Dear Friends,

Russian Colleagues organised a bi-lingual forum on the Diabetic Foot.
It was done because many Russian doctors can't speak English well
enough to take part in our Yahoo DF group.
Posted messages in Russian forum will be translated from/to English,
so I invite everybody to come and take a look on this new and original
resourse.
I hope to translate some practical questions (case stories, etc.) from
there and place them on our (this) website. It would allow Russian
friends to get advises from colleagues worldwide.
Hope for warm relationship between two our websites :)
With the best wishes,
Oleg.

Dear Oleg
We have diod laser in our hospital and are stating to use it for our
patients. It seems work, but I think we should find clear regimens
and indications for its use depending on DFS form.
I saw RCT's and systematic review studied low-level laser therapy
for leg ulcers. Some concluded that laser didn't work in this
patients, some - that it did. But I think may be it's a question of
applied dose.


--- In TheDiabeticFoot@yahoogroups.com, "Dr. Oleg Udovichenko"
<ovu_short@...> wrote:
>
> Wellcomme to this group, Juliana!
>
> Which laser procedures you mean? Have you some experience with
laser
> irradiation of wound? (I saw some patients in whom it seemd to
work but
> I haven't seen any randomized studies :(
>
> With the best wishes,
> Oleg.
>
>
> --- In TheDiabeticFoot@yahoogroups.com, "Juliana Lebedeva"
> <lebedevareg@> wrote:
> >
> > Hello!
> > I am Juliana Lebedeva, Chelabinsk, Russia. I work at faculty
surgery
> > department, Chelyabinsk Medical Academy. My main interests in
> diabetic
> > foot are surgery of foot infection, laser procedures for
diabetic
> > foot, skin grafting, immunology of wound inflammation. Is
anybody
> > interested in one of this fields?
> >
> > I am quite happy to see place where people dealing with diabetic
foot
> > can communicate. But I am a beginner at such a kind of forum -
yahoo
> > groops, so excuse my ignorance. Is this groop a part of a site,
or
> > bigger community on diabetic foot or is it independent?
> >
>

Dear Friends and Colleagues,

Thank you all again for your comments about my patients.
But the story was continued… :(
After Isablle's opinion that pathogen initially sensitive to Fusidic
acid could become resistant to it I repeated culture (results
obtained on 30 Oct):

It revealed MRSA (as previously) resistant also to:
Gentamicin
Eruthromycin
Clindamycin
Tetracyclines
Minocycline
Quinolones of the 2nd generation
Levofloxacin
Fucidic acid
Rifampicin

It was sensitive to:
Vancomycin
Teicoplanin
Nitrofurantoin
Co-trimoxazole

In the 1st culture picture was similar but MRSA was sensitive also
to Minocycline, Fucidic acid and Rifampicin

Both cultures were made in good laboratory with good internal and
external quality controls. Bacteria were cultivated on Mueller-
Hinton  culture medium, sensitivity to antibiotics was assessed
using automated analysis with antibiotics-containing strips.

Now we are in deep thoughts what to do with these results…

With the best wishes,
Oleg.

Wellcomme to this group, Juliana!

Which laser procedures you mean? Have you some experience with laser
irradiation of wound? (I saw some patients in whom it seemd to work but
I haven't seen any randomized studies :(

With the best wishes,
Oleg.


--- In TheDiabeticFoot@yahoogroups.com, "Juliana Lebedeva"
<lebedevareg@...> wrote:
>
> Hello!
> I am Juliana Lebedeva, Chelabinsk, Russia. I work at faculty surgery
> department, Chelyabinsk Medical Academy. My main interests in
diabetic
> foot are surgery of foot infection, laser procedures for diabetic
> foot, skin grafting, immunology of wound inflammation. Is anybody
> interested in one of this fields?
>
> I am quite happy to see place where people dealing with diabetic foot
> can communicate. But I am a beginner at such a kind of forum - yahoo
> groops, so excuse my ignorance. Is this groop a part of a site, or
> bigger community on diabetic foot or is it independent?
>

My dear Oleg,

I am not sure that we have helped but it was interesting to hear the
story and it will be interesting to know the rest and the end!
About the boot I am using "the Ransart Boot" it is about the same that
you described. You can see it on my website: www.drisabelledumont.com.
If you need more details, just ask. Excuse me to answer so late...
Amitiés,

Isabelle

This group is completely independent.
A lot of members are also members of the DFSG (Diabetic Foot Study
Group) but it is just because the topic is the same!
Every member really involved in diabetic foot care can become a
moderator and post the messages he or she wants.

Wellcome again, you are a new moderator!

Isabelle DUMONT

Hello!
I am Juliana Lebedeva, Chelabinsk, Russia. I work at faculty surgery
department, Chelyabinsk Medical Academy. My main interests in diabetic
foot are surgery of foot infection, laser procedures for diabetic
foot, skin grafting, immunology of wound inflammation. Is anybody
interested in one of this fields?

I am quite happy to see place where people dealing with diabetic foot
can communicate. But I am a beginner at such a kind of forum - yahoo
groops, so excuse my ignorance. Is this groop a part of a site, or
bigger community on diabetic foot or is it independent?

http://www.acfas.org/pubresearch/cpg/diabetic-cpg.htm

Robert FRYBERG said: This is the ACFAS Diabetic Foot Clinical Practice
guideline just published last month and is free by downloading.
Thought you might like an electronic version for your files. Much
easier for you to have it this way than to copy.

Yhank you Bob to let us heve access to this very interesting work.

Dear Jawadur (Dr. Wadud),
Thank you for your comments (sorry for delayed reply).
Last X-ray (in Septebmer) didn't reveal osteomyelitis, but I plan to
repeat it now as now osteomyelitis is highly probable - maybe this
is the cause of excessive exudation. Although 5th metatersal was
resected in ray amputation, now patient seems to need repeated
surgery for resection of infected bone.
Many thanks again to you and all participants who commented this
case.
Oleg.

--- In TheDiabeticFoot@yahoogroups.com, "jrwadud" <jrwadud@...>
wrote:
>
>  Dear Oleg
>
> In your case to minimise the Messaration and exudation you can
make
> a window on TCC over the wound and frequently change the dressing
> and you will recieve a good result. You have to do a X-ray and see
> the presense of osteomyelitis. It also may happen when the surgeon
> amputate the toe he just disarticulate the toe and does not exise
> the head of the metatarsal bone. If so you have to ask your
surgeon
> to remove the head of the metatarsal bone and continue treatment
> with TCC, with window over the wound.
> With best regards
>  Dr. Wadud--- In TheDiabeticFoot@yahoogroups.com, "Dr. Oleg
> Udovichenko" <ovu_short@> wrote:
> >

Wellcome,

We are always happy to see new members.
If you want me to make you a moderator,I would need just a bit more
informations.
If you want to stay a mysterious and anonymous member, no problem,it
is O.K.

Welcome again

Dear Oleg

In your case to minimise the Messaration and exudation you can make
a window on TCC over the wound and frequently change the dressing
and you will recieve a good result. You have to do a X-ray and see
the presense of osteomyelitis. It also may happen when the surgeon
amputate the toe he just disarticulate the toe and does not exise
the head of the metatarsal bone. If so you have to ask your surgeon
to remove the head of the metatarsal bone and continue treatment
with TCC, with window over the wound.
With best regards
  Dr. Wadud--- In TheDiabeticFoot@yahoogroups.com, "Dr. Oleg
Udovichenko" <ovu_short@...> wrote:
>
> Dear Colleagues,
> If somebody uses non-removable cast share please with your
> experience.
> I have a type 1 DM patient with neuropathic 2B (UT) ulcer (see
file
> NR-TCC.jpg) which didn't heal more than 6 months (non-compliance
to
> off-load regimen was considered as the main reason of this).
> According to recent studies of Amstrong, 2005 - 2/3 of patients
with
> removable casts/walkers wear them not constantly, so some patient
> really need more aggressive off-load for healing.
> So I applied non-removable TCC for 3 days and used combination of
> dressings to provide maximum exudate retention capacity:
> Promogran+Actisorb+PermaFoam (latter is a thick foam from
P.Hartmann
> with ability to release excess of fluid to the outer side). Wound
> culture a week before this cast revealed MRSA, so Fusidic acid 500
> mg 3 times daily per os was given.
> But after opening of Non-rem TCC I observed intensive maceration
and
> slight enlargement of the ulcer (see file NR-TCC2.jpg).
> What was wrong?
> Could you advise me more effective strategy to deal with excessive
> exudates?
> Thank you beforehand,
> Oleg Udovichenko.
>

Dear Isabelle,

Thank you for your reply!
We excluded ischemia (good pulses) and osteomyelitis (negative probe
to bone, no bone involvement on X-ray).
Unfortunately we use 'deep swabs' instead of curetage (mainly due to
technical reasons - but I know that we have to decide with our
laboratory that they'll accept tissue and make quantitative analysis
of microorganisms in it).
I saw in one paper (K. Harding et al., if I remember) that MRSA was
cosnidered as pathogen independently of its quantity in material but
I'm agree that we could miss other (and perhaps more important)
pathogens (either anaerobes or bacteria from deeper tissues) and
these pathogens were not sensitive to Fusidic acid.
I am very interested in your technique of casting (do you mean ankle-
foot cast, not cast boot?). Is it different from semi-rigid 3M cast
(usually made of 1 roll of rigid Scotchcast and 2 rolls of semi-
rigid Scotchcast) which is also quite simple?
With the best wishes,
Oleg.

> Dear Oleg,

> If an ulcer B2 is not healing in a TCC I would check if infection is
not more severe e.g. osteomyelitis. Are you sure that the MRSA is
responsible for the infection? Did you just do a swab or a more
profound curetage to be sure that you get the real pathogen and not a
colonising germ?
Are you sure that the arterial supply is good enough?
If you are sure that it is just a B2 ulcer you can treat it either
with a TCC either with a removable cast (I can explain you my technic
if you want it is very easy).

Good luck,

Isabelle
>

>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.

Dear Colleagues,
If somebody uses non-removable cast share please with your
experience.
I have a type 1 DM patient with neuropathic 2B (UT) ulcer (see file
NR-TCC.jpg) which didn't heal more than 6 months (non-compliance to
off-load regimen was considered as the main reason of this).
According to recent studies of Amstrong, 2005 - 2/3 of patients with
removable casts/walkers wear them not constantly, so some patient
really need more aggressive off-load for healing.
So I applied non-removable TCC for 3 days and used combination of
dressings to provide maximum exudate retention capacity:
Promogran+Actisorb+PermaFoam (latter is a thick foam from P.Hartmann
with ability to release excess of fluid to the outer side). Wound
culture a week before this cast revealed MRSA, so Fusidic acid 500
mg 3 times daily per os was given.
But after opening of Non-rem TCC I observed intensive maceration and
slight enlargement of the ulcer (see file NR-TCC2.jpg).
What was wrong?
Could you advise me more effective strategy to deal with excessive
exudates?
Thank you beforehand,
Oleg Udovichenko.

Isabelle

Have you seen this article? What do you think? Please post it on the
site. Has anybody else heard about this treatment???!!!

Marie-France
------------------------------------------------------------------------
----
Autologous transplantation of granulocyte colony-stimulating
factor-mobilised peripheral blood mononuclear cells improves critical
limb ischaemia in diabetes.
Huang, P, Li, S, Han, M, Xiao, Z, Yang, R, Han, ZC.
Diabetes Care 2005;28:2155-2160.

28 DM patients with critical limb ischaemia (CLI) were randomised to
transplant or control. The transplant group were given 5 days sc
recombinant human G-CSF (600 microg/d) and their PBMNCs were collected
and transplanted by multiple im injections into ischaemic limbs. After 3
m, lower limb pain and ulcers were significantly improved in transplant
patients. Laser doppler blood perfusion of lower limbs increased from
0.5 +/- 0.21 to 0.63 +/- 0.25 (P<0.001). 14/18 (77.8%) ulcers completely
healed compared to 7/18 (38.9%) in controls (P+0.016). No adverse
effects observed and no amputations in transplant group v 5 amputations
in controls (P=0.007). Angiographic scores were also significantly
improved v controls (P+0.003). These are very encouraging results,
indicating that this process is simple, safe and effective.


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- The University Hospitals of Leicester NHS Trust cannot be held responsible for
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vested in the University Hospitals of Leicester NHS Trust.

Thank you to Marie-France for sending abstracts about the diabetic
foot.
I was rather disappointed by the article of Kessler et al about
microbiological results of needle puncture in diabetic osteomyelitis.
On the other hand, I very appreciated the paper published by
Senneville et al in Clinical Infectious Diseases (2006;42[1 Jan]:67-
62].
In this article, the authors compare percutaneous bone biopsy vs
superficial swab in diabetic patients with foot osteomyelitis.
Briefly, from January 1996 to June 2004, percutaneous bone biopsy was
performed for suspected osteomyelitis in 190 patients of whom 88 were
suffering from diabetes. In 76 diabetic patients, biopsy was positive
(there were 81 biopsies because 5 patients had 2 different areas of
osteomyelitis); concomittant superficial swab sample were obtained in
69 cases. 125 pathogens were isolated from bone biopsy (1.54 per
biopsy: 96 (76.8%)were gram-positive bacteria in whom 65 (52%) were
Staphylococci; 33 S. aureus (26.4%)were isolated whose 12 (9.6%) were
methicillin-resistant. From superficial swab sample, 109 pathogens
were isolated (1.58 per sample): there were 78 gram-positive bacteria
(71.5%) in whom 41 (37.6%) were Staphilococci; 36 cultures were
positive for S. aureus (33%) whose 11 were methicillin-resistant
(10.1%). Comparing cultures in 69 cases where bone biopsy and
superficial swab were obtained concomitantly, authors found that
results were stictly identical in only 12 cases. Concordance between
the results for swab sample and bone biopsy was 22.5%. The
concordance was very poor for Enterococci, Coagulase-negative
Staphylococci,Anaerobes and Corynebacteria. So, superficial swabing
seems not reliable to identify bone pathogens in osteomyelitic
diabetic foot and in such cases performing percutaneous bone biopsy
should be promoted.According to the authors, no adverse events
occured due to bone biopsy. Moreover, the prevalence of MRSA is
surprising both in bone biopsy and in swab samples althoug patients
were free of antibiotic therapy for at least 4 weeks before sampling.
I have no experience with percutaneous bone biopsy. And you? If yes,
could you comment?

Isabelle

I thought maybe you'd like to know about the following 3 articles. If
you think "le groupe" would be interested in these articles feel free to
post them on the site.

Marie-France
------------------------------------------------------------------------
--

Authors   E. Chantelau

Title     The perils of procrastination: effects of early vs. delayed
           detection and treatment of incipient Charcot fracture

Citation   Diabet Med 2005; 22:1707-1712

At the onset of acute diabetic Charcot foot, therapeutic intervention
may be delayed because plain X-rays may not show fractures. This study
assessed the clinical course of acute Charcot foot in 24 patients
without evidence of definite fractures on the first X-ray after onset of
symptoms, who were referred to the foot clinic for diagnosis and
treatment either early or delayed, i.e. before or after definite
fractures were detectable on repeat X-rays. 11 patients were referred
early (incipient Charcot foot, case group), and 13 patients were
referred delayed (overt Charcot foot, control group). In the foot
clinic, both groups were immediately treated with off-loading and total
contact casting. After the healing process of the Charcot foot was
complete, the extent of fractures and subsequent deformities were
evaluated. Based on X-rays at the onset of symptoms, in 19 of the 24
patients the condition had been misdiagnosed prior to referral (in 11
patients as sprain injury). Additional imaging techniques (MRI, CT scan
or bone scintigraphy) had been performed in 10 patients prior to
referral. While these techniques had been used more frequently in the
cases vs. the controls (P = 0.012), misdiagnosis was less frequent in
the cases vs. the controls (P = 0.013). Only 1 out of 11 case patients
developed extended foot fractures and severe deformity, vs. 12 out of 13
control patients (P < 0.001). Therefore early detection of incipient
Charcot foot is facilitated by imaging techniques other than plain
X-rays. Immediate off-loading of incipient Charcot foot appears to
minimize fractures and incapacitating deformities.
------------------------------------------------------------------------
---

Authors   L. Kessler, Y Piemont, F Ortega, O Lesens, C Boeri, C Averous,
R Meyer, Y Hansmann, D Christmann, J Gaudias, M Pinget

Title   Comparison of microbiological results of needle puncture vs.
superficial swab in infected diabetic foot ulcer with osteomyelitis

Citation   Diabet Med 2006; 23:99-102

This is a prospective study of 2 methods for the bacteriological
diagnosis of osteomyelitis related to diabetic foot ulcer: needle
puncture performed across normal skin surrounding the foot ulcer and
superficial swabbing of the ulcer. Patients with diabetes and with a
foot ulcer complicated by bone or joint infection, as detected by X-ray
imaging, were included in the study. Ulcer swabbing and needle puncture
were performed in each patient. To reach the tissue nearest the bone
surface, needle puncture was guided by X-ray imaging and the drop of
fluid obtained by aspiration was used for both aerobic and anaerobic
bacterial culture. 21 patients were included. The mean number of
microorganisms isolated by needle puncture was significantly lower
compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P <
0.02). Three bacterial species were isolated by needle puncture only in
one patient while three or more bacterial isolates were obtained by
superficial swabbing in six patients. No bacterial isolate was detected
in 5 patients by needle puncture and in two patients by superficial
swabbing. Staphylococcus aureus accounted for 70% of cases (7 patients)
when a single bacterial species was obtained by needle puncture. After
needle puncture, no wound complication or infection was observed.
Culture of samples obtained by needle puncture revealed one or two
bacterial isolates in two-thirds of diabetic patients with osteomyelitis
following foot ulcer. Given the lack of complications, this invasive
diagnostic technique should be considered for deep direct sampling in
diabetic patients with osteomyelitis related to foot ulcer when surgical
debridement is contraindicated or delayed.
------------------------------------------------------------------------
----
Authors   N. Pound, S. Chipchase, K. Treece, F. Game and W. Jeffcoate

Title    Ulcer-free survival following management of foot ulcers in
diabetes

Citation   Diabet Med 2005; 22:1306-1309

All referrals to a specialist diabetic foot clinic over a 31-month
period were analysed and outcomes were determined after a minimum
follow-up of 6 months. 370 patients were referred with a total of 1031
ulcers. 121 (32.7%) never became ulcer free: 56 (46.3% of 121) remained
unhealed, the ulcers of 12 (9.9% of 121) had been resolved by
amputation, 2 remained unhealed after amputation (1.7% of 121) and 51
(13.8% of 370) had died. 231 (62.4% of 370) became ulcer free at some
stage. 5 of these were excluded because of an earlier amputation. 91of
the remaining 226 (40.3%) developed a recurrent or new ulcer after a
median 126 days. Of the 135 who did not have a recurrence, 133 (58.8% of
226; 35.9% of 370) survived ulcer free and with limbs intact, while two
died. Outcome was unknown in 18 (4.9%). Those who never became ulcer
free were older (P < 0.001) and with a greater prevalence of ischaemia
(P < 0.001). Those who healed but went on to suffer a new ulcer had a
greater prevalence of neuropathy (P = 0.027) than those who remained
ulcer free. The authors conclude that the use of ulcer-free survival can
be used as an indication of the effectiveness of foot ulcer management.
It could be adopted as a measure to compare performance between
different specialist units.


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vested in the University Hospitals of Leicester NHS Trust.

Chers amis et collègues,

A tous bonne et heureuse année, pleine de pieds de toutes catégories.

Ceci dit, merci à ceux qui s'impliquent et un mauvaix point aux
absents! J'écris en français car je constate que le trafic venant de
la Gaule est particulièrement faible. Pour rappel, vous pouvez vous
exprimer sur ce site en français ou dans toute autre langue comme il
vous plaira.
Dois-je penser que le monde du pied diabétique français est tellement
riche en experts, congrès et projets qu'il se sent auto-suffisant?
Perfidie de voisinage il est vrai!
Allez les BBR exprimez-vous!

Je serai bonne je ne traduirai pas!
Je ferai encore un peu de pub pour le site au CPC et à l'Alfediam en
espérant augmenter le recrutement...

A bientôt

Dear Members
The EMED Scientific Meeting will be held in Bavaria, July 25-28 2006.
www.esm2006.com
I have been to this meeting previously at a time I did not have access
to the EMED/PEDAR system but still found it very interesting.
Happy New Year, Lindy

Do you know the Malvern Diabetic Foot conference?

If not, it is a must and you should not miss it.
It has been created more than 10 years ago by AJM Boulton and H.Connor
(retired now and replaced by G.Rayman). It is a very sympathic and
friendly meeting "very british" melting every members of the diabetic
team: chiropodist, shoemaker, surgeon, MD and so and so.

Hope to meat you there.

Clic or copy and pasted on the link below to get all the details.

See you soon,

Isabelle,

http://dialex.co.uk/conferences/malvern_2006/malvern_2006.htm

Oleg, really you are "too much".
Your are always ready to put new things on the site and to find answer
for other ones or find new ideas. You feed the site for over 99% of
its content!
Unfortunately we have only one Oleg.

Thanks you for your wishes.

I will put my results on the site as soon as possible. Evaluation is
very important and I do believe that we have to evaluate our work. It
is our job and our duty especially from an ethical point of view and
it will help us to grow up better!!

Thank you for all this work and please continue!

'Calendar' at this site appeared to be a very useful thing!
I added information about this year DFSG Meeting (dates with abstract
deadline and URL address). You can find them there in 'Events list -> All'
In my opinion it'd be cool if other group members add the information
they have about national and international conferences in field of DF,
wound management, diabetes, etc. (for ex., meetings of EWMA and ETRS in Europe,
next Wound Healing Congress, Diabetic Foot Congress (2007?), American
Diabetes Associations meetings (if we take part), some national events).

We often miss some interesting conferences because we just know nothing
about them!
With the best regards,
Oleg.

The problem of malignancy in lower extremity ulcers really seems to be
underestimated. In 2000-2001 similar alerts were published in European
Wound Management Association materials. The file is here:
http://www.ewma.org/pdf/spring01/05-MalignancyAndPre-
malignancyInLegUlceration.pdf

Now I understood that I must refer a patient with leg ulcer whom I
treat unsuccessfully for 3 weeks to wound biopsy.

Isabelle, we all wish good luck to you!
Oleg.

Hi Isabelle

The Lancet 2005; 366:1750 - Malignant melanoma presenting as a foot ulcer

I thought it was worth posting this on the diabetic website but I don't know how
to do it. It's an article from my team published in this week's Lancet. We
presented the case at last year's DFSG. I can get you the full article if you
want to post the picture as well.

Amitiés,

Marie-France



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Welcome to our group!
How are you, what are your news. Here you can see statistics of my
outpatient clinic which I calculate and publish every 3 months. Waiting
for other participants to do similar analysis - we could compare data
regularly.

With the best wishes,
Oleg.

Happy to see that you reach the group. We are waiting for more active
members. Hope that you are the one who will made the number of
exchanges explosed!
You are a moderator, so you may introduce photos, files and everything
you want.

Wellcome again,

Isabelle,

Dear Colleagues,

As I promised to place here results of 'Efficacy monitoring' for our
outpatient wound care, now I place two Excel files (MonitEff 2005 1_6_e
and MonitEff 2005 7_9_e) with data of 1st 6 months of 2005 and of July-
Sept accordingly. See section 'Files' for details.
This appeared to be surprisingly useful for our practice 'internal
audit'!
Have a nice weekend!
Oleg Udovichenko.
P.S. Perhaps later we'll have to organize folders in that section
because as number of files we place here increases, problems with
search for necessary one are possible.

Dear members of The Diabetic Foot Group.

I am happy to become a member of this group. I believe all the members
of this group are interested to contribute something in the field of
Diabetic Foot. I am working in Bangladesh alone and try to developed
this field of medicine. I wants to share my experience with you and
get information from you as well. I am asking all of you participate
actievely and soon we can gethered a huge information and can
contribute in this neglected field of medicine.

Waiting for your mails.

-----Message d'origine-----
De : TheDiabeticFoot@yahoogroups.com [mailto:TheDiabeticFoot@yahoogroups.com] De la part de jan_l_richard
Envoyé : lundi 19 septembre 2005 22:33
À : TheDiabeticFoot@yahoogroups.com
Objet : [TheDiabeticFoot] Communication au DFSG

Isabelle,
En reprenant les résumés des communications du DFSG, j'ai relu la
tienne sur la façon de diminuer les hyperpressions au niveau des
semelles et je ne me rappelle plus si pour réduire les pressions tu
creuses la semelle ou si tu utilises une autre astuce ? Pourrais-tu me
le préciser.
Amitiés
JLouis
PS Merci pour les photos