Severe Foot Research Articles

Mönckeberg's medial calcific sclerosis in diabetic and non-diabetic foot infections.

The aim of this study was to evaluate the prevalence and extent of lower extremity Mönckeberg's Medial Calcific Sclerosis (MMCS) in patients with and without diabetes in patients admitted to the hospital for foot infections. This study retrospectively reviewed 446 patients admitted to the hospital with a moderate or severe foot infection. We defined diabetes based on ADA criteria and reviewed electronic medical records for demographics, medical history and physical examination data. Anterior-posterior and lateral foot radiographs were examined to identify the presence and extent of vascular calcification. We categorised MMCS based on anatomical location: ankle joint to the navicular-cuneiform joint, Lis Franc joint to metatarsophalangeal joints and distal to the metatarsophalangeal joints. The prevalence of MMCS was 40.6%. The anatomic extent of MMCS was 19.3% in the toes, 34.3% in the metatarsals and 40.6% in the hindfoot/ankle. Calcification was not common solely in the dorsalis pedis artery (DP) (3.8%) or solely in the posterior tibial artery (PT) (7.0%). Usually, both DP and PT arteries were affected by MMCS (29.8%). The prevalence of MMCS was higher in people with diabetes (in hindfoot and ankle [50.1% vs. 9.9%, p ≤ 0.01]; metatarsals [42.6% vs. 5.9%, p ≤ 0.01]; and toes [23.8% vs. 4.0%, p ≤ 0.01]). People with diabetes were 8.9 (CI: 4.5-17.8) times more likely to have MMCS than those without diabetes. This is a group that often has poor perfusion and needs vascular assessment. The high prevalence of MMCS raises questions about the reliability of the conventional segmental arterial Doppler studies to diagnose PAD.

151-OR: Social Determinants of Health Predict Diabetic Foot Infection Development

The objective was to identify social determinants of health (SDOH) associated with development of diabetic foot infection using the CDC Healthy People Framework at a tertiary care center. Targeted interrogation of structured and unstructured data using novel electronic medical record search engines was used to analyze patient encounters in individuals with diabetes and a concomitant diabetic foot complication during a twenty-year period (2001-2021). Among ~ 200 million encounters from people with diabetic foot complications, 8351 developed diabetic foot ulcers (DFU), and 1671 suffered a DFU infection. The risk of infection development in people with a DFU was assessed with the neighborhood disadvantaged index score from over 200 million separate patient encounters. The neighborhood disadvantaged index based on available geolocation data, provides a unitless value to describe the relative socioeconomic background of an individual as determined by the proportion (%) of non-Hispanic black, proportion (%) of female headed families with children, and the proportion of households (%) with public assistance income or food stamps in a defined area. The average disadvantaged index score for the DFU population was 0.06 and was comparable to the state of Michigan's average disadvantaged index of 0.05. In those persons who developed DFU infection, the index score averaged 0.13, 2.2x higher than the DFU population (p<0.05). Additionally, divorced individuals represented 2% of all individuals with DFU but accounted for 5% of those who developed DFU infection. This was disproportionate to other marriage statuses. These data strongly support the need to incorporate SDOH into updated DFU standard of care guidelines. Moreover, we clearly demonstrate that SDOH, more specifically geolocation data, can be used to identify individuals who are more likely to develop DFU infection. Thus, it is essential that SDOH are included in patient risk stratification to prevent severe diabetic foot complications. Disclosure B.M.Schmidt: None. A.Burant: None. N.Baker: None. A.Katona: None. C.Martin: Advisory Panel; Nevro Corp. C.M.Holmes: None. R.Busui: Board Member; American Diabetes Association, Consultant; Averitas Pharma, Inc., Lexicon Pharmaceuticals, Inc., Nevro Corp., Novo Nordisk, Roche Diagnostics, Procter & Gamble, Research Support; Novo Nordisk, Medtronic, National Institutes of Health. Funding National Institute of Diabetes and Digestive and Kidney Diseases (1K23DK131261-01A1, 5U01DK119083-05)

152-OR: The Infected Diabetic Foot—The MRSA Incidence, Conversion of Non-MRSA to MRSA Pathogens, and Reinfection in Soft Tissue and Bone Infections

Aim: To evaluate the incidence of MRSA infection, re-infection, and the conversion of non-MRSA bacterial pathogens to MRSA in re-infections. Methods: This was a post hoc analysis of 233 patients that participated in an RCT for moderate and severe diabetic foot infections with 12-month outcomes. We used bone culture and/or pathology to define osteomyelitis (OM). Soft tissue infections (STI) were defined based on negative bone biopsy or negative MRI. Moderate and severe infection was based on criteria of the International. Working Group on the Diabetic Foot infection classification. All subjects required surgery. We evaluated bacterial pathogens from bone and deep soft tissue from their initial infection and when there was re-infection. We defined conversion when a subject did not have MRSA in either their first OM or STI culture and had MRSA when there was re-infection. We used χ2 for comparison of clinical events, with alpha of <0.05. Results: OM was present in 73.0% (n=170) of cases. MRSA incidence was 8.6% (n=20), with no difference between STI and OM (14.3% vs. 6.5%, p=0.06). Reinfection occurred in 29.2% (n=68), with no difference between STI and OM (36.5% vs. 26.5%, p=0.14). MRSA was seen in 29.4% (n=20) of the reinfections, with no difference between STI and OM (13.0% vs. 28.9%, p=0.16). Conversion to MRSA was seen in 14.7% (n=10), with no difference between STI and OM (4.3% vs. 20%, p=0.12). MRSA was 4.4 times more likely in re-infection compared to index infections (29.4% vs 8.6%, CI 2.2-8.9, p<0.01). Conclusion: The incidence of MRSA is 4.4-fold higher after re-infection. The incidence of MRSA for the first infection (8.6%) was low. Re-infection with MRSA (29.4%) and conversion to MRSA (14.7%) were common. There was no difference seen in the incidence rates for reinfection, MRSA, reinfection with MRSA, and conversion to MRSA between patients with STI and OM. Disclosure M.A.Suludere: None. A.L.Killeen: Research Support; 3M/KCI, AstraZeneca, BioTissue surgical, Hologenix, LLC, Integra LifeSciences, Kent Imaging Inc., Microbion, PolarityTE, Inc., Smith+Nephew, Stark Enterprises, LLC, Xyken, VasoActiv, ViOptix. P.Crisologo: None. L.A.Lavery: Research Support; AstraZeneca, Tissue tech, American Diabetes Association, PolarityTE, Inc., Microbion, Jarvis, Integra Lifesciences Holdings Corp, Smith+Nephew.

Altered regulation of oligodendrocytes associated with parvalbumin neurons in the ventral hippocampus underlies fear generalization in male mice.

Fear generalization is a neurobiological process by which an organism interprets a novel stimulus as threatening because of its similarity to previously learned fear-inducing stimuli. Because recent studies have suggested that the communication between oligodendrocyte precursor cells (OPCs) and parvalbumin (PV)-expressing GABAergic neurons (PV neurons) may play critical roles in stress-related disorders, we examined the involvement of these cells in fear generalization. We first tested the behavioral characteristics of mouse models for conventional fear conditioning (cFC) and modified FC (mFC) with severe electric foot shocks and found that fear generalization was observed in mice treated with mFC but not in mice treated with cFC. The expression levels of genes related to OPCs, oligodendrocytes (OLs), and myelin in the ventral hippocampus were lower in mFC mice than in cFC mice. The densities of OPCs and OLs were decreased in the ventral hippocampus of mFC mice compared to cFC mice. The myelination ratios of PV neurons in the ventral hippocampus were lower in mFC mice than in cFC mice. The chemogenetic activation of PV neurons in the ventral hippocampus of mFC mice reduced fear generalization. The expression levels of genes related to OPCs, OLs, and myelin were recovered following the activation of PV neurons. Finally, the myelination ratios of PV neurons were increased after the activation of PV neurons. Our results suggest that altered regulation of OLs specifically associated with axons of PV neurons in the ventral hippocampus may underlie the generalization of remote fear memory following severe stress exposure.

Antibody signatures in hospitalized hand, foot and mouth disease patients with acute enterovirus A71 infection.

Enterovirus A71 (EV-A71) infection is a major cause of severe hand, foot and mouth disease (HFMD) in young children. The characteristics of EV-A71 neutralizing antibodies in HFMD patients are not well understood. In this study, we identified and cloned EV-A71-neutralizing antibodies by single cell RNA and B cell receptor sequencing of peripheral blood mononuclear cells. From 145 plasmablasts, we identified two IgG1 monoclonal antibodies (mAbs) and six IgM mAbs that neutralized EV-A71. Four of the IgM mAbs harbor germline variable sequences and neutralize EV-A71 potently. Two genetically similar IgM antibodies from two patients have recurrent heavy chain variable domain gene usage and similar complementarity-determining region 3 sequences. We mapped the residues of EV-A71 critical for neutralization through selection of virus variants resistant to antibody neutralization in the presence of neutralizing mAbs. The residues critical for neutralization are conserved among EV-A71 genotypes. Epitopes for the two genetically similar antibodies overlap with the SCARB2 binding site of EV-A71. We used escape variants to measure the epitope-specific antibody response in acute phase serum samples from EV-A71 infected HFMD patients. We found that these epitopes are immunogenic and contributed to the neutralizing antibody response against the virus. Our findings advance understanding of antibody response to EV-A71 infection in young children and have translational potential: the IgM mAbs could potentially be used for prevention or treatment of EV-A71 infections.

Clinical application of the wooden shoe to complement surgical management of laminitis and other foot‐related disease in the horse: A report of three cases

SummaryThis article describes three cases in which severe foot pathology was managed with surgery and the application of a wooden shoe. Although all three horses would have fulfilled the grounds for humane euthanasia, they were successfully managed and had a favourable outcome. This article supports current farriery concepts and shows how the wooden shoe can effectively redistribute the horse's weight on the solar surface of the foot, alleviate foot pain, enhance foot biomechanics and serve as a valuable tool for veterinarians and farriers in post‐surgical management of laminitis and other foot‐related injuries.

High glucose-induced IL-7/IL-7R upregulation of dermal fibroblasts inhibits angiogenesis in a paracrine way in delayed diabetic wound healing

It is widely acknowledged that diabetes leads to slow wound healing and ulceration, and severe serious diabetic foot ulceration may result in amputation. In recent years, much emphasis has been placed on exploring diabetic wound healing to protect patients from adverse events. We recently found interleukin-7 (IL-7), a growth factor for B-cells and T-cells, and its receptor was significantly upregulated in high glucose-induced fibroblasts and skin of diabetic mice. Moreover, IL-7 stimulated fibroblasts secreted ANGPTL4, which inhibited angiogenesis of endothelial cells resulting in delayed wound healing. In our previous study, fibroblasts, endothelial cells and keratinocytes were exposed to normal glucose (5.5 mM) or high glucose (30 mM) medium for 24 h, and RNA sequencing showed that IL-7 and IL-7R were significantly upregulated in fibroblasts. To remove the effect of high glucose and explore the influence of IL-7, exogenous rMuIL-7 used to treat normal mice led to delayed wound healing by inhibiting angiogenesis. Vitro experiments revealed that IL-7-induced fibroblasts inhibited endothelial cell proliferation, migration and angiogenesis. Further experiments showed that fibroblast angiopoietin-like-4 (ANGPTL4) secretion exhibited the inhibitory effect which was blocked by culture with the corresponding neutralizing antibody. Overall, our study revealed signaling pathways associated with diabetic wound healing and provided the foothold for further studies on delayed wound healing in this patient population.Graphical abstractMechanism that high glucose activates IL-7-IL-7R-ANGPTL4 signal pathway in delayed wound healing. High glucose upregulates IL-7 and IL-7R in dermal fibroblasts. IL-7 stimulates dermal fibroblasts secreting Angptl4 which inhibits proliferation, migration and angiogenesis of endothelial cells in a paracrine way.

Highlights from the 82nd ADA Scientific Sessions and the 58th EASD Meeting on Diabetic Neuropathy.

Diabetic neuropathy is one of the commonest diabetic complications. It affects 30-50% of people with diabetes mellitus (DM) and may cause severe pain and foot ulcers. Distal symmetric polyneuropathy and diabetic autonomic neuropathy are the main manifestations of diabetic neuropathy. The American Diabetes Association's (ADA) 82nd Scientific Sessions took place in June 2022 in New Orleans, Louisiana, and the 58th European Association for the Study of Diabetes (EASD) Annual Meeting was held in September 2022 in Stockholm, Sweden. Herein, we describe interesting studies in the field of diabetic neuropathy presented in these two meetings.

The Combination of Synoeca-MP Antimicrobial Peptide with IDR-1018 Stimulates Proliferation, Migration, and the Expression of Pro-Regenerative Genes in Both Human Skin Cell Cultures and 3D Skin Equivalents.

In skin lesions, the development of microbial infection affects the healing process, increasing morbidity and mortality rates in patients with severe burns, diabetic foot, and other types of skin injuries. Synoeca-MP is an antimicrobial peptide (AMP) that exhibits activity against several bacteria of clinical importance, but its cytotoxicity can represent a problem for its positioning as an effective antimicrobial compound. In contrast, the immunomodulatory peptide IDR-1018 presents low toxicity and a wide regenerative potential due to its ability to reduce apoptotic mRNA expression and promote skin cell proliferation. In the present study, we used human skin cells and a 3D skin equivalent models to analyze the potential of the IDR-1018 peptide to attenuate the cytotoxicity of synoeca-MP, as well as the influence of synoeca-MP/IDR-1018 combination on cell proliferation, regenerative processes, and wound repair. We found that the addition of IDR-1018 significantly improved the biological properties of synoeca-MP on skin cells without modifying its antibacterial activity against S. aureus. Likewise, in both melanocytes and keratinocytes, the treatment with synoeca-MP/IDR-1018 combination induces cell proliferation and migration, while in a 3D human skin equivalent model, it can accelerate wound reepithelization. Furthermore, treatment with this peptide combination generates an up-regulation in the expression of pro-regenerative genes in both monolayer cell cultures and in 3D skin equivalents. This data suggests that the synoeca-MP/IDR-1018 combination possesses a good profile of antimicrobial and pro-regenerative activity, opening the door to the development of new strategies for the treatment of skin lesions.

Nomographic Model for Predicting Severe Foot Pain in Nurses from Tertiary Hospitals in China

To investigate the prevalence and common sites of severe foot pain among nurses, to define the risk factors of severe foot pain in nurses in tertiary hospital in China, and to construct a nomograph model for predicting individuals' risks for severe foot pain. Between August 2019 and December 2019, a stratified global sampling method was used to select 10691 nurses from 351 tertiary hospitals in China to investigate the incidence of severe foot pain among them. The variables that may affect the occurrence of severe foot pain were analyzed by single factor analysis to identify the influencing factors of severe foot pain in nurses. Furthermore, the independent risk factors of severe foot pain were analyzed by stepwise logistic regression analysis. The statistically significant factors identified in the multivariate regression analysis were incorporated into the nomograph prediction model. The predictive performance of the nomograph was measured by the consistency index (C-index) and calibrated with 1000 Bootstrap samples. A total of 3419 nurses out of the 10691 had foot pain, resulting in an incidence of 31.98%. The incidence of severe pain (VAS score 7-10) was 2.27% (243 of 10691). The locations of severe pain were more commonly found in the soles and heels of both feet. Six factors, including age, education, the material of the work shoes, comfortableness of the work shoes, number of complications, and foot injure history, were incorporated in the nomograph predicting model. The C-index value was 0.706 and the standard curve fitted well with the calibrated prediction curve. The risk prediction model constructed in this study showed sound performance in predicting the risk of severe foot pain in nurses, and all the indicators involved are simple and the relevant data are easily obtained. The model can provide reference for preventing severe foot pain in nurses.

D61. Management of Recurrent Morton’s Neuromas with Targeted Muscle Reinnervation

PURPOSE: Morton’s interdigital neuroma is a common cause of severe foot pain that is detrimental to quality of life. Current operative interventions for this condition include neurolysis, decompression, or neurectomy, which may result in true neuroma formation, with failure rates reported up to 49%. The objective of this study was to evaluate the efficacy of targeted muscle reinnervation (TMR) for the treatment of Morton’s neuromas that have failed previous surgeries. METHODS: A retrospective chart review was performed between March 2018 and April 2021. Eight patients underwent TMR of the medial plantar nerve (MPN), lateral plantar nerve (LPN), and/or sensory plantar common digital nerves. All patients were non-amputees who had previously undergone surgery for Morton’s neuroma and now had recurrent symptoms. The operative techniques employed for TMR of neuromas in the foot were described, along with post-operative outcomes. RESULTS: Of the 8 patients reviewed receiving TMR for neuroma pain in the foot, all of whom had previously undergone excisions of digital nerve neuromas: 7 patients had complete or near complete resolution of their pain; 1 patient had no improvement upon follow-up. Of the successfully treated group, 4 had complete or near complete resolution of paresthesia, dysesthesia, and other neuropathic signs in the relevant nerve distribution. The remaining 3 had partial improvement of these symptoms. The mean follow-up period was 395 days. CONCLUSION: This study is the first to investigate TMR as a treatment and prevention option for the recurrence of Morton’s neuroma. Our technique revealed good clinical outcomes and no procedure-specific complications.

148 Peroneal Nerve Repair With Crossbridge Ladder Technique: Parallel End-to-Side Neurorrhaphies

INTRODUCTION: Multiple nerve transfer techniques are used to treat patients with nerve injuries when a primary repair is not possible. These techniques are categorized to end-to-end, end-to-side, and side-to-side neurorrhaphy. METHODS: Four patients with significant loss of ankle dorsiflexion were seen in the clinic and underwent evaluation, including electrodiagnostic studies. A cross-bridge ladder repair technique was used between the tibial nerve as the donor and the common peroneal nerve as the recipient via one or two nerve grafts coapted in parallel with end-to-side neurorrhaphies. Dorsiflexion strength was measured preoperatively using the Medical Research Council (MRC) grading system and at each postoperative follow-up appointment. RESULTS: All four patients had suffered persistent and severe foot drop (MRC of 0) following trauma that had occurred between 6 and 15 months preoperatively. Three of the four patients improved to an MRC of 2 several months postoperatively. The last patient had an immediate improvement to an MRC of 2 by his first month and had a complete recovery of ankle dorsiflexion within four months from surgery. CONCLUSIONS: We demonstrate the utility and clinical outcomes of the cross-bridge ladder technique in patients with persistent and prolonged food drop following trauma. Both early and late recovery were seen while all patients regained motor function, with some patients continuing to improve up to the most recent follow-up.

307 Machine learning identification of diabetic foot ulcer severity to reduce amputation risk

OBJECTIVES/GOALS: Target: Computationally identify the markers of ulcer severity and risk of amputation from datasets that include demographics data, clinical, laboratory data, and medical history over 6000 patients. METHODS/STUDY POPULATION: In this study we will use tables of demographics such as age, gender, and ethnicity/race. Inspired by previous research we’ll include wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, Wagner grade, being non ambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization. Another table will include laboratory vital signs to include physiological variables such as height, weight, body mass index, pulse rate, blood pressure, respiratory rate, and temperature. We’ll include also social data like smoking status, socio-economic status, housing condition. RESULTS/ANTICIPATED RESULTS: Our project aligns with previous efforts to identify high risk Diabetic Foot Ulcer individuals but also takes a different perspective by collecting and marking clinical data from a subset of patients (e.g., severity, Hispanic versus non-Hispanic) and computationally process these data to provide a tool that can identify DFU severity and high-risk patients. We will obtain samples from Hispanics and non-Hispanics because these two groups are likely to have significant differences in the progression of ulcer severity. The rationale is that by comparing these two groups, we will assess and study the factors that are differentially present. It is our expectation that the proposed project will provide an easy-to-use tool for DFU progression and risk of amputation and contribute to identify high-risk individuals. DISCUSSION/SIGNIFICANCE: Diabetes prevalence estimates in Bexar County, TX exceeds national estimates (15.5% vs. 11.3%) and diagnosed cases are higher among Hispanic adults (13.4%) compared to their non-Hispanic white counterparts (9.5%). Late identification of severe foot ulcers minimizes the likelihood of reducing amputation risk.

The comparisons of procalcitonin and age between mild and severe Hand, foot, and mouth disease.

Hand, foot, and mouth disease (HFMD) is an epidemic infectious disease in children, usually associated with fever, mouth lesions, and limb rashes. Although benign and self-limiting, it can be dangerous or even fatal in rare cases. Early identification of severe cases is crucial to ensure optimal care. Procalcitonin (PCT) is an early marker for predicting sepsis. Therefore, in this study, we aimed to investigate the significance of PCT levels, age, lymphocyte subsets, N-terminal pro-brain natriuretic peptide (BNP) in the early diagnosis of severe HFMD. Using strict inclusion and exclusion criteria, we retrospectively enrolled 183 children with HFMD between January 2020 and August 2021 and divided them into mild (76 cases) and severe (107 cases) groups according to their condition. Data on the patients' PCT levels, lymphocyte subsets, and clinical characteristics at admission were evaluated and compared using the Student's t-test and χ2 test. We found that compared with mild disease forms, the severe disease forms were associated with higher blood PCT levels (P=0.001) and lower ages of onset (P<0.001). The percentages of lymphocyte subsets, including suppressor T cells (CD3+CD8+), T lymphocytes (CD3+), T helper cells (CD3+CD4+), natural killer cells (CD16+56+), and B lymphocytes (CD19+), were identical between the two disease forms in patients under 3 years of age. Age and blood PCT levels play a vital role in the early identification of severe HFMD.

Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers.

To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University. A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA. 992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs. The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.

Treatment of hyperhidrosis and the role of Botulinum Toxin Type A in therapy - a literature review

Introduction: Sweat secretion is a physiological process controlled by the autonomic nervous system, and it operates independently of our will. Primary hyperhidrosis is a disease characterized by excessive sweating, which is thought to result from localized hyperstimulation of sweat glands by cholinergic sympathetic nerve fibers. It can be associated with significant occupational, physical and emotional impairment, as well as significant difficulties in social situations and personal relationships. Available therapies are limited by their short-term efficacy and, in some cases, significant side effects that can expose patients to potentially serious complications. One treatment for primary hyperhidrosis is chemodenervation of the sweat glands using botulinum toxin type A. Objective: To review the current literature and recent reports on hyperhidrosis treatment therapies. To discuss the mechanism of action and the role of botulinum toxin in treatment, as well as the potential risks associated with undertaking treatment. Materials and method: Literature review of PubMed, Google Scholar and Science Direct Conclusions: Intradermal injection of botulinum toxin A is an effective and safe therapy for severe axillary, palmar, forehead, neck and foot hyperhidrosis. Current knowledge does not indicate that this therapy is associated with dangerous complications. Unfortunately, it is not a method that permanently solves the problem of sufferers.

Integrated analysis reveals important differences in the gut and oropharyngeal microbiota between children with mild and severe hand, foot, and mouth disease

ABSTRACT Little is known about alternation and difference in gut microbiota between patients with mild and severe hand, foot, and mouth disease (HFMD). We investigated the differences in gut and oropharynx microbiota between mild and severe HFMD in young children and changes in bacterial profiles as the disease progresses from acute to convalescent phase. Forty-two patients with confirmed HFMD were studied, among which 32 had severe HFMD and 10 had mild HFMD. First rectal swabs were collected from all patients at an average of 2 days (acute phase) after the onset of symptoms, and second rectal swabs were collected from 8 severe patients at day 9 (convalescent phase) after the onset. Oropharyngeal swabs were obtained from 10 patients in the acute phase and 6 in the convalescent phase. 16S rRNA sequencing was performed for all 70 samples. Compared with mild HFMD, severe HFMD exhibited significantly decreased diversity and richness of gut microbiota. Gut microbiota bacterial profiles observed in the acute and convalescent phases resembled each other but differed from those in mild cases. Additionally, 50% of patients with severe HFMD in the acute phase harboured a dominant pathobiontic bacterial genus. However, none of the patients with mild HFMD had such bacteria. Similar bacterial compositions in oropharynx microbiota were detected between mild and severe cases. Our findings indicate that severe HFMD exhibits significantly impaired diversity of gut microbiota and frequent gut and oropharyngeal inflammation-inducing bacteria. However, the results should be interpreted with caution as the number of subjects was limited.

A case report: Pre-gangrene left foot with COPD and hypertension

Pre-gangrene is the penultimate stage of vascular insufficiency before gangrene sets in; the term is usually applied to ischemia of lower limb. A male patient admitted with complains of severe foot pain, tenderness (2-3 months), and tingling &amp; numbness. In a past medical history, he was suffering with hypertension (HTN) and COPD. He was taking amlodipine 5 mg tablet for HTN for daily basis. The X- ray finding shows that patients were suffering COPD. The patient is known case of COPD from last 3 year. After a diagnosis he has go through a surgery for left foot pre-gangrene (below knee amputation). During surgery general anesthetic and some post and pre-operative medication is given. During hospitalization patients taking various medications like antibiotic, bronchodilator and anti-hypertensive. Specifically in this patient amoxicillin and Clavulanic acid anti-biotic combination is used to treat gangrene.&#x0D; Keywords: Hypertension, pre-gangrene, COPD, Antibiotic, bronchodilator.

Factors related to the mortality risk of severe hand, foot, and mouth diseases (HFMD): a 5-year hospital-based survey in Guangxi, Southern China

BackgroundTo understand the factors influencing clinical outcomes of severe hand, foot, and mouth diseases (HFMD), and to provide scientific evidence for reducing the mortality risk of severe HFMD.MethodsFrom 2014 to 2018, children diagnosed with severe HFMD cases in Guangxi, China, were enrolled in this hospital-based study. The epidemiological data obtained through face-to-face interviews with the parents and guardians. Univariate and multivariate logistics regression models were used to analyze the factors influencing the clinical outcomes of severe HFMD. The impact of the EV-A71 vaccination on inpatient mortality was analyzed by a comparison approach.ResultsA total of 1565 severe HFMD cases were enrolled in this survey, including 1474 (94.19%) survival cases and 91 (5.81%) death cases. The multivariate logistic analysis demonstrated that HFMD history of playmates in the last three months, first visit to the village hospital, time from the first visit to admission less than two days, no correct diagnosis for HFMD at the first visit, and having no rash symptoms were the independent risk factors for severe HFMD cases (all p < 0.05). While EV-A71 vaccination was a protective factor (p < 0.05). The EV-A71 vaccination group versus the non-vaccination group showed 2.23% of death in the vaccination group and 7.24% of death in the non-vaccination group. The EV-A71 vaccination protected 70.80% of the death of severe HFMD cases, with an effective index of 4.79.ConclusionsThe mortality risk of severe HFMD in Guangxi was related to playmates had HFMD history in last 3 months, hospital grade, EV-A71 vaccination, patients visit hospital previously, and rash symptom. EV-A71 vaccination can significantly reduce mortality among severe HFMD. The findings are of great significance for the effective prevention and control of HFMD in Guangxi, southern China.

Value of cystatin C in predicting recurrence in patients with severe diabetic foot and diabetic foot ulcer.

Objective: Our objective is to investigate the risk factors and predictive ability of severe diabetic foot(DF) and diabetic foot ulcers (DFUs). Patients & methods: The efficacy of cystatin C in predicting the recurrence of DF and DFU was evaluated using a receiver operating characteristic curve. Results: The findings indicate that, in contrast to non-severe patients, severe cases exhibit elevated levels of cystatin C (p <0.05). Additionally, a statistically significant increase in cystatin C levels was observed in the subgroup of patients with recurrent DFU (p <0.01). Conclusion: Cystatin C emerged as a significant risk factor for severe DF and recurrent DFU, with the potential for predicting their occurrence.