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INTRODUCTION

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Vascular disease includes any condition that affects the circulatory system, encompassing diseases of arteries, veins, and lymph vessels as well as blood disorders that affect circulation. It describes a broad group of clinical conditions ranging from the chronic to the acute and life threatening. The increasing prevalence of peripheral artery disease (PAD) and carotid artery disease among Americans may be related to a rise in the prevalence of diabetes mellitus, just as the increased incidence of varicose veins is linked to rising rates of obesity.

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Vascular disease is a nearly pandemic condition that has the potential to cause loss of limb or even loss of life. It manifests as insufficient tissue perfusion that may be acutely compounded by either emboli or thrombi to an existing atherosclerotic condition. Many people live daily with vascular disease; however, in scenarios such as acute limb ischemia, this pandemic disease can be life threatening, requiring emergency intervention to minimize morbidity and mortality.

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DIABETIC WOUNDS

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ESSENTIALS OF DIAGNOSIS

  • The lifetime risk of developing lower extremity ulceration in patients with diabetes mellitus approaches 25%.

  • Comprehensive annual evaluation of the diabetic foot is recommended.

  • Visual inspection should be performed at every routine visit to the physician.

  • Although multifactorial in origin, diabetic ulceration is linked primarily to poor blood glucose control.

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General Considerations

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Diabetic wounds are associated with substantial morbidity and mortality. Diabetes mellitus is a particularly important risk factor in the development of chronic wounds because it is associated with neuropathy, vasculopathy, and immunopathy. Chronic ulceration affects the lower extremities in 1.3% of adults in the United States. However, among diabetic patients the lifetime risk of developing lower extremity ulceration approaches 25%. Two thirds of nontraumatic amputations performed in the United States are secondary to primary diabetic foot ulcers and their complications.

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These statistics illustrate the importance of evaluation and prevention of diabetic-related skin infections and the necessity of prompt medical–surgical treatment when infections develop. In 2012, the Infectious Disease Society of America updated its guidelines for the diagnosis and management of diabetic foot infections. The current American Diabetes Association guidelines, which largely agree with those of other organizations, recommend comprehensive annual evaluation of the diabetic foot. This evaluation should include inspection of the foot for the presence of erythema, warmth, and callous, bony, or joint-mobility abnormalities, as well as skin integrity, with time taken to fully evaluate between the toes and under pressure-sensitive metatarsal heads. As part of this evaluation, patients should be tested for loss of protective sensation using tactile, vibratory, and reflex testing, and screened for PAD by asking about claudication symptoms, assessing the pedal pulses, and, in those older than 50 years of age or in any patient having other risk factors of PAD, by assessing the ankle–brachial index (ABI). A visual inspection should also be performed at every routine visit to the physician.

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