Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.

Influence of site of obstetric care and delivery on pregnancy management and outcome.

A retrospective cohort study of 863 pregnancies cared for by family physicians at three sites--rural-rural (RR), rural-urban (RU), and urban-urban (UU)--was designed to test the hypothesis that ready on-site access to perinatal subspecialists would improve pregnancy outcome. No differences in delivery type, length of gestation, birth weight, or nursery care were found. An Apgar score of less than 7 at 1 minute or less than 8 at 5 minutes was 2.17 and 2.31 times more likely at RU and 2.48 and 2.60 times more likely at UU, respectively, than at RR. The overall Cesarean section rate was 9.6 percent, forceps rate was 7.2 percent, and nonroutine nursery care rate was 7.9 percent. Neonatal and perinatal mortality rates were 3.5 and 4.6 per 1,000 live births. There is no evidence that on-site perinatal subspecialists improve perinatal outcome when care is provided by board-certified family physicians. Small obstetric centers provide quality perinatal care with outcome dependent on physician's skill rather than on technology.

Spatial disorientation and the Dyke-Davidoff-Masson syndrome.

A patient with Dyke-Davidoff-Masson Syndrome had a lifelong history of spatial disorientation and visual-spatial cognitive defects demonstrated by psychological tests. We suggest that the abnormalities of behavior and test performance may be related atrophic lesions demonstrated by pneumoencephalography and computerized axial tomography. We consider several explanations to account for the lack of compensation for these cognitive defects.