Heal or no heel: Outcomes of ischaemic heel ulcers following lower limb revascularization from a multi‐ethnic Asian Cohort in Singapore

Ischaemic diabetic heel ulcers are difficult to treat and prognosis is often guarded. The aim was to document our outcome of treating heel ulcers following revascularization in a predominantly diabetic Asian cohort presenting with chronic limb threatening ischaemia from Singapore. Retrospective cohort study (n = 66, 66 limbs) over a 5‐year period. Data were collected from hospital electronic health records. Outcomes included time to healing, amputation free survival (AFS), and mortality. Minimum follow‐up period was 6 months. Multivariate regression analysis was performed to look for factors associated with poor outcome. Mean age was 67.4 ± 8.8 years. 62/66 (93.9%) were diabetics. Mean wound size at presentation was 3.6 ± 2.3 cm. Mean Wound, Ischaemia, Foot Infection (WIFI) score was 5 ± 1.6. 12/66 (18%) patients had a patent posterior tibial artery pre‐operatively. Straight line flow was restored in only 31/66 (46.9) patients but 47/66 (71.2%) had successful limb salvage. Median time to wound healing was 90.0 (IQR 60‐180) days. A median of 1 (IQR 0‐2) wound debridement was required. Patients who underwent negative pressure dressing (23/66; 34.8%) required a median of 26 (IQR 13‐33) cycles to achieve healing. Amputation free survival (AFS) was 72% and 68% at 6‐ and 12‐months, respectively. Mortality rate was 16.7% and 19.7% at 6‐ and 12‐months, respectively. Low albumin level and initial Rutherford class were independent predictors of worse 6‐month AFS. Outcomes of heel ulcers post revascularisation may not be as poor as previously described. Persistent attention to wound care with multidisciplinary effort is needed for optimal healing.     

Lethal consequences of home cot modification

Sleeping accidents are a particular risk for infants and young children as they lack an understanding of potentially dangerous situations and are unable to self-extricate. These situations may result in deaths from asphyxia. While safety campaigns have focused on the faulty design of cots that are available for sale, modification of cots at home represents another potential problem area. A 17-month-old girl was found dead with her head wedged between the top side rail of her cot and a broomstick, which had been attached in an attempt to raise the height of the cot side. Death was due to neck compression from head entrapment. This case demonstrates that infant and toddler safe sleeping programmes should alert carers to the potential dangers of structurally altering cots or beds. Home modifications may create dangerous gaps that could result in entrapment with lethal neck compression; such alterations should be carefully assessed and documented by forensic death scene investigators.     

Concurrent Drug-Induced Linear Immunoglobulin A Dermatosis and Immunoglobulin A Nephropathy

Diseases associated with immunoglobulin A (IgA) antibody include linear IgA dermatosis, IgA nephropathy, Celiac disease, Henoch-Schönlein purpura, etc. Although usually idiopathic, IgA antibody is occasionally induced by drugs (e.g., vancomycin, carbamazepine, ceftriaxone, and cyclosporine), malignancies, infections, and other causes. So far, only a few cases of IgA bullous dermatosis coexisting with IgA nephropathy have been reported. A 64-year-old female receiving intravenous ceftriaxone and metronidazole for liver abscess had purpuric macules and papules on her extremities. One week later, she had generalized edema and skin rash with bullae and was diagnosed with concurrent linear IgA dermatosis and IgA nephropathy. After steroid treatment, the skin lesion subsided within two weeks, and kidney function slowly returned to normal. As both diseases occurred after a common possible cause, we predict their pathogeneses are associated.