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Biomedical subjects

L Sullivan

Publications and source records attributed to L Sullivan.

At least 37 records · Page 2Linked to original sources

Nutritional folate deficiency augments the in vivo mutagenic and lymphocytotoxic activities of alkylating agents.

To investigate the interaction of folate deficiency and alkylating agents in vivo, weanling Fischer 344 rats were maintained for 5 weeks on a folate replete, moderately folate deficient, or a severely folate deficient diet. Mutant frequencies at the HPRT locus in splenic lymphocytes were 1.2+/-0.6, 1.9+/-1.1, and 6.4+/-4.0 x 10(-6), respectively (P < 0.01). N-nitroso-N-ethylurea (ENU), 100 mg/kg body weight, was much more mutagenic with progressive folate deficiency (5.0+/-2.4 vs. 16.2+/-7.3 vs. 39.2+/-21.0 x 10(-6)), suggesting a synergistic interaction (P << 0.01). Neither moderate nor severe folate deficiency significantly enhanced the mutagenic effects of cyclophosphamide, 50 mg/kg body weight (18.0+/-7.9 vs. 6.0+/-2.8 vs. 28.5+/-28.2 x 10(-6)). The number of cloning cells/ spleen were reduced 68% in moderately folate deficient rats and by 87% in severely deficient animals (P < 0.05). The combination of folate deficiency and cyclophosphamide reduced the total number of cloning cells further, but ENU alone, or in combination with folate deficiency, did not. These findings indicate that folate deficiency increases the risk of somatic mutations and is lymphocytotoxic in rats. Folate deficiency enhances the mutagenic but not the lymphotoxic effects of ENU, while it increases the lymphotoxic but not the mutagenic activity of cyclophosphamide. Correction of folate deficiency may decrease the immunologic and genetic damage caused by some alkylating agents.

Alkylating Agents↗

Aqueous solubilization of transmembrane peptide sequences with retention of membrane insertion and function.

We recently reported that the peptide C-K4-M2GlyR mimics the action of chloride channels when incorporated into the apical membrane of cultured renal epithelial monolayers. C-K4-M2GlyR is one of a series of peptides that were prepared by the addition of lysine residues to the N- or C-terminus of the M2 transmembrane sequence of the brain glycine receptor. This study addresses how such modifications affect physical properties such as aqueous solubility, aggregation, and secondary structure, as well as the ability of the modified peptides to form channels in epithelial monolayers. A graded improvement in solubility with a concomitant decrease in aggregation in aqueous media was observed for the M2GlyR transmembrane sequences. Increases in short-circuit current (I(SC)) of epithelial monolayers were observed after treatment with some but not all of the peptides. The bioactivity was higher for the more soluble, less aggregated M2GlyR peptides. As described in our previous communication, sensitivity of channel activity to diphenylamine-2-carboxylate, a chloride channel blocker, and bumetanide, an inhibitor of the Na/K/2Cl cotransporter, was used to assess changes in chloride selectivity for the different assembled channel-forming peptides. The unmodified M2GlyR sequence and the modified peptides with less positive charge are more sensitive to these agents than are the more highly charged forms. This study shows that relatively insoluble transmembrane sequences can be modified such that they are easier to purify and deliver in the absence of organic solvents with retention of membrane association, insertion, and assembly.

Amino Acid Sequence↗

Wing-beat frequency mutants and courtship behavior in Drosophila melanogaster males.

Flightless mutations that affect wing-beat frequency (WBF) of Drosophila melanogaster were examined for their effect on male courtship. WBFs were measured using a fixed-wire tether that completely supports the fly in an attitude similar to hovering flight. The two spontaneous mutations, one of which reduces WBF to one-half normal and the other to zero, were placed on an isogenic background and were compared to an isogenic wildtype strain and to a genetically heterogeneous wildtype strain. Time to mating under noncompetitive conditions (single pair matings) was not significantly different among the four male types in one experiment. In a second experiment, although the time to mating varied significantly among the four male types, there was no association between the WBF that was characteristic of a male type and the length of time to mating. Time to mating was not significantly correlated with WBF, wing size, or body mass in either experiment. Genetically heterogeneous wild-type females were significantly more receptive (had shorter times to mating) than inbred wild-type females toward all four male types. During the time-to-mating tests, all four male types appeared to show typical courtship behaviors. Therefore, the male types were compared for possible differences in four components of the male courtship song: sine song frequency, interpulse interval, intrapulse frequency (= carrier frequency), and wing cycles per pulse. One or another of these components showed significant differences among the four male types (e.g., genetically heterogeneous, wild-type males showed a significantly higher sine song frequency and intrapulse frequency than males of the three isogenic types). However, the average values for all four male types were within reported wild-type ranges for each courtship song component. Although the two mutations drastically reduce WBF during tethered flight, they do not have any similar major effect on courtship. Apparently they affect muscles or neuronal control mechanisms that are not common elements shared by the wing movement of flight and male courtship song.

Animals↗

Regional sympathetic function in high spinal cord injury during mental stress and autonomic dysreflexia.

Centrally mediated sympathetic stimulation of subjects who have suffered a spinal cord injury (SCI) does not activate the decentralized part of the body below the level of the lesion, whereas experimental data indicate an exaggerated response above the level of the lesion. SCI subjects may exhibit an autonomic dysreflexia reaction following afferent stimulation below the level of the lesion. In order to investigate the function of the sympathetic nervous system above and below the level of the lesion, regional noradrenaline spillover was measured by means of steady-state isotope dilution technique above (forearm) and below (leg) the level of the lesion at baseline, during mental stress and following bladder stimulation in nine SCI subjects (mean age 41 years; level of injury C7-T4; mean duration of injury 13.8 years). The results from the SCI subjects were also compared with those from 10 weight- and age-matched control subjects, both at rest and during mental stress. Body composition was determined by dual energy X-ray absorptiometry scanning and arm/leg blood flow by occlusion plethysmography. At baseline, total and regional noradrenaline spillover did not differ between the groups. Mental stress increased mean arterial pressure in both groups. Heart rate (76 versus 64 beats/min; P < 0.05) and arm noradrenaline spillover (2.73 versus 1.71 pmol/min/100 g; P < 0.05) increased more in spinal cord injury subjects than in control subjects, whereas total body (2826 versus 3783 pmol/min; P < 0.01) and leg noradrenaline spillover (0.23 versus 0.41 pmol/min/100 g; P < 0.05) increased only in the control group. During bladder stimulation, SCI subjects reacted with a marked increase in mean arterial pressure and leg noradrenaline spillover (from 0.06 to 0.91 pmol/min/100 g; P < 0.05) and their leg blood flow decreased. Regional and total noradrenaline clearance were similar in the two groups. In conclusion, peripheral afferent stimulation below the level of the lesion in spinal cord injury subjects gives rise to a marked noradrenaline spillover from the decentralized part of the sympathetic nervous system suggesting a remaining, but qualitatively altered, neuronal function. Centrally mediated stimulation induced an exaggerated response above the level of the lesion.

Absorptiometry, Photon↗

Regulation of lipolysis by the sympathetic nervous system: a microdialysis study in normal and spinal cord-injured subjects.

To evaluate the regulation of lipolysis by the sympathetic nervous system, eight spinal cord-injured (SCI) subjects with a lesion above T5 resulting in a decentralization of the lower-body sympathetic nervous system and adrenal medulla (age, 36 +/- 2 years; weight, 82 +/- 5 kg; body fat mass, 26.8 +/- 3.0 kg; all mean +/- SE) and nine control subjects (age, 33 +/- 2; weight, 80 +/- 3; NS; body fat mass, 16.1 +/- 1.5 kg; P < .01) were investigated after fasting overnight. Each subject was studied with subcutaneous microdialysis and 133Xe-clearance adipose tissue blood flow (ATBF) in the umbilical and clavicular regions during postabsorptive rest and after sympathoexcitatory stimulation by means of mental stress and isometric handgrip exercise. SCI subjects had an increased body fat mass, hyperinsulinemia, and an elevated lipolytic rate at rest compared with control subjects. ATBF and lipolysis were activated to a normal extent following mental stress and isometric handgrip exercise in the umbilical region in control subjects. ATBF was increased in tissue above but not below the lesion level in SCI subjects following mental stress. Glycerol release was not different between groups in either tissue region despite significantly lower noradrenaline and adrenaline levels in SCI subjects. This finding argues against a significant adrenergic control of the lipolytic rate at rest. Furthermore, the small differences in stimulated glycerol release between groups, as well as the increased plasma glycerol levels in SCI subjects, cast doubt on the view that interruption of adrenergic activity below the lesion is the sole mechanism underlying the increased body fat mass in SCI subjects.

Adult↗

Peripheral afferent stimulation of decentralized sympathetic neurons activates lipolysis in spinal cord-injured subjects.

Spinal cord-injured (SCI) subjects exhibit a normal lipolytic rate despite the failure of centrally mediated sympathoexcitatory stimuli to activate lipolysis. Peripheral afferent stimulation below the lesion level induces an exaggerated autonomic reaction in SCI with lesion levels above T5, ie, so-called autonomic dysreflexia. The metabolic effects of induced dysreflexia were investigated in five SCI subjects (age, 35 +/- 8 years; duration of paresis, 15 +/- 7.5 years [mean +/- SD]; lesion level, T3 to T4, n = 2, C7, n = 3) following bladder stimulation. Subcutaneous glycerol concentrations were measured by microdialysis above and below the lesion level. Diurnal plasma noradrenaline (NA) and adrenaline levels were continuously monitored in seven SCI subjects (lesion level T3 to T4, n = 2; C4 to C7, n = 5). Bladder stimulation resulted in an increased mean arterial pressure ([MAP] 81 +/- 8 to 114 +/- 11 mm Hg, P < .05), a decreased heart rate (70 +/- 3 to 54 +/- 4 beats/min, P < .05), and an increased plasma NA (0.70 +/- 0.49 v 3.27 +/- 1.56 nmol/L, P < .05). Interstitial glycerol was increased in the decentralized region (89 +/- 12 to 135 +/- 21 mumol/L, P < .05), whereas no reaction was found in the centrally innervated region. Plasma concentrations of glycerol and insulin increased. Diurnal monitoring showed periods of increased plasma NA sufficient to induce lipolysis (> 1.4 nmol/L) during 20% of the registration period. The data suggest that peripheral afferent stimulation below the lesion level increases NA release and activates lipolysis and that frequent episodes of activation are found in SCI subjects with tetraplegia or high paraplegia.

Adult↗

Spinal cord injuries: a shortened measure of function and mood.

A brief quality-of-life (QL) questionnaire was derived empirically from a cross-sectional study of 98 SCI-patients (83% men, median age 33.5 years, and median time after injury 2.3 years). A comprehensive general battery of well-established questionnaires (Sickness Impact Profile (SIP), Mood Adjective Check List (MACL), and Hospital Anxiety and Depression (HAD) scale) was combined with a study-specific set of questions to constitute patients' QL. A stepwise analysis model was used to define key areas and questions to be included in a brief SCI-adapted questionnaire. The central areas that independently mattered for SCI-patients' perception of good QL included mental health (no depressive feelings), physical and psychosocial dysfunction (no, or few and minor, limitations in mobility, body care and movement and social interaction), and SCI-related problems (no or little perceived difficulty with loss of independence due to injury). A 22-item questionnaire is suggested for routine clinical follow-up to assess more accurately when optimal treatment and services have been delivered.

Activities of Daily Living↗

The importance of osmolality in hydrophilic urethral catheters: a crossover study.

The longterm use of clean intermittent self catheterisation as an option for bladder management in the care of spinal cord injury patients has shown the possible risk of urethral trauma and chronic infections being developed over time. The basic properties of the catheters being used need to be evaluated. In this crossover study of 14 male spinal cord injury patients, two commercial hydrophilic catheters were compared, as to the maximum friction force during the removal of the catheters after bladder emptying. The friction force, measured by a dynamometer twice daily, showed significant lower values for LoFric (0.87/0.84 N) than for EsiCath/Conveen (1.38/1.27 N). Sticking to the urethral epithelium was reported three times (two patients) with the LoFric catheter, and 42 times (nine patients) with the EasiCath catheter. Osmolality of the outer layer of the catheters was measured using a freezing-point reduction technique. The greater than 10 times higher osmolality (approximately 900 mOsm/kg) of the Lofric catheter may explain the results.

Adult↗

The effects of an HIV/AIDS educational programme on the anxiety level of nursing students.

Acquired immunodeficiency syndrome (AIDS) is a serious disease that has special concern for the health care provider. AIDS has continued to grow despite control efforts. As the disease infectivity period remains lengthy, and the heterosexual population is affected to a greater degree, the level of anxiety has also risen despite educational endeavours. Many fears and anxieties have been associated with AIDS patients by health care workers. The reduction of stress, perceived risk and discomfort following educational efforts have been supported in past research. Educational programmes will need to be given for current health care workers at all levels as well as nursing students. Future nurses must be prepared to meet this challenge. This study was conducted using a convenience sample of nursing students at a university in western United States. Its purpose was to assess any changes that occurred in state anxiety following an educational presentation. Spielberger's State-Trait Anxiety Inventory was used as the measurement instrument. Some anxiety levels were significantly reduced.

Adult↗

Differentiated norepinephrine spillover in human skeletal muscle.

Most neurophysiological studies have shown similar sympathetic outflow to arm and leg. However, some direct microneurographic recordings indicate differentiated sympathetic outflow to limbs both at rest and during mental stress. Hence, differentiated levels of norepinephrine (NE) spillover could prevail. By steady-state infusion of [3H]NE and body composition determination by dual-energy X-ray absorptiometry-scan, we simultaneously assessed arm and leg NE spillover related to 100 g tissue and total limb weight. NE spillover was lower in leg than arm (0.26 vs. 1.51 pmol.min-1.100 g-1, P < 0.05), and the difference remained when expressed as a function of total limb weight (66 vs. 137 pmol/min, P < 0.05). Fractional extraction of [3H]NE was similar in arm and leg. Neuronal uptake blockade by desipramine was more effective in leg than arm; fractional extraction in leg decreased by 32% (P < 0.05) but was unaltered in arm. Thus a lower NE spillover was observed from leg than arm, possibly reflecting a lower sympathetic outflow and a more neuronally dependent reuptake.

Absorptiometry, Photon↗

Bovine tuberculosis in free-ranging white-tailed deer from Michigan.

A 4.5 yr-old male white-tailed deer (Odocoileus virginianus) killed by a hunter during the 1994 firearm hunting season in northeastern Michigan (USA) had lesions suggestive of tuberculosis and was positive on culture for Mycobacterium bovis the causative agent for bovine tuberculosis. Subsequently, a survey of 354 hunter-harvested white-tailed deer for tuberculosis was conducted in this area from 15 November 1995 through 5 January 1996. Heads and/or lungs from deer were examined grossly and microscopically for lesions suggestive of bovine tuberculosis. Gross lesions suggestive of tuberculosis were seen in 15 deer. Tissues from 16 deer had acid-fast bacilli on histological examination and in 12 cases mycobacterial isolates from lymph nodes and/or lungs were identified as M. bovis. In addition, lymph nodes from 12 deer (11 females and 1 male) without gross or microscopic lesions were pooled into 1 sample from which M. bovis was cultured. Although more male (9) than female (3) deer had bovine tuberculosis infections, this difference was not statistically significant. Mycobacterium bovis culture positive deer ranged in age from 1.5 to 5.5 yr with a mean of 2.7 yr (median 2.5 yr) for males and 3.2 yr (median 3.5 yr) for females. This appears to be the first epidemic occurrence of M. bovis in free-ranging cervids in North America. A combination of environmental (high deer density and poor quality habit) and management-related factors (extensive supplemental feeding) may be responsible for this epizootic.

Animals↗

Genetic mapping of RP1 on 8q11-q21 in an Australian family with autosomal dominant retinitis pigmentosa reduces the critical region to 4 cM between D8S601 and D8S285.

The locus (RP1) for one form of autosomal dominant retinitis pigmentosa (adRP) was mapped on chromosome 8q11-q22 between D8S589 and D8S285, which are about 8 cM apart, by linkage analysis in an extended family ascertained in the USA. We have studied a multigeneration Australian family with adRP and found close linkage without recombination between the disease locus and D8S591, D8S566, and D8S166 (Zmax = 1.137-4.650 at theta = 0.00), all mapped in the region known to harbor RP1. Assuming that the mutation of the same gene is responsible for the disease in both families, the analysis of multiply informative meioses in the American and Australian families places the adRP locus between D8S601 and D8S285, which reduces the critical region to about 4 cM, corresponding to approximately 4 Mb, which is completely covered by a yeast artificial chromosome contig assembled recently.

Adult↗

Electromyographical evidence for exercise-induced diaphragm fatigue in patients with chronic cervical cord injury or prior poliomyelitis infection.

UNLABELLED: The purpose of this study was to determine, in exercising patients, how much diaphragm force increases before electromyographical evidence of diaphragm fatigue occurs. The study was performed in ten male patients with complete cervical cord injury (CCI) at the C5 to C8 levels, and five male patients with prior poliomyelitis infection (PPI) requiring chronic treatment with intermittent positive pressure ventilation (IPPV) at night. We studied the time course of the diaphragmatic tension-time index (TTdi), the centre frequency (CFdi) of the diaphragm electromyogram (EMGdi) power spectrum, and the ventilatory parameters, during steady-state submaximal arm/leg exercise. During exercise, early signs of diaphragm fatigue were present in seven out of 10 CCI patients and in four out of five PPI patients, as indicated by a reduction in CFdi. The increase in TTdi achieved before reductions in CFdi occurred was twofold in both the CCI and PPI patients. All patients except for the PPI patients, who demonstrated a reduction in CFdi, showed an increase in minute ventilation (VE), achieved by increasing both their tidal volume (Vt) and the breathing frequency (fb). The PPI patients demonstrating reductions in CFdi during exercise also increased their VE however, this was achieved by increasing fb while Vt remained constant. Following the reductions in CFdi, the CCI patients further increased their TTdi throughout the exercise test, while the PPI patients reduced their TTdi values. IN CONCLUSION: (1) During exercise, electromyographical evidence for diaphragmatic fatigue frequently occurred in the CCI and PPI patients studied; (2) Compared to the eightfold increase in TTdi seen in healthy subjects before reductions in CFdi occur, the TTdi values increased only two-fold before electromyographical evidence of diaphragm fatigue was present in these patients; (3) There is a clear discrepancy between the CCI and PPI patients who demonstrate electromyographical evidence of diaphragm fatigue, in terms of their ventilatory and TTdi responses.

Adult↗

Diaphragm function in patients with cervical cord injury or prior poliomyelitis infection.

Diaphragm function was evaluated in cervical cord injury patients (CCI), 1-3 years after injury (CCI(1-3)) and 10 years or more after injury (CCI(> or = 10)), as well as in a group of prior poliomyelitis infection patients (PPI), requiring intermittent positive pressure ventilation (IPPV) for about 6 h per night. Measurements included transdiaphragmatic pressure swings (delta Pdi) at rest, during maximal inspiratory efforts against closed airways (delta Pdi(max)) and during sniff manoeuvres (ie maximal inhalation through the nose, delta Pdi(sniff)), vital capacity normalized to age and height (VC(%pred)), tidal volume (Vt), relative inspiratory time (Ti/Ttot), breathing frequency (f(b)), and the tension-time index of the diaphragm (TTdi = delta Pdi/delta Pdi(max) x Ti/Ttot). The median VC(%pred) was 50% in the CCI(1-3) group and 57% in the CCI (> or = 10) group, but only 28% in the PPI group. Delta Pdi(max) values were similar for the CCI(1-3) (11.8 kPa) and CCI(> or = 10) (11.9 kPa) groups but were lower (71. kPa) in the PPI group. Due to the reduction in delta Pdi(max), the PPI group had higher delta Pdi/delta Pdi(max) values than the CCI groups, however, the TTdi was similar amongst the different groups studied. A submaximal exercise test in five cervical cord injury patients and in five polio patients with similar delta Pdi(max), delta Pdi(sniff) and TTdi values at rest revealed clear group differences with respect to force development, in that CCI patients showed significant increases in TTdi, while PPI demonstrated only minor changes. In CCI patients, an increase in ventilation was accompanied by an increase in delta Pdi/delta Pdi(max) while in contrast, the PPI patients showed no increase in delta Pdi/delta Pdi(max). We conclude that CCI patients, both recently and previously injured, have a similar maximal inspiratory force and are less impaired than the PPI patients. The TTdi at rest is similar in all groups, but the PPI patients react to inspiratory loads with little increases in TTdi, while the CCI patients increase their TTdi above fatiguing (0.15) levels. The different behaviours may be linked to loss of sensory pathways in the CCI patients.

Adult↗

Mechanical methods in refractive corneal surgery.

The past year has seen considerable advances and debate with regard to several new and some established mechanical means of refractive surgery. Lamellar in situ keratomileusis is gaining increased interest, especially for the treatment of moderate and high myopia, although considerable questions still exist with regard to its safety, predictability, and the possibility of loss of lines of best corrected visual acuity. Mini-radial keratotomy may be of benefit in reducing the risk of traumatic rupture of radial keratotomy incisions, and a refinement of the nomograms for astigmatic keratotomy in the treatment of congenital astigmatism has been proposed. Another report on the use of hexagonal keratotomy for the treatment of hyperopia again raised concerns of its predictability. A blind eye study of intrastromal corneal rings has provided some reassurance with regard to its safety but has also raised doubts over its predictability. Meanwhile, several more reports of the use of both anterior and posterior chamber phakic intraocular lenses for the treatment of myopia have been presented.

Cornea↗

Effect of a prior-authorization requirement on the use of nonsteroidal antiinflammatory drugs by Medicaid patients.

BACKGROUND: Prior authorization--mandatory advance approval for the use of expensive medications--is now the primary method by which Medicaid programs control expenditures for drugs. However, whether this policy reduces expenditures for specific drugs without causing the unwanted substitution of other drugs or medical services has been largely unstudied. We evaluated the effects of a prior-authorization policy involving nongeneric nonsteroidal antiinflammatory drugs (NSAIDs) in the Medicaid program in Tennessee. METHODS: We compared monthly Medicaid expenditures that were potentially affected by the policy change during the year before and the two years after its implementation. We studied prescriptions for NSAIDs, other analgesic or antiinflammatory drugs, and psychotropic drugs, as well as outpatient services and inpatient admissions for the management of pain or inflammation. RESULTS: At the midpoint of the base-line year, 495,821 people were enrolled in Medicaid. During that year, mean annualized Medicaid expenditures for NSAID prescriptions amounted to $22.41. Expenditures decreased by 53 percent (95 percent confidence interval, 48 to 57 percent) during the next two years, for an estimated savings of $12.8 million. The reduction in expenditures resulted from the increased use of generic NSAIDs, as well as from a 19 percent decrease in overall NSAID use (95 percent confidence interval, 13 to 25 percent). There was no concomitant increase in Medicaid expenditures for other medical care. Regular users of nongeneric NSAIDs, those most affected by the policy change, had similar reductions in NSAID expenditures and use, with no increase in expenditures for other medical care. CONCLUSIONS: Prior-authorization requirements may be highly cost effective with regard to expenditures for NSAIDs, drugs that have very similar efficacy and safety but substantial variation in cost.

Adolescent↗

Foot infections in diabetic patients. Decision and cost-effectiveness analyses.

OBJECTIVE: To examine the cost-effectiveness of approaches to the diagnosis and treatment of patients with type II (non-insulin-dependent) diabetes mellitus (NIDDM) who have foot infections and suspected osteomyelitis. DESIGN: Decision and cost-effectiveness analyses were performed using a Markov model. We examined the prevalence of osteomyelitis, the major complications and efficacies of long-term antibiotic therapy and surgery, and the performance characteristics of four diagnostic tests (roentgenography, technetium Tc 99m bone scanning, indium in 111-labeled white blood cell scanning, and magnetic resonance imaging). Data were drawn from the English-language literature using MEDLINE searches and bibliographies from selected articles. SETTING: Primary care. PATIENTS: Patients with NIDDM who had foot infections and suspected osteomyelitis but no signs of systemic toxicity. INTERVENTIONS: Following hospitalization for surgical débridement and intravenous antibiotic therapy: (1) treatment for presumed soft-tissue infection, (2) culture-guided empiric treatment for presumed osteomyelitis, (3) 71 combinations of diagnostic tests preceding antibiotic therapy for osteomyelitis, (4) 71 combinations of tests preceding amputation, and (5) immediate amputation. MAIN OUTCOME MEASURES: Quality-adjusted life expectancy, average costs. RESULTS: Culture-guided empiric treatment for osteomyelitis with 10 weeks of oral antibiotic therapy has similar effectiveness to testing followed by a long course of antibiotic therapy if any test result is positive. However, empiric treatment is the least expensive strategy. CONCLUSIONS: Noninvasive testing adds significant expense to the treatment of patients with NIDDM in whom pedal osteomyelitis is suspected, and such testing may result in little improvement in health outcomes. In patients without systemic toxicity, a 10-week course of culture-guided oral antibiotic therapy following surgical débridement may be as effective as and less costly than other approaches.

Amputation, Surgical↗