The Medical clinics of North America
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Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. ⋯ A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Med. Clin. North Am. · Sep 2013
ReviewPeripheral arterial disease and bypass surgery in the diabetic lower limb.
PAD is very common in people with diabetes and is one of the strongest predictors of developing nonhealing foot ulcers and suffering amputation. There is strong evidence to show that early detection of PAD and revascularization will reduce amputations. Despite this, many patients have no vascular assessment even when they present with a foot ulcer or before amputation. ⋯ Currently there is no evidence to support surgical revascularization over endovascular treatments, but in reality the techniques are complementary and the choice of revascularization procedure should be determined by an experienced multidisciplinary vascular team. Surgical revascularization can achieve good results but careful patient selection, operative planning, and the use of autologous vein are necessary. What is clearly apparent is that at present not enough patients are being offered revascularization to prevent amputation.
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Med. Clin. North Am. · Sep 2013
ReviewEpidemiology of foot ulceration and amputation: can global variation be explained?
Amputation is a treatment, and not simply part of the natural history of foot disease. However, assessment of amputation incidence is the measure most frequently used to document an outcome reflecting the management of diabetic foot disease, mainly because the data are already captured in most health care systems. Nevertheless, interpretation of the results requires great care. ⋯ When 8- to 10-fold variation exists within similar health care systems, a risk as large as any published risk factor for amputation, it is essential that the reasons are explored. While race and social deprivation both make an important contribution to variation, another is likely to relate to aspects of the structure of care, including the training and beliefs of individual clinicians, patients’ access to care, preferences of patients, and the ability of a patient to understand the need for care and execute a care plan. This area of study requires further investigation.
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Med. Clin. North Am. · Sep 2013
ReviewNegative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play.
As of 2012, the number of people with diabetes is increasing in every country, and half of the people with diabetes do not know they are afflicted with the malady.1 Furthermore, it is believed that every 20 seconds a lower limb is lost around the world because of complications related to diabetes.6 In a short period, NPWT has transformed wound care across the globe, and other technologies are beginning to emerge that may provide clinicians with the tools necessary for identifying wounds at risk for delayed healing and recurrence. The future of diabetic limb salvage will rely heavily on these and other advances.
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Med. Clin. North Am. · Sep 2013
ReviewOsteomyelitis in the diabetic foot: diagnosis and management.
Although osteomyelitis of the foot in diabetes remains common in specialist foot clinics across the world, the quality of published work to guide clinicians in the diagnosis and management is generally poor. Diagnosis should be based primarily on clinical signs supported by results of pathologic and radiologic investigations. ⋯ Experts have traditionally recommended surgical removal of infected bone but available evidence suggests that in many cases (excepting those in whom immediate surgery is required to save life or limb) a nonsurgical approach to management of osteomyelitis may be effective for many, if not most, patients with osteomyelitis of the diabetic foot. The benefits and limitations of both approaches need, however, to be established in prospective trials so that appropriate therapy can be offered to appropriate patients at the appropriate time, with the patients' views taken fully into account.