Differences in outcomes across race, ethnicity and income exist for virtually every chronic health condition that Americans experience. Without exception, minority and poor white Americans die younger and suffer more preventable diseases.
November is diabetes awareness month. Few diseases impact every system of the body in the way that diabetes increases the risk for stroke, heart attack and kidney failure.
Of these devastating conditions, loss of limb, or amputation, is one of the most-dreaded complications of diabetes … read more
Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation … read more
Leafer Miller didn’t hear much after the doctor told him they had to “sacrifice the leg.”
Lying on the emergency room gurney, the self-proclaimed video game nerd and former athlete struggled to comprehend life without the leg that had propelled him on the track and to the turf for tackles on the soccer field.
“It was always in the back of my mind as a worst-case scenario,” the 35-year-old Fresno, CA, native says. “But I wasn’t expecting that to be the case.”
The amputation was the result of a recurring American narrative: A diabetes diagnosis in his early 20s; a sequence of layoffs and hirings that left his insurance status in flux; missed primary care visits when providers went out of network; and skipped insulin doses due to unaffordable price tags.
“Sometimes, it would come down to insulin or rent,” Miller says, “I felt like my hands were tied.” … read more
Our institution’s multidisciplinary Prevention of Amputation in Veterans Everywhere (PAVE) program allocates veterans with critical limb threatening ischemia (CLTI) to immediate revascularization, conservative, primary amputation or palliative limb care based on previously published criteria. These four groups align with the approaches outlined by the Global Guidelines for management of CLTI. The current study delineates the natural history of the palliative limb care group of patients and quantifies procedural risks and outcomes … read more
Too few patients underwent angiography or interventions, and suboptimal care was linked with more deaths and readmissions.
Alook back at the care patients with critical limb ischemia (CLI) received in the year prior to amputation suggests that most received minimal vascular care, with 69% not undergoing a revascularization attempt that might have saved the limb or improved overall survival.
Earlier this year, the American Heart Association noted in a policy statement that after a period of decline in the 1990s and early 2000s, major and minor amputations have been on the rise. National surveys, too, reflect a dramatic undertreatment problem in the outpatient setting among patients with PAD … read more
Accessibility of Wound Data in Canada
While even healing wounds require significant health-care resources, ultimately the majority of the resources used are for wounds that are non-healing.1,2 Non-healing wounds, which originate from different etiologies such as arterial and venous insufficiency, pressure and diabetic foot complications, are a serious public health problem that have devastating consequences for patients and result in high costs to health-care systems … read more (PDF)
Proposed Medicare cuts create greater barriers to screening and revascularization services
Few medical procedures are as life-altering as an amputation. But statistics show hundreds of thousands of Americans have their limbs surgically removed each year because they don’t have access to adequate vascular screening and care.
In the rural communities of North Carolina that we serve, the nearest “in-hospital” alternative to our office-based treatment locations is at least 2 to 3 hours away, which can result in delays in care that lead to poor clinical outcomes. The patients we serve are living with vascular diseases such as peripheral artery disease (PAD) and critical limb ischemia (CLI) … read more
Faced with the challenges of non-healing diabetic ulcerations, a patient’s realization of progressively declining health, the burden of expansive health costs and the unrelenting frequency of doctor appointments, can cumulatively lead to a heavy emotional toll and state of despair. In dealing with high-risk patients, how we navigate the nuances of these aforementioned complexities may define our role in the lives we impact. While mental health consequences of chronic disease are well-documented, I feel there is no louder or stronger a case than the fragile cohort of those plagued with diabetes at the critical point where discussion about amputation becomes essential … read more
By Holly Hovan, MSN, GERO-BC, APRN, CWOCN-AP
Peripheral artery disease (PAD) is also known as lower extremity arterial disease (LEAD), peripheral arterial occlusive disease (PAOD), or arteriosclerosis obliterans.1 LEAD is a disease that impacts the circulatory system, specifically the arteries (narrowing, which can result in a decreased supply of blood flow to the limb), and can eventually lead to limb loss or amputations. It is important to bring awareness to LEAD and its diagnosis, treatment, and prevention to improve access to care and screenings and ultimately to prevent limb loss … read more
Results of a Swedish retrospective cohort study showed reduced rates of type 1 diabetes-related amputations over the past 2 decades.
In recent years, Sweden has seen a sharp decline in incidence of lower-level extremity amputations among individuals with type 1 diabetes (T1D), according to results of an observational cohort study. Findings were published in Diabetologia.
Because diabetes-related foot ulcers are common and healing is often delayed, limb loss through amputation “is not an infrequent final outcome,” the authors explained.
In addition, “about half of all nontraumatic amputations in the western world are attributable to diabetes … read more
Amputation in type 1 diabetes is becoming relatively less common in Sweden. The rate has fallen by just over 40 percent over an approximately 20-year period, a University of Gothenburg study shows.
The results, published in the journal Diabetologia, are based on registry data on 46,088 people with type 1 diabetes in the years 1998–2019. The study involved linking data from the Swedish National Diabetes Register, the National Patient Register, and a couple of other Swedish national registers … read more
Healogics, the nation’s leading provider of world-class wound care services, is raising awareness of Peripheral Artery Disease (PAD) throughout September. Through this campaign, Healogics is supporting the American Heart Association’s goal to reduce amputations by 20% by 2030 through increased PAD Awareness, diagnosis and treatment … People with PAD often have non-healing wounds in their extremities due to the restriction of blood flow limiting the natural healing process, potentially leading to complications, such as amputation. PAD affects nearly 10 million Americans and is a contributing factor in up to 30% of non-healing wounds on the lower leg. Common symptoms associated with PAD include cramping, numbness, weakness or heaviness in the leg muscles, however up to 40% of people experience no symptoms. One in four people living with late-stage PAD may require amputation within one year … read more
Adults with type 2 diabetes and established CVD prescribed SGLT2 inhibitor therapy have a twofold increased risk for lower-limb amputation and diabetic ketoacidosis compared with patients prescribed a GLP-1 receptor agonist, according to study findings presented at the European Society of Cardiology Congress.
“Sodium glucose cotransporter 2 inhibitors are playing an increasingly prominent role in the treatment of diabetes, following the reduced risk of major adverse cardiovascular events and heart failure outcomes seen in the EMPA-REG Outcome trial with empagliflozin [Jardiance, Boehringer Ingelheim] and in the CANVAS study with canagliflozin [Invokana, Janssen],” Peter Ueda, MD, PhD, from the department of medicine at the Karolinska Institute in Solna, Sweden, said during a presentation here. “Concerns exist regarding the safety of the drugs, with signals of serious adverse events emerging from clinical trials, case reports and observational studies.” … read more
patients with diabetic foot ulcer in a tertiary health facility in north central Nigeria
INTRODUCTION: Diabetic foot ulcer is a complication of diabetes mellitus of great public health importance. It has the potential of leading to the dreaded sequelae of lower extremity amputation. This outcome is associated with significant morbidity and mortality, hence the need to explore its predictors among persons with diabetic foot ulcers.
METHODOLOGY: The study involved the review of the medical records of seventy (70) in-patients who had received treatment for diabetic foot ulcer at the Federal Medical Centre, Keffi, North Central Nigeria. In addition to obtaining sociodemographic and medical history, information on the Wagner grade of the ulcer, the presence of peripheral sensory neuropathy (using the 10g monofilament) and the presence of osteomyelitis (using plain X-ray of the foot) were obtained and documented. The prevalence rate of lower extremity amputation was also determined.
RESULTS: The study population comprised 52.9% males and 42.1% females. The mean age for male and female participants were 53.4±10.5 and 58.8±13.0 years respectively ( t = 2.35; p = 0.061). Majority of study subjects (37.1%) had Wagner grade 2 disease. Prevalence rate of amputation was 38.6%. Among the potential predictors of lower extremity amputation analyzed (Age, sex, foot care education, duration of diabetes, cigarette smoking, walking bare feet, impaired vision, peripheral neuropathy, hypertension, previous foot ulcer, osteomyelitis), none of them demonstrated a significant association with lower extremity amputation.
CONCLUSION: The list of potential predictors of lower extremity amputation considered in this study is by no means exhaustive. More studies involving larger study populations and other potential predictors of lower extremity amputation not considered in this work (such as peripheral artery disease and glycated haemoglobin) are encouraged.
wound healing in the tail and scarred wound healing in the limb of lizard Hemidactylus flaviviridis
Lizards are unique in having both – regeneration competent (tail) as well as non‐regenerating appendages (limbs) in adults. They therefore present an appropriate model for comparing processes underlying regenerative repair and non‐regenerative healing after amputation. In the current study, we use northern house gecko Hemidactylus flaviviridis to compare major cellular and molecular events following amputation of the limb and of the tail. Although the early response to injury in both cases comprises apoptosis, proliferation and angiogenesis, the temporal distribution of these processes in each remained obscure. In this regard, observations were made on the anatomy and gene expression levels of key regulators of these processes during the healing phase of the tail and limb separately. It was revealed that cell proliferation markers like FGFs were upregulated early in the healing tail, coinciding with the growing epithelium. The amputated limb, in contrast, showed weak expression of proliferation markers, limited only to fibroblasts in the later stage of healing. Additionally, apoptotic activity in the tail was limited to the very early phase of healing, as opposed to that in the limb, wherein … read more
Prosthetic limb technology has advanced by leaps and bounds, giving amputees a range of bionic options, including artificial knees controlled by microchips, sensor-laden feet driven by artificial intelligence, and robotic hands that a user can manipulate with her mind. But such high-tech designs can cost tens of thousands of dollars, making them unattainable for many amputees, particularly in developing countries.
Now MIT engineers have developed a simple, low-cost, passive prosthetic foot that they can tailor to an individual. Given a user’s body weight and size, the researchers can tune the shape and stiffness of the prosthetic foot, such that the user’s walk is similar to an able-bodied gait. They estimate that the foot, if manufactured on a wide scale, could cost an order of magnitude less than existing products … read more
David G. Armstrong, professor of surgery at the Keck School of Medicine of USC
Humanity crossed a line in 2009: For the first time in history, more people in the last decade died from non-communicable disease than from all the plagues in the world combined. We’ve entered what science pundit Steve Jones has, in a rather macabre but perceptive manner, dubbed the Age of Decay.
First was the Age of Disaster — 95 percent of human history — when people died from starvation, accidents, violence and cold temperatures. Around 12,000 years ago, we learned to “circle the wagons,” if you will, as a species. As we became agrarian, we moved closer together to store food. A natural byproduct of this was the Age of Disease, when plagues decimated populations. We’re now in the Age of Decay, when the big killers are non-communicable diseases — cancer, cardiovascular disease and diabetes. Pulmonary disease is fourth.
The longer that I have labored in my line of work, the more I realize it is the height of hubris as a clinician to think that I can “fix” anyone. Rather, I think the best thing I can do is help folks move through the world a little bit better. Our goal in this age as clinicians, scientists, policymakers, is to think not about fixing everything but rather to delay decay.
We all rightly take cancer and heart attacks seriously. Diabetes, however, has not risen to that level. If one were an evil deity and wanted to sock it to humanity, one wouldn’t pick something like cancer or a heart attack. Those are often far too dramatic. One would rather choose diabetes: It is silent, sinister and it happens in the background. No one sees it coming. How, then, does diabetes cause amputations?
Please choose one
Easy choice right? Not for the Government of Ontario Canada. The vast majority of the 2,000 amputations that occur per year in that country would be preventable with common offloading practices (total contact casting*). Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario was assured three years ago by government ‘premieres’ that they would begin to cover such procedures … that’s three years or 6,000 legs or $420,000,000 ago. “We’re willing to pay for the amputations but we’re not willing to pay for the prevention,” offered Grinspun.
Cost and human suffering aside, mortality rates jump significantly after an amputation especially in older patients, diabetes further increases mortality rates. In one rather grim study** 390 patients that had undergone lower extremity amputations were reviewed, of the patients with diabetes “the median time to death was 27.2 months“.
So if you are suffering from diabetic neuropathy and experience a diabetic foot ulcer and happen to be living in Ontario Canada you need to get your affairs in order. But there is hope as The Ontario Health Technology Advisory Committee is currently assessing total contact casting to treat foot ulcers, check back in three years.
*total contact casting is considered “The Gold Standard of off-loading”. A comparison of the three major off-loading methods (total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes) reinforces this point. The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities.
**Mortality and Hospitalization in Patients After Amputation
Off-Loading the Diabetic Foot Wound
A randomized clinical trial