Monitoring of systemic inflammatory response in diabetic patients with deep foot infection treated with negative pressure wound therapy.

BACKGROUND: The purpose of this study was to establish the safety of negative pressure wound therapy (NPWT) in the treatment of acutely debrided, deep diabetic foot infections (DDFI) and to determine the value of inflammatory markers in monitoring of treatment of these infections with negative pressure wound therapy. METHODS: A group of ten patients with DDFI treated by radical surgical debridement and simultaneous NPWT was prospectively studied. During the debridement, a deep tissue sample was obtained and sent for microbiological testing. The patients were followed clinically for 10 days and NPWT dressings were changed every 2 to 3 days or sooner when indicated. The peripheral blood samples were obtained before the radical debridement and 3 and 10 days afterwards and concentrations of white blood cell, neutrophils, lymphocytes and C-reactive protein (CRP) were measured. The changes in concentration of inflammatory markers were analyzed with a Friedman test. RESULTS: In all but one patient the presence of DDFI was confirmed by the culture results. At baseline, the elevated WBC and neutrophil concentrations were observed only in half of the patients while the CRP concentration was elevated in nine patients. During followup, all patients showed a favorable clinical evolution and statistically significant decrease of WBC, neutrophils and CRP (p<0.001). There were not statistically significant changes in lymphocyte count. CONCLUSION: NPWT can be safely applied in acutely debrided DDFI. CRP seems to be the most adequate parameter for both diagnosis and monitoring of treatment of DDFI.

[The attempt of clinical classification of the complicated diabetic foot syndrome].

The experience of surgical treatment of 1532 patients with the complicated forms of diabetic foot syndrome (DFS) was analyzed. The original clinical classification of the complicated DFS was suggested. The classification considered the clinical form (symbol "C"), anatomic localization (symbol "Z") and etiology (symbol "E"). The classification allows to define surgical tactics depending on concrete complications of the DFS, frames conditions for the unification and uniform registration of the form and severity of the disease and volume of the surgical treatment.

Peripheral arterial disease in non-diabetics: don't miss vasculopathy of specific etiology--non atherosclerotic (VSE-NA) in young patients.

AIM: To find out the proportion of non-diabetic peripheral arterial disease (PAD) attributable to systemic connective tissue diseases (CTD) or thrombophillic states as etiology and to identify clinical and laboratory features that would point towards systemic disease other than atherosclerosis. MATERIALS AND METHODS: We studied the etiology of PAD in 45 non-diabetic patients in a tertiary health care center in Mumbai prospectively from January 2004- December '07. History, clinical examination haemogram, routine biochemistry, lipid profile, serological tests for connective tissue diseases and vasculitis, tests for prothrombotic state, vascular Doppler and 2D echo were performed in all cases. Angiography, CT scan and biopsy were done wherever necessary. We classified etiology of PAD as Gr I] Possibly Atherosclerosis OR Idiopathic, Gr II] Vasculopathy of specific etiology--Non Atherosclerotic (VSE-NA): this included patients with CTD and thrombophillic states. We tried to identify clinical and laboratory features, that would differentiate VSE-NA (Gr II)from the other group (Gr I). RESULTS: There were 24 females, 21 males, age 18 to 70 years (average 45). Sixteen patients presented with UE (upper extremity) gangrene, 22 with LE (lower extremity) gangrene and 7 with both UE and LE gangrene. VSE-NA was detected in 44.4% of patients, 28.9% were possibly due to atherosclerosis and 26.6% were idiopathic. In VSE-NA group, 28.9% were due to CTD and vasculitis and 15.6% due to thrombophillias (2 APLA, 4 hyperhomocysteinaemia, 1 hyperviscosity due to multiple myeloma). In the CTD and vasculitis group (N = 13), 9 (20%) were due to vasculitis (5 ANCA-associated vasculitis and 4 ANCA negative vasculitis. Out of 31 surgical referrals, 38.7% were VSE-NA whereas 57.14% of 14 medical patients were attributed to VSE-NA. Younger age of onset (< 41 yr), fever, weight loss, multiple limb involvement, anemia, high ESR, abnormal urine routine- proteinuria and RBCs all point towards a systemic connective tissue disorder. CONCLUSIONS: High index of suspicion, detailed investigations to detect VSE-NA in non-diabetic patients with PAD is important, as all these conditions have specific treatment.

Juvenile gangrenous vasculitis of the scrotum: Is it a variant of pyoderma gangrenosum?

Juvenile gangrenous vasculitis of the scrotum was described by Piñol et al in 1974 as a unique variant of scrotal gangrene of unknown origin, occurring exclusively in young individuals. It was characterized by an acute onset of skin ulcers undergoing complete resolution after appropriate therapy, with no relapses. We present a typical case of this extremely rare disease affecting a 16-year-old boy in whom the scrotal ulcerations were preceded by an episode of pharyngitis with fever. The condition promptly regressed after administration of intramuscular betamethasone in combination with oral ciprofloxacin. According to Piñol et al, juvenile gangrenous vasculitis of the scrotum, although poorly known to dermatologists, should be regarded as a distinctive entity within the wide group of scrotal gangrenes. On the other hand, the hypothesis that this condition may well represent a variant of pyoderma gangrenosum is discussed.

A review of diagnosis and modes of presentation of tropical idiopathic lower limb gangrene.

BACKGROUND: Tropical idiopathic lower limb gangrene (TILLG) is also known as Symmetrical gangrene in the African, Idiopathic gangrene in the African and Idiopathic peripheral gangrene of the tropics. The aetiopathogenesis of this clinical entity is a mystery. OBJECTIVE: To review methods of diagnosing tropical idiopathic lower limb gangrene (TILLG) and highlight its clinical variants. METHOD: All Literature on idiopathic gangrene of the extremities was searched from libraries, colleagues and internet but only literature on TILLG (in Africans) from 1947 to date was scrutinised. Each case was studied to find out the basis of diagnosis. RESULT: TILLG is not fully understood and not easy to recognise. Two sets of criteria are known to be helpful in establishing diagnosis. These criteria can be classified as major and minor criteria. Major criteria are those clinical data that can establish the diagnosis of TILLG. No devices are required to identify them. Minor criteria are pathological changes that are consistent with TILLG. Devices are required to identify them. Three pathomorphological types of TILLG were described in literature and are classified as types A, B and C. CONCLUSIONS: This review is supposed to sensitise the clinician and make diagnosis easier. This will also encourage more researches. As more information becomes available, aetiopathogenesis of TILLG will be clearer and more clinical variants of the disease may be reported. This additional information will help in the prevention of gangrene, reducing the socioeconomic problems arising from amputation.

[Necrotizing soft tissue infections: nomenclature and classification]. / Infecciones necrosantes de partes blandas: nomenclatura y clasificación.

Terminology used to refer to necrotizing infections is extensive because of the absence of clear definitions and the use of classification systems based on a variety of criteria, including etiologic, microbiologic, anatomic, and clinical aspects. This situation has led to some confusion. In the attempt to unify terminology, it might be more appropriate to use only the terms necrotizing fasciitis and myonecrosis, in which differentiation is mainly anatomical. Another option would be to use only the expression necrotizing soft tissue infections, a non-specific term, since these constitute a group of clinical processes having similar pathophysiologic characteristics and therapeutic principles.

Necrotizing fasciitis: a classification of necrotizing soft tissue infections.

Necrotizing fasciitis is a rare, often fatal soft tissue infection. It still remains a confusing entity because of the nomenclature and multiple subtypes described in the past. An interesting case study of a patient with necrotizing fasciitis secondary to nonclostridial gas gangrene is presented. A comprehensive review of necrotizing fasciitis, its disease process and treatment modalities will be discussed.

[An index of the severity of intestinal gangrene due to colonic volvulus]. / Puntaje de severidad de la gangrena intestinal por vólvulo de colon.

This retrospective analysis evaluated 50 patients with gangrenous colonic volvulus two cases with ileocecal volvulus, one case with volvulus of the colon transverse and 47 cases with sigmoid volvulus- who were managed by primary resection with anastomosis (n = 21) or resection plus colostomy (n = 29) at Belén Hospital, Trujillo, Perú, from January 1, 1967 to July 31, 1993. The principal aim of the study was to identify by univariate analysis the combination of predictive risk factors for postoperative mortality. The following factors were associated with increased mortality: mean arterial pressure lower than 70 mmHg (p = 0.004), presence of purulent or fecaloid peritoneal fluid (p = 0.013) or evidence of macroscopic bowel perforation (p < 0.001). A method of quantifying the risk of mortality following gangrene of the loop using these factors was described. Each factor was given a weight value ranging from 0 a 2 (0 = major, 1 = moderate, 2 = minor) according to the severity of injury estimate. The sum of the individual factor scores comprised the final score of the Severity of Gangrenous Colon by Volvulus (S.S.G.C.). In this series the 30-day mortality rate was of 30%. A S.S.G.C. resulted greater than 4 in 34 (68%) of the patients. This was associated with a 9% mortality rate and contrasted to a 75% when the S.S.G.C. was equal to or less than 4. Mortality developed in 33% of the patients operated on using an immediate anastomosis (S.S.G.C., 4.2 +/- 0.99) and it was of 28% in those whose operation was resection plus colostomy (S.S.G.C., 3 +/- 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)