Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB.

AIM: Prevalence, optimal diagnostic approach and consequences of clinically unsuspected osteomyelitis in diabetic foot ulcers are unclear. Early diagnosis of this infection may be crucial to ensure correct management. METHODS: We conducted a prospective study in 20 diabetic patients with a chronic foot ulcer (>8 weeks) without antibiotic pretreatment and without clinical signs for osteomyelitis to assess the prevalence of clinically unsuspected osteomyelitis and to compare the value of magnetic resonance imaging (MRI), 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) and 99mTc-labelled monoclonal antigranulocyte antibody scintigraphy (99mTc-MOAB). Those with suggestive scans underwent bone biopsy for histology (n = 7). RESULTS: Osteomyelitis was confirmed by biopsy in seven of the 20 clinically unsuspected foot ulcers. Presence of osteomyelitis was not related to age, ulcer size, ulcer duration, duration of diabetes or HbA1c. C-reactive protein was slightly elevated in patients with osteomyelitis (35.1 +/- 16.0 mg L(-1) vs. 12.2 +/- 2.6 mg L(-1) in patients with and without osteomyelitis respectively; P = 0.07). MRI was positive in six of the seven patients with proven osteomyelitis, whereas 18F-FDG PET and 99mTc-MOAB were positive only in (the same) two patients. Of the seven patients with osteomyelitis, five had lower limb amputation and in one patient the ulcer was persisting after 24 months of follow-up. In contrast, of the 13 patients without detectable signs of osteomyelitis on imaging modalities only two had lower limb amputation and two persisting ulcers. CONCLUSIONS: Clinically unsuspected osteomyelitis is frequent in persisting foot ulcers and is a high risk factor for adverse outcome. MRI appears superior to 18F-FDG PET and 99mTc-MOAB in detecting foot ulcer-associated osteomyelitis and might be the preferred imaging modality in patients with nonhealing diabetic foot ulcers.

[Hypokalemic thyrotoxic periodic paralysis following rice consumption]. / Hypokaliämische thyreotoxische periodische Parese nach Reismahlzeit.

HISTORY AND ADMISSION FINDINGS: A 38-year-old previously healthy Swiss presented with acute onset of progressive weakness in his legs in the morning hours after a carbohydrate-rich meal the preceding evening. Examination on admission revealed symmetrical paresis affecting the upper and lower limbs without involvement of the respiratory muscles. Hyperthyroidism was suspected. Similar symptoms three weeks before admission had earlier resolved spontaneously. INVESTIGATIONS: Laboratory tests revealed severe hypokalemia of 1.4 mmol/l. Hyperthyroidism, caused by Grave's disease, was confirmed and a diagnosis of hypokalemic thyrotoxic periodic paralysis (TPP) was made. TREATMENT AND FOLLOW-UP: After initiating potassium replacement paresis was observed to disappear within three hours. Symptomatic treatment with propranolol and thyrostatic treatment with carbimazole prevented further episodes of paresis. CONCLUSION: Hypokalemic thyrotoxic periodic paresis is a rare but increasingly common medical condition among people living in Western Europe. Diagnostically one's attention should turn to TPP at the presentation of acute paresis in combination with hypokalemia, especially in young men. Serious cardio-pulmonary complications can be avoided with early diagnosis and treatment.

A plasma glucose concentration below 2.5 mmol L-1 is not an appropriate criterion to end the 72-h fast.

CONTEXT: The classical end-point to terminate the 72-h fast in a patient evaluated for a hypoglycaemic disorder is the occurrence of hypoglycaemic symptoms in association with a low plasma glucose level. However, neither the symptoms nor the plasma glucose level have been exactly defined. OBJECTIVE: To determine whether a useful cut-off plasma glucose concentration as criterion to end the prolonged fast in the absence of neuroglycopenic symptoms can be defined. DESIGN: Single centre case-control study. SETTING: Tertiary referral hospital in Switzerland. SUBJECTS: The 72-h fast was prospectively performed in 23 consecutive patients (17 women and six men) following a standardized protocol between July 1999 and January 2002. All patients were referred to our clinic for evaluation of suspected hypoglycaemia. The criterion to end the fast before 72 h was defined by the occurrence of symptoms or signs typical for neuroglycopenia irrespective of plasma glucose levels. MAIN OUTCOME MEASURE: Insulin levels and insulin to plasma glucose ratios in insulinoma patients and in individuals without insulin-secreting tumours at termination of the fast and at plasma glucose levels

[Practical management of diabetic foot]. / Praktisches Management des diabetischen Fusses.

Prevention and the correct treatment of the diabetic foot have important social and economic consequences. Risk stratification is essential for choosing the appropriate treatment strategy. History and careful clinical examination identify the risk in each individual patient with diabetes. Peripheral neuropathy (PNP), foot deformation, peripheral arterial disease (PAD) and a history of previous ulcer or amputation are the most important risk factors. PAD must be diagnosed and treated by percutan transluminal angioplasty or bypass surgery where necessary. Primary foot deformation or secondary due to PNP require shoe modifications. Good metabolic control of diabetes and treatment of other cardiovascular risk factors (dyslipidemia, hypertension) delay or prevent the development of PNP and PAD. Therefore an early multidisciplinary approach is essential for each patient with diabetes and foot problems. In the presence of a foot ulcer, it's important to diagnose osteomyelitis by clinical or radiological examination. The choice and duration of antibiotic treatment and surgical intervention depends on the localisation and extension of infection around the ulcer and the presence of osteomyelitis. In case of limb threatening infection, the patient should be referred to a specialized treatment facility immediately.