Dean T. Williams

Wound Dressings in Diabetic Foot Disease

Wound dressings represent a part of the management of diabetic foot ulceration. Ideally, dressings should alleviate symptoms, provide wound protection, and encourage healing. No single dressing fulfills all the requirements of a diabetic patient with an infected foot ulcer. Dressings research in this area is generally poor. However, each category of dressings has particular characteristics that aid selection. Nonadhesive dressings are simple, inexpensive, and well tolerated. Foam and alginate dressings are highly absorbent and effective for heavily exuding wounds. Hydrogels facilitate autolysis and may be beneficial in managing ulcers containing necrotic tissue. Dressings containing inidine and silver may aid in managing wound infection. Occlusive dressings should be avoided for infected wounds. All dressings require frequent change for wound inspection. Heavily exudating ulcers require frequent change to reduce maceration of surrounding skin. Dressing choice should be guided by the characteristics of the ulcer, the requirements of the patient, and costs.

Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: A concurrently controlled, prospective cohort study

The objective of this study was to evaluate the effect of sharp debridement on the progression of recalcitrant chronic venous leg ulcers (CVLU) and to assess the feasibility of performing this procedure in an outpatient setting. We performed a prospective study of 55 CVLU (53 patients) over a 12‐month period. The study group, which underwent debridement, contained 28 CVLU whose wound beds had slough, nonviable tissue, and no granulation tissue. The control group was 27 CVLU with minimal (15–20%) granulation tissue, but no slough or nonviable tissue. Treatments were otherwise similar. Age, body mass index, mean ulcer surface area (MSA) and mean ulcer duration were comparable in both groups. Ulcer measurements were taken at 4 weeks before debridement, at the time of debridement, and 4 and 20 weeks post‐debridement. There was no change in the MSA from 4 weeks before to the time of debridement in either group. At 4 weeks post‐debridement, the study ulcers showed a 6 cm2 reduction in the MSA vs. a 1 cm2 reduction in controls (P = 0.02). By week 20 post‐debridement, the study ulcers achieved a 7.4 cm2 reduction in the MSA vs. an increase of 1.3 cm2 in controls (P = 0.008). Between weeks 8 and 20 post‐debridement, 16% of study ulcers vs. 4.3% of control ulcers achieved complete healing. Infection rates and antimicrobial usage were similar. We conclude that sharp debridement is effective in stimulating healing of recalcitrant CVLU. It is safe, well tolerated, and can be performed in an outpatient setting.

Diagnosing foot infection in diabetes

Infection represents the presence of an inflammatory response and tissue injury due to the interaction of the host with multiplying bacteria. The disease spectrum is a consequence of the variability in these interactions. Diabetes, because of its effects on the vascular, neurological, and immune systems, can compromise the local and systemic response to infection, potentially masking the typical clinical features and hindering diagnosis. The early recognition of infection, particularly osteomyelitis, is paramount in the management of diabetic foot disease. Careful clinical appraisal remains the cornerstone of the assessment. Hematologic, biochemical, and radiological investigations are important aids in assessing the severity of infection. Microbiological assessment, particularly in more severe infection, requires good-quality samples, combined with rapid transport in an appropriate medium and effective communication with the laboratory. A focused, systematic approach to the accurate diagnosis and treatment of infection, combined with careful monitoring, ensures the maintenance of optimal management.

Healing responses of skin and muscle in critical illness.

ObjectiveMany aspects of the care and underlying pathologies in patients suffering critical illness can detrimentally influence the normal healing processes of skin and soft tissues. Although a great diversity of pathologies exists, some aspects of the diseases and their treatments are common in critically ill patients. We aimed to identify some features, both common and specific, that could influence wound healing and the mechanisms by which they may do so. DesignIn this review, we first outline the biology of normal skin and muscle healing and then explore how critical illness may influence the normal healing cascade. FindingsThe healing of skin and skeletal muscle in critical illness is influenced by both underlying disease processes and the intensive care environment. Local and systemic factors can contribute to impaired healing, with the potential to prolong functional disability and increase the likelihood of wound complications. The frequency and number of soft tissue injuries derived from accidental injury, surgical intervention, and the need for invasive monitoring and therapies in the intensive care unit setting are likely to compromise the innate immunity and potentially further jeopardize the patient’s ability to heal. Alterations in coagulation, tissue perfusion, inflammation, immune functioning, metabolism, nutrition, and drug therapies will influence healing responses by modifying the biological responses to tissue disruption. Locally, wound contamination, sepsis, tissue hypoxia, edema, and excessive or prolonged local pressure all have the potential to compromise soft tissue healing. One or more of these factors may be present at any time. ConclusionThe skin and soft tissues are vulnerable to both injury and compromised healing when a patient is critically ill and exposed to a critical care environment. The identification of risk factors may aid in forming and modifying treatment strategies when caring for the critically ill patient with soft tissue injuries.

Phaeochromocytoma: views on current management

AIMS To evaluate the current investigation and management of phaeochromocytoma. METHODS Retrospective analysis of patients who underwent surgical excision of phaeochromocytoma in the Department of Endocrine Surgery at the University Hospital of Wales, Cardiff. Forty-seven patients (24 female and 23 males) were studied. Preoperative diagnosis was established by measurement of urinary catecholamines (HMMA, metadrenalines, and fractionated catecholamines). Tumour localisation was achieved by using ultrasound, CT, MRI and MIBG scintigraphy. Preoperative medical preparation and control of hypertension was achieved in the majority of cases by alpha adrenergic blockade with phenoxybenzamine and the beta blocker propranol. Surgery was performed by a variety of approaches which included laparotomy, posterior extraperitoneal and laparoscopic methods. All patients were followed up post-operatively in a surgical endocrine clinic. RESULTS Seventy percent of patients presented with hypertension but only 21.3% gave a history of paroxsmal hypertension. CT scanning and MRI proved to be the most sensitive localisation investigations. Excellent preoperative control of hypertension was achieved with alpha adrenergic blockade but induction of anaesthesia, rather than tumour handling was noted to be associated with most hypertensive surges of blood pressure. There was a zero 30 day post-operative mortality but 10 complications of surgery occurred in 8 patients (21.3%). Cure of hypertension was achieved in 80% of patients. Attempts to perform cortex sparing procedures in patients with familial disease and multiple tumours was not successful in the long term. CONCLUSIONS Surgical excision of phaeochromocytoma is a procedure, which can be performed with zero mortality and a low morbidity resulting in a high cure rate for hypertension. Adequate preoperative pharmacological control of hypertension is mandatory. Localisation techniques permit a focussed approach with increasing use of laparoscopy. Those patients with familial disease and those with multiple tumours pose particular management challenges. For an optimum and satisfactory outcome a planned multidisciplinary approach is required.

Delay in discharge and its impact on unnecessary hospital bed occupancy.

BackgroundElderly patients are potentially more vulnerable to prolonged hospital stay as they frequently require additional resources to facilitate their discharge. In an acute hospital setting, we aimed to quantify and compare length of stay (LOS) for all patients over and under the age of 65, and identify the number and cause of days lost under the care of a single surgical unit.MethodsOver a 4 month period from January to April 2010, data on the management and source of potential delay was collected daily on consecutive patients admitted and discharged under the care of one consultant surgeon at a district general hospital. Statistical analysis was then performed with particular focus on actual delays affecting elderly patients.ResultsA total of 99 complete inpatients episodes were recorded. There were 30 elective and 69 acute admissions. 10 (33%) elective vs. 42 (61%) acute patients encountered delays, losing 39 and 232 days respectively (χ2 [1, N = 99] = 6.36, p = .012). 23 of a total 39 elderly patients admitted acutely required specialist care of the elderly opinion and placement in community hospitals resulting in delays of 188 days. vs. 36 days for the 16 discharged home and 8 days for 30 patients under 65 (χ2 (2, N = 69) = 26.54, p = <.001).ConclusionsElderly patients experiencing acute surgical admission and discharge to community hospitals had prolonged LOS due to significant delays associated with care of the elderly provision. The financial considerations behind bed capacity in primary and secondary care and the provision of care of elderly services need to be balanced against unnecessary occupancy of acute hospital beds with its associated health and economic implications.

A Diabetic Foot Service Established by a Department of Vascular Surgery: An Observational Study

BACKGROUND The mechanism by which the multidisciplinary approach to diabetic foot disease reduces amputation rates is unclear. Ischemia, sepsis, and necrosis represent aspects of severe diabetic foot disease amenable to intervention. In 2006, a vascular unit introduced a rapid access service for severe foot disease, augmenting the established community provision. This study aimed to determine whether concurrent changes in amputation rates were observed, and to identify areas that may have influenced outcomes. METHODS Unit data prospectively collected during 4 years for patients with lower-limb disease were compared with data retrieved over 2 years before the foot service. Outcome measurements were major amputations, foot surgery, vascular interventions, admissions, and length of stay. RESULTS Major amputation rates associated with diabetes peaked in 2005 at 24.7/10,000 vs. 1.07/10,000 in 2009; (relative risk = 0.043, 95% confidence interval = 0.006-0.322). The proportion of diabetic to nondiabetic amputations decreased; foot surgery rates also dropped (53.7/10,000 in 2006 vs. 7.5/10,000 in 2009). The number of open revascularization procedures decreased, but the rates of endovascular procedures remained generally constant. Hospital admission rates decreased after initially peaking, and the length of stay was unchanged (16 vs. 15.5 days in 2004 and 2009, respectively). CONCLUSIONS The integration of a vascular unit with community care has been associated with improved outcomes for patients with diabetic foot disease. Improvements were not related to the increased number of vascular procedures or hospitalizations, but did coincide with a greater proportion of patients attending the foot unit. The referral of patients to the unit facilitates the rapid management of severe disease, reducing delays deleterious to outcomes.

The influence of exercise on foot perfusion in diabetes

Aims  Diabetic foot disease is associated with both macro‐ and microvascular disease. Exercise has both positive and negative effects on the perfusion of lower limbs with peripheral arterial occlusive disease (PAOD). We aimed to measure changes in foot perfusion following a brief period of lower‐limb exercise in individuals with and without Type 2 diabetes and non‐critical PAOD.

Review: The clinical evaluation of lower limb perfusion in diabetic foot disease

Athorough clinical assessment and evaluation of foot perfusion is essential in managing diabetic foot disease. The treatment of macrovascular disease is key to reducing the high amputation rates seen in diabetic patients, particularly as small vessel dysfunction may make diabetic individuals more vulnerable to the effects of macrovascular, atherosclerotic disease. The clinical assessment remains paramount in the management of diabetic foot disease. The confounding effects of peripheral neuropathy on the symptoms and signs of lower limb arterial insufficiency can make assessment difficult. This article provides a resume of the clinical manifestation of lower limb ischaemia and neuropathy and the importance of accurate evaluation of the diabetic foot. Br J Diabetes Vasc Dis 2003;3:394‐8

Review: The laboratory evaluation of lower limb perfusion in diabetes mellitus. A clinical review

Non-invasive laboratory tests are commonly employed in the assessment of lower limb perfusion. The accuracy of non-invasive assessments in diabetes remains a concern. We evaluated the more commonly used methods with particular reference to diabetic foot disease. A literature review and clinical evaluation of tests for macrovascular disease, including hand held Doppler, blood pressure measurement and indices, Doppler waveform analysis, colour duplex imaging and plethysmography was performed. Tests reflecting tissue perfusion, including infrared detectors, transcutaneous oxygen tension, laser Doppler, capillaroscopy and skin temperature were also reviewed. Non-invasive laboratory tests reduce the requirement for invasive investigations and their inherent risks. More traditional non-invasive methods are being replaced by evolving techniques employing ultrasound technology. Arterial calcification and peripheral neuropathy associated with diabetes can potentially reduce the reliability of these methods. Distal limb and tissue perfusion assessments are more likely to reflect local vascularity. Tissue perfusion indicators are generally slow and vulnerable to environmental influences, thus limiting their clinical use. Nevertheless, non-invasive tests are an important adjunct to the clinical evaluation of diabetic foot disease. However, diabetes potentially reduces their reliability and the results require careful interpretation. Distal perfusion tests have potential advantages over macrovascular assessments. The influence of diabetes on non-invasive tests needs further evaluation. Br J Diabetes Vasc Dis 2005;5:64‐70