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Objective:A new compound, Debrichem (DEBx Medical BV, the Netherlands), a topical desiccation agent (TDA), is an active gel that contains an acidic species with a potent hygroscopic action. When in contact with microorganisms and necrosis, rapid desiccation and carbonisation of the proteins in these microorganisms, as well as of the extracellular matrix of biofilms and necrosis, occurs. The resulting ‘precipitate’ rapidly dislodges from the wound bed, resulting in a clean wound which granulates, which is a prerequisite for healing by secondary intention.Method:In a retrospective study, a series of mostly large and hard-to-heal lesions of different aetiologies were treated with a one-time application of the TDA, followed by weekly dressing changes.Results:Of the total of 54 lesions included in this case series, 22 were diagnosed as venous leg ulcers (VLUs), 20 as diabetic foot ulcers (DFUs), nine as post-traumatic, hard-to-heal lesions, two as vascular ulcers and one as an ischaemic ulcer. All of the VLUs, 75% of the DFUs and all of the other lesions reached complete granulation.Conclusion:The use of a TDA may contribute to the consistent, fast and easy removal of both biofilms and necrosis, and hence to wound healing.

The objective of this analysis was to describe in real-life settings the clinical outcomes and safety associated with daptomycin treatment in a cohort of patients with complicated skin and soft tissues infection (cSSTI). All patients with cSSTI who had received at least one dose of daptomycin between January 2006 and April 2012 were identified from a non-interventional, multicenter, retrospective registry (European Cubicin®Outcome Registry and Experience; EU–CORESM). Of the 6075 patients included in the EU-CORE registry, 1927 (31.7%) were diagnosed with cSSTI (male, 63.8%; median age, 63 years). The most frequent underlying diseases were cardiovascular disease (58.1%) and diabetes mellitus (40.7%). The most frequent cSSTIs included surgical site infections (34.9%), wound infections (20.2%) and diabetic foot infections (19.9%). The most frequently prescribed doses of daptomycin were 4 mg/kg/day (38.9%) and 6 mg/kg/day (35.2%). A total of 1126 (58.4%) patients received antibiotics prior to daptomycin treatment; treatment failure (53.7%) was the most common reason for switching to daptomycin. The majority of hospitalized patients (61.8%) were treated with concomitant antibiotics. Among patients with positive cultures, Staphylococcus aureus(51.9%; 673/1297) was the most common pathogen. The overall clinical success rate was 84.6%; for infections caused by S. aureus, the success rate was 87.2% (methicillin susceptible, 87.8%; methicillin resistant, 87.0%). Adverse events possibly related to daptomycin treatment were reported in 2.4% of patients and adverse events led to drug discontinuation in 2.4% of patients. Daptomycin treatment resulted in high clinical success rates in patients with different cSSTI subtypes, the majority of whom having failed previous antibiotic therapy. Daptomycin was well tolerated and there were no new or unexpected safety findings.

Background: Diabetic foot infection (DFI) is a serious, difficult-to-treat infection, especially when caused by methicillin-resistant Staphylococcus aureus(MRSA). Vancomycin has been the standard treatment for MRSA infection, but lower response rates in MRSA skin infections have been reported. This analysis assessed the outcome and safety of daptomycin therapy in patients with a DFI caused by MRSA.Methods: Using the Cubicin Outcomes Registry and Experience and the European Cubicin Outcomes Registry and Experience (2006–2009), 79 patients with MRSA DFI were identified and included in this analysis.Results: In the 74 evaluable patients, daptomycin was administered at a median dose of 4.8 mg/kg primarily every 24 hours (85.1) and for a median of 15.0 days. Overall, 77.0 of the patients (57 of 74) received initial therapy with activity against MRSA; however, of patients receiving daptomycin as second-line therapy (n 31), only 45.2 were treated with an antibiotic agent active against MRSA. The overall clinical success and treatment failure rates were 89.2 and 10.8, respectively. Success with daptomycin therapy was higher in patients who had surgery and in those whose initial therapy was daptomycin. Eleven patients had 14 adverse events, two of which were possibly related to daptomycin use and led to discontinuation.Conclusions: In a large real-world cohort of patients with MRSA DFI, daptomycin therapy was shown to be generally well tolerated and effective. The use of an anti-MRSA antibiotic agent should be considered when implementing first-line antibiotic drug therapy for DFI in countries where MRSA is common to avoid inappropriate empirical treatment and potential negative effects on outcomes.

BACKGROUND: Two different diagnostic strategies are used to perform compression (real-time) ultrasound for the diagnosis of clinically suspected deep-vein thrombosis. One is to examine the entire proximal venous system from common femoral to distal popliteal vein; the other is a limited examination of only the common femoral and the entire popliteal vein. The latter strategy, which is less time-consuming and requires less expensive equipment, is based on a strong impression from prospective studies using limited compression ultrasound that proximal vein thrombi always involve the common femoral or popliteal vein. This impression, which is supported by the demonstrated safety at long-term follow-up of not treating patients whose limited compression ultrasound is normal at presentation and then repeated within the next week, has not been tested in a formal study. Therefore, we reviewed a large series of venograms performed in consecutive patients with clinically suspected venous thrombosis to determine the distribution of venous thrombosis in symptomatic patients. METHODS: Venograms were performed using 150 mL of radiographic contrast material. Before the study, a panel of experts agreed on the standardized criteria for the assessment of venograms. Venograms were adjudicated blindly for the presence of deep vein thrombosis and to determine the distribution of proximal vein thrombosis and isolated calf-vein thrombosis, the size of proximal thrombi, and whether they were occlusive or nonocclusive. Subsequently, the duration of symptoms was related to the venographic findings. RESULTS: Five hundred sixty-two venograms from consecutive patients with a first episode of clinically suspected deep vein thrombosis were adjudicated. Of these, 20 (3.6%) were inadequate for interpretation. In the remaining 542, venous thrombosis was demonstrated in 189 instances (prevalence, 35%; 95% confidence interval, 31% to 39%) and were located in the proximal veins in 166 (88%; 95% confidence interval, 82% to 92%) venograms. Isolated calf-vein thrombosis was present in the remaining 23 (12%; 95% confidence interval, 8% to 18%) venograms. Proximal with concurrent calf thrombosis was detected in 164 (99%) of the 166 patients. Proximal thrombi involved only the popliteal vein in 16 (10%); the popliteal and superficial femoral veins in 70 (42%); and the popliteal, superficial, and common femoral vein in eight (5%); whereas thrombi involving the entire proximal deep venous system were detected in 58 (35%) venograms. Isolated thrombosis of the superficial femoral, common femoral, and iliac vein was not observed. Proximal venous thrombi were occlusive in 146 (88%) patients. No relation between the duration of symptoms and the extent or the occlusiveness of venous thrombi could be demonstrated. CONCLUSIONS: Most symptomatic patients have extensive occlusive proximal vein thrombosis at the time of presentation. Thrombi isolated to the superficial femoral or iliac vein were not observed in this large sample of consecutive patients. Our data support the use of the relatively simple, inexpensive, and rapid compression ultrasound method that limits the examination of the proximal veins to the common femoral and popliteal veins.(Arch Intern Med. 1993;153:2777-2780)

BACKGROUND: Epidemiologic studies on deep-vein thrombosis (DVT) have been mainly confined to the inpatient population. The aim of this study was to investigate the association between DVT and acquired risk factors in a large cohort of outpatients with clinically suspected DVT. METHODS: Consecutive outpatients with clinically suspected DVT were enrolled in the study. Before objective testing, all patients were interviewed by a trained physician for the presence of risk factors for DVT development. Subsequently, the presence or absence of DVT was assessed with venography. RESULTS: Approximately 50% of cases of DVT were considered to be secondary to a major risk factor (immobilization, trauma, and/or recent surgery). Among additional risk factors, only increased age (over 60 years), male gender, malignant neoplasm, heart failure, systemic lupus erythematosus, and arteriopathy were independently associated with the risk of acute DVT. CONCLUSION: Major risk factors for venous thromboembolism are a common cause of DVT among symptomatic outpatients; therefore, the usefulness of extending DVT prophylaxis in the outpatient setting should be tested. The role of additional risk factors in the development of DVT needs to be established by properly designed studies.(Arch Intern Med. 1994;154:164-168)

Deep-vein thrombosis of the lower extremity is a frequent disorder associated with morbidity and mortality due to pulmonary embolism and the postthrombotic syndrome. It was not until the introduction of contrast venography that the inaccuracy of the clinical diagnosis became apparent. Since then, management decisions have usually been based on objective diagnostic test. Venography is generally considered the reference method for the diagnosis of deep-vein thrombosis, but it is invasive and associated with serious side effects. Several noninvasive or less invasive objective diagnostic methods have been developed. These diagnostic methods are distinctly different in technology and consequently in their ability to demonstrate or refute deep-vein thrombosis. In this review, a critical analysis is provided on the accurary of the current noninvasive diagnostic approaches to venous thrombosis in patients with a first episode of clinically suspected deep-vein thrombosis. Results of studies were considered only when their methodology fulfilled the essential criteria for evaluation of a diagnostic test.

An important plasminogen activator-inhibitor (PAI-1) is present in plasma and concentrated in α-granules of platelets. PAI-1 is released during platelet stimulationin vitro. It is presently unknown to what extent the treatment with acetylsalicylic acid (ASA) inhibits platelet PAI-1 release and if release inhibition has an effect on plasma PAI-1 levels. We therefore investigated by a double-blind placebo-controlled crossover study the effects of oral ASA (500 mg/day for 3 days) on platelet PAI-1 release and on plasma PAI-1 levels of healthy male volunteers. The PAI-1 release from platelets stimulated by arachidonic acid and collagen was significantly reduced by ASA: from average values of 88 and 80% to 14 and 17%, respectively (p<0.01). However, plasma PAI-1 levels were not modified by this treatment. We can conclude that platelet PAI-1 release does not play a role in modulating the plasma PAI-1 levels in healthy volunteers.

BACKGROUND.— Serial testing with impedance plethysmography or compression ultrasonography has been demonstrated to be feasible and accurate for the detection of deep vein thrombosis (DVT) in symptomatic outpatients, and these techniques are replacing contrast venography in this patient category. Limited data, however, are available on the clinical utility of these noninvasive tests in symptomatic hospitalized patients. The objectives of our study were to determine the feasibility of ascending contrast venography and to evaluate the accuracy of these two noninvasive methods for the detection of DVT in symptomatic hospitalized patients. METHODS.— A prospective, "blind" comparison of impedance plethysmography and compression ultrasonography with ascending contrast venography was performed in consecutive hospitalized patients with clinically suspected DVT of the leg. RESULTS.— Of the 127 potentially eligible patients, 44 had to be excluded; 25 of these could not undergo venography (feasibility of venography, 80.3%). The sensitivity, specificity, and positive and negative predictive values of impedance plethysmography for proximal DVT were 96%, 83%, 82%, and 97%, respectively. For compression ultrasonography, these measures for proximal DVT were 97%, 86%, 87%, and 97%, respectively. The overall prevalence of DVT was 53%, of which 85% was located proximally. CONCLUSIONS.— Contrast venography cannot be performed in about 20% of consecutive symptomatic patients. Both impedance plethysmography and compression ultrasonography are feasible and valid alternatives to contrast venography in the diagnostic treatment of these patients.(Arch Intern Med. 1992;152:1901-1903)