Phase I trial on the safety of topical rhVEGF on chronic neuropathic diabetic foot ulcers

OBJECTIVE

To assess the safety/tolerability and perform a preliminary efficacy evaluation of a multiple-dosing regimen of recombinant human vascular endothelial growth factor (VEGF165 or rhVEGF; telbermin) applied topically to chronic diabetic neuropathic foot ulcers.

METHOD

Subjects with type 1 or 2 diabetes mellitus were randomised to receive either topical applied telbermin (72 microg/cm2) (n=29) or placebo (n=26) treatment to the foot ulcer surface in conjunction with standard ulcer care. Subjects received treatment every 48 hours (maximum three doses per week) for up to six weeks. Weekly 35mm photography, quantitative planimetry and physical examinations documented the ulcer appearance, surface area and stage. Safety endpoints included incidence of clinically significant hypotension, adverse events and ulcer infection. Exploratory efficacy endpoints included percentage reduction in total ulcer surface area, incidence of complete ulcer healing and time to complete ulcer healing.

RESULTS

Incidence of adverse events was comparable in the two treatment groups. None of the adverse events were attributed to study drug, and no hypotension was observed as a result of telbermin treatment. Occurrence of infected study ulcers appeared to be balanced between the treatment groups. Positive trends suggestive of potential signals of biological activity were observed for incidence of complete ulcer healing (41.4% telbermin versus 26.9% placebo at day 43 [P=0.39]) and time to complete ulcer healing (25th percentile of 32.5 days telbermin versus 43.0 days placebo [log-rank P=0.13]).

CONCLUSION

The topical application of telbermin 72 microg/cm2 three times a week for up to six weeks appeared to be well tolerated. Further studies are required to characterise the safety/efficacy of telbermin more completely.

Sonographic analysis of Morton's neuroma

A prospective study was performed whereby 73 patients exhibiting clinical symptoms of 109 Morton's neuromas were examined using ultrasound. Reproducible hypoechoic densities were identified as neuromas if they measured greater than 5 mm. in transverse dimension, with those 4 mm. or less in dimensions called "suspicious" if they were well-defined and if the patient had marked pain in the examined interspace. Sixty of the neuromas were surgically excised, with 49 being managed conservatively. Of the surgical cases, all but three (95%) of the neuromas were positively identified on sonographic examination and all excised masses demonstrated pathological findings consistent with Morton's neuroma. Thirty-nine percent of the conservatively treated neuromas were negative on sonogram. The average sonographic size of the resected neuromas was 6.2 mm., while the size of those not resected averaged 4.9 mm. This study provides evidence that preoperative sonography is an additional aid in the evaluation of Morton's neuroma, and reaffirms previous evidence that symptomatic neuromas are likely to be at least 5 mm. in diameter on sonogram.

Complications of lesser metatarsal surgery

Complications of lesser metatarsal surgery are the result of inappropriate procedure choice, poor surgical technique, inadequate fixation, or a lack of patient compliance. Postoperative complications include transfer lesions, malunion, delayed union, nonunion, displacement of fixation devices, and resultant digital contracture. Despite good results with treatment of tailor's bunion deformities, results of osteotomies of the central three metatarsals are inconsistent. Conservative care is preferred for treatment of plantar hyperkeratoses.

The two-sex problem with persistent unions: a generalization of the birth matrix-mating rule model

The birth matrix-mating rule (BMMR) model solves the two-sex problem of classical stable population theory by allowing births to adjust to changes in a population's age-sex composition. To avoid complications the BMMR model assumes that unions last for only a single period. This paper drops that assumption and presents the BMMRPU (BMMR persistent unions) model. To establish the existence of equilibrium in the BMMRPU model, the existence proof used in the BMMR model is supplemented by a fixed-point argument.

Total first joint replacement in hallux valgus and hallux rigidus. Long-term results in 484 cases

Long-term results of 484 cases of Silastic total first joint replacement are presented. The history, discussion of other total first implants, and a descriptive surgical technique with a discussion of complications are also presented. The authors propose a new, universal grading system for assessment of results following bunion surgery.

Patient expectations of elective foot surgery

A two-part questionnaire was dispensed by five different podiatrists to 73 surgical patients over a 3-month period. Seventy-two (99%) of the patients were satisfied with postoperative results. The average time required to return to shoes, work, and exercise was 6.0, 4.5, and 9.0 weeks, respectively. Age, number of procedures, and type of procedure did have an effect on these values. Subjective comments indicate that surgical patients are most concerned with pain, postoperative swelling, and time needed for recovery.