Identification of monoclonal antibodies suitable for blocking IGF-1 receptors in the horse

Prolonged hyperinsulinemia is thought to be the cause of equine endocrinopathic laminitis, a common and crippling disease of the foot, for which there are no pharmacologic treatments other than pain relief. It has been suggested that insulin causes its effects on the lamellae by activating IGF-1 receptors (IGF-1R), as insulin receptors (InsR) are scarce in this tissue, whereas IGF-1R are abundant and become downregulated after prolonged insulin infusion. As a first step toward confirming this mechanism and beginning to develop a therapeutic anti-IGF-1R monoclonal antibody (mAb) for horses, it was necessary to identify available human IGF-1R mAbs that would recognize equine receptors. Four IGF-1R mAbs were tested using soluble equine IGF-1R, with ELISA and flow cytometry. Frozen equine lamellar and liver tissue was also used in radioligand binding assays. The results demonstrated that only one of the mAbs tested (mAb1) was able to compete effectively with IGF-1 for binding to its receptors in equine lamellar tissue, with an IC₅₀ of 5 to 159 ng/mL. None of the 4 mAbs were able to bind to equine hepatic InsR. This study has generated valuable structure-activity information and has identified a prototype anti-IGF-1R mAb suitable for further development.

Characterization of Foot Mycetoma Using Sonography and Color Doppler Imaging

BACKGROUND AND OBJECTIVE

Mycetoma of the foot, commonly referred to as Madura foot, is a chronic granulomatous infection, which impacts vascularization of the affected region. This study aimed to evaluate foot mycetoma using Doppler and sonography techniques to identify the principle sonographic features and blood flow patterns associated with the condition.

MATERIALS AND METHODS

This was a cross-sectional prospective single-center study conducted at the Mycetoma Research Center (MCR) in Khartoum State, Sudan. Sixty patients with Madura foot were examined using a Duplex ultrasound machine with a 7-10 MHZ linear probe. Data was analyzed using SPSS software. The distribution of demographic data was evaluated by simple descriptive statistics. Statistical tests was performed using Student's independent t-tests to compare different forms of mycetoma and Chi-square tests to examine differences in blood flow patterns between fungal (eumycetoma) and bacterial (actinomycetoma) forms of the infection.

RESULTS

The presence of multiple cavities and aggregated grains were more common in eumycetoma than in actinomycetoma. The echotexture was significantly more heterogeneous in eumycetoma than in actinomycetoma (p = 0.03). Eumycetoma had higher vascularity than actinomycetoma.

CONCLUSION

Mycetoma has characteristic sonographic features and patterns of vascularity, which are essential to differentiate between the fungal and bacterial forms of mycetoma.

Persistent rash on feet

A 49-year-old Hispanic woman presented with a 4-month history of scaling and a macerated rash localized between her toes. The rash was malodorous, mildly erythematous, and sometimes associated with pruritus. The patient had no relevant medical history. Potassium hydroxide testing was performed and found to be negative. So a Wood's lamp was used to examine the patient's toes--and it revealed the diagnosis. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Acitretin for the treatment of recalcitrant plantar warts

Plantar warts caused by human papilloma virus (HPV)may be challenging to treat when conventionalmodalities fail. We report a case of severely recalcitrantplantar warts, successfully treated with oral acitretinand topical 40% urea cream.

Behavioural assessment of pain in commercial turkeys (Meleagris gallopavo) with foot pad dermatitis

Two experiments were conducted to investigate the differences in susceptibility to foot pad dermatitis (FPD) of two medium-heavy lines of turkeys, and whether FPD is painful, by detailed analysis of behaviour in birds with and without analgesic treatment (betamethasone). Turkeys housed on dry litter in the first experiment generally had more frequent bouts of different behaviours that were of shorter duration than birds on wet litter. T-patterns (behavioural sequences) were more frequent, varied and complex on dry than on wet litter. Betamethasone-injected birds of line B, but not breed A, had shorter resting and longer standing durations on wet litter than saline-injected birds. In the second experiment, turkeys on wet litter given saline stood less and rested more than all other treatment groups, suggesting that they experienced pain that was alleviated in birds receiving betamethasone. Turkeys on dry litter had more frequent, varied and complex patterns of behaviour than turkeys on wet litter and birds kept on intermediate litter wetness. Betamethasone provision increased pattern variety regardless of litter treatment. Turkeys with low FPD scores transferred to wet litter and given saline injections had a longer total duration of resting and shorter duration of standing compared to betamethasone-treated birds. Low FPD birds transferred to wet litter had a similar number of patterns and total pattern occurrence as high FPD birds transferred to dry litter. Betamethasone increased pattern variety and frequency compared to saline injections whereas overall pattern complexity was similar. It was concluded that wet litter affects the behaviour of turkey poults independently of FPD and that betamethasone may also change the behaviour of turkeys. There was some evidence from analgesic treatment and T-pattern analyses that FPD was painful. However, there was no evidence of differences in susceptibility to FPD of the two commercial hybrids.

Use of a Vascular Access Port for Antibiotic Administration in the Treatment of Pododermatitis in a Chicken

Bacterial culture and susceptibility testing results of a wound on the plantar aspect of the foot of a 4-year-old, male chicken with a class IV pododermatitis revealed a multidrug-resistant Escherichia coli bacterium, sensitive to only a few antibiotics including ceftazidime. Concerns over the volume and frequency of antibiotic injections, combined with the likely duration of treatment, led to the use of a vascular access port to facilitate intravenous antimicrobial therapy. The port was placed and maintained for 5 months without complication, and the infection was resolved. This case illustrates the feasibility and application of a vascular port in an avian patient requiring long-term intravenous therapy.

Case report: Actinomycetoma caused by Nocardia aobensis from Lao PDR with favourable outcome after short-term antibiotic treatment

BACKGROUND

Mycetoma is a neglected, chronic, localized, progressively destructive, granulomatous infection caused either by fungi (eumycetoma) or by aerobic actinomycetes (actinomycetoma). It is characterized by a triad of painless subcutaneous mass, multiple sinuses and discharge containing grains. Mycetoma commonly affects young men aged between 20 and 40 years with low socioeconomic status, particularly farmers and herdsmen.

METHODOLOGY/PRINCIPAL FINDINGS

A 30 year-old male farmer from an ethnic minority in Phin District, Savannakhet Province, Lao PDR (Laos) developed a painless swelling with multiple draining sinuses of his right foot over a period of approximately 3 years. X-ray of the right foot showed osteolysis of tarsals and metatarsals. Aerobic culture of sinus discharge yielded large numbers of Staphylococcus aureus and a slow growing Gram-positive rod. The organism was subsequently identified as Nocardia aobensis by 16S ribosomal RNA gene sequencing. The patient received antimicrobial treatment with amikacin and trimethoprim-sulfamethoxazole according to consensus treatment guidelines. Although slight improvement was noted the patient left the hospital after 14 days and did not take any more antibiotics. Over the following 22 weeks the swelling of his foot subsequently diminished together with healing of discharging sinuses.

CONCLUSION

This is the first published case of Actinomycetoma caused by Nocardia aobensis and the second case of Actinomycetoma from Laos. A treatment course of only 14 days with amikacin and trimethoprim-sulfamethoxazole was apparently sufficient to cure the infection, although long-term treatment up to one year is currently recommended. Treatment trials or prospective descriptions of outcome for actinomycetoma should investigate treatment efficacy for the different members of Actinomycetales, particularly Nocardia spp., with short-term and long-term treatment courses.

Bortezomib in type I cryoglobulinemic vasculitis: are we acting too late?

Type II and type III cryoglobulinemic vasculitis (CV) are characterized by a deranged immune function due to concomitant chronic infections or rheumatic disorders. Conversely, type I CV is caused by plasma cell dyscrasia. Bortezomib is a proteasome inhibitor that is largely employed as a first-line treatment for multiple myeloma. The use of bortezomib in cases of monoclonal gammopathy of undetermined significance (MGUS)-related refractory type I CV has been reported in only four patients. In the current report, we discuss the efficacy of bortezomib treatment in a patient with type I CV, with a focus on the suitability and early application of this drug.

Unusual form and location for a tumor: multiosseous Ewing sarcoma in the foot

Ewing sarcoma, as the prototype of a small round blue cell tumor of bone, typically affects adolescents and young adults. The most commonly involved sites include the diaphyses of long bones, ribs, and flat bones, such as the pelvis and scapula. We report a case of multifocal Ewing sarcoma involving multiple bones in the foot. Given the multifocal nature of the disease confined to the foot, the initial impression was that of osteomyelitis. We describe the histologic, radiologic, and diagnostic features of the tumor and outline treatment and prognosis. To our knowledge, this is the first report of multifocal Ewing sarcoma involving multiple bones in the foot.

Use of imiquimod for residual acral melanoma

Recent reports suggest that topical imiquimod cream is an effective treatment option for certain types of melanomas. No reports exist on the efficacy of using imiquimod cream to treat melanoma located on the plantar surface of the foot. We present two patients with a melanoma of the foot who had residual melanoma following surgical excision with acceptable margins. The patients were then treated with topical imiquimod for 8 weeks after which a repeat biopsy of the affected region showed no evidence of residual melanoma in situ. The use of topical imiquimod cream should be considered in the management of residual melanoma in situ of the plantar surface of the foot.

Palmoplantar papules and hyperkeratosis in a deaf man

A 31-year-old man presented with a history of extensive thickened skin of the palms and soles since the age of 7. The patient reported difficulty in ambulating and in using his hands secondary to his skin condition and associated pain. He also reported being seen by numerous specialists in the past for his hands, feet, and fingernails. He tried various topical medications, none of which were successful in minimizing the lesions on the hands and feet. Pertinent review of systems was positive for complete deafness diagnosed at 9 months of age. The patient did not speak and used sign language to communicate. His family history was significant for two brothers, both of whom are deaf and who have a similar skin condition of their hands and feet, but with lesser severity than the patient. The patient had no other medical issues.

A forgotten disease in a returning traveler from Thailand

Cutaneous diphteria is a forgotten disease. We must consider this in our differential diagnosis, not only when a patient presents with a cutaneous ulcer and has travelled to tropical areas, but also in patients who subsist in low socio-economic conditions, especially in homeless people and people with a history of alcohol or drug abuse. Vigilance for this forgotten disease is warranted because most physicians in developed countries have never seen one case. In an era of increasing globalisation, we might see more cases in the future. We report a case of a foot infection with a non toxigenic C. diptheriae biovar gravis in a 16 year old girl, who has travelled to Thailand.

Clinical case of Botryomycome fulminant at the Center of Diagnostic and Treatment of Tuberculosis of Baleng (West - Cameroon)

Botryomycome also called pyogenic granuloma, is an inflammatory tumor of the skin and mucous membranes often caused by superinfection of minor traumatism. Its uniqueness lies in its granulomatous organization in which each granulation contains bacteria and the predominance of many newly formed blood vessels, with the lights on variables ratings and a turgid endothelium responsible for the ulcero-hemorragic appearance. This delicate condition poses a real problem of treatment which included: an appropriate antibiotherapy, surgical removal or electrocoagulation which, until today is more difficult in countries with limited income. An octagenarian came to our hospital with a large mass on the left foot. This mass had the appearance of a malignant tumor. However, the anatomopathologic diagnosis showed that it was a pyogenic granuloma. The importance of the mass, its location on the sole of the foot, imposed the functional impairment of this member. Electrocoagulation is not available in our hospital and the surgical excision proposed was refused by the patient. The patient was treated with the antibiotics Ceftriaxone and Gentalline at indicated doses for 15 days. After the failure of that antibiotherapy treatment, as a last resort, the patient was treated for a month with another combination of antibiotics (free of cost) made of dapsone and rifampicin. This new combination gave very good results. This example shows dapsone and rifampicin can be use as a new weapon for the management of pyogenic granuloma in countries with limited incomes.

Anti-inflammatory and analgesic activity of total flavone of Cunninghamia lanceolata

The present study was undertaken to investigate the anti-inflammatory and analgesic activity of total flavone of branches and leaves of Cunninghamia lanceolata (TFC) to provide a scientific basis for its clinical use and resource development. TFC was evaluated for anti-inflammatory and analgesic activity in mice or rats using chemical and thermal models of nociception, including acetic acid-induced writhing test, hot plate latency test, formalin test and carrageenan induced paw oedema test. Results showed that TFC given orally can significantly attenuate acetic acid-induced writhing in mice in a dose-dependent manner. In the hot plate latency test, TFC showed common activity in prolonging duration time only at the highest dose (400 mg/kg). Each dose of TFC could not significantly inhibit the first phase but was active in the later phase of formalin-induced pain, whereas morphine showed notable activity in the two phases. In the carrageenan-induced paw oedema model, TFC could significantly and dose-dependently reduce the carrageenan-induced paw edema at the third and fifth hour, and decrease the content of PEG₂ in paw edema tissue and that of COX-2 in blood serum. It may be concluded that TFC showed both anti-inflammatory and analgesic effects, showing that it can be of importance in drug development, especially in the field of pain and inflammation.

Qualitative content analysis of complementary topical therapies used to manage diabetic foot in Jordan

In order to alleviate diabetic foot problems, patients sometimes seek complementary therapies outside the professional context. This paper describes the use of complementary remedies as a topical treatment for diabetic foot ulcers among Jordanians. Qualitative content analysis was used to analyse written responses of 68 patients with diabetes who have used complementary therapies to treat diabetic foot problems. These 68 persons represented a subgroup of the study population surveyed using a questionnaire, to the effect of investigating diabetic foot treatments provided in Jordan. Informants were recruited from eight healthcare facilities established in the southern part of Jordan plus from one hospital established in the Jordanian capital. The study was approved by the Boards of Ethics of the participating healthcare facilities. Content analysis yielded the category "Complementary Therapies Used", which included a range of household items (olive oil, sesame oil, honey, and vinegar), and also some indigenous Jordanian herbs (Wormwood, Myrrh, Caper, and Henna among others). The remedies were used either as a monotherapy or as mixtures, to the common goal of treating diabetic foot problems. Other interventions like Al-cowy were also sought from traditional healers. Educational campaigns are required to increase the awareness of patients and their families on possible hazards of unwise complementary therapy use. The decisions on the use of such therapies should be made in agreement with the attending healthcare professionals.

Tubercular dactylitis with discharging sinus in an adult patient

Tubercular dactylitis, a term used for tuberculosis of short and tubular bones of hands and feet, rarely shows involvement of the foot. It is more commonly found in children as compared with adults. A 27-year-old male, came with history of discharging sinus over dorsum of great toe of right foot. Clinical assessment led to the suspicion of tuberculosis which was later confirmed by biopsy. This case highlights the importance relying on clinical impression and considering tuberculosis as an aetiology even at unusual sites of involvement.

Feed enzyme supplementation does not ameliorate Foot Pad Dermatitis in broiler chickens fed on a corn-soyabean diet

1. Foot Pad Dermatitis (FPD) can be a serious health, quality and welfare problem in poultry production, with a significant affect on the economics of production. The physico-chemical properties of (NSP) have been correlated with increases in excreta viscosity and adherence, and hence FPD in broiler chickens. 2. Two broiler experiments were conducted to evaluate the effects of different dietary non-starch polisaccharide (NSP) applications to corn-soyabean based diets in replicated floor pens. In addition to live performance, the incidence and severity of FPD was scored and, in experiment 2, intestinal viscosity and ammonia volatilization were measured. 3. Live performance did not vary with the different treatments in either experiment and the incidence and severity of FPD, and ammionia volatisation in experiment 2, were unaffected. However, birds reared on enzyme supplemented diets had lower (P < 0·001) intestinal viscosity levels in experiment 1. 4. In this study with corn-soyabean meal based diets, dietary enzyme supplementation had no affect on the incidence and severity of FPD. The lack of an association between the excreta viscosity and FPD is attributed to the multifactorial etiology of this condition.

[Diabetic foot infections: microbiological aspects]

The diagnosis of wound infection is based on clinical signs and local and/or systemic inflammation. Therefore, the examination has a major role in the diagnosis of infected lesions of the foot. Once the clinical diagnosis of infection is made, the next step is to determine the etiology with the aim to undertake a rational and appropriate treatment. The most reliable method for assessing microbiological etiology is the specimen of material from infected lesion to perform a bacterioscopic examination and culture. The microorganisms involved in the etiology of diabetic foot depends on the type of injury and on specific patient features (antibiotic therapy, previous hospitalization). The most frequently detected pathogen is Staphylococcus aureus. Mild infections are mostly caused by Gram positive cocci, with a prevalence of S. aureus. Moderate infections are mostly supported by pyogenic Gram positive cocci, but also Gram-negative bacteria can be involved. In severe infections the etiology is polymicrobial. As regards the involvement of fungi in diabetic foot infections data are few and mostly conflicting.

[Management of diabetic foot infections]

All infected diabetic foot wounds require antibiotic treatment. Antibiotic treatment is influenced by the patient's features as the vascular status, the leukocyte function and the kidney activity. The initial antibiotic regimen is usually chosen empirically and it can be modified on the basis of the microbiological information obtained subsequently. The initial empiric therapy should be based, on one hand, on the grade of infected lesion and, secondly, on the epidemiological data. Almost all of the mild/moderate infected wounds can be treated with antibiotics with a spectrum of activity limited to Gram-positive cocci. Treatment with oral antibiotics is sufficient in most cases in patients with mild/moderate infections. With severe infections is more appropriate to use a broad-spectrum antibiotic therapy. Furthermore it is safer to start a parenteral therapy, possibly modifying it into an oral administration if the patient has stabilized. The most frequently pathogen observed in diabetic foot infections is Staphylococcus aureus. It is important to understand whether there are elements that may lead to the suspicion of MRSA infection in order to establish an appropriate antimicrobial therapy.

[Anti-inflammatory effects of amitriptyline, diazepam and mebicar using model of acute carrageenan-induced paw edema in rats]

The anti-inflammatory activity of amitriptyline, diazepam and a new, Russian tranquilizer mebicar was studied in a wide range of therapeutic doses on carrageenan-induced paw edema in rats. Mebicar at low doses showed greater and longer (up to 24 h) lasting anti-inflammatory activity as compared to that of amitriptyline and diazepam.

Unknown: Unusual exophytic nodule on the plantar foot

Kaposi sarcoma (KS) may be categorized into four primary clinical variants: classic, iatrogenic, endemic or African, and epidemic or acquired immunodeficiency syndrome (AIDS)-related KS. Acquired immunodeficiency syndrome-associated Kaposi sarcoma typically presents on the face and trunk as pink to red macules and papules and can be rapidly progressive leading to disseminated visceral involvement and death. Rarely has AIDS-associated KS been described as presenting on the feet. We report a case of AIDS-associated nodular KS manifesting as an exophytic nodule on the plantar foot.

Multivariable analysis of factors influencing outcome of 2 treatment protocols in 128 cases of horses responding positively to intra-articular analgesia of the distal interphalangeal joint

REASONS FOR PERFORMING STUDY

There is limited knowledge available of factors influencing response to treatments of the DIP-joint in horses with lameness responding to diagnostic analgesia of the DIP-joint. For this reason a multivariable statistical analysis was performed.

HYPOTHESIS

Horses with lameness reduced by > or = 75% 10 min after intra-articular analgesia of the DIP-joint, can be treated successfully by intra-articular medication of the joint. Multiple factors influence the response to treatment.

METHODS

The study was performed retrospectively based on clinical records of horses treated with either polysulphated glycosaminoglycan (PSGAG) or methylprednisolone acetate (MPA) in the DIP-joint between January 1996 and January 2003. Information was collected from clinical records and from the owners of the horses via a detailed questionnaire, in which they described their perception of the outcome a minimum of one year after treatment. Allocation of the horses to the 2 treatment groups was done mainly because of a change in treatment policy. In Regime A all horses received 3 intra-articular injections of PSGAG approximately 8 days apart, whereas in Regime B all horses received a single intra-articular injection of MPA as a first treatment. If the horse did not improve sufficiently to return to work by 4 weeks, a series of 3 intra-articular PSGAG injections was administered.

RESULTS

Of the horses receiving Regime A, 67% had a successful outcome, compared with 46% of the group receiving Regime B. A significantly better result was obtained in dressage horses than in jumping horses (eventing and showjumping). Other variables such as age, duration of lameness, distribution of lameness, degree of lameness, response to DIP-joint analgesia and radiographic observations were also associated with success of treatment.

CONCLUSIONS AND POTENTIAL RELEVANCE

There is a rationale for using either PSGAG or MPA intra-articularly in the treatment of lameness, reduced > or = 75% within 10 min of analgesia of the DIP-joint.

Dermojet delivery of bleomycin for the treatment of recalcitrant plantar warts

BACKGROUND

Plantar warts may cause significant morbidity. Intralesional bleomycin is effective. When bleomycin is injected with a needle and syringe, it is difficult to prevent the bleomycin from infiltrating the dermis adjacent to the wart, producing unnecessary acute pain, persistent pain, and potential sloughing of normal adjacent skin. Efficacy of delivery by dermojet is not yet established.

OBJECTIVES

To assess the response of recalcitrant plantar warts to bleomycin delivered by dermojet.

METHODS

A total of 47 patients with 138 plantar warts present for more than 2 years and resistant to 10 cycles of cryosurgery, were recruited. Bleomycin (1 U/ml) was delivered intralesionally by dermojet at 5-week intervals for 25 weeks.

RESULTS

Out of 138, 124 (89.9%) plantar warts showed complete or partial clearance after one to five sets of bleomycin injections. The recurrence rate was 6/138 (4.4%), and 8/138 (5.8%) warts failed to clear. The reduction in mean surface area of the plantar warts after each set of bleomycin injections compared to baseline surface area was statistically significant. Local side effects were similar to other methods of delivery. No systemic side effects were reported.

CONCLUSIONS

This study assesses therapeutic efficacy of bleomycin delivered by dermojet in solely recalcitrant plantar warts. It provides preliminary evidence that this method of delivery may benefit a group of patients with particularly recalcitrant plantar warts and is safe and easy to use in routine dermatology practice.

[Effect of preemptive intrathecal lornoxicam on foot swelling of formalin test in rats]

OBJECTIVE

To investigate the anti-inflammatory effect of preemptive intrathecal Lornoxicam on foot swelling of formalin test in rats.

METHODS

Eighteen healthy male adult Sprague-Dawley (SD) rats (about 250 g) were randomized into 3 groups: intrathecal solvent group (group S, solvent 20 microL), intramuscular Lornoxicam group (group IM, Lornoxicam 300 microg/20 microL) and intrathecal Lornoxicam group (group IT, Lornoxicam 300 microg/20 microL). After measuring the basic volumes of the left hind paws, rats were injected with corresponding solution intrathecally or intramuscularly, and followed by an intra-plantar administration of 100 microL of 5% formalin 10 minutes later. The volumes of left hind paws were measured again at 10 min, 30 min, 1 h, 2 h, 3 h, 4 h, 24 h after formalin injection.

RESULTS

There was no statistical difference of weights or basic volumes among three groups. At 10 min after formalin injection, the left hind paw volume of group IT [(1.53 +/- 0.06) mL] were smaller than that of group S [(1.67 +/- 0.09) mL], P=0.039, but there was no statistically difference between group IT and group IM [(1.65 +/- 0.06) mL]. At 30 min after formalin injection, the left hind paw volume of group S [(1.88 +/- 0.88) mL] was larger than that of group IM [(1.77 +/- 0.05) mL, P<0.05] and group IT [(1.61 +/- 0.06) mL, P<0.01]. The feet swelling degree of group IT was less than that of group IM, P<0.05. At 1 h, 2 h and 3 h after formalin injection, the left hind paw volume of group S was similar to that of group IM, and the volume of group IT was smaller than the other two groups. At 4 h and 24 h after formalin injection, there were no statistic differences of the left hind paw volume among the three groups.

CONCLUSION

At 10 min to 3 h after formalin injection, swelling of rat feet induced by formalin was alleviated by preemptive intrathecal Lornoxicam.

[Application of traditional Chinese drug soaking, continual irrigation and focus elimination for the treatment of foot osteomyelitis complicated with massive skin defect and denervation]

OBJECTIVE

To evaluate therapeutic effects of traditional Chinese drug soaking,continual irrigation and focus elimination for foot osteomyelitis complicated with massive skin defect and denervation.

METHODS

There were 25 males and 28 females in the study. All the patients suffering from foot osteomyelitis complicated with massive skin defect and denervation were treated with comprehensive therapy including preoperative traditional Chinese drug soaking, skin release, focus elimination,continual irrigation, and two-stage suture if necessary. Among the patients, there were 42 cases of left foot and 11 cases of right one. Fifty-one patients complicated with skin defect and sinus tract,only 2 patients complicated with skin defect. There were 48 patients with denervation caused by spina bifida, 5 patients by other causes.

RESULTS

The follow-up duration was from 1 to 12 years,the mean time was about 5 years. Osteomyelitis recurred in 3 cases and skin defect reoccurred in original position in 9 cases.

CONCLUSION

The methods of traditional Chinese drug soaking, continual irrigation and elimination of focus have good effects for foot osteomyelitis complicated with massive skin defect and denervation. To some degree,this therapy may avoid skin flap transplantation, bone graft and amputation. It deserves further studies and promotion.

A cardiologist's experience undergoing quadruple coronary artery bypass surgery

This article describes the past medical history of a 76-year-old cardiologist, the symptoms which led him to have a stress echocardiogram, the results of his coronary angiography, his experience undergoing quadruple coronary artery bypass surgery, his recovery at home, his readmission and hospitalization for a massive left pleural effusion and an infection of his left foot, and his recovery at home.

[Adult-onset primary focal foot dystonia]

INTRODUCTION

Adult-onset primary focal foot dystonia is a rare event. Up to now, only 7 cases have been reported in the literature. Since the idiopathic-type food dystonia is uncommon in adults, secondary types must be ruled out.

CLINICAL REPORT

We present the case of a 51 year woman with a 3 year history of focal food dystonia. She had abnormal posture of the foot with plantar flexion and inversion, which worsened with action. Complementary studies aimed at ruling out secondary causes were all negative. The dystonia remained limited to her food and she did not develop any other neurological symptoms. She benefited from botulinum toxin treatment.

CONCLUSIONS

Primary focal foot dystonia is uncommon in adults. The most common pattern is plantar and five toes flexion. Associated pain is common. Its pathogenesis is only partially understood, the neurophysiologic studies and functional resonance showing a loss of inhibitory control at spine and brainstem levels, abnormal cortical plasticity and altered sensorimotor integration. The response of this disorder to drugs is poor, however, the patients may benefit from botulinum toxin infiltrations of the muscles involved.

Treatment of hand and foot psoriasis with emphasis on efalizumab

Hand and foot psoriasis is a chronic and debilitating disease that manifests as plaque-type or pustular-type lesions. Although the palms and soles represent only 2% of the total body surface area, psoriasis of these regions may lead to physical dysfunctions that can greatly impair dexterity, mobility, and the quality of life of affected individuals. Deregulation of T-lymphocyte-mediated immune response is important in the pathophysiology of psoriasis. Efalizumab (Raptiva, Genentech) is an anti-CD11a monoclonal antibody that disrupts the interaction between T cells and antigen-presenting cells, thereby inhibiting various T-cell-mediated immune processes that include activation and trafficking. Recent evidence indicates that efalizumab may be beneficial for patients with hand and foot psoriasis.

Efficacy of chemical neurolysis for the treatment of interdigital nerve compression of the foot: a retrospective study

BACKGROUND

Dilute alcohol injection has been described as a nonsurgical treatment option for interdigital nerve compression of the foot, also known as "Morton's neuroma." This study reviews the efficacy of the procedure in 49 feet at one treatment center.

METHODS

In this historical cohort study, data from 42 patients who had undergone alcohol injection therapy were obtained from clinic records. A total of 49 feet were reviewed.

RESULTS

Symptoms were improved or resolved in 30 (61%) of 49 feet. Nineteen feet (39%) were unimproved, with 12 of those progressing to surgical neurectomy. Feet that received five or more injections were more likely to improve (74%) than those that received fewer than five injections (39%). Three patients reported mild complications associated with dilute alcohol injection, all of which resolved spontaneously within 2 days of the injection.

CONCLUSIONS

Dilute alcohol injection is a safe and effective treatment option for patients with Morton's neuroma who want to avoid a surgical procedure and any associated complications. The procedure may be more successful if the patient receives at least five injections.

[Involvement of the foot in metabolic diseases]

In the acute stage of gout, the hallux is most commonly involved followed by the mediotarsal joints and the Achilles tendons. Diagnosis of gout is established when typical monosodium urate crystals can be identified. Apart from NSAIDs, colchicine can be used when there is no renal impairment. Hypouricemic agents (allopurinol or uricosuric drugs) must be initiated one or two weeks after the acute attack of gout because there are risks of exacerbation. Losartan as well as fenofibrate have uricosuric properties. Chondrocalcinosis of the foot can be observed in hemochromatosis. Diffuse idiopathic skeletal hyperostosis (DISH) can cause severe talagia. Hypercholesterolemia can induce xanthomas of the Achilles tendons. Apatite rheumatism can be observed in chronic dialysis patients.

In vivo study of the anti-inflammatory effect of Rhus toxicodendron

BACKGROUND

Homeopathic Rhus toxicodendron (Rhus tox) is used in various inflammatory conditions. We screened its effect compared to succussed ethanol controls and appropriate active controls.

METHOD

We initially experimented with Rhus tox 6, 12, 30 and 200 cH, using carrageenan-induced paw oedema in rats. The 6 cH dilution appeared most effective and was used in subsequent assays. We used pre-treatment and single treatment regimes in Wistar rats, and mice.

RESULTS

We found significant reductions compared to control in carrageenan-induced paw oedema, vascular permeability, writhing induced by intraperitoneal acetic acid and stress induced gastric lesions.

CONCLUSIONS

Rhus tox in homeopathic dilution appears to interfere with inflammatory processes involving histamine, prostaglandins and other inflammatory mediators.

Treatment of Morton's neuroma with alcohol injection under sonographic guidance: follow-up of 101 cases

OBJECTIVE

Morton's neuroma is a common cause of forefoot pain. For this study, we assessed the efficacy of a series of sonographically guided alcohol injections into the lesion.

SUBJECTS AND METHODS

One hundred one consecutive patients with Morton's neuroma were included in this prospective series. An average of 4.1 treatments per person were administered, and follow-up images were obtained at a mean of 21.1 months after the last treatment (range, 13-34 months).

RESULTS

Technical success was 100%. Partial or total symptom improvement was reported by 94% of the patients, with 84% becoming totally pain-free. The median visual assessed pain score decreased from 8 before treatment to 0 after treatment (p < 0.001). Transitory increased local pain occurred in 17 cases (16.8%). There were no major complications. Thirty patients underwent sonography at 6 months after the last injection and showed a 30% decrease in the size of the neuroma.

CONCLUSION

We conclude that alcohol injection of Morton's neuroma has a high success rate and is well tolerated. The results are at least comparable to surgery, but alcohol injection is associated with less morbidity and surgical management may be reserved for nonresponders.

Ultrasound guided steroid injection in the treatment of interdigital neuralgia

The aim of this study was to assess the clinical effectiveness of ultrasound guided injection in the management of Morton's Metatarsalgia. Patients clinically diagnosed with interdigital Morton's neuroma were treated with ultrasound guided injection of local anaesthetic and steroid. Fifty four patients were available for follow-up, and all had detailed telephone questionnaires completed. These questionnaires included a pre and post injection symptom score, and Johnson Satisfaction score. The results indicate that 69% of patients had ultrasound diagnosis of Morton's neuroma and 31% had an ultrasound diagnosis of intermetatarsal bursa. Mean follow-up was 11.4 months. Sixty seven percent of the patients were satisfied with the results of treatment. At follow-up 63% of patients had no limitation in activity levels, and had no need to modify shoe wear. Of all patients included in the study, only three have gone on to require surgery for ongoing symptoms. Although some studies have suggested that neither injection nor imaging have a role in the treatment of Morton's neuroma, this study, however, demonstrates that ultrasound guided placement of local anaesthetic and steroid in either an intermetatarsal bursa or Morton's neuroma gives a good short and medium-term symptom relief and in the majority of cases avoids or at least delays the need for surgery.

An infectious disease update on antibiotics: emerging resistance

Podiatric physicians often encounter infectious processes in the lower extremity in inpatient and outpatient settings. Bacterial resistance to antibiotics is a growing concern for clinicians treating these infections, especially in complex patients who have immune compromise such as diabetes. Although a number of antibiotic options are available for the treatment of lower-extremity soft tissue and bone infections, a careful examination of bacterial susceptibilities, drug resistance, and treatment efficacy can result in better patient care and limb salvage.