Cyanosis of the digits may have several etiologies ranging from trauma to connective tissue disease; however, the most common cause of the so-called blue toe syndrome is atheroembolic disease or aneurysm and is frequently misdiagnosed on initial presentation. Pedal pulses are often palpable which may misdirect the physician from a diagnosis of vascular pathology. Furthermore, the proximal source of embolic shower may be far from the sight of symptoms. Noninvasive vascular testing, peripheral angiography, abdominal and popliteal ultrasonography, and echocardiography are all techniques that may be beneficial in discovering the origin of emboli. Atheroembolisms and aneurysms can be limb-threatening or life-threatening and hence early diagnosis is imperative.
Background: Diabetic foot care has yet to be enhanced in a universal health-care system in which specialized podiatric medical services are unavailable. This baseline assessment surveyed diabetic patients attending group education to improve current foot-care practices.
Methods: Of 302 diabetic patients receiving usual outpatient care, 155 received group patient education on general diabetes-related information, which included foot care and an annual checkup by a diabetes association during the previous 2 years, and 147 did not. Patient foot-care behaviors, physician practice patterns, and patient self-perceived foot risk as cross-checked with the neurologic and vascular assessments were investigated by conducting retrospective medical record reviews and structured interviews.
Results: More than half of the patients in both groups reported inappropriate self-care behaviors (eg, walking barefoot and heating or soaking their feet). The percentages of patients receiving documented examinations and referrals for foot problems were low in both groups and were not significantly different. Among at-risk patients, 56% of the diabetes association group but only 30% of the non–diabetes association group perceived themselves to be at risk for future foot problems (P < .01).
Conclusions: Many diabetic patients were not offered adequate foot-specific information during group lectures, even those with high-risk foot problems. To improve this, combining caregiver and patient education in foot-care practices is important, and systems of networked multidisciplinary professionals are believed to be needed, particularly in delivering customized interventions to at-risk patients based on the initial evaluation. (J Am Podiatr Med Assoc 99(4): 295–300, 2009)
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.
Benjamin A. Lipsky, Anthony R. Berendt, Paul B. Cornia, James C. Pile, Edgar J. G. Peters, David G. Armstrong, H. Gunner Deery, John M. Embil, Warren S. Joseph, Adolf W. Karchmer, Michael S. Pinzur, and Eric Senneville
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.
Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
Background: Patient complaints of excessively warm or cold feet are common in medical practice. Such symptoms can be caused by underlying vascular or neurologic disease, and measurement of foot temperature during daily activity and sleep could provide a deeper understanding of their actual thermal basis.
Methods: We used a Thermochron iButton to assess surface foot temperature variation and its relationship to ambient temperature during the day with activity and at night during sleep in 39 healthy individuals aged 18 to 65 years in a temperate region of the United States. We simultaneously used actigraphy to record leg movement.
Results: We identified a mean ± SD awake temperature of 30.6° ± 2.6° C and asleep temperature of 34.0° ± 1.8° C, with values reaching as low as 15.9°C in the winter and as high as 37.5°C in the summer. Foot temperature was found to be independent of foot movement or sex; however, there was, as expected, a strong association between foot temperature and ambient temperature (r = .59, P < .001). Several measures of foot temperature variation demonstrated a significant or near-significant reduction with increasing age, including the Euclidean distance (r = −.38, P = .02) for awake periods and the variance (r = −.30, P = .06) during sleep.
Conclusions: These results provide data on the normal variation of foot temperature in individuals living in a temperate climate and demonstrate the potential use of Thermochron iButton technology in clinical contexts, including the evaluation of patients with excessively warm or cold feet. (J Am Podiatr Med Assoc 100(4): 258–264, 2010)
Foot problems are common in diabetic patients, with neuropathy and peripheral vascular disease being the main causative factors. Identification of high-risk feet can be accomplished by using basic clinical skills and simple equipment. Limb amputation is the most preventable of the long-term diabetes complications and a multidisciplinary approach can achieve a dramatic reduction of major limb amputations.
Fractures of the talus are significant injuries and are usually intra-articular. The authors discuss the evaluation and management of a patient with a delayed union of a talar body fracture. Assessment of talar vascularity and joint integrity should be performed preoperatively. The role of internal fixation and continuous passive motion is discussed.
Acute dysvascular limb in young adults is a rare entity. Diagnosis is often difficult because symptoms are not recognized as ischemic. The most common causes of this condition are premature atherosclerosis, thromboangiitis obliterans, microemboli, popliteal entrapment syndrome, collagen vascular disease, Takaysu's arteritis, and coagulopathy. A case study is presented to illustrate the disease process. A systematic approach to diagnosis, consisting of history and physical examination, palpation and auscultation of peripheral pulses at rest and following exercise, and noninvasive vascular examination at rest and following exercise, is recommended. Suggestion of an ischemic condition following noninvasive studies should be followed up with an arteriogram. The prognosis is dependent on the underlying etiology of the ischemia, early detection, and appropriate treatment.
Surgical matrixectomies and phenol alcohol matrixectomies have been effective in eliminating certain nail conditions. The complication rate is at an acceptable level; however, there is a need for comparison to other techniques, such as negative galvanism, trephine, osteotripsy, and laser ablation. Of the 353 patients in this study, two were known diabetics who were seen preoperatively by a vascular surgeon for vascular studies and by their internist. Both consultants agreed that the patients would heal. Both patients healed without complications. The author described the use of a modified Frost partial matrixectomy and modified Fowler total matrixectomy in this review. The phenol alcohol technique had a total complication rate of 9.6%, as did the partial matrixectomy. The total matrixectomy had an overall complication rate of 10.9%.
A second case of compartment syndrome affecting the dorsal aspect of the foot has been presented. The syndrome was arrested by fasciotomy. There were no permanent neurologic, vascular, or musculoskeletal sequelae. Although techniques exist to obtain quantitative measurements of intracompartmental pressure, the diagnosis rests heavily on clinical assessment. Practitioners who encounter trauma victims must recognize the symptoms of the condition and be familiar with the procedures necessary to interrupt it.