Primary wound closure of diabetic foot ulcers by debridement and stitching.

OBJECTIVE: The role of stitching in healing diabetic foot ulcers (DFUs) has little attention, with few reports published on the technique. This study aimed to report on the role of stitching in healing of neuropathic DFUs. METHOD: This comparative study was between patients with diabetes with neuropathic foot ulcers who had undergone wound stitching and those on conventional wound care. The study was carried in Jabir Abu Eliz Diabetic Center Khartoum (JADC) during between January 1 2011 and January 1 2013. All patients presented with neuropathic diabetic septic foot on the plantar aspect or extending up the leg were included. Initial surgical sharp debridement under intravenous broad spectrum antibiotics was performed and oral antibiotics were given 3 days later after the results of the bacterial culture were received. Regular wound debridement was performed with the aim of pairing the wound edges for stitching. Primary closure was performed when the wound was clean from any necrotic tissues and partial closure when the wound was still oozy to secure drainage and avoid splaying of the wound edges. All patients were using either crutches or wheel chair initially until any sepsis cleared and then proper off-loading by shoes purpose made in our centre. RESULTS: A 160 patients with neuropathic DFUs that needed debridement and frequent dressing changes as outpatients were included. Both groups had the same tap water wound dressing either daily, every other day or every two days according to the wound progress. Absorbent dressings and negative pressure wound therapy (NPWT) were unavailable. Half of the patients (n=80) had debridement, frequent dressing change using tap water throughout the period of study (group 1) while the rest (n=80) in addition to wound debridement underwent stitching of their wounds (group 2). Complete healing was achieved in 46 patients in Group 1 (57.5%) compared with 19 patients (23%) in group 2 (p=0.001). The average number of dressings used was 19 in stitch group compared with 30 in the non-stitch group (p=0.000). The average duration of healing in stitch group was 2.9 months compared with 5.7 months in non-stitch group (p=0.000). CONCLUSION: Stitching of neuropathic DFUs reduced the duration of wound healing and the frequency of wound dressing change.

Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes.

OBJECTIVE: The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers. METHOD: This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up. RESULTS: The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02). CONCLUSION: Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time. DECLARATION OF INTEREST: The authors have no conflict of interest to declare.

Extended leg infection of diabetic foot ulcers: risk factors and outcome.

OBJECTIVE: To identify the risk factors for extension of infection to the leg in diabetic foot ulcers (DFU) and to evaluate its role as a prognostic measure regarding limb salvage and healing time. METHOD: This retrospective case-control study took place in Jabir Abu Eliz Diabetic (JADC) during 2006-2008. Forty-eight patients diagnosed with a diabetic foot ulcer (DFU) with the infection extending to the leg (case group) were compared with an equal number of patients with a DFU without extension (control group). Risk factors for extension were identified by univariate analysis and both groups were compared with regard to limb salvage and healing time. RESULTS: Previous history of toe amputation was more frequent in the case group (p=0.004). The case group patients were significantly more likely to present with fever (p=0.01), pallor (p=0.02), confusion (p=0.04), and necrosis (p=0.004). Ulcers located in the heel were more frequent in the case group when compared with controls (p=0.0001) while more toes ulcers were found in the control group (p=0.001). A significant number of patients in the case group had an ulcer of more than 5cm diameter compared with those in the control group (p=0.001). The total number of patients presented with severe disease (Wagner grade 3-5) was significantly more in the case group compared with controls (p=0.004). Patients with severe infection (grade 4) were more in the case group compared with the controls (p=0.04). There were no significant differences between the two groups with regard to major and minor amputation rate. The case group had a longer duration of healing when compared with the controls. Seventy-five per cent of the controls healed by 6 months (n=31) compared with 22% in the case group (n=8 ; p=0.001). CONCLUSION: Toe amputation, wound located in the heel, wound size more than 5cm and advanced Wagner grade (3-5) and severe sepsis, grade 4, may be considered as risk factors for extension of infection to the leg in DFU. However, this extension did not carry a poor prognostic value to the final outcome if adequate therapeutic measures were followed.

Atypical antipsychotics in bipolar and schizoaffective disorders.

No data are available comparing the relative efficacy of different atypical agents in patients with bipolar disorder. A chart review of bipolar and schizoaffective disorder patients who had received courses of at least two atypical agents (n = 33) in a community psychiatry system was conducted. No differences in rates of hospitalizations were found between individual atypical agents or between atypical agents as a class and conventional neuroleptics. However, a significant reduction in rates of emergency room visits was found with atypical agents compared to conventional neuroleptics, with a trend toward greater reduction with clozapine compared to other atypical antipsychotics. Larger prospective studies are needed to confirm these preliminary observations.

Psychiatric diagnoses in inner city outpatients with moderate to severe asthma.

OBJECTIVE: Psychiatric symptoms may be associated with increased asthma morbidity and mortality. However, no investigations have identified syndromal psychiatric diagnoses in asthma patients using current diagnostic criteria or examined treatment received for mental illness. METHOD: We conducted structured clinical interviews on 32 patients with moderate to severe asthma to identify current and past psychiatric illness. RESULTS: Twenty-five percent of subjects had current major depressive disorder, but only 25 percent of these received antidepressants. Anxiety disorders, including panic disorder (16 percent), and social (13 percent) and specific phobias (28 percent) were also common. All subjects with panic disorder were receiving appropriate therapy. CONCLUSIONS: Asthma patients with moderate to severe asthma treated at community health facilities may have high rates of often untreated mood and anxiety disorders. Interventions aimed at identifying and treating psychiatric disorders in this population are needed.