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Consumptive coagulopathy resulting in a disseminated intravascular coagulation is most often seen in infectious diseases and hematologic malignancies. Solid tumors may be associated with disseminated intravascular coagulation that results in gangrene of the upper extremity. A case report of lower-extremity gangrene as the pathology for gastric carcinoma is presented. The need for a multidisciplinary approach to this clinical presentation is noted. (J Am Podiatr Med Assoc 92(3): 149-152, 2002)
Protein S Deficiency and Lower-Extremity Arterial Thrombosis
Complicating a Common Presentation
A 42-year-old woman presented to the emergency department with progressive painful discoloration of the digits of her right foot and symptoms previously diagnosed as neuroma. She was admitted to the hospital for dorsalis pedis arterial occlusion and ischemic foot pain. Despite attempts to restore perfusion to the right leg, ischemia of the right foot persisted and progressed to digital gangrene. The patient subsequently required right transmetatarsal amputation and eventually below-the-knee amputation. After extensive inpatient vascular and hematologic work-up of this otherwise healthy woman, test results revealed that she had protein S deficiency, hepatitis C, and human immunodeficiency virus type 1. In addition to describing this patient’s evaluation and treatment, we review protein S deficiency, including its correlation with human immunodeficiency virus type 1 infection and laboratory diagnosis. This case promotes awareness of protein S deficiency and serves as a reminder to the physician treating patients with vascular compromise and a history of human immunodeficiency virus type 1 to include protein S deficiency in the differential diagnosis. (J Am Podiatr Med Assoc 97(2): 151–155, 2007)
Proposed Mechanism of Action of Topically Applied Autologous Blood Clot Tissue
A Quintessential Cellular and Tissue-Based Therapy
Background: Chronic wounds, especially in patients with diabetes, often represent clinical challenges. Recently, the use of a topically applied blood clot has garnered significant interest. This stromal matrix contains viable cells that are autologous, biocompatible, biological, and consistent with a metabolically active scaffold. It has been shown to be safe, effective, and cost-efficient. However, the mechanism of action of this modality remains elusive. We sought to identify a potential mechanism of action of an autologous blood clot.
Methods: Review of clinical and scientific literature hypothesizes on how autologous blood clots may stimulate healing and facilitate the movement of critical substrates while lowering bioburden and fostering angiogenesis.
Results: Blood serves as a carrier for many components: red blood cells, white blood cells, platelets, proteins, clotting factors, minerals, electrolytes, and dissolved gasses. In response to tissue injury, the hemostatic mechanism uses a host of vascular and extravascular responses initiating primary, secondary, and tertiary hemostasis. The scaffold created by the autologous blood clot tissue provides a medium in which the body can transform the wound from a nonhealing chronic condition into a healing acute condition. The autologous blood clot tissue also creates a protective setting for the body to use its own mechanisms to promote wound healing in an organized manner. This transient scaffold recruits surrounding fibroblasts and promotes cell ingrowth to foster granulation tissue remodeling. Cells in this matrix sense not only soluble factors but also their physical environments. This well-orchestrated mechanism includes signals from soluble molecules, from the substrate/matrix to which the cell is adherent, from the mechanical or physical forces acting on it, and from contact with other cells. Topically applied autologous blood clot tissue can lower bacterial bioburden while stimulating angiogenesis and fostering the movement of keratinocytes and fibroblasts.
Conclusions: Topically applied autologous blood clot tissue is a formidable cellular and tissue-based therapy that has been shown to be safe and effective. Although the central component of this therapy is blood, the autologous clot tissue creates a scaffold that performs as a biological delivery system that functions to control the release of growth factors and cytokines over several days.
Anesthetics containing epinephrine have long been thought unsuitable for use in the foot and, particularly, the digits. However, research suggests that epinephrine use is beneficial in the appropriately selected patient. These benefits include a decreased local anesthetic plasma concentration; an increased duration of anesthesia, with a decreased need for additional narcotic use after surgery; decreased development of hemorrhage and postoperative hematoma, without occlusion of vessels; and a lack of complications (in millions of patients reported on in the literature). A retrospective review of more than 150 patients receiving local anesthetics containing epinephrine revealed no complications in the foot and ankle. (J Am Podiatr Med Assoc 93(2): 157-160, 2003)
