Postoperative healing in the diabetic foot is impacted by discharge destination.

The aim of this study was to evaluate the impact of discharge destination on diabetes-related limb salvage surgery outcomes post-hospitalisation. This was a single-centre, observational, descriptive study of 175 subjects with diabetes who underwent limb salvage surgery of a minor foot amputation or wide incision and debridement for an acutely infected diabetic foot ulcer (DFU). Comparisons were made between subjects discharged home vs a skilled nursing facility (SNF) for 12 months postoperatively. Univariate, multivariate, and time-to-event analyses were performed. The SNF discharge group (n = 40) had worse outcomes with longer healing time (P = .022), more rehospitalisations requiring a podiatry consult (P = .009), increase of subsequent ipsilateral major lower-extremity amputation (P = .028), and a higher mortality rate (P = .012) within the 12-month postoperative period. There was no significant difference between the cohorts in surgically cleared osteomyelitis (P = .8434). The Charlson Comorbidity Index values for those discharged home and those in a short-term nursing facility were similar (P = .3819; home x ¯ =5.33 ± 2.84 vs SNF x ¯ =5.75 ± 2.06). The planned discharge destination after limb salvage surgery among people with an acutely infected DFU should be an added risk factor for healing outcomes. Patients discharged to SNFs experience additional morbidity and mortality compared with patients discharged home post-hospitalisation.

Eccrine Porocarcinoma: Avoiding Diagnostic Delay.

Skin cancer is the most common cancer within the United States. Reports estimate that 1 in 5 Americans will develop some form of skin cancer. Eccrine porocarcinoma is a rare type of skin cancer of sweat gland origin. Eccrine porocarcinoma is most commonly found on the lower extremities. Clinically it may appear similar to benign skin lesions and it has significant metastatic potential. The authors present a case report with 22 months' follow-up. It describes a multiyear delay in diagnosis involving 3 specialties, including primary care, dermatology, and wound physical therapy. Information is given on techniques when high-risk cutaneous cancers are suspected or encountered. A multispecialty treatment plan is discussed.Levels of Evidence: Level V.

Making the equivocal unequivocal: standardization of clean margins in diabetic foot osteomyelitis.

BACKGROUND: The prevalence of diabetes mellitus continues to rise. Diabetic foot ulcers with osteomyelitis are a diabetes-related complication presenting a significant burden to this cohort. A cure to diabetic foot osteomyelitis remains elusive and standard of care has failed to improve outcomes. To advance research and better patient outcomes, the authors offer specific guidance with terminology to enhance operative dictations which may improve surgical practice and guide treatment. METHODS: A consecutive review of podiatric surgical dictations for inpatient diabetic foot osteomyelitis within a tertiary care facility was performed. Surgical descriptors of bone were standardized: density, anatomic structure, vascular thrombosis, color, and draining sinus. Correlations between the five categories and histopathological results were performed after kappa analysis for interrater reliability was performed. RESULTS: Kappa coefficient demonstrated high inter-reliability of surgical findings. This suggests potential agreement amongst surgeons performing similar procedures. It was also found that specific bone descriptors had moderate to strong correlation with clean histopathologic bone margins when biopsied. This further suggests that the use of standardized terms may help guide definitive therapy. CONCLUSIONS: The authors suggest a standardized approach which includes consistent descriptors of intraoperative bone. With use of standardized terms, vague and blanket descriptors are eliminated. This has potential to improve understanding of changes within bone as a result of infection and diabetes. Early and improved communication of intraoperative findings will enhance the multidisciplinary approach. This could potentially lead to changes in diabetic foot management and may limit hospital waste waiting for final cultures and pathology reports.

Vehicle ergonomics contributing to a diabetic foot ulcer.

BACKGROUND: Diabetes mellitus continues to be a rising concern in the United States. It affects an estimated 9.4% of the population and approximately 1.5 million Americans are diagnosed annually. Approximately 85% of diabetic foot ulcers are associated with diabetic peripheral neuropathy and an infected diabetic foot ulcer is often the first sign of diabetes. There are countless studies within the literature that investigate how insensate feet and the manifestation of a foot ulcer further decrease quality of life and increase risk for mortality. Literature focuses on gait and kinematics that contribute to the formation of a diabetic foot ulcer. While pressure and shear forces are etiologic factors that may lead to the formation of diabetic foot ulcers, the position of the foot while driving an automobile has been ignored as a possible risk factor. CASE PRESENTATION: The clinical case will describe the events of healing a neuropathic diabetic foot ulcer beyond the standard of care treatment plan. It is one of the first case reports to describe vehicle ergonomics as an etiologic factor contributing to a diabetic foot ulcer. Once the patient becomes aware of the unnecessary source of pressure, education and care is provided to manage this likely source of daily pressure to the neuropathic foot. CONCLUSION: The article emphasizes the importance of a complete assessment, including nontraditional factors, which may lead to diabetic complications.

An epifluorescent attachment improves whole-plant digital photography of Arabidopsis thaliana expressing red-shifted green fluorescent protein.

BACKGROUND AND AIMS: Studies have shown that levels of green fluorescent protein (GFP) leaf surface fluorescence are directly proportional to GFP soluble protein concentration in transgenic plants. However, instruments that measure GFP surface fluorescence are expensive. The goal of this investigation was to develop techniques with consumer digital cameras to analyse GFP surface fluorescence in transgenic plants. METHODOLOGY: Inexpensive filter cubes containing machine vision dichroic filters and illuminated with blue light-emitting diodes (LED) were designed to attach to digital single-lens reflex (SLR) camera macro lenses. The apparatus was tested on purified enhanced GFP, and on wild-type and GFP-expressing arabidopsis grown autotrophically and heterotrophically. PRINCIPAL FINDINGS: Spectrum analysis showed that the apparatus illuminates specimens with wavelengths between ∼450 and ∼500 nm, and detects fluorescence between ∼510 and ∼595 nm. Epifluorescent photographs taken with SLR digital cameras were able to detect red-shifted GFP fluorescence in Arabidopsis thaliana leaves and cotyledons of pot-grown plants, as well as roots, hypocotyls and cotyledons of etiolated and light-grown plants grown heterotrophically. Green fluorescent protein fluorescence was detected primarily in the green channel of the raw image files. Studies with purified GFP produced linear responses to both protein surface density and exposure time (H(0): ß (slope) = 0 mean counts per pixel (ng s mm(-2))(-1), r(2) > 0.994, n = 31, P < 1.75 × 10(-29)). CONCLUSIONS: Epifluorescent digital photographs taken with complementary metal-oxide-semiconductor and charge-coupled device SLR cameras can be used to analyse red-shifted GFP surface fluorescence using visible blue light. This detection device can be constructed with inexpensive commercially available materials, thus increasing the accessibility of whole-organism GFP expression analysis to research laboratories and teaching institutions with small budgets.