Is this bone infected or not? Differentiating neuro-osteoarthropathy from osteomyelitis in the diabetic foot

Osteomyelitis (bone infection) and neuro-osteoarthropathy (Charcot arthropathy) are limb-threatening complications of diabetic neuropathy with very different therapies. Distinguishing between them may be difficult, but it is important. In Charcot arthropathy, noninfectious soft tissue inflammation accompanies rapidly progressive destruction, first of joints, then of bone. This occurs in a well-vascularized and severely neuropathic, but nonulcerated, foot. In osteomyelitis, chronic soft tissue ulceration precedes infection of bone, which may be physically exposed. Magnetic resonance imaging and bone biopsy are the preferred diagnostic tests, provided adequate technical and interpretive skills are available.     

Effect of luminal acidification on guinea pig gastric mucosa

H⁺ secretion was studied in guinea pig fundic mucosa incubated in (A) bicarbonate-Ringer's gassed with 95% O₂-5% CO₂, or (B) HEPES gassed with 100% O₂ before and after luminal pH was lowered to 2.0 for periods up to 90 min. At pH 2.0 for 60 min, H⁺ secretion in group A tissues fell by 35±4% (P=0.02) from a control rate of 1.35±0.09 eq/cm²/hr and in group B tissues by 50±11% (P=0.01) from a control rate of 1.59±0.08 eq/cm²/hr. After 90 min at pH 2.0, H⁺ secretion in group A fell by 53±8% (P=0.02) from a control rate of 1.47±0.07 eq/cm²/hr and in group B fell by 44±6% (P=0.01) from a control rate of 1.38±0.07 eq/cm²/hr. Histamine 1×10^–4 M stimulation following exposure to pH 2.0 for 90 min increased secretion in group A tissues from 0.80 ±0.14 to 1.06±0.13 eq/cm²/hr (P<0.05), compared with an increase in nonacidified controls from 1.15±0.22 to 1.80±0.20 eq/cm²/hr (P<0.05) and in group B tissues from 1.27±0.10 to 1.56±0.19 eq/cm²/hr (P<0.05) compared with nonacidified controls from 1.43±0.22 to 2.23±0.41 eq/cm²/hr (P<0.05). Secretory function and electrical characteristics were adversely affected by luminal acidification to pH 2.0 and suggested a breach in the mucosal barrier with damage to parietal cells.This study was funded by the National Institute of Health Grant No. AM 15681.     

Changes in Quality of Life after 3 months of Usual Care in a Large Sample of Patients with Noncancer Pain: The “QOOL: Quality of Life and Pain” Study

Large‐scale observational studies can provide useful information on changes in health outcomes over time. The aim of this study was to investigate the effect of 3 months of usual care on quality of life (QOL) and pain outcomes in noncancer chronic pain patients managed by pain specialists and to examine factors associated with changes in QOL. This was assessed using the EQ‐5D and pain outcomes using the Brief Pain Inventory (BPI). Changes in QOL and pain were studied for the overall sample and in subgroups defined by baseline pain severity. Multivariate regression was used to investigate factors associated with change on EQ‐5D. Three thousand and twenty‐nine patients were included for analysis. After 3 months of usual care, a mean of 40.9% of patients showed improvement on individual EQ‐5D dimensions, with the highest rates of improvement seen on the pain/discomfort (50.8%) and anxiety/depression (48.3%) dimensions. The EQ‐5D Index increased from a mean (SD) of 0.35 (0.2) to 0.58 (0.21) points between baseline and month 3, and the thermometer from 41.5 (19.4) to 58.7 (17.8), indicating a large effect. Improvements in QOL were larger in those with severe baseline pain. The BPI severity summary score improved from a mean (SD) of 6.5 (1.4) to 4.1 (1.7) and the interference summary score from 6.6 (1.5) to 4.2 (1.9). Changes on the BPI severity and interference scores were associated with changes in the EQ‐5D Index and thermometer. In conclusion, 3 months of usual care in noncancer pain patients led to substantial improvements in QOL and pain outcomes.     

Prosthetic joint infection

Total joint replacement has been one of the most remarkable successes of modern medical technology. Once John Charnley had solved the problems of implant design, choice of materials, implant fixation, and infection (initial rates of infection were approximately 10%), the way was clear for the widespread use of this valuable treatment, which is highly effective at removing pain and restoring function. Unfortunately, infection still remains an important, though less common, problem. It is associated with serious morbidity (pain, loss of function, wound breakdown, wound discharge, implant failure) and sometimes mortality. It may be impossible to eradicate or suppress infection in the long term without removal of the prosthesis, and most clinicians would consider it unwise to re-implant a new prosthesis in the presence of infection. Hence, patients with infected prosthetic joints generally require multiple additional operations and prolonged periods of antibiotic therapy. Even radical attempts at cure may fail (in 10% to 15% of cases in most series), requiring further cycles of treatment with progressively deteriorating function. Thus, the treatment of prosthetic joint infection is arduous for the patient and the health care team, with no guarantee of success.     

Maintaining dignity for residents of care homes: A qualitative study of the views of care home staff,community nurses,residents and their families

This study uses the Framework approach to qualitative analysis to explore and compare the views of residents in care homes for older people, their families and care providers on maintaining dignity. We interviewed 33 care home managers, 29 care assistants, 18 care home nurses, 10 community nurses, 16 residents and 15 members of residents' families. The most prevalent themes were: “independence,” and “privacy”; followed by “comfort and care,” “individuality,” “respect,” “communication,” “physical appearance” and “being seen as human.” Residents and their families sometimes described incidents where a resident's dignity had been compromised. How to help residents maintain dignity and focusing on fostering dignity, can be a starting point for improving the quality of care and quality of life of residents. It is, however, important to remove the gap between the rhetoric of dignity conserving care and the reality experienced by residents in these and other care settings.