Microbiology of diabetic foot osteomyelitis - Is it geographically variable?

INTRODUCTION: Diabetic foot osteomyelitis (DFO) is a dreaded complication as both diagnosis and treatment of the condition is laborious. However, for proper decision on antibiotics in medical management of DFO, accurate determination of microbes is necessary to narrow the spectrum of coverage and to reduce adverse effects of long-term administration of antibiotics. With differing pattern of use of antimicrobials and their resistance pattern in different countries, it is empirical to determine the microbiological characteristics of bone cultures in DFO from a referral institute in South India. MATERIALS AND METHODS: This study was a retrospective chart review of all cases of proven DFO who had consented for debridement and bone culture or those who underwent amputation. Both deep soft tissue (DST) and bone cultures were obtained for aerobic bacteria. Clinical characteristics and site(s) of DFO were recorded. Investigations for peripheral artery disease were performed if clinically indicated. RESULTS: In all, 105 patients with DFO were reviewed. Mean age was 62 years and 70% were men. Of those who were screened, 57% had evidence of peripheral arterial disease by arterial doppler. 46% of bone culture samples were sterile. Gram- negative organisms were more common (58%). Following staphylococcus, pseudomonas was the second common isolate. Of total staphylococcal isolates 37% were MRSA and 33% of klebsiella isolates were ESBL producing. Concordance rate between DST and bone cultures was 66%. 90% were mono-bacterial isolates. The commonest site of involvement of DFO was terminal phalanges of toes rather than base of 1st metatarsal. CONCLUSION: Widespread use of antibiotics, tropical climate and route of entry of organisms causing DFO differed in our cohort of patients. Further studies from different regions of world would shed light onto different pattern of microbes causing DFO.

Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study.

Introduction Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India. Methods The study was conducted as a prospective analytical study. Indications for endoscopy were classified as "ASGE appropriate" and "ASGE inappropriate". The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed. Results ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively. Conclusion According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.

Mild hypothyroidism improves glucose tolerance in experimental type 2 diabetes.

BACKGROUND: Co-existence of type 2 diabetes and hypothyroidism is an emerging trend observed in clinical practice. Although the effects of isolated type 2 diabetes and hypothyroidism are well known, there are limited studies addressing the metabolic complications when these two conditions co-exist. The aim of the present study was to assess the interaction between type 2 diabetes and hypothyroidism with respect to glucose tolerance, dyslipidemia and redox balance in a state were these two diseases coexist. METHODS: Sixty male Wistar Albino rats were randomised into six groups. Group 1: control, Group 2: overt hypothyroidism, Group 3: mild hypothyroidism, Group 4: type 2 diabetes, Group 5: mild hypothyroidism + type 2 diabetes, Group 6: overt hypothyroidism + type 2 diabetes. Experimental hypothyroidism was created by the administration of propyl-2-thiouracil and type 2 diabetes by feeding rats with 60% fructose (w/w). The duration of the study was 6 weeks. All the parameters were estimated at the start (basal) and the end of the study. Intraperitoneal glucose tolerance test was carried out and area under curve (AUC) calculated to assess the glucose tolerance. Thyroid profile, lipid profile and oxidative stress parameters were also measured. RESULTS: Plasma TSH level was elevated 3-fold in the mild hypothyroid group and 15.2-fold in the overt hypothyroid group in comparison to the control group. Thyroid profile was found to be normal in type 2 diabetic group. There was no significant difference between hypothyroidism and hypothyroidism+diabetes groups with respect to thyroid profile. Among the six groups the degree of glucose intolerance was found to be maximum for overt hypothyroidism+diabetes group, followed by diabetes group and overt hypothyroidism group. An interesting finding was that glucose intolerance was significantly reduced in mild hypothyroidism+diabetes group (increase in AUC: 48.04%) in comparison with isolated diabetes group (increase in AUC: 71.63%). Similar results were obtained with parameters of oxidative stress. Oxidative stress was observed in overt hypothyroidism+diabetes, diabetes, overt hypothyroidism groups with severity decreasing in that order. Coexistence of mild hypothyroidism with diabetes decreased oxidative stress in comparison with isolated diabetes group. There was no statistical difference in lipid profile between mild hypothyroidism+diabetes and isolated diabetes group. CONCLUSION: Presence of mild hypothyroidism in type 2 diabetes confers a protective effect with respect to glucose tolerance and redox balance whereas presence of overt hypothyroidism in type 2 diabetes has a deleterious effect. The increased incidence of hypothyroidism in diabetes, especially subclinical hypothyroidism, could be a reflection of a physiological attempt by the body to mitigate damage wrought by diabetes.