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Reducing Risks of Foot Complications in Diabetes

Reducing Risks of Foot Complications in Diabetes

Foot complications such as amputation and foot ulceration are common consequences of diabetic neuropathy and peripheral arterial disease (PAD). These complications have been identified as major causes of morbidity and disability in people with diabetes. “Early recognition and management of risk factors for foot complications is critical,” says Paul J. Kim, DPM, MS. “Efforts to identify and treat these complications early in the disease course can prevent or delay adverse outcomes.” The American Diabetes Association notes that the risk of foot ulcers or amputations is increased in people who have various risk factors. “Neuropathy, peripheral vascular disease, and foot deformities are the most important risk factors for foot complications,” says Dr. Kim. “Poor blood glucose control is the trigger for the cascade for these complications.” Helpful Exams A range of tests might be useful when identifying patients at risk for foot ulceration, but this has created some confusion among practitioners as to which screening tests should be adopted in clinical practice. To clear this confusion, the American Diabetes Association has issued several recommendations on what should be included in comprehensive foot exams for adults with diabetes in its annual Standards of Medical Care in Diabetes (Table 1). All adults with diabetes are recommended to undergo a comprehensive foot examination to identify high-risk conditions at least once a year. During these exams, clinicians should ask patients about their history of previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, tobacco use, and foot care practices. A general inspection of skin integrity and musculoskeletal deformities should also be performed. Neurologic exams are designed to identify loss of protective...
Guidelines for Diagnosing & Treating Diabetic Foot Infections

Guidelines for Diagnosing & Treating Diabetic Foot Infections

As the incidence of diabetes has steadily increased over the last several decades throughout the United States, diabetic foot infections have also become increasingly common. As many as one in four people with diabetes will have a foot ulcer in their lifetime, and these wounds can easily become infected. If left unchecked, they can spread and may ultimately require amputation of the toe, foot, or part of the leg. Nearly 80% of all nontraumatic amputations occur in people with diabetes, 85% of which begin with a foot ulcer. “Lower extremity amputation severely affects quality of life in people with diabetes because it reduces independence and mobility,” says Warren S. Joseph, DPM, FIDSA. “Furthermore, about 50% of patients who have foot amputations die within 5 years, which ranks as a worse mortality rate than for most cancers.” However, about half of lower extremity amputations that are not caused by trauma can be prevented through proper care of foot infections. Preventing amputations is vital. In most cases, these infections can be prevented or cured when properly managed. Recommendations for Diabetic Foot Infections In a 2012 issue of Clinical Infectious Diseases, the Infectious Diseases Society of America (IDSA) published a clinical practice guideline for diagnosing and treating diabetic foot infections. The guideline addresses 10 common questions with evidencebased answers that experts have determined are most likely to help healthcare providers treating these infections. The guideline is a revision and update of IDSA’s 2004 recommendations for managing diabetic foot infections. With regard to diagnosis, the guideline recommends that infections in foot wounds be defined clinically by the presence of inflammation or purulence, and...

Women & Peripheral Arterial Disease: A Call to Action

About 8 million people in the United States have peripheral artery disease (PAD), a condition that, if left untreated, increases heart attack and stroke risks, severely limits walking ability, and causes tissue death requiring limb amputation. The prevalence of PAD is nearly equal between men and women (Figure). Only about 10% of individuals with PAD experience classic, recognized exertional claudication, and many people experience no symptoms at all. As a result, few individuals with PAD receive prompt diagnosis or treatment. “The mortality rate and healthcare costs associated with PAD are comparable to those of heart disease and stroke,” says Alan T. Hirsch, MD. “Women, in particular, suffer an immense burden from PAD, but current data suggest that most women remain unaware of their risk. PAD continues to go largely unrecognized and untreated in women.” An Important Scientific Statement on PAD In the March 20, 2012 issue of Circulation, the American Heart Association (AHA), in collaboration with the Vascular Disease Foundation and the P.A.D. Coalition, released a scientific statement on women and PAD. It recommends that healthcare providers proactively increase awareness of and test women at risk for PAD. It also calls for more women-focused research into the disease. “There is a great need to identify women with PAD and those who are at risk for it, especially African-American women, so that we can help lower cardiovascular ischemic event rates,” says Dr. Hirsch, who was the chair of AHA writing group that developed the call-to-action statement. “This may also reduce the loss of independent functional capacity and ischemic amputation rates.” He notes that women in the United States already attend...
2012 Guidelines for Diabetic Foot Infection

2012 Guidelines for Diabetic Foot Infection

New guidelines released by the Infectious Diseases Society of America (IDSA) and publishing in the June issue of Clinical Infectious Diseases emphasize that proper treatment of diabetic foot infections not only saves limbs – but can save lives. Diabetic foot infections are becoming more common, and about 50% of patients who have a foot amputation die within 5 years. According to the new IDSA guidelines, about half of lower extremity amputations that aren’t caused by trauma can be prevented through proper care of foot infections. The new guidelines include 10 common questions with extensive, evidence-based answers, which the panel that wrote the guidelines determined were most likely to help a healthcare provider treating a patient with diabetes who has a foot wound. Key points from the guidelines include: Evidence of infection generally includes at least two of the following signs: redness, warmth, tenderness, pain, or swelling.  The guidelines note that half of ulcers are not infected and don’t require antibiotics. Rapid and appropriate therapy for treating infected wounds on the feet, typically including debridement, antibiotic therapy, and/or removing pressure on the wound and improving blood flow to the area. When a foot sore infection is detected, imaging the foot is usually necessary to determine if the bone is infected. A culture of infected wounds should be performed to determine the bacteria causing the infection and to help guide antibiotic treatment. Antibiotic therapy is often insufficient in the absence of proper wound care and surgical interventions. Use of a multidisciplinary team to assess and address various aspects of the problem is recommended. Over-prescribing and inappropriate prescribing of antibiotics is common...

Preventing Diabetes Complications to Improve Outcomes

More than 84 million people in America have diabetes or are on the verge of getting it, and 90% of these people have type 2 diabetes. Between 2002 and 2007, the cost of diabetes-related complications to the United States healthcare system more than doubled from $24.6 billion to $58 billion. In many cases, type 2 diabetes can be managed or avoided with lifestyle changes like weight loss and exercise. Unfortunately, many people with type 2 diabetes struggle to find the motivation needed to make these changes. As a result, they are experiencing life-altering complications such as heart attack, stroke, blindness, limb amputation, and kidney failure at alarming rates. New Survey Data A survey commissioned by Boehringer Ingelheim Pharmaceuticals and conducted by Sermo recently convened a multidisciplinary steering committee to assess attitudes about diabetes-related complications. It showed that complications are prevalent in type 2 diabetes. More than 40% of physicians surveyed said that over half of their patients develop at least one complication as a result of uncontrolled type 2 diabetes. Nearly all physicians surveyed (94%) believed that kidney health is an important consideration in understanding the risk of other complications, but 40% did not believe the majority of their newly diagnosed patients even know that type 2 diabetes can lead to kidney disease. “To reduce the disease burden, complications related to type 2 diabetes must be decreased.” Physicians participating in the survey reported that lack of motivation, lack of medication adherence, and an inability to lose weight were the most common reasons for ineffective control of their patients’ type 2 diabetes. Compliance with lifestyle modifications and medications and poor...
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