IPC對于糖尿病足(病例報告)

1、Case ReportIPC對于糖尿病足（病例報告）Diabetic limb salvage using the Arterial Assist Device. ArtAssistPaul S. van Bemmelen, MD. PhD, Port Jefferson, NY andGerald J. Furst, DPM, Port Jefferson, NY 66 Year Old Male 35 Year Hx of diabetes Renal Failure Contralateral Tibial Bypass Poor Ambulation Small Vessel Dise

2、ase Amputation Great Toe/Metatarsal I Platelet Released Growth Factors IV and Oral Antibiotics Topical Antibiotics Surgical Debridements Applies Compression to Foot, Ankle and Calf Up to 100 mmHg Home use for 30 min. QID Improved Circulation Prepared Foot For Revision Surgery Figure 1Pulse Volume Re

3、cordingsFigure 2A 66 year old man with a 35 year history of diabetes (NIDDM) and chronic renal failure (peritoneal dialysis) presented with dry necrosis of his right great toe. He ambulated very little outside of his home and he had previously undergone a tibial bypass of the opposite leg. He was be

4、ing treated with platelet released growth factors for poor healing of his left distal ankle incision. Ankle blood pressure was not obtainable due to non-compressibility, but waveforms were consistent with disease of the small vessels distal to the knee. The metatarsal pulse volume recording is shown

5、 (Fig. 1) and is essentially flat. Toe-pressure was in the ischemic range. The patient underwent repeated selective digital intra-arterial angiography, which demonstrated patent arteries to the level of the ankle only, without named run-off vessels in the foot. After explaining the poor chances of h

6、ealing of a toe amputation to the patient, he underwent amputation of the right great toe and metatarsal head. Treatment with the ArtAssist device was not available at that time. The toe amputation failed and complete dehiscence, with exposed metatarsal bone was apparent in debridements and immediat

7、e treatment with growth factors were instituted. Further deterioration occurred slowly. Further revision foot amputation was not considered to be a worthwhile option and below-knee amputation would be the next surgical step.Intermittent compression with the ArtAssist device was started two months af

8、ter the toe amputation for at least 30 minutes, QID. Compression was well tolerated and after one week of home treatment, the patient noticed blood on his dressings. Slowly some granulation tissue appeared and the wound edges bled well with minor debridements. Improvement of the metatarsal pulse vol

9、ume recording was noted. In view of the exposed metatarsal bone, with retracted skin edges, a further resection of Metatarsal I and the adjacent second toes was performed after two months of compression therapy. Oral antibiotics were given based on culture results. The growth factor treatment was st

10、opped. The resulting wound is now healed by secondary intention (Fig 2). Further improvements occurred of the pulse volume recording at the metatarsal level, to the same amplitude as the bypassed side.Case ReportIPC對于糖尿病足（病例報告）Treatment of Non-Healing Lower Extremity UlcerationWith a New Form of Pro

11、gressive, Rapid, Pneumatic CompressionNancy D Shebel, MHA, RN, BSN, CVN, RVT and Duane Amundsen, MD, FACSGeneral Surgery/Section of Vascular SurgeryKaiser Permanente Medical Center Panorama City, California 36 y.o. male, 20+ years type I diabetes Retinopathy and peripheral neuropathy Renal failure,

12、6 years on hemodialysis Left below knee amputation Large right heel necrotic ulcer No runoff vessels for bypass surgery Surgical debridements IV, oral and topical antibiotics Standard wound care treatment Applies compression to foot, ankle and calf at 120mmHg Home use for 30 min.QID Increases blood

13、circulation Ulcer size decreased substantially Limb was saved Before ArtAssist TreatmentAfter 3 Months TreatmentAfter 8 Months TreatmentWe describe a new technology for treating non-healing arterial ulcers and limb salvage. This device increases blood flow by 2 to 4 times in diabetics and other pati

14、ents with ischemic limbs that are non-surgical candidates.1 We are reporting on a diabetic patient with a non-healing arterial heel ulcer expected to undergo right below knee amputation, since he was not a bypass candidate. The treatment options were amputation or to attempt ulcer healing with this

15、new technology- the ArtAssist*. Saving his leg would mean he could be fitted with a left leg prosthesis allowing a more normal lifestyle for a relatively young man. It was also a consideration that if the heel ulcer could be healed and the leg saved, he would be considered a candidate for a kidney t

16、ransplant.ArtAssist is a home use device that applies rapid progressive pneumatic compression while the patient is seated comfortably in a chair with the treated limb in a dependent position. ArtAssist rapidly applies 120mmHg pressure beginning at the foot, continuing to the ankle and then the calf,

17、 3 times a minute. The treatment consisted of 4, half hour sessions daily. This compression regimen simulates the beneficial effects of brisk walking, without pain or tissues trauma. Patient compliance is measeured with a hidden internal hour metter accessible only to the nurse.The limb was saved, d

18、espite the patients poor compliance (only 37 min. daily out of the 120 prescribed). Ulcer size decreased substantially over 8 months and complete healing was imminent. After the 8-month visit our patient did not return for any follow-up visits in our department, despite numersous attempts and phone

19、calls to him. Review of the clinical record after his demise 6 months later revealed that the heel ulcer never healed completely, but did not further deteriorate. The final reading from the internal hour meter indicated that the ArtAssist had not been used since his last visit.Recent clinical trials

20、 have proven the efficacy of ArtAssist for patients with intermittent claudication.2 Patients showed improvement in ankle brachial indices, and increased walking distances. The authors hypothesize these improvements are due to increased collateral circulation. Our experience at Kaiser Permanente sup

21、ports these findings in our limb threatened ulcer patients.Conclusion: Any patient presenting with a non-healing ulcer should be considered a candidate for this new therapy. We feel this is an important adjunct in treating our patients with peripheral arterial disease and we advocate its use in non-

22、surgical patients.References:1. Eze AR, Comerota AJ, Cisek PL, Holland BS, Robb PK, Veeramasuneni R, Comerota Jr. AJ. Intermittent calf and foot compression increases lower extremity blood flow. Society for Clinical Vascular Surgery, 24th Annual Symposium on Vascular Surgery. March 1996.2. Nicolaide

23、s AN, et. al. New Horizons and Techniques in Vascular and Endovascular Surgery. 24th Annual Symposium on Current Critical Problems. November 1997.Case ReportIPC對于糖尿病足（病例報告）Treatment of non-reconstructable PVD with the Arterial Assist DevicePaul S. van Bemmelen, MD, Stony Brook, NY andValerie A. Brun

24、etti, DPM, Northport, NY 68 y.o. male with diabetes 4-month history of rest pain and progressive necrosis PVRs were diminished, flat wave form at toe level No run-off towards the toe Applied intermittent compression to foot, ankle and calf at 120mmHg Home use 1 hour, q.i.d. Metatarsal PVR-amplitude

25、increased The lesions are almost healed (second toe completely healed) Figure 1Figure 2Figure 3Patient is a 68 year-old man with diabetes; status post Coronary Artery Bypass Graft (CABG), Carotid Endarterectomy (CEA) and bilateral femoro-popliteal bypass and bilateral profundaplasty. Patient present

26、ed with a 4-month history of rest-pain and progressive necrosis of the right hallux (figure 1). A small lesion was developing on the tip of the second toe. Non-invastive pulse-volume recording (PVR) demonstrated a diminished amplitude of 3mm at the metatarsal level, with a flat waveform at toe level

27、. Arteriography demonstrated patent vessels down to the ankle, but no run-off towards the forefoot (figure 2). Patient used ArtAssist compression for one hour, q.i.d. Topical treatment consisted of a non-adherent dressing only and minor debridements in the office. After completion of a 3-month compr

28、ession protocol, the lesions were almost healed (figure 3). Metatarsal PVR-amplitude increased to 9mm. Note the tip of the second toe, which was already healed after one month. ArtAssist can increase skin-flow more than 4 times.1,2UPDATE: COMPLETELY HEALEDReferences:1. van Bemmelen PS, Weiss-olmanni

29、 J, Ricotta JJ: Rapid intermittent compression increases skin circulation in chronically ischemic legs with infra-popliteal obstruction. VASA 2000;29:47-52.2. Eze AR, comerota AJ, et al. Intermittent calf and foot compression increases lower extremity blood flow. Am J Surg. 1996;172:130-135.WEB上，并且開

30、發(fā)出了HotJava的第一個版本。當(dāng)SUN公司1995年正式以Java這個名字推出的時候，幾乎所有的WEB開發(fā)人員都心生感嘆：噢，這正是我想要的！于是Java成了一顆耀眼的明星，丑小鴨一下子變成了白天鵝。異常表示程序運行過程中可能出現(xiàn)的非正常狀態(tài)，運行時異常表示虛擬機的通常操作中可能遇到的異常，是一種常見運行錯誤。java編譯器要求方法必須聲明拋出可能發(fā)生的非運行時異常，但是并不要求必須聲明拋出未被捕獲的運行時異常。6、說出Servlet的生命周期，并說出Servlet和CGI的區(qū)別。Servlet被服務(wù)器實例化后，容器運行其init方法，請求到達時運行其service方法，service方法

31、自動派遣運行與請求對應(yīng)的doXXX方法（doGet，doPost）等，當(dāng)服務(wù)器決定將實例銷毀的時候調(diào)用其destroy方法。與cgi的區(qū)別在于servlet處于服務(wù)器進程中，它通過多線程方式運行其service方法，一個實例可以服務(wù)于多個請求，并且其實例一般不會銷毀，而CGI對每個請求都產(chǎn)生新的進程，服務(wù)完成后就銷毀，所以效率上低于servlet。7、說出ArrayList,Vector, LinkedList的存儲性能和特性ArrayList和Vector都是使用數(shù)組方式存儲數(shù)據(jù)，此數(shù)組元素數(shù)大于實際存儲的數(shù)據(jù)以便增加和插入元素，它們都允許直接按序號索引元素，但是插入元素要涉及數(shù)組元素移動等

32、內(nèi)存操作，所以索引數(shù)據(jù)快而插入數(shù)據(jù)慢，Vector由于使用了synchronized方法（線程安全），通常性能上較ArrayList差，而LinkedList使用雙向鏈表實現(xiàn)存儲，按序號索引數(shù)據(jù)需要進行前向或后向遍歷，但是插入數(shù)據(jù)時只需要記錄本項的前后項即可，所以插入速度較快。8、EJB是基于哪些技術(shù)實現(xiàn)的？并說出SessionBean和EntityBean的區(qū)別，StatefulBean和StatelessBean的區(qū)別。EJB包括Session Bean、Entity Bean、Message Driven Bean，基于JNDI、RMI、JAT等技術(shù)實現(xiàn)。SessionBean在J2EE

33、應(yīng)用程序中被用來完成一些服務(wù)器端的業(yè)務(wù)操作，例如訪問數(shù)據(jù)庫、調(diào)用其他EJB組件。EntityBean被用來代表應(yīng)用系統(tǒng)中用到的數(shù)據(jù)。對于客戶機，SessionBean是一種非持久性對象，它實現(xiàn)某些在服務(wù)器上運行的業(yè)務(wù)邏輯。對于客戶機，EntityBean是一種持久性對象，它代表一個存儲在持久性存儲器中的實體的對象視圖，或是一個由現(xiàn)有企業(yè)應(yīng)用程序?qū)崿F(xiàn)的實體。Session Bean 還可以再細分為 Stateful Session Bean 與 Stateless Session Bean ，這兩種的 Session Bean都可以將系統(tǒng)邏輯放在 method之中執(zhí)行，不同的是 Stateful

34、 Session Bean 可以記錄呼叫者的狀態(tài)，因此通常來說，一個使用者會有一個相對應(yīng)的 Stateful Session Bean 的實體。Stateless Session Bean 雖然也是邏輯組件，但是他卻不負責(zé)記錄使用者狀態(tài)，也就是說當(dāng)使用者呼叫 Stateless Session Bean 的時候，EJB Container 并不會找尋特定的 Stateless Session Bean 的實體來執(zhí)行這個 method。換言之，很可能數(shù)個使用者在執(zhí)行某個 Stateless Session Bean 的 methods 時，會是同一個 Bean 的 Instance 在執(zhí)行。從內(nèi)存方面來看， Stateful Session Bean 與 Stat