>Dear Oleg,
>Did you check arterial supply? Was diabetes balanced? Are you
experienced in putting on casts or do you have a good orthopedic
surgeon in your team? If yes, then
please go on using TCC, but remove the first cast after 3 days or
one week, then the following casts will stay on longer, since the
ulcer will heal, leg and foot will be less swollen, and exudate will
get less automatically.
>Was the ulcer merely colonized or was it infected? Did you get rid
of the MRSA or did it get resistant also to fusidic acid ?
>Dr. Mieke Flour
>Dermatology Dept., Vascular Centre, Diabetic Foot clinic
>B-3000 Leuven
>Belgium

Dear Dr. Flour,

Thank you very much for your comments.

Here is some additional information about this patient and our
practice:

* Arterial supply is very good (4/4 pulses palpable).

* Diabetes conrtol is far from good (blood sugar 5-15 mmol during
the day) - although unlikely this is a direct cause of excessive
exudation, it can retard infection elimination. We have to address
it.

* I make casts more that 3 years, now there are usually no technical
defects (which were common on 'learning curve'). We use technique of
semi-rigid casting with ScotchCast and SoftCast (as recommended by
manufacturer (3M) and described by Boogers and Drogmans (2001)). Our
orthopedic surgeons usually don't make casts. We could consider
surgery for correction of severe deformities but this patient has
not so severe deformity which could need surgery.

* According to ISDFG 2003 Consensus on DF infection ("the presence
of systemic signs of infection (e.g., fever, chills, leukocytosis,
elevated inflammatory markers), or purulent secretions (pus), or two
or more local signs or symptoms of inflammation (e.g., redness,
warmth, induration, pain or tenderness) suggests the wound is
infected. ") this ulcer was colonised rather than infected. But this
Consensus postulates also "In addition, the presence of
cellulitis, ... implies infection, as may the failure to heal of an
otherwise properly treated wound".

* Thank you for you advise about checking for complete elimination
of MRSA. We should make repeated culture (and check sensitivity to
fusidic acid again although in the first culture the pathogen was
sensitive to it).

* I thought also about allergy to some of our antiseptic solutions
as a cause of high level of exudation - we'll also try to exclude
this.

Thank you very much again,

Oleg Udovichenko.