Previous Ulcer Research Articles

Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

BackgroundA two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.MethodsAdult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.ResultsSixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).ConclusionsPressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

Reflection on the cause and avoidance of recurrent venous leg ulcers: An interpretive descriptive approach.

To gain insight into the experience of recurrent venous leg ulcers from the individual's perspective and provide knowledge on potential risks of recurrence not previously investigated. Venous leg ulcers are a consequence of chronic venous disease and frequently recur. They are costly and can impact on physical and psychological health. Despite research suggesting the risk can be reduced through compression and lifestyle changes, recurrence rates are often high. This study provides an insight into individual's perceptions of the cause of their ulcers and how they try to avoid them. A qualitative design guided by the Chronic Illness Trajectory Model and Social Cognitive Theory. A purposive sample of three males and four females were recruited from a community nursing clinic. Participants were ulcer free, had experienced at least two previous venous leg ulcers and could speak and comprehend English. An interpretive descriptive approach was taken using semi-structured interviews and thematic analysis. Three themes each containing three categories emerged: The Increasing Influence of the Recurring Wound on Mind and Body, Reflection on Past Experiences and Optimism in the Face of Adversity. Most participants reported traumatic injury and lower leg surgery triggered ulcer recurrence. Failure to replace compression stockings was also deemed a cause. Compression was reported essential, but some participants were unaware of the level they were wearing and how often it should be replaced. Other preventive activities included avoiding injury and securing immediate assistance if wounding occurred. Clinicians need to be aware that lower leg surgery may trigger recurrent venous ulceration and that individuals require ongoing emotional, physical and financial support throughout the trajectory of venous disease. The continued use of old compression stockings should be avoided and recurrence prevented by adoption of evidence-based practice rather than reflection on past experiences. This research raises the awareness of factors from the individual's perspective which can influence the recurrence of venous leg ulcers.

Classic Ulcerative Pyoderma Gangrenosum Is a T Cell-Mediated Disease Targeting Follicular Adnexal Structures: A Hypothesis Based on Molecular and Clinicopathologic Studies.

Pyoderma gangrenosum (PG) is a debilitating ulcerative skin disease that is one of the most common associated diseases seen in patients with inflammatory bowel disease and rheumatoid arthritis. Although PG is classified as a neutrophilic dermatosis, its pathophysiology is poorly understood. Use data obtained from patient-reported histories, immunohistochemistry, and gene expression analysis to formulate a hypothesis on PG pathophysiology. Ten PG patients participated and answered questions about new ulcer formation. Skin biopsies of healed prior ulcers and adjacent normal skin were obtained from four patients for immunohistochemistry. Scars from healthy patients and patients with discoid lupus were used as additional controls. New onset PG papules were analyzed using immunohistochemistry and gene expression analysis via quantitative real-time PCR. All PG patients reported that healed sites of previous ulceration are refractory to re-ulceration. Simultaneous biopsies of healed and uninvolved skin triggered ulceration only in the latter. On immunohistochemistry, healed PG scars showed complete loss of pilosebaceous units, which were present in normal skin, and to a lesser extent in control scars, and discoid scars. Early PG papules showed perivascular and peripilosebaceous T cell infiltrates, rather than neutrophils. These early inflammatory events were dominated by increased gene expression of CXCL9, CXCL10, CXCL11, IL-8, IL-17, IFNG, and IL-36G and transcription factors consistent with Th1 phenotype. Small sample size was the main limitation. We put forth the hypothesis that PG is a T cell response resulting in the destruction of pilosebaceous units.

Effect of Ramadan Fasting Upon Perforated Peptic Ulcer Patients: A Descriptive Analysis

Background: Perforated peptic ulcer (PPU) is relatively rare, but life threatening with the mortality varying from 10% to 40%. While common causes of peptic ulcer disease are H. Pylori, increased inadvertent use of NSAIDS, smoking and stress of modern life, the specific etiologic agent cannot be incriminated in the causation of its perforation.Objective: The aim of this study is to evaluate the effect of perforated peptic ulcer in fasting Muslims.Methods: This prospective analysis was conducted for the risk factors associated with perforated peptic ulcer (PPU) in patients attending Surgical Emergency hospital & Sulaimaniyah Teaching Hospital on 312 cases (246 male & 66 females) during the period of one month before Ramadan (Shaban), holy Ramadan and one month after Ramadan (Shawal) for ten successive years from 2006 to 2015. Descriptive analysis and Chi square test was used to find an association between studying variables.Result: The number of PPU per month was higher in Ramadan, 16.6 patients per month vs. 7.3 patients per each other month and also high among group 1 fasting patients. Predisposing factors played a major role in these differences.Conclusion: This study found that the incidence of PPU is relatively high among people who have predisposing factors, including young adults age, but earlier in non-fasting people , male gender, but no difference between the two groups in those using non -steroidal anti-inflammatory drugs, history of dyspepsia. Those patients have previous peptic ulcer disease diagnosed on esophagogastroduodenoscopy more prone to perforation. Long period day after day fasting, but not daytime length duration may increase PPU.Recommendations: This study recommends that the people with these risk factors must be well informed and need special care to avoid such complications. This study also suggests further studies regarding this subject.

Prevalence of peripheral arterial disease among diabetic patients in Santo Domingo, Dominican Republic and associated risk factors.

IntroductionPeripheral arterial disease (PAD) is a major risk factor of coronary artery disease and a major complication of atherosclerosis. Peripheral arterial disease can be diagnosed with simple and low cost techniques. There are major risk factors of PAD that have been studied for different countries. However, no such study has been done for the Dominican Republic. We conducted a cross-sectional study to determine the prevalence of PAD and the risk factors among patients with diabetes in Santo Domingo, Dominican Republic.Material and methodsSix hundred randomly chosen patients with previously diagnosed diabetes were enrolled in our study. Their blood pressure and ankle brachial index were calculated and a questionnaire was provided to gather information regarding gender, age, weight, ethnicity, known duration of diabetes along with any history of smoking, hypertension and hyperlipidemia. A physical examination was also done to assess for any active diabetic ulcers, previous foot ulcers and non-traumatic amputation. A microfilament test was conducted to check for peripheral neuropathy.ResultsEighty-four diabetic patients were diagnosed with PAD with a prevalence of 14% in Santo Domingo, Dominican Republic. Statistically significant associations (p < 0.05) was found for female gender, presence of active foot ulcers, history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia and peripheral neuropathy. Glycated hemoglobin (HbA1c), age and smoking were not statistically significant in our study.ConclusionsDiabetic patients who are either female, have active foot ulcers, a history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia or peripheral neuropathy are more at risk of developing PAD.

Predictors of lower extremity amputation among patients with diabetic foot ulcer in a tertiary health facility in North Central Nigeria

INTRODUCTION : Diabetic foot ulcer is a complication of diabetes mellitus of great public health importance. It has the potential of leading to the dreaded sequelae of lower extremity amputation. This outcome is associated with significant morbidity and mortality, hence the need to explore its predictors among persons with diabetic foot ulcers. METHODOLOGY : The study involved the review of the medical records of seventy (70) in-patients who had received treatment for diabetic foot ulcer at the Federal Medical Centre, Keffi, North Central Nigeria. In addition to obtaining sociodemographic and medical history, information on the Wagner grade of the ulcer, the presence of peripheral sensory neuropathy (using the 10g monofilament) and the presence of osteomyelitis (using plain X-ray of the foot) were obtained and documented. The prevalence rate of lower extremity amputation was also determined. RESULTS : The study population comprised 52.9% males and 42.1% females. The mean age for male and female participants were 53.4±10.5 and 58.8±13.0 years respectively ( t = 2.35; p = 0.061). Majority of study subjects (37.1%) had Wagner grade 2 disease. Prevalence rate of amputation was 38.6%. Among the potential predictors of lower extremity amputation analyzed (Age, sex, foot care education, duration of diabetes, cigarette smoking, walking bare feet, impaired vision, peripheral neuropathy, hypertension, previous foot ulcer, osteomyelitis), none of them demonstrated a significant association with lower extremity amputation. CONCLUSION : The list of potential predictors of lower extremity amputation considered in this study is by no means exhaustive. More studies involving larger study populations and other potential predictors of lower extremity amputation not considered in this work (such as peripheral artery disease and glycated haemoglobin) are encouraged. KEY WORDS : Amputation, Neuropathy, Osteomyelitis

Risk factors for diabetic foot ulcer recurrence: A prospective 2-year follow-up study in Egypt

ObjectivesTo determine the frequency of diabetic foot ulcer recurrence and its potential risk factors. MethodsThis study included 93 patients with type 2 diabetes and followed for 2 years after primary healed foot ulceration. Demographic, diabetes related, comorbid and ulcer related variables were investigated as risk factors. Multiple logistic regression analysis was used to identify independent risk factors. Results61.3% of patients had recurrent ulcers particularly in the forefoot (33.3%) and big toe (24.6%). Peripheral neuropathy, peripheral arterial disease or both were reported in 69%, 12% and 19% of feet with recurrent ulcers respectively. In multivariate analysis, the significant independent potential risk factors for recurrence of foot ulcers were smoking (P=0.040), poor glycemic control [HbA1c cutoff of 10%] (P=0.010), peripheral neuropathy with lost ankle reflex (P=0.0001), peripheral arterial disease (P=0.0001) and previous ulcer location (P=0.050). ConclusionThe frequency rate of recurrent diabetic foot ulceration in patients with type 2 diabetes is high particularly in the first year despite regular follow-up and patient education.

Pressure Ulcer-Related Pelvic Osteomyelitis: Evaluation of a Two-Stage Surgical Strategy (Debridement, Negative Pressure Therapy and Flap Coverage) with Prolonged Antimicrobial Therapy

Background A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.Methods Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e.,, additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan–Meier curve analysis.ResultsSixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 [IQR 36–63]) were included. Osteomyelitis was mostly plurimicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae (44%), and anaerobes (44%). Flap coverage was performed after 7 (IQR 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; P = 0.022). An increased prevalence of coagulase negative Staphylococci (P = 0.017) and Candida (P = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae was found in one (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; P = 0.005). Treatment duration was as 20 (IQR 14–27) weeks, including 11 (IQR 8–15) after reconstruction. After a follow-up of 54 (IQR 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; P = 0.025) and Actinomyces infection (OR, 9.5; P = 0.027).Conclusion Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. Carbapenem should be reserved for ESBL at-risk patients only, including those with previous fluoroquinolone use. The uncorrelation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.Disclosures T. Ferry, HERAEUS: Consultant, Speaker honorarium

Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study

BackgroundAdults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort.MethodsThis study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes.ResultsMean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation.ConclusionsDialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration.

A study protocol for a multicentre randomised clinical trial evaluating the safety and feasibility of a bioengineered human allogeneic nanostructured anterior cornea in patients with advanced corneal trophic ulcers refractory to conventional treatment

IntroductionThere is a need to find alternatives to the use of human donor corneas in transplants because of the limited availability of donor organs, the incidence of graft complications, as...

A study to find the causes of diabetic foot infections in a selected community

Background: Ulcerations associated with diabetes are the most common cause of foot infections. Most of these ulcers are a direct result of loss of sensation secondary to peripheral neuropathy. The prevalence of leg ulceration is approximately 1% to 2%, and is slightly higher in the older adult population. Venous ulcers are the most common form of leg ulcers, accounting for almost 80% of all lower extremity ulcerations. Peak prevalence is between 60 and 80 years. Approximately one third of patients with chronic venous insufficiency will develop venous ulceration before the age of 40 years. In addition, venous ulcers may have a prolonged duration and are associated with a high rate of recurrence, which contributes to their prevalence. Approximately 15% of persons with diabetes will develop foot ulceration during their lifetime. Most lower extremity amputations in India are preceded by a foot ulcer. This study is done to find the commonest causes of foot infection in the background of neuropathy among the selected population.Methods: Total of 153 patients were included in this study. Detailed history was taken and all the wounds were classified according to Wagner’s grades. Foot infections in the grade 3,4, 5 (which required debridement/amputations) were included in the study. Foot ulcerations without infections were excluded from the study.Results: 142 (92%) of the patients with infection had diabetic neuropathy. All patients with diabetic neuropathy presented with sensory neuropathy. 33 (21%) patients presented with infection due to previous callus. 52 (33%) patients presented with infection due to previous non-healing ulcer. 20 (13%) patients with deformities developed callus at bony pressure areas due to neuropathy or post-surgery sequel. One patient had hot water burns injury. Five (0.03%) patients had Ingrown nails. 14 (0.09%) patients related to barefoot walking/thorn prick injuries. 6 (0.03%) patients had fungal infection. Two (0.01%) patients had itching and scratching over legs. 15 (0.09%) patients had history of previous amputation. Vigorous massage was the cause in 1 patient (0.006%). Shoe bite injury resulted in foot ulcer in 2 (0.02%) patients. Two (0.02%) patients presented with infection due to deep cracks in heels.Conclusions: Neuropathic changes is the most common cause of diabetic foot infections among which callus, non-healing trophic ulcer and previous amputee are the predominant causes. Patient education has a crucial role in prevention of diabetic foot infections by foot care precautions.

İntestinal obstrüksiyonun nadir bir nedeni jejunal fekalom: Olgu sunumu

Fecalomas are usually found in the colon or the rectum. In adult ages, jejunal giant fecaloma is a very rare condition. It has been thought that there should be any kind of chronic diseases leading to the occurrence of such fecalomas at the unexpected localizations. In this case, it was aimed to present a 50-year-old male patient with small bowel obstruction caused by jejunal giant fecalomas. There was previous gastrojejunostomy with vagotomy as the peptic ulcer surgery 25 years ago. Jejunal resection was performed due to the presence of small necrotic areas on the affected segment caused by impacted jejunal fecaloma. Fecalomas may be considered as a differential diagnosis of small intestinal obstruction in a patient with previous peptic ulcer surgery.

Gastrointestinal safety of celecoxib versus naproxen in patients with cardiothrombotic diseases and arthritis after upper gastrointestinal bleeding (CONCERN): an industry-independent, double-blind, double-dummy, randomised trial

Present guidelines are conflicting for patients at high risk of both cardiovascular and gastrointestinal events who continue to require non-steroidal anti-inflammatory drugs (NSAIDs). We hypothesised that a cyclooxygenase-2-selective NSAID plus proton-pump inhibitor is superior to a non-selective NSAID plus proton-pump inhibitor for prevention of recurrent ulcer bleeding in concomitant users of aspirin with previous ulcer bleeding. For this industry-independent, double-blind, double-dummy, randomised trial done in one academic hospital in Hong Kong, we screened patients with arthritis and cardiothrombotic diseases who were presenting with upper gastrointestinal bleeding, were on NSAIDs, and require concomitant aspirin. After ulcer healing, an independent staff member randomly assigned (1:1) patients who were negative for Helicobacter pylori with a computer-generated list of random numbers to receive oral administrations of either celecoxib 100 mg twice per day plus esomeprazole 20 mg once per day or naproxen 500 mg twice per day plus esomeprazole 20 mg once per day for 18 months. All patients resumed aspirin 80 mg once per day. Both patients and investigators were masked to their treatments. The primary endpoint was recurrent upper gastrointestinal bleeding within 18 months. The primary endpoint and secondary safety endpoints were analysed in the modified intention-to-treat population. This study was registered with ClinicalTrials.gov, number NCT00153660. Between May 24, 2005, and Nov 28, 2012, we enrolled 514 patients, assigning 257 patients to each study group, all of whom were included in the intention-to-treat population. Recurrent upper gastrointestinal bleeding occurred in 14 patients in the celecoxib group (nine gastric ulcers and five duodenal ulcers) and 31 patients in the naproxen group (25 gastric ulcers, three duodenal ulcers, one gastric ulcer and duodenal ulcer, and two bleeding erosions). The cumulative incidence of recurrent bleeding in 18 months was 5·6% (95% CI 3·3-9·2) in the celecoxib group and 12·3% (8·8-17·1) in the naproxen group (p=0·008; crude hazard ratio 0·44, 95% CI 0·23-0·82; p=0·010). Excluding patients who reached study endpoints, 21 (8%) patients in the celecoxib group and 17 (7%) patients in the naproxen group had adverse events leading to discontinuation of treatment. No treatment-related deaths occurred during the study. In patients at high risk of both cardiovascular and gastrointestinal events who require concomitant aspirin and NSAID, celecoxib plus proton-pump inhibitor is the preferred treatment to reduce the risk of recurrent upper gastrointestinal bleeding. Naproxen should be avoided despite its perceived cardiovascular safety. The Research Grant Council of Hong Kong.

Foot Complications in a Representative Australian Inpatient Population.

We investigated the prevalence and factors independently associated with foot complications in a representative inpatient population (adults admitted for any reason with and without diabetes). We analysed data from the Foot disease in inpatients study, a sample of 733 representative inpatients. Previous amputation, previous foot ulceration, peripheral arterial disease (PAD), peripheral neuropathy (PN), and foot deformity were the foot complications assessed. Sociodemographic, medical, and foot treatment history were collected. Overall, 46.0% had a foot complication with 23.9% having multiple; those with diabetes had higher prevalence of foot complications than those without diabetes (p < 0.01). Previous amputation (4.1%) was independently associated with previous foot ulceration, foot deformity, cerebrovascular accident, and past surgeon treatment (p < 0.01). Previous foot ulceration (9.8%) was associated with PN, PAD, past podiatry, and past nurse treatment (p < 0.02). PAD (21.0%) was associated with older age, males, indigenous people, cancer, PN, and past surgeon treatment (p < 0.02). PN (22.0%) was associated with older age, diabetes, mobility impairment, and PAD (p < 0.05). Foot deformity (22.4%) was associated with older age, mobility impairment, past podiatry treatment, and PN (p < 0.01). Nearly half of all inpatients had a foot complication. Those with foot complications were older, male, indigenous, had diabetes, cerebrovascular accident, mobility impairment, and other foot complications or past foot treatment.

Measuring Weight-Bearing Activities in Patients With Previous Diabetic Foot Ulcers.

The purpose of this article was to evaluate the accuracy of 2 physical activity monitors, monitors 1 and 2, for measuring weight-bearing activity in persons with prior diabetic foot ulcers. Cross-sectional design. Two recently developed monitors were used to differentiate anatomical postures such as lying, sitting, and standing upright. One monitor was designed to distinguish between duration of standing and walking and the other combines duration of standing and walking into 1 measure. Thirty-one subjects were recruited; all participants had experienced a diabetic foot ulcer and completed participation in a previous cohort study. The study setting was 2 medical centers in the Midwestern United States. Subjects simultaneously wore the 2 monitors while performing 14 weight-bearing (ie, walking and standing) and non-weight-bearing (ie, sitting and lying) activities. The duration spent on each activity and the total number of steps taken for each walking activity were directly observed and recorded with each monitor. The accuracy of monitors 1 and 2 was assessed via direct observation as a reference standard. Paired-samples t tests were used to examine the difference in accuracy between the 2 monitors. For measuring duration of activity, the accuracy of monitor 1 ranged from 73% to 100% for walking, 50% for standing, and from 42% to 100% for sitting/lying. In contrast, the accuracy of monitor 2 ranged from 98% to 100% for walking, 100% for standing, and from 97% to 100% for sitting/lying. The accuracy of monitor 1 for counting the number of steps ranged from 43% to 81%, while the accuracy of monitor 2 ranged from 91% to 99%. Monitor 2 was significantly more accurate than monitor 1 in measuring duration of standing still, slow walking, pedaling while sitting, lying on the left, and lying on the right, as well as measuring steps across different kinds of walking activities. Differences in monitor accuracy between subjects with and without foot pain and between subjects with and without foot amputation were not statistically significant. These findings suggest that monitor 2 is a more accurate measure of weight-bearing activities than monitor 1 among patients with previous diabetic foot ulcers. Additionally, the 2 monitors differ in terms of function; monitor 2 distinguishes standing from walking, whereas monitor 1 combines standing and walking into 1 measure. We recommend monitor 2 to examine the impact of weight-bearing activity on foot ulceration in patients with diabetic neuropathy.

The safety and efficacy of vitamin K antagonist in atrial fibrillation patients with previous ulcer bleeding: Long-term results from a multicenter study.

This study aimed to evaluate the safety and efficacy of vitamin K antagonist (VKA) in atrial fibrillation (AF) patients with previous ulcer bleeding.In this multicenter, retrospective analysis, clinical outcomes of 754 AF patients with a history of ulcer bleeding were evaluated. After ulcer treatment, 458 patients (61%) were treated with VKA, and the outcomes were compared to 296 patients (39%) without VKA.VKA treatment significantly increased major bleeding (7.3%/year vs 3.2%/year, P < 0.001), and reduced major adverse cardiac events (MACE) (5.4%/year vs 10.0%/year, P < 0.001). Specifically, risk of gastrointestinal bleeding was significantly higher in the VKA group than no-VKA group (5.7%/year vs 2.6%/year, P < 0.001). Consequently, there was no difference in the incidence of composite of a MACE and major bleeding, between the 2 groups. In patients with time in the therapeutic range (TTR) ≥65%, VKA significantly decreased MACE (2.8%/year vs 10.0%/year, P < 0.001) without increasing major bleeding. Net clinical benefit model showed beneficial effects of VKA in patients with TTR ≥65%, and harmful effects in those with TTR < 55%.In AF patients with previous ulcer bleeding, VKA treatment did not improve clinical outcomes unless the international normalized ratio level was constantly maintained (TTR ≥65%), as the gastrointestinal bleeding (GIB) risk significantly increased.

The silent overall burden of foot disease in a representative hospitalised population.

The aims of this study were to investigate the point prevalence, and associated independent factors, for foot disease (ulcers, infections and ischaemia) in a representative hospitalised population. We included 733 (83%) of 883 eligible adult inpatients across five representative Australian hospitals on one day. We collected an extensive range of self-reported characteristics from participants. We examined all participants to clinically diagnose foot disease (ulcers, infections and ischaemia) and amputation procedures. Overall, 72 participants (9·8%) [95% confidence interval (CI):7·2-11·3%] had foot disease. Foot ulcers, in 49 participants (6·7%), were independently associated with peripheral neuropathy, peripheral arterial disease, previous foot ulcers, trauma and past surgeon treatment (P < 0·05). Foot infections, in 24 (3·3%), were independently associated with previous foot ulcers, trauma and past surgeon treatment (P < 0·01). Ischaemia, in 33 (4·5%), was independently associated with older age, smokers and past surgeon treatment (P < 0·01). Amputation procedures, in 14 (1·9%), were independently associated with foot infections (P < 0·01). We found that one in every ten inpatients had foot disease, and less than half of those had diabetes. After adjusting for diabetes, factors linked with foot disease were similar to those identified in diabetes-related literature. The overall inpatient foot disease burden is similar in size to well-known medical conditions and should receive similar attention.

Submitted, Not Presented: Clinical Vignettes/Case Reports - Stomach.

Introduction: Primary gastric lymphoma accounts for accounts for < 5% of primary gastric neoplasms. Common misconceptions exist in clinical practive regarding the management of gastric MALT. lymphoma. We present patient with H. pylori-positive gastric MALT lymphoma who had subseuent eradication of H. pylori with histologically persistent MALT. Case Report: A 68-year-old male with no significant medical history presented to the emergency department with 2 weeks history of abdominal pain and nonbilious/nonbloody vomiting. Besides a hemoglobin level of 7.7g/dL, all other laboratory parameters were within normal limits. Esophagogastroduodenoscopy (EGD) revealed a large ulcer with irregular borders on the greater curvature of the stomach (Fig. 1). Immunohistochemical stains were positive for H. pylori infection. Ulcer biopsies revealed morphological findings concerning for extranodal marginal zone lymphoma (gastric MALT). Immunohistochemical stains were positive for CD20, consistent with B cell lineage. PCR of the biopsied specimen demonstrated clonal B cell re-arrangement—findings consistent with the diagnosis of gastric MALT. These biopsies were also positive for H. pylori. He received 14 days of triple therapy and had repeat EGD approximately 3 months later. Repeat EGD demonstrated dramatically healed mucosa (Fig. 2) at the site of the previous ulcer. Biopsies from the site once again showed morphologic and immunohistochemical features consistent with a diagnosis of gastric MALT, however H. pylori was negative. The patient was subsequently lost to follow-up.Figure 1Figure 2Discussion: Several studies have clearly indicated a positive correlation between H. pylori and the development/progression of gastric MALT lymphoma. In addition, tumor regression following H. pylori eradication has been repeatedly demonstrated. Current international guidelines suggest bacterial eradication therapy for all patients with MALT lymphoma. The above case highlights a common misconception in managing MALT lymphoma. H. pylori was successfully eradicated following triple therapy however the patient still had morphologic and immunohistochemical features consistent with gastric MALT. In actuality, complete remission of gastric MALT lymphoma after H. pylori eradication can take more than 12 months. Most protocols recommend waiting at least for 12 months after successful eradication therapy before being diagnosed as a ‘nonresponder’ and moving on to more aggressive adjuvant therapy.

Study of Risk Factors for Foot Ulceration in Type 2 Diabetes Mellitus Patients with Special Reference to HBA1C

Background And Objectives:India, one of the largest countries in the Southeast Asian region, has more than 67 million people with diabetes. With an aging population and the increase in prevalence of DM in the younger age group, the secondary complications are common. Foot problems in diabetes needs increasing attention in view of the fact that they account for 85% of the non- traumatic lower extremity amputations and cause significant morbidity and mortality. The aim is to study the risk factors for foot ulceration in type 2 DM patients in Basaveshwara Teaching & General Hospital (BTGH), Gulbarga. and to educate patients with risk factors regarding foot care. Methods:A total of 50 type 2 DM patients from Basaveshwara Teaching & General Hospital (BTGH), Gulbarga over a period of 1 year formed the study population. Detailed clinical examination including of the feet was done. Risk factors were assessed by l0g/5.07 monofilament and ABI (ankle brachial index) for peripheral sensory neuropathy and peripheral vascular disease respectively . Glycemic control was assessed by HBA1c. Results:The prevalence of neuropathy, PVD, foot deformities are 48.0%, 16.0%, 18.0% respectively. 6.0% had a history of previous ulcer or amputation. 64.0% are unaware that diabetes can cause foot problems and 56.0% of the study population walk bare foot. Statistically significant association (P<0.05) was found between increasing duration of diabetes, worsening glycemic control, increasing age and the prevalence of neuropathy, PVD and foot deformities. Interpretation And Conclusion :Use of simple screening techniques such as monofilament testing and ABI can help in identifying the foot at risk. Patient education, glycemic control, and regular foot examination by a trained health professional can prevent the occurrence of foot ulcers and amputations.

Paediatric infectious keratitis at tertiary referral centres in Vancouver, Canada

ObjectiveTo report the clinical and microbiological profiles of paediatric patients with infectious keratitis in Vancouver, Canada.DesignIn this observational case series, the microbiology results and medical records of 17 eyes with...