Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment.

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.

Diabetic heel ulcer in the Sudan: determinants of outcome.

Heel ulceration, on average, costs 1.5 times more than metatarsal ulceration. The aim of this study was to analyze the determinant factors of healing in diabetic patients with heel ulcers and the late outcomes at Jabir Abu Eliz Diabetic Centre Khartoum, Khartoum, Sudan. Data were collected prospectively for 96 of 100 diabetic patients presenting with heel ulcers at the Jabir Abu Eliz Diabetic Centre Khartoum from May 2003 to January 2005. Late outcome was assessed 3 years later (February 2008). Heeling was achieved in one half of the patients (n = 48). In the remaining 48 patients, 22 ended with major lower extremity amputation and 22 were still receiving wound care. A total of 8 patients died, 4 in each group, the healed and unhealed. The most significant determinants of healing using a logistic multivariate regression model, 95% confidence intervals, and odds ratios included a shorter duration of diabetes (p < .009), adequate lower limb perfusion (p < .043), and a superficial foot ulcer (p < .012). Three years later, of the 88 patients who could be traced, 78 were alive and 59 had healed ulcers (7 had died of unrelated causes and 3 of diabetic-related complications), and no additional lower extremity amputation was recorded. Mortality in the series was 18 patients, of whom 14 had undergone a previous lower extremity amputation. Superficial heel ulcers in diabetic patients with a short history of diabetes and with good limb circulation are more likely to heal within an average duration of 25 weeks. At 3 years of follow-up, 75% showed a favorable outcome for ulcer healing, and 22 patients underwent lower extremity amputation (25%), of whom 14 were dead within 3 years.

Role of jejunostomy feeding catheter as a model for nutritional support.

INTRODUCTION: The advancement in oesophageal cancer care during the last two decades has resulted in a decrease in the use of feeding jejunostomy catheter to maintain adequate nutrition. We aim to examine the validity of feeding jejunostomy catheter in maintaining adequate nutrition for patients with oesophageal cancer. PATIENTS AND METHODS: A prospective longitudinal study was conducted on oesophageal cancer patients presenting to Khartoum Teaching Hospital with complete dysphagia between June 2005 and September 2007. Nutritional assessment was performed pre- and post-insertion of the feeding jejunostomy catheter and data were tested for any significant difference. RESULTS: Among 99 patients enrolled in the study, 48 had the feeding catheter inserted during oesophagectomy, 41 prior to neoadjuvant therapy and 10 as a palliative measure. Catheter dislodgement occurred in 3% of patients while blockage occurred in 10% and migration in only 1%. The mean ± SD of patients' weight pre-insertion was 48.08 ± 10.29, while the mean ± SD weight on day 10 post-insertion was 48.41 ± 10.27 and on day 30 was 48.14 ± 10.29. Patients on jejunostomy catheter feeding were considered optimised to receive neoadjuvant therapy based on clinical assessment, mobility and sense of well being. The post-resection mortality rate was 11.5% vs 10% compared to patients on oral feeding. CONCLUSION: Jejunostomy feeding catheter provided nutritional access to oesophageal cancer patients with complete dysphagia using a locally prepared formula. Patients managed to maintain their weight up to 30 days post-insertion of the feeding catheter. Feeding jejunostomy catheter in combination with a locally prepared feeding formula provided a reliable nutritional option for oesophageal cancer patients in developing countries.