Biomedical subjects
Publications and source records attributed to R Sage.
Four diabetic patients with gangrene of the forefoot and infection ascending above the ankle were treated with open amputation of the foot combined with open fasciotomy and debridement of the involved proximal muscle compartments. All four patients healed their wounds and returned to their premorbid community ambulation status. The management and indications in these unusual patients are discussed.
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93 patients were enrolled into a prospective randomised study to determine the efficacy and safety of netilmicin, cefotaxime or their combination in the treatment of sepsis caused by susceptible strains of Enterobacteriaceae or staphylococci. 83 patients were evaluable for safety, 74 for clinical efficacy and 63 for microbiological response including 36 patients (57%) with positive blood cultures. There were significantly more clinical failures with cefotaxime than with netilmicin even when urinary tract sepsis was excluded. Microbiological failures occurred more frequently in the cefotaxime arm and were associated with Klebsiella and Enterobacter spp. Four cefotaxime failures were subsequently successfully treated with netilmicin. More mixed infections were however enrolled by chance into the cefotaxime arm. The statistical difference between netilmicin and cefotaxime is not significant if mixed infections are excluded. There was no difference in efficacy between the netilmicin and combination groups although superinfection was seen in the latter group. The incidence of nephrotoxicity was greater in the netilmicin group but not significantly so. Only one minor case of ototoxicity was detected in the 41 patients receiving netilmicin who had serial audiograms. The results suggest that netilmicin is a more effective agent than cefotaxime for treating life-threatening infections with susceptible Enterobacteriaceae or staphylococci particularly with infections in non-urinary tract sites. If dosage of netilmicin is closely monitored by measuring serum concentrations, toxicity is minimal.
28 patients with serious Pseudomonas aeruginosa sepsis were enrolled into a prospective open study using ceftazidime (CAZ). 10 patients had rapidly fatal underlying pathology, including 5 neutropenic (neutrophils less than 1.0 X 10(9)/l) patients with malignancy. 9 patients including all those with neutropenia also received concomitant therapy with other active antipseudomonal antibiotics (mainly aminoglycosides). All isolates were initially sensitive to CAZ. A favourable response was seen in 18/27 (67%) evaluable cases. Genitourinary infection and osteomyelitis responded well with 100% and 83% favourable responses respectively. Soft tissue and respiratory tract infection responded less well. Results with biliary sepsis were disappointing (all 3 failed therapy). Of the 9 patients failing treatment 5 responded to alternative antibiotics (usually combination therapy of ureidopenicillin plus aminoglycoside). 2 died primarily from underlying pathology and 2 as a direct result of Ps. aeruginosa sepsis. Toxicity was minimal. In the few cases observed other agents and underlying pathology possibly contributed. The most disturbing feature of the study was the emergence of multiple beta-lactam resistance in organisms whilst treated with CAZ. 5 cases occurred, 4 in the infected strain and 1 in a superinfecting strain, occurring in 4 patients within 10 days of starting therapy. 2 cases occurred in patients receiving concomitant aminoglycosides.
Recent trends in amputation surgery favor amputation at the most distal level to preserve the patient's ability to walk. This paper reports the results of sixty-four amputations performed at the level of the middle of the foot in fifty-eight patients. All were performed in patients with peripheral vascular disease who had a diagnosis of either gangrene or resistant, nonhealing ulcers. Forty-three patients (74 per cent) had diabetes. Nutritional evaluation of the patient was used to improve the potential for healing. In the initial forty-six patients, a retrospective review of the serum albumin level, the blood total-lymphocyte count, and the Doppler ischemic index was performed. A prospective study was performed in the final twelve patients, in whom a minimum level in each of these three factors was required before the distal amputation was done. The healing rate for all sixty-four amputations was 81 per cent. When all three factors were above the minimum level, the healing rate was increased to 92.2 per cent. When one or two of the factors was below the minimum level, the rate of healing decreased to 38.5 per cent. Aggressive distal amputation can be performed with a high rate of success when the factors influencing the decision on the amputation level include non-invasive vascular testing and nutritional evaluation.
The minimum inhibitory concentrations (MICs) of 11 aminocyclitol antibiotics were determined for 773 recent clinical isolates from infected hospital patients, most of whom were immunocompromised. There was a bias towards aminoglycoside-resistant organisms, and 21% of Pseudomonas aeruginosa isolates were resistant to gentamicin. The antibiotics included the natural agents gentamicin, tobramycin, sissomicin and kanamycin and the semi-synthetic compounds amikacin, netilmicin and dibekacin with some newer agents, including O-demethyl fortimicin, Hapa gentamicin B and 5-epi-sissomicin, not available commercially. Tobramycin, sissomicin and gentamicin had similar spectra with tobramycin more active against Ps. aeruginosa, sissomicin more active against proteus and gentamicin more active against serratia. The differences in spectrum between amikacin and netilmicin were marginal, reflecting the relatively low prevalence of acetyltransferase-producing organisms in our collection. Hapa-gentamicin B was the most active aminoglycoside against staphylococci and indole-positive proteus, netilmicin against Escherichia coli and 5-epi-sissomicin against Ps. aeruginosa. Overall 5-epi-sissomicin was the most active aminoglycoside tested. Both Hapa-gentamicin B and 5-epi-sissomicin have potentially valuable antibacterial spectra which merit clinical studies.
A fatal case of endocarditis due to Listeria monocytogenes is reported. Case reports of endocarditis due to this organism are rare but indicate a higher mortality than with many other causes of bacterial endocarditis. The size of the problem may be underestimated because the organism has a "diphtheroid' appearance and may be incorrectly dismissed as a contaminant.
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Twenty-nine ray resection amputations of the lower extremity were performed in 25 dysvascular patients during a four-year period. The indications for amputation were localized gangrene, resistant localized osteomyelitis of a metatarsal, or both. Specific criteria included: (1) foot Doppler pressure of 70 mm Hg, (2) ankle-arm Doppler arterial pressure ratio of at least 0.5, (3) lateral ray resection only when healthy tissue margins could easily be produced, and (4) central ray resection only for persistent deep infection resistant to local treatment. Only 31% healed without further amputation or ulceration. Analyzed retrospectively, the results demonstrate that ray resection has a poor potential for success in the presence of "localized" gangrene and is only moderately successful in the treatment of chronic resistant localized infection.
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The multiple opinions expressed in this Grand Rounds section make it clear that management of the diabetic patient with a foot wound is complex at best. Several significant points are repeated many times. The need for a detailed history and physical exam, accurate assessment of neurologic, vascular, metabolic status, and addressing the etiologic factor involved are all essential. All authors point to multispecialty integrated treatment protocols to produce the greatest success. Little mention is made of the use of topical agents to accelerate healing. This is due to the lack of unbiased studies, and the many available reports that demonstrate rapid healing when a complete and objective protocol is followed. The aims of this Grand Rounds are to stimulate interest in this important subject, and to provide the practitioner with a scaffold with which to build their own wound care management protocols.
Fractures of the great toe sesamoids occur much less frequently than fractures of other bones, and, as such, the literature is sparse in dealing with this topic. Two cases of a rare occurrence of tibial and fibular sesamoid fractures on the same metatarsal are reported. Each case had a traumatic origin, and successful healing occurred in one case following 6 weeks of short leg casting. Total excision of both sesamoids was required in case 2 after complete healing was not achieved by short leg casting alone.
The records of 28 patients who underwent 37 ray resections at Hines Veterans' Administration Hospital and Loyola University Medical Center were reviewed. Indications included localized gangrene, osteomyelitis, or both. Underlying medical diagnoses included diabetes, chronic ethanol abuse, arteriosclerosis obliterans, and gout. The overall success rate was only 34%. These results suggest that the usefulness of ray resections as a definitive procedure in such cases may be limited.
Large vessel disease, small vessel disease, and neuropathy leave the diabetic foot especially vulnerable to ulceration. The degree of vascular impairment of diabetic feet can vary, and such, patients with ulcers can be separated into ischemic and nonischemic groups. The degree of ischemia, and not necessarily the extent of the lesion, is the most significant factor in evaluating the potential outcome of treatment. Forty-eight cases of diabetic ulceration treated with local surgical intervention in an effort to avoid higher amputation were classified as ischemic and nonischemic, based on Doppler studies and physical examination. The success rate in the ischemic group was 25%. The success rate of the nonischemic group was 83%. It is concluded that local surgical management of diabetic ulceration can be a successful alternative to radical amputation in the diabetic patient, especially when adequate blood flow can be verified. Various surgical and nonsurgical approaches to all grades of diabetic feet are also discussed.