Coccidioidomycosis in selected immunosuppressed hosts.

After contracting coccidioidomycosis, persons with impaired cellular immunity are more likely than healthy persons to have severe infection, disseminated infection, and higher mortality rates. In this brief review, we summarize the clinical manifestations, diagnosis, treatment, and prevention of coccidioidomycosis in persons infected with human immunodeficiency virus (HIV), recipients of solid organ or hematopoietic stem cell transplants, and recipients of biologic response modifiers. Among individuals infected with HIV, a diagnosis of acquired immunodeficiency syndrome (AIDS) and a CD4 T-lymphocyte count <250 cells/μl were associated with more severe coccidioidomycosis, whereas less severe disease occurred among those with undetectable HIV-RNA and higher CD4 T-lymphocyte counts, indicating that controlled HIV viremia and improved cellular immune status are important in limiting disease.

Student pharmacist experiences as inpatient psychiatry medication education group leaders during an early immersion program.

Background And Purpose: While research suggests that pharmacists generally hold positive attitudes toward consumers of psychiatric medications, they often feel less comfortable talking about these medications and providing services for patients with mental illness. The purpose of this program was to train second and third year student pharmacists as psychiatry medication education groups leaders and to examine resulting student self-efficacy and mental health stigma.

Educational Activity And Setting: In partnership with the University of North Carolina (UNC) Eshelman School of Pharmacy, the inpatient psychiatry service at UNC Medical Center expanded weekly medication education groups with the help of trained student pharmacists.

Ewing sarcoma in a diabetic male with history of foot ulceration.

Ewing sarcoma is a rare diagnosis, with as few as 225 new cases diagnosed in North America annually, and only 3% occurring in the foot. They generally present in the second decade of life and are very infrequently found in patients older than 40 years. The diagnosis of Ewing sarcoma can be difficult, especially in older patients with diabetes and a history of ulceration, because it can have an appearance on radiography similar to that of osteomyelitis.

Do US veterans wear appropriately sized shoes?: the Veterans Affairs shoe size selection study.

Poorly fitting footwear has frequently been cited as an etiologic factor in the pathway to diabetic foot ulceration. However, we are unaware of any reports in the medical literature specifically measuring shoe size versus foot size in this high-risk population. We assessed the prevalence of poorly fitting footwear in individuals with and without diabetic foot ulceration.

Gamma-irradiated human skin allograft: a potential treatment modality for lower extremity ulcers.

Gamma-irradiated human skin allograft consists of epidermis and dermis. Unlike bioengineered tissues which require cold storage and timely use once received from the manufacturer, gamma-irradiated human skin allograft can be stored for as long as 24 months at room temperature. This modality is applied in a fashion similar to that of bioengineered skin grafts.

Outcomes of allogenic acellular matrix therapy in treatment of diabetic foot wounds: an initial experience.

The purpose of this study was to evaluate outcomes of persons with UT grade 2A neuropathic diabetic foot wounds treated with an acellular matrix. Data were abstracted for 17 consecutive patients with diabetes--76.5% males, aged 61.

Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration.

This study compares the potential benefit of fifth metatarsal head resection versus standard conservative treatment of plantar ulcerations in people with diabetes mellitus. Using a retrospective cohort model, we abstracted data from 40 patients (22 cases and 18 controls) treated for uninfected, nonischemic diabetic foot wounds beneath the fifth metatarsal head. There were no significant differences in sex, age, duration of diabetes mellitus, or degree of glucose control between cases and controls.

Maggot therapy in "lower-extremity hospice" wound care: fewer amputations and more antibiotic-free days.

We sought to assess, in a case-control model, the potential efficacy of maggot debridement therapy in 60 nonambulatory patients (mean +/- SD age, 72.2 +/- 6.8 years) with neuroischemic diabetic foot wounds (University of Texas grade C or D wounds below the malleoli) and peripheral vascular disease.

Decreasing foot pressures while implementing topical negative pressure (vacuum-assisted closure) therapy.

Over the past generation, there have been a number of significant advances in wound healing in general. Unfortunately, much of this has not translated into increased success in healing wounds on the sole of the foot. We believe that much of this therapeutic disconnect has to do with an inadequate merging of pressure off-loading technologies and active wound-healing technologies.

Cooling the foot to prevent diabetic foot wounds: a proof-of-concept trial.

The etiology of neuropathic diabetic foot wounds can be summarized by the following formula: pressure x cycles of repetitive stress = ulceration. The final pathway to ulceration consists of an inflammatory response, leading to tissue breakdown. Mitigation of this response might reduce the risk of ulceration.

Osseous metaplasia in plantar fibromatosis: a case report.

A case report about extensive osseous metaplasia of a plantar fibromatosis is presented. The authors are unaware of previous reports in the literature describing osseous metaplasia within plantar fibromatosis in this manner. This case shows that plantar fibromatosis may undergo osseous metaplasia in a fashion similar to fibromatous lesions elsewhere.

Treatment of Freiberg's infraction with the titanium hemi-implant.

Freiberg's infraction is a relatively rare disease for which there is currently no consensus regarding surgical management. We present a case study describing a surgical procedure that uses a novel metatarsophalangeal hemi-implant. This procedure does not alter the metatarsal parabola, and it allows for other surgical procedures to be performed in the future.

Plantar pressure changes using a novel negative pressure wound therapy technique.

This study evaluated changes in pressure imparted to diabetic foot wounds using a novel negative pressure bridging technique coupled with a robust removable cast walker. Ten patients had plantar pressures assessed with and without a bridged negative pressure dressing on the foot. Off-loading was accomplished with a pressure-relief walker.

Guidelines regarding negative wound therapy (NPWT) in the diabetic foot.

The purpose of these guidelines is to the summarize consensus of a multidisciplinary expert advisory panel convened to determine appropriate use of negative pressure wound therapy (NPWT), also known as Vacuum-Assisted Closure or V.A.C.

Use of a maggot motility index to evaluate survival of therapeutic larvae.

Maggot debridement therapy is rapidly increasing in popularity at major diabetic foot and wound care centers worldwide. However, we are unaware of specific guidelines on the short-term storage of larvae. We sought to evaluate differences in maggot motility over time in larvae refrigerated versus those stored at room temperature.

Advances in the treatment of diabetic foot infections.

Lower extremity infections are frequent causes of substantial morbidity and mortality in the diabetic population, and these infections consume a large portion of resources expended on diabetic complications. Gram-positive cocci, particularly Staphylococcus aureus, are the most important pathogens in diabetic foot infections. These organisms are predominant both in mild infections (which are often monomicrobial), as well as in more severe and chronic infected wounds that more often have a polymicrobial cause.

Computerized activity monitoring preoperatively and postoperatively.

One of the central goals of reconstructive foot and ankle surgery is restoration of or improvement in the quality of physical activity. Until recently, objective assessment of how well this goal has been attained has been elusive at best. Recent advances in activity monitoring have advanced sufficiently to help many clinicians and researchers objectively measure and potentially modulate activity.

Combating opportunistic infections: coccidioidomycosis.

Coccidioidomycosis is a growing problem in the southwestern US. Although most cases of symptomatic coccidioidomycosis occur in healthy individuals, individuals with depressed cellular immunity are at particular risk. These include individuals with HIV infection, those who have undergone allogeneic transplantation and others on immunosuppressive medications.

Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes.

Objective: To evaluate the safety and efficacy of first metatarsophalangeal joint arthroplasty compared with standard, nonsurgical management of wounds at the plantar hallux interphalangeal joint in patients with diabetes.

Research Design And Methods: We evaluated 41 patients with ulcers classified as University of Texas Grade 1A or 2A at the plantar aspect of the hallux interphalangeal joint using a case-control model [correction]. Case subjects were patients treated with resectional arthroplasty and control subjects received standard nonsurgical care.

Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen.

Objective: To evaluate the activity of patients with diabetic foot ulcerations and their adherence to their pressure off-loading device.

Research Design And Methods: We enrolled 20 subjects treated for neuropathic diabetic foot wounds corresponding to University of Texas grade 1 stage A. All were off-loaded using a removable cast walker (RCW).

In vitro modulation of cytokine production by lymphocytes in human coccidioidomycosis.

The modulation of the cytokine response to coccidioidal antigen by lymphocytes from donors with coccidioidomycosis was examined. In initial experiments, samples from 13 healthy immune donors and seven donors with active coccidioidomycosis anergic to the coccidioidal antigen T27K were assessed for CD3 lymphocyte expression of intracellular IFN-gamma using whole blood analysis. Addition of 10 ng/ml of recombinant IL-12 significantly increased response to T27K among immune and anergic subjects (p<0.

Classifying diabetic foot surgery: toward a rational definition.

The purpose of this manuscript was to describe a classification of diabetic foot surgery performed in the absence of critical limb ischaemia. The basis of this classification is centered on three fundamental variables which are present in the assessment of risk and indication: 1) the presence or absence of neuropathy (loss of protective sensation); 2) the presence or absence of an open wound; 3) the presence or absence of acute, limb-threatening infection. The conceptual framework for this classification is to define distinct classes of surgery in an order of theoretically increasing risk for high-level amputation.

Healing the diabetic wound and keeping it healed: modalities for the early 21st century.

The incidence of lower extremity wounds, infections, and amputations continues to increase worldwide. Fortunately, the past decade has seen a surge of activity in research into new modalities in wound healing and, even more recently, prevention. This article discusses the basic physiology of wound healing, with particular attention being paid to current and potential wound healing modalities.