Date: 7/12/2008
TUMSPR News: On July 10, 2008, Professor Schernthaner, a leading Austrian scientist in the world working on diabetes and diabetic foot ulcers, updated the participants of the conference for diabetes and osteoporosis networks held at Tehran University of Medical Scientists (TUMS) Museum of History of Medicine.
Professor Schernthaner, an authority in the field of diabetic foot ulcers has traveled to Iran to give a lecture on the latest achievements regarding diabetic foot ulcers and closely examine the results of the new drug, Angipars, discovered by researchers at TUMS’ Diabetes Research Institute and some other universities in Iran.
The professor categorized the major manifestations of atherothrombosis as
Cerebrovascular disease,
Coronary artery disease,
Renal artery stenosis,
Visceral arterial disease,
and Peripheral arterial disease which result in
– Intermittent claudication
– Critical limb ischemia
Then he talked on diabetes treatment and research in Europe and the five-year aims of St. Vincent Declaration (1989):
- Implementation of effective measures for prevention of costly complications
- Reduction of the rate of new cases of blindness due to diabetes by one third or more
- Reduction of the numbers of people entering endstage diabetic renal failure by at least one third
- Reduction by one half in the rate of limb amputations for diabetic gangrene
- Cut morbidity and mortality from coronary heart disease in the diabetic by vigorous programmes of risk factor reduction
- Achieve pregnancy outcome in the diabetic woman that approximates to that of the non-diabetic woman
The professor said that Diabetic Foot Syndrome had been first described on December 31st 1887 and Defined it as a complication of diabetes with an increased risk for trauma, infection and gangrene.
He said that: “Almost 100% of diabetic patients suffering from both peripheral arterial disease (PAD) and a diabetic ulcer (= full picture of the diabetic foot syndrome) are dying within 4 Years
And the Risk of Diabetic Patients for Foot Ulcer and Foot Amputation include:
The lifetime risk for a diabetic patient developing a foot ulcer: 25%
Every 30 seconds a lower limb is lost in the world as a consequence of diabetes
In the USA, diabetic foot complications are a major cause of hospital admission
In 1997, nearly 70% of all amputations were diabetic patients"
On the Epidemiology of Foot Ulcer and Amputation in Diabetic Patients he said:
Annual Incidence of Foot Ulcers: 2–6%,
Prevalence of Foot Ulcers: 3–8%
Recurrence Rates of Foot Ulcers: 50–70% within 5 Years
Average healing Rates of Foot Ulcers: 11–14 weeks
Amputations are preceded by foot ulcers Foot Ulcers in 75–85% of cases, usually in association with infection and gangrene
1-Year Amputation Rates: 15%
On costs of management and treatment of foot ulcers and foot amputations in diabetic patients he said that:
"Up to 20% (7–20%) of total expenditure on diabetes might be attributable to the diabetic foot (USA and Europe) and it also includes the indirect costs of foot complications related to loss of productivity, individual patients’ and family costs and loss of quality of life".
On the frequency and causes of foot ulcers in diabetic patients he said:
A population study on 1077 patients with diabetes melitus
7,4 % of all Patients presented at the time of the study or in the past with a diabetic Foot Ulcer and the causes were:
39,4 % neuropathic
24,2 % vascular
36,4 % vascular + neuropathic
And Diabetic Complications include:
Microangiopathy
Macroangiopathy
Neural factors
Which they give rise to:
Retinopathy
Nephropathy
Neuropathy
Diabetic neuropathy is one of the most common diabetic complications, occuring in the majority of patients after 10-20 years of diabetes
Diabetic Osteo-arthropathy (Charcot syndrome)
Charcot's original description of neurogenic arthropathy in 1869 was limited to patients with syphilis. Today diabetes melitus is the leading etiology for the development of a Charcot joint.
The Charcot foot in the diabetic patient is a progressive condition with three stages that is not confined to bones but affects all of the tissues in the lower extremity.
It is often complicated by osteomyelitis and massive infection of the foot necessitating early identification and management to prevent amputation of the lower extremity.
The professor emphasized that only 1 in 10 patients with PAD has classical symptoms of intermittent claudication.
The American Diabetes Association recommends screening for PAD in patients with diabetes and recommended the use of screening for ABI in diabetic patients.
Those >50 years of age
• If normal an exercise test should be carried out
• The ABI test should be repeated every 5 years
Those <50 years of age who have other risk factors associated with PAD • Smoking • Hypertension • Hyperlipidaemia • Duration of diabetes For more than10 years. • Foot care is also important in diabetic patients as PAD is a major contributor to diabetic foot problems2 The professor said that the prevalence of PAD increases with age and there is a strong two-way association between decreased ABI and increased risk for cardiovascular death. • He said that the outcome after leg bypass surgery for critical ischemia was poor in patients with diabetes. He recommended using the guidance for PAD diagnosis: In STEP 1: Assess patient for risk factors smoking diabetes hypertension age: men >55 years and women >65 years
hyperlipidaemia
history of cardiovascular disease
Assess patient for leg symptoms
intermittent claudication
critical limb ischaemia
Tools: PAD checklist, Rose or Edinburgh questionnaire,
And in STEP 2:
If suspicion of PAD, perform an ABI to confirm diagnosis using a hand-held Doppler
He recommended the reduction of risk factors in an approach to include:
Smoking cessation
Weight reduction
Total cholesterol <175 mg/dL / <4.5 mmol/L LDL cholesterol <100 mg/dL / <2.6 mmol/L Glycosylated hemoglobin <7.0% Blood pressure (BP) <140/90 mm Hg For patients with diabetes BP < 130/80mm Hg Platelet inhibition He assessed the Pioglitazone’s effects on recurrent stroke in patients with previous stroke to about 47%. The professor knew Tissue Samples and Wound Smear in Patients with Diabetic Foot Syndrome (DFS) as vital, as different bacteria are responsible for the disease. He said that significant progress in the treatment of infections in patients with Diabetic Foot Syndrome had been taken place and: • Much better Antibiotic Drugs are now available • Bone culture - based antibiotic therapy is persuaded as bone culture-based antibiotic therapy was the only variable associated with remission. On tissue penetration of antibiotic drugs he classified them as: +++ Chinolone , Clindamycin , Trimethoprim , Fucidins, Linezolid , Metronidazol , Fosfomycin ++ Rifampicin , Carbapeneme , Cephalosporine , Penicilline , Makrolide + Aminoglykoside , Glykopeptide Conclusion: Bone culture - based antibiotic therapy is a factor predictive of success in diabetic patients treated nonsurgically for osteomyelitis of the foot.
Strategies for Improvement of the Prognosis of the Diabetic Foot Syndrome
Establishment of a specialised diabetic foot care team with a community-based chiropody service.
Such a program should include protocols for managing diabetic foot problems with input from a vascular and orthopedic surgeon, orthotist, diabetic chiropodists, and a diabetologist.
Educational events to raise awareness of diabetes foot complications
Angioplasty practice changed over the last decade. An increased rate of angioplasties per angiogram is now seen, but the rate of increase is greater among individuals with diabetes than in non-diabetic patients
Wide use of medication for modifying cardiovascular risk:lipid-lowering, antihypertensive, and antiplatelet medication.
Education of Diabetic Patients with Foot Ulcer is an important issue but in a study it was offered to half of the Patients
Assessing the diabetic foot
(A) Neuropathic assessment
History to include neuropathic symptoms
Examination to include:
Testing pressure sensation by 10 g monofilament
Testing vibration sensation by 128 Hz tuning fork
(B) Structural assessment
Identifying structural abnormalities such as calluses, bunions, hammer toes, claw toes and flat foot
Identifying Charcot neuroarthropathy
(C) Vascular assessment
History to include claudication symptoms
Identifying cutaneous trophic changes such as corns, calluses, ulcers or frank digital gangrene
Palpating pedal pulses
ABPI/ TBI/ Arterial Doppler in selected cases
Rationale for Preventive Foot Care in People with Diabetes
Diabetic foot ulcers and lower-extremity amputations are serious and expensive complications that befall up to 15 % of people with diabetes during their lifetime
Approximately 85 % of all amputations are preceded by a nonhealing foot ulcer
Relatively simple and inexpensive interventions may decrease the amputation rate up to 85 %
Four Foot-Related Risk Conditions are associated with an increased Risk of Amputation in Diabetic Patients
• Peripheral Neuropathy
• Altered Biomechanics ® Evidence of increased Pressure (Callus, Erythema, Hemorrhage under a Callus) ® Limited joint mobility, bony deformity or severe nail pathology
• Peripheral vascular disease
• A history of ulcers or amputation
Rationale for Preventive Foot Care in People with Diabetes
The Role of the Diabetologist in the Diabetic Foot Clinic
• Assessment of patient with full medical history and examination, including a foot examination
• To diagnose the diabetic foot syndromes - neuropathic or neuroischaemic foot, oedema, lesions and signs of sepsis
• Optimal treatment of diabetes (i.v. insulin) and infection (i.v. antibiotics)
• Discussion and cooperation with the vascular surgeon
• Organisation of education programme
• Frequent follow-up visits of diabetic foot patients
Rationale for Preventive Foot Care in People with Diabetes:
Foot Examination
• All diabetic patients should receive foot examination at least once a year to identify high-risk foot conditions
• This examination should include an assessment of protective sensation, foot structure and biomechanics, vascular status and skin integrity
• People with one or more high risk–foot conditions should be evaluated more frequently
• Evaluation of neurological status should include a quantitative somatosensory threshold test (monofilament)
Key learning points:
REMEMBER
Only 1 in 10 patients with PAD has typical claudication:
Patients with diabetes are at high risk of PAD
It is important to improve the management of PAD to protect patients from an increased risk of ischemic events.
ACTION
Ensure aggressive and early risk management of patients who are at high risk but may be asymptomatic
Screen patients with diabetes >50 years of age, and those <50 years of age who have additional risk factors associated with PAD
Risk stratification of the diabetic foot
The DIABETIC FOOT CARE TEAM proposed by the professor and currently in usee the Department of Medicine I, Rudolfstiftung Hospital inVienna, Austria:
• Diabetes Education Team (3 Medical Doctors, 1 Diabetes Nurse, 2 Dietitians)
• Diabetologist (working for 10 Years in this particular field)
• Interventional Radiologist
• Vascular Surgeon
• Orthopedic (Plastic) Surgeon
• Orthotist
• Diabetic chiropodists
• Expert in Antibacterial Chemotherapy
Latest papers of Schernthaner, G (Guntram http://lib.bioinfo.pl/auid:2402638):
PICTURE GALLERY
http://publicrelations.tums.ac.ir/gallery/detail.asp?galleryID=328
1- Professor Guntram Schernthaner is the Head of the Department of Medicine I, Rudolfstiftung Hospital Vienna, Austria.
2- The discovery was disclosed by the minister of Health and Medical Education in Imam Khomeini Conference Hall in early 2008.
A Novel Drug to Treat Diabetic Foot Ulcers Unveiled in Iran
http://publicrelations.tums.ac.ir/english/news/detail.asp?newsID=6217
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