A critical review of the literature: part II: antibiotic treatment of osteomyelitis in patients with diabetes and foot ulcers.

The diagnosis and treatment of osteomyelitis in the diabetic patient with a foot ulcer presents a difficult challenge for WOC nurses. Treatments vary greatly in terms of time, cost, and invasiveness, as does the accuracy of the underlying diagnosis. For example, the choice of oral versus parenteral antibiotics, the length of therapy, and decisions about surgical intervention or aggressive debridement are based on accurate differentiation of osteomyelitis from soft tissue infection, osteoarthropathy, or other related conditions. This article is the second of a critical literature review designed to identify the best evidence for diagnosing and treating osteomyelitis in patients with diabetes. It focuses on the existing evidence base for antibiotic therapy.

A critical review of the literature: part I: diagnosing osteomyelitis in patients with diabetes and foot ulcers.

Despite our best efforts, chronic wounds continue to confound us. Cases of patients with diabetes who have wounds are particularly perplexing and challenging to manage. The diagnosis and treatment of osteomyelitis in this population are of great interest to clinicians. Much of wound care is based on tradition and expert opinion. The current focus is on evidence-based practice. The purpose of this critical literature review is to determine the best evidence for diagnosing osteomyelitis as a basis for providing appropriate therapy to patients with diabetes and foot ulcers. Treatments vary greatly in terms of time, cost, and invasiveness depending on the accuracy of the diagnosis. The choice of oral versus parenteral antibiotics, the length of the treatment, and decisions about surgical intervention or aggressive debridement are based on correctly differentiating osteomyelitis from soft tissue infection, osteoarthropathy, and other conditions. It is difficult to differentiate soft tissue infection from bone infection in the patient with diabetes and neuropathic bone disease. The precision of available tools for diagnosing osteomyelitis in patients with diabetes and foot ulcers is widely debated. A gold standard as a reference test for clinical trials and treatment decisions has not been consistently used in published research studies. Without a reference test that is reliable and valid, the conclusions regarding effectiveness of diagnostic modalities and antibiotic treatment regimens are questionable.

The effect of a modified functional appliance on obstructive sleep apnea.

This study combined the use of cephalometrics and overnight polysomnographic monitoring to analyze the effects of a modified functional appliance on airway, sleep, and respiratory variables in patients with obstructive sleep apnea (OSA). Twelve patients without overt anatomic or pathologic evidence of obstruction were selected on the basis of an initial single night of polysomnographic monitoring, which confirmed the diagnosis of obstructive sleep apnea syndrome. The patients subsequently were fitted with a modified functional appliance designed to securely hold the mandible in an anterior-inferior position. A subsequent overnight polysomnographic study was obtained with each patient wearing the appliance. Lateral cephalometric radiographs with and without the appliance in place were also obtained. The mean vertical and horizontal changes in mandibular position while wearing the appliance were 8.49 mm and 2.28 mm, respectively. The findings indicate that 10 of the 12 patients had decreases in the rate of complete airway obstructions from a mean of 28.86 to 18.69 events per hour, and in the total apnea index from a mean of 53.81 to 35.99 events per hour. A reduction in the rate of obstructive events is attributed to the effect of the appliance on the oropharyngeal structures. Six cephalometric measurements are presented to provide a means of assessing effects of the appliance on the oropharynx and associated structures. The modified functional appliance is a conservative, successful treatment alternative that could benefit patients with obstructive sleep apnea syndrome.