The surgical care of diabetic feet: a survey about clinics, acute care, and the surgical specialists involved.

INTRODUCTION: Diabetic foot problems are becoming increasingly common. Diabetic foot care services are fundamental in managing them, and there is the further issue of acute surgery for foot sepsis. The involvement of different surgical specialists has been variable; this survey aimed to provide information about current service provision. METHODS: Questionnaires were emailed to Vascular Society members, and targeted approaches were then undertaken. RESULTS: We aimed to obtain information from 61 localities identified as providing shared services, and received informative responses from 46 (75%). These described diabetic foot clinics each day (11%), or once (50%), twice (13%) or three times (17%) weekly - attended regularly by vascular surgeons, and less frequently by orthopaedic surgeons. The frequency of clinics was considered inadequate by 30% of respondents, and only 75% reported written policies for diabetic foot care pathways. Operations for acute foot sepsis are done by vascular surgeons in 98% of localities and by orthopaedic surgeons in 22% (in some localities by both): the latter are orthopaedic foot specialists in all localities but two. Both specialties perform a range of foot procedures, including toe/foot-preserving operations. Major amputations are done by vascular surgeons in 98% of localities and by orthopaedic surgeons in only 9%. All deformity correction procedures are performed by orthopaedic surgeons. CONCLUSION: This survey shows that diabetic foot clinics are now held frequently in most localities. There is variation in the involvement of vascular and orthopaedic surgeons. Some localities need to consider increased provision of clinics and better defined pathways of care.

Systematic review: the use of nitrous oxide gas for lower gastrointestinal endoscopy.

BACKGROUND: Nitrous oxide gas (N(2)O) has been proposed as an alternative to intravenous (i.v.) analgesia in patients undergoing lower gastrointestinal endoscopy. AIM: To perform a systematic review of randomized studies where N(2)O was compared against control in patients undergoing either flexible sigmoidoscopy or colonoscopy. METHODS: Electronic databases were searched; reference lists were checked and letters were sent to authors requesting data. Methodological quality was assessed. Data were tabulated on the duration and difficulty of the procedure, quality of sedation and speed of patient recovery. RESULTS: A total of 11 studies were identified containing 623 patients. No differences were seen between groups for duration, difficulty of procedure or complications. Patient-reported pain was similar for N(2)O when undergoing flexible sigmoidoscopy vs. no sedation and when undergoing colonoscopy vs. i.v. sedation. Differences in delivery of N(2)O were identified. In all studies, N(2)O was associated with a more rapid recovery than i.v. sedation. CONCLUSION: For patients undergoing colonoscopy, N(2)O provides comparable analgesia to i.v. sedation. The rapid psychomotor recovery with N(2)O enables quicker patient discharge and removes the need for a patient to be chaperoned. Benefit was not seen from N(2)O in patients undergoing flexible sigmoidoscopy possibly because it was delivered on demand rather than continuously.