Cost of lameness in dairy herds: An integrated bioeconomic modeling approach.

Foot disorders are costly health disorders in dairy farms, and their prevalence is related to several factors such as breed, nutrition, and farmer's management strategy. Very few modeling approaches have considered the dynamics of foot disorders and their interaction with farm management strategies within a holistic farm simulation model. The aim of this study was to estimate the cost of foot disorders in dairy herds by simulating strategies for managing lameness. A dynamic and stochastic simulation model (DairyHealthSim) was used to simulate the herd dynamics, reproduction management, and health events. A specific module was built for lameness and related herd-level management strategies. Foot disorder occurrences were simulated with a base risk for each etiology [digital dermatitis (DD), interdigital dermatitis, interdigital phlegmon, sole ulcer (SU), white line disease (WLD)]. Two state machines were implemented in the model: the first was related to the disease-induced lameness score (from 1 to 5), and the second concerned DD-state transitions. A total of 880 simulations were run to represent the combination of the following 5 scenarios: (1) housing (concrete vs. textured), (2) hygiene (2 different scraping frequencies), (3) the existence of preventive trimming, (4) different thresholds of DD prevalence detected and from which a collective footbath is applied to treat DD, and (5) farmer's ability to detect lameness (detection rate). Housing, hygiene, and trimming scenarios were associated with risk factors applied for each foot disorder etiologies. The footbath and lameness detection scenarios both determined the treatment setup and the policy of herd observance. The economic evaluation outcome was the gross margin per year. A linear regression model was run to estimate the cost per lame cow (lameness score ≥3), per case of DD and per week of a cow's medium lameness duration. The bioeconomic model reproduced a lameness prevalence varying from 26 to 98% depending on the management scenario, demonstrating a high capacity of the model to represent the diversity of the field situations. Digital dermatitis represented half of the total lameness cases, followed by interdigital dermatitis (28%), SU (19%), WLD (13%), and interdigital phlegmon (4%). The housing scenarios dramatically influenced the prevalence of SU and WLD, whereas scraping frequency and threshold for footbath application mainly determined the presence of DD. Interestingly, the results showed that preventive trimming allowed a better reduction in lameness prevalence than spending time on early detection. Scraping frequency was highly associated with DD occurrence, especially with a textured floor. The regression showed that costs were homogeneous (i.e., did not change with lameness prevalence; marginal cost equals average cost). A lame cow and a DD-affected cow cost €307.50 ± 8.40 (SD) and €391.80 ± 10.0 per year on average, respectively. The results also showed a cost of €12.10 ± 0.36 per week-cow lameness. The present estimation is the first to account for interactions between etiologies and for the complex DD dynamics with all the M-stage transitions, bringing a high level of accuracy to the results.

Evidencia científica del tratamiento ortopodológico en pie afectado por artritis reumatoide / Evidence of orthopodiatric treatment affected by rheumatoid arthritis on foot

Antecedentes: La artritis reumatoide afecta más a mujeres. La prevalencia en nuestro país es de 0.5%. Se debe abordar mediante un equipo multidisciplinar. Los signos característicos en el pie son sinovitis de las articulaciones, entesitis, nódulos reumatoides y vasculitis. Las modalidades de tratamiento conservador son: ortesis, calzado, estiramientos, terapia manual e incluso ejercicios terapéuticos mediante Tai-chi. Objetivos: Valorar la evidencia científica sobre el tratamiento conservador del pie reumático mediante ortesis plantares y calzado terapéutico. Conocer los últimos avances y que opción es la más indicada para tratar esta patología que afecta al pie. Material y métodos: Se ha realizado una revisión bibliográfica de los últimos 15 años en Pubmed. Resultados: Se ha encontrado relación entre el dolor de antepié, subluxación metatarsofalángica y erosión del cartílago articular con el aumento de presión a nivel metatarsal plantar lo que justifica la realización de tratamiento ortopodológico encaminado a reducir la misma. El tratamiento conservador está enfocado a la utilización de ortesis y de zapato terapéutico para mejorar el dolor, la marcha y la funcionalidad. Hay evidencia científica para tratar la metatarsalgia con diferentes tipos de ortesis, que no solo ayudan a mejorar el dolor sino que además reducen el nº de articulaciones inflamadas. La combinación con zapato terapéutico con o sin modificaciones externas produce mejores resultados. Conclusión: Existe escasa evidencia científica sobre el uso de tratamiento ortopodológico para el pie reumático pero se han encontrado algunos artículos que avalan su eficacia, por lo que es imprescindible realizar estudios en este campo (AU)

Background: Rheumatoid arthritis affects more women. The prevalence in our country is 0.5%. It should be approached by a multidisciplinary team. Characteristic foot signs' are synovitis of joints, enthesitis, rheumatoid nodules and vasculitis. The conservative treatment modalities are: orthotics, footwear, stretching, manual therapy and therapeutic exercises even by Tai-chi. Objectives: To evaluate the scientific evidence on the conservative treatment of rheumatoid foot with orthotics and therapeutic footwear. Aware of progress and that is the most suitable option for treating this disease that affects the feet. Material and methods: We carried out a literature review of the past 15 years in Pubmed. Results: We found the relationship between pain forefoot metatarsophalangeal subluxation and erosion of articular cartilage with increasing pressure to plantar metatarsal level which justifies conducting orthosis treatment aimed at reducing it. Conservative treatment is aimed at the use of orthoses and shoe therapy to improve pain, gait and functionality. There is scientific evidence for treating metatarsalgia with different types of orthotics that not only help improve the pain but also reduce the number of swollen joints. The combination with therapeutic shoe with or without external changes produces better results. Conclusion: There is little scientific evidence on the use of orthosis treatment for rheumatoid foot but found some articles that support its effectiveness, so it is essential to carry out studies in this field (AU)

Fever--an update.

Fever is an active yet nonspecific response of the body to infections and other insults that cause immune cells to release cytokines, resulting in a brain prostanoid-mediated rise in body temperature. The causes, types, clinical management, and postoperative consequences of fever are reviewed in this article. Physicians use fever as a clinical sign for diagnoses and prognoses, but "fevers of unknown origin" continue to be problematic. Fevers that arise 1 or 2 days after surgery are usually due to stress and trauma, but later postoperative fevers often have more serious causes and consequences, such as wound infection. Fever is commonly encountered by podiatric physicians and surgeons, and certain procedures with the lower extremity are more likely to eventuate in fever.

[Application of traditional Chinese drug soaking, continual irrigation and focus elimination for the treatment of foot osteomyelitis complicated with massive skin defect and denervation].

OBJECTIVE: To evaluate therapeutic effects of traditional Chinese drug soaking,continual irrigation and focus elimination for foot osteomyelitis complicated with massive skin defect and denervation. METHODS: There were 25 males and 28 females in the study. All the patients suffering from foot osteomyelitis complicated with massive skin defect and denervation were treated with comprehensive therapy including preoperative traditional Chinese drug soaking, skin release, focus elimination,continual irrigation, and two-stage suture if necessary. Among the patients, there were 42 cases of left foot and 11 cases of right one. Fifty-one patients complicated with skin defect and sinus tract,only 2 patients complicated with skin defect. There were 48 patients with denervation caused by spina bifida, 5 patients by other causes. RESULTS: The follow-up duration was from 1 to 12 years,the mean time was about 5 years. Osteomyelitis recurred in 3 cases and skin defect reoccurred in original position in 9 cases. CONCLUSION: The methods of traditional Chinese drug soaking, continual irrigation and elimination of focus have good effects for foot osteomyelitis complicated with massive skin defect and denervation. To some degree,this therapy may avoid skin flap transplantation, bone graft and amputation. It deserves further studies and promotion.

The use of maggot therapy in the treatment of a malignant foot wound.

Mrs T presented with a necrotic wound to her right foot secondary to malignant adenocarcinoma. Maggot therapy was used to successfully debride the wound, which had failed to respond to conventional treatment. The maggot therapy removed the necrotic tissue and appeared to initiate the process of granulation, which allowed the wound to be dressed with conventional materials and progress towards healing.

Extracorporeal shockwave therapy (ESWT) in patients with chronic proximal plantar fasciitis.

The aim of this study was to compare the effect of extracorporeal shockwave therapy (ESWT) in patients with chronically painful proximal plantar fasciitis with a conventional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, heel cup, orthoses and/or shoe modifications, local steroid injections and electrotherapy. Forty-seven patients (49 feet) with a previously unsuccessful conservative treatment of at least six months were randomized to two groups. Treatment of Group 1 (25 heels) started immediately with three sessions of ESWT (3000 shockwaves/session of 0.2 mJ/mm2) at weekly intervals. In the patients of Group 2 (24 heels) treatment was continued for 12 weeks. After this period they were treated using the protocol of Group 1. No significant difference of pain and walking time after further non-ESWT treatment (three months) was seen. Six months after ESWT pain decreased by 64% to 88% on the visual analog scale (VAS) and the comfortable walking time had increased significantly in both groups.

Metastatic calcinosis circumscripta treated with an oral charcoal absorbent in a dog.

A five-year-old West Highland white terrier dog was admitted to the teaching hospital of Nippon Veterinary and Animal Science University due to swelling and pain of the foot pads. Examinations revealed that the dog had renal failure and calcinosis circumscripta on its foot pads. The diagnosis was metastatic calcinosis circumscripta secondary to renal failure. An oral charcoal adsorbent (Kremezin) was used to treat this condition. Following this treatment, a significant decrease in the Ca x P value (the serum calcium level x the serum phosphorus level) was observed, and the dog's condition improved dramatically. This case suggests that charcoal adsorbent (Kremezin) may be useful for treating metastatic calcinosis circumscripta in dogs.

Randomized prospective controlled trial of recombinant granulocyte colony-stimulating factor as adjunctive therapy for limb-threatening diabetic foot infection.

Adult diabetic patients admitted to our Diabetes Center from September 1996 to January 1998 for severe, limb-threatening foot infection were consecutively enrolled in a prospective, randomized, controlled clinical study aimed at assessing the safety and efficacy of recombinant human granulocyte colony-stimulating factor (G-CSF) (lenograstim) as an adjunctive therapy for the standard treatment of diabetic foot infection. Forty patients, all of whom displayed evidence of osteomyelitis and long-standing ulcer infection, were randomized 1:1 to receive either conventional treatment (i.e., antimicrobial therapy plus local treatment) or conventional therapy plus 263 microg of G-CSF subcutaneously daily for 21 days. The empiric antibiotic treatment (a combination of ciprofloxacin plus clindamycin) was further adjusted, when necessary, according to the results of cultures and sensitivity testing. Microbiologic assessment of foot ulcers was performed by both deep-tissue biopsy and swab cultures, performed at enrollment and on days 7 and 21 thereafter. Patients were monitored for 6 months; the major endpoints (i.e., cure, improvement, failure, and amputation) were blindly assessed at weeks 3 and 9. At enrollment, both patient groups were comparable in terms of both demographic and clinical data. None of the G-CSF-treated patients experienced either local or systemic adverse effects. At the 3- and 9-week assessments, no significant differences between the two groups could be observed concerning the number of patients either cured or improved, the number of patients displaying therapeutic failure, or the species and number of microorganisms previously yielded from cultures at day 7 and day 21. Conversely, among this small series of patients the cumulative number of amputations observed after 9 weeks of treatment appeared to be lower in the G-CSF arm; in fact, only three patients (15%) in this group had required amputation, whereas nine patients (45%) in the other group had required amputation (P = 0.038). In conclusion, the administration of G-CSF for 3 weeks as an adjunctive therapy for limb-threatening diabetic foot infection was associated with a lower rate of amputation within 9 weeks after the commencement of standard treatment. Further clinical studies aimed at precisely defining the role of this approach to this serious complication of diabetes mellitus appear to be justified.

Atypical presentation of plantar fasciitis secondary to soft-tissue mass infiltration.

This article describes a patient with plantar fascial pain who presented to the office of one of the authors. Physical examination and the patient's description of the history of symptoms revealed classic signs and symptoms of plantar fasciitis. The patient was treated with numerous conservative modalities, including ultrasound, nonsteroidal anti-inflammatory medications, trigger-point injections, over-the-counter orthoses, and stretching exercises. When the pain was not relieved by these conservative measures, magnetic resonance imaging of the area was performed. Visualization of the insertional area of the plantar fascia revealed a mass inferior to, as well as infiltrated into, the plantar fascia. Surgical excision of the lesion resulted in complete elimination of the patient's pain.

Pápulas piezogénicas dolorosas de los pies / Painful piezogenic pedal papules

Presentamos el caso de una paciente obesa de 65 años con un cuadro clínico e histopatológico de pápulas piezogénicas dolorosas del pie derecho, haciendo especial énfasis en la confusión terminológica del proceso, así como en su etiopatogenia y las posibles soluciones terapéuticas (AU)

Cost-effectiveness of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients.

A cost-effectiveness analysis was performed following a double-blind, randomized study of ampicillin/sulbactam (A/S) versus imipenem/cilastatin (I/C) for the treatment of limb-threatening foot infections in 90 diabetic patients. There were no significant differences between the treatments in terms of clinical success rate, adverse-event frequency, duration of study antibiotic treatment, or length of hospitalization. Costs of the study antibiotics, treatment of failures and adverse events, and hospitalization were calculated. Mean per-patient treatment cost in the A/S group was $14,084, compared with $17,008 in the I/C group (P = .05), primarily because of lower drug and hospitalization costs and less-severe adverse events in the A/S group. Sensitivity analyses varying drug prices or hospital costs demonstrated that A/S was consistently more cost-effective than I/C. Varying the clinical success rate for each drug revealed that I/C would have to be 30% more effective than A/S to change the economic decisions.

Necrotizing fasciitis.

Necrotizing fasciitis is a rapidly progressing soft-tissue infection characterized by extensive necrosis of subcutaneous fat and fascia. It is frequently accompanied by moderate to severe systemic toxicity and can be fatal without prompt recognition and aggressive surgical treatment. The podiatric physician must be aware of these infections because the extremities are common sites of involvement. Necrotizing, fasciitis must be treated as a medical emergency calling for prompt surgical intervention and high doses of broad-spectrum antibiotics.

Oral clindamycin and ciprofloxacin therapy for diabetic foot infections.

Infected foot ulcers are a common complication in persons with diabetes. In general, treatment consists of intravenous administration of antibiotics, for which the patients are customarily hospitalized. The average length of hospital stay for this therapy in our institution is 15.6 days. We evaluated a regimen of oral clindamycin plus ciprofloxacin, which patients could take at home, with respect to the clinical eradication of the infection and treatment cost savings. Our results demonstrated that with these oral agents, patients' length of hospital stay was greatly reduced, and the pharmacy realized significant cost avoidance.

Podiatric management of the patient with renal disease.

The increasing number of patients with chronic renal failure must serve to make the podiatrist aware of the uniqueness and peculiarities of the disease process. This article reviews the literature on the nature and consequences of progressive renal failure and gives analysis of some of the pre- and postoperative considerations encountered in the patient with end-stage renal disease of concern to the podiatric surgeon.