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Diabetes and diabetic foot ulcers revisited

BY EFTHYMIOS GKOTSOULIAS, DPM, Foot and Ankle Surgery, Greater Houston Physicians Medical Association

Diabetes is currently the seventh leading cause of death in the United States. Over the past three decades the numbers of adults with diagnosed diabetes has quadrupled. The increase in the number is due in part to people with the disease living longer because of improvements in the self-management and health care services. A new study by the CDC suggests that after decades of growth in prevalence and incidence the rate of growth has begun to slow but the numbers are still alarmingly high. Trends from 2012 on figure 1 adopted by CDC.

Of the estimated 29.1 million (9.3% of the population) Americans with Diabetes, 8.1 million (27.8%) are undiagnosed. Of those 15% to 20% will develop a diabetic foot ulcer (DFU) in their lifetime. Foot complications have become the leading cause of hospitalization for patients with Diabetes. People with Diabetes are 15 times more likely to require a major amputation than people without Diabetes, and Diabetics are 25 times more likely to lose a leg than people without Diabetes. Worldwide more than 60% and as close to 70 % of all non-traumatic leg amputations are performed to people with DM; a leg is lost to DM every 30 seconds. 85% of those amputations are presented by a foot ulcer. In developed countries one out of every 6 people with Diabetes develop a DFU. It is estimated that 85% of all amputations due to Diabetes could be prevented.

Factors posing a risk to developing a DFU include peripheral motor/sensory/ autonomic neuropathy, Charcot neuroosteoarthropathy, vascular (arterial) insufficiency, hyperglycemic and other metabolic disorders, patient disabilities, maladaptive patient behaviors, and health care system failures. Increase risk of those DFU getting infected are loss of protective sensation, wound open more than 30 days, recurrence of ulcers, presence of PVD, renal insufficiency, history of barefoot walking, and a previous lower extremity amputation.

The mortality in new-onset DFU (duration < one month) stratified by etiology has been investigated in UK with astonishing findings: Five year mortality rate was 45% for neuropathic ulcers. Of note the mortality for ischemic ulcers was 55%. Cause of death was ascertained with cardiac and cerebrovascular diseases responsible for the majority with 38%, followed by pneumonia 27%, septicemia 12%, malignancy 12%, emphysema 8%, and 4% from renal failure. Other Confounding variables unaccounted for. Controlled clinical trials involving patients with type 1 and type 2 Diabetes have demonstrated that intensive diabetes therapy (achieving glucose control as close to the non-diabetic range as safely possible) aimed at lowering glycemic levels reduce the risk of developing diabetic retinopathy, nephropathy, and neuropathy. This significantly reduced the overall risk for morbidity and mortality as it pertains to cardiovascular events by 42% and major clinical events (non-fatal MI, stroke, death from cardiovascular event) by 57% when compared to conventional therapy. In addition the DCCT/EDIC study was able to show that 6.5 years of intensive Diabetes therapy had a long term sustained effect on future risk of microvascular complications.

Management of DFU is a multifactorial process. Team members may vary depending on patient’s needs and care setting and may include but not limited to nurses, nutritionists, physical and occupational therapists, ortotists/ prosthetists, nephrologists, podiatrists, endocrinologists, primary care physicians, vascular surgeons, infectious disease specialists and social workers. The literature is replete with research studies supporting multidisciplinary care for better outcomes in both the qualitative sector which affords more efficient and effective care due to the speed of the referral process, and plan of care as well as the quantitative sector with decrease in admission rate, improved healing outcomes, and quality of life.

CDC has improvise resources for education, as well as the prevention and control. Some of the newer developments include: Prevent Diabetes STAT: screen, Test, Act – Today™ and the New task force and community Guide Publications - Diabetes prevention and control. The Diabetes report card gets published biennium based on the catalyst to better diabetes care in patient protection and affordability care act. CDC developed Healthy people 2020 which represents the nation’s agenda improving the health of all Americans. The goal is to reduce diabetes, the cost associated with it and improve the quality of life for all people who have or at risk for Diabetes; figure 2 by CDC illustrating the targets met.

DFU pose a unique challenge to physicians due to aforementioned factors innate to the disease process. Our role is not only to prevent those situations (diabetic foot ulcers and subsequent infections) but to ensure that when patients get those infections we eradicate them before they propagate becoming a threat to their lives. Then priority is given to limb salvage while ensuring their functional capacity is maximized following amputations that are sometimes a necessity to eradicate infections. Despite the ongoing advances aiding in the diagnosis, management, and treatment of diabetes and DFU there is no substitute for multidisclipinary team approach and close monitoring not only to manage ongoing problems but also to recognize and reduce risk of death from comorbidities to save the limb and life.

References:

Centers for Disease Control and prevention. Diabetes 2014 Report card: http://www.cdc.gov/ diabetes/pdfs/library/diabetesreportcard2014. pdf

American Diabetes Association. National Diabetes Fact sheet 2011: http://www. stopdiabetes.com/assets/files/get-the-facts/ press-materials/national_diabetes_fact_ sheet_2011-cdc.pdf

Silverbook Diabetes facts: http://www. silverbook.org/condition/diabetes/ Frykberg RG. Diabetic foot ulcers: Current concepts. Journal of foot and Ankle surgery 1998 Sep; 37 (5)440-446. International Working Group on the Diabetic foot. This email address is being protected from spambots. You need JavaScript enabled to view it.

Pecoraro RE, Reiber GE, Burgess EM. Pathways to Diabetic Limb Amputation: Basis for Prevention. Diabetes Care 1990 May; 13 (5): 513-521.

Moulik PK, Tonga RM, Gill GV. Amputation and mortality in New-onset Diabetic foot ulcers stratified by etiology. Diabetes Care. 2003 Feb; 26 (2): 491-494.

Armstrong DG, Wrobel J, Robbins JM. Are Diabetes-related wounds and amputations worse than cancer? International Wound Journal 2007; 4 (4): 286-287.

The Diabetes control and complications trial/ epidemiology of diabetes interventions and complications (DCCT/EDIC) study Research Group. Intensive Diabetes treatment and cardiovascular disease in patients with type a diabetes. New England Journal of Medicine 2005 Dec: 353 (25): 2643-2653.

Lorimer K. Continuity through best practice: design and implementation of a nurse led community leg ulcer service, Canadian Journal of Nursing Research 2004 Jun; 36 (2): 105-112.

Jaramilo O, Elisondo J, Jones P et al. Practical guidelines for developing a hospital based wound and ostomy clinic. Ostomy/Wound Management 1997; 43 (4): 28-39.

Centers for Disease Control and prevention. What’s new in Diabetes: http://www.cdc.gov/ diabetes/new/index.html