neuropathy status, vascular disease, and orthopedic and gait examinations. Univariate predictors included height, weight, body surface area, body weight per square inch of foot surface area, bunion deformity, hammer toe, Romberg’s sign, insensitivity to monofilament, absent joint position sense, decreased ankle dorsiflexion, and fat pad atrophy. Variables that remained significantly associated with high plantar pressures (≥4 kg/cm2) in multivariate analysis included height, body weight per square inch of foot surface area, Romberg’s sign, and insensitivity to monofilament. These results may be useful in identifying patients who would benefit from interventions designed to decrease plantar foot pressures. (J Am Podiatr Med Assoc 93(5): 367-372, 2003)
The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis. (J Am Podiatr Med Assoc 92(6): 336-349, 2002)
Background:
Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO.
Methods:
This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation.
Results:
Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA.
Conclusions:
Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.
Introduction: A study of 72 subjects conducted in the European Union and Australia assessed the safety and efficacy of Apligraf (Organogenesis, Inc, Canton, Massachusetts), a bilayered cell therapy composed of living keratinocytes and living fibroblasts in the treatment of non-infected, diabetic foot ulcers (DFU). The design and patient population of this study were similar to a 208-subject United States study (Veves et al., 2001), which led to FDA approval of Apligraf for the treatment of DFU. EU patient outcomes were compared and contrasted to established US-based patient outcome parameters.
Methods: Subjects with a non-infected neuropathic diabetic foot ulcer present for at least two weeks were enrolled in these prospective, multicenter, randomized, controlled, open-label studies that compared Apligraf used in conjunction with standard therapy (sharp debridement, standard wound care, and off-loading) against standard therapy alone.
Results: The design, conduct, and patient populations of the EU and US studies were comparable. Pooling of data was able to be performed because of the similarity and consistency of the two studies. Efficacy and safety results remained consistent across studies independent of mean ulcer duration that was significantly longer in the EU study (21 months, compared to 10 months in the US). Reported adverse events through 12 weeks were comparable across treatment groups in the two studies. Multiple efficacy measures consistently demonstrated superiority of Apligraf treatment over control treated groups in both studies. Combining the data from both studies, 55.2% (80/145) of Apligraf subjects had complete would closure by 12 weeks, compared to 34.3% (46/134) of Control subjects (P = 0.0005; Fisher3s exact test), and Apligraf subjects had a significantly shorter time to complete wound closure (P = 0.0004; log-rank test).
Conclusions: Both the EU and US studies exhibited superior efficacy and comparable safety for subjects treated with Apligraf compared to control treated subjects. The similar outcomes of the two studies provide robust, consistent evidence of the benefit of Apligraf in treating geographically disparate DFU patient populations.
Background:
Offloading devices for diabetic foot ulcers (DFU) generally restrict exercise. In addition to traditional health benefits, exercise could benefit DFU by increasing blood flow and acting as thermotherapy. This study functionally evaluated a cycling cleat designed for forefoot DFU.
Methods:
Fifteen individuals at risk of developing a DFU used a recumbent stationary bicycle to complete one 5-minute cycling bout with the DFU cleat on their study foot and one 5-minute bout without it. Foot stress was evaluated by plantar pressure insoles during cycling. Laser Doppler perfusion monitored blood flow to the hallux. Infrared photographs measured foot temperature before and after each cycling bout.
Results:
The specialized cleat significantly reduced forefoot plantar pressure (9.9 kPa versus 62.6 kPa, P < .05) and pressure time integral (15.4 versus 76.4 kPa*sec, P < .05). Irrespective of footwear condition, perfusion to the hallux increased (3.97 ± 1.2 versus 6.9 ± 1.4 tissue perfusion units, P < .05) after exercise. Infrared images revealed no changes in foot temperature.
Conclusions:
The specialized cleat allowed participants to exercise with minimal forefoot stress. The observed increase in perfusion suggests that healing might improve if patients with active DFU were to use the cleat. Potential thermotherapy for DFU was not supported by this study. Evaluation of the device among individuals with active DFU is now warranted.
