WASHINGTON –  A 24-year-old American soldier died of rabies after being bitten by a dog last year in Afghanistan, US health officials said Thursday following an investigation into the rare case.

The otherwise healthy soldier started experiencing symptoms of shoulder and neck pain and tingling sensations in his hands soon after arriving at Fort Drum, N.Y., in mid-August 2011.

His condition escalated to include nausea, vomiting, anxiety and trouble swallowing. By the time he was admitted to an emergency room, he was dehydrated and hydrophobic, meaning he developed an intense fear of drinking liquids because of the painful muscle spasms he experienced while swallowing.

“He was lucid and described having received a dog bite on the right hand during January 2011 while deployed to Afghanistan,” said the report by the US Centers for Disease Control and Prevention (CDC).

The soldier tested positive for a strain of rabies associated with dogs in Afghanistan and doctors attempted an experimental treatment to save him from certain death.

But within days, the patient was suffering from severe brain hemorrhaging and his family decided to take him off life support. He was the first US service member to die of rabies since 1974.

At the time of the bite, the soldier told family members and close friends that he had been bitten by a feral dog in Afghanistan and had sought medical treatment, “which he described as wound cleansing and injections,” the report said.

But an investigation by the US Army turned up no documentation of a reported bite wound or treatment, nor any record of a dog tested for rabies, according to the report.

The soldier’s case prompted a scare that he may have spread the disease other people and a CDC investigation tracked down about 190 individuals he interacted with while potentially infectious.

At least 22 of them received treatment as a preventive measure.

Rabies can spread through saliva, tears, spinal fluid or brain tissue that enters the body through a bite a broken skin. With the exception of transplantation, the CDC said “human-to-human rabies transmission has not been laboratory-documented.”

April 21, 2012 12:00 am by Lawrence Gerson, V.M.D.

Spring is in full bloom, and peak allergy season is not far behind. just like people, pets react to inhaled allergens.

Ask anyone with a black car if tree pollens are out this time of year, as you can actually see the pollen on the surface of a clean car. Later in the season grass pollens fill the air followed by the weeds late in the summer. Add in the possibility of food allergies, and in some cases flea allergy, and that is why we see itchy pets until winter sets in.

Additionally molds, dust and a number of other substances can stimulate an itchy reaction in pets. Sneezing and a runny nose are not seen as much in pets. What we see is itching, especially of the face and feet, as well as ear and skin irritation. we often call the itchy condition atopy.

Atopy and its associated hot spots and ear problems are the most common ailments we see in companion animals. Some dogs can be itchy without any skin lesions. others scratch themselves and create open bleeding sores.

Owners may learn to avoid exposure to the outdoors with allergic pets. Keeping pets away from fresh cut grass or high weeds can help prevent reactions. Even a simple bath can remove allergens and reduce itching. Some of these dogs do not need treatment, but some do better with a prescription for antihistamines.

Moderately affected dogs may require antihistamines and corticosteroids. Veterinarians must use corticosteroids carefully due to the side effects of increasing water consumption and urine output. many a dog has had urine accidents in the home from too much medication. Owners are always cautioned to use as little corticosteroid medication as possible to provide relief from allergy symptoms. after controlling atopy we taper the dose of corticosteroids to an every other day schedule when possible to not further suppress the adrenal gland. The cortico-steroids are anti-inflammatory and help to stop the body from reacting to the allergen.

Severe problems in dogs can be seen when allergies persist for a prolonged period of time and dogs have irritated their face and feet. Some of the severe atopy in dogs requires allergy testing and hypo sensitization. this process is similar to allergy injections in people with a slow increase in exposure to antigens. The process can be difficult and not always successful after months or even a year of injections. The benefit is, if injections work, we can decrease the use of other medication.

Recently we have been using cyclosporine as an immune modulator to decrease the reaction to allergens. although expensive and with some potential side effects, cyclosporine can be useful to decrease the chronic use of corticosteroids. this new treatment may be safer in the long run to help animals be more comfortable.

In pets that are itchy all year we sometimes suspect foods as an additional factor. Special diets with limited antigens of protein and carbohydrates are sometimes tried in a food elimination trial. many pets will benefit from diets of fish and potatoes because of the limiting of other antigens in the regular food and the high fatty acids in the fish. Owners who change their pet diets to lamb or fish will make it more difficult to use that type of diet in a food trial later in life. When we have an itchy pet we always make sure they are on a good diet and we often supplement with omega-3 fatty acid supplements.

Flea season brings a whole new set of pets into the office. Even if no fleas are seen on exam, fleas can be an issue as pets react to the flea saliva. Combine an allergic pet with a few flea bites, and it can have a massive breakout of skin issues. Cats can often groom off fleas, and veterinarians often have to look for flea dirt or observe the distribution pattern of the hair loss.

Cats are seen at the veterinary office for a variety of skin issues. Flea allergy and other itchy conditions are often treated with a long-acting corticosteroid injection. although less of a problem with side effects, caution is again advised because diabetes in cats can be an issue with too frequent injections.

Dogs that are itchy can scratch or chew large open sores called “hot spots” very quickly. these hot spots need to be shaved, cleaned and treated before they progress to larger and deeper wounds. Topical and oral antibiotics and corticosteroids are used to help these hot spots to heal. Additionally tranquilizers and Elizabethan collars are sometimes needed to prevent self trauma.

Veterinarians see ear infections in pets daily. although we usually use a combination with topical antibiotics, corticosteroid and yeast medications along with an ear cleaner, the underlining problem is often atopy.

Once a pet's skin is irritated, skin infections can be the primary or secondary problem. Weeks of appropriate antibiotic therapy may be needed to get skin infections under control.

Allergies in pets can be mild, moderate or severe. getting a proper diagnosis and treatment is critical to control atopy, and that can make pets more comfortable throughout the allergy season.

MAHASKA COUNTY – Mahaska Health Partnership Public Health cautions you to protect yourself against tick bites.

“It’s not just spring flowers that came out early this year due to our unseasonably mild winter, ticks have also become active in recent weeks,” MHP Public Health Coordinator Patty Malloy, RN, said. “It’s important to protect yourself because ticks can carry and spread many viruses.”

The Iowa Department of Public Health (IDPH) said the best way to prevent tick bites is to avoid wooded and grassy areas, where ticks are usually found. If you do spend time in these areas, they recommend:

· Wearing long-sleeved shirts and long, light-colored pants tucked into your socks or boots.

· Staying on trails when walking or hiking and avoiding tall grass.

· using insect repellents that contain DEET (closely follow the label instructions, not recommended for children under 2 months of age).

· Checking yourself, your children and your pets for ticks after spending time outside. Ticks tend to prefer the back of the knee, armpit, scalp, groin and neck area.

“Ticks can carry organisms that cause Rocky Mountain Spotted Fever, Ehrlichiosis and Lyme disease,” Malloy said. “Lyme disease is the most common virus ticks spread, and it doesn’t always cause the same symptoms in every infected person. The earliest sign of Lyme disease is a rash that may appear within a few days to a month of a tick bite.

“The rash will first look like a small, red bump; then it will expand until it begins to look like a bulls eye, with a red center and red ring around it.”

If you discover a tick on your body, the IDPH recommends removing it right away. The Centers for Disease Control (CDC) suggested carefully grasping the tick’s mouthparts with tweezers. this part will usually be close to the skin; do not squeeze the tick’s body. Pull steadily away from the skin; then clean the wound and disinfect the insect bite.

“Following these instructions can reduce your risk of developing a tick-related illness,” Malloy said. “Folk remedies such as burning the tick with a match or covering it with petroleum jelly or nail polish are not effective.”

For more information about tick activity in your area, visit ent.iastate.edu/medent/ticks_IA. to learn more about how Mahaska Health Partnership is making Healthcare Personal, visit mahaskahealth.org.

If you are planning to get pregnant and are suffering from hypertension, you had better work on your hypertension first!

Research at the Department of Psychiatry and Behavioral Sciences at the University of Washington has shown that women with hypertension before pregnancy had a 55-65% more chance of developing post-partum depression. The study was done on around 2300 women receiving prenatal care at a clinic in Seattle, Washington. The subjects were evaluated for depressive symptoms and the evidence of pre-existing hypertension. Previously, it was suspected that post-partum depression was linked to pregnancy-induced hypertension and pre-eclampsia. However, this study showed that there is no such link.

December 28, 2011 12:35 PM

Avoid ‘Sunburn’ If you have Lupus

By Zulkiple Ibrahim This is the second of two articles on Systemic Lupus Erythematosus (SLE), also known as lupus, while lupus is a widespread disease, awareness of it among Malaysians lags behind many other illnesses. According to medical authorities, if there were greater lupus awareness, lupus patients would not feel so isolated and would receive the support they deserve. KUALA LUMPUR, Dec 28 (Bernama) — Fans of Malay television drama will certainly recall a recent series named “Stanza Cinta,” in which a doctor told the lead character to avoid excessive sunlight. the lead character happened to be a patient diagnosed with Systemic Lupus Erythematosus (SLE), which is also known as “lupus’. According to medical experts, many people with lupus are sensitive to sunlight and ultraviolet radiation. Lupus patients should avoid being under the sun during the times when the sun is at its most intense, between lOam and 3pm. AUTOIMMUNE DISEASE Dr H. Tan, a medical specialist, said lupus is an autoimmune disease characterised by acute and chronic inflammation of various tissues of the body. he said autoimmune diseases are illnesses that occur when the body’s tissues are attacked by its own immune system. “People with lupus produce abnormal antibodies in their blood that target tissues within their own body, rather than foreign infectious agents. “As the antibodies and accompanying cells of inflammation can affect tissues anywhere in the body, lupus has the potential to affect a variety of areas,” he said, adding that lupus can cause diseases of the skin, heart, lungs, kidneys, joints, and nervous system. “A person cannot get lupus from another individual. it is not cancer and it is not related to AIDS,” he said. some scientists believe that the lupus can be precipitated or aggravated by only a brief period of sun exposure. he said the reason rashes develop is the ultraviolet (UV) waves in the sunlight. UV light damages cells in the skin (keratinocytes), causing them to die. In healthy people without lupus, these dead cells are cleared away quickly and any inflammation induced by the sun (sunburn) is short-lived. However, in lupus patients, skin cells may be more sensitive to sun-induced damage, and there is increasing evidence that the dying (apoptotic) cells are not cleared away efficiently. as a result, the contents of dying cells may be released and cause inflammation. also, cell contents such as genetic material and other molecules, which are never normally exposed to cells of the immune system, are available to generate an immune response. IMMUNE RESOPONSE Immune responses and inflammation are the normal reactions of the body to infection, but in lupus they are generated inappropriately by the dying cells, and the body mounts an immune response against its own cell constituents (autoimmunity). Dr Tan said the end result of this process in susceptible people with certain types of lupus is the development of characteristic photosensitive rashes. Antibodies are often found in people with these rashes, he said. “Why the rashes affect only some parts of the body at any one time and are not always sun-sensitive is still not understood,” he said. FLARE the rheumatologist said when symptoms of lupus appear, it is called a “flare.” “These signs may come and go. you may have swelling and rashes one week and no symptoms at all the next. you may find that your symptoms flare after you’ve been out in the sun or after a hard day at work,” said Dr Tan. even if a patient takes medicine for lupus, he or she may find there are times when symptoms become worse. Learning to recognise that a flare is coming can help the patient take steps to cope with it. Many people feel very tired or have pain, a rash, a fever, stomach discomfort, headache, or dizziness just before a flare. Steps to prevent flares, such as limiting the time a person spends in the sun and getting enough rest and quiet, can be helpful. ARE ALL LUPUS PATIENTS AFFECTED? Dr Tan said some 60 per cent of lupus patients get sun-induced rashes. “New immune responses can take over a week to develop, so the effects of sunlight will not necessarily be evident on the same day. “In general, all lupus patients are advised to avoid sun exposure, as it is one of the easiest ways of avoiding something that we know can make lupus worse in many sufferers,” he said. can photosensitive rashes and other sun-induced manifestations of lupus be prevented? to some extent photosensitive rashes and other sun-induced problems can be prevented by keeping sun exposure to a minimum and using sunblocks regularly, Dr H. Tan said. he advises against going out under the hot sun. “The sunblock lotion is effective against the UV light. “It is also advisable to wear long-sleeve shirts, long pants and a wide-brimmed hat when out in the sun. the use of UV film on windows may also be necessary for those who are particularly sun-sensitive,” he added. — BERNAMA

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The SmartMeter, Dianna Glidden decided, had to go.

Soon after she moved into her Santa Cruz home in September, she started feeling pressure in her head and buzzing under her skin. Glidden blamed her symptoms on transmissions from the property’s new wireless SmartMeter, which Pacific Gas and Electric co. had installed shortly before she arrived.

PG&E refused to remove the meter, so Glidden hired an electrician to disconnect it and replace it with a more traditional, analog model.

In response, PG&E shut off her power.

The company has given Glidden a choice. She can have her electricity service back if she lets PG&E reinstall the SmartMeter. Or she can choose a new digital meter that doesn’t contain a transmitter. if she doesn’t agree to either option, her home will remain dark.

Glidden isn’t the only one. Fed up with a company they say is bullying them, some SmartMeter critics have had the devices removed, and seen their power cut as a result. according to PG&E, fewer than 20 people have disconnected their SmartMeters.

PG&E maintains that disconnecting SmartMeters is dangerous, and the company doesn’t want the idea to spread. Hence the decision to cut off power to people who do so.

“If this dangerous practice is allowed to continue without some sort of consequence, other people could do the same thing, and that’s what we’re trying to deter,” said company spokesman Jeff Smith.

Suspicious of meter

Glidden, a real estate agent, is suspicious of the nontransmitting digital meter, which PG&E offered two days after the company shut off her electricity.

She has heard from other people who say they are sensitive to radio-frequency radiation that a power-switching device within digital meters gives off harmful emissions, even if the devices lack a transmitter.

“I’m not an activist,” said Glidden, 59. “I really don’t want to be doing this. And you know what? the other people involved don’t want to be doing this.”

Most of her symptoms have disappeared since she removed the SmartMeter, she said. She won’t accept having another one installed.

“It’s really clear that we’re being bullied by PG&E,” she said.

PG&E, California’s largest utility, has faced a persistent rebellion over its $2.2 billion SmartMeter program, intended as a first step toward building a smarter and more resilient electricity grid.

While opposition at first focused on the meters’ accuracy, it has now turned into a battle in the larger fight over wireless technology and its possible effects on human health.

People convinced that wireless signals can cause debilitating headaches, insomnia, ringing in the ears and other symptoms have repeatedly asked state regulators to halt the SmartMeter program.

the notion that wireless technology can have such effects remains in deep dispute among researchers.

‘Opt-out’ alternatives

The California Public Utilities Commission in January will consider two “opt-out” alternatives for SmartMeter opponents.

both would give PG&E customers the choice of receiving a new digital meter that does not transmit its data to the utility via wireless communication.

Both would also force customers to pay extra for that privilege, an idea that opponents liken to extortion. neither alternative would let customers keep their old analog meters.

The people removing their SmartMeters say they’re frustrated with PG&E and the utilities commission alike.

“I called the CPUC, and it seems like they’re in bed with PG&E,” said Bianca Carn of Santa Cruz. She paid an electrician to remove her home’s new SmartMeter after her children started suffering headaches and nosebleeds soon after its installation.

the company cut her power on Tuesday, and her children are now sleeping at their grandmother’s home.

“They know they have the upper hand, because they’re a monopoly,” Carn, 45, said of PG&E. “If people think there are health effects, give them a choice. I don’t think that’s asking too much.”

The company initially insisted that it would restore service only if those customers agreed to have another SmartMeter installed.

but after news of the shutoffs appeared in the Santa Cruz Sentinel and on local television stations, the company decided to offer the option of a digital, nontransmitting meter as well.

Several customers have accepted that offer, according to the company. others remain undecided.

This article appeared on page D – 1 of the San Francisco Chronicle

(Medical Xpress) — Scientists at the Friedrich Miescher Institute for Biomedical Research (FMI) of the Novartis Research Foundation have elucidated the mechanisms underlying the repair of UV-induced damage in DNA, which frequently causes skin cancer. The protein structures additionally determined by these researchers will improve our understanding of how the body protects itself against skin cancer. these studies lay the foundations for the development of a new class of anti cancer agents. The findings were published today in Cell.

Without capturing public attention, the number of new cases of skin cancer is continuously increasing. This type of cancer is now more common than breast, colon and lung cancer combined. no less discouraging is the fact that the number of deaths from skin cancer is also steadily rising – in contrast to the trends observed for many other cancers, where survival rates are improving thanks to effective treatments. But reliable treatments can only be developed if the molecular mechanisms underlying skin cancer are better understood. Here, scientists at the FMI have made an important breakthrough, as they report in the latest issue of Cell.

It is well known that skin cancer arises from damage caused by the sun’s ultraviolet (UV) radiation. This radiation produces mutations in DNA which influence cellular processes, possibly leading to cancer. although the body has various strategies for repairing such damage, the most frequent type of UV lesion turns out to be particularly problematic. in this case, two components of DNA combine to form structures known as cyclobutane pyrimidine dimers (CPDs). these are difficult for the cell’s repair system to detect – partly because they are inconspicuous, given the size of the entire genome, but also because they remain hidden within tightly coiled DNA.

Group Leader Nicolas Thomä and his team at the FMI, working together with colleagues from Kobe and Osaka, have now identified the molecular machinery which allows the cell to recognize lesions not detected by the normal repair system.

In these processes, a key role is played by a protein complex known as DDB1-DDB2-Cul4 ubiquitin ligase. A subunit of this complex, DDB2, specifically recognizes CPDs even if they are located in parts of the DNA which are tightly coiled. The researchers also showed how another protein in this complex, ubiquitin ligase, is activated by the binding of DDB2 to damaged DNA and thus directly triggers degradation processes in cells. Thomä comments: “With this work, for the first time, we’ve traced the steps whereby these common but treacherous genomic UV lesions are recognized and the cells are ultimately eliminated. The mechanism works like molecular sun cream, protecting cells from damage and thus preventing skin cancer.”

But the findings are also relevant to diseases caused by defects in this repair mechanism, such as Cockayne syndrome or xeroderma pigmentosum. in both of these conditions, patients are extremely sensitive to UV radiation. however, they also exhibit other symptoms attributable to the accumulation of DNA errors. As Thomä explains, “The protein structures we’ve determined are a foundation on which specific inhibitors can be developed. Of particular interest here are the ubiquitin ligases, which not only play a role in rare diseases, but have been implicated in the development of many types of cancer.”

More information: Fischer ES, Scrima A, Böhm K, Matsumoto S, Lingaraju GM, Faty M, Yasuda T, Cavadini S, Wakasugi M, Hanaoka F, Iwai S, Gut H, Sugasawa K, Thomä NH. (2011). “The molecular basis of CRL4(DDB2/CSA) ubiquitin ligase architecture, targeting and release of signalosome inhibition”. Cell, 147, 5.

Provided by Friedrich Miescher Institute for Biomedical Research

SAN FRANCISCO (Reuters) – Professional social network LinkedIn took the wraps off a tool that allows jobseekers to apply for open positions by sending their LinkedIn profiles directly to prospective employers.

The feature is launching as LinkedIn tries to keep its service ahead of the curve amid competition from new networks such as Google’s Google +, which allows users to segregate contacts into a professional category.

The feature, known as Apply With LinkedIn, allows employers to add a button to online job listings so applicants can click on it and send their information directly to the company. Applicants have an opportunity to personalize the information with a cover letter.

For the employer, “it enables them to prioritize better,” said Deep Nishar, senior vice president of products and user experience at LinkedIn.

To some extent, the new service streamlines a process that already takes place, Nishar said. For example, prospective employers often already check applicants’ LinkedIn profiles for insights such as if they know employees at the hiring company.

Prospective employer companies already using the service include movie service Netflix, daily deals service LivingSocial, photo site Photobucket — and, of course, LinkedIn itself.

LinkedIn has 100 million users, but a majority of them don’t visit the site regularly. The new Apply With LinkedIn feature will prompt jobseekers to update their profiles by alerting them of the date of their last update.

The tool comes on the heels of LinkedIn’s March introduction of the LinkedIn Today service, which allows members to see news stories that are popular within their networks or industries.

It also comes as Google’s new network steamrolled past the 20 million user mark in just a few weeks, according to ComScore. Nishar said competition helped LinkedIn stay sharp.

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An illness associated with tick bites and not seen in Delaware since 2003 has been confirmed in a Kent County man.  State Public Health officials say a 45 year old man is hospitalized with Tularemia – and responding to treatment.  Officials say the illness is not spread person to person, however domestic cats are very susceptible to tularemia and can transmit it to humans. 

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NEWS RELEASE:  DPH LAB IDENTIFIES FIRST CASE OF TULAREMIA SINCE 2003On Oct. 6, the Delaware Public Health Laboratory confirmed Delaware’s first case of tularemia since 2003, in a 45 year-old Kent County man. the man is hospitalized and responding to treatment. Although Delaware has not reported a case of tularemia in eight years, each year an estimated 125 to 150 cases are reported nationwide.

Tularemia is associated with tick bites and is not spread person to person. Domestic cats are very susceptible to tularemia and have been known to transmit the bacteria to humans. Humans can become infected by handling infected animal tissue when hunting or skinning infected rabbits, muskrats and other rodents; by inhaling dust or aerosols contaminated with the bacteria, such as during farming or landscaping activities, especially when tractors or mowers run over an infected animal or carcass. the disease can also be transmitted by drinking untreated water contaminated with the bacteria introduced by animal contact.

Symptoms of tularemia usually appear three to five days after exposure to the bacteria, but can take as long as 14 days. Symptoms may include: sudden fever, chills, headaches, diarrhea, muscle aches, joint pain, dry cough and progressive weakness. People can also develop pneumonia with chest pain, cough and difficulty breathing. Other symptoms of tularemia depend upon how the person was exposed. These symptoms can include ulcers on the skin or in the mouth, swollen and painful lymph glands, swollen and painful eyes and a sore throat.

Anyone exposed to tularemia should be treated as soon as possible since the disease can be fatal. Because the disease is difficult to diagnose, it is important to share with your health care provider any likely exposures, such as tick and deer fly bites, or contact with sick or dead animals. Blood tests and cultures can help confirm the diagnosis. Delaware laboratories and healthcare providers are required to report any diagnosed case of tularemia to the Division of Public Health’s Bureau of Epidemiology.“Preventing tick bites is the best way to protect yourself from tularemia,” said Dr. Karyl Rattay, DPH director. “Use insect repellent containing DEET on your skin, or treat clothing with repellent containing permethrin, to prevent insect bites.” In addition, use care and wear gloves when handling sick or dead animals. Be sure to cook food thoroughly and that your water is from a safe source. Note any change in the behavior of your pets (especially rodents and rabbits) or livestock, and consult a veterinarian if they develop unusual symptoms.for more information, see cdc.gov/tularemia/faq/ or call DPH’s Bureau of Epidemiology at 1-888-295-5156.

Lesions on the skin that are caused by pressure resulting in tissue damage are often found on the lower limbs, but can occur almost anywhere

Pressure ulcers — better known as bedsores — are lesions on the skin that are caused by unrelieved pressure resulting in tissue damage. they usually develop over bony areas of the body, often in the lower limbs (ankles and hips are common), but they can occur almost anywhere (for example, in the nostrils of patients with feeding tubes, in the corners of the mouth in patients with endotracheal tubes, and between fingers in patients with rheumatoid arthritis).

Pressure ulcers are quite common in hospitals and other institutional settings. in acute care hospitals they occur in about 3-15 percent of patients; (1) (2) (3) (4) they occur in about a third of elderly patients who have had hip fractures; (5) and the number rises to as much as 50 percent in critical care patients. (6) ten to 35 percent of patients admitted to nursing homes have pressure ulcers, though this rate decreases somewhat for patients who have been there longer. (7) (8) (9) (10) because there are other reasons for skin breakdown, it is important to be examined and diagnosed by a doctor so that the appropriate treatment can be determined. in this article, we’ll discuss the symptoms and diagnosis of ulcers, as well as their treatment and tips for prevention.

TYPES OF ULCERS

There are several types of skin ulceration. Pressure ulcers or bedsores occur when the skin is subjected to constant pressure, which is why they happen so frequently in hospitals and in older patients. they generally start as a blister, and then become an open sore, finally ending in a “crater.” in addition to pressure ulcers, areas of skin breakdown may be due to other types of ulcers, having to do with insufficient blood flow or to diabetic neuropathy.

Insufficient blood flow through the veins usually occurs in the lower legs, and can result in venous insufficiency ulcers, which are often chronic and difficult to heal. they can cause pain in the foot and usually appear purplish in color. they are never found above the level of the knee or in the forefoot, and may occur singly or in multiples.

A related condition, caused by insufficient blood flow through the arteries, is known as arterial insufficiency ulcers, which are painful lesions that usually occur over the ankle or other areas of the foot. although they may be seen near bony prominences (i.e., joints), they are distinguished from pressure ulcers by their “punched-out” or star-like appearance. The wound may be pale and dry, surrounded by red and taut skin, and can include an area of dead skin.

Diabetic ulcers occur on the foot, usually over the joints or on the top of the toes. these ulcers often occur on the ball of the foot in diabetic patients, due to neuropathy or repetitive injury. Diabetic foot ulcers are often surrounded by a significant thickening of the skin, and are usually insensitive to touch.

There are other, less common causes of ulcers in the legs and feet, which include connective tissue diseases (e.g., rheumatoid arthritis), sickle cell disease, and certain forms of cancer. One’s doctor should take special precaution to rule out these more serious conditions before arriving at a diagnosis of an ulcer.

CAUSES AND RISK FACTORS OF PRESSURE ULCERS

Internal and External Risk Factors

There are both external and internal risk factors for ulcers. Pressure, friction, shearing (two layers of skin sliding on each other in opposite directions), and moisture (which can cause softening of skin) are considered external (or extrinsic) risk factors. Internal or intrinsic factors have to do with the patient’s state of health: these including underlying medical conditions, immobility, inactivity, fecal and urinary incontinence, malnutrition, decreased consciousness, steroid use, and smoking, which can all influence one’s likelihood of developing an ulcer.

Medical conditions linked to intrinsic risk factors are far-ranging and include anemia, infection, peripheral vascular disease, edema, diabetes, stroke, dementia, delirium, alcoholism, fractures, and malignancies. Simple, age-related factors such as reduced fat and muscle mass with which to dissipate pressure also increase risk. lower levels of Vitamin C as one ages may also increase the risk of pressure ulcers by causing blood vessels and connective tissue to become fragile and reducing the number of blood vessels serving the tissue of the skin, and other factors.

The Underlying cause of Ulcers: Tissue Ischemia

A main cause of pressure ulcers is tissue ischemia, which occurs when there is a loss of adequate blood supply to the tissue (skin) in question, caused by excessive pressure on the skin. Pressure to the skin lasting longer than two hours produces irreversible changes in skin tissue. in patients who tend to develop pressure ulcers post-operatively, there is impairment in skin blood flow over bony areas of the skin during surgery. (11)

When a person sits, their sitting bones bear the greatest pressure, often pressure than your capillaries can technically take. (12) Pressure ulcers can actually occur from the “inside-out” given that the muscle is more sensitive to pressure than is the skin. (13) because the outer layer of the skin shows signs of tissue death relatively late in the development of an ulcer, (14) once the skin starts to show indications of the presence of an ulcer, the ulcer may be even more progressed than meets the eye. Factors such as hypotension (low blood pressure), dehydration, heart failure, or medications may also contribute to pressure ulcer development. (6) (15) (16) (17) (18) (19)

(1) Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement–The National Pressure Ulcer Advisory Panel. Decubitus 1989; 2:24-8.

(2) Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care 2001; 14:208-15.

(3) Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. J am Geriatr Soc 1996; 44:22-30.

(4) Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol a Biol Sci Med Sci 2006; 61:749-54.

(5) Baumgarten M, Margolis DJ, Orwig DL, Shardell MD, Hawkes WG, Langenberg P, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J am Geriatr Soc 2009; 57:863-70.

(6) Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA 1993; 269:1139-43.

(7) Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:2905-9.

(8) Spector WD, Kapp MC, Tucker RJ, Sternberg J. Factors associated with presence of decubitus ulcers at admission to nursing homes. Gerontologist 1988; 28:830-4.

(9) Shepard MA, Parker D, DeClercque N. The under-reporting of pressure sores in patients transferred between hospital and nursing home. J am Geriatr Soc 1987; 35:159-60.

(10) Reed JW. Pressure ulcers in the elderly: prevention and treatment utilizing the team approach. Md State Med J 1981; 30:45-50.

(11) Sanada H, Nagakawa T, Yamamoto M, Higashidani K, Tsuru H, Sugama J. The role of skin blood flow in pressure ulcer development during surgery. Adv Wound Care 1997; 10:29-34.

(12) Lindan O, Greenway RM, Piazza JM. Pressure distribution on the surface of the human body. I. Evaluation in lying and sitting positions using a “bed of springs and nails”. Arch Phys Med Rehabil 1965; 46:378-85.

(13) Le KM, Madsen BL, Barth PW, Ksander GA, Angell JB, Vistnes LM. An in-depth look at pressure sores using monolithic silicon pressure sensors. Plast Reconstr Surg 1984; 74:745-56.

(14) Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J am Acad Dermatol 1982; 6:1014-21.

(15) Bergstrom N, Braden B. a prospective study of pressure sore risk among institutionalized elderly. J am Geriatr Soc 1992; 40:747-58.

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