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Re: From the archive: Against the Rum Ration.

Posted in BMJ at Sat, 28 Mar 2015 10:54:11

Mikey W

Posts: 194
Joined: 15 Nov 2009

I've done some clay pigeon shooting. Never on rum though!

I remember that rum article Odysseus. Can't find it now 

Re: Breast is best - but are we doing enough to support it?

Posted in General clinical at Sat, 28 Mar 2015 10:41:27

Mikey W

Posts: 194
Joined: 15 Nov 2009

It is encouraging to read that all pramila's neonate patients are exclusively breast fed, but to realise that at least two other female medics on here have struggled with insufficient support demonstrates quite strongly that something is amiss. 

My wife (also a medic) struggled at first with each of our babies. You'd think after the first one it would be easy but it proved almost as tough with baby 2. The babies need to learn it too which can take time. 

 

Re: Should boxing be banned following Braydon Smith's death?

Posted in News & media at Sat, 28 Mar 2015 10:25:23

Odysseus

Posts: 4551
Joined: 24 Feb 2009

If women want to box let them. How about sparring. I do that. In WW1 young women by the thousands packed TNT into shells with mallets in England and about 140 died from TNT poisoning or explosions.

My point is that we don't live in a perfect world, that the zest of life is freedom, risk and danger.

If we ban boxing, we ban football i.e. rugby and gridiron as more are damaged, die and develop dementia from this than from boxing. 

Ban risk and you ban life. Sterilise life, and you stultify human existence. It becomes controlled by a higher power which is not of the will of the people but  by some political apparatcheks in government and monitored by CCTV looking into your bedroom. 

Limitation of personal freedoms is rarely followed by liberalisation of personal freedoms. It is the thin end of the wedge which leads to Nuremburg, Moscow, stalags, gulags, and the Hunger Games.

Odysseus

Self Confidence Psychology

Posted in General at Sat, 28 Mar 2015 05:11:48

JoeFulton

Posts: 1
Joined: 28 Mar 2015

Success comes from who you are. The significant problem with self confidence is that in one or other way we are programmed to pay attention to our faults instead of our expertise and qualities. With this thought processes, your intention to treat the faults can't affirm a solid self-confidence. It is best to focus with developing ones capacity and also abilities to understand your pure talent and also strengthen ones confidence in yourself. Everyone is unique in her or his way. There can be nobody nowadays that is precisely like other individual. People fail in their life endeavors given that they try to be like somebody else, do not make an effort to replicate someone else's career journey or fashion. You may weaken ones resolve and also hinder your individual progress by doing this.

Have confidence in yourself, you skill and ways to do the idea differently to other people and this will offer more than any other person. After you look within the mirror, you ought to see one who cannot become compared. There's uniqueness on this individuality, irreplaceable in its one particular uniqueness. You cannot begin to find success without having self-confidence. The luck and a circumstance is needed for someone to attain ones goals and that can easily manifest only in the event you believe in yourself.

How can be anybody about to confident in you when you not confident in yourself? You may glow like a beacon attracting all of the positive circumstances of success for those who have self-confidence. Here is the simple way the entire world works, as you project ones plans think of this as perspective and work on this facet of development.

Employ your time and energy in improving yourself by means of other people’s writing so that you shall come easily with what others get labored hard for.   After you spend period improving on your own, you turn out to be better person and produce your self-image; the most effective way to reach one's destination is to follow along with what others must impact as a result of their lifestyle experience.

The difficulties about our appearance; how we are perceived and also understood; may perhaps, to a great extent, impact self-confidence in ourselves. Our upbringing and also circumstances of your childhood and also education can make us produce negative thinking about you. Those people with a noticeable charisma haven't any such problems, and with the power of self-confidence can easily forge a definite path in direction of their goals and ambitions.

More typically than not necessarily, it is not just talent that will uplift these people. Many averagely gifted people range the heights of their chosen career fields, based on the self-confidence and also an easy drive to ensure success. We head to school, get qualifying measures and shell out our dues so that you can advance yourself in tasks, in rank and in lifestyle, but many of us forget the thing that can easily guarantee good results with almost all certainty: self-confidence.

Salary for CT1

Posted in Careers at Sat, 28 Mar 2015 00:15:40

wellingtongoose

Posts: 1
Joined: 28 Mar 2015

I recently received a job offer in London for two years as a core medicine trainee. I had a look at the rent prices and was horrified.

I have been told that the jobs I will be doing are the equivalent of 1B banded but I am having a great deal of difficulty understanding the point system on the BMA's pay for doctors website. I gathered my minimum pay in CT1 is 30,000 but do I then get another 40% on top of that as I used to as a FY2 if I have a 1B banded job?

Can anyone tell me how much I would earned after tax per month as a CT1?

Re: Jolie's informed decision to undergo prophylactic salpingo-oophorectomy

Posted in General clinical at Fri, 27 Mar 2015 23:04:51

Dr Linda

Posts: 203
Joined: 20 May 2010

"body part"    Pardon the typos.

Re: Mysterious severe right upper quadrant abdominal pain........please help

Posted in General clinical at Fri, 27 Mar 2015 17:37:50

sken

Posts: 905
Joined: 13 Oct 2009

These real problems of RUQ pain are often a real challenge - one which is hard to resolve (and sometimes one needs the test of time) although it is not too difficult to list someof the rareties which eventually emerge. Personally I think a good clinical gastroenterologist opinion well worth while - someone who thinks more about what presents with abdo symptoms and not just diseases of "their bit" . Some pain clinic specialists are also brilliant. Both will spend quite a time on detailed history.

Meanwhile have a look at this months JRSM on the management of patients when the test come back normal...

Joanna3Buck - fascinating - the number of times (as a gastro doc) I have asked myself : 1."Could this be endometriosis ?"  2. "Could this be ovarian?" but with few positives. Sometimes we spend too long chasing the untreatable rather than thinking about those disorders where we have quite a bit too offer.

Does anyone do laparoscopy these days?

Incidentaly how did she take psychological (a good psychiatrist might be better). I always remember the fairly straightforward chap (as opposed to many of the others who resented it ) who went along with our referral as part of the work-up for difficult left UQ pain. Psyche nice and normal but about 10 days later he developed a pleural effusion - with an amylase in the thousands...

Unremitting constant pain is a bit odd for the diagnoses that usually top the list - what has hapened to her overall health in the meantime and how does she spend her days?

Re: MCQ: A 50 year old man with multi drug-resistant tuberculosis and worsening vision

Posted in Respiratory medicine at Fri, 27 Mar 2015 17:18:02

Charlie Hall

Posts: 18
Joined: 19 Feb 2013

I'll post the answer here next week

Re: New to doc2doc? Introduce yourself here...

Posted in General at Fri, 27 Mar 2015 16:53:49

Sabreena

Posts: 1204
Joined: 07 Sep 2009

Hi Susanna and welcome.

It would be good to have your opinion on some of our respiratory medicine threads and blogs when you get chance.

Feel free to email me smalik@bmj.com if you have any problems 

Lovely to have you on doc2doc

Re: Jolie Effect

Posted in News & media at Fri, 27 Mar 2015 15:03:50

Mukhtar Ali

Posts: 917
Joined: 14 Nov 2010

Angelina Jolie has ovaries and fallopian tubes removed

 

http://www.bbc.com/news/entertainment-arts-32030154

Re: Unfading Shadow of Ebola

Posted in Public health at Fri, 27 Mar 2015 14:54:39

Mukhtar Ali

Posts: 917
Joined: 14 Nov 2010

The authorities in Sierra Leone are enforcing a three-day lock-down to curb the spread of Ebola, with the entire population ordered to stay at home.

http://www.bbc.com/news/world-africa-32083363

Re: Should eating on the street be banned?

Posted in General clinical at Fri, 27 Mar 2015 14:35:24

DuaneF

Posts: 1500
Joined: 09 Dec 2011

In Response to Re: Should eating on the street be banned?:[QUOTE]

Certainly the police have so little to do  today it would be nice to see them occupied rounding up  errant hot-dog dealers rather than sitting in the station trying to close   the last  few cold cases- they would certainly be fitter too, and it would help     feed the 100,000 extra Alsations we would need as a minimum to fix this scourge.


Posted by rcdeacon[/QUOTE]

As a Veteran Retired Police Officer of 32 years service,  I offer the following to your slanderous accusation that police have "SO LITTLE TO DO TODAY"   Welcome to the modern world where crime is rampant,  cybercrime is new and expanding,  and Terrorism is a constant threat!  Perhaps you should try a stint as a Police officer,   see how you handle a 6'9" Samoan weighing 450 pounds all jacked up on PCP, trying to cave your head in with a baseball bat!   Mind you,  after you tasered him twice, and he removed both sets of taser barbs!   Yes there are some people who are immune to taser effects.   The Police have much to do,    you should educate yourself before trying to minimize the service of millions of Police officers!!!

 

DuaneF

Re: Question of the week: How well do TV dramas portray mental illness?

Posted in Psychiatry at Fri, 27 Mar 2015 14:34:13

babyoccdoc

Posts: 4
Joined: 07 Oct 2014

Well I know one soap that asks for OM advice on storylines. 

GP Locum work locations

Posted in GP Locums at Fri, 27 Mar 2015 11:54:05

Kloud

Posts: 1
Joined: 27 Mar 2015

Hi,

 

Im currently doing market research on the ways GP locums find work, is this through Agencies, word of mouth, recommendations etc?

how is technology used is this process?

 

 

Thanks

 

Andy

What practical programs should implement a student organisation for preclinical years? Ideas

Posted in Careers at Fri, 27 Mar 2015 07:05:35

george0razvan

Posts: 2
Joined: 24 Mar 2015
Hi, i'm 2nd year! My medschool has a student society, and we do different activities, but we don't have a department to implement practical activities to help students in medical practice. Recently I was at a conference where, in some workshops, I learned how to do a urethral catheterization, how to put a catheter, some basic clinical techniques. I want to create such a department and want some ideas of such practices. If you can help me and guide what and how to do it, I'd be happy. Excuse my English.

if you want to talk more about this , and give me some help, i have a email : nokia3244@yahoo.com ( stupid email, don't ask)

 

What practical programs should implement a student organization for preclinical years? Ideas

Posted in Student BMJ at Fri, 27 Mar 2015 06:58:20

george0razvan

Posts: 2
Joined: 24 Mar 2015

Hi, i'm 2nd year! My medschool has a student society, and we do different activities, but we don't have a department to implement practical activities to help students in medical practice. Recently I was at a conference where, in some workshops, I learned how to do a urethral catheterization, how to put a catheter, some basic clinical techniques. I want to create such a department and want some ideas of such practices. If you can help me and guide what and how to do it, I'd be happy. Excuse my English.

if you want to talk more about this , and give me some help, i have a email : nokia3244@yahoo.com ( stupid email, don't ask)

Who should one sue?

Posted in Careers at Thu, 26 Mar 2015 12:21:45

sken

Posts: 905
Joined: 13 Oct 2009

The failure to take adequate steps over blood products when HIV and Hep C were emerging problems is pretty emotive stuff and is in the news again.  But there seem to be 2 groups who must share some responsibility - firstly the providers but secondly the prescriber. Patient groups often did their best to educate about the risks but doctors often seemed to have a simple-minded trust about risk - and often used blood products when they were not clearly indicated clinically. One of my first bits of HIV education came from a haemophiliac deling treatment for a minor joint effusion because of the HIV risk , whereas the doctor was trying to insist. 

It would be interesting medically and legally to know just how often these products were given unnecessarily - certainly that applied to blood transfusions to a major extent and I expect it is still much the same. Management had an interesting response too - surgeons often cross-matched blood (sometimes same blood for more than 1 patient) but often did not use it and were therefore wasteful , whereas physicians crossed matched lots and lots of blood and always seemed to pour it in and were therefore more efficient !

Re: An end to the routine use of manual thrombectomy in STEMI?

Posted in Cardiology at Thu, 26 Mar 2015 10:53:19

Sabreena

Posts: 1204
Joined: 07 Sep 2009

You can read more from ACC.15 in cardiology blogs: CABG v drug eluting stents

PALcohol? No Pal Of Mine!

Posted in General clinical at Thu, 26 Mar 2015 04:59:41

ahyperdoc

Posts: 12
Joined: 13 Nov 2014

I'm not sure about the rest of the world but here in the United States there is a new beverage--going to market in a few short weeks--powdered EtOH mix sold in a pouch which you just simply add H2O and you're good to go. Marketed under the brand-name PALcohol, the distributors of this "instant drunkenness" can't say enough about how innovative the concept is and that it's gonna be the best thing since sliced bread. Does anybody--besides the biased makers/sellers--think this is actually a step in the right direction? It's disturbing to me. I mean, how labor intensive is it to grab a normal wine; beer or spirit, pour than consume? Maybe it'll be a convenient way to stockpile alcoholic beverages in a paranoid, doomsday-prepper's underground shelter. The truth is that the alcohol industry is ALWAYS trying/searching to find more ways to sell their products; what better than making EtOH easier to consume and convenient like mixing Kool-Aid for the kiddies. Speaking of children, do you suppose this PALcohol might aid in the underage drinking phenomenon? One could say that this is the 21st century after all and chalk one up for innovators of such a convenient mind-altering (literally) and novel creation. On the other hand, one could say this is the 21st century with more children experimenting; more chronic alcoholics; and deaths--from accidents and chronic usage--than in the last 20 years. I think this so-named PALcohol should be relegated to the nearest trash receptacle and become extinct like the Doe-Doe bird before it...Gone AND forgotten! Comments? Opinions? Thank you for your time.

Re: Best organisations to use for a medical volunteering programme abroad?

Posted in Student BMJ at Wed, 25 Mar 2015 22:51:52

NCantley

Posts: 425
Joined: 23 Dec 2011

I would say just beware as much as possible about what you do and how you do it if you do do volunteering. So much risk of volunteerism and what not out there that it is a delicate balance of doing actual good for the community that actually lasts versus short term gains that last very short time after you leave.

I wish you luck though and hope you find somewhere!

Re: Should patients have the right to record consultations?

Posted in News & media at Wed, 25 Mar 2015 19:03:01

somany

Posts: 1
Joined: 25 Mar 2015

Today, a lot of information is available in order to help you make a wise choice when you are shopping water filters. Water filters reviews are a great way to know about different filters as they provide real experiences of consumers using them.

There are different types of water filtration systems from on-the-tap faucet filtration systems dispensers and pitchers using carbon filters, to those using reverse osmosis technique etc. Before making a decision it is important to go through water filters reviews to evaluate features like filter-change indicators as well as overall value, so you can be certain about the right kind of filter according to your requirement.

.........................................

[url=http://www.ezdia.com/epad/water-filter-reviews-information-water-filter-system/6864/] WATER FILTER REVIEWS AND INFORMATION [/url]

Re: Should medical publications include summaries for patients?

Posted in General clinical at Wed, 25 Mar 2015 17:30:31

Chappie

Posts: 4
Joined: 25 Mar 2015

In Response to Re: Should medical publications include summaries for patients?:[QUOTE]

All (?) published papers have an abstract - sometimes that's all a busy clinician has time to read - that presents the contents in short form.   How much shorter/simpler would/could you make it?   For instance, I read this paper the other day, it answers something I've been wondering about:

  • Albrecht E,
  • Kern C, 
  • Kirkham KR
  • A systematic review and meta-analysis of perineural dexamethasone for peripheral nerve blocks.   Anaesthesia 2015; 70: 71-83

    The Abstract:   We systematically reviewed the safety and efficacy of perineural dexamethasone as an adjunct for peripheral nerve blockade in 29 controlled trials of 1695 participants. We grouped trials by the duration of local anaesthetic action (short- or medium- vs long-term). Dexamethasone increased the mean (95% CI) duration of analgesia by 233 (172–295) min when injected with short- or medium-term action local anaesthetics and by 488 (419–557) min when injected with long-term action local anaesthetics, p < 0.00001 for both. However, these results should be interpreted with caution due to the extreme heterogeneity of results, with I2 exceeding 90% for both analyses. Meta-regression did not show an interaction between dose of perineural dexamethasone (4–10 mg) and duration of analgesia (r2 = 0.02, p = 0.54). There were no differences between 4 and 8 mg dexamethasone on subgroup analysis.

    Isn't it patronising and simplistic to reduce that to, "There was no difference when dexamethazone was injected with a local anaesthetic."?   Joe Public needs to know how this was arrived at, by metanalysis, not direct experiment.  But before that, he probably needs to know what dexamethazone is, and what local anaesthesia is, so we need to add that.  So then if we add, in a single sentence, an explanation of of "metanalysis" and what it is worth, we have a useful databite for the person on the street?  I don't think so.

    John

     

Posted by John D[/QUOTE]

Expecting that all members of public understand systematically reviewed' and what it means in the context of research is possible unrealistic, not to mention 'efficacy', and that's just the first sentence of the abstract. We assume that such terms are common knowledge and what is meant be a 'systematic review' is obvious. Public involvment must be aimed at the lowest common denominator, which if done badly can come across as patronising and condescending.

I absolutely agree with you that we should avoid wasting time speaking in layman terms when it comes to cutting-edge science either in articles or in conferences as it detracts from the debate. (A bit like trying to discuss a book review with someone who hasn't done their homework). Contributors and researchers in any area have normally earnt the right to sit within these circles, through study and discovery, science has always been a meritocracy (To avoid sounding elitist I should also say that believe everyone should have equal access to these circles through access to high quality, universal education).

Public involvement in research is essential, especially in healthcare as patients are both the participants and the consumers. Therefore making sure it is accessible and understandible is fundamental. Rather than 'simplifying' abstracts, articles, conferences etc, information about studies can be presented in a number of formats to increase public engagement. This could include better public access on journal websites explaining what the findings are and what they mean, which could include links with explanations of key terms in order to differentiate information for those who have little/no knowledge of research to those that are fairly research-wise but are not up to date with that particular field. This wouldn't hurt for doctors to read either, I will be the first to admit I don't understand every article I read about health, nevermind articles about advanced robotics that I may be interested in if they were more accessible. Better public understanding would also increase interest in further research and less resistance to patient involvement.

The reason we have such a problem with 'bad' health reporting is down to the fact that we leave a lot of the education about health research to the media rather than actively do it ourselves. However, we are constrained by a perceived threat to our authority, after all, knowledge is power.

Re: Should EM doctors be entitled to more annual leave than GPs?

Posted in Careers at Wed, 25 Mar 2015 16:17:44

Chappie

Posts: 4
Joined: 25 Mar 2015

Hello everyone

In response to Vivek, recruitment at entry level doesn't seem to be a problem, given that ACCS EM competition ratios were reportedly 2.3 applicants per vacancy during round 1 for 2015/16 entry. CT1/ST1 posts therefore still attract juniors and run-through training is also becoming the norm for trainees in core training within ACCS, which should go some way towards solving retention issues going into higher training posts (which is currently where most vacancies seem to remain unfilled).

I do however get the impression that entry into EM will reduce in the next few years however as many of my colleagues who would be applying for jobs are instead taking gap years, and this is becoming increasingly popular. Having the time to think about speciality training will, I expect, reduce applicant numbers to EM.

Consultant posts are difficult to fill, although possibly less so than registrar posts at present. The time-lag of these figure seem to suggest we will run into a dire lack of EM consultant in the next few years. Some of the vacancy levels I saw presented recently within my region are eye-watering.

Work intensity and out of hours work makes maintaining the same pace of work into middle/older age a daunting prospect. Incentives are needed not only to increase the ability to lead a life outside EM but also to recognise that work within EM as a professional ages will require even more effort than another speciality, e.g. general practice. Better pay, more leave, earlier retirement age, reduced working hours/ nights/ shift length as you age are all potential incentives. I agree that having all the money in the world means nothing if you have no time to spend it, so just increasing pay is not the answer.

EM is an evolving and relatively young speciality and is only recently finding its voice. I believe something is going to have to change soon to stop a workforce planning catastrophe in the next decade. Understaffing is a viscious circle and retention is key to longterm success of any organisation. As I will be starting CT1 ACCS EM training in August, I hope these changes come sooner rather than later!

Re: MRCP Part 1 Question of the Day from OnExamination - SLE

Posted in General clinical at Wed, 25 Mar 2015 16:07:05

Sabreena

Posts: 1204
Joined: 07 Sep 2009

The answer is:

Diffuse proliferative glomerulonephritis

Hypertension, pedal oedema, nephritic urinary sediments (blood and protein positive) in a patient with systemic lupus erythematosus (SLE) suggests the diagnosis of class IV (diffuse proliferative glomerulonephritis) or class III (focal segmental glomerulonephritis) lupus nephritis. ds-DNA antibodies increase the risk of lupus nephritis.

Mesangial glomerulonephritis presents with mild proteinuria.

Minimal change, or membranous glomerulonephritis present with proteinuria, which may be in the nephrotic range.

The renal manifestations of SLE are highly variable, ranging from mild asymptomatic proteinuria and/or haematuria to rapidly progressive uraemia. The various presentations are difficult to classify into clinical syndromes and histological classes. Although lupus nephritis affects a third of patients early in the disease it is frequently unrecognised until nephritic and/or nephrotic syndrome with renal failure occur.

Histologically, a number of different types of renal disease are recognised in SLE, with immune-complex mediated glomerular disease being the most common.

The standard classification divides these into five different patterns:

  • I - No disease
  • II - Mesangial
  • III - Focal proliferative
  • IV - Diffuse proliferative
  • V - Membranous.

Mesangial nephritis represents the earliest and mildest form of glomerular involvement. It presents clinically as microscopic haematuria and/or proteinuria. Hypertension is uncommon and nephrotic syndrome and renal impairment are very rarely seen. Biopsy demonstrates segmental areas of increased mesangial matrix and cellularity. The prognosis is good and specific treatment is indicated only if the disease progresses.

Focal proliferative disease is more advanced, but still affects less than 50% of glomeruli. Haematuria and proteinuria is almost always seen, and nephrotic syndrome, hypertension and elevated creatinine may be present. Electron microscopy shows immune deposits in the subendothelial space of the glomerular capillary wall and the mesangium. Prognosis is variable.

Diffuse proliferative glomerulonephritis is the most common and severe form of lupus nephritis. Haematuria and proteinuria are almost always present, and nephrotic syndrome, hypertension and renal impairment common. Biopsies demonstrate profuse deposits of IgG within the glomeruli. Immunosuppressive therapy is required in these cases to prevent progression to end-stage renal failure.

Patients with membranous lupus nephritis tend to present with nephrotic syndrome. Microscopic haematuria and hypertension may also be seen. Biopsies show diffuse thickening of the glomerular capillary wall. Progression is variable, and immunosuppression is not always needed.

With regard to the management of lupus nephritis a biopsy is indicated in those patients with abnormal urinalysis and/or reduced renal function. This can provide a histological classification as well as information regarding activity, chronicity and prognosis.

Cyclophosphamide, mycophenolate mofetil and azathioprine reduce mortality in proliferative forms of lupus glomerulonephritis.

References:

  1. Contreras G et al. Lupus nephritis: a clinical review for practicing nephrologistsClin Nephrol. 2002;57(2):95-107.
  2. Molino C et al. Clinical approach to lupus nephritis: recent advancesEur J Intern Med. 2009;20(5):447-53.

Re: MRCP part 1 sample question from OnExamination - diabetic ulcer

Posted in Diabetes at Wed, 25 Mar 2015 16:03:15

Sabreena

Posts: 1204
Joined: 07 Sep 2009

The answer is:

Staphylococcus aureus

Diabetic foot ulcers can be divided into:

  • Those in neuropathic feet, and
  • Those in feet with ischaemia.

The neuropathic foot is warm and well perfused with palpable pulses, sweating is decreased and the skin may be dry and prone to fissures.

The ischaemic foot is cool and pulseless with thin, shiny skin which often lacks hair. There may also be atrophy of the subcutaneous tissues, but intermittent claudication and rest pain may be absent due to co-existent neuropathy.

Diabetic foot infections are common and always serious, and range in severity from superficial paronychia to deep infection and gangrene.

Other manifestations include:

  • Cellulitis
  • Myositis
  • Abscesses
  • Necrotising fasciitis
  • Septic arthritis
  • Tendonitis, and
  • Osteomyelitis.

All are associated with increased frequency and length of hospitalisation, and risk of lower extremity amputation.

Neuropathy, vascular insufficiency and reduced neutrophil function all mean that diabetics are more susceptible to foot ulceration.

Once skin ulceration occurs, the underlying tissues are exposed to colonisation by pathogenic organisms. The inflammatory response is often impaired, and therefore early signs of infection may be subtle. Local signs of wound infection are:

  • Granulation tissue that becomes increasingly friable
  • Yellow or grey moist tissue at the base of the ulcer
  • Purulent discharge, and
  • An unpleasant odour.

The most common pathogens in acute, previously untreated superficial ulcers in diabetic patients are aerobic Gram positive bacteria (particularly Staphylococcus aureus and beta-haemolytic Streptococci).

In patients who have recently received antibiotics or who have deep tissue involvement, infection is usually caused by a mixture of aerobic Gram positive, Gram negative (for example, Escherichia coliProteusKlebsiella) and anaerobic organisms (for example, BacteroidesClostridium).

Methicillin-resistant Staphylococcus aureus (MRSA) is more common in patients who have been previously hospitalised or who have received antibiotic therapy, although increasingly it is community acquired.

If infection is suspected, deep swab and tissue samples should be sent for culture and broad-spectrum antibiotics started. The presence of deep infection with abscess, cellulitis gangrene or osteomyelitis is an indication for hospitalisation.

Indications for urgent surgical intervention are:

  • A large area of infected sloughy tissue
  • Localised fluctuance and expression of pus
  • Crepitus in the soft tissues on radiological examination, and
  • Purplish discolouration of the skin (which indicates subcutaneous necrosis).

Antibiotic treatment should subsequently be tailored according to the clinical response, culture results and sensitivity. If osteomyelitis is present, surgical resection should be considered and antibiotics continued for four to six weeks.

References:

  1. Bader MS. Diabetic Foot InfectionAm Fam Physician 2008;78(10)71-9.
  2. Edmonds M, Foster AVM. ABC of wound healing. Diabetic foot ulcersBMJ 2006;332:407-411.
  3. Frykberg RG. Diabetic Foot Ulcers: Pathogenesis and ManagementAm Fam Physician 2002;66:1655-1662.