Lawrence Lavery - Academia.edu (original) (raw)

Papers by Lawrence Lavery

Research paper thumbnail of 99-OR: Outcomes of Patients With and Without Severe Renal Impairment Admitted with Moderate and Severe Diabetic Foot Infections

Diabetes

Renal impairment considerations have largely been absent diabetic foot literature, despite eviden... more Renal impairment considerations have largely been absent diabetic foot literature, despite evidence that people with severe renal impairment are at elevated risk complications following diabetic foot infections. We evaluated clinical outcomes in patients who were admitted to hospital with diabetic foot infections with severe renal impairment compared with patients without a disability. This was a retrospective study of patients with diabetes mellitus who had been hospitalized at a level 1 trauma center with moderate and severe diabetic foot infections. Patients were grouped according to their Glomerular Filtration Rate (GFR). Patients with severe renal impairment were defined as having a GFR < 30mL/min. Primary outcomes were mortality, wound healing and reinfection rates. Primary and secondary outcomes were compared using multivariable regression RStudio. A total of 307 patients with diabetic foot infections (62 patients with SRI and 245 patients without SRI) were included in the...

Research paper thumbnail of 负压创伤疗法治疗糖尿病足损伤是否安全有效?

Research paper thumbnail of Infected Puncture Wounds of the Hand

Southern Medical Journal, 1992

Research paper thumbnail of Diyabetik alt ekstremite Infeksiyonları: Fiziksel, psikolojik ve toplumsal faktörlerin etkileri

Amaç: Literatür yetersiz olmakla birlikte, düşük sosyal gruba mensup hastaların diyabetik komplik... more Amaç: Literatür yetersiz olmakla birlikte, düşük sosyal gruba mensup hastaların diyabetik komplikasyonlara daha açık oldukları ortak bir inanıştır. Bu çalışmanın amacı ciddi ayak infeksiyonlarına ve ardından gelen amputasyonlara yol açabilen lokal, sistemik ve psikolojik ...

Research paper thumbnail of Incidence of Complications and Risk Factors for Nonunion After Ankle Fracture in Diabetes Mellitus

Journal of the American Podiatric Medical Association

Background: To evaluate complications and risk factors for nonunion in patients with diabetes aft... more Background: To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture. Methods: We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcot’s arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcot’s arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and χ2 tests to compare dichotomous variables, with α = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable. Results: Complications were common: nonunion (24.5%), Charcot’s arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus ...

Research paper thumbnail of Elective Surgery in the Diabetic Foot to Heal Foot Ulcerations and Prevent Re-ulceration

Diabetic Foot Reconstruction, 2022

Research paper thumbnail of The Effect of Implanted Functional Electrical Stimulation on Gait Performance in Stroke Survivors: A Systematic Review

Sensors, 2021

The emerging literature suggests that implantable functional electrical stimulation may improve g... more The emerging literature suggests that implantable functional electrical stimulation may improve gait performance in stroke survivors. However, there is no review providing the possible therapeutic effects of implanted functional electrical stimulation on gait performance in stroke survivors. We performed a web-based, systematic paper search using PubMed, the Cochrane Library, and EMBASE. We limited the search results to human subjects and papers published in peer-reviewed journals in English. We did not restrict demographic or clinical characteristics. We included 10 papers in the current systematic review. Across all included studies, we found preliminary evidence of the potential therapeutic effects of functional electrical stimulation on walking endurance, walking speed, ankle mobility, and push-off force in stroke survivors. However, due to the heterogeneity between the included studies, small sample size, and lack of randomized controlled trials, more studies are critically nee...

Research paper thumbnail of A Comparison of Pathogens in Skin and Soft-Tissue Infections and Pedal Osteomyelitis in Puncture Wound Injuries Affecting the Foot

Journal of the American Podiatric Medical Association, 2020

Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal os... more Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal osteomyelitis (OM) in patients with and without diabetes with puncture wounds to the foot. Methods: We evaluated 113 consecutive patients between June 1, 2011, and March 31, 2019, with foot infection (SSTIs and OM) from a puncture injury sustained to the foot. Eighty-three patients had diabetes and 30 did not. We evaluated the bacterial pathogens in patients with SSTIs and pedal OM. Results: Polymicrobial infections were more common in patients with diabetes mellitus (83.1% versus 53.3%; P = .001). The most common pathogen for SSTIs and OM in patients with diabetes was Staphylococcus aureus (SSTIs, 50.7%; OM, 32.3%), whereas in patients without diabetes it was Pseudomonas (25%) for SSTIs. Anaerobes (9.4%) and fungal infection (3.1%) were uncommon. Pseudomonas aeruginosa was identified in only 5.8% of people with diabetes. Conclusions: The most common bacterial pathogen in both SSTIs and pe...

Research paper thumbnail of Amputations and foot-related hospitalisations disproportionately affect dialysis patients

International Wound Journal, 2013

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We ... more Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD-9 250.X), ulceration (ICD-9 707·10, 707·14 and 707·15) and dialysis (CPT 90935-90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow-up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person-years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001); however, there were more foot-related hospital admissions in the dialysis group (32·9% versus 14·0%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001) during the 30-month evaluation period. The incidence of ulcers, amputations and all-cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot-related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high-risk group.

Research paper thumbnail of Fracture Healing and Biomarker Expression in a Diabetic Zucker Rat Model

Journal of the American Podiatric Medical Association, 2014

Background Persons with diabetes have a higher incidence of fractures compared with persons witho... more Background Persons with diabetes have a higher incidence of fractures compared with persons without diabetes. However, there is little published information concerning the deleterious effect of late-stage diabetes on fracture healing. There are no studies using animal models that evaluate the effect of advanced diabetes on fracture healing. The purpose of our study was to evaluate cytokine expression, specifically macrophage inflammatory protein 1 (MIP-1) and vascular endothelial growth factor, in fracture healing in a type 2 diabetes rat model. Methods We evaluated biomarker expression after femur fracture using a rat model. The two groups consisted of 24 Zucker diabetic rats (study group) and 12 Zucker lean rats (control group). An independent reviewer was used to assess delayed union. We evaluated serum samples 2, 4, 7, and 14 days after surgery for MIP-1, vascular endothelial growth factor, leptin, and other cytokine levels. Results At 3 weeks, Kaplan-Meier estimates showed that...

Research paper thumbnail of Specific guidelines for treatment of diabetic foot osteomyelitis

Diabetes/Metabolism Research and Reviews, 2008

Research paper thumbnail of Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae

The American Journal of Emergency Medicine, 2009

/VS); 30-day mortality was a secondary outcome. Results.dThe study included 1062 patients with CA... more /VS); 30-day mortality was a secondary outcome. Results.dThe study included 1062 patients with CAP potentially eligible for ICU admission. Each of the 9 minor criteria was associated with increased risk of MV/VS and 30-day mortality in univariate analysis. Two hundred seven patients had $3 minor criteria (19.5%). The IDSA/ ATS 2007 criteria had an area under the receiver operating characteristic curve of 0.85 (0.82e0.88) for prediction of MV/VS, 0.85 (0.82e0.88) for prediction of ICU admission, and 0.78 (0.74e0.82) for prediction of 30-day mortality. The IDSA/ATS 2007 criteria were at least equivalent to more established scoring systems for prediction of MV/VS and ICU admission and equivalent to alternative scoring systems for predicting 30-day mortality in this patient population. Conclusions.dIn a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality. : In their 2007 jointly issued guidelines for management of community-acquired pneumonia (CAP), the American Thoracic Society and Infectious Diseases

Research paper thumbnail of Interventions in the management of infection in the foot in diabetes: a systematic review

Diabetes/metabolism research and reviews, 2016

The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabe... more The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomis...

Research paper thumbnail of Reaching closure with skin stretching. Applications in the diabetic foot

Clinics in podiatric medicine and surgery, 1998

At the present time, there are no evidence-based protocols outlining the use of the Sure-Closure ... more At the present time, there are no evidence-based protocols outlining the use of the Sure-Closure Skin Stretching System on diabetic, neuropathic wounds. Ideally, surgical correction of the precipitating deformity and appropriate shoe gear accommodation should be performed con-comitantly with skin stretching (as indicated) to achieve an optimal long-term result. For several years, we have used the Sure-Closure device as an adjunctive treatment for diabetic-foot wound closure, and believe that, ultimately, this device more likely will be used in a clinical setting. In this manner, a patient with an open wound may, under aseptic conditions, be sequestered for a period of 1 to 2 hours during a clinical visit to allow for skin stretching. This procedure may be carried out two or three times weekly until closure is achieved. Mechanically assisted delayed primary closure is a relatively new category of wound closure; however, this device is by no means a panacea. Appropriate patient select...

Research paper thumbnail of Evidence-based options for off-loading diabetic wounds

Clinics in podiatric medicine and surgery, 1998

Whereas the treatment of the diabetic wound has received a great deal of attention in the medical... more Whereas the treatment of the diabetic wound has received a great deal of attention in the medical literature, the majority of the focus of recent research has been centered on dressings and advanced wound healing modalities. All these methods, however, are less than effective if the central tenet of treating the diabetic wound, namely reducing plantar pressure through off-loading, is not addressed primarily. This article examines the most commonly used off-loading methods in the medical literature and discusses the attributes and disadvantages of many of these devices.

Research paper thumbnail of Guidelines regarding negative wound therapy (NPWT) in the diabetic foot

Ostomy/wound management, 2004

The purpose of these guidelines is to the summarize consensus of a multidisciplinary expert advis... more 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. Therapy, in the treatment of diabetic foot wounds. The Tucson Expert Consensus Conference (TECC) on V.A.C. Therapy was convened in an effort to guide the direction for future research either to confirm or refute current consensus while providing practical guidance to the clinician currently treating diabetic foot wounds. The consensus committee discussed and commented on the following ten key questions regarding NPWT: 1) How long should NPWT be used in the treatment of a diabetic foot wound? 2) Should NPWT be applied to a wound that has not been debrided? 3) How should the patient using NPWT be evaluated on an outpatient basis? 4) When should NPWT be applied following lower-extremity bypass? 5) When should NPWT be applied after incision and drainage o...

Research paper thumbnail of A Retrospective Study of Patients With Diabetes Mellitus After Partial Foot Amputation and Hyperbaric Oxygen Treatment

The Journal of Foot and Ankle Surgery, 2005

A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxyge... more A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxygen (HBO) therapy after partial foot amputation between 1990 and 2000. Preoperative transcutaneous partial pressure of oxygen (tcPo 2) levels, the number of hyperbaric treatments, time to final outcome, use of revascularization procedures, and postsurgical outcome were extracted from the charts. Seventy percent (n ϭ 28) had a successful outcome, defined as complete healing and absence of ulceration at the amputation site, and lack of further surgical procedures to heal the amputation site; whereas 30% (n ϭ 12) had a failed outcome, defined as lack of healing or the presence of an ulcer at the site of amputation or the need for further surgery to heal the amputation site. The level of amputation, use of revascularization procedures, time to final outcome, and number of hyperbaric treatments were not significantly different (P Ͼ .05) between the 2 postsurgical outcome groups. The mean preoperative tcPo 2 levels were greater (P Ͻ .01) in the successful (24 Ϯ mm Hg) than in the failed (11 Ϯ mm Hg) outcome groups. All patients with a tcPo 2 level Ͼ 29 mm Hg had a successful outcome. Patients with a successful postsurgical outcome had a mean of 20 HBO treatments and took 44 days to final outcome, while those with a failed postsurgical outcome had 16 HBO treatments and took 216 days to final outcome.

Research paper thumbnail of Risk factors for developing osteomyelitis in patients with diabetic foot wounds

Diabetes Research and Clinical Practice, 2009

Aims: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain l... more Aims: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain largely undefined. In a prospectively followed cohort we assessed risk factors for developing osteomyelitis. Methods: We enrolled consecutive persons with diabetes who presented to a managed-care diabetes disease management program. The patients underwent standardized assessments. We monitored for all foot complications, defined infections by criteria consistent with International Working Group guidelines, and defined osteomyelitis as a positive culture from a bone specimen. Results: 1666 persons were enrolled, 50% male, mean age 69 years. Over a mean of 27.2 months of follow-up, 151 patients developed foot infections, 30 (19.9%) of which involved bone. Independent risk factors for osteomyelitis were: wounds that extended to bone or joint (relative risk [RR] = 23.1), previous history of a wound prior to enrollment (RR=2.2), and recurrent or multiple wounds during the study period (RR = 1.9). Conclusions: In this study population, managed in a specialized diabetic foot care center, the results suggest that independent risk factors for developing osteomyelitis are deep, recurrent and multiple wounds. These results may help clinicians target their efforts at diagnosing foot osteomyelitis to the highest risk patients.

Research paper thumbnail of Risk Factors for Recurrent Diabetic Foot Ulcers: Site matters

Research paper thumbnail of Risk Factors for Foot Infections in Individuals With Diabetes

Diabetes Care, 2006

OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with d... more OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with diabetes. RESEARCH DESIGN AND METHODS—We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care–based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem. RESULTS—During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture–proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3–102.2; P < 0.001) and the risk of amputation was 154.5 tim...

Research paper thumbnail of 99-OR: Outcomes of Patients With and Without Severe Renal Impairment Admitted with Moderate and Severe Diabetic Foot Infections

Diabetes

Renal impairment considerations have largely been absent diabetic foot literature, despite eviden... more Renal impairment considerations have largely been absent diabetic foot literature, despite evidence that people with severe renal impairment are at elevated risk complications following diabetic foot infections. We evaluated clinical outcomes in patients who were admitted to hospital with diabetic foot infections with severe renal impairment compared with patients without a disability. This was a retrospective study of patients with diabetes mellitus who had been hospitalized at a level 1 trauma center with moderate and severe diabetic foot infections. Patients were grouped according to their Glomerular Filtration Rate (GFR). Patients with severe renal impairment were defined as having a GFR < 30mL/min. Primary outcomes were mortality, wound healing and reinfection rates. Primary and secondary outcomes were compared using multivariable regression RStudio. A total of 307 patients with diabetic foot infections (62 patients with SRI and 245 patients without SRI) were included in the...

Research paper thumbnail of 负压创伤疗法治疗糖尿病足损伤是否安全有效?

Research paper thumbnail of Infected Puncture Wounds of the Hand

Southern Medical Journal, 1992

Research paper thumbnail of Diyabetik alt ekstremite Infeksiyonları: Fiziksel, psikolojik ve toplumsal faktörlerin etkileri

Amaç: Literatür yetersiz olmakla birlikte, düşük sosyal gruba mensup hastaların diyabetik komplik... more Amaç: Literatür yetersiz olmakla birlikte, düşük sosyal gruba mensup hastaların diyabetik komplikasyonlara daha açık oldukları ortak bir inanıştır. Bu çalışmanın amacı ciddi ayak infeksiyonlarına ve ardından gelen amputasyonlara yol açabilen lokal, sistemik ve psikolojik ...

Research paper thumbnail of Incidence of Complications and Risk Factors for Nonunion After Ankle Fracture in Diabetes Mellitus

Journal of the American Podiatric Medical Association

Background: To evaluate complications and risk factors for nonunion in patients with diabetes aft... more Background: To evaluate complications and risk factors for nonunion in patients with diabetes after ankle fracture. Methods: We conducted a retrospective study of 139 patients with diabetes and ankle fractures followed for 1 year. We evaluated the incidence of wounds, infections, nonunions, Charcot’s arthropathy, and amputations. We determined Fracture severity (unimalleolar, bimalleolar, trimalleolar), nonunion, and Charcot’s arthropathy from radiographs. Nonunion was defined as a fracture that did not heal within 6 months of fracture. Analysis of variance was used to compare continuous variables, and χ2 tests to compare dichotomous variables, with α = 0.05. Logistic regression was performed with a binary variable representing nonunions as the dependent variable. Results: Complications were common: nonunion (24.5%), Charcot’s arthropathy (7.9%), wounds (5.2%), wound site infection (17.3%), and leg amputation (2.2%). Patients with nonunions were more likely to be male (55.9% versus ...

Research paper thumbnail of Elective Surgery in the Diabetic Foot to Heal Foot Ulcerations and Prevent Re-ulceration

Diabetic Foot Reconstruction, 2022

Research paper thumbnail of The Effect of Implanted Functional Electrical Stimulation on Gait Performance in Stroke Survivors: A Systematic Review

Sensors, 2021

The emerging literature suggests that implantable functional electrical stimulation may improve g... more The emerging literature suggests that implantable functional electrical stimulation may improve gait performance in stroke survivors. However, there is no review providing the possible therapeutic effects of implanted functional electrical stimulation on gait performance in stroke survivors. We performed a web-based, systematic paper search using PubMed, the Cochrane Library, and EMBASE. We limited the search results to human subjects and papers published in peer-reviewed journals in English. We did not restrict demographic or clinical characteristics. We included 10 papers in the current systematic review. Across all included studies, we found preliminary evidence of the potential therapeutic effects of functional electrical stimulation on walking endurance, walking speed, ankle mobility, and push-off force in stroke survivors. However, due to the heterogeneity between the included studies, small sample size, and lack of randomized controlled trials, more studies are critically nee...

Research paper thumbnail of A Comparison of Pathogens in Skin and Soft-Tissue Infections and Pedal Osteomyelitis in Puncture Wound Injuries Affecting the Foot

Journal of the American Podiatric Medical Association, 2020

Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal os... more Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal osteomyelitis (OM) in patients with and without diabetes with puncture wounds to the foot. Methods: We evaluated 113 consecutive patients between June 1, 2011, and March 31, 2019, with foot infection (SSTIs and OM) from a puncture injury sustained to the foot. Eighty-three patients had diabetes and 30 did not. We evaluated the bacterial pathogens in patients with SSTIs and pedal OM. Results: Polymicrobial infections were more common in patients with diabetes mellitus (83.1% versus 53.3%; P = .001). The most common pathogen for SSTIs and OM in patients with diabetes was Staphylococcus aureus (SSTIs, 50.7%; OM, 32.3%), whereas in patients without diabetes it was Pseudomonas (25%) for SSTIs. Anaerobes (9.4%) and fungal infection (3.1%) were uncommon. Pseudomonas aeruginosa was identified in only 5.8% of people with diabetes. Conclusions: The most common bacterial pathogen in both SSTIs and pe...

Research paper thumbnail of Amputations and foot-related hospitalisations disproportionately affect dialysis patients

International Wound Journal, 2013

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We ... more Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD-9 250.X), ulceration (ICD-9 707·10, 707·14 and 707·15) and dialysis (CPT 90935-90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow-up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person-years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001); however, there were more foot-related hospital admissions in the dialysis group (32·9% versus 14·0%, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0·001) during the 30-month evaluation period. The incidence of ulcers, amputations and all-cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot-related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high-risk group.

Research paper thumbnail of Fracture Healing and Biomarker Expression in a Diabetic Zucker Rat Model

Journal of the American Podiatric Medical Association, 2014

Background Persons with diabetes have a higher incidence of fractures compared with persons witho... more Background Persons with diabetes have a higher incidence of fractures compared with persons without diabetes. However, there is little published information concerning the deleterious effect of late-stage diabetes on fracture healing. There are no studies using animal models that evaluate the effect of advanced diabetes on fracture healing. The purpose of our study was to evaluate cytokine expression, specifically macrophage inflammatory protein 1 (MIP-1) and vascular endothelial growth factor, in fracture healing in a type 2 diabetes rat model. Methods We evaluated biomarker expression after femur fracture using a rat model. The two groups consisted of 24 Zucker diabetic rats (study group) and 12 Zucker lean rats (control group). An independent reviewer was used to assess delayed union. We evaluated serum samples 2, 4, 7, and 14 days after surgery for MIP-1, vascular endothelial growth factor, leptin, and other cytokine levels. Results At 3 weeks, Kaplan-Meier estimates showed that...

Research paper thumbnail of Specific guidelines for treatment of diabetic foot osteomyelitis

Diabetes/Metabolism Research and Reviews, 2008

Research paper thumbnail of Validation of the Infectious Diseases Society of America/American Thoracic Society criteria to predict severe community-acquired pneumonia caused by Streptococcus pneumoniae

The American Journal of Emergency Medicine, 2009

/VS); 30-day mortality was a secondary outcome. Results.dThe study included 1062 patients with CA... more /VS); 30-day mortality was a secondary outcome. Results.dThe study included 1062 patients with CAP potentially eligible for ICU admission. Each of the 9 minor criteria was associated with increased risk of MV/VS and 30-day mortality in univariate analysis. Two hundred seven patients had $3 minor criteria (19.5%). The IDSA/ ATS 2007 criteria had an area under the receiver operating characteristic curve of 0.85 (0.82e0.88) for prediction of MV/VS, 0.85 (0.82e0.88) for prediction of ICU admission, and 0.78 (0.74e0.82) for prediction of 30-day mortality. The IDSA/ATS 2007 criteria were at least equivalent to more established scoring systems for prediction of MV/VS and ICU admission and equivalent to alternative scoring systems for predicting 30-day mortality in this patient population. Conclusions.dIn a population of patients with CAP without contraindications to ICU care, the IDSA/ATS minor criteria predict subsequent requirement for MV/VS, ICU admission, and 30-day mortality. : In their 2007 jointly issued guidelines for management of community-acquired pneumonia (CAP), the American Thoracic Society and Infectious Diseases

Research paper thumbnail of Interventions in the management of infection in the foot in diabetes: a systematic review

Diabetes/metabolism research and reviews, 2016

The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabe... more The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomis...

Research paper thumbnail of Reaching closure with skin stretching. Applications in the diabetic foot

Clinics in podiatric medicine and surgery, 1998

At the present time, there are no evidence-based protocols outlining the use of the Sure-Closure ... more At the present time, there are no evidence-based protocols outlining the use of the Sure-Closure Skin Stretching System on diabetic, neuropathic wounds. Ideally, surgical correction of the precipitating deformity and appropriate shoe gear accommodation should be performed con-comitantly with skin stretching (as indicated) to achieve an optimal long-term result. For several years, we have used the Sure-Closure device as an adjunctive treatment for diabetic-foot wound closure, and believe that, ultimately, this device more likely will be used in a clinical setting. In this manner, a patient with an open wound may, under aseptic conditions, be sequestered for a period of 1 to 2 hours during a clinical visit to allow for skin stretching. This procedure may be carried out two or three times weekly until closure is achieved. Mechanically assisted delayed primary closure is a relatively new category of wound closure; however, this device is by no means a panacea. Appropriate patient select...

Research paper thumbnail of Evidence-based options for off-loading diabetic wounds

Clinics in podiatric medicine and surgery, 1998

Whereas the treatment of the diabetic wound has received a great deal of attention in the medical... more Whereas the treatment of the diabetic wound has received a great deal of attention in the medical literature, the majority of the focus of recent research has been centered on dressings and advanced wound healing modalities. All these methods, however, are less than effective if the central tenet of treating the diabetic wound, namely reducing plantar pressure through off-loading, is not addressed primarily. This article examines the most commonly used off-loading methods in the medical literature and discusses the attributes and disadvantages of many of these devices.

Research paper thumbnail of Guidelines regarding negative wound therapy (NPWT) in the diabetic foot

Ostomy/wound management, 2004

The purpose of these guidelines is to the summarize consensus of a multidisciplinary expert advis... more 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. Therapy, in the treatment of diabetic foot wounds. The Tucson Expert Consensus Conference (TECC) on V.A.C. Therapy was convened in an effort to guide the direction for future research either to confirm or refute current consensus while providing practical guidance to the clinician currently treating diabetic foot wounds. The consensus committee discussed and commented on the following ten key questions regarding NPWT: 1) How long should NPWT be used in the treatment of a diabetic foot wound? 2) Should NPWT be applied to a wound that has not been debrided? 3) How should the patient using NPWT be evaluated on an outpatient basis? 4) When should NPWT be applied following lower-extremity bypass? 5) When should NPWT be applied after incision and drainage o...

Research paper thumbnail of A Retrospective Study of Patients With Diabetes Mellitus After Partial Foot Amputation and Hyperbaric Oxygen Treatment

The Journal of Foot and Ankle Surgery, 2005

A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxyge... more A retrospective chart review was conducted of 35 patients (40 feet) who received hyperbaric oxygen (HBO) therapy after partial foot amputation between 1990 and 2000. Preoperative transcutaneous partial pressure of oxygen (tcPo 2) levels, the number of hyperbaric treatments, time to final outcome, use of revascularization procedures, and postsurgical outcome were extracted from the charts. Seventy percent (n ϭ 28) had a successful outcome, defined as complete healing and absence of ulceration at the amputation site, and lack of further surgical procedures to heal the amputation site; whereas 30% (n ϭ 12) had a failed outcome, defined as lack of healing or the presence of an ulcer at the site of amputation or the need for further surgery to heal the amputation site. The level of amputation, use of revascularization procedures, time to final outcome, and number of hyperbaric treatments were not significantly different (P Ͼ .05) between the 2 postsurgical outcome groups. The mean preoperative tcPo 2 levels were greater (P Ͻ .01) in the successful (24 Ϯ mm Hg) than in the failed (11 Ϯ mm Hg) outcome groups. All patients with a tcPo 2 level Ͼ 29 mm Hg had a successful outcome. Patients with a successful postsurgical outcome had a mean of 20 HBO treatments and took 44 days to final outcome, while those with a failed postsurgical outcome had 16 HBO treatments and took 216 days to final outcome.

Research paper thumbnail of Risk factors for developing osteomyelitis in patients with diabetic foot wounds

Diabetes Research and Clinical Practice, 2009

Aims: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain l... more Aims: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain largely undefined. In a prospectively followed cohort we assessed risk factors for developing osteomyelitis. Methods: We enrolled consecutive persons with diabetes who presented to a managed-care diabetes disease management program. The patients underwent standardized assessments. We monitored for all foot complications, defined infections by criteria consistent with International Working Group guidelines, and defined osteomyelitis as a positive culture from a bone specimen. Results: 1666 persons were enrolled, 50% male, mean age 69 years. Over a mean of 27.2 months of follow-up, 151 patients developed foot infections, 30 (19.9%) of which involved bone. Independent risk factors for osteomyelitis were: wounds that extended to bone or joint (relative risk [RR] = 23.1), previous history of a wound prior to enrollment (RR=2.2), and recurrent or multiple wounds during the study period (RR = 1.9). Conclusions: In this study population, managed in a specialized diabetic foot care center, the results suggest that independent risk factors for developing osteomyelitis are deep, recurrent and multiple wounds. These results may help clinicians target their efforts at diagnosing foot osteomyelitis to the highest risk patients.

Research paper thumbnail of Risk Factors for Recurrent Diabetic Foot Ulcers: Site matters

Research paper thumbnail of Risk Factors for Foot Infections in Individuals With Diabetes

Diabetes Care, 2006

OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with d... more OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with diabetes. RESEARCH DESIGN AND METHODS—We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care–based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem. RESULTS—During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture–proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3–102.2; P < 0.001) and the risk of amputation was 154.5 tim...