Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial

AIMS

Among people with diabetes, 10-25% will experience a foot ulcer. Research has shown that supplementation with arginine, glutamine and β-hydroxy-β-methylbutyrate may improve wound repair. This study tested whether such supplementation would improve healing of foot ulcers in persons with diabetes.

METHODS

Along with standard of care, 270 subjects received, in a double-blinded fashion, (twice per day) either arginine, glutamine and β-hydroxy-β-methylbutyrate or a control drink for 16 weeks. The proportion of subjects with total wound closure and time to complete healing was assessed. In a post-hoc analysis, the interaction of serum albumin or limb perfusion, as measured by ankle-brachial index, and supplementation on healing was investigated.

RESULTS

Overall, there were no group differences in wound closure or time to wound healing at week 16. However, in subjects with an albumin level of ≤ 40 g/l and/or an ankle-brachial index of < 1.0, a significantly greater proportion of subjects in the arginine, glutamine and β-hydroxy-β-methylbutyrate group healed at week 16 compared with control subjects (P = 0.03 and 0.008, respectively). Those with low albumin or decreased limb perfusion in the supplementation group were 1.70 (95% CI 1.04-2.79) and 1.66 (95% CI 1.15-2.38) times more likely to heal.

CONCLUSIONS

While no differences in healing were identified with supplementation in non-ischaemic patients or those with normal albumin, addition of arginine, glutamine and β-hydroxy-β-methylbutyrate as an adjunct to standard of care may improve healing of diabetic foot ulcers in patients with risk of poor limb perfusion and/or low albumin levels. Further investigation involving arginine, glutamine and β-hydroxy-β-methylbutyrate in these high-risk subgroups might prove clinically valuable.

Applying split-thickness skin grafts: a step-by-step clinical guide and nursing implications

Wounds in the lower extremities represent a complex medical dilemma and a significant financial burden on the healthcare system. Often, skin grafts and flaps must be incorporated into the treatment of complex defects. Wound management has developed from a multidisciplinary to a collaborative forum, blurring treatment lines among the specialties. Various clinicians and specialists are playing an increasingly larger role in the healing algorithm of wounds in the lower extremities, including the application of skin grafts. This allows the plastic surgeon to deal with the more complex free flaps and microscopic surgical procedures. A patient's status following skin grafting can be an issue in many nursing care environments. This paper provides a pictorial review of a reliable split-thickness skin graft technique that fosters imbibition and inosculation. The points relevant to nursing care include nursing implications (for the graft and donor site), complications, and what to expect in patients who have undergone the procedure.

Osteomyelitis in the diabetic patient: diagnosis and treatment. Part 2: Medical, surgical, and alternative treatments

In the diabetic population, wound and foot infections are often mixed, containing from three to six organisms. This creates a significant problem regarding antibiotic protocols. Many of these episodes result in contiguous bone infections with subsequent erosive changes, sequestra, and involucrum. A multidisciplinary approach to treatment is often required. Studies have shown that a protocol of 6 weeks of intravenous antibiotics may be appropriate to treat osteomyelitis; however, this is controversial and often not curative. Osteomyelitis is a surgical disease; a subtle balance between medical and surgical therapy is necessary if a potentially curative outcome is to be achieved. The duration of antibiotic therapy may be shortened considerably after surgical intervention. In cases of infection mitigated by severe peripheral vascular disease, end-stage renal disease, diabetes, or other medical problems where surgery is not an option, long-term antibiotics may be used as suppressive therapy along with adjunctive local treatments. The following is the second article of a two-part series. The first paper discussed the diagnosis and microbiology of contiguous osteomyelitis in the diabetic foot. This article outlines the various medical, antibiotic, and surgical options available to the clinician. Adjunctive and alternative therapies also are discussed.

Osteomyelitis in the diabetic patient: diagnosis and treatment. Part 1: Overview, diagnosis, and microbiology

Foot ulcerations are common among people with diabetes and often lead to mixed infections that require hospitalization and create significant challenges for clinicians. Many result in contiguous bone infections. Regimens used to treat osteomyelitis often are seen as controversial. A subtle balance between medical and surgical therapy is necessary if a potentially curative outcome is to be achieved. The following article is one of a two-part series. This, the first manuscript, discusses the diagnosis and microbiology of contiguous osteomyelitis in the diabetic foot.

Calciphylaxis and its relation to end-stage renal disease: a literature review and case presentation

Calciphylaxis is an uncommon phenomenon usually observed in patients with chronic renal failure who are on dialysis and who have secondary hyperparathyroidism. Treatment is multifocal and may include wound debridement, wound excision, and various methods of achieving closure. Removal of the parathyroid glands often is advocated, but this option remains controversial. Despite treatment, there is a fatal outcome in a majority of cases due to septicemia. Prompt recognition and treatment are imperative to help prevent septicemia. A review of the literature and two case studies are presented.

Class II malocclusion correction: an American board of orthodontics case

A Class II open bite malocclusion with a narrowed maxilla, an increased lower anterior facial height, and a tooth size discrepancy are presented. The malocclusion was treated nonextraction in 2 phases. The mixed dentition phase of treatment was maxillary molar uprighting followed by a bonded rapid palatal expander. The vertical dimension was managed with a vertical pull chincup. The full appliance phase included buildups of the maxillary lateral incisors and mechanics to control lower incisor position.

Cadaveric allograft as adjunct therapy for nonhealing ulcers

The objective of this study was to describe the results of a retrospective survey of 27 patients who were treated with cadaveric skin allograft as an adjunct therapy for wound management. The evolution, benefits, indications, and future of cadaveric skin allografts are also discussed. Glycerin-preserved, frozen, cadaveric split-thickness skin allograft was sutured to excised wounds and held in place with a stent dressing. Retrospective data recovered from wound assessment forms and progress reports were used to evaluate the effectiveness of this treatment. The etiology, pre- and postexcisional volume, depth of debridement, time taken for granulation tissue to first appear, allograft life span, volume post allograft removal, healing time, time expired from allograft to skin grafting, and reported pain were documented and presented. A total of 34 ulcers in 27 patients of various etiologies were evaluated. Pre-excisional volume averaged 6448.2 mm3, while the volume post allograft debridement averaged 9159.0 mm3. The length of time the biologic dressing remained in place averaged 29.1 days. Granulation tissue became first apparent through the fenestrations in the graft at an average of 13.4 days. Pain was notably reduced in 53% of the patient's post debridement with application of allograft. Only 12% of the patients experienced an increase in pain and 35% related no change. Most (65%) of the patients healed via secondary intention. The rest (35%) underwent split-thickness skin grafting. The average healing time was 113.9 days. No infections occurred while the allograft was in place. Lower extremity wounds present many challenges that may lengthen the course of treatment. As healing time increases, so too does the risk of various complications such as infection, desiccation, and damage to underlying soft tissues. The benefits of allograft treatment are particularly noteworthy in areas where bone and/or tendon are exposed. In these cases it becomes especially difficult to promote granulation tissue growth. Cadaveric skin allografts aid in preventing desiccation, help to control infection, and can substantially reduce patient discomfort.

Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital

The first 100 consecutive shoulder arthroscopic procedures performed under interscalene anesthesia at a small community-sized military hospital are the basis of this report. This method of anesthesia was compared with 100 shoulder arthroscopies performed in a previous 2-year time period under general anesthesia. A variety of arthroscopic and subsequent open reconstructive procedures about the shoulder were performed using both techniques. Using the interscalene method, 87 regional blocks were entirely successful. Thirteen patients required conversion to general anesthesia for adequate pain control; however, 4 of these had a complete block in the recovery room and required no postoperative narcotics. Seven patients required supplementation with local anesthetic when an open procedure became necessary. There were no major complications. Minor complications included 5 patients with transient Horner's syndrome, 4 patients who experienced anxiety, which was controlled with sedation, and 3 with nausea or pruritus. Interscalene anesthesia provided excellent intraoperative and postoperative analgesia with low morbidity. On a subsequent questionnaire, all patients with a successful block reported that they were extremely satisfied with their experience. Ten patients who had previous shoulder surgery under general anesthesia preferred the interscalene method. In summary, interscalene anesthesia proved to be an excellent method of anesthesia for shoulder arthroscopy. The technique is reproducible within the resources available in most community-level hospitals.

The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study

To evaluate the effect of tourniquet use during anterior cruciate ligament reconstruction, 40 consecutive patients were randomized into two groups: Group I (tourniquet) and Group II (no tourniquet). Preoperative evaluation included electromyography, measurement of thigh and calf girth, and determination of serum creatinine phosphokinase levels. Initial postoperative evaluations included serial creatinine phosphokinase determinations. At 1 and 6 months postoperatively, the electromyographic examination was repeated and thigh and calf girth measurements were obtained. At 6 months and 1 year after surgery, the following evaluations were made: thigh and calf girth, KT-1000 arthrometric testing, isokinetic testing of quadriceps and hamstring muscles, single-legged hop test for time, single-legged hop test for distance, and the Lysholm knee score. In Group I, the tourniquet was inflated for an average of 87 minutes, with an average pressure of 269 mm Hg. At 1 month postoperatively, 6 of 20 patients in Group I had positive electromyographic recordings (compared with 2 of 20 in Group II, P = 0.08). At 1 month, thigh girths measured 10 cm proximal to the medial joint line suggested more atrophy in the tourniquet group (P = 0.07). At 6 months, all electromyographic recordings had returned to normal. At 6 months and 1 year postoperatively, girth measurements, isokinetic strength testing, functional testing, KT-1000 arthrometer evaluation, and the Lysholm knee scores were similar for both groups.

Single versus two-incision arthroscopic anterior cruciate ligament reconstruction

The purpose of this study was to compare single (endoscopic) versus two-incision arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone in a population of young athletes. All patients followed a similar postoperative rehabilitation program. The Lysholm knee score, the International Knee Documentation Committee Score, KT-1000 arthrometric measurements, Lachman tests, pivot shift tests, isokinetic and functional testing, and perioperative complications were used to compare the two techniques. Anteroposterior and lateral radiographs were also evaluated and compared. Group I comprised 51 patients who underwent two-incision arthroscopic ACL reconstruction. The average age was 19.8 years, with a range of 18 to 22. The average follow-up in this group was 31 months (range, 24 to 43 months). Group II, the endoscopic group, consisted of 31 patients with an average age of 19.4 years (range, 18 to 22). The average follow-up was 25 months (range, 24 to 31 months). There were no significant differences between the two groups using subjective, objective, and functional criteria. There did appear to be a trend toward a residual pivot glide in the endoscopic group, but this did not achieve statistical significance. Radiographic analysis demonstrated an increased incidence of screw divergence in the endoscopic group. Intraoperative complications were more common with the endoscopic method.

Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: a preliminary report

Twenty-six consecutive cadet athletes sustained an acute, initial anterior shoulder dislocation. All dislocations required a manual reduction for initial treatment. Arthroscopy was performed within 10 days in all patients. The Beach chair position and interscalene anesthesia were used in each case. At arthroscopy, 25 patients had an avulsion of the anterior-inferior capsulolabral complex (Bankart lesion) from the glenoid rim. One patient had a lateral detachment of the inferior glenohumeral ligament from the humeral neck. Twenty-three patients had a Hill-Sachs lesion and 3 SLAP tears were noted. All Bankart lesions were repaired with a cannulated bioabsorbable fixation device. Nineteen patients, over 1 year postoperative, are the subject of this preliminary report. The average age was 19.5 years (range, 17 to 23 years). Follow-up averaged 19 months (range, 12 to 24 months). The average loss of external rotation was 3 degrees. There have been no recurrent dislocations and 1 patient has had a single episode of resubluxation. Using the Rowe point score, 16 patients were rated excellent, 2 good, and 1 fair. All of the athletes in this study have returned to preinjury performance status. Acute stabilization of initial anterior shoulder dislocations appears to be an effective treatment option in young athletes known to have high recurrence rates with nonoperative treatment. This particular technique has been safe with little morbidity.

An evaluation of a leukocyte esterase/nitrite test strip and a bioluminescence assay for detection of bacteriuria

A leukocyte esterase/nitrite (Chemstrip LNTM) and a bioluminescence assay (LumacTM) were evaluated for detection of bacteriuria in 1,000 urine specimens. Both devices provided high predictive negative values (95.4-97.8%); however, false-negative values at levels of bacteriuria greater than or equal to 10(4) CFU/ml were 22.6% and 12.3%, respectively, for the leukocyte esterase/nitrate and the bioluminescence assay tests. The corresponding false-negative values at levels of bacteriuria of greater than or equal to 10(5) CFU/ml were 16.5% and 3.9%, respectively.

Initial and long-term results in the management of primary chest wall neoplasms

One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.

A comparison of serum isoenzyme levels of creatine phosphokinase and lactic dehydrogenase in patients undergoing thoracic operations and patients admitted to a coronary care unit

A prospective study comparing patients undergoing major thoracic surgical procedures with patients admitted to a coronary care unit was conducted. Surgical patients having bronchoscopy and mediastinoscopy (n = 12), anterior thoracotomy (n = 12), and posterolateral thoracotomy (n = 22) were compared with patients in the coronary care unit who had electrocardiographically proved myocardial infarctions (MI) (n = 11) and those with no electrocardiographic abnormalities (n = 12). Sera were studied by spectrophotometric analysis (creatine phosphokinase [CPK] and lactic dehydrogenase [LDH]), agarose gel electrophoresis (CPK and LDH), and antibody inhibition spectrophotometric analysis (CPK). The levels of total CPK did not rise above the upper limits of normal (100 IU/L) in patients who underwent bronchoscopy and mediastinoscopy. Total CPK elevations in patients undergoing thoracotomy (anterior thoracotomy, 428 +/- 62 IU/L [mean +/- standard error of the mean]; posterolateral thoracotomy, 652 +/- 78 IU/L) were not significantly different from those sustaining acute MIs (463 +/- 84 IU/L). Only transient minimal elevations of CPK-MB isoenzyme were noted, however, in the patients having posterolateral thoracotomy (25 +/- 7 IU/L). These were significantly lower (p < 0.001) than the elevations seen in patients sustaining acute MIs (80 +/- 16 IU/L). In none of the surgical patients did LDH1 exceed LDH2 while all of the patients with MIs had such a shift (p < 0.001). The data support the conclusion that the serum isoenzymes of CPK and LDH are capable of confirming the diagnosis of MI in patients recovering from major thoracic surgical procedures.

Penetration of methicillin, oxacillin, and cephalothin into bone and synovial tissues

The penetrations of methicillin, oxacillin, and cephalothin into cortical bone and synovial tissues were studied 1 h after their intravenous administration in 105 patients having arthroplasty of the hip. Although the lowest serum levels were noted with cephalothin (P < 0.01), more patients receiving cephalothin achieved osseous drug levels inhibitory to staphylococci (P < 0.01). Differences in the penetration of the three agents into synovial tissues were not statistically significant.

Effect of cation content of agar on the activity of gentamicin, tobramycin, and amikacin against Pseudomonas aeruginosa

Fifty-five strains of Pseudomonas aeruginosa were tested against arithmetic increments in concentrations of gentamicin, tobramycin, and amikacin in 14 different lots of Mueller-Hinton agar. The divalent cation content of each lot was determined by atomic absorption spectrometry. The relation between mean minimal inhibitory concentration (MIC) for strains within each lot and cation content was studied by stepwise regression. Among the cations, the content of Zn++ most highly correlated with the MIC of each aminoglycoside; however, Zn++ accounted for only 23%, 60%, and 47% of the variability in the mean MIC of gentamicin, tobramycin, and amikacin, respectively, against all strains. In two-cation models Zn++ with Ca++ or Cu++ was most highly correlated with the mean MICs of the three aminoglycosides against all strains. No divalent cation, either singly or in combination with one or two other cations, gave a good prediction of the MICs of the aminoglycosides in agar. Furthermore, there was variability in the cations that most highly correlated with the MICs for some strains. These observations support the concept that ionic strength, cations, and a variety of other as yet poorly defined components of media influence the activity of aminoglycosides against P. aeruginosa.

Spurious ampicillin resistance by testing Haemophilus influenzae with agar containing supplement C

Ampicillin resistance (minimal inhibitory concentration >/=10 mug/ml) in the absence of beta-lactamase activity by Haemophilus influenzae was noted in tests performed with Mueller-Hinton agar containing one lot of supplement C. All strains, except five with known resistance due to beta-lactamase activity, were inhibited by 0.6 mug or less of ampicillin per ml of chocolatized blood agar.

Analysis of certain variables in the agar dilution susceptibility test

This study examined (i) the activity of gentamicin added to agar in ratios of 1:100 and 1:1,000 to produce a final concentration of 1 mug/ml, (ii) the uniformity of distribution of gentamicin in agar in relation to the amount of mixing, and (iii) the effect of agar depth on the activity of gentamicin against Pseudomonas aeruginosa. Although the ratio of antibiotic solution to agar had no significant effects on activity of the antibiotic, the amount of mixing did. Agar depth had no significant effect on the activity of gentamicin.

Bactericidal activity of combinations of gentamicin with penicillin or clindamycin against Streptococcus mutans

Data derived from testing the bactericidal activity of combinations of penicillin with gentamicin or streptomycin and of clindamycin with gentamicin on nine isolates of Streptococcus mutans were analyzed by preparing isobolograms to determine the presence of additive, synergistic, or antagonistic effects. Synergy with penicillin-aminoglycoside combinations was found in two strains; additive effects occurred in seven instances with penicillin-gentamicin combinations; and antagonism occurred in eight instances with clindamycin-gentamicin combinations.

Four-hour microbiological assay of gentamicin in serum

Since the microbiological assay of the antibiotic content of serum generally requires 18 to 24 hr of incubation, results of such procedures may not become available in time to make appropriate adjustments in subsequent dosages of antibiotic. A 4-hr bioassay for determining concentrations of gentamicin in serum has been developed in which Staphylococcus aureus ATCC 6538P is used as the test organism. Poured plates have yielded satisfactory results after storage at 4 C for 5 days. Results of the 4-hr procedure agree closely with those of a conventional 18-hr disc-plate assay performed with the same test organism.