The Stress of Measuring Plantar Tissue Stress in People with Diabetes-Related Foot Ulcers: Biomechanical and Feasibility Findings from Two Prospective Cohort Studies.

Reducing high mechanical stress is imperative to heal diabetes-related foot ulcers. We explored the association of cumulative plantar tissue stress (CPTS) and plantar foot ulcer healing, and the feasibility of measuring CPTS, in two prospective cohort studies (Australia (AU) and The Netherlands (NL)). Both studies used multiple sensors to measure factors to determine CPTS: plantar pressures, weight-bearing activities, and adherence to offloading treatments, with thermal stress response also measured to estimate shear stress in the AU-study. The primary outcome was ulcer healing at 12 weeks. Twenty-five participants were recruited: 13 in the AU-study and 12 in the NL-study. CPTS data were complete for five participants (38%) at baseline and one (8%) during follow-up in the AU-study, and one (8%) at baseline and zero (0%) during follow-up in the NL-study. Reasons for low completion at baseline were technical issues (AU-study: 31%, NL-study: 50%), non-adherent participants (15% and 8%) or combinations (15% and 33%); and at follow-up refusal of participants (62% and 25%). These underpowered findings showed that CPTS was non-significantly lower in people who healed compared with non-healed people (457 [117; 727], 679 [312; 1327] MPa·s/day). Current feasibility of CPTS seems low, given technical challenges and non-adherence, which may reflect the burden of treating diabetes-related foot ulcers.

Surgical Approach in Management of Posttraumatic Diaphragmatic Hernia: Thoracotomy versus Laparotomy.

Breach in diaphragmatic musculature permits abdominal viscera to herniate into the thoracic cavity. Time of presentation and associated injuries determines the surgical approach in management. This case report sets to highlight the challenges in clinical diagnosis, radiological interpretation, and surgical management approaches of posttraumatic diaphragmatic hernia. We report a case of a 43 years old male who was diagnosed with traumatic diaphragmatic hernia 6 months post blunt thoracoabdominal trauma due to motor traffic accident. He was initially diagnosed with haemothorax, drained with an underwater thoracostomy tube, and discharged. He continued to experience on and off chest pain worsening postfeeding, difficulty in breathing and abdominal pain for the next six months until his eventual diaphragmatic hernia diagnosis. He was scheduled for an elective thoracotomy. A left posterolateral thoracic over the 7th intercostal space incision was used. Intraoperatively, the stomach, left lobe of liver, part of transverse colon, small bowel, and omentum had herniated into the thoracic cavity adhering into thoracic viscera and wall. Adhesiolysis was done, and abdominal organs reduced into abdominal cavity. Rent was closed by interrupted Prolene sutures reinforced with a mesh. In patients with delayed presentation of diaphragmatic hernia post blunt thoracoabdominal injury without associated intra-abdominal visceral injury, we recommend the thoracic diaphragmatic repair approach as long-standing herniated bowels might adhere with thoracic cavity walls or viscera. In such cases, adhesiolysis and rent repair is easier through thoracotomy.

Telehealth and telemedicine applications for the diabetic foot: A systematic review.

The aim of this systematic review is to assess the peer-reviewed literature on the psychometric properties, feasibility, effectiveness, costs, and current limitations of using telehealth and telemedicine approaches for prevention and management of diabetic foot disease. MEDLINE/PubMed was searched for peer-reviewed studies on telehealth and telemedicine approaches for assessing, monitoring, preventing, or treating diabetic foot disease. Four modalities were formulated: dermal thermography, hyperspectral imaging, digital photographic imaging, and audio/video/online communication. Outcome measures were: validity, reliability, feasibility, effectiveness, and costs. Sixty-one studies were eligible for analysis. Three randomized controlled trials showed that handheld infrared dermal thermography as home-monitoring tool is effective in reducing ulcer recurrence risk, while one small trial showed no effect. Hyperspectral imaging has been tested in clinical settings to assess and monitor foot disease and conflicting results on its diagnostic use show that this method is still in an experimental stage. Digital photography is used to assess and monitor foot ulcers and pre-ulcerative lesions and was found to be a valid, reliable, and feasible method for telehealth purposes. Audio/video/online communication is mainly used for foot ulcer monitoring. Two randomized controlled trials show similar healing efficacy compared with regular outpatient clinic visits, but no benefit in costs. In conclusion, several technologies with good psychometric properties are available that may be of benefit in helping to assess, monitor, prevent, or treat diabetic foot disease, but in most cases, feasibility, effectiveness, and cost savings still need to be demonstrated to become accepted and used modalities in diabetic foot care.

Assessment of signs of foot infection in diabetes patients using photographic foot imaging and infrared thermography.

BACKGROUND: Patients with diabetic foot disease require frequent screening to prevent complications and may be helped through telemedical home monitoring. Within this context, the goal was to determine the validity and reliability of assessing diabetic foot infection using photographic foot imaging and infrared thermography. SUBJECTS AND METHODS: For 38 patients with diabetes who presented with a foot infection or were admitted to the hospital with a foot-related complication, photographs of the plantar foot surface using a photographic imaging device and temperature data from six plantar regions using an infrared thermometer were obtained. A temperature difference between feet of >2.2 °C defined a "hotspot." Two independent observers assessed each foot for presence of foot infection, both live (using the Perfusion-Extent-Depth-Infection-Sensation classification) and from photographs 2 and 4 weeks later (for presence of erythema and ulcers). Agreement in diagnosis between live assessment and (the combination of ) photographic assessment and temperature recordings was calculated. RESULTS: Diagnosis of infection from photographs was specific (>85%) but not very sensitive (<60%). Diagnosis based on hotspots present was sensitive (>90%) but not very specific (<25%). Diagnosis based on the combination of photographic and temperature assessments was both sensitive (>60%) and specific (>79%). Intra-observer agreement between photographic assessments was good (Cohen's κ=0.77 and 0.52 for both observers). CONCLUSIONS: Diagnosis of foot infection in patients with diabetes seems valid and reliable using photographic imaging in combination with infrared thermography. This supports the intended use of these modalities for the home monitoring of high-risk patients with diabetes to facilitate early diagnosis of signs of foot infection.

Telemedical home-monitoring of diabetic foot disease using photographic foot imaging--a feasibility study.

We assessed the feasibility of using a photographic foot imaging device (PFID) as a tele-monitoring tool in the home environment of patients with diabetes who were at high risk of ulceration. Images of the plantar foot were taken three times a week over a period of four months in the home of 22 high-risk patients. The images were remotely assessed by a diabetic foot specialist. At the end of the study, 12% of images were missing, mainly due to modem or server failures (66%), or non-adherence (11%). All three referrals for diagnosed ulcers and 31 of 32 referrals for abundant callus resulted in treatment. Health-related quality of life (EQ-5D visual analogue scale), increased from 7.5 at baseline to 7.9 at end of follow-up, but not significantly. Mean scores on a visual analogue scale for different usability domains (independence, ease of use, technical aspects and value) ranged from seven to nine. The study demonstrates the feasibility of using the PFID for the early diagnosis of foot disease, which may prevent complications in high-risk patients with diabetes.

Two cases of acute carpal tunnel syndrome in classic haemophilia.

We present two cases of acute carpal tunnel syndrome in patients with haemophilia A. There have been only a few cases reported and controversy exists as to whether conservative or surgical treatment should be given in the acute phase. We successfully decompressed the carpal tunnel in both cases. The numbers reported are small, however, and a combination of conservative and surgical treatment remains acceptable in the early phase of this syndrome.