Diabetic wound healing and limb salvage in an outpatient wound care program.

Healing wounds and preventing amputations in diabetic patients is a challenge. Baptist Hospital in Nashville, Tennessee, developed an outpatient Wound Care Center program to treat patients with chronic wounds. This comprehensive program includes wound assessment, vascular studies, revascularization, antibiotic therapy, wound debridement, a topical growth factor solution of platelet-derived wound healing factors, protection devices, and patient education. A retrospective study of wound healing and limb salvage was conducted on 54 diabetic patients with 86 wounds. Average previous wound duration was 8 months. Amputation had previously been recommended for 15 limbs. Healing occurred in 88% of the wounds in an average of 15.8 weeks. Ninety-three percent of the limbs for which amputation had been recommended were salvaged. Healing efficacy and amputation reduction have been demonstrated in this program.

Foot wounds in diabetic patients. A comprehensive approach incorporating use of topical growth factors.

Managing nonhealing foot wounds in diabetic patients requires an understanding of the wounds' multiple contributing causes, including neuropathy, vascular occlusive disease, infection, and impaired wound healing. Proper attention to each cause may require consultations with vascular or orthopedic surgeons, diabetic education nurses, podiatrists, orthotists, and pedorthists. Wounds that fail to heal may respond to topical application of growth factors as part of a comprehensive clinical approach to the diabetic foot wound. An aggressive approach to diagnosis and treatment can result in improved wound healing and limb salvage.

Recent experiences with duodenal trauma.

In a 10-year period ending December 1983, 56 patients with duodenal injuries were treated at Vanderbilt University and Metropolitan Nashville General Hospitals. Most injuries consisted of isolated duodenal lacerations or perforations (37), five patients had duodenal hematomas, and 14 patients had injuries involving the duodenum, pancreas, ampulla, and/or common bile duct. Most injuries were successfully managed with suture repair. The Whipple procedure was necessary in five cases. Overall morbidity was 39.2 per cent, but complications directly related to the duodenal injury occurred in only six patients (10.7%). Only three patients died (5.3%). Excellent results can be achieved even with extensive duodenal injuries by the use of careful debridement and primary closure. When injuries to the duodenum are associated with injury to the ampulla of Vater, the head of the pancreas, or the common bile duct, a Whipple procedure is usually necessary. It has not been necessary to employ duodenal bypass or diverticulization.

Aortic and renal vascular disease. Factors affecting the value of combined procedures.

Assessment of the predictive value of preoperative factors in the determination of operative risk in 50 patients who underwent simultaneous aortic and renovascular procedures over a 10-year period is reported. There were six operative mortalities (12%). Factors associated with increased mortal risk were azotemia (43% vs. 7%), associated complex renal or visceral procedures (31% vs. 5%), treatment of aortic aneurysm vs. occlusive disease (17% vs. 5%), positive EKG (19% vs. 4%), age over 60 years (20% vs. 4%), and a history of diffuse peripheral vascular disease (18% vs. 7%). None of these differences, by themselves, had statistical significance. Through discriminate analysis with assignment of weighted scores to the five most powerful predictors of operative death (complex procedure--4, azotemia--4, aortic aneurysm repair--3, positive electrocardiogram--2, history of diffuse vascular disease--2), a weighted score of greater than or equal to 10 predicted operative death with an 83% sensitivity and 93% specificity (p = 0.003). Although advanced age, diabetes, severity of hypertension, and history of heart disease were associated with increased operative risk, they contributed minimal discriminate value to that provided by the preceding five variables. This was because these weaker risk factors were usually found in association with the predictors in the discriminant score. This study suggests that in patients with high weighted discriminant scores (greater than or equal to 10), consideration of operative risk is particularly important in evaluation of the proposed value of combined procedures.