Leg Amputation Research Articles

SYNCHRONOUS AND INVASIVE CUTANEOUS SKIN CANCER IN AN ALBINO PATIENT: A CASE REPORT AND LITERATURE REVIEW

Individuals without natural protection against ultraviolet radiation, eg, albino, are susceptible to cutaneous skin cancer, such as squamous cutaneous cancer (SCC). A male albino, 32 years old, showed at first presentation a synchronous ulcerated skin lesion at the right maxillary region and lateral right leg. Both were invasive lesions and were submitted for biopsy. Histopathologic findings revealed nuclear and cellular pleomorphism and atypical mitosis. The leg lesion was resected and received local radiotherapy. Unfortunately, the SCC relapsed and a leg amputation was performed. The right jaw SCC was submitted for a COMMANDO technique and pectoralis major myocutaneous flap reconstruction. The patient is in adjuvant chemotherapy treatment and no relapse of both lesions was detected Therefore, health professionals must emphasize cutaneous health in individuals with the albinism condition because they are a high-risk group for SCC development, aiming at early diagnosis to avoid mutilating treatments.

OF LIFE AND LIMB: SURGICAL REPAIR OF THE ARTERIES IN WAR AND PEACE, 1890-1960 Justin Barr University of Rochester Press, 2019

In his book, Of Life and Limb: Surgical Repair of the Arteries in War and Peace, 1890-1960, Dr. Justin Barr provides a comprehensive historical account of the evolution of open arterial repair for vascular injuries over a 70-year period. The historical and chronological description takes into account both the technical challenges that surgeons experienced with regard to successful primary repair of arterial injuries and the environmental influences that influenced the delay and acceleration of this surgical intervention.

Fibrosis and Inflammatory Markers and Long-Term Risk of Peripheral Artery Disease: The ARIC Study.

Inflammatory markers, such as hs-CRP (high-sensitivity C-reactive protein), have been reported to be related to peripheral artery disease (PAD). Galectin-3, a biomarker of fibrosis, has been linked to vascular remodeling and atherogenesis. However, its prospective association with incident PAD is unknown; as is the influence of inflammation on the association between galectin-3 and PAD. Approach and Results: In 9851 Atherosclerosis Risk in Communities Study participants free of PAD at baseline (1996-1998), we quantified the association of galactin-3 and hs-CRP with incident PAD (hospitalizations with PAD diagnosis [International Classification of Diseases-Ninth Revision: 440.2-440.4] or leg revascularization [eg, International Classification of Diseases-Ninth Revision: 38.18]) as well as its severe form, critical limb ischemia (PAD cases with resting pain, ulcer, gangrene, or leg amputation) using Cox models. Over a median follow-up of 17.4 years, there were 316 cases of PAD including 119 critical limb ischemia cases. Log-transformed galectin-3 was associated with incident PAD (adjusted hazard ratio, 1.17 [1.05-1.31] per 1 SD increment) and critical limb ischemia (1.25 [1.05-1.49] per 1 SD increment). The association was slightly attenuated after further adjusting for hs-CRP (1.14 [1.02-1.27] and 1.22 [1.02-1.45], respectively). Log-transformed hs-CRP demonstrated robust associations with PAD and critical limb ischemia even after adjusting for galectin-3 (adjusted hazard ratio per 1 SD increment 1.34 [1.18-1.52] and 1.34 [1.09-1.65], respectively). The addition of galectin-3 and hs-CRP to traditional atherosclerotic predictors (C statistic of the base model 0.843 [0.815-0.871]) improved the risk prediction of PAD (ΔC statistics, 0.011 [0.002-0.020]). Galectin-3 and hs-CRP were independently associated with incident PAD in the general population, supporting the involvement of fibrosis and inflammation in the pathophysiology of PAD.

Beta-adrenergic antagonist for the healing of chronic diabetic foot ulcers: study protocol for a prospective, randomized, double-blinded, controlled and parallel-group study

BackgroundDiabetic foot ulcers (DFUs) are the most common cause of leg amputations and their management is extremely challenging. Despite many advances and expensive therapies, there has been little success in improving outcomes of DFUs. In prior work our laboratory has examined the effects of beta-adrenergic antagonists (βAAs) on skin and skin-derived cells. We have shown that βAAs enhance the rate of keratinocyte migration, promote angiogenesis, and hasten wound healing in scratch wounds in vitro, in animal wound models, and in anecdotally reported cases of chronic wounds that healed successfully after topical application of the βAA timolol. Thus, we propose to test timolol directly on DFUs to determine if it improves healing above the current standard of care (SOC). This study will examine the efficacy and safety of topically applied beta-antagonist Timoptic-XE® (timolol maleate ophthalmic gel forming solution) in subjects with DFUs.Methods/designThis is a phase two, randomized, double-blinded, controlled, and parallel-group clinical trial with two treatment arms, SOC plus topical Timoptic-XE® and SOC plus a non-biologically active gel (hydrogel, as placebo drug). Study subjects with a DFU will be selected from the Veterans Affairs Northern California Health Care System (VANCHCS). Study duration is up to 31 weeks, with three phases (screening phase for two weeks, active phase for up to 12 weeks, with an additional second consecutive confirmatory visit after 2 weeks, and follow-up phase comprising monthly visits for 4 months). Subjects will apply daily either the topical study drug or the placebo on the foot ulcer for 12 weeks or until healed, whichever comes first. Measurements of wound size and other data will be collected at baseline, followed by weekly visits for 12 weeks, and then a monthly follow-up period.DiscussionThis is a clinical translation study, moving the investigators’ pre-clinical laboratory research into a translational study in which we will analyze clinical outcomes to assess for safety and estimate the efficacy of a topical beta-antagonist in healing of DFUs. The results from this trial may establish new treatment paradigms and safety profile for DFU treatment.Trial registrationClinicalTrials.gov, NCT03282981. Registered on June 14th, 2018.

The territorial distribution of amputations in healthcare and social context in Hungary in 2016–2017.

Introduction and aim: Peripheral artery disease and lower extremity artery disease occur in 4 to 6% of the population. In Hungary, the number of major amputations was 6798 in the observed period. With timely and appropriate treatment, the number of leg amputations (30-day mortality: 20%, 2-year mortality: 40-60%) can be effectively reduced. The purpose of this study is to identify the territorial differences within Hungary with regard to the care pathways of these diseases. Method: We performed a retrospective data analysis of the peripheral vascular treatment using 2015-2017 claim data of the National Health Insurance Fund of Hungary. Territorial differences in mortality rates were examined by descriptive statistics. Correlation analysis was performed to describe any relationship between mortality rates and other factors. Results: The subregional level analysis (n = 175) revealed 4 times differences across the country proving that high domestic amputation rates are partially due to the extreme amputation rates in 30 percent of the subregions. Multiple stratified regression analysis revealed that the proportion of districts where endovascular therapy is not available (n = 159), the university education level of the population (β1 = -0.13, 95% CI: -0.18 to -0.09) and the proportion of those over 65 years of age (β1 = 0.14, 95% CI: 0.03-0.24) were significantly associated with amputation rate. In districts with available endovascular therapy (n = 14), age distribution of population (β1 = 0.7, 95% CI: 0.42-0.98) was associated with the frequency of amputations. Conclusion: Regional and social disparities in incidence, prevalence and mortality rates significantly vary greatly across Hungary, but also provider capacities (with relevant competencies) influence strongly the development and progression of the disease. Orv Hetil. 2020; 161(18): 744-755.

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications

AimsThe optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. MethodsData were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. ResultsMajor amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. ConclusionsAlthough short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

Long Term Survival of a Patient with Metastatic Rectal Cancer Treated with Oral Regorafenib - A Case Report

A 56-years-old female had a history of radical proctectomy for carcinoma of rectum on 2003/4/29. Pathology report was Dukes’ C adenocarcinoma with 12 of 24 lymph node showing metastasis. She was managed to have six months of adjuvant chemotherapy of 5- fluorouracil with leucovorin. Computed Tomography (CT) scan on 2013/4/16 was reported as having recurrent tumor in left presacral region with. associated left hydronephrosis and hydroureter. 5400 cGy of radiotherapy was given. CT scan on 2013/8/14 was reported as decreased size of recurrent tumor in left presacral region as compared to last CT with persistent left hydronephrosis and hydroureter due to tumor invasion of middle left ureter. She was then arranged to have chemotherapy of capecitabine, irinotecan oxaliplatin, uracil-futrafur with bevacizumab and Ziv-Aflibercept. Above knee amputation of left leg was performed on 2016/3/29 following poor result of fasciectomy for necrotizing fasciitis. CT scan on 2016/6/6 was reported as interval stable of presacral and left pelvic wall soft tissue mass with calcification, associated left hydronephrosis and hydroureter. 160 mg per day of regorafenib was started from 2016/7/14. She was taking regorafenib regularly in the past three years and 6 months with stable disease. Her last CT scan on 2019/12/27 was reported as stationary appearance of the calcified soft tissue lesion in left presacral region with ipsilateral hydronephroureter and obliteration ipsilateral common iliac vein with prominent venous collaterals in anterior wall of pelvis and with mild left thigh edematous change.

Prospective study of clinicoepidemiology, presentation and treatment outcome of lower extremity peripheral artery disease (LE-PAD)

Background: Peripheral arterial disease is one among three major cardiovascular diseases and is an important contributor of death and disabilities in low and middle income countries. Symptoms of peripheral arterial disease depend upon the severity of narrowing of artery. Based on severity of disease there are various modalities of treatment is available to prevent the progress of disease and save the limb.Method: This is a prospective, observational, cross sectional study conducted in the department of general surgery. Detailed chronological clinical history is taken, after that patient was evaluated clinically for vascular abnormalities of lower extremities. All patients were followed for minimum 6 month for the evaluation of course of disease and at each visit detail examination was repeated. Result: Dorsalis pedis artery was more commonly involved in thromboangitis obliterans patients then peripheral artery disease (37.5% vs 4.34%). Regarding mode of treatment all patients in both group received medical treatment and life style modification. Lumber sympathectomy was done in 4(8.6%) patients in PAD group and 1(6.25%) in TAO group. Amputation of leg was done in 18(39.10%) in PAD group. Discussion and Conclusion: Diabetes and hypertension was common comorbid condition associated with PAD. Most of the patients have habit of tobacco use. Gangrene and ulcer are common presentation of patients and most of the patients required amputation and disarticulation. Some symptoms improved by life style modification and medical management. The mean duration of stay in hospital was longer in PAD patients then TAO patients.

Lower limb peripersonal space and the desire to amputate a leg

Body integrity identity disorder (BIID) is a rare condition defined by a persistent desire to amputate or paralyze a healthy limb (usually one or both of the legs). This desire arises from experiencing a mismatch between the internal body model and the actual physical/functional boundaries of the body. People with BIID show an abnormal physiological response to stimuli approaching the affected (unwanted) but not the unaffected leg, which might suggest a retracted peripersonal space (PPS: a multisensory integration zone near the body) around the unwanted limb. Thus, using a visuo-tactile interaction task, we examined leg PPS in a group of healthy men and three men with BIID who desired unilateral leg amputation. PPS size (~ 70 cm) around the unwanted BIID legs did not differ from that of healthy controls. Although the leg feels foreign in BIID, it still seems to maintain a PPS, presumably to protect it and facilitate interactions within the surrounding environment.

Reverse neurocutaneous vs propeller perforator flaps in diabetic foot reconstruction

Introduction Reverse neurocutaneous and propeller perforator flaps are both used to reconstruct diabetic distal lower limb defects. Our study aims to compare outcomes between these two groups of flaps with an emphasis on indications and complication rates.Method A retrospective analysis was conducted, reviewing data from 54 diabetic patients who underwent reconstruction of acute or chronic wounds of the foot and ankle between 2005-2018. Thirty-four patients (Group A) had a reverse neurocutaneous flap (NCF): nineteen sural and fifteen lateral supramalleolar flaps. Twenty patients (Group B) had a propeller flap (PF) based on peroneal (n = 13) or posterior tibial artery perforators (n = 7). All patients had a preoperative Doppler examination to identify the nutrient artery of the flap. In both groups, we recorded patients’ demographics, characteristics of the defect, postoperative complications and time to heal. Follow-up ranged from 6 to 59 months. Student's t-test and chi-squared test were used for statistical analysis.Results Mean patients’ age was 59.1 and 50.8 years for Group A and B, respectively. Defects were located at the Achilles zone (n = 16), posterior heel (n = 14), foot dorsum (n = 9), lateral and medial malleolar areas (n = 8), anterior ankle (n = 5) and lateral foot (n = 2). Mean size of the defect was 42.8 cm2 in Group A and 23 cm2 in Group B. Uneventful healing was recorded in 20/34 neurocutaneous flaps and in 12/20 propeller flaps; complications included two complete flap losses (one NCF, one PF), seventeen distal flap necroses (10 NCFs, 7 PFs), fifteen delayed wound healing events over the donor or recipient site (12 NCFs, 3 PFs). Secondary surgeries were required in 15 NCF and 8 PF patients. Mean healing time was 48.1 and 40.7 days for Group A and B, respectively. All patients, except one NCF case, which resulted in leg amputation, returned to previous levels of ambulation.Conclusion Reverse neurocutaneous and propeller flaps may provide stable reconstruction of diabetic lower limb defects; neurocutaneous flaps are specially indicated for larger and more distally located defects, although they might be associated with longer healing time and additional revision surgeries. Propeller flaps were more frequently used in younger patients for smaller and more proximally located defects.

Diabetic Foot Ulceration in a Secondary Health Facility

Aims: To determine the prevalence, pattern and presentation of the diabetic foot ulcer.
 Background: A diabetic foot ulcer is a major complication in diabetes mellitus and probably the major component of diabetic foot. It occurs in 15% of all patients with diabetes and precedes 84% of all lower leg amputations.
 Poverty, low economic status and ignorance have resulted in this devastating disease. It may worsen in the next decade.
 There are multiple risk factors that predispose an individual to DM foot ulcer; they include age, gender(male), type of DM, glycaemic (HbA1c) or FBG level, duration of DM (>10yrs) occupational status particular habits of self-foot care and infection.
 Patients and Methods: This consists of 69 diabetic patients; male and female included done between the months of January 2019 to March 2019.
 A demographic data questionnaire and social history were obtained. Overnight fasting serum glucose was obtained. Serum glucose was determined by enzymatic glucose oxidase method.
 Data obtained were subjected to Stata Version 11 Software to determine the graphical representation, mean, standard deviation of the analysis.
 Results: Thirty-Five 35 were male and 34 were female had type 2 diabetes. Forty-Three 43 patients had foot ulcer, 21 patients had gangrene and 5 had infection. The number of patients with peak glucose values 10 mmol/L and least glucose at 20-25 mmol/L. Those of duration 4-6 years were the most affected the age group most affected is between 40-59 yrs.
 Discussion and Conclusion: Risk factors for foot ulceration discovered among a host other factors identified in this study, were the infection, low socioeconomic status, improper footwear, poor glycaemic control, structural foot deformity and untreated gangrene.
 The role of poor glycaemic control in the genesis of diabetic complications cannot be overemphasized as the mean FPG was noted to be considerably higher in patients with foot ulceration As part of a comprehensive foot care programme, education on foot care should be directed at patients, family members and healthcare providers.
 Not less than 85% of all diabetic foot-related problems are preventable. This can be achieved through a combination of good care of foot, provided by an inter-professional diabetes care team, and appropriate education for people with diabetes.

An Investigation of Lower Limb Representations Underlying Vision, Touch, and Proprioception in Body Integrity Identity Disorder.

Individuals with Body Integrity Identity Disorder (BIID) have a (non-psychotic) longstanding desire to amputate or paralyze one or more fully-functioning limbs, often the legs. This desire presumably arises from experiencing a mismatch between one’s perceived mental image of the body and the physical structural and/or functional boundaries of the body itself. While neuroimaging studies suggest a disturbed body representation network in individuals with BIID, few behavioral studies have looked at the manifestation of this disrupted lower limb representations in this population. Specifically, people with BIID feel like they are overcomplete in their current body. Perhaps sensory input, processed normally on and about the limb, cannot communicate with a higher-order model of the leg in the brain (which might be underdeveloped). We asked individuals who desire paralysis or amputation of the lower legs (and a group of age- and sex-matched controls) to make explicit and implicit judgments about the size and shape of their legs while relying on vision, touch, and proprioception. We hypothesized that BIID participants would mis-estimate the size of their affected leg(s) more than the same leg of controls. Using a multiple single-case analysis, we found no global differences in lower limb representations between BIID participants and controls. Thus, while people with BIID feel that part of the body is foreign, they can still make normal sensory-guided implicit and explicit judgments about the limb. Moreover, these results suggest that BIID is not a body image disorder, per se, and that an examination of leg representation does not uncover the disturbed bodily experience that individuals with BIID have.

Effectiveness of Physiotherapy While Observing Yourself in a Mirror for Balance and Walking Speed in People Who Underwent Transtibial Amputation

Humans face a variety of difficulties in activities of daily living and mobility after leg amputation. It affects not only their psychoemotional state but also all the locomotor apparatus. Rehabilitation focuses on gait and balance training, as this has important implications for the further development of human independence level. We attempted to ascertain whether the mirrors as the means of feedback during physiotherapy have an effect for the recovery of balance and walking speed after transtibial amputation. The aim of research was to assess the effectiveness of physiotherapy while observing oneself in a mirror for balance and walking speed after transtibial amputation. The study included 22 patients who underwent transtibial amputation 1.5–2 months ago. The study was carried out in "Orthopedijos technika" in February 2009–January 2010. The subjects were randomly divided into two groups of 11 persons. One group took conventional physiotherapy program, other – physiotherapy while observing themselves in a mirror. At baseline and at the end (after three weeks) the subjects’ walking speed and balance were assessed using "Up and go" test, "10 meter-walk" test and Berg test. Results of balance significantly improved and walking speed significantly increased in both groups after physiotherapy (p < 0.05). Physiotherapy while observing yourself in a mirror increased walking speed in persons who underwent transtibial amputation more than conventional physiotherapy but there was no significant impact on balance between these two groups.Keywords: transtibial amputation, balance, walking speed, mirror therapy.

Wound infection with Vibrio harveyi following a traumatic leg amputation after a motorboat propeller injury in Mallorca, Spain: a case report and review of literature

BackgroundVibrio spp. are aquatic bacteria that are ubiquitous in warm estuarine and marine environments, of which 12 species are currently known to cause infections in humans. So far, only five human infections with V. harveyi have been reported.Case presentationA 26-year old patient was transferred to our center by inter-hospital air transfer from Mallorca, Spain. Seven days before, he had suffered a complete amputation injury of his left lower leg combined with an open, multi-fragment, distal femur fracture after he had been struck by the propeller of a passing motorboat while snorkeling in the Mediterranean Sea. On admission he was febrile; laboratory studies showed markedly elevated inflammatory parameters and antibiotic treatment with ampicillin/sulbactam was initiated. Physical examination showed a tender and erythematous amputation stump, so surgical revision was performed and confirmed a putrid infection with necrosis of the subcutaneous tissue and the muscles. Tissue cultures subsequently grew V. harveyi with a minimal inhibitory concentration (MIC) of 16 mg/L for ampicillin, and antibiotic treatment was switched to ceftriaxone and ciprofloxacin. Throughout the following days, the patient repeatedly had to undergo surgical debridement but eventually the infection could be controlled, and he was discharged.ConclusionsWe report the first human infection with V. harveyi acquired in Spain and the second infection acquired in the Mediterranean Sea. This case suggests that physicians and microbiologists should be aware of the possibility of wound infections caused by Vibrio spp. acquired in the ocean environment, especially during hot summer months. Since Vibrio spp. preferentially grow at water temperatures above 18 °C, global warming is responsible for an abundance of these bacteria in coastal waters. This will likely lead to a worldwide increase in reports of Vibrio-associated diseases in the future.

New Perspective in Diabetic Neuropathy: From the Periphery to the Brain, a Call for Early Detection, and Precision Medicine.

Diabetic peripheral neuropathy (DPN) is a common chronic complication of diabetes mellitus. It leads to distressing and expensive clinical sequelae such as foot ulceration, leg amputation, and neuropathic pain (painful-DPN). Unfortunately, DPN is often diagnosed late when irreversible nerve injury has occurred and its first presentation may be with a diabetic foot ulcer. Several novel diagnostic techniques are available which may supplement clinical assessment and aid the early detection of DPN. Moreover, treatments for DPN and painful-DPN are limited. Only tight glucose control in type 1 diabetes has robust evidence in reducing the risk of developing DPN. However, neither glucose control nor pathogenetic treatments are effective in painful-DPN and symptomatic treatments are often inadequate. It has recently been hypothesized that using various patient characteristics it may be possible to stratify individuals and assign them targeted therapies to produce better pain relief. We review the diagnostic techniques which may aid the early detection of DPN in the clinical and research environment, and recent advances in precision medicine techniques for the treatment of painful-DPN.

Deformations, renormgroup, symmetries, AdS/CFT

We consider the deformations of a supersymmetric quantum field theory by adding spacetime-dependent terms to the action. We propose to describe the renormalization of such deformations in terms of some cohomological invariants, a class of solutions of a Maurer-Cartan equation. We consider the strongly coupled limit of N=4 supersymmetric Yang-Mills theory. In the context of AdS/CFT correspondence, we explain what corresponds to our invariants in classical supergravity. There is a leg amputation procedure, which constructs a solution of the Maurer-Cartan equation from tree diagrams of SUGRA. We consider a particular example of the beta-deformation. It is known that the leading term of the beta-function is cubic in the parameter of the beta-deformation. We give a cohomological interpretation of this leading term. We conjecture that it is actually encoded in some simpler cohomology class, which is quadratic in the parameter of the beta-deformation.

CT Scan of the Foot in Patients with Chronic Non-Healing Diabetic Foot Ulcer

Background: Diabetes mellitus is a chronic disease where there is an increased blood sugar level in the body which is either caused due to inability of the pancreas to secrete insulin or the body’s inability to utilize it. The prevalence of diabetes mellitus is growing rapidly worldwide. Statistics show that in the year 2014, there were a total of 422 million cases of DM. Diabetes mellitus is a major cause of heart attacks, kidney failure, blindness and leg amputations. Diabetic foot ulcers are quite common and are estimated to affect nearly 15% of all diabetic patients during their lifetime. In long standing diabetic patients with chronic non-healing ulcers, bony changes or deformities are not uncommon. These bony changes can be identified using CT scans. Materials and Methods: An observational study was conducted on a total of 40 patients with chronic non-healing ulcer attending the surgery outpatient department of Saveetha Medical College, Chennai, Tamilnadu. The CT-scans of their foot were observed for deformities or bony changes. Results: Out of 40 patients, 67.5% were males and 32.5% were females. A maximum number of subjects fell under the age group of 51 - 60 years. The most common site of the ulcer was found to be in the plantar surface of big toe (53%). Among the 40 patients, 33 of them were found to have bony abnormalities on the CT scan of foot and no apparent changes were seen in the rest. Bone erosions (35%), osteopenic changes (22.5%), Charcot’s joint (2.5%), osteophyte formation (12.5) and reduced joint space (10%) were the predominant changes observed on the CT scans of the study population.

Isolation and Distribution of Microorganisms Causing Wound Infections in Diabetic Patients in Kirkuk City, Iraq

Background: Diabetic wound infections are considered one of the main life-threatening diseases among diabetic patients. Foot ulcers are accounting for up to twenty of diabetes-related hospital admission. If leaved untreated, they might result in amputation of feet and legs. The aim of current study was to investigate the isolation and identification of pathogenic microorganisms in wounds of diabetic patients in Kirkuk district, Iraq. Method: Forty diagnosed diabetic patients, (18 males and 22 females)presented with wound infection at Azadi Teaching Hospital, were selected for the study. Swabs of pus and wound exudates were obtained from infected region for bacteriological studies. Then these swabs cultured on blood agar and MacConkey agar for facultative organisms and incubated at 37°C for 24 hours. All cultured isolates were investigated and identified by standard bacteriological and analytical profile index laboratory techniques. Results: Data from current study revealed that single etiology was observed in 24(60%) of isolates. Polymicrobial infections were observed in 4(10%) of patients and 12(30%) isolates were negative. Also, Staphylococcus aureus was the most common cause of infection which comprised 20% of isolates followed by Pseudomonas aeruginosa (15%) isolates. Moreover, it was found that 12 isolates were due to Pseudomonas spp. constituting 30% of isolates followed by Staphylococcus spp. accounting 25%. Conclusion: There is no definite etiology in diabetic wound infections and Pseudomonas spp. were responsible for most of wound infections in diabetic patients.

Macroangiopathy in Systemic Sclerosis-Case Report and Literature Review

The case report of systemic sclerosis debuting in an elderly man with critical ischemia of the lower extremities and with amputation of both legs is described. The features of this case included the large vessels pathology in the very beginning of the disease, as well as the occurrence and rapid progression of significant fibrosis and hyperpigmentation of the lower limbs skin after amputation of one of them. At the same time, the Raynaud phenomenon, sclerodactyly, and signs of visceral pathology were absent in the patient. Possible causes of the development of macroangiopathy in patients with systemic sclerosis are discussed.

A Case of Widespread Fournier Gangrene Caused by Penetration of Progressive Rectal Cancer in Which Debridement and Leg Amputation Improved the General Status

A Case of Widespread Fournier Gangrene Caused by Penetration of Progressive Rectal Cancer in Which Debridement and Leg Amputation Improved the General Status