Health Disparities in Nontraumatic Lower Extremity Amputations. A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic diseases and their associated health outcomes have been known to disproportionately affect people of low socioeconomic status (SES) around the world. The authors aim to examine the association between SES and nontraumatic lower extremity amputation. METHODS: A search of current literature was performed in March 2022 across PubMed, Scopus, Embase, and Medline for relevant literature. Keywords included "socioeconomics", "income", "amputation", and "lower extremities". RESULTS: A total of 1,164,630 patients across 5 studies were incorporated into the meta-analysis of nontraumatic lower extremity amputation and SES. An additional 3 citations were used in the secondary analyses between gender and ethnicity and their relationship with amputation. An association was observed between low SES and nontraumatic lower extremity amputations, odds ratio (OR) = 1.168, (confidence interval [CI]: 1.153, 1.183) P ≤ 0.05. Gender and race subanalyses were also conducted, with associations found with men and non-Caucasians with amputation: OR = 1.044; [CI: 1.036, 1.053] P ≤ 0.05; race OR = 2.893; [CI: 2.866, 2.920] P ≤ 0.05. CONCLUSIONS: SES along with gender and race are associated with nontraumatic lower extremity amputation. These findings add additional perspectives for which populations are disproportionately affected by disease and subsequent health outcomes. The authors anticipate the results presented may further assist in future public health screening methods and interventions. LEVEL OF CLINICAL EVIDENCE: 2.

A Systematic Review and Meta-Analysis of the Effectiveness of LRINEC Score for Predicting Upper and Lower Extremity Necrotizing Fasciitis.

This review and meta-analysis aims to assess the prognostic value of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for detecting necrotizing fasciitis in the extremities. The LRINEC score has been validated in multiple studies as a clinical tool for differentiating necrotizing fasciitis from non-necrotizing infections however many studies do not specify the location of infection. As the prevalence of diabetes and diabetic foot infections continues to rise, the utility of LRINEC scores in these populations becomes of increased importance. Four databases were reviewed for citations between January 2010 and December 2020. English, full text articles reporting the diagnostic effects of LRINEC were utilized in the systematic review portion of this paper. Further inclusion of 2 × 2 tables and discussion specific to the extremities were applied for citations implemented in the meta-analysis. Of the 111 results, 12 citations (n = 932) were included in this review. The diagnostic sensitivity of the LRINEC score ranged from 36% to 77% while specificity ranged from 72% to 93%. Cumulative odds ratio for LRINEC ≥6 among the 4 studies assessing extremity necrotizing fasciitis was 4.3 with p value of <.05. Sensitivity, specificity, positive predictive value, and negative predictive value was 49.39%, 83.17%, 34.91%, and 89.99%, respectively. Accuracy, the classification by whether a patient was correctly classified, was 77.95%. LRINEC score is effective at distinguishing necrotizing fasciitis from other soft tissue infections however the LRINEC's score greatest clinical application may be its ability to rule out necrotizing fasciitis while its ability to accurately identify the presence of infection remains suboptimal.

Anodal transcranial direct current stimulation for chronic pain in the elderly: a pilot study.

BACKGROUND AND AIMS: Transcranial direct current stimulation (tDCS) is a non-invasive neuromodulatory technique that can affect human pain perception. The present open-label, single-arm study investigated whether primary motor cortex anodal tDCS treatment reduces chronic foot pain intensity and improves depression and pain-related anxiety symptoms in patients with chronic plantar fasciitis. METHODS: Ten patients with symptomatic treatment-resistant plantar fasciitis were enrolled in the study. The treatment consisted of anodal tDCS over the motor area of the leg contralateral to the symptomatic foot for 20 min, at 2 mA for 5 consecutive days. Pre-tDCS (T0), post-tDCS (T1), 1 week (T2), and 4 weeks (T3) post-treatment assessments were conducted consisting of the Visual Analog Scale for pain intensity, the Foot Function Index (FFI), the Pain Anxiety Symptom Scale (PASS-20), and the Hamilton Rating Scale for Depression (HDRS-17 items). RESULTS: Anodal tDCS treatment induced a significant improvement in pain intensity; FFI and PASS scores that were maintained up to 4 weeks post-treatment. In addition, patients reported taking fewer pain medication tablets following the treatments. DISCUSSION AND CONCLUSIONS: Our results indicate that anodal tDCS may be a viable treatment to control pain and psychological comorbidity in elderly patients with treatment-resistant foot pain.

Pedal Gangrenous Changes in the Digits of an Adolescent With Ulcerative Colitis: A Case Report.

Ulcerative colitis is an autoimmune inflammatory disease of the colon and is occasionally associated with thrombosis. We report the case of an adolescent with ulcerative colitis who presented with bilateral gangrenous toes without signs of ascending cellulitis. Radiographs indicated the presence of bilateral and erosive changes in the distal phalanges. The vascular team referred the patient for podiatric intervention for distal vasculitis and thrombosis of the digital vessels. Transphalangeal amputations were performed, and postoperative antibiotics were initiated. The surgical sites healed uneventfully, and the patient was able to resume daily activities. Thrombosis of the foot in the context of ulcerative colitis is a rare, but serious, complication that can lead to serious comorbidities, including amputation.

An Aggressively Recurrent Squamous Cell Carcinoma of the Foot.

Squamous cell carcinoma is a malignant tumor that is most commonly found on the head and neck. The current global incidence of squamous cell carcinoma at any site is estimated to be more than 1 million cases per year, with a reported 3-year mortality rate of 30%. Recurrence of squamous cell carcinoma at any site is estimated to be 15% to 50% and has been associated with greater rates of infiltration, perineural invasion, and mortality. Recent studies have shown lower-extremity squamous cell carcinoma to be distinct from squamous cell carcinoma at any site with histologic and clinical differences. Lower-extremity squamous cell carcinoma is suggestively less aggressive and carries less risk of metastasis. However, lower-extremity squamous cell carcinoma prevalence, mortality, and recurrence rates have not been extensively studied. The present report depicts a case of recurrent squamous cell carcinoma originating in 2006 in the dorsal forefoot and provides the clinical management of subsequent recurrence episodes, with excisions from 2015 and 2020.

Subungual melanoma of the great toe in a Hispanic male with Down syndrome: a case report and review of the literature.

Solid mass tumors are not as common as leukemia in individuals with Down syndrome. In this report, we describe the rare case of an adult Hispanic male with Down syndrome who developed advanced subungual melanoma in the hallux. We also describe the course of treatment, which involved hallux amputation along with metastatic work-up and sentinel lymph node biopsy with eventual resection.

A 30-Year-Old Man with an Unusually Large Untreated Plantar Fibrolipoma That Disrupted Ambulation and Required Operative Excision.

A 30-year-old man working as a waiter presented with a progressively enlarging and symptomatic soft-tissue mass on the plantar medial aspect of his left foot. The mass was painful and disrupting ambulation, despite footwear modifications. He ultimately underwent excision of what was a determined to be a fibrolipoma, returning to his regular shoes and all activities. Plantar neoplasms, even when benign, can grow to sizes that can result in significant disability. If left untreated, particularly in individuals engaged in occupations requiring frequent standing or walking, excision of the mass will often require a more aggressive operative approach.

Chopart's amputation for resection of clear cell sarcoma of the foot: a case report and review of the literature.

UNLABELLED: Clear cell sarcoma (CCS) is a subset of soft tissue sarcoma that occurs mainly in young Caucasians. Although on initial presentation these growths might not appear to be malignant, CCS has a tendency to disseminate to regional lymph nodes and ultimately develop distant metastasis. We report a case of CCS from our institution, discussing the radiological and pathological findings, surgical treatments, and survival prognoses. To our knowledge, this is the first reported case of using a Chopart's amputation technique in the resection of CCS of the foot. LEVEL OF CLINICAL EVIDENCE: 4.

Severe chronic heel pain in a diabetic patient with plantar fasciitis successfully treated through transcranial direct current stimulation.

BACKGROUND: Recently, transcranial direct current stimulation (tDCS), a noninvasive brain stimulation technique, was proposed as a suitable method for the treatment of several chronic pain syndromes. We describe a case of severe heel pain in a diabetic patient with plantar fasciitis successfully treated with tDCS. METHODS: The present study investigated whether tDCS treatment could reduce pain and pain-related anxiety in a 65-year-old diabetic man affected by treatment-resistant right heel pain due to plantar fasciitis. The patient underwent five tDCS treatment sessions on 5 consecutive days. Each session consisted of 20-min anodal tDCS over the left primary motor cortex leg area. RESULTS: The neurostimulation protocol induced a decrease in pain intensity and pain-related anxiety that outlasted the stimulation (1 week). Furthermore, the patient stopped the intake of opioid medication. CONCLUSIONS: Therapeutic neuromodulation with tDCS may represent an alternative option for treating severe lower-extremity pain.

Psychometric properties and podiatric medical student perceptions of USMLE-style items in a general anatomy course.

BACKGROUND: In 2010, the New York College of Podiatric Medicine general anatomy course was redesigned to emphasize clinical anatomy. Over a 2-year period, United States Medical Licensing Examination (USMLE)-style items were used in lecture assessments with two cohorts of students (N =200). Items were single-best-answer and extended-matching formats. Psychometric properties of items and assessments were evaluated, and anonymous student post-course surveys were administered. METHODS: Mean grades for each assessment were recorded over time and compared between cohorts using analysis of variance. Correlational analyses were used to investigate the relationship between final course grades and lecture examinations. Post-course survey response rates for the cohorts were 71 of 97 (73%) and 81 of 103 (79%). RESULTS: The USMLE-style items had strong psychometric properties. Point biserial correlations were 0.20 and greater, and the range of students answering the items correctly was 25% to 75%. Examinations were highly reliable, with Kuder-Richardson 20 coefficients of 0.71 to 0.76. Students (>80%) reported that single-best-answer items were easier than extended-matching items. Students (>76%) believed that the items on the quizzes/examinations were similar to those found on USMLE Step 1. Most students (>84%) believed that they would do well on the anatomy section of their boards (American Podiatric Medical Licensing Examination [APMLE] Part I). CONCLUSIONS: Students valued USMLE-style items. These data, coupled with the psychometric data, suggest that USMLE-style items can be successfully incorporated into a basic science course in podiatric medical education. Outcomes from students who recently took the APMLE Part I suggest that incorporation of USMLE-style items into the general anatomy course was a successful measure and prepared them well.

Meta-analysis of flexor tendon transfer for the correction of lesser toe deformities.

BACKGROUND: Transfer of the flexor digitorum longus tendon is one of the surgical techniques described to treat lesser toe deformities. A global analysis of the benefits of this procedure has not been presented in the literature to date. The aim of this meta-analysis was to evaluate the clinical benefit of transfer of the flexor digitorum longus tendon regarding patient satisfaction. METHODS: A reviewer formally trained in meta-analysis abstraction techniques searched several databases to identify relevant published studies. Initially, 203 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in their entirety, of which 17 articles studying 515 procedures with a mean ± SD follow-up of 54.21 ± 20.64 months met all of the inclusion criteria necessary for analysis. RESULTS: Overall crude patient satisfaction after flexor digitorum longus tendon transfer was 86.7% (95% confidence interval, 81.7%-90.5%). A low grade of heterogeneity across studies (Q = 24.458, I(2) =34.583, P = .080) and no influence of the individual studies on overall estimation were found. When adjusting for higher-quality prospective studies, overall patient satisfaction increased to 91.8%, although it did not reach statistical significance. Additional a priori sources of heterogeneity (age, sex, studies with <3 years of follow-up, percentage of patients lost to follow-up, and year of publication) were evaluated by subgroup analysis and meta-regression, but no statistical significance was found. This adjustment also significantly decreased heterogeneity across studies (crude Q = 24.458, high-quality studies Q = 1.504). CONCLUSIONS: Regarding patient satisfaction, this comprehensive analysis provides supportive evidence of the clinical benefit of flexor digitorum longus tendon transfer.

Comparative analysis of moral distress and values of the work organization between American and Spanish podiatric physicians.

BACKGROUND: Moral distress is a stress symptom arising from situations that involve ethical dimensions where the health-care provider believes that he or she is unable to preserve all interests and values at stake. The aims of this study were to evaluate the impact of, and identify possible differences in, moral distress in podiatric physicians in the United States and Spain and to determine the ethical principles most closely related to moral distress. METHODS: A 2008 e-mail survey of 93 US podiatric physicians and 93 Spanish podiatric physicians (N = 186) presented statements about different ethical dilemmas, values, and goals in the workplace. RESULTS: Although moral distress is strongly present across the sample for all of the questions, the US sample shows higher levels of any kind of moral distress concerning questions about patients' treatment and economic constraints, overload of paperwork, and acting against one's conscience. In the US sample, 91.4% of physicians agreed mostly or completely with the statement that they often had to compromise their own values to cope with the demands of the workplace; 89.25% of US podiatric physicians indicated that their own professional values were congruent with the values of the organization; and a similar percentage (77.5%) reported a strong identification with the goals and framework of their work organization. The Spanish sample had similar results. CONCLUSIONS: The results underline the significance of moral distress for both samples, mainly related to time constraints and organizational aspects concerning patients and lack of resources.