Efficacy of a povidone-iodine foam dressing (Betafoam) on diabetic foot ulcer.

This study aimed to assess the efficacy of a new povidone-iodine (PVP-I) foam dressing (Betafoam) vs foam dressing (Medifoam) for the management of diabetic foot ulcers. This study was conducted between March 2016 and September 2017 at 10 sites in Korea. A total of 71 patients (aged ≥19 years) with type 1/2 diabetes and early-phase diabetic foot ulcers (Wagener classification grade 1/2) were randomised to treatment with PVP-I foam dressing or foam dressing for 8 weeks. Wound healing, wound infection, patient satisfaction, and adverse events (AEs) were assessed. The PVP-I foam and foam dressing groups were comparable in the proportion of patients with complete wound healing within 8 weeks (44.4% vs 42.3%, P = .9191), mean (±SD) number of days to complete healing (31.00 ± 15.07 vs 33.27 ± 12.60 days; P = .6541), and infection rates (11.1% vs 11.4%; P = 1.0000). Median satisfaction score (scored from 0 to 10) at the final visit was also comparable between groups (10 vs 9, P = .2889). There was no significant difference in AE incidence (27.8% vs 17.1%, P = .2836), and none of the reported AEs had a causal relationship with the dressings. The results of this study suggest that PVP-I foam dressing has wound-healing efficacy comparable with foam dressing, with no notable safety concerns. This study was funded by Mundipharma Korea Ltd and registered at ClinicalTrials.gov (identifier NCT02732886).

Allogeneic keratinocyte for intractable chronic diabetic foot ulcers: A prospective observational study.

Chronic diabetic foot ulcers (DFUs) are a common problem in patients with diabetes and are often difficult to treat. The application of newly developed dressing material in patients with chronic DFUs has been reported to be effective. The purpose of this study was to evaluate the usefulness of allogeneic keratinocyte treatment for chronic DFUs. We performed weekly allogeneic keratinocyte treatment for up to 12 weeks in 71 patients with intractable DFUs. We investigated healing rate, wound-healing velocity, and time to 50% wound size reduction and analysed factors affecting ulcer healing. Fifty-six patients (78.8%) had complete wound healing. Forty-six patients (64.7%) showed complete healing within an average of 6.1 weeks, and 10 patients (14.1%) showed partial healing with an average 35.5% reduction vs initial size at the end of follow up. The 10 patients who showed partial healing continued to receive treatment after the 12-week study period. The mean time to complete wound healing was 7.8 weeks. Fifteen patients (21.1%) experienced treatment failure because of infection, local necrosis, no change in ulcer size, or osteomyelitis during the follow-up period. No adverse events were observed. Allogeneic keratinocyte treatment is effective for chronic, difficult-to-treat DFUs.

Prevalence of depression and suicidal ideation increases proportionally with renal function decline, beginning from early stages of chronic kidney disease.

Depression and suicidal ideation are prevalent mental health problems in patients with chronic kidney disease (CKD. However, the association between mental health problems and kidney disease has been investigated in severe cases only. Thus, this study evaluated the relationship between mental health problems and renal function in a community-based prospective cohort study comprising patients with mild to moderate kidney disease. A total of 44,938 participants who were participated in Korean National Health and Nutrition Examination Survey IV, V, and VI from 2007 to 2014 were enrolled. Estimated glomerular filtration rate (eGFR) was calculated using the CKD Epidemiology Collaboration equation. The study outcome was the prevalence of depression and suicidal ideations assessed by self-reporting surveys. Logistic regression analysis was performed to evaluate the relationship between renal function and outcomes. The mean age of the study subjects was 49.2 ±â€Š16.6 years, and the mean eGFR was 94.0 mL/min/1.73 m. The prevalence of depression and suicidal ideation increased with decreasing eGFR. Multivariate logistic regression analysis showed that the risk of depression increased in subjects with eGFR <45 mL/min/1.73 m [odds ratio (OR) 1.47; 95% confidence interval (CI) 1.09-1.98]. The risk of suicidal ideation gradually increased in groups with eGFR <90 mL/min/1.73 m (OR, 1.11; 95% CI, 1.03-1.20), even after adjustments for confounding variables. In conclusion, depression and suicidal ideation are related closely with renal dysfunction. The risk of having depression and suicidal ideation increased even in patient with mild renal dysfunction. Therefore, evaluation and management strategies regarding mental health problems should be taken into account throughout all stages of CKD.

Change of Nutritional Status Assessed Using Subjective Global Assessment Is Associated With All-Cause Mortality in Incident Dialysis Patients.

Subjective global assessment (SGA) is associated with mortality in end-stage renal disease (ESRD) patients. However, little is known whether improvement or deterioration of nutritional status after dialysis initiation influences the clinical outcome. We aimed to elucidate the association between changes in nutritional status determined by SGA during the first year of dialysis and all-cause mortality in incident ESRD patients. This was a multicenter, prospective cohort study. Incident dialysis patients with available SGA data at both baseline and 12 months after dialysis commencement (n = 914) were analyzed. Nutritional status was defined as well nourished (WN, SGA A) or malnourished (MN, SGA B or C). The patients were divided into 4 groups according to the change in nutritional status between baseline and 12 months after dialysis commencement: group 1, WN to WN; group 2, MN to WN; group 3, WN to MN; and group 4, MN to MN. Cox proportional hazard analysis was performed to clarify the association between changes in nutritional status and mortality. Being in the MN group at 12 months after dialysis initiation, but not at baseline, was a significant risk factor for mortality. There was a significant difference in the 3-year survival rates among the groups (group 1, 92.2%; group 2, 86.0%; group 3, 78.2%; and group 4, 63.5%; log-rank test, P < 0.001). Multivariate Cox regression analysis revealed that the mortality risk was significantly higher in group 3 than in group 1 (hazard ratio [HR] 2.77, 95% confidence interval [CI] 1.27-6.03, P = 0.01) whereas the mortality risk was significantly lower in group 2 compared with group 4 (HR 0.35, 95% CI 0.17-0.71, P < 0.01) even after adjustment for confounding factors. Moreover, mortality risk of group 3 was significantly higher than in group 2 (HR 2.89, 95% CI 1.22-6.81, P = 0.02); there was no significant difference between groups 1 and 2. The changes in nutritional status assessed by SGA during the first year of dialysis were associated with all-cause mortality in incident ESRD patients.

Barefoot stubbing injuries to the great toe in children: a new classification by injury mechanism.

OBJECTIVE: This study was conducted to categorize barefoot stubbing injuries to the great toe in children by injury mechanism to differentiate benign stubbing injuries from more complex injuries necessitating surgery. DESIGN: Prospective clinical series of consecutively treated patients. SETTING: Tertiary university hospital setting. PATIENTS: Forty-one children who had sustained an indirect injury to the great toe during barefoot sports activities between January 2001 and December 2009 were included. INTERVENTION: Conservative or surgical treatment was done according to clinical and radiological findings. MAIN OUTCOME MEASUREMENT: Information regarding injury mechanism was collected from patients, parents, and coaches using skeletal models and assessed by a pediatric orthopedic surgeon. Mechanisms of injury were identified and grouped as follows: hyperabduction-flexion, hyperflexion, hyperabduction-extension, hyperextension, and hyperextension-adduction. RESULTS: Hyperabduction-flexion was the most common mechanism (n = 16), in which interphalangeal joint dislocation and skin disruption was noted in most cases. The second most common mechanism was hyperabduction-extension (n = 14) in which avulsion fracture of the lateral volar condyle of the proximal phalanx was noted in most cases. This avulsion fracture had the worst prognosis after conservative care. CONCLUSIONS: Based on these results, we have created a grading system and treatment protocol for indirect hallux sports injuries in children. Avulsion fracture of the lateral condyle of the proximal phalanx, a result of hyperabduction-extension, is a high-risk sign of nonunion and should be aggressively treated, contrary to previous guidelines. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Single right coronary artery giving off anomalous origin of left anterior descending artery with diffuse myocardial bridge: the role of computed tomography scan.

A 58-year-old woman who presented with resting chest pain underwent coronary angiography and multidetector computed tomography (MDCT), with detection of a single right coronary artery giving off an anomalous origin of the left anterior descending artery, subpulmonic type with diffuse myocardial bridge. The myocardial bridge was detected by MDCT, not by coronary angiography. Our findings suggest that MDCT has an important role in the more precise evaluation of clinical and anatomical information in patients with a single coronary artery.

A toenail flap based on the fibro-osseous hiatus branch for fingernail reconstruction.

This study included two parts: 1) cadaver dissection to elucidate the perfusion of toenail flaps by the fibro-osseous hiatus branch (FHB), and 2) clinical application of the toenail flap for reconstruction of a fingernail defect. Four second toes of two fresh Korean cadavers were dissected. The plantar digital artery (PDA) and terminal segment branch (TSB) were ligated, and red latex was injected distally into the ligated PDA. Perfusion of the dye into the toenail bed through the FHB was observed. From Oct 2004 to Sep 2009, eight toenail flaps based on the FHB pedicle with or without the distal phalanx and pulp were applied to seven patients for finger nail reconstruction. The toenail flap was marked at 5 mm distal to the nail fold and 5 mm lateral to the paronychium. The toenail complex based on the FHB was elevated and transferred to the finger. The nail and matrix were elevated with or without including the distal phalanx. The results of perfusion study showed that one side of the unilateral FHB was identified and traced proximal to the PDA, which was ligated. The distal toenail bed was perfused by the dye through the FHB. In clinical application, all the toenail flaps flourished and survived. We suggest that the toenail flap based on the FHB may be useful for fingernail reconstruction with minimal donor morbidity.

Arterial anatomy of the second toe nail bed related to toenail transfer.

The aim of this study was to elucidate the exact course of the terminal branches of the plantar digital artery (PDA) to the nail bed of the second toe. Thirteen second toes from seven fresh Korean cadavers were dissected (age range 74-92 years, four men and three women). The terminal segmental branches (TSB) branched off from the PDA at 7.6 ± 0.7 mm proximal to the nail fold. The fibro-osseous hiatus branch (FHB) branched off from the PDA at 3.3 ± 0.7 mm from the nail fold. They were 3.8 ± 1.0 mm lateral to the paronychium. Diameters of TSB and FHB were 0.8 ± 0.2 mm and 0.7 ± 0.1 mm, respectively. Diameter of PDA was 1.4 ± 0.2 mm. Surgeons should stay at least 4 mm proximal to the nail fold to avoid injury to the terminal branch. We believe that second toenail with minimum amount of soft tissue may be transferred using FHB-based vascularized toenail flap. Perfusion study and clinical application should be followed.

Variation in course of cavernous nerve with special reference to details of topographic relationships near prostatic apex: histologic study using male cadavers.

OBJECTIVES: To study interindividual variation in the cavernous nerve course near the rhabdosphincter and the apex of the prostate as a basis for refining nerve-sparing radical prostatectomy. The varying anatomy of the cavernous nerve might account for the disparate potency rates after nerve-sparing radical prostatectomy. METHODS: We examined serial histologic sections from 20 male pelves (7 frontal, 8 sagittal, and 5 axial sections) and performed 5 fresh cadaver dissections. RESULTS: In the fresh dissections, the macroscopically identified neurovascular bundle consistently showed an almost straight proximal-to-distal course along the urethra. However, on histologic analysis, the types of the nerve course were classified as frontal (2 of 7 specimens), sagittal (3 of 8), and axial (2 of 5). In the frontal and sagittal courses, the nerves passed through the connective tissue of a narrow potential space between the rhabdosphincter and the levator ani. In the specimens showing an axial course, the nerves were spatially distinct from the prostate, coursing ventromedially in the pararectal space. Thus, the nerves could display a long, tortuous course, passing through the rectourethral muscle at its thickest portion. In addition, a nerve component supplying the area of the rhabdosphincter seemed to accompany the cavernous nerve. CONCLUSIONS: The neurovascular bundle, previously defined in terms of surgery, is likely to differ from the actual course of the cavernous nerve when this is axial, passing through the pararectal space and rectourethral muscle. To avoid cavernous nerve injury, the rectourethral muscle must be managed carefully in both the retropubic and the perineal approaches.

Inhibition of inducible nitric-oxide synthase expression by silymarin in lipopolysaccharide-stimulated macrophages.

Silymarin, a polyphenolic flavonoid antioxidant, is known to have anti-inflammatory, hepatoprotective, and anticarcinogenic effects. In the present study, we report the inhibitory effect of silymarin on nitric oxide production and inducible nitric-oxide synthase (iNOS) gene expression in macrophages. In vivo administration of silymarin attenuated nitric oxide production by peritoneal macrophages in lipopolysaccharide (LPS)-treated mice. Silymarin also dose dependently suppressed the LPS-induced production of nitric oxide in isolated mouse peritoneal macrophages and RAW 264.7, a murine macrophage-like cell line. Moreover, iNOS mRNA and its protein expression were completely abrogated by silymarin in LPS-stimulated RAW 264.7 cells. To further investigate the mechanism responsible for the inhibition of iNOS gene expression by silymarin, we examined the effect of silymarin on LPS-induced nuclear factor-kappaB (NF-kappaB)/Rel activation, which regulates various genes involved in immune and inflammatory response. In RAW 264.7 cells, the LPS-induced DNA binding activity of NF-kappaB/Rel was significantly inhibited by silymarin, and this effect was mediated through the inhibition of the degradation of inhibitory factor-kappaB. Silymarin also inhibited tumor necrosis factor-alpha-induced NF-kappaB/Rel activation, whereas okadaic acid-induced NF-kappaB/Rel activation was not affected. NF-kappaB/Rel-dependent reporter gene expression was also suppressed by silymarin in LPS-stimulated RAW 264.7 cells. Further study showed that silymarin suppressed the production of reactive oxygen species generated by H(2)O(2) in RAW 264.7 cells. Collectively, these results suggest that silymarin inhibits nitric oxide production and iNOS gene expression by inhibiting NF-kappaB/Rel activation. Furthermore, the radical-scavenging activity of silymarin may explain its inhibitory effect on NF-kappaB/Rel activation.