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Query: UMLS:C0022116 (ischemia)
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Problems of the diabetic foot are frequent. The magnitude of the clinical picture and morbidity mirrors the severity and complexity of the underlying pathobiology. The three pathogenetic mechanism involved are ischemia, neuropathy and infection. Seldom do these mechanisms work in isolation, rather most foot problems result from a complex interplay among all three. The clinical picture of the diabetic foot reaches from the neuropathic deformity with diminished or absent sensation of pain to limited gangrene or superficial ulcer. The polymicrobial infection leads to extensive tissue destruction (plantarphlegmone) with osteomyelitis. The patients often notes no pain and may become aware of the infection only through the presence of drainage or a foul odor. These infections are usually more extensive than would be predicted by clinical signs and symptoms. These lesions must be debrided and drained promptly and completely. This often requires amputations of one or more toes, combined with an incision along the entire course of the infected track on the plantar or dorsal aspect of the foot. Cultures should be taken from the depth of the wound. Initial treatment should be with broad-spectrum antibiotics, with subsequent adjustment based on culture results. The diabetic foot is a clinical problem that can be solved with a high degree of success when the approached by an interdisciplinary team (specialists in infectious and vascular disease, podiatry and diabetology). Arterial reconstruction should be designed to restore maximum perfusion to the foot. The most effective result can be obtained with infra-inguinal vein bypass with distal anastomosis to the most proximal artery with direct continuity to the ischemic territory. The single most important factor in the achievement of the reduction of amputation is the autologous vein bypass. The overall outcome in the diabetic patient in terms of graft patency and limb salvage is equal to that in the nondiabetic.
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PMID:[The diabetic foot]. 982 1

This case is of a man with bilateral lower-extremity ischemia and a solitary nonhealing ulcerated lesion of the right great toe. After revascularization with an aortobifemoral bypass, his right ABI increased from 0.5 to approximately 0.75, but the ulcerated toe lesion did not show signs of healing and instead progressed to a deeper ulceration exposing bone. Because of presumptive osteomyelitis, we performed a great toe amputation, and immunohistochemical analysis of the lesion revealed late plaque stage mycosis fungoides (MF). We present this case to alert the vascular surgeon to this diagnostic possibility when confronted with an apparent ischemic lesion and to describe what made this particular lesion suspicious for MF. To the best of our knowledge, this is the first case of MF presenting solely as an ischemic lesion.
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PMID:Mycosis fungoides masquerading as an ischemic foot. 1034 65

Advanced stages of the diabetic foot syndrome complicated by ischemia and osteomyelitis frequently result in minor amputation, followed by impaired wound healing and higher-level amputation in the context of regular health structures. Even in specialized foot care centers, peripheral arterial occlusive disease and osteomyelitis still represent the greatest challenge in the strife for limb salvage. Whereas the treatment of nonischemic foot lesions has increasingly become a matter of conservative medicine within recent years, for advanced diabetic foot wounds a multidisciplinary treatment policy is essential. A well-coordinated treatment concept aiming at the elimination of the most relevant prognostic factors ischemia and osteomyelitis is required to achieve high limb salvage rates. Surgical revascularization by distal bypass is a crucially important element of this approach. Percutaneous transluminal angioplasty represents a complementary option for short-segment arterial occlusive disease. Foot-sparing minor surgery improves healing time and rates. A specialized diabetologic foot care clinic provides preclinical diagnosis, planning of inpatient procedures, and selection of patients requiring hospitalization for surgical intervention. In addition, it safeguards postinterventional care for wounds with secondary healing and measures of secondary prevention.
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PMID:[Interdisciplinary diagnosis and therapy of ischemic-osteomyelitic diabetic foot syndrome]. 1197 81

The amputation rate in patients with diabetic foot syndrome (DFS) in Germany is still as high as 28,000 per year. Ischemia and osteomyelitis often complicate the DFS. Impaired wound healing frequently requires further surgery with a higher amputation level. The results of treating patients with DFS in our specialized foot care center were evaluated in order to assess our interdisciplinary strategy. Advanced diabetic foot wounds in patients with ischemia and osteomyelitis first require diagnostics concerning polyneuropathy, osteomyelitis, and blood supply. If peripheral arterial vessel disease is present, surgical revascularization by distal bypass grafting is the first and crucially important element of the interdisciplinary approach. Minor amputation or elective resection of the infected bone improves wound healing. Post-interventional care for wounds with secondary healing and prevention of new ulcers are provided in a foot care clinic specialized in diabetes. The clinical and radiological results of 77 patients who underwent this treatment algorithm including bypass surgery and bone resection within 1 year were collected using a standardized questionnaire. Those results were subjected to a historical comparison. Only three patients needed further intervention because of persisting ulcers and osteomyelitis. The frequency of major amputations in all patients with DFS and ischemia combined with osteomyelitis was low (10.3%). This interdisciplinary concept of treatment guarantees a high healing rate in patients even with osteomyelitis and ischemia and allows the reduction of the rate of major amputations. The data obtained allow a fact-based design for future studies.
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PMID:[Interdisciplinary treatment of diabetic foot syndrome]. 1264 39

The foot ulcer is one of most common and devastating complications of diabetes and is associated with considerable morbidity and mortality. The major causes of these ulcers are ischemia/hypoxia, neuropathy, and infection, and they often coexist. Despite conventional therapy including revascularization procedures when appropriate, three situations lead frequently to amputation: persistent critical limb ischemia, soft tissue infection, and impaired wound healing from osteomyelitis. In these conditions, hyperbaric oxygen therapy may be used as an adjunctive treatment and is associated with a better outcome. Randomized, prospective, controlled trails have shown the benefit of hyperbaric oxygen therapy in diabetic ulcers of the lower extremity. Transcutaneous oxygen measurement performed under hyperbaric oxygen therapy has a prognostic significance when used to select patients who are the most likely to benefit from therapy. Hyperbaric oxygen should be added to conventional treatment if the transcutaneous oxygen tension close to the trophic lesion in 2.5 ATA hyperbaric oxygen is over 200 mmHg. Peri-wound transcutaneous oxygen tensions over 400 mmHg in 2.5 ATA hyperbaric oxygen or over 50 mmHg in normobaric pure oxygen predict healing success with adjuncted hyperbaric oxygen therapy with high accuracy.
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PMID:Hyperbaric oxygen therapy of diabetic foot ulcers, transcutaneous oxymetry in clinical decision making. 1461 86

Each year, 82,000 limb amputations are performed in patients with diabetes mellitus. The majority of these amputations could be avoided by following strict protocols. The collective experience treating patients with neuropathic diabetic foot ulcers of 4 major diabetic foot programs in the United States and Europe were analyzed. The following protocol has been developed for patients with diabetic foot ulcers: (1) measurement of the wound by planimetry; (2) optimal glucose control; (3) surgical debridement of all hyperkeratotic, infected, and nonviable tissue; (4) systemic antibiotics for deep infection, drainage, and cellulitis; (5) offloading; (6) moist-wound environment; and (7) treatment with growth factors and/or cellular therapy if the wound is not healing after 2 weeks with this protocol and a new epithelial layer is not forming. In addition, the pathogenesis of diabetic foot ulcers is discussed, as well as the associated costs and complications, including amputation. Debridement, wound-bed preparation, antibiotics, various types of dressings, biological therapies, growth factors, and offloading are described as treatment modalities for patients with diabetic foot ulcers. In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensure rapid healing and minimize morbidity, mortality, and costs, as well as eliminate amputation in the absence of ischemia and osteomyelitis.
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PMID:Protocol for treatment of diabetic foot ulcers. 1514 85

Toe amputations are becoming more prevalent in the diabetic population. To prevent toe amputations, those individuals with the highest risk must be identified prior to developing a precipitating event. There are obvious risk factors for toe amputations, such as digital deformity, diabetic neuropathy, and ischemia. Other, less obvious, systemic comorbidities may be linked to toe amputations. This study also shows that gender plays a significant role as a risk factor for toe amputation. A foot infection, foot abscess, osteomyelitis, diabetic retinopathy, and diabetic nephropathy were also significant risk factors for toe amputations. This suggests a significant relationship between these complications and comorbidities that put these individuals at a higher risk for toe amputations.
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PMID:A case-control study of the risk factors for toe amputation in a diabetic population. 1586 23

Through-transmission alveolar ultrasonography (TAU) is a novel imaging modality in dental medicine. A brief introduction to through-transmission ultrasonography (TTU) is followed by a description of the first commercially available TAU device, the Cavitat CAV 4000 (Cavitat Medical Technologies, Inc., Alba, TX). Recent associations between systemic osteoporosis, oral osteoporosis, periodontal diseases, and cardiovascular diseases underline the importance of early detection and treatment of oral cancellous bone pathologies associated with low bone density (LBD), such as regional ischemic osteoporosis, chronic nonsuppurative osteomyelitis, bone marrow edema, and cavitational ischemic osteonecrosis (osteocavitation). While the impact of osteoporosis on maxillofacial bones is acknowledged, there is a lack of reliable prevalence rate, and the National Institutes of Health (NIH) recommend that more attention should be paid to skeletal health, especially in persons with conditions known to be associated with secondary osteoporosis. TAU, a safe and effective imaging modality, can be a valuable tool in research as well as for the clinical assessment of alveolar cancellous bone pathologies associated with LBD and ischemia.
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PMID:Introduction to through-transmission alveolar ultrasonography (TAU) in dental medicine. 1589 66

Almost all diabetic foot infections originate from a foot ulcer. Decreased pain perception and structural deformities such as previous partial foot amputation, Charcot joints, and toe deformity in combination with chronic ischemia lead to a propensity for skin breakdown and subsequent infection. Magnetic resonance (MR) imaging is increasingly performed to evaluate for potential bone infection, but diagnosis of osteomyelitis can be complicated because signal changes from acute Charcot arthropathy, fractures, and postoperative residues may be mistaken for infection. Signal alterations of bone infection may be atypical in sclerosing osteomyelitis and gangrene. Differentiation between osteomyelitis and acute or subacute neuroarthropathy requires careful analysis of the location of bone signal alterations, their distribution, and pattern because qualitative changes are often identical. Presence of secondary signs such as adjacent ulcer, cellulitis, and sinus tract is indicative of osteomyelitis. Differentiation of noninfected neuroarthropathy from infected neuroarthropathy based on MR examinations is difficult. Presence of a sinus tract, disappearance of subchondral cysts, diffuse bone marrow abnormality, and bone erosions are in favor of infection.
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PMID:Differential diagnosis of pedal osteomyelitis and diabetic neuroarthropathy: MR Imaging. 1624 26

EXECUTIVE SUMMARY: 1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic Gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture before starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic Gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 12 weeks usually suffices, but some require an additional 12 weeks; for moderate and severe infections, usually 24 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 46 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to 1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II). 19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).
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PMID:Diagnosis and treatment of diabetic foot infections. 1547 38


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