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What percentage of persons living with diabetes will experience a diabetic foot ulcer (DFU)?How are copper nanoparticles effective in the treatment of DFUs?What are common adjunct therapies in the treatment of DFUs?What pathogens commonly colonize DFUs, and how are they approached?

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Many patients hospitalized with coronavirus disease 2019 are treated with venovenous extracorporeal membrane oxygenation and prone positioning to optimize oxygenation. However, this combination can result in lower extremity tissue necrosis, especially without adequate offloading. We report the case of a 31-year-old man who required mechanical ventilation and venovenous extracorporeal membrane oxygenation secondary to complications from coronavirus disease 2019, and subsequently developed pedal dry gangrene. The patient was discharged and healed without requiring an amputation. Our institution has since revised the prone positioning protocol to address offloading the lower extremities and feet.

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OBJECTIVE: To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices. DATA SOURCES: Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015). STUDY DESIGN: We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator. PRINCIPAL FINDINGS: Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy. CONCLUSIONS: Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

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OBJECTIVE: To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. METHODS: Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. RESULTS: In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. CONCLUSION: Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

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Two new species, Fomitopsis mounceae and F. schrenkii (Polyporales, Basidiomycota) in the F. pinicola species complex in North America, are described and illustrated. Previous molecular phylogenetic analyses identified three well-delimited lineages that represent F. mounceae and F. ochracea from Canada, the Appalachian Mountains, and the northern United States and F. schrenkii from western and southwestern regions of the United States. Fomitopsis pinicola sensu stricto is restricted to Eurasia and does not occur in North America. Morphological descriptions of basidiocarps and cultures for F. mounceae, F. schrenkii, and F. ochracea are presented. The three species are readily differentiated by nuc rDNA internal transcribed spacer (ITS1-5.8S-ITS2 = ITS) sequence, geographic distribution, and basidiospore size. Polyporus ponderosus H. Schrenk is an earlier illegitimate synonym of F. schrenkii. Both F. mounceae and F. schrenkii have a heterothallic multiallelic incompatibility system.

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OBJECTIVE: The purpose of this study is to determine the utility of using indocyanine green fluorescence angiography (IGFA) in assessing perfusion of chronic wounds after hyperbaric oxygen (HBO2) therapy. METHODS: From May 2016 to January 2018, 26 patients underwent both HBO2 and IGFA. A near-infrared charge-coupled camera measured the flow of intravenous indocyanine green into the wound. IGFA was done pre-HBO2, after approximately 10 HBO2 sessions, and upon completion of HBO2. The ingress rate at baseline, mid-therapy and post-HBO2 values were compared using descriptive statistics. RESULTS: A total of 26 chronic wounds were identified. Baseline median ingress rate was 0.90 units/second (IQR: 0.28 to 6.10). Median ingress rate after approximately of 10 HBO2 sessions was 2.45 units/sec (IQR: 0.48 to 6.35). Six of 11 patients, however, exhibited a decrease in ingress rate from baseline to mid-therapy. Finally, median ingress rate post-HBO2 was 3.70 units/second (IQR: 0.30 to 9.90). Median increase in ingress and rate from baseline to mid-HBO2 treatment 0.30 units/second (IQR: -0.25 to 3.10) and from mid- to post-HBO2 was -0.40 units/second (IQR: -1.50 to 2.60). CONCLUSIONS: This preliminary study shows capability of IGFA to detect changes in blood flow to wounds following HBO2 therapy. Results support the use of IGFA to evaluate the changes in perfusion of patients undergoing HBO2 for chronic wounds. A larger sample size may help clarify the benefit of IGFA to predict potential for wound healing.

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Fungal species with a broad distribution may exhibit considerable genetic variation over their geographic ranges. Variation may develop among populations based on geographic isolation, lack of migration, and genetic drift, though this genetic variation may not always be evident when examining phenotypic characters. Fomitopsis pinicola is an abundant saprotrophic fungus found on decaying logs throughout temperate regions of the Northern Hemisphere. Phylogenetic studies have addressed the relationship of F. pinicola to other wood-rotting fungi, but pan-continental variation within F. pinicola has not been addressed using molecular data. While forms found growing on hardwood and softwood hosts exhibit variation in habit and appearance, it is unknown if these forms are genetically distinct. In this study, we generated DNA sequences of the nuc rDNA internal transcribed spacers (ITS), the TEF1 gene encoding translation elongation factor 1-α, and the RPB2 gene encoding the second largest subunit of RNA polymerase II for collections across all major geographic regions where this fungus occurs, with a primary focus on North America. We used Bayesian and maximum likelihood analyses and evaluated the gene trees within the species tree using coalescent methods to elucidate evolutionarily independent lineages. We find that F. pinicola sensu lato encompasses four well-supported, congruent clades: a European clade, southwestern US clade, and two sympatric northern North American clades. Each clade represents distinct species according to phylogenetic and population-genetic species concepts. Morphological data currently available for F. pinicola do not delimit these species, and three of the species are not specific to either hardwood or softwood trees. Originally described from Europe, F. pinicola appears to be restricted to Eurasia. Based on DNA data obtained from an isotype, one well-defined and widespread clade found only in North America represents the recently described Fomitopsis ochracea The remaining two North American clades represent previously undescribed species.

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Fungal species with a broad distribution may exhibit considerable genetic variation over their geographic ranges. Variation may develop among populations based on geographic isolation, lack of migration, and genetic drift, though this genetic variation may not always be evident when examining phenotypic characters. Fomitopsis pinicola is an abundant saprotrophic fungus found on decaying logs throughout temperate regions of the Northern Hemisphere. Phylogenetic studies have addressed the relationship of F. pinicola to other wood-rotting fungi, but pan-continental variation within F. pinicola has not been addressed using molecular data. While forms found growing on hardwood and softwood hosts exhibit variation in habit and appearance, it is unknown if these forms are genetically distinct. In this study, we generated DNA sequences of the nuc rDNA internal transcribed spacers (ITS), the TEF1 gene encoding translation elongation factor 1-α, and the RPB2 gene encoding the second largest subunit of RNA polymerase II for collections across all major geographic regions where this fungus occurs, with a primary focus on North America. We used Bayesian and maximum likelihood analyses and evaluated the gene trees within the species tree using coalescent methods to elucidate evolutionarily independent lineages. We find that F. pinicola sensu lato encompasses four well-supported, congruent clades: a European clade, southwestern US clade, and two sympatric northern North American clades. Each clade represents distinct species according to phylogenetic and population-genetic species concepts. Morphological data currently available for F. pinicola do not delimit these species, and three of the species are not specific to either hardwood or softwood trees. Originally described from Europe, F. pinicola appears to be restricted to Eurasia. Based on DNA data obtained from an isotype, one well-defined and widespread clade found only in North America represents the recently described Fomitopsis ochracea The remaining two North American clades represent previously undescribed species.

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Necrotizing fasciitis is a rare and potentially fatal infection, with mortality of up to 30%. This case report describes a patient recovering from a laryngectomy for laryngeal squamous cell cancer who developed nosocomial necrotizing fasciitis of the lower extremity due to Serratia marcescens . Only eight cases of necrotizing fasciitis exclusive to the lower extremity due to S marcescens have been previously reported. Patients with S marcescens necrotizing fasciitis of the lower extremity often have multiple comorbidities, are frequently immunosuppressed, and have a strikingly high mortality rate.

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Previous research has not compared implicit affective responses to smoking-related stimuli in occasional (i.e., those who smoke less than one cigarette per day) and daily smokers (i.e., those who smoke at least once per day). In addition to assessing their motivations for smoking, implicit affective responses were measured using the Affect Misattribution Procedure (AMP) in occasional (n=19) and daily smokers (n=34) to smoking-related and neutral cues. Half of the cues depicted a human interacting with an object (i.e., active), whereas the remaining cues depicted objects alone (i.e., inactive). Results indicated that for the active cues, daily smokers responded more positively to smoking-related than to neutral cues, whereas occasional smokers showed no difference in their implicit responses. In addition to smoking frequency, relative differences in implicit responses to active cues were related to cognitive enhancement motivation. For inactive cues, implicit responses were related to cognitive enhancement as well as reinforcement. Because daily smokers have more positive implicit responses to active smoking-related cues than occasional smokers, these cues may play an important role in maintaining smoking behavior in daily smokers.

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Synovial sarcoma arising in the foot is a rare finding. We report a 64-year-old female with synovial sarcoma involving the calcaneus and central plantar compartment. The patient presented with a 2-year history of painful heel with soft tissue mass presentation 21 months after initial pain. We performed an incisional biopsy with frozen section; histopathology was consistent with synovial sarcoma.

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Verrucous carcinoma is a rare variant of well-differentiated squamous cell carcinoma. It usually occurs in the oral cavity, genital area, and sole. Verrucous carcinoma of the sole, also called epithelioma cuniculatum, often presents a diagnostic challenge both clinically and histopathologically. The authors report such a case that mimics infected epidermal cyst and gout clinically.

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