RecommendationsClassification/diagnosis
1.Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low).
2.Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate).


Osteomyelitis
3.For an infected open wound, perform a probe-to-bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high-risk patient, a positive test is largely diagnostic (strong; high).
4.Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate).
5.A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate).
6.A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe-to-bone, serum inflammatory markers, plain X-ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak).
7.Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate).
8.Obtain plain X-rays of the foot in all cases of non-superficial diabetic foot infection (strong; low).
9.Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate).
10.When MRI is not available or contraindicated, consider a white blood cell-labelled radionuclide scan, or possibly single-photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine-18-fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate).


Assessing severity
11.At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate).
12.At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low).


Microbiological considerations
13.Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high).
14.Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low).
15.Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low).


Surgical treatment
16.Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low).
17.Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low).
18.Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X-ray or bone protruding through the ulcer (strong; low).


Antimicrobial therapy
19.While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low)
20.Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate).
21.A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high).
22.Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low).
23.Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high).
24.For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate).
25.We suggest not using any adjunctive treatments for diabetic foot infection (weak; low).
26.When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).

https://onlinelibrary.wiley.com/doi/pdf/10.1002/dmrr.2699

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes.

This overview article proposes a revised approach to improve the urban realm, against the backdrop of new models for delivering transport services as digitalisation, collaborative consumption and autonomous technologies take hold. We propose the concept of modal efficiency illustrated through a conceptual framework situating both existing and emerging modes of transport around spatial and temporal dimensions. This framework helps us evaluate how the push towards smaller and more flexible transport services in questionable settings can have significant and adverse effects on road capacity, increasing congestion and in the longer term impacting urban form. We propose linking urban land use characteristics to travel price and modal efficiency to improve the broader transport system and guide the sustainable development of our cities. Mobility as a service (MaaS) based on shared mobility and modal integration constitutes a major opportunity to deliver on these ideals, if organised appropriately. Widely diverging service delivery models for MaaS are introduced, including commercially-motivated models (which may exacerbate efficiency issues), and systems which incorporate an institutional overlay. We propose consideration of a government-contracted model for MaaS, where road pricing is incorporated as an input into package price, defined by time of day, geography and modal efficiency. In amidst the hype of new mobility technologies and services, a critical assessment of the realm of possibilities can better inform government policy and ensure that digital disruption occurs to our advantage.

Mobility as a service (MaaS): Charting a future context

Efficiency and effectiveness in the urban public transport sector: A critical review with directions for future research

This paper presents a multi-level framework to measure public transit service performance. This framework uses a combination of subjective and objective measures to assess the service quality. It allows for the opinions of the various stakeholders of public transit services (users, operators, and service providers) to be incorporated in a multi-criteria evaluation process. The framework can evaluate the public transit service performance at different levels of details (system level and route level). It can be used to assess the performance at the route level, which can then be used to provide specific recommendations to enhance the operation for specific routes, and also it can be used at a more macroscopic level to identify the operational deficiencies or areas of improvement at the system level. The route analysis level is based on a multi-criteria evaluation procedure that involves weighted scoring techniques. A case study on a transit system of 12 operating routes in Abu Dhabi city is conducted to illustrate the framework.

A multi-dimensional framework for evaluating the transit service performance

The need to measure transit system performance along with its various dimensions such as efficiency and effectiveness has led to the development of a wide array of approaches and vast literature. However, depending upon the specific approach used to examine performance, different conclusions are oftentimes reached. Using data from 15 European transit systems for a ten year time period (1990-2000), this paper discusses three important transit performance questions; (i) Do different efficiency assessment methodologies produce similar results? (ii) How are the two basic dimensions of transit performance, namely efficiency and effectiveness, related? and, (iii) Are findings regarding organizational regimes (public operations, contracting and so on) sensitive to the methodological specifications employed? Results clearly indicate that efficiency scores and associated regime recommendations are sensitive to the models used, while efficiency and effectiveness are – albeit weakly – positively related; these two findings can have far reaching policy implications.

Efficiency Measurement in Public Transport: Are Findings Specification Sensitive?

The paper undertakes a comparative efficiency analysis of public bus transport in Spain using Data Envelopment Analysis. A procedure for efficiency evaluation was established with a view to estimating its technical and scale efficiency. Principal components analysis allowed us to reduce a large number of potential measures of supply- and demand-side and quality outputs in three statistical factors assumed in the analysis of the service. A statistical analysis (Tobit regression) shows that efficiency levels are negative in relation to the population density and peak-to-base ratio. Nevertheless, efficiency levels are not related to the form of ownership (public versus private). The results obtained for Spanish public transport show that the average pure technical and scale efficiencies are situated at 94.91 and 52.02%, respectively. The excess of resources is around 6%, and the increase in accessibility of the service, one of the principal components summarizing the large number of output measures, is extremely important as a quality parameter in its performance.

/pdf/technical-and-scale-efficiency-in-spanish-urban-transport-26tzizflg1.pdf

Technical and Scale Efficiency in Spanish Urban Transport: Estimating with Data Envelopment Analysis

Diabetic foot infection, particularly if it is associated to ischaemia, is the most common cause of lower limb amputation, in the general population, of hospital admissions, and a decrease in the quality of life in diabetics. Of all diabetics, 15% of them are going to suffer from a foot infection during their life, with an annual incidence of 1-4%, preceded by a foot ulcer in more than 80% of cases. They are complex infections and the prognosis is influenced by many factors, depending on the ulcer (location, extension, whether chronic or not, previous amputation, ischaemia grade), and the patient (age, renal impairment, time of onset of diabetes, associated comorbidity). All these must be taken into account when establishing its treatment.

/pdf/consensus-document-on-treatment-of-infections-in-diabetic-3ona9vf7k3.pdf

Consensus document on treatment of infections in diabetic foot

Editorial Comment The Sea Inside (2004) and Million Dollar Baby (2004) Two Oscars to medicine

Microbiology owes its discovery to the French chemist Louis Pasteur (1822-1985). This famous investigator put an end to the theory of spontaneous generation by showing that the content of open swan-necked flasks would stay sterile with the passing of time. Furthermore, his investigations demonstrated the microbial theory connecting infectious diseases to specific bacteria. Among his achievements is the development of vaccines, which established the scientific processes of obtaining them. These studies began in 1881 and culminated in 1885 by vaccinating a human being for the first time against rabies. Pasteur started the process of sanitizing food called pasteurization (1866-1887). He drew an endless number of followers, which contributed significantly to the growth of microbiology. He also created the institute with his that carries his name (1888), which continues making important contributions to the field of microbiology1. The German doctor Robert Koch (18431910) is associated with the scientific birth of medical microbiology. With his famous postulates (18761884), he demonstrated the specific origins of a grand part of infectious diseases. In addition, he discovered the agents responsible for diseases such as tuberculosis (1882-1884) and cholera (1883). He and the members of his school made important contributions in the fields of dyeing, cultivating, isolating and identifying bacteria. In 1905, he received the Nobel Prize of Physiology and Medicine for his contribution to bacteriology. The first of its kind was given in 1901 to his disciple, Emil Adolf von Behring, for his development of an anti-diphtheria serum2.

García Sánchez

Papers

Technical and Scale Efficiency in Spanish Urban Transport: Estimating with Data Envelopment Analysis

Consensus document on treatment of infections in diabetic foot

Editorial Comment The Sea Inside (2004) and Million Dollar Baby (2004) Two Oscars to medicine

The Founders of Microbiology on Movie Posters

or Research in Microbiology