Always Foot Care

Foot care on the go

2008-03-31T14:50:00.001-07:00

Foot care on the go

Pair of Richmond nurses offer medical treatment for your ailing feet, right in your home

Philip Raphael, Staff Reporter

Got a problem with your heart, make an appointment to see a heart specialist. Need some help with a sore back, go to a chiropractor.

Experiencing some nagging problems with your poor old feet?

Well, you'll deal with that yourself, when you get around to it, right?

That's the scenario played out by many people who give their feet the brush off instead of getting proper care.

But thanks to a new service, professional medical attention to those painful callouses, in-grown toenails, or more serious problems like poor circulation and feeling due to diabetes, can walk right through your front door because a pair of Richmond nurses are offering in-home foot treatments.

And it is starting to catch on, especially since waits to see a foot specialist (podiatrist) can be as long as eight weeks, and a foot care nurse like Michelle Jackson or Shamim Murji can be on your doorstep literally the next day.

Started in September, Jackson's M.J. Footcare, and Murji's Shmamim's Foot Care Clinic provide professional treatment and advice that goes beyond just keeping a pair of feet looking their best.

"It's not about pedicures," explains Jackson, who has been a registered nurse since 1965, and has spent the last seven years working with patients at Minoru Extended Care facility. "It's about proper care for your feet, which a lot of people tend to overlook."

"For some reason or another, people don't seem to take the extra effort to take care of their feet," adds Murji. "For some of our older clients, perhaps it's a question of mobility...Now, we can come out right to their homes."

For Jackson, starting the service was a way of charting a new career path. Knowing that her position was being phased out and replaced by staff with licenced practical nurse qualifications, Jackson decided to seek another line of work that would take her extensive medical experience, and work with the elderly, into account.

And she found it when she came across the Foot Care Course offered by the Victorian Order of Nurses, a four-day program that teaches how to assess a patient's condition and recognize certain problems.

"We see some pretty horrible things out there because people have spent a good part of their lives wearing shoes that are probably too small for them, or living with things like callouses, corns, or simply haven't had their toenails trimmed properly in quite a long time," Jackson says. "Many of the conditions we find people in could have been prevented if they had looked after their feet properly at the beginning."

Tools of the trade include special burrs, and even a hand-held power grinder like a Dremel tool fitted with a special foot care disc, to help quickly and easily remove built up layers of skin.

"Some clients I see have callouses that are half an inch thick, and with the special training we have, a foot nurse can take that down gradually," she explains.

In more serious conditions, like those brought on by diabetes, prompt medical attention from a foot care nurse can head off potentially dire consequences.

Jackson says when diabetes patients lose proper circulation and feeling in their feet, even slight foot discomfort due to ill-fitting shoes, or even socks, can create dangers.

"Damage can be done sometimes just by wearing the wrong type of shoes, or even socks with seams that put pressure on parts of their feet."

While they are prevented from any type of invasive procedures, Jackson and Murji said they can tell clients what problems to look for that may require the hand of a specialist.

"We want the (clients) to be well-educated on the health of their feet," Murji says.

Aside from the hands-on treatment during their home visits, Jackson and Murji can also help customers dispel some foot care fallacies, such as putting moisturizing cream between their toes, which is a big "no-no," Jackson says, because it can provide the perfect habitat nurture and spread harmful bacteria.

One of the most common conditions they see is a fungal infection that can get under the nail bed of the toe and discolour the nail. Proper foot cleansing techniques to inhibit the fungus spread are provided, and, "We can teach them to treat themselves by making a solution of water and either Dettol or Pine-Sol, soaking a rag in it, and then placing the rag in their shoes overnight to help kill off any further fungus problems," Jackson says.

The treatments are not covered by B.C.'s Medical Services Plan, and cost clients $35 for the initial visit which includes getting a complete medical history. Subsequent sessions are $30 each.

"You can't even get a plumber come out to your house for that," Jackson quips.

So far, the clients span most age groups and walks of life.

"What we're finding is that people don't know that this type of service exists. But when they do, they are very thankful," Jackson says.

The trend for foot treatment specialists is more commonplace in Victoria where a larger retirement age population has given rise to as many as 30 full-time foot care nurses in that city. In the Lower Mainland, White Rock, with its large retirement age base, has spawned a small group of foot care nurses with whom Jackson and Murji hope to strike an informal alliance.

But the ultimate plan is to establish a stand alone foot clinic where clients could visit on a regular basis.

Until then, Jackson said she will work on the goal one foot at a time.

nFor more information on foot care, call M.J. Foot Care at 604-340-3916 or Shamim's Foot Care Clinic at 604-218-4220.

NEFCA 17th Annual Footcare Conference

2008-03-26T12:11:00.000-07:00

“Step into the Future” Conference Registration Form

April 11 & 12, 2008

Days Inn Kingston Hotel & Convention Centre

33 Benson St., Kingston, ON K7K 5W2

Phone (613) 546-3661 Fax (613) 544-4126

Friday Registration @ 4:00 pm – Saturday Registration @ 7:30 am

Dates

Member

Non-Members

March 3, 2008

$175.00

$200.00

Cheques must be postmarked by the above dates.

Send Conference Fee to:

NEFCA

C/O Ann Moore

237 Pineland Court

Waterloo, Ontario

N2J 2S3

Member □ Non-Member □

Name:

Business Name:

Street Address:

City/Town:

Postal Code:

Phone:

Refund Policy

Full refunds, less $50.00 processing fee will be given for cancellations received in writing

10 days prior to the conference / program date.

Refunds will not be issued for non-attendance.

NSF cheques – There will be a $35.00 charge.

NEFCA 17^th Annual Footcare Conference

“Step into the future”

Friday, April 11^th, 2008

4:00 - 5:30 p.m.	Registration / Shopping / Networking
5:30 – 6:30 p.m.	Welcome from the President / AGM
6:30 – 7:30p.m.	Dinner
7:30p.m. – 8:30p.m.	Networking with Jack McAlpine, Walkwel Shoes
8:30p.m.	Break / shopping / networking

Saturday April 12^nd, 2008

7:30 - 8:30 a.m.	Registration / Breakfast / shopping / networking
8:30 - 8:40 a.m.	Welcome from the President
8:40 - 9:00 a.m.	Exhibitor Introductions /Announcements
9:00 - 10:30 a.m.	Nail Pathology, Graham Curryer, Chiropodist
10:30– 11:00 a.m.	Break / shopping / networking
11:00 a.m.– 12:00 p.m.	Compression Therapy, Sigvaris
12:00 – 1:00 p.m.	Lunch / shopping / networking
1:00 - 2:30 p.m.	Disinfection, Sterilization Ministry of Health, Clare Berry
2:30 – 3:00 p.m.	Break / shopping /networking
3:00 – 4:30 p.m.	Infection control putting into practice, Jeanne Boniface
4:30p.m.	Closing and thanks from President

Foot Care Canada- Sunday April 13,2008. Kingston Ontario

2008-03-26T12:07:00.000-07:00

FOOT CARE CANADA

Sunday April 13, 2008. Kingston, Ontario

Invitation:

The newly appointed committee of FOOT CARE CANADA would like to take this opportunity to invite any interested foot care nurse, regulatory body, educator and/or policy maker to attend a workshop April 13, 2008 from 9:00 am – 3:15 pm, held at St. Lawrence College in Kingston, Ontario (detailed below). Nurses wishing to be considered as a Provincial /Territorial Advisor should attend this workshop and submit their resume (details attached) and a position statement to the committee for consideration. This workshop will follow a foot care conference on April 11-12^th.

Background:

On September 22, 2007, a group of 60 foot care nurses, educators and managers from across Canada met in Winnipeg, Manitoba to discuss how to introduce national foot care nurse guidelines for skills, education and certification. All 60 participants supported a draft position statement proposed by an Ad Hoc committee and a consensus was reached to begin the development of a national communication strategy that could reach an estimated 3,000 – 6,000 foot care nurses in Canada. It is understood that this is a huge undertaking, and there are many steps that need to happen in order for the ultimate goal of national guidelines and certification for foot care nurses to occur.

How do I register for Foot Care Canada’s workshop on April 13^th?

There will be no cost to attend! Updates on this workshop will be posted in the ‘Foot Care Canada’ section, on the following website http://www.cawc.net/open/library/clinical/specialty.html.

Currently, we are a volunteer committee without funding or office support, so if you are interested in attending the April 13^th workshop, we kindly ask that you please email your name and contact information directly to our new email address at footcarecanada@yahoo.ca and we’ll look forward to meeting you! See attached agenda and mission statement.

How do I register for the foot care conference on April 11 – 12^th?

Our workshop will follow a local foot care conference in Kingston, Ontario at the Day’s Inn. To register for the conference contact Linda Heber at hebers@sympatico.ca (NEFCA).

Please share this memo with any and all who may be interested.

We hope to see you there!

Foot Care Canada Committee:

Cindy Lazenby RN (Kingston, ON),

Pat MacDonald LPN (Winnipeg, MB),

Donna Schofield RN, CNephC (Cornwall, ON),

Mary MacKay RN, IIWCC (Halifax, NS)

Sandra Bird LPN (Winnipeg, MB).

FOOT CARE CANADA

Sunday April 13, 2008. Kingston, Ontario

Location: St. Lawrence College, 100 Portsmouth Avenue, Kingston Ontario.

(go to www.stlawrencecollege.ca/?iPageID=69&iMenuID=5 for virtual directions)

Flying? Book a flight directly to Kingston (it’s an easy transfer from the Toronto Airport).

Workshop Agenda

9:00 am: Welcome and Introductions:

Ø National & Regional Co-Chairs

Ø Collaboration with other Organizations

o Canadian Association of Wound Care (CAWC)

o Provincial and territorial registering bodies and nursing associations

9:30 am: Past and Present of Nursing Foot Care

10:00 am: Networking & refreshment break (Tim Horton is in the building!)

10:30 am: Nursing Foot Care: Barriers and Solutions

Ø Interactive exercise led by Pat MacDonald LPN

11:30 am: Future of Nursing Foot Care:

Ø Foot Care Canada’s Mission Statement and Goals (see attached)

Ø What can You do?

o Send us your contact info

o Attend Foot Care Canada events

o Provincial /Territorial Advisors

o Clinical or evidenced-based articles

12:15 pm: Networking & lunch (cafeteria style)

1:15 pm: What is Evidence-Based Practice and How do we Implement it?

Ø Interactive exercise led by Cindy Lazenby RN

3:15 pm: Closing

Foot Care Canada Position Statement (Jan 2008)

The Mission of Foot Care Canada is to advance the practice of foot care through a collaborative and networking process for all individuals providing foot care.

Goals:

Collaborate with health care professionals across Canada to promote optimal care and improve client outcomes.

Develop educational opportunities, national guidelines and a certification process for nursing foot care.

Promote public awareness of the benefits of foot care and of the role of a foot care nurse within the health care team.

Facilitate the development and publication of clinical and research based articles related to the advancement of nursing foot care.

What Can You Do?

Send us your contact information at our new email address footcarecanada@yahoo.ca.
Attend Foot Care Canada’s events. Go to www.cawc.net (Canadian Association for

Wound Care) for updates on the following upcoming events:

April 13, 2008 workshop in Kingston ON.
September 28-29, 2008 foot care conference/workshop in Halifax NS.
November 2009 foot care/wound care conference in Quebec City, Quebec. (date TBA)

Apply/submit to one of the following (go to www.cawc.net for job descriptions and specifications):

Provincial/territorial advisor
Conference speaker
Conference sponsor
Conference exhibitor
Clinical or evidence-based article

Spread the word…tell two colleagues and they’ll tell two colleagues…

2008 Organizational Chart:

Ø 1 Chair: Cindy Lazenby

Ø 4 Co-Chairs: Northern (Sandra Bird, acting)

Western (Pat MacDonald)

Central (Donna Schofield)

Eastern (Mary Mackay)

Ø 12-24 Provincial/Territorial Advisors (TBA)

Blog Questions

2008-03-22T15:26:00.001-07:00

Q: Hi Always Foot Care and welcome to Askablogr. I had hoped this tool would be useful to resource sites like yours, so I'll be eager to hear any feedback, your readers and patients have on the product.

Posted by Chris DeVore

A: Hi Chris, thanks. We look forward to seeing how things work out here. We are sure our readers will benefit from this resource.

Saving diabetics’ feet

2008-03-20T14:40:00.000-07:00

Saving diabetics’ feet

Diabetic foot syndrome (DFS) is one of the most serious sequela of diabetes mellitus - Disease management programmes (DMP) yield first results

DFS, described in the Wagner classification system by six grades from the initial wound to amputation, is a slowly developing condition that presents a major challenge for the medical team, which should include podiatrists and orthopaedic technicians. In Germany alone, current estimates indicate 29,000 diabetes mellitus-induced amputations annually, most of these following an infection – particularly MRSA. 10% of all diabetics with DFS will undergo a major amputation of the lower extremities, and 20% of these patients will not survive the surgical intervention.

The problem and causes of DFS
The crucial issue with DFS is the sensor and motor polyneuropathy that affects about 60% of these patients. Sensor polyneuropathy reduces pain sensitivity, which means the patient or the family notice a weeping wound on the sole of the foot only because socks or shoes are wet. Fairly often, it is only upon discovery of such a wound and subsequent consultation with a doctor that the patient realises s/he suffers type II diabetes mellitus that needs treatment. In many such cases the patients had not paid much attention to their feet and overlooked previous symptoms, such as reduced sweat secretion, excessively warm, dry, chapped and callous feet and even deformations caused by motor neuropathy. The latter atrophies the short foot muscles and causes changes in the form of the plantar arch, which in turn leads to a different distribution of pressure when walking and, consequently, to callus formation on the foot where the pressure is most intense. Often, these physical developments are ignored because they are taken as normal signs of ageing. According to a Health Care Monitoring study, patients take their bodies for granted, or maybe fall into one of the following categories:

l 21% of adults take only the most basic measures to maintain health; they consider a visit to the doctor’s surgery is an easy way out and tend to reject self-medication
l 15% of adults feel healthy; they talk and think little about their health; they know that their personal healthcare is inadequate but see no point in changing their behaviour
l 17% of adults are not interested in their individual health; they feel healthy and rarely see a doctor (Source: Health Care Monitoring, a German study involving 3,000 people.

Details: www.psychonomics.de)

According to this study 46.6% of the adult population have little or no interest in their health and react too late to a condition that would have prompted the other half of the population to see a doctor. This disinterest might explain why so many patients present with severe medical conditions.

A further consequence of neuropathic disorders is diabetic neuropathic osteo-arthropathy (DNOAP or ‘Charcot foot’), which causes the plantar arch to collapse, leading to deformities due to increased pressure and callus formation.

About 30% of these patients suffer a combination of peripheral arterial disease (PAD) and diabetic neuropathy, 10% have ischaemia. In both cases the prognosis is even worse than for neuropathy due to the vascular situation and poor circulation. Vascular diagnostics and reconstruction are imperative – a fact that underlines the necessity for close cooperation between diabetologists and vascular surgeons, if the patient is to have a chance to avoid amputation.
Even better: the patient can be convinced to participate in a disease management programme (DMP).

In Germany, such programmes have shown very promising results. In December 2006, the first data analyses to provide an indication as to the effectiveness of DMPs became available. In one German Federal State the condition of 44,995 patients with type II diabetes mellitus were recorded for six months (April to September) in 2006, and the study showed that very few cases of diabetic keto-acidosis had been reported. This means that diabetics in Germany are quite well prepared to avoid this dreaded life-threatening metabolic disorder. After all, 30.1% of them could get rid of typical diabetes symptoms, such as fatigue, polyuria and polydipsia (excessive thirst). High blood pressure was under control in almost 40% of them. 92.9% of the patients underwent a foot examination but only 48.6% participated in diabetes training.

These figures show that the education issue requires much more attention. This might well be the most difficult task for the medical team: The patient has to understand that he will benefit from that education and learn to control the disease and its consequences rather to be controlled by it.
Source: Phasengerechte Versorgung beim Diabetischen Fußsyndrom, Coloplast GmbH, Hamburg)

This article was published on 08/31/2007

Putting feet first: diabetic foot care worldwide

2008-03-20T13:57:00.000-07:00

he International Diabetes Federation Consultative Section and International Working Group on the Diabetic Foot (IWGDF) publishes its fourth document in the Time to Act series to coincide with the 2005 Year of the Diabetic Foot. Diabetic feet tend to be under-recognised as a health issue, despite the fact that ulceration, gangrene, and amputations are more common complications of diabetes than dialysis and blindness. The statistics are startling: one in six diabetic patients will have a foot ulcer, with even more patients affected in developing countries; over 1 million amputations for diabetes-related complications occur every year.

A worldwide increase in type 2 diabetes means that health-care planners and professionals are facing an ever growing tide of patients with diabetes-related complications. Better prevention, restructuring of diabetes care, and advances in treatment are all needed. Diabetes and Foot Care: Time to Act aims to educate people with diabetes, health-care professionals, and policymakers about the disease and ways to prevent amputations. This is both its strength and its weakness. The concentration on organisation of care, education, and structures is exactly what is needed in countries and centres without structured foot care. But each chapter has to cover such a broad range of topics that some sections are disjointed and occasionally baffling. I would have preferred a separate section for each of the three target audiences, although the colour-coding key for each of the interest groups is useful.

The prevention and treatment of diabetic foot disease is challenging. I would, however, take issue with the statement that foot care problems are the easiest of all the diabetic complications to prevent. Surely, if it were true then rates of recurrent ulceration would not exceed 50% in most series. This is not to decry screening and preventative treatment. They are vital and have probably had a major role in the changing nature of foot ulceration. As the book makes clear, the number of peer-reviewed publications about the diabetic foot has increased ten-fold in the past decade. Despite this progress, there is still no clear evidence for the effectiveness of most individual interventions. The clearest evidence—and even this is from case-control studies—is for secondary sector multidisciplinary foot care teams. For this reason, and rightly, the book devotes as many pages to developing such systems on local and national scales as to the minutiae of ulcer treatment.

The section on treatment of foot ulceration is the weakest part of the book. There is an evidence gap about the specifics of such treatment. A Cochrane review has concluded that debridement of ulceration is a good thing, but there is no guidance on how much, how often, and for which ulcers. The control of infection is important, since infection plays a large part in tissue destruction leading to amputation. However, there is no evidence about the best antibiotic regimen or for how long it should be taken. The IWGDF steers a middle ground of consensus. Their document informs this book and so cannot be expected to be different. Offloading is, once again, stated as the most important aspect of care for diabetic foot ulcers. Although recent evidence suggests that non-removable devices are most effective, the book again has to take a broader view because of the diversity of its audience and so the advice is diluted. Various devices are presented as solutions for offloading, but few if any are validated by more than small case series. Medicine is often described as being as much of an art as a science, and this is particularly true of the care of diabetic foot ulceration. The evidence gap means that local services find their own solutions, informed where possible by the published literature and their own experiences. Most clinics see too few ulcer patients to do more than this. This book varies between prescriptive rules and generalised advice; this is a difficult balance and is partly successful.

The remit of the International Diabetes Federation is to raise standards in diabetes care globally and the sections on worldwide initiatives focus on each region. These initiatives are inspiring and give clues about how to set up your own service, but to use half the book to do this is surprising. A shorter section would have sufficed and allowed more space to address service requirements—from basic provision to centres of excellence. Such information would perhaps have met the organisational aspirations of those wishing to develop foot care services.

This is an ambitious book that succeeds in its main goal of raising awareness. The message that is clearly learnt from the book is that structured care can reduce the number of amputations in diabetic patients by at least half. This is the key message for people with diabetes, health-care professionals looking after them, and policymakers organising diabetes care. Although the book does not impart much new information to established practitioners, it highlights the seriousness of diabetic foot problems around the world and underlines how far each region needs to go to reach a common standard for the good of all patients.

Diabetes Prevalence

2008-03-20T12:36:00.001-07:00

Diabetes is a serious condition for the individual and society. Its rapidly increasing global prevalence is a significant cause for concern.

In 2007, it is estimated that there are 246 million people with diabetes in the adult population in the seven regions of IDF. In 2003, the total was 194 million.

Type 2 diabetes constitutes about 85% to 95% of all diabetes cases in developed countries and accounts for an even higher percentage in developing countries. The epidemic nature of diabetes continues to affect ever-increasing numbers of people around the world while public awareness remains low.

In 2007, it is estimated that 7.3% of adults aged 20-79 in all IDF member countries have diabetes. The Western Pacific Region and the European Region have the highest number of people with diabetes, approximately 67 and 53 million respectively. The highest rate of diabetes prevalence is to be found in the North American region (9.2%) followed by the European Region (8.4%).

Visit www.eatlas.idf.org for more information and data about the global diabetes epidemic.
Download the World Diabetes Day media kit (pdf, 5MB).

Diabetes: a forecast

The number of people with diabetes is expected to increase alarmingly in the coming decades. In 1985, an estimated 30 million people worldwide had diabetes; in 2000, a little over a decade later, the figure had risen to over 150 million. By 2025, the figure is expected to rise to 380 million.

The prevalence of diabetes is higher in developed countries than in developing countries, but the latter will be hit the hardest by the escalating diabetes epidemic. Increased urbanization, westernization and economic development in developing countries have already contributed to a substantial rise in diabetes.

The prevalence of diabetes in adults is projected to rise in both developed and developing countries. While diabetes is most common among the elderly in many populations, prevalence rates are significantly rising among comparatively young and productive populations in the developing world.

Causes of the rise

The alarming increase of diabetes prevalence is projected to occur because of:

Population ageing
Unhealthy diet
Overweight and obesity
A sedentary lifestyle

All over the world, traditional lifestyles and dietary patterns that have sustained people over generations are disappearing. Socio-economic realities mean that families are often forced to move away from rural areas and into urban areas to seek employment. Diabetes is primarily concentrated in urban areas and this characteristic is destined to increase in the future as a result of rapid industrialization in many countries.

The Cost of Diabetes

2008-03-20T12:31:00.001-07:00

The human, social and economic impact of diabetes

The global diabetes epidemic has devastating human, social and economic effects. The largest costs of diabetes worldwide are its devastating effects on families and national economies.

Impact on families and people with diabetes

Diabetes is expected to cause 3.8 million deaths worldwide in 2007, about 6% of total global mortality, about the same as HIV/AIDS. Using World Health Organization (WHO) figures on years of life lost per person dying of diabetes, this translates into more than 25 million years of life lost each year.

The International Diabetes Federation (IDF) estimates that the equivalent of an additional 23 million years of life are lost to the disability and to reduced quality of life caused by the preventable complications of diabetes.

People living with diabetes and their families feel the impact of diabetes most directly. They feel the often crushing expenses of diabetes treatments as costs are not subsidized, and family income is frequently reduced when diabetes interferes with work.

It is often the case that caring for diabetes steals valuable time from education, paid work and leisure. In many countries, individuals and families fear and experience the disability, reduced quality of life, and the lost years of life that untreated diabetes brings.

People with diabetes face the near certainty, in many countries the stark reality, of premature death.
Type 1 diabetes is particularly costly in terms of mortality in poor countries, where many children die because access to life-saving insulin is not subsidized by governments (who instead tax it heavily), and is often not available at any price.
Studies recently carried out in Zambia, Mali and Mozambique highlight a stark reality: a person requiring insulin for survival in Zambia will live an average of 11 years; a person in Mali can expect to live for 30 months; in Mozambique a person requiring insulin will be dead within 12 months.
In the poorest countries, people with diabetes and their families bear almost the entire cost of whatever medical care they can afford.
In Latin America, families pay 40-60% of diabetes care costs out of their own pockets.
In India, for example, the poorest people with diabetes spend an average of 25% of their income on private care. Most of this money is used to stay alive by avoiding fatally high blood sugar levels.

Impact on national economies

Diabetes affects all people in society, not just those who live with diabetes.

WHO estimates that mortality from diabetes, heart disease and stroke cost about 250 billion international dollars (ID) in China, ID225 billion in the Russian Federation, and ID210 billion in India in 2005. Much of the heart disease and stroke in these estimates was linked to diabetes.

WHO estimates that diabetes, heart disease and stroke together will cost about:

$555.7 billion in lost national income in China over the next 10 years
$303.2 billion in the Russian Federation
$333.6 billion in India
$49.2 billion in Brazil
$2.5 billion even in a very poor country like Tanzania

These estimates are based on lost productivity, resulting primarily from premature death. Accounting for disability might double or triple these figures.

If nothing is done, diabetes threatens to subvert the gains of economic advancement globally.
Government budgets worldwide will face the immense strain of diabetes care on disability payments, pensions, social and medical service costs, and revenue.
Private health insurers and employers will face the spiralling costs of treating the growing number of people with diabetes.

Because diabetes is increasing faster in the world’s developing economies than in its developed ones, it is the developing world that will bear the brunt of the future cost burden.

Disparities developed – developing world

More than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries.
Less than 20% of expenditures are made in the middle- and low-income countries, where 80% of people with diabetes will soon live.
One country, the United States of America, is home to about 8% of the world’s population living with diabetes and spends more than 50% of all global expenditure for diabetes care.
Europe accounts for another quarter of spending on diabetes care.
The remaining industrialized countries, such as Australia and Japan, account for most of the rest.
In the world’s poorest countries, not enough is spent to provide even the least expensive life-saving diabetes drugs.
IDF’s new (and probably generous) estimates of national diabetes-care spending for 2007 include USD6 per person with diabetes in Burundi, USD10 in Tajikistan, USD78 in Guyana and USD48 in Haiti. Some of these amounts could not cover the annual wholesale price of a generic oral agent capable of preventing acute, life-threatening high blood sugar.
The economic opportunities that the United Nations want to create for developing countries with its Millennium Development Goals, will be greatly undermined by the economic impact of diabetes.

If nothing changes, the disparity in spending for diabetes care between the industrialized countries and the rest of the world will only increase. Overall, world treatment costs for diabetes are growing more quickly than the world population.

Dramatic rise in medical care costs for diabetes

Diabetes is costly even before it is diagnosed. This is true both in industrialized and developing countries. In 2007, the world is estimated to spend at least US$ 232 billion to treat and prevent diabetes and its complications. By 2025, this lower-bound estimate will exceed US$ 302.5 billion.

Where the costs lie

In industrialized countries, about 25% of medical expenditures for diabetes go to treating elevated blood sugar; 25% goes to treating long-term complications, largely cardiovascular disease, and 50% is consumed by the additional general medical care that is associated with diabetes.
The cost, for example, of a person with diabetes who has end-stage kidney disease is 3 to 4 times higher than the cost of a person with diabetes and no complications.
In the USA, acute hospitalization consumes 44% of diabetes-attributable costs; followed by:

22% for outpatient care
19% for drugs and supplies
15% for nursing care

Similar proportions are reported for other high-income countries such as Finland.
In middle-income countries, half of diabetes medical expenditures are used for blood sugar control, which is essential for the prevention of acute life-threatening hyperglycaemia. The remainder is split between general medical care and chronic complications.
In Latin America and the Caribbean, for example, drugs to reduce blood sugar levels are believed to account for about 50% of all spending.
It is believed that in low-income countries almost all expenditure for diabetes is directed towards drugs to prevent death from high blood sugar.

Access to care

Although the medical care costs of diabetes are much higher in industrialized countries, nearly all of these countries have organized medical care insurance systems and/or governmental provisions for medical services. This allows families to survive financially when diabetes strikes. However, costs in these countries are much higher than they need to be because insufficient money is invested to prevent expensive complications such as heart disease, stroke, kidney disease, and amputations.

In developing countries, however, people living with diabetes bear the brunt of the medical costs out of their own pocket because many countries lack an adequate healthcare infrastructure.

Source: All economic impact data are drawn from the Diabetes Atlas, third edition, International Diabetes Federation 2006.

Did You Know?

2008-03-20T12:30:00.001-07:00

Did You Know?

Diabetes currently affects 246 million people worldwide and is expected to affect 380 million by 2025.
In 2007, the five countries with the largest numbers of people with diabetes are India (40.9 million), China (39.8 million), the United States (19.2 million), Russia (9.6 million) and Germany (7.4 million).
In 2007, the five countries with the highest diabetes prevalence in the adult population are Nauru (30.7%), United Arab Emirates (19.5%), Saudi Arabia (16.7%), Bahrain(15.2%), and Kuwait (14.4%).
By 2025, the largest increases in diabetes prevalence will take place in developing countries.
Each year a further 7 million people develop diabetes.
Each year 3.8 million deaths are attributable to diabetes. An even greater number die from cardiovascular disease made worse by diabetes-related lipid disorders and hypertension.
Every 10 seconds a person dies from diabetes-related causes.
Every 10 seconds two people develop diabetes.
Diabetes is the fourth leading cause of global death by disease.
At least 50% of all people with diabetes are unaware of their condition. In some countries this figure may reach 80%.
Up to 80% of type 2 diabetes is preventable by adopting a healthy diet and increasing physical activity.
Diabetes is the largest cause of kidney failure in developed countries and is responsible for huge dialysis costs.
Type 2 diabetes has become the most frequent condition in people with kidney failure in countries of the Western world. The reported incidence varies between 30% and 40% in countries such as Germany and the USA.
10% to 20% of people with diabetes die of renal failure.
It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy.
Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialized countries.
On average, people with type 2 diabetes will die 5-10 years before people without diabetes, mostly due to cardiovascular disease.
Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and much disability.
People with type 2 diabetes are over twice as likely to have a heart attack or stroke as people who do not have diabetes. Indeed, people with type 2 diabetes are as likely to suffer a heart attack as people without diabetes who have already had a heart attack.

Sources:

Diabetes Atlas, third edition, International Diabetes Federation, 2007.
Diabetes and Cardiovascular Disease: Time to Act, International Diabetes Federation, 2001.
World Health Organisation Diabetes Unit - www.who.int/diabetes.

International Working Group on the Diabetic Foot

2008-03-20T12:23:00.000-07:00

Foot Note Zanzibar

In July of 2004 my 18 year old daughter Clare and I accepted an invitation to learn of the conditions for people with diabetes in the developing world. Our extensive diabetes advocacy efforts for the last 11 years and recent appointment to the IDF Consultative Section on Childhood and Adolescent Diabetes enhanced our desire to learn more and perhaps share what we found with others.

Our diabetes journey took us to a hospital ward “foot clinic” on Zanzibar . I stress the term "foot clinic" in quotation marks for a reason. If there was ever a hell on earth, this had to be it. With one dedicated Dr. who makes under $100 a month and works 20 hour days, this was purgatory at it's worst. Thirty or more men lay in hospital beds in an open air room awaiting amputation. Their feet overwhelmed with gangrene ( dead and decay of tissue), and the flies and smell almost unbearable. Yet, Clare sat on beds, holding the hands of these men, listening to their stories. Nothing she could tell them would ease their pain...pain which was mental because the blessing in this is, diabetes kills the nerves first and they really did not recognize their blackened limbs.

As I watched my daughter with these men, my own protective instincts played havoc with my heart. Clare also has diabetes. She was diagnosed with Type 1 at age seven. Without quality diabetes education and support, Clare too could face this fate.

Then I turned from the scene before me to observe a nurse in a stark white, perfectly pressed uniform, change a dressing on a wound of the patient in the next bed. Her skill was flawless. Tenderness and compassion foremost in her every move. She shared with me that this man has six children. If he loses the foot he will no longer be able to provide for them. She is honored to help because she can make a difference in his life. Her wish would be that education and supplies could be made available earlier so her job would not be so difficult.

There are remarkably dedicated health care professionals in remote areas in the developing world. There are committed organizations and corporate partners who are making progress as well. My observation is these efforts are dwarfed by the magnitude of this problem and help is genuinely needed. Quality diabetes education, access to supplies and treatment as well as encouragement of others to join in this endeavor is paramount if we are to make real progress.

The decision to provide this opportunity for education, to allow us to see first hand the plight of these people, was insightful. The knowledge that any person should face amputation caused by a disease that is treatable is unacceptable. Armed with this new education, Clare and I are even more committed to spreading the word of our findings. We welcome any and all who wish to join in this advocacy effort.

Iran finds herbal diabetic foot cure

2008-03-13T14:48:00.001-07:00

Iran finds herbal diabetic foot cure
Sat, 02 Feb 2008 22:57:49

Iranian scientists have successfully produced a new anti diabetes herbal medication which can effectively treat diabetic foot ulcers.

'Angipars' has passed animal and human testing without any reported side effects.

Scientists claim that the drug did not cause any genetic and DNA changes or other acute complications during tests on lab animals.

In addition, its topical, oral and intravenous forms have successfully been tested on human volunteers.

Diabetes is the leading cause of death in all industrialized nations. Diabetic foot is one of its most frequent complications resulting in amputation in the majority of the patients.

Having a healthy lifestyle and balanced diet and regular exercise can control blood sugar levels and prevent or minimize the complications secondary to the disease.

PKH/HGH

Charcot Foot: A Story of Foot Reconstruction

2008-03-13T14:08:00.000-07:00

Before and AfterCharcot Foot: A Story of Foot Reconstruction

Josephine Kulman has had type 1 diabetes for 45 years, ever since she was five years old. For much of her life, her blood sugars were rarely in control.

Before she went on the pump a few years back, her A1c used to hover around 10%, and she'd often drag herself to work with blood glucose levels of up to 600 mg/dl.

In her forties, it all started to catch up with her. She got gastroparesis, lost vision in one eye, suffered a left-foot ulcer, and developed carpal tunnel syndrome and kidney problems.

On December 8, 2006, while walking in Manhattan, Josephine tripped. Three days later, she couldn't get her right shoe on. Looking down, she was appalled to find that her right foot was three times its normal size. In mid-December she entered the hospital for tests to discover why her foot was so inflamed.

Cellulitis was suspected, but eventually x-rays revealed that Josephine had Charcot foot. "My foot was shaped like an S," she says. "My ankle bone on the inside of my leg was underneath my arch. The one on the outside of my leg was in front of my foot. My foot was split from the big toe straight up, so half of my foot was going one way and half of it was going the other way."

Charcot foot is a softening of the bones of the foot that occurs in people with severe peripheral neuropathy. Their muscles lose the ability to support the foot, leading to a slackness of ligaments, dislocation of joints, damage to bone and cartilage, and deformity.

The bones slip out of position and then push on the soft tissue, breaking it down and leading to ulcers. The patient, unable to feel the pain that warns healthy people of injury, continues to walk on the broken foot, exacerbating the damage. That's exactly what happened to Josephine.

Amputation has always been a very real threat in cases of Charcot foot. But Josephine's story has a different ending, largely because she was fortunate enough to come under the care of Dr. Andrew Sands. Dr. Sands, the chief of foot and ankle surgery at St. Vincent's Catholic Medical Centers in Manhattan, is one of an innovative group of surgeons who is breaking new ground in the treatment of Charcot foot.

Dr. Sands was inspired to help people with diabetes by his cousin, who had type 1 diabetes and died at age 38 from a heart attack. "I went through everything with him," says Dr. Sands, "including partly amputating his foot." As a result of his cousin's influence, "I stay involved with diabetes and do new and exciting things for people with diabetes to save their feet."

In the past, says Dr. Sands, "people were very afraid to operate on diabetic feet, and a lot of people treated them in casts or in bulky boots or shoes. Wound care centers can treat the ulcers, but if the bone malposition isn't addressed, the foot is going to break down again the instant the patient starts walking on it again. More and more, people like me are operating on them and fixing the deformities. We're developing new and better implants, which are metal screws that fit inside the bones. Basically, it's like when a foundation collapses and then the walls start collapsing. You can shore it up with implants and allow the patients to keep their foot. Suddenly, a lot of people who before would have become wheelchair-bound or had an amputation are staying active on their own feet."

In Josephine's case, says Dr. Sands, "her forefoot was basically swept away from the rest of her foot. One row of bones 'bayoneted' over another row, shifting up, over, and on top of other bones. To get that back into alignment, you have to bring it all down and hold everything with screws. We took her forefoot and brought it around and lined it up again, and put big stainless steel screws through her bones to hold everything. The most important screw, which was about 4-1/2 inches long, went from the base of her big toe up into the big bone under her ankle. We recreated her entire arch."

These new operations are the product of a change in philosophy over the past ten to fifteen years, away from conservative treatments like casts and boots and toward more aggressive reconstruction. The trend has been fueled by advances in technology.

The older implants were too bulky to work well in a foot, but now the screws have been redesigned, says Dr. Sands, "to have a smaller head and a stronger shaft, so that they are strong enough to use in a foot, which bears the entire weight of the body."

"It used to be," says Dr. Sands, "that if someone had a terrible deformity in their hind foot or their ankle, the only option was to amputate. Now we have new implants that we can put through the heel and up through the sole of the foot, and we can lock the foot to the leg and save the foot. Sometimes the heel bone is still intact and the bones around it are destroyed, but now we can fix it."

Dr. Sands emphasizes that to benefit from foot reconstruction, patients must be "good partners" in the process. They must have good control of their blood sugar, and they must definitely not smoke.

"If you have a foot ulcer and you smoke," says Dr. Sands, "stop. If you're not a smoker and you have good circulation, if your foot is warm, then chances are strong that we can at least try to save your foot. Even if you have numbness up to your knee, as long as you have good circulation, we can get you to heal."

With regard to smoking with diabetes, Dr. Sands is adamant. "We guarantee very little in medicine," he says. "But to the degree that it is possible to guarantee anything in medicine, I can guarantee that if you have diabetes and you are a smoker, you will have an amputation. It's just that bad." Stop smoking, he advises, and then "keep your hopes up and keep your health up, because we're going to be able to do a lot more" when it comes to saving feet.

As for Josephine, she will be required to wear a special boot for about six months, but she expects to be fully healed once the boot comes off. Her best advice to people with a similar dilemma is to find the very best doctor they can.

"That was the key," she says. "It took time to get to Dr. Sands, but nobody else would have even considered doing a foot reconstruction. The foot would have eventually healed in an S shape, and I would have had problems for the rest of my life."

Disorders of the Diabetic Skin

2008-03-13T13:47:00.000-07:00

Skin Care:
Disorders of the Diabetic Skin
- Robert A. Norman, DO, MPH

Diabetes is a disease that has a huge impact on our culture. It is estimated to account for 15% of all healthcare costs in the United States.¹ It has been implicated as the chief cause of nontraumatic lower extremity amputations, 35% of new cases of end-stage renal disease (ESRD), and a significant amount of cardiovascular disease. It has also been said that 100% of all diabetic patients have their skin affected in one way or another.² When you consider the elderly population, this effect is even greater.
As many as 16 million people are affected with diabetes³; the tremendous impact of the cutaneous manifestations of diabetes is obvious. The pathogenesis of these skin diseases is becoming clearer as more research is conducted. Even without that knowledge, some disorders are characteristically associated with diabetes. For example, diabetic bullae, the syndrome of waxy skin and limited joint mobility, and diabetic dermopathy are virtually pathognomonic.

Diabetic dermopathy is one of the most common skin abnormalities affecting persons with diabetes.

Disorders of the diabetic skin that contribute to its pathology include microangiopathy, infection, and metabolic disturbances of the tissue. These problems cause disease in other parts of the body as well. Consequently, it is important to understand the dermal manifestations of diabetes to effectively manage these common comorbidities.

Necrobiosis Lipoidica Diabeticorum

Necrobiosis lipoidica diabeticorum (NLD) is not exclusive to diabetes. Actually, it is relatively rare and has an incidence of 0.7% in patients with diabetes.⁴ The disorder has a greater incidence in women and is 4 times more common in Caucasians. Although the average age of those affected is 34, there is a predominance of presentation in the young.⁵ One paper reports that at the time of diagnosis, two-thirds of patients will have diabetes, and all but 10% of the rest will develop it within 5 years; the rest will have an abnormal glucose-tolerance test or first-degree relative with diabetes.³
Initially, NLD presents as an erythematous, nonscaly plaque on the pretibial and malleolar areas of the legs. Eventually, these areas enlarge and coalesce into larger plaques that then develop yellow, atrophic centers. The borders of NLD are irregular and enlarge slowly. The atrophy extends down into the dermis. Additionally, there are prominent telangiectasias, and approximately one-third of the lesions ulcerate. Slightly more than half of the patients diagnosed with NLD have associated retinopathy and/or other signs of microvascular compromise.⁶ The time required to see improvement varies from 3–4 years. Spontaneous resolution is sometimes noted. The mainstay of treatment is tight diabetic control. Topical and/or injected corticosteroids are also indicated. Intralesional injection of 0.1 ml triamcinolone 2.5–10mg/ml every 2–4 weeks has been found to be effective in severe cases.⁵

Granuloma Annulare

The cause of granuloma annulare is unknown. It is a benign condition that has several clinical forms. The classic type is most common. The less common forms include generalized, multiple, perforating, and subcutaneous forms. This condition has lesions similar to NLD without the atrophic center. Lesions are common over trauma areas, such as the dorsum of the hand and elbows. It begins as papules and expands into annular borders with central areas of hyperpigmentation. In spite of its appearance, there are few other symptoms. There are several forms of treatment, including liquid nitrogen, to ablate the annular borders of the lesion.

Diabetic Dermopathy

Diabetic dermopathy has been called one of the most common skin signs of diabetes, but it can be seen in non-diabetics as well. Prevalence is most noted in men with diabetes who are 60 years of age or above.⁵
The exact cause of this disorder is unknown. Some theories about the pathogenesis include post-traumatic atrophy due to a thermal or mechanical insult or post-inflammatory hyperpigmentation in poorly vascularized skin.⁵ There is little evidence of angiopathy or its relationship to other diabetic angiopathies, but its incidence does correlate well with the severity of diabetes.⁶
Diabetic dermopathy begins as pink patches approximately 0.5–1 cm in diameter on the pretibial and lateral leg areas. Eventually, they become hyperpigmented brown papules with a fine scale and surface atrophy. They are round, circumscribed, shallow, bilateral, and usually not symmetrical. They finally heal, forming scars. Treatment is episodic; these lesions often resolve spontaneously.

Acanthosis Nigricans

Acanthosis nigricans is a disorder that can be found in disorders of insulin resistance, such as diabetes, obesity, and paraneoplastic syndromes. It has been reported to occur with an incidence approaching 74% in healthy obese adults, 66% in primary school children who weigh 200% of the ideal body weight, 28% of children weighing 120% of ideal body weight, and 71% in an unselected population of primary school children.^7-8 It has also been demonstrsted to occur with increased frequency in certain ethnic populations. American Indians have an incidence of acanthosis nigricans of 54%, and it occurs at an incidence of 40% in Hispanic populations.⁹
Most authors have causally linked acanthosis nigricans to pathology related to the insulin growth factor (IGF) receptors found in the epidermis.¹⁰ The defect has been postulated as being related to defects in the receptor itself, postreceptor function, antibodies, or obesity.¹¹ Additionally, there are 3 lines of evidence that associate this disorder with high plasma levels of insulin. These include the finding of classic insulin receptors and IGF receptors in fibroblasts and keratanocytes in the epidermis. Second, acanthosis nigricans has also been found locally at the site of injection of insulin. Finally, as previously mentioned, most of the conditions associated with the disorder have a form of insulin resistance.
Symptoms include velvety, hyperpigmented plaques. These are found on the flexural areas and the back of the neck. Additionally, there can be an associated papillomatosis. These lesions can range from shallow to deep. Histologically, the lesions show marked hyperkeratosis and papillomatosis, and they are mildly acanthotic.¹² Some also display atrophy and increased amounts of melanin in the basal epidermis.
There are several ways to treat this disorder. One way is to use keratolytic agents like salicylic acid. Some success has also been found using omega-3 fatty acids and a diet rich in fish oils. Finally, good success has been found using weight control and exercise.¹ A combination of these, with good serum glucose control, is most likely to help.

Cutaneous Infections

Cutaneous infection is the area of diabetic skin disease that is most often thought about. Actually, well-controlled patients with diabetes probably are no more susceptible to infection than the normal population. However, poor control (especially ketoacidosis) compromises resistance. The poorly controlled get more severe, protracted, and resistant infections. Once serum glucose control is reestablished, resistance usually returns to normal. Contrary to logic, hyperglycemia contributes little to the growth of most cutaneous organisms. In support of this, topically applied sugar and honey have actually been used in healing ulcers of the skin.¹³ A well-known exception involves Candida. It has been shown to have a direct correlation between growth and sugar concentration in the saliva.

New Hope for Diabetic Foot Ulcers

2008-03-13T12:31:00.001-07:00

New Hope for Diabetic Foot Ulcers

Human-cell derived wound care products promote healing even in severe cases

After nearly a decade of unsuccessful treatment for a chronic foot wound, Paul, a sixty-something patient with diabetes faced the strong possibility of amputation. As a last attempt to avoid amputation, the Oklahoman entered a clinical trial at a specialty wound care center in Oklahoma City. Within seven weeks of beginning the revolutionary treatment, the dime-sized hole in Paul's foot was completely healed.

Like Paul, the 18.2 million Americans with diabetes¹ are particularly vulnerable to the types of wounds that resist treatment. These wounds are costly, but often futile to treat. They greatly limit a patient's physical activity, regularly forcing their exit from the workforce. The longer the ulcer persists, the greater the possibility the patient will develop a serious infection that can lead to hospitalization and possible amputation.

In addition to the devastating effects these wounds have on patients, their lifestyles and their productivity, the direct and indirect economic costs of treating them is enormous. Costs for the care of ulcerated wounds in the United States have been estimated at $5,457 per year per wound care patient-amounting to a total national annual cost of $5 billion².

Despite the high cost of care, many patients with diabetes experience wounds that never heal, leading to the rapid increase in amputation rates in recent years. Dr. Douglas Sowell, the Oklahoma City podiatrist who treated Paul, says the number of amputations has grown from 50,000 in 1986 to 86,000 in 2000.

Dr. Sowell attributes the increase in amputations to the sharp rise in the number of patients with diabetes and the high rate of obesity, which leads to complications like foot ulcers. Total direct and indirect costs of lower extremity amputations have been estimated at greater than $1 billion³.

For millions of Americans facing chronic wounds and the health care system that cares for them, the groundbreaking treatment Paul received offers great promise. The process, which uses a human cell-based material to jump start the healing process, has been successful in even seemingly hopeless cases like Paul's. Equally important for patients and payers, this healing procedure can take weeks, rather than years, meaning patients can return to their lives, and payers are not faced with an open-ended and often fruitless treatment process.

Paul's Story
Suffering from diabetes for nearly 20 years, Paul faced a number of complications from the disease, including neuropathy-a profound numbness of the limbs that primarily affects the lower extremities.

This loss of feeling in the limbs, particularly the feet, contributes to the high rate of chronic wounds faced by those with diabetes. Callouses build up and often ulcerate-meaning the tissue erodes and can become infected-before the patient notices. By then, it is extremely difficult to treat the wounds effectively. An estimated 15 percent of patients with diabetes will develop a lower extremity ulcer during the course of their disease⁴.

Paul was one of those patients. About ten years after being diagnosed with diabetes, drainage and odor from the wound on his foot drew his attention for the first time-he never felt any pain associated with it. For the next eight to ten years, Paul received regular, conventional treatment in his doctor's office for the wound, but it failed to heal.

Revolutionary treatment
Wounds like Paul's are typically treated with some type of antibiotic ointment and dressed with gauze, often on a weekly basis, in a doctor's office. Usually, though, by the time a wound has been present for more than six weeks, it needs much more than frequent dressing changes and antibiotic ointment to heal completely.

The bodies of diabetic patients are so compromised in terms of blood flow that when there is a wound, it requires extraordinary measures to initiate healing. In such cases, the dermal layer-the layer of tissue below the surface skin-needs to be healthy and growing before the wound can heal completely.

Researchers and doctors understood this problem and developed a new medical technology that combines living, fast-growing human cells with a high-tech mesh to create a growth-promoting skin substitute. The cells are embedded in the mesh, where they multiply and develop many of the characteristics, including the growth factors and proteins, found in natural skin. When the mesh-which is ultimately absorbed by the body-is placed in the wound, the human cells within it activate and help both the deeper and surface layers of the patient's own skin to grow.

Clinical trials show that this treatment approach promotes healing of diabetic foot ulcers significantly faster than ulcers treated with conventional therapy alone. "It's another modality that allows us to heal wounds. It's a great addition to the arsenal of wound treatment options. Particularly for diabetic foot wounds, it's just outstanding," says Dr. Sowell.

Some human cell-derived products available for chronic wound care management the foreskin of newborns as the donor cells. The fast-growing cells in the donor skin multiply quickly, which means limited donors are needed to produce large amounts of the product. One manufacturer of a human-cell based skin substitute says one foreskin has the potential to produce six football fields of the product. The company is still using cells from foreskin donations made in 1997 in its manufacturing process.

The cells used in the production process are tested frequently throughout the process to insure the tissue is disease free. The mother of the donor and the donor skin is tested before it is used to make the product. The final product is also tested extensively before it is sent to physicians for use with patients. The mesh is shipped and stored in a frozen state, and used in patients for up to six months.

Quick healing is efficient healing
Cost comparison data is difficult to gather for wound care treatments. Wound severity, the presence or absence of infection, and the size of the wound vary greatly from patient to patient. In addition, patient compliance-adherence to limitations on bearing weight on the wound, for example-impact the outcome of any treatment.

However, says Dr. Sowell, when a patient is properly screened for appropriateness of treatment and works with the doctor to aid the healing process, the human-cell derived skin substitute can promote healing in weeks instead of many months or even years.

When patients undergo treatment for years at a time, says Dr. Sowell, the costs just keep adding up. "If you can get it all done very quickly-get them healed and get them on with their lives-that's how we demonstrate cost-effectiveness," he says.

As the incidence rate of diabetes continues to grow, efficient treatment will become increasingly important. Estimates suggest the national cost of diabetes could grow to $156 billion by 2010 (in 2002 dollars) and to $192 billion by 2020. Direct medical costs could increase from $92 billion in 2002 to $138 billion in 2020, while indirect costs from lost productivity could increase from $40 billion in 2002 to $54 billion in 2020⁵.

The actual future cost of diabetes is likely to be substantially higher than these projected amounts if the prevalence of diabetes continues to grow-especially for type 2 diabetes, which is correlated with the growing problem of obesity in the U.S.-even after controlling for changing demographic characteristics⁶.

The availability of advanced wound management technologies for non-healing chronic wounds could greatly reduce these costs in future years.

¹ American Diabetes Association,

Patients Treated 20 weeks with O2Misly(TM) were Healed

2008-03-13T12:18:00.000-07:00

IYIA Launches Technology to Reduce Amputations Due to Diabetic Foot Ulcer

CHICAGO -- Everyday, someone someplace will have their lower limb amputated due to continual complications from a diabetic foot ulcer. Approximately 2.4 million diabetic foot ulcers are diagnosed each year in the U.S., many progressing to lower limb amputation. It is estimated that the U.S. healthcare costs for treating diabetic foot ulcers and related amputations exceed $10 billion per year.

IYIA Technologies Inc., San Marcos, CA, announced the launch today at the American Diabetes Association annual meeting, their medical device, O2Misly(TM), for the treatment of slow healing diabetic foot ulcers. The O2Misly device offers a combination, adjunctive therapy to the standard of care in the treatment of non-healing ulcers. O2Misly provides oxygen infused under tension in a closed chamber blended with a mist, which also delivers an antimicrobial to the affected area. This therapy can be conveniently delivered in a clinician's office and does not require the patient to be enclosed in a pressurized tube, as with total hyperbaric oxygen therapy. The O2Misly office based therapy will be a lot less expensive compared to the hospital based hyperbaric chamber treatment.

IYIA has conducted a clinical trial over the last 18 months and the results have been dramatic. Patients in the study had to have failed previous standard of care therapy before they could be included in the trial. 75.5% of the patients treated with O2Misly(TM) were healed within 12 weeks. 100% of the patients treated 20 weeks with O2Misly(TM) were healed.

Clark Adams, Chairman, IYIA Technologies, stated, "It is unfortunate that the medical device industry has taken so long to develop a cost- and clinically-effective system to treat and heal diabetic foot ulcers, which could reduce lower limb amputations. IYIA is proud to launch a system to help these patients to not only improve their quality of life but maintain their mobility as well."

Diabetic foot ulcers: —new technologies

2008-03-13T12:09:00.000-07:00

Diabetic foot ulcers: old problems—new technologies

Gerit D. Mulder

Regional Burn Center Wound Clinic, University of California San Diego Medical Center, California, USA

Introduction

The association of diabetic foot ulcers with a high incidenceof amputation, morbidity and mortality is well documented inthe international literature including guidelines from the AmericanDiabetes Association, the International Consensus Panel of DiabeticUlcers, and the German literature on Diabetic Foot Syndrome. The cost of care incurred by the diabetic withfoot lesions is surpassed only by the total cost of medicalproblems related to the disease. A brief review of the pathophysiologyof diabetic ulcers and an understanding of the difference betweenchronic wounds will facilitate decisions related to the useof new technologies, including recombinant growth factors. Thefollowing overview of new technology related to diabetic footulcer care will summarize relevant information related to acuteversus chronic wounds, assist in defining a chronic wound, andprovide concise guidelines on appropriate prescription of newtechnologies.

Acute vs chronic wound healing

The cellular mechanism of wound repair in the acute wound hasbeen extensively studied and documented in the medical literature. The inflammatory, proliferative (granulation phase)and remodelling phases can be categorized according to the activityof their cellular components, including cytokines, chemicalmediators, and cellular components. Intrinsic medical conditionsor extrinsic environmental factors rarely affect the repairprocess in the healthy individual.

The chronic wound, in contrast to the above, has phases of repairthat do not follow the expected sequence of healing. Wound treatmentexperts in the United States have made attempts to define chronicwounds.

Unresponsive wounds on debilitated patients and those with multiplemedical problems must be addressed based on a triad of care.Intrinsic, extrinsic and wound environment factors must be simultaneouslytreated for optimal outcomes. Intrinsic factors include thepatient's medical status, prescribed medications and concomitantdisease. Extrinsic factors concern repetitive trauma, off-loadingand pressure reduction. The wound environment examination includes,but is not limited to, the wound bed status (amount of necrotictissue, type and amount of exudate, fibrotic tissue, per centgranulation, re-epithelialization), cellular activity in thewound, and devices and dressings used for treatment. When appliedto the diabetic, the above triad translates to control of thediabetic disease, selection of appropriate shoes and devicesto reduce or eliminate pressure on the lower extremity, andaggressive wound debridement, treatment and dressing selection.Neglecting any one of the three approaches to the unresponsivewound may delay or prevent wound closure.

Definition of chronic wounds

The majority of wounds that are considered chronic respond toestablished treatment and dressing regimens. However, 15–20%of patients with chronic wounds do not respond to conventionaltherapy and may require the use of advanced technologies tostimulate and expedite tissue repair. The physician needs todifferentiate between a responding chronic wound, which willclose with conventional treatment, and a truly non-respondingwound, which will require a different approach.

Pecoraro et al. determined that not all diabetic ulcersare responders. Those ulcers not showing a reduction in sizein a one-month treatment period with good pressure reductionand ulcer therapy can be classified as non-responders. Furthermore,Sihl et al. determined that approximately 15% of all diabeticsunder good control would still not demonstrate normal healingrates. The delay in wound repair may be attributable to endogenouswound factors including senescent cells, absence of growth factors,and other cellular abnormalities. Agren et al. found thatfibroblasts in diabetic ulcers, as with venous ulcers, are diseased.Wounds that remain open for extended periods of time are morelikely to have diseased cells. Phillips et al. describedthe presence of senescent cells at the margins of chronic venousulcers. Senescent cells are characterized by cells, which areviable but have lost their proliferative capacity. The lattercells would not be expected to respond well to the presenceof endogenous or exogenous growth factors in the wound milieu.Debridement of senescent cells, non-viable tissue, fibrotictissue, wound debris, and other unwanted wound components maysignificantly expedite wound closure while increasing the availabilityof viable cells able to produce and respond to growth factorsand other cytokines. Debridement and its correlation to thesignificant increase in wound closure, particularly when followedby the application of platelet-derived growth factor (rhPDGF-BB)is supported by a large randomized double-blinded and controlledtrial.

The presence of a prolonged inflammatory response may furtherdelay closure by promoting on-going activity of matrix-metaloproteinases[MMP). High levels of MMP activity may contribute to proteinand growth factor degradation. Repetitive trauma and high levelsof bacterial colonization may result in increased inflammationactivity with an associated influx of macrophages and neutrophils.Appropriate levels of MMP activity during the phases of woundrepair are known to promote wound repair, while prolonged levelsmay delay closure through matrix, growth factor, and growthfactor receptor degradation.

Advanced technology for diabetic foot ulcers

The use of advanced technology, including platelet-derived growthfactor, may assist with wound closure in the diabetic patient.Based on medical literature, the clinician should be able todetermine within the first few weeks of treatment, whether awound will respond to conventional therapies (responders) orremain chronic (non-responder).

Available literature suggests that a visible decrease in woundsize during the first few weeks of administering appropriatewound care is an indicator of chronicity. Wounds that decreasein size by greater than 0.109 cm per week have been found tocorrelate with responsive wounds, while rates less than 0.032cm per week are classified as non-responders. A decreasein surface area of less than 10% per month may also correlatewith non-responding chronic wounds. Once a physician has establishedthe status of a wound as being chronic, advanced modalitiesmay be selected to improve treatment and cost outcomes.

Diabetic ulcers, which remain open, are associated with increasedcost of care and morbidity. Foot ulcers are knownto significantly affect the cost of care in diabetic patients.Shortening the time to closure by even a week may prevent infection,complications and ulcerations. The cost of amputation well exceedsthe cost of wound closure and limb salvage. The cost of growthfactor therapy may be less than the cost of other prescribedmedications and antibiotics used in the course of standard carewhen an ulcer remains chronic. Growth factors need to be consideredfor appropriate and advanced care of the non-responding diabeticfoot lesions and chronic wounds.

Recombinant platelet derived growth factor—relevance to diabetic foot ulcers

The complications and cost associated with unresponsive diabeticfoot ulcers has prompted extensive biomolecular research duringthe last decade. Chemical mediators, including growth factors,have received particular attention as a result of their importancein stimulating and directing cellular activity in the woundenvironment. While various growth factors have been studied,the only government approved prescription drug (approved inUS, UK, Germany and Austria) is becaplermin (recombinant platelet-derivedgrowth factor or rhPDGF-BB).

The wound environment contains a variety of growth factors.Platelet-derived growth factor is of particular relevance dueto its chemotactic, mitogenic, angiogenic, and stimulatory effectsleading to matrix formation and wound bed granulation.PDGF may be of significant benefit of diabetics as recalcitrantdiabetic wounds have been found to be deficient in or absentof PDGF. A total of 922 patients have been studied in well-designedand controlled trials and have resulted in data supporting safetyand statistically significant benefits. A phase IIIrandomized placebo-controlled double-blind study on 382 patientswith diabetic foot ulcers supported that becaplermin gel 100µg/g, in conjunction with good wound care, significantlyincreased the incidence of complete wound closure and significantlyreduced the time to complete closure of chronic diabetic neuropathiculcers.

Experience by the author with becaplermin during the last 2years at the University of California San Diego Medical Center,Regional Burn Center Wound Clinic, has supported a significantcost and treatment benefit when used on patients with diabeticfoot ulcers as well as ulcers of other aetiologies. Applicationhas been extended beyond diabetics to wounds of other aetiologies.Figure 1 illustrates a patient with a large tissue effect exposingunderlying tendons of the foot. Grafting is necessary to decreasethe risk of limb loss but is made difficult by the full-thicknessnature of the wound. Application of rhPDGF-BB once a day fora 2-week period resulted in rapid granulation (Figure 2). Thepatient was successfully grafted and the trauma and expenseof limb loss avoided. Growth factor therapy may be cost andtreatment effective when applied to non-responsive wounds thathave been appropriately prepared through removal of necroticand fibrotic tissue.

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Fig. 1. Patient with a large tissue effect exposing underlying tendons of the foot. (Photograph courtesy of Dean Vayser, Scripps lnstitute, La Jolla, California).

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Fig. 2. Rapid granualation following application of rrPDGF-BB once a day for a two-week period. (Photograph courtesy of Dean Vayser, Scripps lnstitute, La Jolla, California).

Successful treatment and cost outcomes when using growth factorsmust include addressing the above referenced triad of woundcare. The wound environment may be sufficiently stimulated byrhPDGF-BB yet fail to indicate repair. This may result frommedical problems outside the wound environment and not addressedby growth factor therapy. Addressing the patient's medical statusincluding control of the diabetes, appropriate nutrition, pressurereduction and appropriate shoes or footwear, and simultaneouslytreating concomitant medical conditions, is necessary as adjunctivetreatment.

Aggressive and complete debridement of all wound debris, necrotic,fibrotic, and non-viable tissue from the wound bed is necessaryfor optimal therapy response. Steed et al. studied theeffects of debridement on response to rhPDGF-BB in randomized-blindedplacebo-controlled studies. Results were consistent with improvedtissue repair correlating with debridement. Debridement in conjunctionwith growth factor therapy resulted in a statistically significantdifference between placebo and drug therapy. Receptors for growthfactors may be found on viable cells and not necrotic tissue.Removal of the necrotic tissue increases the number of availablereceptors allowing interaction between cells and applied drugtherapy.

Vascular exams are necessary to determine whether sharp debridementis appropriate. When sharp/surgical debridement is not possible,alternative means of wound cleansing, including enzymatic, mechanical,and biological can be considered.

Control of infection and high levels of contamination reducethe negative effect of prolonged inflammation and high levelsof enzymatic activity on proteins including growth factors andgrowth factor receptors. Debridement, unless contra-indicated,assists with the removal of necrotic tissue, lowers bacterialcount, and may provide an environment optimal for tissue repair.

Summary

Advanced and developing biotechnologies, including growth factors,are offering new approaches to the treatment of difficult-to-treatwounds. The majority of chronic wounds (‘responders’)may respond well to conventional therapies. A smaller, yet significantpercentage of patients (15–20%) may have recalcitrant(‘unresponsive’) wounds that do not decrease insize with standard care. The latter population may experiencerapid closure with the application of growth factors. Whilecurrent indications are for diabetic neuropathic foot ulcersof specific size and duration, growth factors are not diseasespecific and may bind to receptors on wounds of any size andof non-diabetic aetiology. Clinicians may attempt the use ofthese cytokines for full-thickness and large wounds of non-diabeticetiologies. As growth factors may be deficient in patients withdiabetes or other recalcitrant wounds, use of advanced modalities,including PDGF, need to be considered to expedite wound closure,reduce disease-associated morbidity, and to lower the cost ofcare. Physician and patient education on appropriate use andmechanism of action will further ensure optimal outcomes.

Disease Management Program

2008-03-12T16:03:00.000-07:00

Disease Management Program Cuts Lower Extremity Amputation Rate in Diabetes Patients: Presented at ADA

By Jill Stein

NEW ORLEANS, LA -- June 17, 2003 -- Population-based lower extremity screening combined with a treatment program leads to a progressive decrease in the rate of amputation in patients with diabetes, researchers reported here June 15^th at the 63^rd Scientific Sessions of the American Diabetes Association.

Dr. Robert Wunderlich, from the Diabetes Research Group, in San Antonio, Texas, United States, presented 4-year results in 2,700 diabetes patients who participated in such a program.

The screening evaluation focused on identifying factors that would put patients at risk of subsequent diabetic foot pathology. These factors included a history of ulceration or amputation, peripheral sensory neuropathy, peripheral vascular disease, and musculoskeletal deformities of the foot.

After screening, patients were placed into a low-risk or high-risk group. Low-risk patients had no history of ulceration or amputation, had intact protective sensation, and had no evidence of peripheral arterial occlusive disease. High-risk patients had one or more of the following: a history of foot ulceration or amputation, loss of protective sensation, or evidence of peripheral arterial occlusive disease.

Patients in the low-risk group were referred to a patient education program supervised by a certified diabetes nurse educator, and foot care was provided on an as-needed basis. Screening evaluations were repeated annually.

Patients in the high-risk group were evaluated by a staff podiatrist and referred to a certified pedorthist for fitting of therapeutic shoes and insoles. Most patients were prescribed extra-depth shoes with dual density bilaminar accommodative insoles. These patients were seen at 8- to 12-week intervals for infrared dermal temperature testing and palliative foot care. Acute foot problems were treated immediately by a staff podiatrist. Patients with acute peripheral arterial occlusive disease were promptly referred to a vascular surgeon.

All patients in the high-risk group were also referred to a patient education program.

The investigators identified an amputation incidence of 70.4 per 10,000 patients during the first year of intervention (1999). After continued implementation of the screening and prevention program, the amputation incidence was reduced to 48.4 per 10,000 patients during the most recent year of intervention (2002) -- a 31.3% reduction.

There was a 47.3% reduction in above-knee and below-knee amputation incidence compared to the first year of the study.

"From a financial standpoint, traditional health care spending models focus only on the most acute cases," Dr. Wunderlich said. "Our approach focuses on the entire population. This effectively shifts the spending mean to a lower value, thus reducing health care costs for the entire diabetic population."

Simple Test Predicts Diabetes Amputation Success

2008-03-12T15:34:00.000-07:00

Simple Test Predicts Diabetes Amputation Success

By E.J. Mundell
HealthDay Reporter

FRIDAY, July 30 (HealthDayNews) -- Each year, more than 10,000 Americans with diabetes face agonizing decisions as the disease leads to foot ulcers that just won't heal, indicating a need for amputation.

In about 75 percent of cases, the partial amputation of a foot may be enough to stop ulcer progression. But for the remaining 25 percent, this type of operation will fail, leaving doctors no choice but to remove the leg from below the knee in yet another costly and painful surgery.

Now, Canadian researchers say a simple blood sugar reading can predict which patients will fare best with partial-foot amputations.

"The findings underscore the importance of controlling blood sugar after the surgical procedure is done," said Dr. Eugene Barrett, past president of the American Diabetes Association. "This points out that if blood sugar is poorly controlled, then the likelihood of success is diminished."

The finding was presented July 29 at the annual meeting of the American Orthopaedic Foot and Ankle Society in Seattle.

Chronic diabetes can restrict blood flow to the lower limbs, especially in older individuals. Poorer blood flow means impaired healing, raising risks for hard-to-treat diabetic ulcers.

Complicating matters, many patients also suffer from diabetic neuropathy -- a deadening of nerves in the feet and legs -- that leaves them without the sensation of pain that might otherwise send them into early treatment.

Neuropathy can leave feet and lower legs so numb patients "could walk around with a nail under their foot for a day and not realize it," Barrett explained. By the time many patients seek treatment, their ulcers are already surrounded by gangrenous tissue and the foot or limb cannot be saved.

In the past, a below-the-knee removal of the affected leg was standard procedure. But over the past decade, a limb-sparing surgery called transmetatarsal amputation (TMA) has become more popular, where just the front part of the foot is removed.

For most, amputation stops there. TMA fails some patients, however, leaving them no choice but below-the-knee amputation.

In their study, researchers Dr. Alastair Younger and Dr. Colin Meakin, of St. Paul's Hospital in Vancouver, looked for markers that could predict those patients in whom TMA would be most successful. They compared factors such as age, smoking status, duration of ulcer, and blood sugar levels in 21 diabetic patients for whom TMA was successful and 21 patients for whom the operation had failed.

The study found that, in patients with blood sugar levels greater than 10 percent of the blood "the TMA is bound to fail," Younger said in a prepared statement. These patients may require full below-the-knee surgery, and should not be put through the prior stress and expense of partial amputation.

On the other hand, in patients with blood sugar levels of 7 percent or lower "the rate of success is high, and a surgeon should perform a TMA," Younger said.

Barrett had one caveat to add, however. In his opinion, too many U.S. doctors still don't realize a surgical alternative to below-the-knee amputation even exists.

"The people who end up doing this procedure [below-the-knee amputation] are usually general surgeons or orthopedic surgeons," many of whom received their training prior to the advent of TMA, he explained. "If when they were trained they were told, 'For diabetic foot ulcer, you do a below-the-knee amputation,' that's what they do." According to Barrett, better education of surgeons may be key to saving more limbs through TMA.

Diabetic foot ulcers can also have a devastating impact on patients' psychological well-being, according to a second study presented at the Seattle meeting by Dr. Michael Pinzur of Loyola University Medical Center in Chicago.

According to Pinzur, patients treated for foot ulcers experience bouts of deep depression just as frequently as patients who have already undergone amputation, probably because these ulcers so often precede amputation.

"There's something very profound that occurs when you tell someone that they're going to lose a foot or leg," Barrett said. "I've had patients say that they'd just as soon die."

According to Pinzur, that's just one more reason to opt for the less-disabling TMA procedure whenever possible. In a prepared statement, he said experts must "work to come up with methods of treatment that will not impact [patients'] lives as much as it does now."

1st Diabetic Limb Salvage conference: a team approach

2008-03-12T14:56:00.000-07:00

1st Diabetic Limb Salvage conference: a team approach

This report is from a conference that took place on 27-29 September 2007 at the JW Marriott Hotel, Washington DC, US. The event was sponsored by Georgetown University Hospital.

Introduction

The 1st Diabetic Limb Salvage conference took place in Washington D.C from the 27th to the 29th September. The conference was organised by the diabetic footcare team at Georgetown University Hospital. It was attended by over 1000 delegates from 29 different countries, including the UK, with 50 of the American states represented. The conference was presented as a single track, highlighted with live surgical cases and a choice of workshops and symposiums. This report was written by Paul Chadwick and Jane McAdam, Principal Podiatrists, Salford PCT and Hope Hospital.

The first session, 'Defining the Problem and Gaining Perspective', covered the growing problem of the increasing incidence of diabetes in the US, due to obesity, a changing racial mix, longer life expectancy and familial history. The incidence is growing rapidly in specific racial groups. For example, 50% of Pima Indians suffer from diabetes, possibly due to their recent adoption of a 21st century lifestyle with which their genetic profile is not able to cope. This group have a 'thrifty gene' which has the role of protection from starvation during times of deprivation, but results in increased body fat during more plentiful times.

The complications of diabetes were discussed, especially in terms of morbidity and health costs. For example, 50% of people with diabetes and peripheral arterial disease (PAD) will have a cardiovascular incident, a myocardial infarction or pass away within 5 years of diagnosis. Furthermore, this group account for 20% of the case load, 70% of the interventions and 90% of health care costs.

Developments in the last decade

David Armstrong spoke about the major developments that have improved diabetic foot care over the last decade. He summarised developments in ulcer management in three ways.

1. What you take off the wound--the elimination of the edge effect, debridement.

2. What you put on the wound to encourage healing for example, topical negative pressure, matrix replacements, skin-grafting, non-removable casting techniques.

3. How to prevent recurrence. This was the most difficult and under-researched area. He demonstrated that patients with PAD had a ten-fold risk of developing a new lesion, and that ulcerations on the plantar hallux had a five-fold increase risk of re-ulceration.

Neuropathy

The second session covered neuropathy and was opened by Andrew Boulton who covered the epidemiology of sensory loss in the diabetic foot. This was followed by an interesting presentation by Ivica Ducic who outlined the surgical decompression of peripheral nerves in some cases of unilateral neuropathic patients. He emphasised the importance of patient selection, physical examination (including a positive Tinel's sign) and the skill of the surgeon, to increase the chances of success.

Delegates were then given a chance to reflect on the issue of compliance, including a discussion of motivational interviewing and the 'stage of change' theory. The major point made was that as practitioners we should talk to our patients about how they manage their condition by asking questions, rather than telling them what they should be doing.

Vascular disease

The following morning focused on vascular interventions, in particular on the differing approaches to revascularisation: endovascular versus distal bypass. Although after a long and sometimes heated debate, there was no clear conclusion about which was the more successful approach, it was clear that vascular intervention was aggressively pursued in the presence of ulceration. While endovascular surgery was rapidly becoming the surgery of choice, most surgeons advocated bypass to address larger wounds. It was also clear that distal procedures (for example of the dorsalis pedis artery) were commonly performed. It was highlighted that while no single revascularisation procedure lasted indefinitely, bypass has proven durability whereas endovascular work still has this to prove.

Delegates were encouraged not use the term microvascular disease, but to use microvascular dysfunction and that the presence of the latter should not preclude people from reconstructive surgery. Within the vascular session speakers also advocated obtaining an Ankle Brachial Pressure Index (ABPI) for all individuals. While we had some difficulty with this principle, in terms of its reliability in people with diabetes due to vascular calcification, the emphasis from the speakers was that a reduced ABPI was the best indicator of systemic vascular disease, thus giving an early opportunity to modify risk factors. Anton Sidawy said 'The first person who diagnoses PAD determines the outcome of the limb and the person'.

A final point highlighted was the presentation of PAD being a predominantly tibial vessel disease. One study suggested 36% of people with pre-diabetes (impaired glucose tolerance) have an increased risk of tibial PAD, with the pattern of blockage mimicking that of a person with diabetes.

Biomechanics

The Friday afternoon began with a session entitled 'Biomechanics or Biomagic? Tackling the dilemmas of foot function'. Michael Mueller presented the case for tendo achilles lengthening as part of the surgical management of forefoot ulcers. Lawrence Lavery then gave a very good summary of the research underlying offloading techniques and use of footwear in preventative care. He highlighted the importance of reducing shear and explained the development of insoles to address this issue.

A further session was devoted to Charcot foot. There was a summary of the patho-physiology of this disorder which reflected the work of William Jeffcoate. Surgical reconstruction was strongly advocated, with the techniques described including use of external fixators, internal locking plates and tendo achilles lengthening. Aggressive bracing post-surgery was advocated.

Workshops

The final day began with the opportunity to attend three workshops from a choice of nine including debridement, vascular assessment, dressings, total contact casting and living cell therapy. These were sponsored by companies and as such had a product focus. On the whole the workshops were informative, with the hands on approach allowing delegates to experience use of new or unfamiliar products.

Wound care

The final session focused on changing a non- healing wound to one that was healing. This covered some basics such as dressing choice, the role of antibiotics post-amputation and a rational approach to improving glycaemic control to aid wound healing. It also had some in-depth presentations, including the role of microcirculation, the push-pull theory and the role of biofilms in the process of delayed wound healing. The latter described how rapidly biofilms regenerate following debridement and the case for individuals removing the biofilms on dressing changes using a surgical scrub, similar to the way dentistry has developed the use of brushing teeth to remove plaque (a biofilm).

Summary

Overall the conference was a very positive experience. It gave the team a chance to reflect on their practice, benchmark their service against practice in the USA and importantly to gain new knowledge and approaches to the care of the diabetic foot. At times, the approach felt more aggressive than that sometimes taken in the UK and this may be a reflection of public versus private healthcare. However, this approach can certainly teach lessons and encourage debate. Furthermore, the link between diabetic foot disease, either well-established or incipient, and overall health was highlighted, clarifying the role of podiatrists in recognising potential morbidity and taking actions to prevent this undesirable outcome.

As Small as a Bottle Cap

2008-03-11T13:16:00.000-07:00

Preventing Foot Ulcers Caused By Diabetes

The personal and economic costs of foot infections and amputations are enormous

By Lindsay Lyon

Posted January 28, 2008

Nothing felt awry as Cornelius McGill soldiered through his eight-hour shift of heavy lifting at Kmart last February. But when he got home, he made an unsettling discovery: Lodged in his foot was a serrated bottle cap. Had it not been for his blood-soaked sock, McGill, 42, might not have noticed for days. Even so, his resulting foot ulcer—a type of nonhealing wound that afflicts up to 25 percent of diabetics like McGill—became a life-threatening condition when infection set in and spread to his bloodstream and bones. In a frantic effort to save his life, doctors prepared to amputate his leg. Today, he feels lucky to have lost only a toe. "My God, that this little cap did all that damage!" says McGill, of Waukegan, Ill. "It was shocking."

Diabetics are prone to foot ulcers, due to neurological and vascular complications.

(Craig Zuckerman/Getty Images)

Because of the nerve damage caused by his diabetes, McGill feels no pain in his feet; indeed, 60 percent to 70 percent of the 20 million or so Americans who suffer from the disease experience the neuropathy that can lead to numbness in the extremities. About 30 percent of all diabetics 40 or older lose some feeling in their feet, the first step toward the infected ulcers that predispose diabetics to amputation. Published studies indicate that 1 in 5 infected foot ulcers requires amputation—at which point the chance of dying within five years is estimated to be upward of 50 percent.

The economic burden that diabetes and its related complications has placed on the U.S. healthcare system—now $174 billion each year, a 32 percent increase since 2002, according to a study released online last week by the American Diabetes Association—is creating a new urgency to prevent experiences like McGill's before they happen. (A related report to be published in the March/April edition of the Journal of the American Podiatric Medical Association estimates that about a fifth of those costs are directly related to diabetic foot ulcers and amputations, says lead author Lee Rogers, an amputation prevention specialist at Broadlawns Medical Center in Iowa.) "Every 30 seconds, someone in the world is losing a limb to diabetes," says David Armstrong, a podiatric medicine specialist at Rosalind Franklin University of Medicine and Science in North Chicago and the surgeon who treated McGill. "I can't stress enough how sinister this disease is."

But research indicates that most foot ulcers are preventable, and become deadly only when neglected, Armstrong says. Several studies, including one published in the American Journal of Medicine in December, have found that daily monitoring of skin temperature is an effective way to stave off ulceration in high-risk diabetics. Wounds heat up before skin breaks down, Armstrong explains. If patients detect an abnormality—a spot on one foot 4 degrees hotter than the corresponding spot on the other foot—conditions might be ripe for an ulcer. They may then decide to stay home rather than risk a day of walking, for example, or consult their doctor for more specific recommendations. In the latest trial led by Armstrong, patients using hand-held thermometers (specifically the $150 TempTouch) to track temperature differences between sites on their feet were three times less likely to develop ulcers than patients doing visual inspections alone.

Another technique used off-label to prevent ulcers entails injecting small amounts of liquid silicone into the balls of the feet to replace eroding fatty tissue. Although the method still hasn't been cleared by the Food and Drug Administration for this purpose, it's used for treating retinal detachment. By reducing the risk that a pain-free diabetic will walk right through his or her skin, advocates say, the procedure lowers the likelihood that ulcers will form.

"It's criminal it's not approved," says Sol Balkin, 82, a retired podiatrist and pioneer in using injectable liquid silicone to treat foot ailments. He estimates that in 40 years of practice he's administered more than 30,000 injections. Balkin and a U.S. company are currently working to gain approval to market this treatment in Europe.

Some specialists have qualms. "It's potentially dangerous," says Stephen Kominsky, a podiatric surgeon and diabetic foot expert at Washington Hospital Center in D.C. "Patients with diabetes are compromised, so injecting them with a foreign substance might trigger a negative reaction." In healthy patients—the procedure is often used to relieve pain and pressure in normally aging people losing the fatty padding in their feet—injecting silicone "makes all the sense in the world," Kominsky says. To heal foot ulcers before infection strikes, Kominsky uses a technique that he finds particularly effective: the application of living skin grown in laboratories from neonatal foreskins saved during circumcisions. The skin is placed atop clean ulcers to promote new tissue growth.

What experts can agree on is this: Informing people about the possible complications of diabetes is the best way to avoid infection and amputation. Patients alert to signs of danger can often minimize the damage. "If someone had just educated me about this," McGill says, "I'd say I'd be better off than I am now." He's unable to return to work, and there's no guarantee he won't lose his leg in the future.

Controlling Foot Care Benefit Costs in Canada

2008-03-11T12:38:00.000-07:00

PEDORTHIC ASSOCIATION OF CANADA
Suite 503 - 386 Broadway
Winnipeg, Manitoba R3C 3R6
Toll Free: 1-888-268-4404
Toll Free Fax: 1-866-994-9925
E-mail: info@pedorthic.ca
www.pedorthic.ca

Controlling Foot Care Benefit Costs in Canada:
An Open Letter to Insurers and other Third Party Payers

The Pedorthic Association of Canada (PAC) shares your concerns regarding the escalating use of this benefit, the increased costs
incurred by plan sponsors and the inconsistent quality of foot care that your clients receive. It is our perspective that the increasing
use of footcare benefits by subscribers has been strongly influenced by two major factors:

• an influx of noncertified footcare providers who see financial benefit in providing foot care products; and,
• the lack of an independent gatekeeper to ensure the medical necessity of care, complicated by the fact that some prescribers are also service providers.

PAC recognizes the need to ensure quality of care, optimal standards and evaluation of practice and cost control. It is our position that:

• treatment should be reimbursed only if the care is provided by a recognized foot care specialist
• separation of the provider / prescriber relationship is critical in eliminating conflict of interest
• primary care and specialist physicians, trained in full body diseases, should be the prescribing/referring agents as they are best able to:

• provide appropriate differential diagnoses
• rule out global pathologies
• determine if pharmacological, diagnostic or rehabilitative recommendations are necessary
• determine whether orthotics are a reasonable medical expense based on the clinical evidence and an holistic consideration of the clinical findings

• pedorthists effectively assist physicians, through physical and biomechanical evaluation, to confirm the need for orthotics and determine the amount and type of correction and/or accommodation required about the Pedorthic Profession
The practice and profession of pedorthics has matured in Canada over the last ten years, under the guidance of the Pedorthic Association of Canada. Certified Pedorthists (Canada) are trained and tested in the assessment, manufacture and dispensing of foot orthoses, as well as fitting and modifying footwear. The College of Pedorthics of Canada (the College) is the certifying and regulatory body for the profession and has established stringent standards of practice for
certified members. Clinicians undergo rigorous written and practical testing processes and are required to comply with the pedorthic code of ethics. Complaint mechanisms are readily
available to consumers and stakeholders (please refer to www.cpedcs.ca for more information).
Pedorthists are not physicians and are not trained in full spectrum global diagnosis. We do not prescribe treatment.
Our code of ethics also prohibits Certified Pedorthists from establishing business partnerships with any referral source, such as a physician.
The Certified Pedorthic Clinicians play a critical role in supporting the health and wellbeing of Canadians. Accountability, standards of practice, and monitoring of ethical practices through the College along with education and training through our Association, (PAC)
ensure high standards of pedorthic practice. We take great pride in our role in patient care in Canada and we would welcome any opportunity to discuss these issues further with your organization.

Assessing Diabetic Foot Ulceration

2008-03-07T14:13:00.000-08:00

Correctly assessing diabetic foot ulceration

Lorna Hicks
DPodM
Lead Diabetes Specialist Podiatrist
Conwy and Denbighshire
NHS Trust
Glan Clwyd Hospital
Wales

Diabetic foot ulceration is a significant health problem worldwide. In the UK the estimated annual cost of ulceration, infection, osteomyelitis and amputation associated with diabetic peripheral neuropathy is £251.5 million.(1) Approximately 15% of people with diabetes develop at least one foot ulcer during their lifetime, and 75% of these cases have neuropathy. Up to 35% of the diabetic population have peripheral neuropathy; the majority are asymptomatic.(2) For these reasons neuropathy is the most important risk factor to assess for. The prevalence of peripheral neuropathy in type 2 diabetes is around double that found in type 1.(3)
However, foot ulcer risk and neuropathy are not the same thing; a third of patients may have neuropathy, but only a fifth of these at any one time have had a foot ulcer.(4) There are, however, other factors to consider.
Over the last 15 years there has been a huge increase in the amount of research and investigations into the causes and impact of diabetic neuropathy, and more is now known about what to assess and how the disease process is influenced by health interventions and patient actions. A recent literature review reveals the vast amount of information available to us for assessment and management of the foot in diabetes.(5) The patient's perception of his or her risk appears to be what drives behaviour.(6) Therefore the assessment and education provided for the patient needs to be carefully considered if it is to cause behavioural change that will preserve feet.

Factors to consider
There are a multitude of factors that indicate risk of ulceration. These may be classified as key or contributory factors (see Box 1).

Essentially the difference is that contributory factors may exist but are unlikely to cause foot ulceration unless one or more of the key factors is present, for example corns and callus – the reason for their inclusion is that it should form part of the primary assessment because its presence is a reason for referral for treatment. Similarly, peripheral vascular disease – if it is present and the foot is otherwise unaffected – does not tend to precipitate ulceration. However, its presence may require further investigation or intervention. This is particularly the case when there are symptoms, and it is strongly linked to the risk of amputation as well as delayed healing, as wounds can occur resulting in chronic ischaemic ulcers.
These factors do not all contribute equally to the risk. How well these are assessed and graded will impact significantly on the success of any assessment, screening and prevention programme. It is vital to assess a person for presence or absence of risk factors, then identify their level of risk and provide education and intervention as appropriate.
Screening and assessment should be a key part of any prevention strategy. Expert observation of feet allows us to spot many of the key indicators of ischaemia or neuropathy. However, when these coexist the signs become confusing and symptoms may be masked.
Tests for peripheral neuropathy and peripheral arterial disease give quantitative results that are the foundation for future assessors and evaluation of the disease process.

Assessment

Neuropathy
Neuropathy is the most important factor to test for because it is involved in the majority of diabetic foot ulcerations, and merely identifying it and providing simple education can reduce the number or severity of ulcerations. There are several valid tools for assessment of this, such as the neuropathy symptom score and the neuropathy disability score.(7) It was observed that symptomatic peripheral neuropathy affects 10% of the diabetic population at any one time and is characterised by typical symptoms (see Box 2).(2) Up to a further 25% are asymptomatic, characterised by numbness and absence of feeling. Typical features of the neuropathic foot include claw toes, prominent metatarsal heads and marked callus formation, which is susceptible to ulceration (see Figure 1). Equipment that may be used for the physical assessment is listed in Table 1.

click this image

It could be useful to find out what other healthcare staff in your area are doing or to approach your local diabetes service advisory group (LDSAG) for guidance on any existing local protocol. Using a common, repeatable system for assessment allows valuable audit that can improve effectiveness in future.
The monofilament test used alone has a direct correlation with risk of ulceration. Patients who could not feel a monofilament were 10 times more likely to ulcerate over a given period than those who could feel the monofilament.(10) The monofilament does not diagnose neuropathy on its own, but when used properly as a single test it accurately identified a person's risk status for ulceration. Put simply, if the patient can feel it then protective sensation is intact; if the patient cannot feel it then sensation is not good enough to protect their feet from injury. For example, patients may wear shoes that are too tight because they cannot feel the correct size shoe adequately. Sometimes the repetitive stress of walking has worn a hole in their foot under the callus that has not been removed because they could not feel the discomfort it would normally cause.
There are five sites to test on each foot.(2) The monofilament comes with instructions for this. The sites are the pulp of the great toes and one, two, three and five metatarsal heads. The test has failed if the subject feels eight or fewer sites. There has been recent debate about how many and which sites, but general consensus is that a calibrated 10g monofilament is important (see Table 1) as this produces accurate reproducible results. Experience tells us that common risk sites for pressure ulceration are the great toe and metatarsal heads.
Vibration perception threshold studies produced some of the earliest evidence that insensate feet were at increased risk of ulceration. The study showed a 7.7-fold increased risk of ulceration with an inability to feel 25V on a neurothesiometer test,(3) however, this is expensive equipment. A 128Hz tuning fork is simple to use with no replaceable parts and no need to charge up. It may produce satisfactory results.
If the results of your tests show sensory deficit then there is a need for detailed education and advice, which should include recommending the patient inspects their feet and footwear every day, as sensation is not capable of indicating whether there is something wrong.
Education around evidence of sensory deficit should be clear and easy to understand: for example, if it looks like it should be painful, then treat it as if it is painful. Patients should be advised to seek help and rest their foot until they get help.
Advice should be rephrased for the individual's needs. Scare tactics may frighten patients into inertia and not seeking help early enough. However, ambiguity should be avoided.
If sensory neuropathy has been detected then it is wise to refer for podiatry evaluation, particularly if callus is present. Plantar pressure evaluation would be the next step. Insoles, footwear and orthotic therapy need to be considered.

Elevated plantar pressure
Elevated plantar pressure is second only to neuropathy as a contributor to diabetic foot ulceration.(11,12) When combined with neuropathy the effect can be devastating if left undetected and therefore untreated (see Table 2). The study of a semiquantitative plantar pressure device for detection of elevated plantar pressure validated interobserver agreement and sensitivity reached 90% specificity.(13) The product they used was Podotrack, which is called Pressurestat(TM) in the UK. It is simple to use and produces a pressure map of the patient's foot that can form part of the patient's records. It may be folded without distorting the image. The map is in shades of grey, so it is easily photocopied to append to referrals. It has a semicalibrated scale; pressure areas more than 6kg/cm(2) are at high risk for ulcer development.

Corns and callus
Corns and callus contribute to elevated foot pressures.(14) Meticulous debridement is imperative to significantly reduce the pressure and thus avoid ulceration.(15) Simple inspection of feet for the presence of callus then referral to the podiatrist for further management will deal adequately with this factor. The podiatrist may prescribe insoles to reduce callus and corn formation and thus further reduce risk.

Foot deformity
Simple foot inspection will enable identification of foot deformity, and referral for footwear, insoles or orthoses may be arranged if required. The presence of foot deformity is a proven risk factor for ulceration.16 Extra-depth footwear is needed to prevent pressure ulcers on the dorsum of deformed insensate toes or to accommodate insoles or orthoses. These are needed to modify pressure distribution and prevent plantar ulcerations.

Peripheral vascular disease
The usual examination for this involves observation and palpation of dorsalis pedis and posterior tibial pulses. Observations should include colour and quality of the skin, soft tissues and nails, noting any atrophy, cyanosis or ischaemic rubor. Presence of hair is usually a good sign, but its absence may be normal for that individual.
Posterior tibial pulse is behind the medial malleolus. Dorsalis pedis pulse is on top of the arch of the foot lateral to the long extensor tendon of the great toe.
Symptoms such as intermittent claudication and rest pain may be masked by the presence of neuropathy.
Ankle brachial pressure index may be falsely elevated if there is arterial calcification.
Capillary refill time (CRT) should be less than four seconds. This is when pressure is applied to cause blanching of the skin. Pinch the toe then release and the time for colour to be restored is recorded as CRT. Prolonged refill times suggest the tissues are not well perfused and injuries would have prolonged healing times. Repair of injured tissues has five times greater demand on the arterial supply than maintenance of intact tissues. It is therefore essential to protect feet with impaired circulation from injuries (see Figure 2). The importance of protection should be conveyed without causing alarm.

Education
Fear of amputation sometimes scares people into not seeking help; it may be seen as putting off the inevitable. However, the risk of ulceration needs to be explained. Any written information provided after assessment should be discussed.
Seeking help early is vital if serious complications are to be avoided. In order to get help early the problem needs to be detected in the first instance, which requires daily inspection of feet and footwear. The patient is more likely to check their footwear if they see their footwear and insoles checked as part of the assessment, and it elevates the importance of this simple task. If the footwear is not examined then important factors could be missed.
As well as written information, which has to be standardised to a degree, discussing and tailoring the information to the patient's needs and lifestyle can make the difference between healthy-living advice that gets ignored and behaviour-changing advice.
One-stop shops for assessing all aspects of diabetes are popular, but we need to be aware of information overload.
There is a need to revise information that is supplied in the same way a student revises for an exam. Pictures are more easily recalled, and illustrated advice is often better remembered.
The International Diabetes Federation recently published a book and data on issues surrounding diabetes and foot complications. There is guidance for patients, carers, clinicians, service providers and policymakers of all professions. There is also useful educational material available from this not-for-profit organisation.

Professional roles and boundaries
The complexity of the diabetic foot, its screening and treatment needs means there is often a blurring of doctor, nurse and podiatrist roles, whether they are specialists in secondary care centres or in a primary care setting. It would be fair to say that some skills are common to most practitioners in the diabetes field, so there is considerable overlap, whereas other skills are definitely within the scope of a particular profession.
Often the major driving forces behind delivery of a high-quality service are local professional interest and what the purchasers wish to pay for.
In some areas the initial screening of sensation and circulation is carried out by the practice nurse during the annual review, then the patient is referred to the podiatry department for further assessments and treatment requirements to be addressed. Further assessments may include some of the sensory testing described in this article if it is not performed in the annual review along with assessment of deformity, footwear, plantar pressures and biomechanics.
In other areas a podiatrist is part of the annual review team in the GP surgery; this allows a slightly different assessment to be done involving pressure analysis and biomechanical evaluation, which tend to be podiatry skills.
Some practice nurses have extended their skill base to cover all aspects of diabetic foot assessment but usually find they work quite closely with a podiatrist to deliver treatment needs.
Often it is the drive of an individual that awakens the latent interest in other professionals. It is useful to find out the extent of local services for onward referral, community services and secondary care services.
This takes some effort but is worthwhile in that it facilitates the formation of a robust network, ensuring that each professional can guide the patient's pathway through the various services. It also makes it easier to seek advice and guidance when more difficult cases are presented.
Ultimately, whichever model is adopted, it is important to ensure all aspects are dealt with but wasteful duplication is avoided.

Conclusion
There is still a great deal to be understood and discovered about diabetic foot problems, such as development of Charcot foot – a condition associated with neuropathy and most commonly seen in diabetes. It usually presents in the acute phase as a hot, red swollen joint, frequently in the foot, with no memorable cause and may look like a severe sprain or septic arthritis. The joint will in time deform and produce chronic pain or discomfort for the sufferer, often with associated ulceration at the load-bearing site of the deformity.
Early detection of neuropathic and/or vascular risk factors is vital in improving morbidity in the diabetic population.
While we cannot prevent all foot ulcerations, a simple quick foot assessment will allow early identification of those risk factors involved.
Time spent in the early stages providing assessment and education gives patients the opportunity to avoid serious foot complications that may otherwise have threatened life and limb.
Two pivotal studies into complications – the UKPDS (1998)(17) and the DCCT (1993)(18) – demonstrated the impact of well-controlled diabetes, hypertension and cholesterol in reducing the incidence of all complications of diabetes. Furthermore, assessment of these three areas and taking the necessary action forms part of the NICE guidelines for foot care in type 2 diabetes.(19)

Nutrition and Wounds

2008-03-07T13:50:00.003-08:00

Food for thought: nutrition and wound healing

Wound care

Victoria Richardson
BSc(Hons)
PGDipDiet
Registered Dietitian
Department of Nutrition and Dietetics
York Hospital

Many nutritional factors such as weight, body mass index and dietary intake are associated with poor wound healing and the development of pressure ulcers.(1) Despite the lack of good-quality studies, it is frequently documented that good nutrition facilitates healing, whereas malnutrition delays the healing process. However, no cause–effect relationship for poor nutritional status and the development of pressure ulcers has been established. Despite this, nutrition remains a factor in prevention strategies because it is a potentially reversible risk factor.(1,2) Nutritional recommendations have not been validated, but the following information will provide a review of some literature to guide clinical practice.(1)

Malnutrition
Although malnutrition is not a consistent risk factor in all studies, evidence does suggest a positive correlation between severe malnutrition and the risk of delayed wound healing and pressure ulcer development.(1,3,4,5)

Identifying potential causes of malnutrition can help determine an appropriate nutritional care plan. Common causes of malnutrition include:

Decreased appetite.
Dependency on help for eating.
Impaired cognition and/or communication.
Poor positioning, gastrointestinal losses.
Medications that decrease appetite.
Decreased thirst response.
Intentional fluid restriction because of fear of incontinence or choking if dysphagic.
Psychosocial factors such as isolation and depression.
Monotony of diet, and higher nutrient requirements with the demands of illness and disease.

Before we look at nutritional assessment, we need to look at the macro- and micronutrients that have key roles in the healing process.

Energy
Building and repairing tissue requires adequate amounts of calories and protein to fuel repair mechanisms.(6,7) Calorie requirements will vary greatly depending on several factors, such as the severity of the wound, stage of the healing process, comorbidities, age and body weight.(1)

For people who are not severely ill or injured, nor at risk of refeeding syndrome, the suggested nutritional prescription for total intake should provide 25–35 calories/kg/day total energy (including that derived from protein) and 0.8–1.5g protein/kg/day.(1,8) There is no known benefit of overfeeding on wound healing.(1)

Protein
Protein requirements increase to aid wound healing, as protein is required for part of the inflammatory process, the immune system and development of granulation tissue. Requirements increase if extensive nitrogen losses can occur from draining wounds or fistulae. However, they are difficult to quantify.(1) Similarly, protein depletion can affect the rate of wound healing by reducing collagen synthesis as well as the immune response.(1,2,7)

Studies show that a high protein intake does aid wound healing, especially in malnourished patients.(1,3,6) However, it is not known whether the same benefit would occur in well-nourished people.(6) It is worth noting that excess dietary protein intake may unduly tax renal and/or hepatic function. For these reasons, positive nitrogen balance remains the goal.(1)

Carbohydrate
Carbohydrate is the primary energy substrate required for cellular metabolism. As part of the inflammatory response process, the body increases cellular activity, fuelled by adenosine triphosphate (ATP), which is derived from glucose.(1) Glucose requirements for the chronically sick and healthy individuals range from 4–5g/kg/day.

If glucose from carbohydrate is unavailable, for example through inadequate dietary intake, amino acids from protein will be oxidised to meet the energy requirements of the wound healing process, thus depleting the amino acids available for reconstruction and tissue repair.(2)

Fat
Fat is an important energy source (providing 9 calories/ gram, compared with carbohydrate and protein, which provide 4 calories/gram) and a significant component of cell membrane structure and function, required for wound healing. Lipid requirements for the healthy to critically ill range from 0.8g–1.5g/kg/day. However, the proportion and quantity of fatty acids to aid healing is yet to be determined. (1) Particular fatty acids are "essential" – they cannot be made by the body and so must be provided by the diet. The two types are the omega-3 fatty acids (found in oily fish, sardines, salmon, trout, herring, walnuts and flaxseed oil) and the omega-6 fatty acids (sunflower, soya oils). The exact role of essential fatty acids (EFAs) in wound healing is unclear, and has not been adequately researched, but as they are involved in the synthesis of new cells, and help regulate the inflammatory response, it is believed depletion would delay wound healing.(1,5,9)

Animal studies have shown EFA deficiency reduces tensile strength and epithelisation of wounds. However, in humans, EFA deficiency is rarely encountered, unless the patient suffers from severe fat malabsorption.(1) Conversely, another study has found that high doses of omega-3 fatty acid supplementation may result in increased synthesis of prostaglandins.(1) This would impair the inflammatory response and result in a weaker wound. Due to conflicting evidence regarding benefits of EFAs, no recommendation on EFA supplementation can be made.

Fluid
Adequate fluid intake is required to maintain good skin turgor and blood flow to wounded tissues.(1) General guidelines for fluid requirements based on age range from 30–35ml/kg.(8) These guidelines are not specific for wound healing, and any additional fluid losses must be considered. Evaporation and fluid loss can be difficult to quantify, but fluid replacement may be necessary in those with fever, open or draining wounds or fistulae.(1) The concern regarding dehydration is that it can lead to an electrolyte imbalance and impaired cellular function.

To prevent dehydration, oral fluid intake needs to be strongly encouraged. Any fluid counts towards this nutritional requirement: water, milk and cordial. Foods such as ice cream, lollipops, ice cubes and jelly can contribute to fluid intake due to their high fluid content. Tea, coffee and some carbonated drinks contain caffeine, which is a mild diuretic and can cause some potential fluid loss. However, drinking caffeinated drinks is better than not drinking at all.(12)

Micronutrients
There have been a number of studies conducted on various vitamins and minerals regarding optimal nutrition for wound healing. The following micronutrients are selected as these seem to be a sample of the most frequently discussed nutrients involved in the healing process.

B complex vitamins
B complex vitamins, especially thiamine (also known as vitamin B1, found in pork, poultry, fish and beans) and pantothenic acid (vitamin B5, found in yeast and wholegrains) are co-factors in metabolic functions involved in wound healing. They are particularly involved in the energy release from carbohydrates, and collagen cross-linkage. Although there is insufficient evidence to place evidence-based recommendations on supplementation to aid wound healing, as human research is lacking, some alternative healthcare practitioners recommend a high-potency B vitamin supplement to promote wound healing.(4) There have been no toxic effects of pantothenic acid reported, but >3g/day of thiamine can have detrimental effects on heath.

Vitamin C
Vitamin C (also referred to as ascorbic acid, good dietary sources of which include citrus fruits and potatoes) has an important role in the formation of collagen, increasing its strength and stability. Many pieces of evidence suggest that vitamin C requirements increase during periods of severe injury, stress and sepsis, and deficiency delays healing. (1,4,5,6,7) However, no evidence exists to suggest that mega doses of vitamin C improve clinical outcomes as humans lack the ability to store vitamin C.(2,4)

Some studies indicate that there is a statistically significant reduction in the pressure ulcer area after supplementation, compared with a placebo group, and that supplementation may be indicated for optimal wound repair.(4) Conversely, larger studies indicate that control groups had better rates of healing when receiving a minimal supplement of ascorbic acid compared with the intervention group.(3) Further conflicting evidence occurs as to whether vitamin C supplementation in nondeficient people improves wound healing.(1,4,6,4) Therefore it is better practice to recommend sufficient intake to prevent deficiency.(7) Intakes exceeding 1g/day of vitamin C may cause cramps and diarrhoea, and caution must be used in patients with chronic renal failure.

Vitamin E
Vitamin E, found in eggs and vegetable oils, is the major lipid-soluble antioxidant in the skin(4) and is popular in alternative medicine for preventing scar formation. However, there is no clear role for vitamin E supplements in healing surgical wounds or pressure ulcers; indeed, research has shown its use may adversely affect healing by inhibiting collagen synthesis.(1,4,10)

Vitamin A
Vitamin A supplementation has been shown to improve wound healing and should be considered a supplement in steroid-dependent patients.(2,7) This may be due to the fact that vitamin A is a potent immune stimulant, which can reverse glucocorticoid suppression of wound healing.(1,4,7) It is, however, not as effective in reversing the effects of nonsteroidal anti-inflammatory drugs. Supplements have also been recommended in patients with sepsis. Concern about the potential toxicity of higher doses of vitamin A has led to uneasiness about its use in pregnant women and perioperatively,(4) and caution must be exercised, especially when the anti-inflammatory effects of steroids are essential. Dietary sources of vitamin A include dairy foods and liver.

Minerals
Zinc is required for wound healing as it is a co-factor in enzymatic reactions involved in protein synthesis and cell proliferation, has an inhibitory effect on bacterial growth and is involved in the immune response.(1,4,6,9) Low serum zinc levels have been associated with impaired wound healing.(4,7) Early studies suggest zinc supplementation, over and above that of the hospital diet, speeds wound healing. Rationale for supplementation may occur due to poor dietary intake, increased losses from large skin wounds (up to 20% of total body zinc is found in the skin)(1,7) or impaired absorption from gastrointestinal tract due to diarrhoea. Recent studies, however, have shown no benefit, unless the patient already has low serum zinc levels.(1,2,4) Caution regarding zinc supplementation is recommended because prolonged use of high zinc supplementation can adversely affect the immune response and lipid profiles and cause gastrointestinal upset. Small sample sizes in studies have indicated that zinc does not have significant effects on pressure ulcer healing.(3) Further research on nutritional supplementation is recommended to clarify the appropriate use of zinc supplementation.(4) Zinc is found in our diet from red meat, dairy foods and lentils..

Iron is a co-factor in DNA synthesis and is required for collagen cross-linkage, and therefore it is believed a lack of iron would impair cell proliferation and collagen synthesis involved in wound healing.(7,10) Absorption of haem iron (ie, iron from animal sources such as red meat and offal) is improved with the presence of vitamin C. Excessive intakes of iron (<1,800mmol) can be lethal. Again, however, due to insufficient evidence, routine iron supplementation is not therefore recommended for wound healing.(1)

Supplementation
The issue of nutritional supplementation to aid wound healing is debatable as sufficient intake of all nutrients is needed, and requirements may be raised during illness.(9) Solitary nutrient depletion is rare, and replacement should include a combination of appropriate nutrients, as it is doubtful that the patient will require specific vitamin mineral supplements.(4,8,10) There is some argument for vitamin C and zinc supplementation, but only when serum levels are low.(9) Again, there is a lack of evidence showing statistically significant difference when comparing the speed of wound healing with a multinutrient supplement or placebo group.(3)

The ideal way to meet requirements is to consume adequate oral intake of normal foods.(8) Patients may require a high-protein, high-calorie diet and latterly may need supplements (sip feeds). Treatment should take into account patients' needs and preferences when considering nutrition support.(8)

Nutrition support should be considered in people who are malnourished, as defined by the following;

A body mass index (BMI) of less than 18.5kg/m(2).
Unintentional weight loss greater than 10% within the last 3–6 months.
A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.(8)

Nutrition support should also be considered in those patients who are at risk of developing malnutrition, defined as those who have:

Eaten little or nothing for more than five days and/or are likely to eat little or nothing for five days or longer.
A poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.(8)

Due to increased nutritional requirements combined with a poor appetite, oral sip feeds may not be sufficient in meeting nutritional requirements, enteral feeding may be initiated in the form of nasogastric or gastrostomy/jejunostomy feeding. Enteral feeding overnight can be helpful in meeting nutritional requirements while encouraging oral intake during the day.

Immune-enhancing enteral formulas may have beneficial effects on wound healing by reducing the incidence of wound infection. However, to date, no study has focused specifically on the wound healing population, other than burns patients. However, no effect on mortality was observed.(1) Disappointing results from a study on enteral nutrition to nursing home patients did not consistently improve markers of nutritional status or prevent development of pressure ulcers, although tube- fed patients with pressure ulcers received more calories and protein than the control. The combined effects of disease, sepsis, immobility and severe neurologic deficits were considered
possible causes for this outcome.(1)

Nutritional assessment
It is important to include evidence of nutritional assessment and interventions (eg, dietetic referral) in individual care plans.(5) Nutritional screening should assess body mass index and percentage unintentional weight loss, and should also consider the length of time for which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake, shown as:
Body mass index = weight (kg)/height (m(2))
Percentage weight loss =
pre-illness weight − current weight/pre-illness weight × 100

The Malnutrition Universal Screening Tool (MUST), for example, may be used for this.(8) MUST is a validated tool to help provide a consistent and reliable nutritional screening method, and can be recommended for clinicians in practice to identify malnourished patients.

It is worth noting that serum albumin cannot be used as a sole indicator of malnutrition. Serum albumin can only indirectly identify patients who may benefit most from nutritional assessment and early intervention. This is because many factors during critical illness will alter serum albumin more readily than nutritional status. Blood loss, the acute-phase response and perioperative fluid resuscitation will contribute to postoperative reduced albumin levels. During this response, albumin will reduce, regardless of nutrition support, as it will not return to normal until the inflammatory response has resolved.(1,8)

Conclusion
Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection. Malnutrition and clinically evident deficiencies are commonly associated with a delayed healing response. Nutritional intake should be varied and balanced to provide all the essential nutrients.(7) There is little evidence that supplementing a patient's diet with specific nutrients in isolation improves clinical outcome. While major wounds significantly raise protein and calorie requirements, optimal healing may require dietary changes, such as food fortification and/or supplements always encouraging food first, from a varied and balanced diet.

Lack of sufficient good-quality evidence limits the ability to determine the optimal nutritional regimen to enhance wound healing.(1) Further research is needed to identify the levels of supplement that will benefit malnourished patients.(2,10) Many studies have too small sample sizes, and high dropout rates, indicating that results should be reviewed with caution.(3) Most treatment studies have short trial periods, and healing of pressure ulcers or wounds is therefore unlikely to be detected.(3)

The lack of an accurate indicator of nutritional status may be one reason for inconsistent association between malnutrition and the risk of developing pressure ulcers, and delaying wound healing. Also, the criterion for defining malnutrition varies greatly between studies.(1) This at least supports the consistent use of a validated screening tool, such as MUST, to provide a consistent method of nutritional screening.

Honey Dressing for Wounds

2008-03-07T13:46:00.000-08:00

Honey dressings "do not significantly improve healing"

Wednesday 9th January 2008

Treating leg ulcers with honey-impregnated dressings does not seem to speed up the healing process in comparison with usual care, a study shows.

Venous leg ulcers have been treated with compression bandages for years but recently there has been renewed interest in honey as a potential healing agent.

However a trial run of 368 patients found that those treated with honey dressings experienced significantly more adverse events than those treated with conventional dressings.

The rate of healing in both conventional and honey dressing groups was also similar.

Lead author Andrew Jull said: "In our trial the honey dressing did not significantly improve healing, time to healing, change in ulcer area, incidence of infection or quality of life.

"The current focus of venous ulcer management should remain on compression and other treatments that have demonstrated that they improve compression's ability to work or prevent ulcer recurrence."

Tissue viability nurse Una Adderley told nursinginpractice.com: "Although honey is known to have an antimicrobial effect, the results of this well–designed trial from this respected New Zealand Research team suggest that there are no clinical benefits and increased clinical risks and costs associated with the topical use of honey.

"Patients often perceive 'alternative' or 'natural' products as superior but forget that all treatments should be judged on effectiveness, safety and cost.

"Unfortunately, just because a product is natural does not mean it is less likely to have less unwanted side effects. This trial confirms compression as the current mainstay treatment for venous leg ulceration."

British Journal of Surgery

Protect Your Feet

2008-03-07T13:42:00.000-08:00

Nurses urged to protect their feet

Nearly two thirds of nurses find it hard to concentrate because of their painful feet, reveals a new survey.

This June, the Society of Chiropodists and Podiatrists is launching their "Working Feet" campaign as part of "Feet for Life Month".

The campaign hopes to raise awareness about the dangers of working feet too hard and offers helpful foot care advice.

The society says that 93% of nurses commonly experience problems with their feet, knees or back due to long shifts.

Standing all day can subject feet to high pressure causing blisters, corns, calluses and damaged joints.

Of the nurses surveyed, 93% said they also suffer from hot, swollen and painful feet after their shift.

Despite these complaints, only 16% of nurses said they had visited a chiropodist or podiatrist in the last year.

Nita Parmar from the Society of Chiropodists and Podiatrists says: "Protect your feet at work. Feet can spend hours in the same shoes and if your feet hurt it can affect your concentration, efficiency and attitude to work.

"Ignoring painful feet could also lead to problems in the longterm."

Feet for life