The Medical clinics of North America
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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.
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Many surgical and nonsurgical options exist with the aim of improving quality of life and preventing amputation in patients with CN. A multidisciplinary approach is necessary to achieve the best outcomes in this high-risk group. ⋯ Although the surgeons of today are better equipped to manage CN, the optimal timing and specific method of surgical treatment have yet to be defined. Multicenter, prospective studies may be the best way to study this relatively uncommon problem.