Posts for: November, 2013

Over 4,00,000 Pakistanis suffer from foot ulcers

Tuesday, October 08, 2013 - Karachi—Foot complications are among the most serious and costly complications of diabetes and in Pakistan about 10% of the diabetics suffer from foot problems, many of which lead to leg amputation, stated Prof Abdul Basit, Chairman Pakistan Working Group on Diabetic Food.

In an interview Dr Abdul Basit disclosed that currently there are over 400,000 people with foot ulcers in the country.

He described Diabetic foot a source of huge economic burden as the direct cost of treating a diabetic foot ulcer comes to Rs 3500- 61000, which is more than 10 times the average health expenditure of a Pakistani and added that to treat all the people with foot ulcers an amount double the total health budget of Pakistan, is needed.

He said unawareness, shortage of trained health care professionals and scarcity of foot care facilities are major causes of diabetes related leg amputations, 45-89% of which are preventable through timely and efficient foot care. “We have been conducting nation wide training programs and have established 115 diabetic foot clinics However further 1700 such clinics are required”.

He pointed out that Pakistan Working on Diabetic Foot (PWGDF) in collaboration withBaqai Institute of Diabetology andEndocrinology organized a symposium on diabetic as part of efforts to create greater awareness against this serious problem..

Dr Zahid Miyan, Chairman of Organizing Committee emphasized the need to discuss the current practices in Diabetic Foot management, to provide hands-on skills. He pointed out that the symposium organized in this regard at the end of last month, encompassed a wide horizon of diabetic foot problem, including prevention and early diagnosis, clinical & surgical management and recent advances in targeted therapies for diabetic foot.

He said over 200 health care professionals from across the country including subject specialists and eminent experts shared their diversified experience in this area.

Dr Zafar Iqbal Abbasi, Symposium secretary stated that the event proved a great leaning opportunity for doctors, family physicians and health care professionals.—APP

Diabetes affects 26 million people in the US and more than 366 million people worldwide. Diabetes Association

The top 10 diabetes nations 
International Diabetes Federation /
Diabetes kills more people annually than breast cancer and AIDS combined.
American Diabetes Association, 2009

80% of people with diabetes are from low and middle income nations
International Diabetes Federation, 2012

The number of people with diabetes is increasing in every single nation
International Diabetes Federation/World Health Org 2012

Half of people with diabetes don't know they have it.
American Diabetes Association / International Diabetes Federation, 2012

Quiet. Slow. Deadly. Expensive: Chronic Diseases Account for 75% of our Healthcare Costs.



Seconds Count: Every 7 seconds someone dies from diabetes. Every 20 seconds someone is amputated. 

International Diabetes Federation /
By 2030, at least 550 million people will have diabetes- approximately 10% of the world's adult population.
International Diabetes Federation (IWGDF), 2011

There are now approximately 79M people with pre-diabetes in the USA
That is the equivalent of the total population of 30 states. 
American Diabetes Association, 2012
2010 United States Census

The population of diabetes in the USA is greater than the population of the nation's 10 largest cities.
American Diabetes Association, 2012
2010 United States Census

The population of Diabetes in Arizona (home of SALSA) would make it the fourth largest city in the state.
American Diabetes Association, 2012
2010 United States Census


60-70% of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet.
Dyck et al.  Diabetic Neuropathy 1999
More than 90% of people with diabetic peripheral neuropathy are unaware they have it.
Up to 25% of those with diabetes will develop a foot ulcer.
Singh, Armstrong, Lipsky.  J Amer Med Assoc 2005

The yearly incidence of diabetic foot ulcers ranges from 2% to 32%, depending on ADA risk classification
Boulton, Armstrong, et al, Diabetes Care 2008
Lavery , et al, Diabetes Care  2008
Sibbald, et al, Adv Skin Wound Care, 2012

More than half of all foot ulcers (wounds) will become infected, requiring hospitalization and 20% of infections result in amputation.
Lavery, Armstrong, et al.  Diabetes Care 2006
Diabetes contributes to approximately 80% of the 120,000 nontraumatic amputations performed yearly in the United States.
Armstrong et al. Amer Fam Phys 1998
"Every 20 seconds, somewhere in the world, a limb is lost as a consequence of diabetes"
DFCon11, Bakker (after Boulton),
Boulton, The Lancet (cover), Nov. 2005
After a major amputation, 50% of people will have their other limb amputated within 2 years.
Goldner. Diabetes 1960
Armstrong, et al, J Amer Podiatr Med Assn, 1997
More than half of people with  osteomyelitis of the heel will undergo high level amputation
Faglia, et al, Foot Ankle Int, 2013
The relative 5-year mortality rate after limb amputation is 68%. When compared with cancer – it is second only to lung cancer (86%).  (Colorectal cancer 39%, Breast cancer 23%, Hodgkin's disease 18%, Prostate cancer 8%)
Armstrong, et al, International Wound Journal, 2007
Amer Cancer Society; Facts & Figures 2000
Singh, Armstrong, Lipsky et al. J Amer Med Assoc 2005
Icks, et al, Diabetes Care, 2011

Median time to healing for diabetic foot wounds: 147,188, and 237 days for toe, midfoot and heel ulcers.
Pickwell, et al, Diabetes Metab Res Rev, 2013 

People with a history of a diabetic foot ulcer have a 40% greater 10 year mortality than people with diabetes alone.
Iversen, et al, Diabetes Care, 2009
Every 30 minutes a limb is lost due to a landmine.
Every 30 seconds, a limb is lost due to diabetes.
Bharara, Mills, Suresh, Armstrong, Int Wound J, 2009
  1. Having a wound immediately doubles one's chances of dying at 10 years compared with someone without diabetes.
  2. Iversen, et al, Diabetes Care2009
    One third of patients seeking care for ischemic wounds die unhealed
    Elgzyri, et al, Eur J Vasc Endovasc Surg, 2013

    For people on dialysis receiving an amputation, 2 year mortality is 74%
    Ndip, et al, 2012, Diabetes

    Diabetic foot ulcers double mortality and heart attack risk while increasing risk for stroke by 40%
    Brownrigg, et al, Diabetologia, 2012

    Chronic wounds affect some 8 million Americans each year. That's one wound every 3.8 seconds in the USA, alone.
    Harsha , 2008 and Tomic-Canic 2010
    Each $1 invested in care by a podiatrist for people with diabetes results in $27 to $51 of healthcare savings.

    JAPMA, 101(2), 2011

    Podiatry care not only reduces amputation risk, but also dramatically impacts rate of hospitalization and reulceration
    Gibson, et al, Int Wound Journal, 2013

    Podiatric medical care in people with history of diabetic foot ulcer can reduce high level amputation from between 65% and 80%
    Gibson, et al, Int Wound Journal, 2013

    Instituting a structured diabetic foot program can yield a 75% reduction in amputation rates and a near four-fold reduction in inpatient mortality
    Weck, et al,  Cardiovascular Diabetology, 2013


1.Inspect your feet daily for blisters, bleeding, or lesions between toes. Use a mirror to see the bottom of the foot and the heel
2.Have a family or friend check your feet if you are unable to do so.
3.Have regular foot examinations by your diabetic foot care specialist.
4.Always remove both shoes and stockings when visiting your doctor.
5.Always wear well-fitted stockings or socks with your shoes. Padded hosiery may reduce pressure and be more protective.
6.Inspect the soles and inside your shoes for foreign objects before putting them on.
7.Shoes should be properly measured, comfortable, and easy to put on at the time of purchase.
8.Wear leather shoes with adequate room for the toes. Running or athletic shoes are best for recreational walking.
9.Change shoes every four to six hours.
10.In cold weather, wear insulated boots or heavier socks. Be sure the shoes allow enough room to allow for heavier socks.
11.If you’ve lost sensation, do NOT walk barefooted in the house, outside, or at the beach.
12.Do NOT use hot water bottles or heating pads to warm your feet. Use warm socks instead.
13.Do NOT soak your feet.
14.Do NOT use acids or chemical corn removers.
15.Do NOT perform "bathroom surgery" on corns, calluses, or ingrown toenails.
16.Wash feet daily and be sure to dry well between the toes. Apply moisturizing cream liberally, but avoid between the toes.
17.Test the temperature of the bath water with your ELBOW or THERMOMETER. Do NOT let hot water drip onto your toes.
18.Call your foot care specialist immediately if you detect a new lesion or if your foot becomes swollen, red, or painful. Stay off your foot until you see your doctor.
19.Learn all you can about your diabetes and how it can affect your feet.
20.Maintain good diabetes control and do not smoke

Statins Reduce Cognitive Decline

Elderly adults with normal cognition at baseline who used statins had a slower rate of annual worsening in cognitive decline than nonusers....

This longitudinal study conducted by Steenland et al explored the effects of statins on cognitive decline in healthy elderly adults. Over 5000 research volunteers were evaluated in the minimum requirement of at least 3 annual visits with an average follow-up of 3 years. The effect of statins on cognitive decline in subjects with normal cognition at baseline and subjects with mild cognitive impairment (MCI) at baseline were evaluated separately.

Cognitive performance was assessed according to 10 neuropsychological indices and the Clinical Dementia Rating Sum of Boxes (CDR-SOB). Repeated-measures analysis were conducted and adjusted for age, sex, comorbidities, education and a family history of dementia. The inclusion criteria required that participants have a diagnosis of normal cognition or MCI from the clinicians at each center.

Longitudinal linear regression analyses were conducted to determine whether there was a difference in cognitive change over time between statin users and nonusers. Of participants with normal cognition at baseline, statin users performed significantly better across all visits and had significantly slower annual worsening in CDR-SOB scores (P = .006). For participants with MCI, statin users performed significantly better across all visits on attention measures, verbal skills, and executive functioning, but there were no differences in cognitive decline between users and nonusers. Thus the authors postulate that statins exert an effect only before significant deterioration is observed. Supplemental stratified analyses considered the approximately 60% of the population in the study with data on apolipoprotein E (APOE). The data were stratified according to APOE4 status (variant, present or absent). A stronger protective effect of statins against the Mini-Mental State Examination (MMSE) decline was found in participants with normal cognition at baseline in those without the APOE4 variant, although this protective effect was not significant (P = .08); no suggestion of a protective effect was found for those with the variant (P = .95). In sum, this study demonstrated a modest but positive effect of statin use for those with normal cognition but not for those with MCI.

Practice Pearls:

  • Elderly adults with normal cognition at baseline who used statins had a slower rate of annual cognitive decline.
  • Statin users performed significantly better across all visits on attention measures, verbal skills, and executive functioning in participants with MCI.
  • For participants with MCI, there were no differences in cognitive decline between users and nonusers.

Journal of the American Geriatrics Society, September 2013


New First-ever Guidelines for Type 2 Kids

Step One – Start on insulin, according to the American Academy of Pediatrics which has issued guidelines for the management of type 2 diabetes in children and teenagers aged 10 to 18....

Until recently, pediatricians have mostly had to deal with type 1 diabetes, which has a different cause and usually requires different management than type 2 diabetes. But, today, due largely to the rise in childhood obesity, as many as one in three children diagnosed with diabetes has type 2.

Dr. Janet Silverstein, division chief of pediatric endocrinology at the University of Florida, in Gainesville, one of the authors of the guidelines said, "Pediatricians and pediatric endocrinologists are used to dealing with type 1 diabetes." "Most have had no formal training in the care of children with type 2."

"The major reason for the guidelines is that there's been an increase in overweight and obesity in children and adolescents, with more type 2 diabetes in that population, making it important for general pediatricians as well as endocrinologists to have structured guidelines to follow," she said.

For example, it can be very difficult to distinguish immediately whether or not a child has type 1 or type 2 diabetes, especially if a child is overweight. The only way to tell for sure is a test for islet antibodies. Because type 1 diabetes is an autoimmune disease, a child or teen with type 1 will have islet antibodies that destroy the insulin-producing cells in the pancreas. But, it can take weeks to get the results of these tests.

Weight doesn't play a role in the development of type 1 diabetes, but it's possible that someone with type 1 could be overweight, making an immediate diagnosis of the type of diabetes very hard. If someone with type 1 diabetes is mistakenly diagnosed with type 2 diabetes, and given oral medications such as metformin instead of the insulin they must have, they can get very sick, very quickly.

That's why the first new guideline is to start a child or teen on insulin if it's at all unclear whether a child has type 1 or type 2 diabetes. The guideline further recommends that they continue using insulin until the diabetes type can be definitively determined.

Other key guidelines include the following:
  • Once a child or teen has been diagnosed with type 2 diabetes, prescribe metformin and lifestyle changes, including nutrition and physical activity.
  • Monitor A1c levels every three months. If treatment goals aren't being met, the physician should make appropriate changes to the treatment regimen.
  • Home monitoring of blood glucose is appropriate for those using insulin, anyone changing their treatment regimen, those who aren't meeting their treatment goals and during times of illness.
  • Physicians should incorporate the Academy of Nutrition and Dietetics' Pediatric Weight Management Evidence-Based Nutrition Practice Guideline in nutrition counseling of children with type 2 diabetes.
  • Children with type 2 diabetes should be encouraged to exercise at least 60 minutes a day and to limit their nonacademic "screen time" (video games, television) to less than two hours a day.

Dr. Rubina Heptulla, chief of the division of pediatric endocrinology and diabetes at Children's Hospital at Montefiore in New York City, stated that, "There's a need for type 2 guidelines in the pediatric population, and I think the new guidelines are good. But, there are a lot of unanswered questions." Dr. Heptulla added that, "There's really only one large study on type 2 diabetes and children." "These guidelines are a first step, and they highlight the critical need for more research."

The U.S. Centers for Disease Control and Prevention estimates that about 3,600 children are being diagnosed with type 2 diabetes every year, so pediatricians need to be aware that they may begin seeing children with type 2 in their practices.

Silverstein said that pediatricians should monitor A1C levels in overweight children, because it's much easier to prevent the disease than to treat it after it has occurred.

Type 1 diabetes tends to cause excessive thirst and frequent urination, but Silverstein said these symptoms aren't always present or as evident in children with type 2. If children have urethritis (inflammation of the tube that drains the bladder) or yeast infections in girls, doctors should consider testing their blood sugar levels.

Once a patient is diagnosed, management of children and adolescents with type 2 diabetes requires team care, with coordination between the primary care physician and endocrinologist specialist, along with a nutritionist, diabetes educator, and importantly, psychologist or social worker to address behavioral issues.

In addition to the American Academy of Pediatrics, the documents were developed with support from the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association).

This guideline was designed to provide a framework for management of type 2 diabetes in youth and is geared to general pediatricians, family physicians, pediatric endocrinologists, and other healthcare providers who deal with children.

The 10-member panel that developed the evidence-based guidelines included 2 pediatric endocrinologists -- Dr. Silverstein and the other cochair, Kenneth C. Copeland, MD, from the Department of Pediatrics, University of Oklahoma, Oklahoma City -- along with 4 general pediatricians, 2 family physicians, an epidemiologist, and a nutritionist.

The clinical practice guidelines, along with a separate technical document on screening for comorbidities, were published in the February issue of Pediatrics, which was published online January 28.


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