Poor People With #Diabetes Much More Likely to be amputated: Study

(HealthDay News) -- Poor people with diabetes are much more likely to lose a limb to the disease than affluent patients are, new research suggests. Researchers from the University of California, Los Angeles, found the odds of having a toe, foot or leg amputated was up to 10 times higher for diabetics who live in low-income neighborhoods. Most of these amputations are preventable if patients are diagnosed and get proper medical care sooner, the study authors noted. They added that their findings should prompt public officials to implement laws that help reduce barriers to health care. "When you have diabetes, where you live directly relates to whether you'll lose a limb to the disease. Millions of Californians have undergone preventable amputations due to poorly managed diabetes," lead author Dr. Carl Stevens, a clinical professor of medicine at the David Geffen School of Medicine at UCLA, said in a university news release. "We hope our findings spur policymakers nationwide to improve access to treatment by expanding Medicaid and other programs targeting low-income residents, as we did in California in 2014," Stevens added. Uncontrolled diabetes can weaken the immune system and cause neuropathy -- nerve death or damage. As a result, a small cut could go undetected and quickly progress to a life-threatening infection. The early diagnosis of diabetes, proper management of the disease and expert wound care can help prevent complications that could lead to amputation. "I've stood at the bedsides of diabetic patients and listened to the surgical residents say, 'We have to cut your foot off to save your life.' These patients are often the family breadwinners and parents of young children -- people with many productive years ahead of them," noted Stevens, who has worked as an emergency physician for 30 years at Harbor-UCLA Medical Center. In conducting the study, the researchers analyzed U.S. Census Bureau data on household incomes and state hospital discharge data that tracked amputations due to diabetes by California ZIP code. This information was cross-referenced with information from a UCLA survey, which estimated the number of people who had diabetes in various low-income areas in California to create a map that revealed diabetes-related amputation rates by neighborhood for patients aged 45 and older. In 2009 alone, California doctors amputated nearly 8,000 legs, feet and toes from 6,800 people with diabetes, the study published in the August issue of Health Affairs showed. About 1,000 of these patients had more than one amputation. Every day, on average, 20 diabetic patients underwent an amputation in the state. "Amputation rates in California were 10 times higher in the poorest neighborhoods, like Compton and East Los Angeles, than in the richest neighborhoods, such as Malibu and Beverly Hills," study co-author Dylan Roby, director of health economics at the UCLA Center for Health Policy Research, said in a university news release. Race also played a role in the findings. Less than 6 percent of diabetics in California are black. Still, black people accounted for nearly 13 percent of those who had one or more amputations in 2009. Meanwhile, Asians made up 12 percent of the diabetic population, but had less than 5 percent of amputations linked to diabetes that year. In most cases, the investigators found, diabetic patients who needed a limb surgically removed were most likely to be black or non-English speaking men who were over the age of 65. The study authors said they plan to continue their research by identifying the most important factors contributing to amputations, and developing strategies to address these risk factors for low-income patients.

Inflammatory markers at start and end of acute Charcot Arthropathy: Use TNF alpha and IL6?

Compelling work from our friends Nina Petrova, Mike Edmonds, et al at King's College, London. Inflammatory and bone turnover markers in a cross-sectional and prospective study of acute Charcot osteoarthropathy N. L. Petrova1,*, T. K. Dew2, R. L. Musto2, R. A. Sherwood2, M. Bates1, C. F. Moniz2 andM. E. Edmonds1 Aims To assess markers of inflammation and bone turnover at presentation and at resolution of Charcot osteoarthropathy. Methods We measured serum inflammatory and bone turnover markers in a cross-sectional study of 35 people with Charcot osteoarthropathy, together with 34 people with diabetes and 12 people without diabetes. In addition, a prospective study of the subjects with Charcot osteoarthropathy was conducted until clinical resolution. Results At presentation, high-sensitivity C-reactive protein (P=0.007), tumour necrosis factor-α (P=0.010) and interleukin-6 (P=0.002), but not interleukin-1β, (P=0.254) were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. Serum C-terminal telopeptide (P=0.004), bone alkaline phosphatase (P=0.006) and osteoprotegerin (P

Grand Rounds: Segment # 2 Participant Questions

Please review the questions below and answer in the comment section.

Q1. What CPGs are you considering at this point in the case?
Q2. What is your interpretation of the AP and Lateral X-Rays on Slide?
Q3. What laboratory, other radiographic and special studies would you order at this point in the case?
Q4. What consultants would you order?
Q5. What is your initial differential diagnosis?
Q6. Does this patient need hospital admission?
Q7. Is this patient a candidate for HBO?

Grand Rounds: Patient Arteriograms

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Grand Rounds: History Of Present Illness, Segment #2

History of Present Illness

Physical Examination:
1. Partial thickness necrosis and infection of R Achilles tendon
2. No palpable DP, PT pulses B/L
3. No signs of fascial or osseous tracking of infection
4. Passive ROM of ankle was painful during examination. Unable to bear weight on R foot

Progressive Plan of Care

These are the first four of the Essentials as they appear in the flow sheet in CPG W01.01

1. Adequate perfusion and/or oxygenation
2. Removal of all non-viable tissue present
3. Infection and/or inflammation controlled
4. Edema controlled, venous reflux treated

These are the last five of the Essentials as they appear in the flow sheet in CPG W01.01
5. Wound microenvironment optimized to support healing
6. Tissue growth optimized
7. Offloading and/or pressure relief appropriate
8. Pain controlled
9. Host factors optimized 

When the NHC Wound Healing Clinical Assessment Pathway is reviewed with reference to the Nine Essentials, the concordance is obvious.

W05.01 Essential 1: Essential Step 1A/B Perfusion and Oxygenation.

The design of each Clinical Practice Guideline addressing the Nine Essentials includes the appropriate section of the decision tree or flow sheet, Critical Principles, and a detailed section describing appropriate steps in Assessment and appropriate steps in Treatment, decision trees or flow sheets, and other important supplemental information and references are then provided.

In the HealSource™ document, for the sake of brevity and greater utility of this condensed pocket version, only the decision tree or flow sheet segment, Critical Principles, and additional decision tree are included as in this example.

Note the Critical Principles with the guiding principle being that (1) all patients with a lower extremity wound need additional arterial vascular assessment beyond a vascular history, pulse examination, and ABI because of the importance of malperfusion and hypoxia in this subset of the population at large, and (2) all patients suspected of having a VLU should receive a properly performed venous duplex ultrasound.