Onychomycosis in diabetes. Management considerations.

With exciting recent developments in the field of medical mycology and a new generation of oral antifungal agents, there has been renewed interest in the management of onychomycosis. Epidemiologic surveys report an overall disease prevalence of 2% to 13% and evidence of steadily rising incidence worldwide. Onychomycosis, beyond being a mere cosmetic nuisance, as it has been labeled historically, can be a serious infection that may have a deleterious impact on patients' overall quality of life and well-being. Across medical disciplines, onychomycosis is well recognized as being arduous both to diagnose and to manage. In addition to the importance of treating onychomycosis in the general population, there is strong clinical impetus to treat patients with concomitant conditions in order to prevent primary disease-related complications that, ultimately, can be life-threatening.

The safety of itraconazole in the diabetic population.

This study examined the safety of itraconazole for the treatment of onychomycosis in patients with diabetes mellitus compared with standard palliative treatment. Fifty-two diabetic subjects in a large Veterans Affairs health system who had been diagnosed as having lower-extremity complications and distal dermatophytic subungual onychomycosis of the toenail were randomized to receive either intermittent itraconazole, 200 mg twice daily, or standard palliative care, consisting of toenail trimming, cleaning, and soaking. Adverse events were reported in 4 of the 27 itraconazole subjects; no adverse events were reported in the 25 palliative treatment subjects. One itraconazole subject was withdrawn from the study because of elevated liver function test results; the other three adverse events (rash, diarrhea, and pedal edema) were considered self-limiting and did not interfere with protocol completion. Analyses of prestudy and poststudy hemoglobin A1c and liver function test results in both treatment groups were comparable, with no statistically significant differences. Itraconazole was found to be safe for the treatment of distal dermatophytic subungual onychomycosis in diabetic patients with lower-extremity complications having multiple concomitant disorders and requiring concurrent pharmacologic regimens.

Partnership between a Veterans Affairs medical center and a podiatric medical college.

The health care academic delivery system is dramatically changing in today's economy. In order to survive, the delivery system must decrease its costs and increase productivity. Integration of academic affiliates and community health care facilities has produced a more efficient health care system and improved medical education. The formation and methodology of the mutual benefits and responsibilities between a health care system and a college of podiatric medicine are examined in detail. Developing unique sharing partnerships can mutually improve medical student experiences, reduce financial burdens, combine joint research projects, and ultimately improve patient care.