Linezolid-Associated Serotonin Syndrome. A Report of Two Cases.

Linezolid, a mild monoamine oxidase inhibitor, is a commonly used antibiotic drug for the treatment of complicated skin and skin structure infections, including diabetic foot infections. Use of linezolid has been associated with serotonin syndrome, a potentially life-threatening condition typically caused by the combination of two or more medications with serotonergic properties, due to increased serotonin release. The goals of this article are to highlight the risk factors associated with the development of serotonin syndrome related to the use of linezolid and to aid in its prevention and early diagnosis. In this case series we report on two hospitalized patients who, while being treated with linezolid for pedal infections, developed serotonin syndrome. Both individuals were also undergoing treatment with at least one serotonergic agent for depression and had received this medication within 2 weeks of starting the antibiotic drug therapy. In these individuals, we noted agitation, confusion, tremors, and tachycardia within a few days of initiation of linezolid therapy. Owing to the risk of serotonin toxicity, care should be taken when prescribing linezolid in conjunction with any other serotonergic agent. Although serotonin syndrome is an infrequent complication, it can be potentially life threatening. Therefore, risks and benefits of therapy should be weighed before use.

Limb salvage using advanced technologies: a case report.

Patients with severe acute and chronic lower extremity wounds often present a significant challenge in terms of limb salvage. In addition to control of infection, assuring adequate perfusion and providing standard wound care, advanced modalities are often required to facilitate final wound closure. We herein present a case study on a diabetic patient with gangrene and necrotising soft-tissue infection who underwent a forefoot pedal amputation to control the sepsis. Despite his non invasive vascular studies demonstrating poor healing potential at this level, he was not deemed suitable for revascularisation by our vascular surgeons and ankle-level amputation was recommended. Nonetheless, over a 5-month period using multiple advanced wound care therapies, wound closure was ultimately achieved.

Small area variation in diabetes prevalence in Puerto Rico.

OBJECTIVE: To estimate the 2009 prevalence of diagnosed diabetes in Puerto Rico among adults ≥ 20 years of age in order to gain a better understanding of its geographic distribution so that policymakers can more efficiently target prevention and control programs. METHODS: A Bayesian multilevel model was fitted to the combined 2008-2010 Behavioral Risk Factor Surveillance System and 2009 United States Census data to estimate diabetes prevalence for each of the 78 municipios (counties) in Puerto Rico. RESULTS: The mean unadjusted estimate for all counties was 14.3% (range by county, 9.9%-18.0%). The average width of the confidence intervals was 6.2%. Adjusted and unadjusted estimates differed little. CONCLUSIONS: These 78 county estimates are higher on average and showed less variability (i.e., had a smaller range) than the previously published estimates of the 2008 diabetes prevalence for all United States counties (mean, 9.9%; range, 3.0%-18.2%).

Small area variation in diabetes prevalence in Puerto Rico / Variación en un área pequeña de la prevalencia de la diabetes en Puerto Rico

OBJECTIVE: To estimate the 2009 prevalence of diagnosed diabetes in Puerto Rico among adults > 20 years of age in order to gain a better understanding of its geographic distribution so that policymakers can more efficiently target prevention and control programs. METHODS: A Bayesian multilevel model was fitted to the combined 2008-2010 Behavioral Risk Factor Surveillance System and 2009 United States Census data to estimate diabetes prevalence for each of the 78 municipios (counties) in Puerto Rico. RESULTS: The mean unadjusted estimate for all counties was 14.3% (range by county, 9.9%-18.0%). The average width of the confidence intervals was 6.2%. Adjusted and unadjusted estimates differed little. CONCLUSIONS: These 78 county estimates are higher on average and showed less variability (i.e., had a smaller range) than the previously published estimates of the 2008 diabetes prevalence for all United States counties (mean, 9.9%; range, 3.0%-18.2%).

OBJETIVO: Calcular la prevalencia en el año 2009 de casos con diagnóstico de diabetes en Puerto Rico en adultos de 20 años de edad o mayores, para conocer mejor su distribución geográfica con objeto de que los responsables políticos puedan encauzar más eficientemente los programas de prevención y control. MÉTODOS: Se ajustó un modelo multinivel bayesiano a la combinación de datos del Sistema de Vigilancia de Factores de Riesgo del Comportamiento 2008-2010 y del Censo de los Estados Unidos del 2009 para calcular la prevalencia de la diabetes en cada uno de los 78 municipios de Puerto Rico. RESULTADOS: El cálculo del valor medio no ajustado para todos los municipios fue de 14,3% (intervalo por municipio de 9,9 a 18,0%). La amplitud promedio de los intervalos de confianza fue de 6,2%. Hubo poca diferencia entre los cálculos ajustados y los no ajustados. CONCLUSIONES: Los valores obtenidos mediante estos cálculos correspondientes a 78 municipios fueron por término medio más elevados y mostraron menor variabilidad (es decir, el intervalo era más pequeño) que los cálculos anteriormente publicados sobre la prevalencia de la diabetes en todos los municipios de los Estados Unidos en el 2008 (media, 9,9%; intervalo de 3,0 a 18,2%).

Heparin-induced thrombocytopenia in the setting of perioperative bridging for podiatric surgery: a case report.

Heparin is an anticoagulant commonly used to treat and prevent deep venous thrombosis. Heparin-induced thrombocytopenia and possible thrombosis are serious complications associated with its use. This can occasionally complicate treatment of patients undergoing podiatric surgery. Heparin-induced thrombocytopenia is often not immediately recognized and is underreported in podiatric medicine literature. The goal of this case report is to highlight the multiple risk factors associated with the development of heparin-induced thrombocytopenia and to aid with early recognition, understanding of pathogenesis, and treatment options.

Association of statin use with peripheral neuropathy in the U.S. population 40 years of age or older.

BACKGROUND: Peripheral neuropathy is a serious complication of diabetes and several conditions that may lead to the loss of lower extremity function and even amputations. Since the introduction of statins, their use has increased markedly. Recent reports suggest a role for statins in the development of peripheral neuropathy. The aims of the present study were to assess the association between statin use and peripheral neuropathy, and to determine whether this association varied by diabetes status. METHODS: Data from the lower extremity examination supplement of the 1999-2004 National Health and Nutrition Examination Survey were used. RESULTS: The overall prevalence of statin use was 15% and the prevalence of peripheral neuropathy was 14.9%. The prevalence of peripheral neuropathy was significantly higher among those who used statins compared with those who did not (23.5% vs 13.5%, respectively; P < 0.01). Multivariate logistic regression revealed that statin use (adjusted odds ratio 1.3; 95% confidence interval 1.1-1.6; Wald P = 0.04) was significantly associated with peripheral neuropathy, controlling for diabetes status, age, gender, race, height, weight, blood lead levels, poverty, glycohemoglobin, use of vitamin B12 , alcohol abuse, hypertension, and non-high-density lipoprotein-cholesterol. Diabetes status, age, gender, height, weight, blood lead levels, poverty, and glycohemoglobin were also significantly associated with peripheral neuropathy. We found no effect modification between statin use and diabetes status, race, gender, age, vitamin B12 , blood lead levels, or alcohol abuse. CONCLUSIONS: In the present cross-sectional study, we found a modest association between peripheral neuropathy and statin use. Prospective studies are required to determine the causal direction.

Prevalence of equinus in diabetic versus nondiabetic patients.

BACKGROUND: There are no conclusive data to support the contention that diabetic patients have an increased frequency of ankle equinus compared with their nondiabetic counterparts. Additionally, a presumed contributing cause of foot ulceration is ankle joint equinus. Therefore, we sought to determine whether persons with diabetes have a higher prevalence of ankle joint equinus than do nondiabetic persons. METHODS: A prospective pilot survey of 102 outpatients (43 diabetic and 59 nondiabetic) was conducted. Demographic and historical data were obtained. Each patient underwent a standard lower-extremity examination, including the use of a biplane goniometer to measure ankle joint range of motion. RESULTS: Equinus, defined as ankle dorsiflexion measured at 0° or less, was found in 24.5% of the overall population. In the diabetes cohort, 16 of 43 patients (37.2%) were affected compared with 9 of 59 nondiabetic participants (15.3%) (P = .011). There was a threefold risk of equinus in the diabetic population (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.28-8.44; P < .013). The equinus group had a history of ulceration in 52.0% compared with 20.8% of the nonequinus group (P = .003). Equinus, therefore, imparted a fourfold risk of ulceration (OR, 4.13; 95% CI, 1.58-10.77; P < .004). We also found a 2.8 times risk of equinus in patients with peripheral neuropathy (OR, 2.8; 95% CI, 1.11-7.09; P < .029). CONCLUSIONS: Equinus may be more prevalent in diabetic patients than previously reported. Although we cannot prove causality, we found a significant association between equinus and ulceration.

A case history of multimodal therapy in healing a complicated diabetic foot wound: negative pressure, dermal replacement and pulsed radio frequency energy therapies.

Advanced multimodal therapies are being used with increasing frequency in the management of difficult or complex wounds. Although the primary goal remains to expedite complete healing, secondary goals include avoidance of superimposed infection, repeated hospitalisations and subsequent amputations. We describe a case involving a limb- and life-threatening necrotising infection in a diabetic patient in which we successfully applied negative pressure wound therapy, dermal replacement therapy and pulsed radio frequency energy to achieve definitive healing. Further study is warranted to elucidate the most effective combinations of such therapies to promote healing of similarly complex wounds.

Cell proliferation induction: healing chronic wounds through low-energy pulsed radiofrequency.

Chronic lower extremity wounds are a major source of morbidity and health care expenditure across the world. In the last decade, numerous advanced modalities have become available that can help expedite wound healing when standard wound care modalities are unsuccessful. In this case report, the authors present their early experience with one such modality that uses pulsed radiofrequency energy to initiate cell proliferation induction in chronic lower extremity wounds of different etiologies that had failed to respond to standard therapy.

Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus.

OBJECTIVE: To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus. STUDY DESIGN: Cross-sectional analysis. METHODS: Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans. RESULTS: Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement. CONCLUSIONS: Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.

Intra-osseous gout in a diabetic patient.

UNLABELLED: The following case is an interesting presentation of gout and its long-term affects in a diabetic individual. The patient initially presented with ankle pain and, after radiographic examination, a suspicious lytic lesion in the talus and a fracture of the medial malleolus were identified. A full workup with bone biopsy was undertaken and, although the patient did not present in the typical fashion, gout was ultimately diagnosed. Based on our experience with this patient, we recommend that gout be included in the list of differential diagnoses in diabetic patients with ankle pain and radiographic evidence of articular and bone destruction. The diagnosis and treatment of gout are addressed in this paper as well. LEVEL OF CLINICAL EVIDENCE: 4.

Reductions in excess mortality rates among people with diabetes by selected cause of death.

We applied Bayesian methods to estimate excess mortality rates by selected causes of death for decedents with diabetes compared to those without diabetes in North Dakota and assessed changes in the excess rate between 1992-1998 and 1999-2003. We report the probability (Pr) of a rate decrease in the age-adjusted excess rate and considered the evidence strong if the probability was 0.90 or higher. Among men with diabetes, the evidence was strong for a probable decrease in excess rate for heart disease (8.7 per 1000 to 6.5), cerebrovascular disease (1.2 per 1000 to 0.75) and arterial disease (0.24 per 1000 to 0.08). Among women with diabetes, the evidence was strong for a probable decrease in excess rates for the overall (total) rate (17.8 per 1000 to 12.6), for heart disease (6.1 per 1000 to 4.4), IHD (4.4 per 1000 to 3.1), cerebrovascular disease (1.4 per 1000 to 0.5), arterial disease (0.17 per 1000 to 0.10) and cancer (2.1 per 1000 to 1.3) as underlying cause of death. The data reflect a high likelihood that cause-specific excess mortality is decreasing for men, and especially for women, with diabetes.

Race/ethnicity and economic differences in cost-related medication underuse among insured adults with diabetes: the Translating Research Into Action for Diabetes Study.

OBJECTIVE: To examine racial/ethnic and economic variation in cost-related medication underuse among insured adults with diabetes. RESEARCH DESIGN AND METHODS: We surveyed 5,086 participants from the multicenter Translating Research Into Action for Diabetes Study. Respondents reported whether they used less medication because of cost in the past 12 months. We examined unadjusted and adjusted rates of cost-related medication underuse, using hierarchical regression, to determine whether race/ethnicity differences still existed after accounting for economic, health, and other demographic variables. RESULTS: Participants were 48% white, 14% African American, 14% Latino, 15% Asian/Pacific Islander, and 8% other. Overall, 14% reported cost-related medication underuse. Unadjusted rates were highest for Latinos (23%) and African Americans (17%) compared with whites (13%), Asian/Pacific Islanders (11%), and others (15%). In multivariate analyses, race/ethnicity significantly predicted cost-related medication underuse (P = 0.048). However, adjusted rates were only slightly higher for Latinos (14%) than whites (10%) (P = 0.026) and were not significantly different for African Americans (11%), Asian/Pacific Islanders (7%), and others (11%). Income and out-of-pocket drug costs showed the greatest differences in adjusted rates of cost-related medication underuse (15 vs. 5% for participants with income $50,000 and 24 vs. 7% for participants with out-of-pocket costs >$150 per month vs.

A Bayesian approach to assess heart disease mortality among persons with diabetes in the presence of missing data.

Some states' death certificate form includes a diabetes yes/no check box that enables policy makers to investigate the change in heart disease mortality rates by diabetes status. Because the check boxes are sometimes unmarked, a method accounting for missing data is needed when estimating heart disease mortality rates by diabetes status. Using North Dakota's data (1992-2003), we generate the posterior distribution of diabetes status to estimate diabetes status among those with heart disease and an unmarked check box using Monte Carlo methods. Combining this estimate with the number of death certificates with known diabetes status provides a numerator for heart disease mortality rates. Denominators for rates were estimated from the North Dakota Behavioral Risk Factor Surveillance System. Accounting for missing data, age-adjusted heart disease mortality rates (per 1,000) among women with diabetes were 8.6 during 1992-1998 and 6.7 during 1999-2003. Among men with diabetes, rates were 13.0 during 1992-1998 and 10.0 during 1999-2003. The Bayesian approach accounted for the uncertainty due to missing diabetes status as well as the uncertainty in estimating the populations with diabetes.

Syme amputation for limb salvage: early experience with 26 cases.

The Syme amputation is often overlooked as an alternative to below-knee amputation or above-knee amputation in cases of limb-threatening foot infections and gangrene. Even though the advantages of the Syme amputation over major amputation are well cited in the literature, many surgeons do not view this amputation as a viable option for limb salvage. We herein present our initial experience with this operation in a series of patients at imminent risk for major lower extremity amputation. This study included our initial 26 patients at high risk (92% had diabetes) with infection and/or significant peripheral arterial disease who underwent ankle disarticulation for limb salvage. Medical records were abstracted for pertinent demographic and clinical data. Variables of interest included diabetes status and duration, presence of peripheral arterial disease, infection, osteomyelitis, and gangrene. Our primary outcome variable was a healed amputation, whereas secondary outcomes included time to healing, subsequent major amputations, and complications. Despite prior recommendation for below-knee amputation or above-knee amputation in each of these patients, 50% remained healed at an average of 49.3 weeks of follow-up. Although 17 patients (65.4%) ambulated in a Syme prosthesis after healing of the original Syme operation, several patients went on to major amputation for progressive sepsis or recurrent ulcers, and 1 patient subsequently died. Because of the relatively small number of study subjects, we could find no significant predictors of success or failure of this procedure. However, all 10 patients eventually succumbing to major amputation and all 3 patients who died during follow-up had diabetes mellitus. At the end of follow-up, 46.2% (12/26) patients were functioning well in a Syme prosthesis. In this high-risk cohort of patients in whom major amputation had been recommended, we achieved a healing rate of 50% at an approximate 1-year follow-up. With the majority of patients having diabetes and peripheral vascular disease, we could not find any clear predictive factors for failure or successful outcome in this small population. Nonetheless, the Syme amputation deserves further study and consideration as a viable limb salvage option in patients threatened with major lower extremity amputation.

Who is tested for diabetic kidney disease and who initiates treatment? The Translating Research Into Action For Diabetes (TRIAD) Study.

OBJECTIVE: We examined factors associated with screening for albuminuria and initiation of ACE inhibitor or angiotensin receptor blocker (ARB) treatment in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted surveys and medical record reviews for 5,378 patients participating in a study of diabetes care in managed care at baseline (2000-2001) and follow-up (2002-2003). Factors associated with testing for albuminuria were examined in cross-sectional analysis at baseline. Factors associated with initiating ACE inhibitor/ARB therapy were determined prospectively. RESULTS: At baseline, 52% of patients not receiving ACE inhibitor/ARB therapy and without known diabetic kidney disease (DKD) were screened for albuminuria. Patients > or =65 years of age, those with higher HbA(1c), those with cardiovascular disease (CVD), and those without hyperlipidemia were less likely to be screened. Of the patients with positive screening tests, 47% began ACE inhibitor/ARB therapy. Initiation of therapy was associated with positive screening test results, BMI > or =25 kg/m(2), treatment with insulin or oral antidiabetic agents, peripheral neuropathy, systolic blood pressure > or =140 mmHg, and CVD. Of the patients receiving ACE inhibitor/ARB therapy or with known DKD, 63% were tested for albuminuria. CONCLUSIONS: Screening for albuminuria was inadequate, especially in older patients or those with competing medical concerns. The value of screening could be increased if more patients with positive screening tests initiated ACE inhibitor/ARB therapy. The efficiency of screening could be improved by limiting screening to diabetic patients not receiving ACE inhibitor/ARB therapy and without known DKD.