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The lifetime risk that a person with diabetes will develop a foot ulcer may be as high as 15%–25%, and every year an estimated 1 million people lose a leg as a consequence of this condition, equating to one amputation every thirty seconds. Diabetic foot ulceration imposes a significant medical, social, and economic burden. Disorders of the foot account for more hospital admissions than any other long-term medical condition and also increase morbidity and mortality. A clear understanding of the etiology and pathogenesis of ulceration is essential if the incidence is to be reduced and subsequent amputation prevented. This chapter presents an overview of the pathway to ulceration.

Skin and soft tissue infections (SSTIs) can be sub-divided based on the anatomical structure(s) affected from superficial to deep. Impetigo affects children more commonly than adults, starting as a macule of erythema and evolving into vesicles that rupture, leaving a golden crusted appearance. Fever and systemic signs are absent. It is highly transmissible and children should be excluded from school until exposed lesions have resolved. Folliculitis is a superficial infection presenting with small papules or pustules on an erythematous base around a hair. Fever and systemic signs are absent. If extension into deeper tissues occurs a dermal abscess (‘boil’ or ‘furuncle’) may occur, and several lesions may coalesce into a ‘carbuncle’. Deeper infection may cause discomfort, fever, and systemic upset. Any hair-bearing area may be affected, but sites most commonly affected include the face, scalp, axilla, inguinal area, thighs, or eyelid (‘stye’), and may be associated with shaved or occluded skin. Cellulitis is rapidly spreading erythema of the skin associated with pain, swelling, fever, and systemic features such as nausea and malaise. It may be seen as a complication of tinea pedis, superficial abrasions, or insect bites, venous insufficiency, lymphoedema, chronic ulcers, and diabetes. It is almost always unilateral and bilateral cellulitis is extremely rare and should prompt consideration of an alternative diagnosis. The Eron grading system can help guide treatment and admission decisions: ● Class I: the patient has no signs of systemic toxicity and no uncontrolled comorbidities. ● Class II: the patient is either systemically unwell or systemically well but with a comorbidity such as peripheral vascular disease, chronic venous insufficiency, diabetes, or obesity, which may complicate or delay resolution of infection. ● Class III: the patient has significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension, or unstable comorbidities that may interfere with a response to treatment, or a limb-threatening infection due to vascular compromise. ● Class IV: the patient is septic or has life-threatening infection such as necrotizing fasciitis.

Basic sciences: Applied anatomy

Which of the following structures is unlikely to be damaged during a carotid endarterectomy procedure?

Hypoglossal nerve

Buccal branch of the facial nerve

External laryngeal nerve

Ansa cervicalis

Pharyngeal branch of the vagus nerve

Sepsis is defined as life- threatening organ dysfunction caused by a detrimental host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular abnormalities are profound enough to substantially increase mortality. Septic shock is characterized by: ● The need for vasopressors to maintain mean arterial pressure (MAP) > 65mmHg despite adequate volume resuscitation. ● A serum lactate > 2mmol/L In lay terms, it is hypoperfusion with evidence of metabolic derangement. The mortality for both criteria is ~40%, compared to 20–30% for a single item. Please also refer to: https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0686 The old definitions of sepsis described a heterogeneous group of patients and did not discriminate between infectious and non- infectious causes such as pancreatitis and trauma. The new definitions also allow easier recognition, based on a combination of symptoms and signs. Key parameters include: decreased level of consciousness, rigors, severe myalgia, high or low temperature, pulse > 130/min, systolic blood pressure < 90mmHg, respiratory rate (RR) > 25/ min, creatinine > 170μmol/ L, platelets < 100 x 109/l and bilirubin > 33μmol/ L. The Clinical Quality Commission recommend that NHS trusts use the national early warning score (NEWS), and a score > 5 is an indication to consider moving a patient to critical care. SIRS is defined as any of the two following criteria: acutely altered mental state, temperature < 36°C or > 38°C, pulse > 90/ min, RR > 20/ min, WCC > 12 or < 4 x 109/L and hyperglycaemia in the absence of diabetes mellitus. In the former definitions (1991 and 2001), sepsis was defined as infection plus SIRS. SIRS, however, was not good at separating infected patients who died from those who recovered from infection. SIRS was often an appropriate reaction to infection and many hospitalized patients meet the SIRS criteria. Also, as many as one in eight patients admitted to critical care units with infection and new organ failure did not have two SIRS criteria required to fulfil the sepsis definition. SIRS is no longer part of the new definitions.