Sensory substitution in the diabetic neuropathic foot.
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Biofeedback, Psychology↗
Biomedical subjects
S C Walker
Publications and source records attributed to S C Walker.
A mixture of mivacurium and rocuronium is comparable in clinical onset to succinylcholine.
STUDY OBJECTIVES: To compare the clinical onset and duration of a combination of mivacurium and rocuronium with succinylcholine, and to determine the efficacy of this mixture for rapid tracheal intubation. DESIGN: Observer-blind prospective study. SETTING: Teaching hospital. PATIENTS: 70 ASA status I and II patients having general anesthesia for elective surgery. MEASUREMENTS AND MAIN RESULTS: After induction of general anesthesia, patients randomly received succinylcholine 1.0 mg/kg, rocuronium 0.6 mg/kg, or a combination of rocuronium 0.6 mg/kg and mivacurium 0.15 mg/kg. Evoked muscular response at the adductor pollicis was measured by mechanomyography. The time from injection of muscle relaxant(s) to ablation of T1 (clinical onset) and recovery of T1 to 25% of control height (clinical duration) was recorded. Intubating conditions 45 seconds after administration of muscle relaxants were assessed. There was no significant difference in clinical onset time between succinylcholine (mean +/- SD, 47.4 +/- 6.5 seconds) and the combination of mivacurium-rocuronium (51.2 +/- 13.4 seconds). Intubating conditions with mivacurium-rocuronium were comparable to those of succinylcholine. The clinical duration of rocuronium 0.6 mg/kg (38.9 +/- 12.3 minutes) was prolonged by the addition of mivacurium (49.0 +/- 9.6 minutes). CONCLUSIONS: This combination of mivacurium and rocuronium is comparable to succinylcholine in both clinical onset time and quality of intubating conditions. When rapid onset of dense neuromuscular blockade and intermediate clinical duration is desirable, this mixture may be an acceptable alternative to succinylcholine.
Adjuvants, Anesthesia↗
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↗
Nebulized tetracaine attenuates the hemodynamic response to tracheal intubation.
BACKGROUND: Local anesthetics, principally lidocaine, are commonly administered in an attempt to blunt the hemodynamic response to tracheal intubation. There are no prior investigations evaluating the use of tetracaine in this setting. METHODS: In the present study, 30 female patients (ASA I-II) scheduled for elective surgery were randomized to receive inhaled nebulized tetracaine 0.5 mg/kg or nebulized saline. Subsequently, anesthesia was induced with thiopental 5mg/kg and succinylcholine 1.0 mg/kg. Sixty seconds later, the trachea was intubated. Vital signs were recorded at intubation and at 1-minute intervals for the next 5 minutes. RESULTS: Patients treated with tetracaine had a significantly (P < 0.05) lower mean heart rate at intubation and all subsequent times. Similarly, there were significant differences (P < 0.05) in mean arterial pressure between tetracaine and control patients at all times post-intubation except at 2 minutes. The inhalation of nebulized tetracaine produced no adverse side effects. CONCLUSION: We conclude that nebulized tetracaine significantly attenuates the hemodynamic response to tracheal intubation.
Administration, Topical↗
Incorporation of 5-bromo-2'-deoxyuridine into colorectal liver metastases and liver in patients receiving a 7-day hepatic arterial infusion.
Preclinical and clinical data suggest that the combination of hepatic arterial bromodeoxyuridine (BrdUrd), a thymidine analogue radiation sensitizer, and high-dose three-dimensional conformal radiation therapy offer a high potential for improving the local control of intrahepatic cancers. A key step in the design of a successful protocol is to determine in patients the conditions for BrdUrd administration that would be expected to produce selective radiosensitization of the tumor. Therefore, we designed a clinical trial to assess BrdUrd incorporation into the DNA of hepatic colorectal metastases and normal liver after a 7-day continuous BrdUrd infusion at a dose rate of 25 mg/kg/day (the maximal tolerated dose for a 14-day infusion) for patients undergoing laparotomy for either resection of liver metastases or hepatic arterial catheter and pump placement. Thirteen patients were entered into this study. We found that the average replacement of thymidine by BrdUrd in the tumor and normal liver were 11.6 +/- 1.2% and 1.1 +/- 0.2%, respectively. This extent of incorporation would be expected to produce a single fraction radiation enhancement of 1.5 in the tumor without detectable sensitization of the normal liver. Immunohistochemical staining for BrdUrd revealed heterogeneity of incorporation with a range of approximately 60-80% of the cells labeled in different regions of the specimens. These findings suggest that hepatic arterial BrdUrd given at this dose and schedule has a high likelihood of producing clinically significant radiosensitization for patients with hepatic metastases from colorectal cancer. Furthermore, the demonstrated selectivity of tumor perfusion that can be obtained with hepatic arterial infusion combined with the high proliferative rate of colorectal metastases (versus normal liver) suggests that these patients may be good candidates for tumor-directed gene transfer therapy by using regionally delivered retroviral vectors.
Adult↗
Infected puncture wounds in diabetic and nondiabetic adults.
OBJECTIVE: To evaluate bone and soft tissue pathogens resulting from puncture wounds among diabetic and nondiabetic adults. RESEARCH DESIGN AND METHODS: We used a case-control design to compare bacterial pathogens in diabetic and nondiabetic subjects with foot infections precipitated by puncture injuries. We used ICD-9-CM code E920.8 to identify 77 diabetic and 69 nondiabetic patients admitted to the hospital for infected puncture wounds. We identified surgical bone and soft tissue cultures and number and type of organisms per culture. RESULTS: Nondiabetic subjects had significantly less osteomyelitis (13 vs. 35%, P < 0.01) than diabetic subjects and were infected by fewer organisms. Pseudomonas was the most common cause of osteomyelitis among nondiabetic subjects (P < 0.001). Staphylococcus aureus was more common in diabetic bone (P < 0.001) and soft tissue (P < 0.001) infections. Polymicrobial osteomyelitis was more common in diabetic subjects. There was a longer delay until diabetic subjects received medical treatment compared with nondiabetic subjects (8.7 vs. 5.3 days, P < 0.002). Diabetic subjects were more likely to have neuropathy (P < 0.001) and to have sustained their injuries while barefoot (P < 0.006). CONCLUSIONS: Puncture wounds in diabetic subjects were commonly associated with polymicrobial infections. Pseudomonas was the most common cause of nondiabetic osteomyelitis. These results have implications for differential emergent and chronic treatment of puncture wounds in diabetic versus nondiabetic subjects.
Adult↗
Caring through activities.
Home care patients require help with health-related activities, but they also want to engage in activities that they like to do, such as reminiscing or listening to music. Home care professionals can improve the lives of their patients by integrating some special activities into daily caregiving activities and teaching these activities to informal caregivers.
Activities of Daily Living↗
Total-contact casting, sandals, and insoles. Construction and applications in a total foot-care program.
It must be stressed that these tools do not exist in a vacuum and that no single tool is particularly useful unless it is a part of a comprehensive, lifelong foot-care program. A partnership between the health care provider and the patient is essential in making any of these techniques useful. On the positive side, a program incorporating these techniques can be very successful with even the most difficult population. The very successful Parkland Memorial Hospital program provides care for a county hospital population that is often difficult in terms of compliance. Without question, the reasons for incorporating such a program in a public facility are sound. Amputations are avoided; and patients remain or become more functional, thus decreasing hospital cost and patient morbidity and mortality and increasing the patient's potential for contributing to society. Similarly, in private facilities, once the program is established, costs need not run high and considerable amounts can be saved by helping heal and/or prevent the horrendous sequelae of diabetic neuropathies.
Biomechanical Phenomena↗
Characterization of IHNV isolates associated with neurotropism.
Rainbow trout with a 'neurotropic' form of infectious hematopoietic necrosis (IHN) exhibited behavioral abnormalities and had high virus concentrations localized in brain tissue. Fish with 'hematopoietic' IHN exhibited typical disease signs with the highest concentrations of virus detected in kidney-spleen tissue. Infectious hematopoietic necrosis virus (IHNV) isolates obtained from brain or kidney-spleen tissue were tested for serological relatedness and virulence and pathogenicity differences in 2 sizes of rainbow trout. No major differences were detected by indirect fluorescence tests. Serum neutralization profiles showed 2 predominant patterns that differed dependent upon tissue of origin. However, virulence and pathogenicity differences were not evident.
Animals↗
Clinical pharmacology of hepatic arterial infusions of 5-bromo-2'-deoxyuridine.
This investigation was undertaken to determine the pharmacokinetic parameters relevant to hepatic arterial (HA) infusion of 5-bromo-2'-deoxyuridine (BrdUrd) and to ascertain the maximum tolerated dose and related toxicities of BrdUrd administered as a 14-day HA infusion. In the pharmacokinetic study, 6 patients received a 2-h i.v. infusion (to steady-state) of BrdUrd at each of 5 escalating dose rates (10 to 160 mg/kg/day) with simultaneous blood sampling for BrdUrd levels from HA and hepatic venous catheters. Dose dependent HA and hepatic venous drug levels, total body clearance, hepatic extraction, and estimated regional exposure advantage were determined. The total body clearance of BrdUrd was high and dose rate dependent, falling from 3340 ml/min with a 10-mg/kg/day infusion to 2180 ml/min at a 160-mg/kg/day dose rate. Hepatic extraction was high and dose rate dependent as well, declining from 80% extraction at 10 mg/kg/day to 68% at 160 mg/kg/day. The calculated estimate for the exposure advantage achievable with HA as compared with i.v. infusion reflects the dose rate dependence of total body clearance and hepatic extraction and decreases from a 70-fold advantage at 10 mg/kg/day to a 30-fold advantage at 160 mg/kg/day. In the Phase I study aimed at determining the maximum tolerated dose, successive groups of 3 patients were administered continuous HA infusions for 14 days at escalated BrdUrd dose rates (5, 10, 15, 25, and 35 mg/kg/day) in order to ascertain dose-limiting toxicity. The maximum tolerated dose of BrdUrd for a 14-day continuous HA infusion was found to be 35 mg/kg/day with reversible thrombocytopenia as the sole dose-limiting toxicity. Skin and other toxicities were infrequent, minor, reversible, and non-dose dependent. No hepatic toxicity was detected despite direct drug infusion into the liver. The high total body clearance and hepatic extraction of BrdUrd substantiate its administration via the hepatic artery as a means to achieve higher exposure with intrahepatic tumors than can be obtained by systemic administration. Despite higher hepatic exposures, no hepatic toxicity was noted, and readily reversible systemic toxicity (thrombocytopenia) was dose limiting for the 14-day continuous HA infusion. Thus, HA infusion of the potent radiosensitizer BrdUrd is both pharmacokinetically rational and well tolerated.
Adult↗
Hepatic radioembolization with yttrium-90 containing glass microspheres: preliminary results and clinical follow-up.
UNLABELLED: The treatment of hepatic tumors remains unsatisfactory. These lesions receive most of their blood supply from the hepatic artery, therefore the hepatic artery administration of beta-emitting particulate radiopharmaceuticals is an attractive approach to deliver therapeutic irradiation to the liver and differentially to tumors within the liver. METHODS: A Phase I dose escalation study of the hepatic tolerance to radiation delivered by 90Y containing glass microspheres was carried out in 24 patients with hepatic malignancy. Doses of 90Y microspheres to achieve an estimated whole-liver nominal absorbed radiation dose of 5000 cGy (two patients), 7500 cGy (six patients), 10,000 cGy (seven patients), 12,500 cGy (six patients), and 15,000 cGy (three patients) were administered via the hepatic artery. The administered nominal absorbed radiation dose (NARD) was estimated based on liver volume determined from CT scans and the assumption of uniform distribution of microspheres throughout the liver. RESULTS: No hematologic, hepatic or pulmonary toxicity was encountered in the dose range examined during a mean follow-up period of up to 53 mo. Reversible gastritis or duodenitis was encountered in four patients without imaging or biopsy evidence for extrahepatic deposition of microspheres. Response data, based on CT scans obtained 16 wk after treatment, showed progressive disease in eight patients, stable disease in seven patients, minimal response in four patients and partial response in five patients. Subsequent follow-up revealed three long-term survivors at 204, 216 and 228 wk. CONCLUSIONS: These preliminary data demonstrate that in the examined dose range, radiation may be safely delivered to liver tumors by means of 90Y glass microspheres with encouraging response data.
Adult↗
Hepatic parenchymal changes after intraarterial Y-90 therapy: CT findings.
The serial contrast material-enhanced computed tomographic scans of 23 patients treated with intraarterial yttrium-90 microspheres as therapy for hepatic metastatic disease were reviewed for evidence of parenchymal changes in the liver in areas not involved with tumor. Irregular low-attenuation geographic areas that developed in the hepatic parenchyma after therapy were graded as mild, moderate, or severe and were evident in 12 of 23 patients. In nine cases of mild to moderate changes in the hepatic parenchyma, the abnormality was either focal or asymmetric. In all three patients receiving the highest dose (15,000 cGy), severe diffuse parenchymal changes were seen in all hepatic segments. In the remaining 11 patients, no parenchymal changes were seen. The most pronounced changes were seen at 8 weeks after therapy and were partially or completely reversible at 16-24 weeks. All patients had minimal or no change in liver function and no clinical sequelae attributable to liver injury.
Adult↗
Evidence for a common genetic pathway controlling susceptibility to mouse skin tumor promotion by diverse classes of promoting agents.
The present study has compared different mouse stocks and strains with known sensitivity to phorbol ester skin tumor promotion for their sensitivities to skin tumor promotion by a prototypic organic peroxide (benzoyl peroxide, BzPo) and anthrone (chrysarobin, Chr) tumor promoter. Following initiation with either 7,12-dimethylbenz(a)anthracene and/or N-methyl-N'-nitro-N-nitrosoguanidine, groups of mice were promoted with several different doses of each promoting agent. Among mice selectively bred for sensitivity to phorbol ester promotion, the order of sensitivity to BzPo was inbred SENCAR (SSIn) greater than SENCAR greater than CD-1. With Chr as the promoter, the order of sensitivity was SENCAR greater than SSIn greater than CD-1. Concurrent tumor promotion experiments examined the responsiveness of two common inbred mouse strains, DBA/2 and C57BL/6. The phorbol ester-responsive mouse strain, DBA/2, was more sensitive to skin tumor promotion by Chr than was C57BL/6 at all doses tested but was clearly less sensitive than both SENCAR and SSIn mice. Finally, DBA/2 and C57BL/6 mice were similar in their responsiveness to BzPo promotion, but again both of these inbred strains were significantly less sensitive than were SSIn and SENCAR mice to this organic peroxide type of skin tumor promoter. Histological evaluations comparing SENCAR and C57BL/6 mice revealed that a major difference between these strains in response to multiple Chr and BzPo treatments was in the inflammatory response (measured by edema formation). Unlike 12-O-tetradecanoylphorbol-13-acetate, Chr and BzPo did not induce dramatic differences in the epidermal hyperplasia (as measured by epidermal thickness) in these two mouse lines. The results presented in this paper suggest that there is a common pathway controlling susceptibility to skin tumor promotion by 12-O-tetradecanoylphorbol-13-acetate, BzPo, and chrysarobin. These results are discussed in terms of a possible genetic model(s) for skin tumor promotion in mice.
9,10-Dimethyl-1,2-benzanthracene↗
Recurrence of neuropathic ulceration following healing in a total contact cast.
Total contact casting has been clearly shown to be an effective technique in the healing of diabetic neuropathic foot ulcerations. The purpose of this study was twofold: (1) to determine the rate of ulcer recurrence in a large population of patients whose ulcerations had healed in a total contact cast, and (2) to determine the reason for which ulcerations had recurred. A random sample of 102 patients was taken from a much larger population, all of whom had healed in a total contact cast. There were 54 men and 48 women, all of whom were diabetics, averaging 50.5 years of age. These patients had an average wound size of 2.6cm by 1.9cm prior to casting and an average healing time of 33.9 days. At the time the sample was drawn, it had been an average of 25 months since casting for this group. Twenty (19.6%) of the 102 patients had ulcer recurrences since initially healing in a cast. Causes of ulcer recurrence were failure to comply with follow-up foot-wear/foot-care protocol (n = 8), biomechanical faults (n = 5), osteophyte or bone fragment (n = 4), osteomyelitis (n = 5), and Charcot joint (n = 4). Some patients had multiple etiologies.
Adult↗
Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location.
This study investigated healing rates of chronic diabetic neuropathic foot ulcerations located on the plantar surface of the forefoot (n = 30) versus those located on other parts of the foot (n = 25). Each type of ulceration was treated with total contact casting. Ulcerations in the first group were located on the metatarsal heads and toes, while ulcerations in the second group were located on the dorsum of the foot, heel, plantar arch, ankle, medial aspect of foot, and toe or transmetatarsal amputation sites. Successfully healed diabetic neuropathic foot ulcerations treated with total contact casting were rated according to patient age, ethnic origin, sex, patient weight, ulcer size, ulcer location, duration of ulcer prior to casting, and ulcer grade. Analysis of variance and posthoc analyses demonstrated that (1) total contact casting was a highly effective method of treatment regardless of ulcer location (forefoot ulcer healing time mean = 30.6 days; nonforefoot ulcer healing time mean = 42.1 days) and (2) forefoot ulcerations healed significantly faster than ulcerations located on other parts of the foot. Complex correlational relationships were explored in this study, and multiple regression equations were developed for each location grouping.
Casts, Surgical↗
New bone formation at amputation sites in electrically burn-injured patients.
Sixty-one amputation sites in 43 electrically injured men were examined for significant new bone formation. Twenty-eight amputations were classified as long bone (6 above knee, 4 below knee, 4 above elbow, 14 below elbow); 28 small bone (9 hand or finger and 19 foot or toe); and 5 disarticulations. Significant new bone formation occurred at the amputation site in 23 (82%) of the 28 long bone cases, but none occurred in the small bone or disarticulation cases. This difference was significant at the 0.0001 level (chi square = 40.53, 2 df). Fourteen (78%) of upper and nine (90%) of lower extremity sites had significant new bone formation. The average time from amputation to diagnosis of new bone was 38 weeks, range from 5 to 110 weeks. Eight of these 23 patients required surgical revision of the stump and/or revision or reconstruction of their prosthesis. Clearly, the ability to predict new bone formation in electrical burn amputees has important clinical and economic applications.
Adolescent↗
Return to work following hand burns.
Time to return to work following hand burns was studied in 70 patients in relation to several variables: 1. total body surface area (TBSA) burned; 2. hand burned; 3. grafting; 4. patient age; 5. occupational category. Return to work data were also compared by meta-analysis to data in prior reports on return to work in nonburn hand injuries. Patients were evaluated during their hospital stay on all independent variables, and at 8 months following discharge as to the date of return to work. Of the 70 patients selected for the study, 52 (74%) had returned to work at the 8-month assessment. The best predictor of time to return to work was TBSA burned, followed by "grafting" and "hand burned." No significant differences or predictors were found for patient age, occupational category, or between nonburn hand trauma patients in prior reports. Conclusions are drawn concerning the usefulness of these results in terms of case management and economic impact in hand-burn injuries.
Adolescent↗
The utility of SPECT for 99mTc-MAA hepatic arterial perfusion scintigraphy.
The utility of single-photon emission computed tomography (SPECT) for hepatic arterial perfusion scintigraphy was evaluated in 86 patients (91 studies). Previous reports have shown planar studies to be valuable for the clinical management of patients receiving intraarterial chemotherapy and more reliable than angiography in determining blood flow distribution. However, overlying areas of intra- and extrahepatic perfusion can sometimes make interpretation of these two-dimensional images difficult. Since SPECT has the potential to depict the three-dimensional distribution of perfusion, separate out overlying activity, and improve contrast resolution, SPECT Tc-MAA perfusion studies were compared to planar studies. Planar and SPECT studies both demonstrated the extent of hepatic and tumor perfusion, although occasionally SPECT added additional information. SPECT was most useful in confirming or excluding extrahepatic perfusion that was suspected but not definite on planar studies. Extrahepatic abdominal perfusion was found to be present in 11 (12%) of 91 studies. All patients with confirmed extrahepatic perfusion who received intraarterial chemotherapy had symptoms of drug toxicity compared to only a 23% incidence in those without evidence of extrahepatic perfusion (p less than 0.001). This report demonstrates that SPECT can improve the qualitative interpretation of hepatic arterial perfusion studies.
Adult↗