This study of 213 recruited patients not only looked at wound healing differences between silver containing dressings and non-silver low adherence dressings in the treatment of VLU but also the cost effectiveness of the two.  The primary measure was complete ulcer healing at 12 weeks with secondary measures being; time to healing, quality of life and the aforementioned cost-effectiveness.  Although I do have some issues with the study design including the leeway given in dressing selection, compression definition and number of visits, I do find the results interesting. 

As one might reasonably expect given the paucity of good evidence on the effectiveness of silver dressings as a class, the VULCAN study found that there were no significant differences between dressings in the number of ulcers healed at 12 weeks (59.6% silver, 56.7% non-sliver) nor to median time to healing. As could also be expected, silver dressings cost significantly more to use ($46.60 vs. $8.70 as converted from the reported £).  The authors concluded that “There was no evidence to support the routine use of silver-donating dressings beneath compression for venous ulcerations”. 

This finding won’t surprise anyone who has heard me lecture on “Differentiating infected from non-infected wounds” as I did at the APMA meeting, who has read the chapter on Diabetic Foot Infections in the 3^rd Edition (specifically page 120), or has read my blog post from March 3, 2010 entitled “Bioburden and Wound Healing”.  Silver dressings are everywhere.  Just about every wound healing product line includes a number of silver donating products in every imaginable format.  Yet, there is little to no evidence to support that they are of any benefit in wound healing or preventing wound infection.  This revelation first came to me upon reading the Cochrane Collaborative systematic review of the literature on silver dressings which, like the VULCAN trial, found little evidence to support their routine use.  This does not mean I don’t use them.  Like most clinicians, if I see a heavily colonized wound I am seemingly genetically programmed to reduce the bioburden and kill the bugs. 

What I am saying is that we should be practicing evidenced based medicine and not costing our patients or the health care system dollars that none of us can afford to spend on a therapy without solid science behind it.  So, next time a sales rep comes to speak to you about their latest and greatest silver product, ask for scientific proof, not some pretty “before and after” pictures, that it contributes to wound healing.  Unfortunately, I doubt you will get much.  These products are all approved by the FDA as 510k medical devices.  Therefore, there is little clinical science necessary to get them approved.   

REFERENCES

Lipsky BA, Holroyd KJ, Zasloff M. Topical versus systemic antimicrobial therapy for treating mildly infected diabetic foot ulcers: a randomized, controlled, double-blinded, multicenter trial of pexiganan cream. Clin Infect Dis.  2008;47:1537-45.

Michaels JA, Campbell B, King B, Palfreyman SJ, Shackley P, Stevenson M. Randomized controlled trial and cost-effectiveness analysis of silver-donating antimicrobial dressings for venous leg ulcers (VULCAN trial). Br J Surg. 2009;96:1147-56.

 Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT. Topical silver for treating infected wounds. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005486

“The purpose of this site is twofold; to allow me to interact with anyone interested in the treatment of lower extremity infections and to give me an opportunity to update the readership on new developments in infectious diseases as they become available.  I regularly review the ID literature for manuscripts that have a direct bearing on the way we treat the lower extremity and attend ID meetings.  This blog allows me to disseminate that information rapidly which would be impossible if I had to wait for my next book revision.

I envision this site as being interactive.  If you have a question about an interesting case (you can even post pictures), have recently heard a lecture, been detailed by an antibiotic representative or just randomly thought of a question on which you would like my thoughts, ASK AWAY!  I will do my best to answer in a timely manner with the best available evidence to support what I say, not to mention a dose of my opinion/experience.    In the future I hope to start running the occasional poll to capture what others may do in a given situation.  If you have any other ideas for this site, please let me know.  I am open to suggestions on how to make it of value to you”

When you register, it is completely free with no obligation; you will get an email notification whenever I post something.  I don’t have a strict timeframe for posting.  I only put up something when I feel it will be of interest.  I may go a few weeks without any or do a few in a row. The best, most convenient way to know is to register. 

Although loaded with information, any textbook is static.  Once it is published, the information does not change.  Given the rapid pace of development in ID, diabetic foot and wound care, I feel it is important to have a means of keeping folks up to date with the latest information.   Thank you for your interest and please feel free to contact me with your thoughts and suggestions.

(Link to PubMed Abstract: http://www.ncbi.nlm.nih.gov/pubmed/20585070) 

This was a population based, nested control study of a population >66 year olds who were receiving Angiotensin Converting Enzyme Inhibitors and various antibiotics.  The numbers were impressive.  This was a 14 year study with 4148 identified admissions involving hyperkalemia.  To quote the Conclusions, it was found that “Compared with amoxicillin, the use of TMP/SMX was associated with a nearly 7 fold increased risk of hyperkalemia-associated hospitalization.  No such risk was found with the use of comparator antibiotics”.

I still believe that if you have a mild CA-MRSA infection or are considering a “step down” from either vancomycin or linezolid, then doxycycline or minocycline is frequently preferable over TMP/SMX for therapy. Sure, I have used TMP/SMX in some cases.  One of the more recent that comes to mind was a patient with CA-MRSA plus Stenotrophomonas maltophilia.  Using TMP/SMX gave me a single agent I could use to cover both bugs.  I don’t want to “trash” TMP/SMX but given all of the data out there on potential problems with it, I would encourage you to chose it with a full understanding of the issues surrounding it and not just because you see others prescribing it so freely and randomly.

This short piece in the paper was reporting on the results reported in a study published in the June 9, 2010 issue of the Journal of the American Medical Association by Schaefer MK, et al entitled “Infection Control Assessment of Ambulatory Surgical Centers.” Ambulatory surgical centers in 3 states were assessed specifically looking at hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning and handling of blood glucose monitoring equipment.  Despite the centers knowing that they were being observed 67.6% had at least one lapse.  Also of interest was the breakdown on numbers and types of procedures.  Almost a full 1/3 of all of the procedures performed at these surgi-centers were classified as “Podiatry”.  I did not find where the study differentiated lapses in infection control by types of procedure and, unlike the USA Today piece, the JAMA article did not specifically single out “foot operations”.

The reason for me reporting on this study, besides the public relations nightmare from the USA Today piece, is that I know many podiatric physicians have financial interest in an ambulatory surgical center.  All I can do is plead with you to maintain the absolute highest level of vigilance in your infection control practices.  This WILL come back and “bite” you if you do not.  After a report like this in a journal like JAMA you know that more regulations are not far behind!

Along the same vein, I sit on my hospital’s Infection Prevention and Control Committee.  At our most recent meeting the RN Infection Control Coordinator passed out an article which was a position paper from the Association for Professionals in Infection Control and Epidemiology (APIC) on safe injection practices:  Dolan SA, et al. APIC position paper: Safe injection, infusion and medication vial practices in health care. Am J Infect Control 2010, 38:167-72.  Why I found this particularly pertinent to what we do in lower extremity practice is that it discusses the use of multi-dose medication vials.  I have personally reviewed a few mal-practice cases of docs being sued for allegedly causing infection by using these vials.  Apparently, there is some controversy about how long one of these vials can be used. The United States Pharmacopeia (USP) requires that a multi dose vial must be disposed of 28 days after the initial stopper penetration unless the Product Insert states otherwise.  The Centers for Disease Control and Prevention (CDC), however, takes the stance that the bottle can be used until the manufacturers’ expiration date or if there are concerns about its sterility.

Taking these different opinions into account the APIC Guidelines suggests “…adhering to strict aseptic technique when accessing the vial, using a new sterile needle and a new sterile syringe for every access, removing all access devices from the vial, storing the vial in a clean protected location according to the manufacturer’s directions and ensuring that any vial whose sterility may be compromised is immediately discarded.”  I rather like one of their other comments and suggest to  you that, although not economically viable, and not currently “standard of care”, may be the best advice to protect your patient and yourself…”Use multi-dose medication vials for a single patient whenever possible…Infection transmission risk is reduced when multi-dose vials are dedicated to a single patient”.

1.  The article starts out by talking about all of the attention and “millions of dollars” spent each year for drug company marketing of onychomycosis in a “futile” attempt to treat the condition.  Apparently, Dr. Lipman has not been watching for direct-to-consumer (DTC) ads on TV, looking for journal advertisement about onycho products or seeing Pharma reps in his office.  If he did, he would know that there is not, nor has there been for about 2-3 years, ANY money spent on onychomycosis product advertisements at all!  All 3 FDA approved products are currently generic and no money is spent on marketing them.  I would also take exception to his classification of the treatment as “futile”.  Both clinical trials, and clinical experience showed terbinafine and itraconazole to be rather effective agents.  Even if they do not work all of the time, their use is far from futile. 

2.  Dr. Lipman states that the treatment is “only occasionally medically necessary” except to prevent secondary bacterial infection particularly in diabetic patients and the immunocompromised. Despite many studies showing quality of life issues and other medical complications of onycho, the entire “cosmetic vs. medically necessary” argument has been going on for years, mainly perpetuated by the insurance companies who used it as an excuse to not pay for the drug.   It is interesting that, now that the drugs are generic and inexpensive, suddenly there seems to be little trouble getting them covered.  I guess the generic forms are medically necessary while the name brands were not. 

3.  His comments on the “do it yourself” Internet market for onychomycosis products is right on target.  Although some are capable of killing fungus few if any have been subject to randomized controlled trials.  This also goes for most of those products being sold by our colleagues out of their offices. (Anecdotal testimony perpetuated by representative, i.e. “According to Drs. Smith and Jones, it works 90% of the time” does NOT equal medical evidence!)

4. Dr. Lipman’s discussion on prescription options is also mostly correct.  I would challenge his comment that a “3-month course of treatment can run up to several hundreds of dollars not including doctor’s visits and cost of tests”.  Now that these drugs are generic we are all familiar with the $4 Rx of terbinafine that many of our patients are now able to receive from discount pharmacies.  In fact, oral therapy of onychomycosis is actually quite inexpensive. The downside to his is that it has stymied any new oral therapy development since few Pharma companies want to develop a new, expensive drug to challenge such inexpensive therapy.

5. My final comment is in regard to his comment that a single laser treatment, “usually by a podiatrist, may be effective nearly 90% of the time but at around $1200 a pop”.  I find it quite interesting that Dr. Lipman is critical of prescription orals and topical and all of the anecdotal remedies holding them up to scrutiny for their lack of clinical evidence yet he mentions a 90% success rate with lasers. I need to point out that NONE of the lasers have been proven to work anywhere near the 90% mark with a single treatment and only one, the Noveon system, has any published data whatsoever.  (For full disclosure, I have been a consultant to both Nomir and Patholase).  The Noveon data just published last week by Adam Landsman, DPM, PhD and colleagues in the May/June issue of the Journal of the American Podiatric Medical Association used 4 treatments and evaluated at 180 days.  They found that 85% of the nails were improved as judged by an independent, blinded expert panel. Patholase has just completed their prospective study on the PinPointe system but it has not yet been published.

Do yourselves a favor and find the piece since you know that your patients are going to be questioning you about it!   

Ulceration under a mycotic nail in a patient with diabetes

McCarthy NL, et al.  Health care-associated and community associated MRSA infections: A comparison of Definitions.  American Journal of Infection Control, 2010:  This retrospective chart review attempts to determine risk factors for CA-MRSA and HA-MRSA based on two commonly used definitions; the epidemiology of the infection and the phenotypic antibiotic sensitivity without looking at the genotype (i.e. looking for the SCCmecIV gene to determine a USA300 strain).  Not surprisingly, to quote their Conclusion from the Abstract “We found few differences between CA- and HA-MRSA infections regardless of how health care association was found. We believe that the migration of CA-MRSA into health care settings and the recent increasing antibiotic resistance of CA-MRSA strains contribute to the lack of factors associated with HA (vs CA) MRSA.”  One finding I did think was particularly relevant was that CA-MRSA accounted for the overwhelming majority of skin and soft tissue infections (p <.0001).

For the past year or two I have been lecturing and writing that the use of classic “risk factors” to determine HA vs CA was a technique of the past. This was recently driven home to me when I saw 3 patients in the hospital with MSSA, 2 of whom were 80+ years old and lived in long term care facilities while I had a perfectly healthy 30 something with no pertinent medical history whatsoever present with a CA-MRSA.  I still continue to use the phenotypic method of looking at antibiotic susceptibilities, particularly toward Bactrim and tetracyclines since we have not seen much CA-MRSA resistance to these drugs at our facility.  It is becoming clearer that perhaps we will need to do the genetic typing, such as the TEM-PCR I discussed in a recent post to really know what we have.  Of course, it may be a moot point in skin and skin structure infections since, as validated by this report, I don’t remember seeing an HA-MRSA in over 2 years.

Nagoba BS et al. A Simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades.  International Wound Journal, April 23, 2010:  This is a retrospective case series from India that collected data from 1998 into 2009.  They looked at the application of a 3% citric acid gel preparation onto 115 diabetic foot ulcerations of various Wagner classification severities up to, and not including grades IV and V.  Of interest to me was that they took cultures of all of the wounds and performed broth dilution sensitivities of all the organisms against the citric acid.  They found that in grade I-II ulcerations they had 94%+ healing in 5-34 applications.  They also found that in deeper wounds there was marked decrease in slough and drainage with increases in healthy granulation.  They concluded that citric acid was safe and maybe even promoted granulation tissue while killing the bacteria found on the wounds.   

I find various problems with the design of this study and am not reporting it because I consider it an earth shattering breakthrough.  Rather, I bring it to your attention because, currently, one of the “Holy Grails” of wound healing is to find an safe, effective, affordable topical antimicrobial to, perhaps, assist in wound healing.  Heck, I am still not even convinced that bioburden reduction is all that many claim it is, as I have blogged before, however, we are all programmed to kill bacteria on a wound and maybe this is an option.  It should probably at least be looked at in more detail.

Traunmuller F, et al. Linezolid concentrations in infected soft tissue and bone following repetitive doses in diabetic patients with bacterial foot infections.  International Journal of Antimicrobial Agents, 2010:  This study assayed fluid from interstitial spaced, inflamed subcutaneous adipose tissue and metatarsal bone from patients with inflamed diabetic foot infections who were at steady state condition after 600 mg twice daily dosing of linezolid.  What they found was not particularly surprising; in all tissues linezolid penetrated to a level that was similar, if not slightly higher than what was found in plasma.  To quote their Abstract “We conclude that linezolid administered at 600 mg twice daily may be considered an effective treatment in diabetic patients suffering from bacterial foot infections complicated by osteomyelitis”. 

We all know that linezolid is not FDA indicated for the treatment of osteomyelitis.  In fact, NO antibiotic marketed in the past 10-12 years has been indicated for osteo, not because they don’t work but because the FDA has not developed “Guidance for Industry” on how to perform an osteomyelitis study.  I have also never been a believer in the concept of “bone penetration” as being an important indicator of osteo efficacy.  They techniques have never been standardized and really, to my mind, penetration numbers mean nothing. That all being said, at least this paper gives those of you who remain stuck on the concept of bone penetration evidence that linezolid does get into, not only bone but also frankly infected diabetic foot tissues.  This is not unlike data published by Gary Stein, PharmD and recently reviewed in the Jan/Feb 2010 issue of the Journal of the American Podiatric Medical Association (Nicolau DP, Stein GE. Therapeutic options for diabetic foot infections: A review with an emphasis on tissue penetration characteristics)

Prior to my session, I will be in the Exhibit Hall from 9:30 – 11:30 at the Data Trace Booth to sign copies of the Handbook, talk about this blog and just answer questions anyone might have about treating infections.

I hope to see folks there!

The current standard for making a bacteriologic diagnosis of a lower extremity infection is the use of a culture and sensitivity.   The problem with this test is that it may take several days to obtain a result while the patient has been placed on empiric antibiotic therapy that may be either too broad or too narrow spectrum.  Although Polymerase Chain Reaction (PCR), to look at the DNA of the organisms found on a specimen, has been used for a number of years to rapidly identify the bacteria, it has been limited mostly to reference laboratories and is hindered by usually only being able to identify one organism at a time.  This is changing with the use of Target Enriched Multiplex-PCR (Tem-PCR) which has the ability to identify up to 25 or more organisms with a single sample and to do it within just a few hours. A company based out of Huntsville, AL, Diatherix, is now commercializing this technology so that any physician in an office or wound center can order this test.  The clinician receives swabs and transfer materials, including overnight mailers from the company.  They take a specimen, as they would a standard C&S; place it in the mailer to Diatherix which receives it the next morning.  By that afternoon a result is communicated to the clinician including the identity of the organism, its relative frequency compared to other bacteria found in the specimen and any genetic markers for resistance, such as the presence of the mecA gene indicating MRSA.

By accurately identifying disease-producing pathogens early, Tem-PCR results can assist physicians in forming a more accurate diagnosis. This provides them the opportunity to accurately diagnosis the condition which leads to the appropriate treatment rather than treating empirically. By enabling physicians to link diagnostics to therapeutics, Tem-PCR results can assist by eliminating the inappropriate use of antibiotics eliminating unnecessary treatments, reducing the development of genetic drug resistance, potentially reducing cost of therapy and providing a better patient outcome.

The Tem-PCR technology provides multiplex amplification of genomic material from multiple pathogens with greatly increased sensitivity compared to standard multiplex PCR.  Standard multiplex PCR in general cannot amplify multiple pathogens in a single analysis due to each set of primers requiring differing optimum conditions for best amplification.  Tem-PCR works around this by essentially turning the multiplex into a singleplex reaction needing one primer set and one set of optimum conditions so that the best amplification can be obtained.  This allows more results from a single sample as a benefit of Tem-PCR over both singleplex PCR and qPCR (real time PCR).

Three significant benefits of producing multiple results from a single sample are being able to accurately identify pathogens causing infection in a rapid fashion, the identification of co-infections and the identification of genetic drug resistance. If a patient presents with a wound that is not healing a physician will perform a culture in order to identify the pathogen or pathogens present. At this point the physician will often treat the symptoms empirically due to the multitude of pathogens that could be causing the infection.  If the patient is on antibiotics at the time the sample is taken for culture there is a very good chance the culture will be negative which leaves the physician to continue empiric treatment. If on the other hand the physician had obtained a sample to be performed by Tem-PCR up to 25 pathogens would be tested including genetic drug resistance providing the physician with definitive information leading to proper treatment.

Diatherix claims that the test is covered by most insurance companies.

A Diabetic Foot Infection in Malatya, Turkey

In preparation for my talks I was asked to concentrate on the importance of a team approach to amputation prevention. Having just returned from DFCON I was up to date with the latest published data and reports from around the world about the successes that true amputation prevention teams have achieved in reducing the rates of “major” amputation. I have always found it amazing, if not a bit troubling, that smaller, less developed nations can codify a network of diabetic foot centers throughout their countries more than we have accomplished here in the United States. Even Pakistan and Kosovo, as discussed at this year’s DFCON, are able to reduce amputation rates by starting these centers. Turkey has made some progress towards the goal of developing amputation prevention teams.  Just last year Yesil, et al from Dokuz Eylul University Medical Center in Izmir (a facility, unfortunately, I did not have a chance to visit) reported a reduction of major amputations after starting such a team. (Yesil S. et.al. Exp Clin Endocrinol Diabetes, 2009).  In Istanbul I was honored to meet Dr. N. Saltoglu at Cerrahpasa Medical School, Istanbul University, when I gave one of my lectures to their Infectious Diseases faculty.  Dr. Saltoglu has just recently started a multidisciplinary diabetic foot team at this large institution of >1800 beds.  They are already beginning to see positive outcomes. 

During my trip I also lectured to the infectious disease faculties at Universities in the cities of Malatya and Kayseri both in the Eastern Provinces of the country.  They were very interested in the concept of starting comprehensive diabetic foot teams but were stymied by much the same turf battles and, dare I say, ego issues that we find here in the US.  Patients are treated by their local primary physicians for protracted periods before being sent to the hospital specialists.  Once admitted they are shuttled between various services including endocrinology, vascular surgery, orthopedic surgery and internal medicine with each passing the patient off to another service once their particular part of the job is completed with little coordination of effort.  The ID physicians, in particular, play a very primary role in the treatment of DFI and expressed frustration that, by the time they see the patient, it is often very late in the progression of the disease and they are dealing with infections that have received multiple, often inadequate antibiotics and now present with multi drug resistant pathogens.  The universal regret, oft expressed at DFCON, about the patient being seen too late in the progression of the disease was repeated time and time again.  It just goes to show that you can travel 5000 miles from home to a totally different culture, yet some issues are universal! 

A few other thoughts and interesting findings about lower extremity infections in Turkey:

1.  MRSA is not the problem we have here.  In fact, in most hospitals the rates have been decreasing the past 5 years.  Furthermore, they do not differentiate MRSA into HA- vs. CA- strains. The common thinking is that CA-MRSA is not a widespread problem and they just do not worry about it.  This is a huge difference from here where I need to treat everybody as if they have CA-MRSA until proven otherwise. 

2.  There are different antibiotics.  Whereas we use so much vancomycin for our MRSA in-patient soft tissue infections, their drug of first choice is teicoplanin.  This is another glycopeptides that, although widely used in other parts of the world, never received its US approval.  Like vancomycin, teicoplanin presents its own set of problems with dosing including having to give adequate loading dose, measuring troughs and the potential for liver toxicity. There may also be “MIC Creep” issues with MRSA and teicoplanin.  Another unique antibiotics is cefoperazone/sulbactam a β-lactamase inhibitor combination I remember reading about 20 years ago when it was thought that it might be brought into the US.  Other drugs are the same including piperacillin/tazobactam, ertapenem and imipenem. 

3.  ESBLs are a major problem.  Whereas we are just now beginning to see extended spectrum β-lactamase (ESBL) producing gram negative rods here in our US diabetic foot infections, Turkey has had them for years.  In fact, there are enzymes found in Turkey that you would be hard pressed to find anywhere else in the world.   Surveillance surveys have found gram negative resistance rates to cephalosporins and even quinolones in the 50-60% range.  It is felt that some of this may be caused by the long term, inadequate antibiotic therapy that is often started by primary physicians or even pharmacists before the patient is seen by the ID specialists.  And, of course, the universal overuse of the flouroquinolones is thought to contribute.   

4.  Acinetobacter, especially multi-drug resistant strains, is a problem.  I found this particularly interesting given the well documented outbreak of Acinetobacter infections that has been reported in our troops returning from the current Middle Eastern conflict.  When in some of these Eastern sections of Turkey one is not far from Iraq and Syria.  Perhaps there is something in the environment or the locale that propagates this organism.

With Dr. Bayindir, Director of Infectious Diseases, University Hospital, Malatya, Turkey

Edward James Olmos, my wife Judy and me at DFCON

Up to this point I have resisted using this blog as a “social networking” tool to just post pictures of myself lecturing someplace or another.  It has been my contention that readers of this site are interested in new science about lower extremity infections and the last thing you care to see is my visage staring out at you.  So, you will please indulge me this post.  Besides, I will still discuss some more substantive issues further down.

I was extremely honored to receive the 7^th Annual Edward James Olmos Award for Advocacy in Amputation Prevention given annually at the DFCON (International Diabetic Foot Conference) Meeting held each March in Los Angeles, California. The Olmos award is named for the actor Edward James Olmos who has been active in raising awareness of the ravages of diabetes and the importance of limb preservation in the Latino community. Each year during the presentation of the award Ed relates how every male member of his family including his father and all of his uncles had either died or lost limbs as a result of diabetes. He himself has not been diagnosed with the disease but is a realist about the potential that he will eventually. For this reason he carefully watches what he eats and exercises regularly. He tells a particularly touching tale about how one of his uncles, upon learning that he would have to lose one of his legs, decided to commit suicide rather than having to face the prospect of an amputation. He has made it his mission to educate the community which has one of the highest rates of diabetes and limb amputation in the country. Each year he personally attends DFCON so that he can present the award himself. On a personal note, I should say that I found him to be the antithesis of what one expects from a Hollywood celebrity. My wife and I found him to be warm, gracious, human and a very grounded individual.

Past winners of the Olmos award have included true “Superstars” in the international world of diabetic foot disease. They have included Karel Bakker, Andrew Boulton, Gary Gibbons, Chris Attinger, Ben Lipsky and Peter Cavanaugh.  To even have been considered amongst people I have looked up to for much of my professional career is an incredibly humbling feeling. I am also the first podiatrist to win the award despite others, including Lee Sanders, Larry Harkless and Bob Frykberg being incredibly deserving.

Enough about me and the award and on to DFCON! As far as I am concerned, this meeting is the scientific highlight of the year.  It has become the largest annual international diabetic foot meeting attracting close to 1000 delegates from all 50 states and over 40 countries.  It is one of the most egalitarian meetings I attend.  It does not matter what degree you hold or in which part of the world you practice.  All are listened to and respected, there united by a conviction to save limbs in this at risk population.  Probably my favorite day of the meeting is on the first day, Thursday. During this session speakers from all over the world present information on what is being achieved in diabetic limb salvage in their countries. This year in particular there were two incredible presentations about work being done in Kosovo and Pakistan. Despite incredible hardships, healthcare providers in these two countries have managed to begin to save limbs by simply setting up diabetic foot screening centers.  Streams of these lectures will soon be posted on the meeting’s website www.dfcon.com and I highly recommend them to my readers (not to mention all of the other talks from the conference).   What I always find slightly disturbing is that the US frankly lags behind many 2^nd and 3^rd world countries in codifying the concept of amputation prevention and setting up dedicated centers.  If Pakistan can manage, primarily through the efforts of a single individual, Dr. Basit, to set up screening centers throughout that country, why can’t we?  Currently, in the US, there are maybe 6 true, multidisciplinary, dedicated “limb salvage” centers, the latest being the incredible facility just dedicated on the Wednesday before DFCON at Valley Presbyterian Medical Center in Van Nuys, CA.  Kudos to Dr. George Andros who has invested blood, sweat and tears to achieve this life goal.  All in the Los Angeles area owe it to themselves to stop by for a look at this state of the art center.