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Biomedical subjects

L A Lavery

Publications and source records attributed to L A Lavery.

At least 55 records · Page 3Linked to original sources
PubMed1997

Infrared dermal thermometry for the high-risk diabetic foot.

BACKGROUND AND PURPOSE: The purpose of this study was to compare skin temperatures in patients with asymptomatic peripheral sensory neuropathy, patients with neuropathic ulcers, and patients with Charcot's arthropathy using the contralateral limb as a control. SUBJECTS: On a retrospective basis, patients with diabetes (N = 143) were divided into three groups: patients with asymptomatic sensory neuropathy (n = 78), patients with neuropathic foot ulcers (n = 44), and patients with neuropathic fractures (Charcot's arthropathy) (n = 21). METHODS: We evaluated the subjects' skin temperatures with a portable hand-held infrared skin temperature probe at the time pathology was initially identified and at subsequent clinical visits for an average of 22.1 months (SD = 6.4). Skin temperatures of the contralateral foot were measured as a control. RESULTS: There were differences in skin temperature between the affected foot and the contralateral (i.e., nonaffected) foot among the patients with Characot's arthropathy (8.3 degrees F) and the patients with neuropathic ulcers (5.6 degrees F), with no difference identified among the patients with asymptomatic sensory neuropathy. Five patients with neuropathic ulcers experienced reulceration a mean of 12.2 months (SD = 6.4) after initial healing, with a corresponding increase in skin temperature. (89.6 degrees +/- 1.2 degrees F versus 82.5 degrees +/- 2.9 degrees F) at the clinic visit immediately preceding reinjury. CONCLUSION AND DISCUSSION: The data suggest that monitoring of the corresponding contralateral foot site may provide clinical information before other clinical signs of injury can be identified.

Aged↗
PubMed1997

Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults.

We reviewed the hospital course of 77 diabetic and 69 nondiabetic subjects who had incision, drainage, and exploration of infected puncture wounds of the foot. Diabetics were 5 times more likely to have multiple operations and 46 times more likely to have a lower extremity amputation than nondiabetics. The interval from injury to surgery was significantly longer in diabetics than nondiabetics. Total lymphocyte count and hemoglobin, hematocrit, and albumin values were significantly lower in diabetics than in nondiabetics. Diabetic amputees had higher prevalences of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitis as compared with diabetic nonamputees. The neuropathic diabetic foot is not protected by pain. When combined with other comorbid factors, this may increase morbidity associated with puncture wounds of the foot.

Adult↗
PubMed1997

Reducing plantar pressure in the neuropathic foot. A comparison of footwear.

OBJECTIVE: To compare the effectiveness of therapeutic, comfort, and athletic shoes with and without viscoelastic insoles. RESEARCH DESIGN AND METHODS: We compared pressure reduction at ulcer sites under the hallux (n = 10), first metatarsal (n = 10), and lesser metatarsals (n = 12), using extra-depth, athletic, and comfort shoes with and without viscoelastic insoles. A rubber-soled canvas oxford was used to establish baseline pressure values. RESULTS: When used in conjunction with a viscoelastic insole, all shoe types reduced mean peak plantar pressure better than their non-insoled counterparts (P < 0.05). Consistently, comfort shoes reduced pressure significantly better than both the cross trainers and extra-depth shoes for ulcers under the first and lesser metatarsals (P < 0.05). For each shoe type, the addition of the viscoelastic insole provided a significant reduction in mean peak pressure (P < 0.05). Compared with stock insoles, viscoelastic insoles reduced pressures an additional 5.4-20.1% at ulcer sites. The same trend was also observed at regions of the foot not associated with an ulceration. CONCLUSIONS: When used in conjunction with a viscoelastic insole, both the comfort and athletic cross-trainer shoes studied were as, if not more, effective than commonly prescribed therapeutic shoes in reducing mean peak first and lesser metatarsal pressures. Furthermore, comfort shoes were as effective as therapeutic shoes in reducing pressure under the great toe. Both of these shoe types may be viable options to prevent the development or recurrence of foot ulcers.

Adult↗
PubMed1997

1997 William J. Stickel Bronze Award. Comparison of strategies for reducing pressure at the site of neuropathic ulcers.

Few scientific data are available on the effectiveness of commonly used modalities for reducing pressure at the site of neuropathic ulcers in persons with diabetes mellitus. The authors' aim was to compare the effectiveness of total contact casts, half-shoes, rigid-soled postoperative shoes, accommodative dressings made of felt and polyethylene foam, and removable walking casts in reducing peak plantar foot pressures at the site of neuropathic ulcerations in diabetics. Using an in-shoe pressure-measurement system, data from 32 midgait steps were collected for each treatment. There was a consistent pattern in the devices' effectiveness in reducing foot pressures at ulcer sites under the great toe and ball of the foot. Removable walking casts were as effective as or more effective than total contact casts. Half-shoes were consistently the third most effective modality, followed by accommodative dressings and rigid-soled postoperative shoes.

Adult↗
PubMed1997

Amputation and reamputation of the diabetic foot.

The authors compare the level of foot amputation by age, prevalence of arterial disease as a precipitating factor, gender, and ethnicity in persons with diabetes mellitus. Medical records were abstracted for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas in south Texas. Amputation level was defined by ICD-9-CM codes and were categorized as foot, leg, and thigh amputations. Foot-level amputations were further subcategorized as hallux or first ray, middle, fifth, multiple digit or ray, and midfoot amputations. Only the highest amputation level for each individual was used in the analysis. Of 1,043 subjects undergoing a lower extremity amputation in south Texas in the year 1993, 477 received their amputation at the level of the foot. African-Americans requiring a foot-level amputation were at significantly higher risk to undergo a midfoot-level amputation than was the rest of the population. Nearly 40% of all subjects undergoing a foot-level amputation had a previous history of amputation. However, nearly 40% of subjects undergoing foot amputations had not been diagnosed either before or during admission with peripheral arterial occlusive disease, suggesting a causal pathway dependent primarily on neuropathy. This implies that better screening of diabetic patients with appropriate risk-directed treatment at the primary care level may significantly impact the large number of preventable diabetes-related lower extremity amputations.

Black or African American↗
PubMed1997

The acutely infected diabetic foot is not adequately evaluated in an inpatient setting.

OBJECTIVE: To evaluate the standard of evaluation and treatment of the infected diabetic foot ulceration at a 551-bed university teaching institution. DESIGN: A retrospective review of a 4-year consecutive sample (1991-1994). POPULATION: Two hundred fifty-five patients who were admitted to a hospital for care of an infected diabetic foot ulceration. Patients were subdivided into the following 4 dichotomous variables: (1) whether the patient underwent a lower-extremity amputation, (2) whether the patient was admitted once or multiple times, (3) whether the patient underwent intraoperative debridement, and (4) whether the patient was admitted to medical or surgical services. RESULTS: All groups that were evaluated had undergone a less than adequate foot examination. Of the admitted patients, 31.4% did not have their pedal pulses documented; 59.7% of the admitted patients were not evaluated for the presence or absence of protective sensation. Nearly 90% of the wounds were not evaluated for involvement of underlying structures, and foot radiographs were not performed in 32.9% of the patients. There were more blood cultures ordered (62.0%) than wound cultures (51.4%). CONCLUSION: The results of this study highlight the need for a systematic, detailed lower-extremity examination for every diabetic patient who is admitted to a hospital, particularly those who are admitted with a primary diagnosis that involves a foot complication.

Aged↗
PubMed1997

Novel methodology to obtain salient biomechanical characteristics of insole materials.

Viscoelastic inserts are commonly used as artificial shock absorbers to prevent neuropathic foot ulcerations by decreasing pressure on the sole of the foot. Unfortunately, there is little scientific information available to guide physicians in the selection of appropriate insole materials. Therefore, a novel methodology was developed to form a rational platform for biomechanical characterizations of insole material durability, which consisted of in vivo gait analysis and in vitro bioengineering measurements. Results show significant differences in the compressive stiffness of the tested insoles and the rate of change over time in both compressive stiffness and peak pressures measured. Good correlations were found between pressure-time integral and Young's modulus (r2 = 0.93), and total energy applied and Young's modulus (r2 = 0.87).

Biomechanical Phenomena↗
PubMed1997

The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic.

The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25% of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.

Acute Disease↗
PubMed1997

Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults.

We reviewed the hospital course of 77 diabetic and 69 nondiabetic subjects who had incision, drainage, and exploration of infected puncture wounds of the foot. Diabetics were 5 times more likely to have multiple operations and 46 times more likely to have a lower extremity amputation than nondiabetics. The interval from injury to surgery was significantly longer in diabetics than nondiabetics. Total lymphocyte count and hemoglobin, hematocrit, and albumin values were significantly lower in diabetics than in nondiabetics. Diabetic amputees had higher prevalences of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitia as compared with diabetic nonamputees. The neuropathic diabetic foot is not protected by pain. When combined with other comorbid factors, this may increase morbidity associated with puncture wounds of the foot.

Adult↗
PubMed1997

Soft tissue and bone infections from puncture wounds in children.

We report on the prevalence of osteomyelitis, the prevalence of soft tissue infections, and the type and number of pathogens encountered in bone and soft tissue infections caused by puncture wounds in children. In addition, we seek to establish whether shoe gear plays a role in the flora in infected puncture wounds and if laboratory indices are indicative of the presence of infection. The group consisted of 44 nondiabetic children admitted to hospital for puncture wounds of the foot. Cultures were positive for osteomyelitis in 7 patients (16%), all involving the forefoot (P < .04). The most common pathogen in soft tissue infections was Staphylococcus aureus. The most common pathogen in osteomyelitis was Pseudomonas aeruginosa. There was no significant difference in the prevalence of osteomyelitis and soft tissue infection based on footwear. There were no cases of osteomyelitis encountered among barefoot children (P < .04). In 10 cases (83%), P aeruginosa infection (both soft tissue and bone) occurred while the patients were wearing tennis shoes (P < .04). In this study, the leukocyte count (normal in 29 patients [66%]), erythrocyte sedimentation rate (normal in 28 patients [64%]), and temperature (normal in 44 patients [95%]) did not have any predictive value in differentiating soft tissue infection from osteomyelitis in children.

Age Distribution↗
PubMed1997

Classification of diabetic foot wounds.

Foot ulcers in persons with diabetes are one of the most common precursors to lower extremity amputation. Appropriate care of the diabetic foot ulceration requires a clear, descriptive classification system that may be used to direct appropriate therapy and possibly predict outcome. Ideally, this system would be used by all participants in a multidisciplinary limb salvage team. We describe a clinical classification system for diabetic foot wounds that evaluates wound depth, the presence of infection, and peripheral arterial occlusive disease in every category of the wound assessment. The goal of this system is to improve communication, leading to a less complex, more predictable treatment course, and, ultimately an improved result.

Diabetic Foot↗
PubMed1997

Monitoring healing of acute Charcot's arthropathy with infrared dermal thermometry.

The purpose of this study was to describe the use of skin temperature assessment in diabetics with acute Charcot's arthropathy to monitor resolution of inflammation longitudinally throughout the course of treatment and to predict development of neuropathic ulcers. Thirty-nine diabetic subjects presenting with acute Charcot's arthropathy received thermometric monitoring throughout their treatment course. Subjects were treated with a standard protocol involving total contact casting, removable cast walkers, and progression to therapeutic shoes. There was a steady decrease in temperatures during the casting regimen. After temperature gradients normalized, subjects were progressed to custom therapeutic shoe gear and insoles and were followed for a mean 22.6 +/- 7.1 months. Following quiescence, 8% returned during the follow-up period with a new-onset neuropathic ulceration. Temperature gradients during taken the visit prior to ulceration were significantly higher in this group than for the rest of the population. Elevated temperatures were strongly correlated with the location of arthropathy. Temperatures decreased in a predictable manner as acute arthropathy resolved. Additionally, increased temperature gradients may be predictive of future ulceration.

Acute Disease↗
PubMed1996

The acutely infected diabetic foot is not adequately evaluated in an inpatient setting.

OBJECTIVE: To evaluate the standard of evaluation and treatment of the infected diabetic foot ulceration at a 551-bed university teaching institution. DESIGN: A retrospective review of a 4-year consecutive sample (1991-1994). POPULATION: Two hundred fifty-five patients who were admitted to a hospital for care of an infected diabetic foot ulceration. Patients were subdivided into the following 4 dichotomous variables: (1) whether the patient underwent a lower-extremity amputation, (2) whether the patient was admitted once or multiple times, (3) whether the patient underwent intraoperative debridement, and (4) whether the patient was admitted to medical or surgical services. RESULTS: All groups that were evaluated had undergone a less than adequate foot examination. Of the admitted patients, 31.4% did not have their pedal pulses documented; 59.7% of the admitted patients were not evaluated for the presence or absence of protective sensation. Nearly 90% of the wounds were not evaluated for involvement of underlying structures, and foot radiographs were not performed in 32.9% of the patients. There were more blood cultures ordered (62.0%) than wound cultures (51.4%). CONCLUSION: The results of this study highlight the need for a systematic, detailed lower-extremity examination for every diabetic patient who is admitted to a hospital, particularly those who are admitted with a primary diagnosis that involves a foot complication.

Aged↗
PubMed1996

In-hospital mortality and disposition of diabetic amputees in The Netherlands.

The purpose of this study is to identify in-hospital mortality of diabetic amputees and the disposition of survivors in The Netherlands in 1991 and 1992. A database including all hospitalizations in The Netherlands was used. Amputees who died while in the hospital were analysed separately. Survivors were categorized according to different types of discharge: home, nursing home, rehabilitation facility, and other health care facilities. Overall 9.0% of diabetic amputees died while in hospital. The age-adjusted mortality incidence for the diabetic population was 36.3 per 1000 diabetic amputees (95% CI: 18.7-53.9) and 28.2 per 1,000 non-diabetic amputees (95% CI: 20.5-35.9). Non-diabetic amputees with PVD has proportionally more mortality than diabetic amputees with PVD (P < 0.01), diabetic amputees without PVD (P < 0.01), and non-diabetic amputees without PVD (P < 0.001). Using Cox regression analysis age (B(age) = 0.023, RR = 1.024) and the occurrence of multiple amputations during the hospitalization (Bmultiple = 0.325, RR = 1.383) were significant negative predictors for survival. As age and level of amputation increased, more diabetic and non-diabetic amputees were discharged to facilities other than home (P < 0.001).

Age Factors↗
PubMed1996

Regional variation in the incidence of diabetes-related amputations in The Netherlands.

The purpose of this study is to identify the incidence of diabetes-related lower extremity amputations in 27 health regions in the Netherlands. A secondary database was used that contains all hospitalizations for a lower extremity amputation in the Netherlands in 1991 and 1992, recorded separately for 27 health regions. The age-adjusted incidence lower extremity amputations per 10,000 diabetic patients in the Netherlands was 25.05, and among the regions it ranged from 10.15 to 44.64. In the non-diabetic population, the age-adjusted incidence in the Netherlands was 1.24 and ranged by region from 0.77 to 1.77. Overall, diabetic males had higher age-adjusted incidence rates than diabetic females, although in four health regions the situation was reversed. In the Netherlands, there was an increasing incidence of diabetes-related lower extremity amputation as age increased: < 45 years, 11.15; 45-64 years, 33.84; 65-74 years, 61.22; and 75 + years, 107.92 (P < 0.001). This continued to be a significant phenomenon for every health region (P < 0.001). This study found a wide range in the incidence of diabetes related lower extremity amputations in the 27 health regions in the Netherlands. A possible explanation could be differences in the severity of diabetes, in local treatment philosophies or the availability of subspecialties.

Adult↗
PubMed1996

Puncture wounds: normal laboratory values in the face of severe infection in diabetics and non-diabetics.

PURPOSE: Using infected puncture wounds as a basis for comparison, we pose the question of whether white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) is lower in diabetic patients with foot infections as compared with nondiabetic patients. PATIENTS AND METHODS: This case control study consisted of two groups, both with infected puncture wounds of the foot, admitted to a 700-bed urban university teaching hospital between 1985 and 1992. The experimental group contained 77 patients with diabetes mellitus. The control group consisted of 69 patients without diabetes. All subjects received emergent incision and drainage of the affected site. RESULTS: Results revealed a normal WBC count in 57.6% of patients. The ESR was normal in 36.3% of admissions. More nondiabetic patients presented with normal ESR than diabetic patients (62.3% versus 13.7%, respectively; P < 0.0001). Diabetic patients had a significantly higher mean WBC count and ESR than did nondiabetic patients. Pain was the principal complaint more frequently in nondiabetic patients (92.9% NDM versus 70.1% DM, respectively; P < 0.005). Erythema (72.7% versus 51.4%; P = 0.008), and drainage (36.4% versus 7.1%; P < 0.001) were more common in diabetic patients. CONCLUSION: We conclude that, while a glaringly elevated WBC count or ESR should alert the clinician to the possibility of infection, normal values should not be relied upon to rule out a serious event.

Adult↗
PubMed1996

Outcomes associated with diabetes-related amputations in The Netherlands and in the state of California, USA.

OBJECTIVE: The purpose of this study is to compare the incidence, relative risk, in-hospital mortality and hospital stay of diabetes-related lower extremity amputations in the state of California and the Netherlands in the year 1991. RESEARCH DESIGN AND METHODS: We used established data obtained from the Office of Statewide Planning and Development for the state of California and from SIG Health Care Information in the Netherlands to identify all hospitalisations for lower extremity amputations. We used age- and sex-specific prevalence rates of diabetes mellitus from the National Health and Nutrition Examination Survey and the Hispanic Health and Nutrition Examination Survey for the state of California and rates from the Central Bureau of Statistics for the Netherlands. A direct standardisation technique with the 1991 Netherlands population as the standard population was used to calculate age-adjusted incidence rates. Age was categorised into four different groups: 25-44, 45-64, 65-74 and 75+. Amputations were defined by four levels; toe, foot, leg and thigh. RESULTS: The age-adjusted incidence of diabetes-related lower extremity amputations was significantly higher in the state of California than in the Netherlands (49.9 vs. 36.1 per 10000 diabetics, P < 0.01). The relative risk, comparing the risk in the diabetic with that in the non-diabetic population, was California 23.7 vs. the Netherlands 19.7. The length of hospital stay was significantly higher in the Netherlands: 40.8 vs. 16.0 (P < 0.01). CONCLUSIONS: There are some significant differences in the outcomes associated with diabetes-related lower extremity amputations. Some of these differences may be explained by differences in access to health care.

Adult↗