Dosing Activity and Returning to Pre-Ulcer Function in Diabetic Foot Remission: Patient Recommendations and Guidance from the Limb Preservation Consortium at USC and The National Rehabilitation Center at Rancho Los Amigos

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality and healthcare costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility, decreased moderate intensity exercise when compared to people with diabetes without ulcers. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year following healing and the majority occurs in the first three months following wound healing. Hence this period after ulceration is called "remission" due to this risk for re-ulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate offloading and monitoring in people with a recently healed foot ulcer, foot reconstruction or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring which can identify dangerous "hot spots" prone to recurrence. By understanding areas at risk, it empowers patients to maximize ulcer-free days and to enable an improved quality of life. There is a current absence of high-quality evidence and standardized clinical algorithms for the post-ulcerative period. This perspective outlines this institution's unified strategy to treat patients in the remission period after ulceration. This approach utilizes the available evidence, identifies patient preferences, and relies on good clinical judgement for the best long-term outcomes for this patient population. Hence this position statement aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patient to ensure a safe transition to footwear and return to activity.

TATALAKSANA STOMATITIS ALERGICA PADA PENDERITA YANG MENGALAMI STRESS (Management of Allergic Stomatitisin Patient with Stress)

Introduction: Allergic stomatitisis ahypersensitivity reaction caused by allergens, such as drugs, food, and dental materials. Manifestation allergic reaction to food in oral cavity can be recurrent ulcer. Purpose: This case report pupose to report management allergic stomatitis in Stress condition.Case: female was a 44-year-old with complaintmany stomatitis in oral cavity. Patients say often since ± 6 years ago without knowing the cause. Stomatitis often moving location but also in the same site. On intra oral examination found ulcer multiple, variant size, irregular shape, paintfull.Management: the patient performed examination of total IgE with a result of 642.98 (normal<150), skin prick test in patients results positive on dust house, dog hair, cotton, beef, cow's milk, chicken egg yolk, shrimp, milkfish, pindang, chocolate, and peanuts.Patients given aloe vera extract oral rinse at the first visit, then after skin prick test was given methylprednisolone, hepaprotector caplet, multivitamin B-Complex plus Zinc. Patients are also given education and instruction to avoid a food become allergic. Conclusion: Allergic Stomatitis diagnosis requires a complete history and supportive examination. In this case, the treatment requires good cooperation between the patient and the dentist so that treatment can be done thoroughly.

An Atypical Case of Vasculitis: When ‘Occult’ 18FDG-PET Scan Findings Create a Classification Dilemma

We describe a 66-year old patient with a recurrent ulcer on her right ankle. Biopsy revealed medium-vessel vasculitis consistent with cutaneous polyarteritis nodosa. There were no signs or symptoms suggestive of systemic vasculitis, but a 18FDG-PET scan showed areas of increased uptake around the large arteries and the pelvic and shoulder girdles. These findings suggested polymyalgia rheumatica in the setting of large-vessel vasculitis. This case thus supports the statement from the Chapel-Hill consensus conference that classification of systemic vasculitis by vessel size is based on the vessels predominantly involved, but vessels of other sizes may also be affected.

Treatment for Canine Corneal Ulcer using Adipose Tissue-derived Mesenchymal Stem Cell Therapy - Case Report

Corneal ulcer (CU) is an ophthalmopathy characterized by depression of the corneal surface with at least one stromal loss. CU is common in canine and feline species and is usually caused, among others, by trauma, infections, toxic contamination and endocrine disorders. They usually result from an increased inflammatory response and are associated with some clinical signs such as blepharospasm, photophobia, epiphora, pain and loss of corneal transparency. Despite advances in conventional and pharmacological therapy, in many cases indolent and recurrent ulcer treatments still lead to loss of visual acuity of the animal. This paper aims to report the effect of topical application of canine adipose tissue-derived mesenchymal stem cell (cATMSCs) as treatment of recurrent CU in a Poodle dog breed that showed clear difficulty in the healing process associated with diabetes. The animal was submitted to two applications of cATMSCs and showed improvement in the blepharospasm, conjunctival hyperemia, mucopurulent ocular secretion, photophobia, corneal opacity, chemosis, pigmentation, neovascularization, and pain parameters. Besides, Fluorescein test, Schirmer test and ocular fundus exam also showed improvement in their values concomitantly with lesion resolution. Due this, we showed that cATMSC therapy contribute to the regeneration of corneal tissue in CU and may contribute to the treatment to others ophthalmopathies.

Treatment for Canine Corneal Ulcer using Adipose Tissuederived Mesenchymal Stem Cell Therapy - Case Report

Corneal ulcer (CU) is an ophthalmopathy characterized by depression of the corneal surface with at least one stromal loss. CU is common in canine and feline species and is usually caused, among others, by trauma, infections, toxic contamination and endocrine disorders. They usually result from an increased inflammatory response and are associated with some clinical signs such as blepharospasm, photophobia, epiphora, pain and loss of corneal transparency. Despite advances in conventional and pharmacological therapy, in many cases indolent and recurrent ulcer treatments still lead to loss of visual acuity of the animal. This paper aims to report the effect of topical application of canine adipose tissue-derived mesenchymal stem cell (cATMSCs) as treatment of recurrent CU in a Poodle dog breed that showed clear difficulty in the healing process associated with diabetes. The animal was submitted to two applications of cATMSCs and showed improvement in the blepharospasm, conjunctival hyperemia, mucopurulent ocular secretion, photophobia, corneal opacity, chemosis, pigmentation, neovascularization, and pain parameters. Besides, Fluorescein test, Schirmer test and ocular fundus exam also showed improvement in their values concomitantly with lesion resolution. Due this, we showed that cATMSC therapy contribute to the regeneration of corneal tissue in CU and may contribute to the treatment to others ophthalmopathies.

PO 18251 - Functional clinical outcome of the conservative treatment of calcaneal fractures in patients with diabetic neuropathy

Introduction: Calcaneal fractures are potentially serious in diabetic patients with foot insensitivity. The consensus is that surgical treatment involves a high risk of complications in these cases, and conservative treatment is the option of choice because it allows monitoring of the onset of pressure ulcers and the degree of hindfoot collapse, which usually occurs as Charcot arthropathy progresses. Objective: To retrospectively evaluate the mid-term functional clinical outcome of conservative treatment of calcaneal fractures in diabetic patients with advanced peripheral neuropathy associated with loss of protective foot sensitivity. Methods: Fifteen patients (16 feet), 12 men and 3 women, whose mean age at the time of the calcaneal fracture was 53 years (ranging from 34 to 70 years) were retrospectively evaluated after conservative treatment with total contact casting. We considered a functional clinical outcome good when the foot was plantigrade and ulcer-free and the patient could wear deep footwear with custom-made insoles for insensitive feet. The outcome was considered acceptable when the patient had residual deformity requiring custom-made polypropylene ankle-foot orthosis (AFO) braces. The outcome was considered poor when extremity amputation was required, when the patient was unable to bear weight on the foot during gait due to hindfoot instability as a result of the fracture, or when the patient showed recurrent ulcer due to bone prominence resulting from fracture malunion. Results: After a mean follow-up time of 40 months (ranging from 12 to 168 months), we assessed a good outcome in 10 feet, an acceptable outcome in 2 feet with braceable residual deformity, and a poor outcome in 4 feet, 3 of which had recurrent ulcers in the foot support area and another that required amputation due to severe infection. Conclusion: Conservative treatment with total contact casting efficiently produced plantigrade, shoeable or braceable feet without pressure ulcers in approximately two-thirds of our small series of patients with diabetic foot insensitivity who suffered calcaneal fracture.

Temporal Vascular Changes in Leg with Ulcer Due to Autonomic Neuropathy

Background Vascular dysfunction dominates the clinical picture of peripheral autonomic neuropathy in lower extremity. Patients and Methods We have studied functional changes of leg vasculature in 30 patients with chronic ulceration due to peripheral autonomic neuropathy between clinical stages 1 and 3. They suffered from lower extremity wounds. After sympathetic skin response test, pedal arterial blood flow analysis including peak systolic velocity (PSV) and pulsatility index (PI) was made by duplex ultrasonography (DUS) in involved legs. Vascular anatomy of leg was also examined by magnetic resonance angiography. Results The mean PSV value was found 58.32 cm/s in stage 1, 35.31 cm/s in stage 2, and 15.71 cm/s in stage 3. The mean PI value was observed 1.17 in stage 1, 1.43 in stage 2, and 1.87 in stage 3. In chronic stage 3, three patients had inadequate arterial blood supply and recurrent ulcer. Conclusions We suggest that reduced sympathetic activity due to small fiber neuropathy causes temporal variations in leg blood flow. There was a nonlinear relationship between vascular functional changes and stages of disease with increased, intermediate, and decreased blood flow, respectively. DUS assessment of pedal arteries contributed to differentiation of clinical stages and permitted vascular evaluation in the course of peripheral autonomic neuropathy.

Prevention of recurrent idiopathic gastroduodenal ulcer bleeding: a double-blind, randomised trial

ObjectivePatients with a history of Helicobacter pylori-negative idiopathic bleeding ulcers have a considerable risk of recurrent ulcer complications. We hypothesised that a proton pump inhibitor (lansoprazole) is superior to a histamine 2 receptor antagonist (famotidine) for the prevention of recurrent ulcer bleeding in such patients.DesignIn this industry-independent, double-blind, randomised trial, we recruited patients with a history of idiopathic bleeding ulcers. After ulcer healing, we randomly assigned (1:1) patients to receive oral lansoprazole 30 mg or famotidine 40 mg daily for 24 months. The primary endpoint was recurrent upper GI bleeding within 24 months, analysed in the intention-to-treat population as determined by an independent adjudication committee.ResultsBetween 2010 and 2018, we enrolled 228 patients (114 patients in each study group). Recurrent upper GI bleeding occurred in one patient receiving lansoprazole (duodenal ulcer) and three receiving famotidine (two gastric ulcers and one duodenal ulcer). The cumulative incidence of recurrent upper GI bleeding in 24 months was 0.88% (95% CI 0.08% to 4.37%) in the lansoprazole arm and 2.63% (95% CI 0.71% to 6.91%) in the famotidine arm (p=0.313; crude HR 0.33, 95% CI 0.03 to 3.16, p=0.336). None of the patients who rebled used aspirin, non-steroidal anti-inflammatory drugs or other antithrombotic drugs.ConclusionThis 2-year, double-blind randomised trial showed that among patients with a history of H. pylori-negative idiopathic ulcer bleeding, recurrent bleeding rates were comparable between users of lansoprazole and famotidine, although a small difference in efficacy cannot be excluded.Trial registration numberNCT01180179; Results.

Successful Treatment of medically refractory scleroderma digital gangrene with long-term continuous brachial plexus block

Raynaud’s phenomenon (RP) is the earliest and most common clinical manifestation of scleroderma, occurring in 90 to 98% of patients [1]. A combination of sympathetically mediated vasospasm and vasoocclusive disease has been implicated in the etiology of digital ischemic phenomenon [2,3], and treatment of RP is directed towards relieving vasospasm and restoring blood flow. Therefore, cervicothoracic or peripheral sympatholysis and digital artery reconstruction have been performed for medically refractory RP with scleroderma even though all procedures have some limitations. Thoracoscopic symapthectomy has recently been shown to have an initial improvement, although almost always relapses 6 months after the treatment [4,5]. Surgery of the hand, including digital sympathectomy and arterial reconstruction, for scleroderma might have favorable outcomes [6,7]. However, it would be a limited treatment option because of a recurrent ulcer after surgery [8], delayed wound healing [8,9], and development of complex regional pain syndrome [10]. Another alternative and less invasive treatment for blocking the sympathetic outflow would be a sympathetic block with local anesthetics [11,12]. These therapies are based on the premise that excessive sympathetic activity may be involved in the pathogenesis of digital ischemia.