Forefoot ulcer risk is associated with foot type in patients with diabetes and neuropathy.

AIMS: To stratify the ulceration risk according to the foot morphology in people with diabetes and a history of forefoot neuropathic ulceration. METHODS: A cross-sectional study was performed on 139 neuropathic individuals with diabetes and previous forefoot ulcers between January 2012 and February 2014. Foot position of the participants was evaluated by using the foot-posture index. A multivariate analysis adjusted for confounding variables was performed with the ulceration risk factors that were found in the univariate analysis. RESULTS: Two hundred and fifty-eight feet were analysed, 104 (40.3%) feet had a history of ulceration on the forefoot and 154 (59.7%) feet had no previous ulceration. Two positive tests of neuropathy (p<0.001; CI[1.961-6.249] OR 3.500), presence of deformities (p=0.043; CI[1.020-3.599] OR 1.916) and foot type (p=0.039) showed an association with ulceration risk in multivariate analyses. Pronated feet showed a higher risk of ulceration than supinated feet (p=0.011; CI[1.253-5.708] OR 2.675), while significant differences between neutral and supinated feet were not found (p=0.221; CI[0.719-2.753] OR 1.476). CONCLUSIONS: A pronated foot has a higher risk of ulceration on the forefoot in neuropathic people with deformities and diabetes mellitus. Foot type should be evaluated in people at risk of ulceration.

Inter-observer reproducibility of probing to bone in the diagnosis of diabetic foot osteomyelitis.

AIMS: The objectives of our study were (i) to analyse the inter-observer reproducibility or diagnostic variability of the probing-to-bone test, depending on the training of the professional involved, and (ii) to assess whether the probing-to-bone test can be extrapolated to any professional specialty that deals with these patients. METHODS: This was a cross-sectional study, involving 75 patients with diabetic foot ulcer and clinical suspicion of osteomyelitis. A registration sheet was completed for all patients involved in the research study, gathering data relative to the results of the probing-to-bone test performed by three observers. Observer 1 was a very experienced professional with several years of experience in the treatment of the diabetic foot; observer 2 was a medium-experienced professional whose experience ranges from 6 to 12 months in the treatment of the diabetic foot; observer 3 was a healthcare professional without experience in the treatment of the diabetic foot. Data were gathered confidentially by a fourth researcher. RESULTS: The results showed a kappa index of 0.593 (95% CI 0.407-0.778) between observer 1 and observer 2, 0.397 (95% CI 0.188-0.604) between observer 1 and observer 3 and 0.53 (95% CI 0.335-0.725) between observer 2 and observer 3. CONCLUSIONS: The probing-to-bone test demonstrated moderate to fair concordance with an experienced examiner, although the degree of concordance is not significant between groups.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement.

AIMS/HYPOTHESIS: We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation. METHODS: A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. RESULTS: Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. CONCLUSIONS/INTERPRETATION: Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.

Primary colorectal lymphoma.

OBJECT: To analyze our experience in the treatment of primary colorectal lymphomas. PATIENTS: During the recent period from 1989 to 1995, a total number of 406 cases of malignant neoplasms of large intestine were treated at Department of Surgery, Hospital del S.A.S de Jerez de la Frontera. There were 5 cases of primary colorectal Non-Hodgkin's lymphomas, constituting 1.2% of all colorectal malignancies. METHODS: Medical records of all five patients were carefully reviewed. Surgical pathology specimens were retrospectively reexamined to confirm the diagnosis, and immunohistochemistry staining methods were performed. Dawson, Cornes and Morson criteria were used to distinguish primary colonic lymphoma. For tumor staging, a modification of the Ann-Arbor system for gastrointestinal lymphoma proposed by Musshoff and Schmidt-Vollmer was used. RESULTS: All cases were Non-Hodgkin's lymphomas. There were no cases of lymphoma of the rectum. There were 2 males and 3 females. Their ages ranged from 12 to 73 years, with an average age of 31 years. The cecum was the site of the lesions in 4 patients and the other was located in the sigmoid colon. Acute abdomen in three cases, undiagnosed abdominal mass in one and intussusception in the other one were the clinical presentation. Inmunohistochemical studies showed B-cell phenotype in 4 and non-B non-T Ki-1-positive phenotype in 1 patient. Chemotherapy was administered following resection in 100% of patients. CONCLUSIONS: Intraoperative diagnosis of lymphoma was not suspected in all cases but the malignancy was always present. The cecum is the commonest site of involvement. Both of our two patients presented with perforated lymphoma were associated with a poor short term prognosis. It is necessary to unify the staging system and the histologic classifications enabling a comparison of several studies.

[A computer program for hospital artificial nutrition]. / Programa informático de nutrición artificial hospitalaria.

In this study we present a computer program of artificial nutrition, designed with the aim of obtaining a useful and simple working tool, which simplifies the different steps to be taken when the need for artificial nutrition is indicated in a patient. It has been developed, by the authors, with the aim of organizing and improving the artificial nutrition at the level of our facility. This is a General Hospital with 300 beds, without a nutrition unit, and with an Intensive Care Unit which acts as a nutritional consultant for patients admitted to other departments. In our experience, it has proven to be of great use, with the following advantages: criteria of all the aspects referring to artificial nutrition have been unified (indications, requirements...), the time needed to calculate the requirements and make up the nutritional formula has been reduced, protocolization has been simplified, as well as the nutritional follow up, and it has allowed us to individualize the nutritional treatment, adjusting it to the evolutive changes of our patients.