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The choice for endovascular reperfusion strategies in these patients was predicated on evidence that with greater clot burden and larger vessel occlusion (eg, ICA, M1 stem, etc), systemic thrombolysis, though a more expeditious treatment, may be less effective. 20 22 However, it is likely that in certain patients, should the site of occlusion a priori be known to exist in a small branch, CDM may also help triage candidates who might benefit from systemic thrombolysis alone.

Major weaknesses in this study relate to several imaging-related points. First, not all the patients by protocol underwent follow-up MR imaging or CT at a prespecified time point, making it difficult to comment on infarct expansion, a main study outcome in the articles of Davalos et al 10 and Prosser et al. 11 These studies also used volumetric analysis to quantify the area of DWI involvement. Due to above-cited reasons, we used crude methods for measurement. More rigorous modes of DWI measurement must be used in any future prospective study.

Another limitation of this analysis is the small number of patients. Although endovascular treatment seemed to protect against END and lower final NIHSS scores were found, the small sample size prevents drawing any firm conclusions. Finally, because data were reviewed retrospectively from hospital in-patient records alone, long-term follow-up data are not available for this analysis. This would be of prime importance in any future study. Still, we are encouraged by most of the treated patients who experienced ENI and by the absence of ICH among all patients. Whereas strict treatment windows in a general stroke population with limited selection criteria (noncontrast head CT) is important, a certain population of patients with stroke may still be treated safely and successfully in a delayed fashion. The identification of ideal patients for delayed therapy and validation of alternate triaging methods remain to be studied. The CDM may be useful to identify such patients. Further data are needed to more rigorously study delayed revascularization in AIS based on CDM. A phase I study is planned.

Tissue plasminogen activator for acute ischemic stroke: The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.
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Intra-arterial prourokinase for acute ischemic stroke: The PROACT II study—a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism.

ADA = American Diabetes Association .

Adapted with permission from Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists . Diabetes Care. 2008;31(8):1684 .

ADA = American Diabetes Association .

Adapted with permission from Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists . Diabetes Care. 2008;31(8):1684 .

Data Sources: A PubMed search was completed in Clinical Queries using the terms diabetic, foot, and infections. The search included meta-analyses, randomized controlled trials, clinical trials, reviews, expert opinions, and guidelines. We also searched the Cochrane database, Clinical Evidence, and Essential Evidence Plus. Search dates: February 1, 2012, to November 30, 2012.

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FASSIL W. GEMECHU, MD, is a staff physician and assistant professor in the Department of Family Medicine at MetroHealth Medical Center in Cleveland, Ohio. ...

FNU SEEMANT, MD, is a fellow in primary care sports medicine in the University Orthopedic Center at the State University of New York at Buffalo. At the time this article was written, he was a fellow in the Department of Family Medicine at MetroHealth Medical Center.

CATHERINE A. CURLEY, MD, is division director in the Division of Hospital Medicine and an assistant professor of medicine at MetroHealth Medical Center.

Address correspondence to Fassil W. Gemechu, MD, MetroHealth Medical Center, 4229 Pearl Rd., Cleveland, OH 44109 (e-mail: fgemechu@metrohealth.org ). Reprints are not available from the authors .

Author disclosure: No relevant financial affiliations.

1. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care . 1999;22(1):157–162. ...

2. Lipsky BA, Berendt AR, Cornia PB, et al.; Infectious Diseases Society of America. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. . 2012;54(12):e132–e173.

3. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. . 2005;366(9498):1719–1724.

4. Vardakas KZ, Horianopoulou M, Falagas ME. Factors associated with treatment failure in patients with diabetic foot infections: an analysis of data from randomized controlled trials. . 2008;80(3):344–351.

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10. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. . 2008;47(4):519–527.

11. Kapoor A, Page S, Lavalley M, Gale DR, Felson DT. Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis. . 2007;167(2):125–132.

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13. Peters EJ, Lipsky BA, Berendt AR, et al. A systematic review of the effectiveness of interventions in the management of infection in the diabetic foot. . 2012;28(suppl 1):142–162.

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18. Aragón-Sánchez J, Lipsky BA, Lázaro-Martínez JL. Diagnosing diabetic foot osteomyelitis: is the combination of probe-to-bone test and plain radiography sufficient for high-risk inpatients? . 2011;28(2):191–194.

19. Lavery LA, Armstrong DG, Peters EJ, Lipsky BA. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic? . 2007;30(2):270–274.

20. Morales Lozano R, González Fernández ML, Martinez Hernández D, Beneit Montesinos JV, Guisado Jiménez S, Gonzalez Jurado MA. Validating the probe-to-bone test and other tests for diagnosing chronic osteomyelitis in the diabetic foot. . 2010;33(10):2140–2145.

21. Armstrong DG, Perales TA, Murff RT, et al. Value of white clood cell count with differential in the acute diabetic infection. . 1996;36(5):224–227.

22. Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O. Does this patient with diabetes have osteomyelitis of the lower extremity? . 2008;299(7):806–813.

23. Kaleta JL, Fleischli JW, Reilly CH. The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study. . 2001;91(9):445–450.

24. Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. . 2009;48(1):39–46.

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31. Wieman TJ. Principles of management: the diabetic foot. . 2005;190(2):295–299.

32. Aragón-Sánchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. . 2010;9(1):37–59.

33. Schaper NC, Andros G, Apelqvist J, et al. Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. . 2012;28(suppl 1):218–224.

34. Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE study. . 2008;51(5):747–755.

35. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-related wounds and amputations worse than cancer? . 2007;4(4):286–287.

36. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/ Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. . 2006;113(11):e463–e654.

37. Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. . 2008;31(8):1679–1685.

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