Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status.

PURPOSE: The intermediate success and outcome of primary forefoot amputations in patients with diabetes mellitus who have sepsis limited to the forefoot and presumed adequate forefoot perfusion, as determined by means of noninvasive methods, was studied. METHODS: Cases of a university hospital-based practice from January 1984 to April 1998 were retrospectively reviewed. Patients included had diabetes mellitus with forefoot sepsis requiring immediate hospitalization for digit amputations who had adequate arterial circulation for healing based on noninvasive and clinical assessment: palpable pedal pulses (29%), "compressible" ankle pressure of 70 mm Hg or higher (48%), pulsatile metatarsal waveforms (67%), and/or toe pressure higher than 55 mm Hg (36%). All patients underwent a primary single- or multiple-digit amputation (through the interphalangeal joint, metatarsal head, or metatarsal shaft). Additional forefoot procedures (debridement, digit amputation) were performed during the follow-up period as needed for persistent or recurrent infection. The main outcome variables were recurrent or persistent foot infection (defined as requiring rehospitalization for antibiotics, wound care, and/or reoperation), the number of repeat operations and hospitalizations for salvage of limbs with recurrent or persistent infections, and time to complete forefoot healing or foot amputation. RESULTS: Ninety-two patients who had diabetes mellitus with 97 forefoot infections comprised the study group. Ninety-seven primary digit amputations (34 through interphalangeal joints, 28 through metatarsal heads, 35 through metatarsal shafts) were performed. The median length of hospital stay was 10 days. There were no operative deaths. The mean follow-up period was 21 months (range, 3 days to 105 months). The primary amputation healed (without persistent infection) in only 38 limbs (39%), at a mean time of 13 +/- 10 weeks. Twenty-three limbs (24%) had not healed the primary amputation without evidence of persistent infection at last follow-up (mean, 12 weeks). Infection persisted in 35 limbs (36%), and infection recurred in 15 of 38 (40%) healed limbs. An average of 1.0 reoperations (range, 0 to 3) and 1.6 rehospitalizations (range, 1 to 4) were involved in salvage attempts in these recurrent/persistent infections. Five persistent and five recurrent infections ultimately healed (mean, 53 weeks). Complete healing was achieved in only 33 of 97 limbs (34%). Twenty-two foot amputations (20 transtibial, two Syme's) were performed (mean, 49 +/- 74 weeks; 20 for persistent infection). Eighteen persistent/recurrent infections remained unhealed at the last follow-up examination (mean, 105 weeks). CONCLUSION: Patients with diabetes mellitus who have sepsis limited to the forefoot requiring acute hospitalization and undergoing primary digit amputations have a high incidence of intermediate-term, persistent, and recurrent infection, leading to a modest rate of limb loss, despite having apparently salvageable lesions and noninvasive evidence of presumed adequate forefoot perfusion.     

Book Review: Adolescents, Alcohol and Substance Abuse: Reaching Teens Through Brief Interventions. Edited by Peter M. Monti, Suzanne M. Colby, and Tracy A. O'Leary, New York, The Guilford Press, 2001, 350 pp., ISBN 1-57230-658-0 (Hardback)

The book reviewed in this article discusses the use of brief interventions in the treatment of adolescent substance abuse. Topics covered include the developmental context within which adolescent substance use occurs, the use of the harm reduction approach to reduce substance use, current assessment instruments, and the role of cognitive and genetic factors in the etiology of substance abuse. Examples of specific brief interventions with adolescents are described and possible avenues for future transdisciplinary research are explored. This expansive sourcebook will be of value to clinicians and academicians alike.     

Diphenylhydantoin-induced pure red cell aplasia after neurological surgery: report of two cases

Pure red cell aplasia (PRCA) is characterized by severe anemia, reticulocytopenia, marked selective hypoplasia of the erythroid precursor cells in the bone marrow and normal peripheral leukocyte and platelet counts. We reported two cases of diphenylhydantoin (DPH)-induced PRCA after neurological surgery. They recovered completely with discontinuance of DPH therapy. Neurosurgeons should be aware of this side effect because most reported cases of PRCA have occurred about a few months after neurological surgery under general anaesthesia and DPH therapy.     

Current vena cava filter devices and results

The critical focus in the acute management of deep vein thrombosis (DVT) continues to be the effective prevention of associated life-threatening pulmonary embolism (PE) and the achievement of survival for those in whom such emboli occur. As such, primary treatment for DVT or PE demands adequate anticoagulation with intravenous heparin followed by maintenance oral warfarin for 3 to 6 months. This centered approach successfully prevents 90% to 95% of cases of associated pulmonary embolism. However, under circumstances in which anticoagulation cannot be used, or in which it fails, there is clear indication for placement of a mechanical filter into the inferior vena cava to provide a protective barrier against the passage of clinically significant emboli from pelvic or lower extremity veins. Considerable technical ingenuity and continued evolution of materials and design have propelled the development and number of vena cava filters available for clinical use. Variable data on safety and effectiveness require physicians to match the best filter to each patient's particular situation and anatomy. However, many interventional radiologists and surgeons often base their filter selection on ease of insertion and device cost. Thus, it is paramount that physician users of these devices remember that the primary objective of vena cava filtration is to provide a safe and effective device for permanent implantation. If this objective is not met, the quality of care in the management of deep venous thrombosis or pulmonary embolism will diminish.     

After shoulder dystocia: managing the subsequent pregnancy and delivery

Among risk factors for shoulder dystocia, a prior history of delivery complicated by shoulder dystocia is the single greatest risk factor for shoulder dystocia occurrence, with odds ratios 7 to 10 times that of the general population. Recurrence rates have been reported to be as high as 16%. Whereas prevention of shoulder dystocia in the general population is neither feasible nor cost-effective, intervention efforts directed at the particular subgroup of women with a prior history of shoulder dystocia can concentrate on potentially modifiable risk factors and individualized management strategies that can minimize recurrence and the associated significant morbidities and mortality.     

A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer

BACKGROUND: Sentinel lymph node biopsy (SLNB) is an established means of staging the axilla in patients with breast cancer. Recently, methylene blue dye has been shown to be an efficacious and cost-effective alternative to isosulfan blue. With the increasing popularity of SLNB, the potential complications of isosulfan blue use must be appreciated. METHODS: A literature search for English language articles available on MEDLINE from 1985 to November 2002 using the search terms allergy, allergic reaction, anaphylactic reactions, anaphylaxis, blue dye, breast cancer, isosulfan blue, methylene blue, and sentinel lymph node biopsy identified 24 reports. CONCLUSIONS: The use of isosulfan blue due for SLNB is associated with a significant number of allergic reactions, some of which are life-threatening. Because methylene blue dye has been shown to be equally effective and does not pose a serious risk of serious allergic reactions, it offers an improved technique above isosulfan blue dye for SLNB.