Saturday, December 09, 2006
DIABETES ARTICLES - To Prevent Amputations, Doctors Call for Aggressive Care
DIABETES ARTICLES
To Prevent Amputations, Doctors Call for Aggressive Care
After leaving her job at NASA’s Goddard Space Flight Center in Maryland, Elaine Fry mapped out her life as an active retiree: daily outdoor excursions, meetings with friends, cross-country trips.
But as her legs inexplicably began retaining more and more fluid, swelling like ripening melons, just leaving her bedroom became a struggle. Last year, an ulcer appeared on her bloated right calf, with an infection that festered for months and turned the surrounding tissue black. Her doctor confirmed her worst fears: an above-the-knee amputation was the only option.
Following the surgery, Ms. Fry, now 63, sold her house and went to live with her daughter, her son-in-law and their four children in a basement apartment of their Columbia, Md., home that she describes as “not wheelchair friendly.”
“Before, if I wanted to go to the bookstore or grocery store, I could,” she said. “But now, my daughter can’t just drop everything and do whatever I want to do. Losing my independence has been really hard.”
Ms. Fry’s story is a surprisingly common one, though amputation is often stereotypically viewed as a side effect of war, not a consequence of disease. About 1.8 million Americans have had amputations; every year, more than 100,000 non-accident-related, lower-limb amputations are performed in the United States.
The high numbers have prompted the medical community to debate whether most foot and leg amputations can be prevented — and, if so, how.
Dr. Karel Bakker, a foot specialist who is a chairman of the International Diabetes Federation, believes that more effective foot care and patient education strategies would render up to 85 percent of these procedures unnecessary. Lower-limb ulcers are the most reliable harbingers of future amputation: according to a study published earlier this year in the journal Diabetes Care, nearly 9 in 10 nontraumatic foot and leg amputations come after the development of these infected sores, which can spread and quickly destroy surrounding tissue.
Some of these amputations, like Ms. Fry’s, can be traced to ulcers resulting from edema or other conditions that affect blood flow to the lower extremities. Others — as many as 60 percent, according to some estimates — are due to a common complication of diabetes: lower-limb numbness resulting from nerve damage from the disease.
Dr. Michael S. Pinzur, an orthopedic surgeon at Loyola University in Chicago, has had diabetes patients who have lost so much sensation in their feet that they have been oblivious to large objects, like cigarette lighters or toy trucks, that have gotten lodged in their shoes.
“Normally, if you’ve got something as small as an ingrown toenail, you feel it,” Dr. Pinzur said. “These people can’t feel it.”
Because there is no pain to alert them to potential danger, these patients often continue walking on increasingly sore, infected legs until they resemble hunks of raw meat.
With proper education, observation and follow-up care, Dr. Bakker argues, most patients at high risk of amputation could be healed before reaching the point of no return. He envisions an across-the-board protocol of aggressive wound care that would function a little like early-stage cancer treatment, vanquishing relatively minor sores and irritations before they have a chance to become something more serious.
“Some people do go to clinics for their ulcers and have them treated, but there often isn’t any follow-up,” he says. “There’s no good recall system. If you have an ulcer, you should really be seen every three months.”
At present, he points out, only 14 percent of general practitioners perform foot exams during yearly patient visits. He hopes this percentage will increase greatly as doctors become more aware of the benefits of preventive foot care, which includes checking the feet for redness, cuts and sores.
The World Health Organization has also lobbied for better preventive foot care to eliminate the need for amputations.
“Any amputation, especially for conditions like diabetes, is a human tragedy and a gross failure of public health efforts,” said Dr. Robert Beaglehole, W.H.O.’s director of chronic diseases and health promotion. “We are failing desperately to prevent the most preventable conditions.”
Dr. Pinzur, however, thinks it is unrealistic to expect the levels of patient compliance needed to achieve the results that Dr. Bakker and Dr. Beaglehole envision. Many diabetics, he notes, have difficulty learning to administer proper wound care, and many other patients do not follow doctors’ orders or show up for scheduled visits. “ “One-on-one patient education is really the only solution,” he said.
But Dr. Vivian Ho, an economist at Rice University, said that raising awareness about amputation danger signs among patients and doctors only addresses part of the problem. Her 2005 analysis of Medicare claims data showed that adding one vascular surgeon for every 33,000 Medicare beneficiaries in a region yielded a 1.6 percent decrease in amputations.
These results suggest that in many poor or rural regions of the United States, there simply are not enough specialists available to perform foot- and leg-saving procedures.
“Whether or not you have an amputation is a function of who you get sent to,” Dr. Ho said. “If there are only six vascular specialists in the entire state, many patients won’t get told to see a vascular surgeon at all.”
While general practitioners are trained to perform amputations, they are not usually qualified to perform complex limb-saving operations like bypasses or balloon angioplasties.
Economically and socially marginalized groups, Dr. Ho adds, get the shortest shrift in the amputation lottery. Among diabetics in North America, Hispanics and African-Americans are 1.5 to 2.5 times more likely than whites to undergo lower limb amputations. “There’s no advocacy group for this condition the way there is for something like breast cancer,” she said. “It’s a disease of the lower class.”
Dr. Ho argues that Medicare reimbursement rates in underserved regions should be raised to create an economic incentive for specialists to move to those areas.
“There’s correlation between the supply of specialists and how attractive an area is in terms of culture and economy — all the factors you’d find in the Places Rated Almanac,” she said. “But doctors will respond to higher rates. Anywhere dollar signs come into play, you’ll see an effect.”
Some physicians, though, think Dr. Ho’s focus on the drought of specialists is misguided. “The obvious answer is, ‘Let’s get everyone to see a vascular surgeon,’ but that won’t solve anything,” Dr. Pinzur said. “Vascular surgeons only start seeing patients at the point when they already have nonhealing ulcers, and at that point a lot of the damage has been done.”
Even in areas where specialists are plentiful, said Dr. Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey, doctors may be performing amputations that are not absolutely necessary.
“Doctors have to decide whether to spend three or four hours doing a complicated salvage procedure, or 35 minutes for a short, quick amputation,” he said.
Still, doctors caution against viewing amputation as something to be avoided at all costs. “Some people say: ‘If you take my leg off, my life is over. I’m going to die’ ” Dr. Pinzur said. “But it’s not a black-or-white issue. You always have to ask, ‘Will a salvage outperform an amputation in this case?’ ”
One of Dr. Pinzur’s patients, vehemently opposed to amputation, had been in and out of the hospital for years as a recurring infection smoldered in his foot.
“Finally he said, ‘Enough is enough,’ ” Dr. Pinzur said, “and two weeks after his amputation, he was walking around with a prosthesis and asking, ‘Why did I wait so long?’ ”
For Elaine Fry, the recovery process has been slower — just healing her surgical wound took several months.
A year after surgery, she has been attending physical therapy to get used to a recently fitted prosthesis and has been learning to drive with a left-leg accelerator pedal.
“I’m looking forward to doing all the things I used to do,” she said.
by Elizabeth Svoboda at The New York Times, published on Nov 7 2006
To Prevent Amputations, Doctors Call for Aggressive Care
After leaving her job at NASA’s Goddard Space Flight Center in Maryland, Elaine Fry mapped out her life as an active retiree: daily outdoor excursions, meetings with friends, cross-country trips.
But as her legs inexplicably began retaining more and more fluid, swelling like ripening melons, just leaving her bedroom became a struggle. Last year, an ulcer appeared on her bloated right calf, with an infection that festered for months and turned the surrounding tissue black. Her doctor confirmed her worst fears: an above-the-knee amputation was the only option.
Following the surgery, Ms. Fry, now 63, sold her house and went to live with her daughter, her son-in-law and their four children in a basement apartment of their Columbia, Md., home that she describes as “not wheelchair friendly.”
“Before, if I wanted to go to the bookstore or grocery store, I could,” she said. “But now, my daughter can’t just drop everything and do whatever I want to do. Losing my independence has been really hard.”
Ms. Fry’s story is a surprisingly common one, though amputation is often stereotypically viewed as a side effect of war, not a consequence of disease. About 1.8 million Americans have had amputations; every year, more than 100,000 non-accident-related, lower-limb amputations are performed in the United States.
The high numbers have prompted the medical community to debate whether most foot and leg amputations can be prevented — and, if so, how.
Dr. Karel Bakker, a foot specialist who is a chairman of the International Diabetes Federation, believes that more effective foot care and patient education strategies would render up to 85 percent of these procedures unnecessary. Lower-limb ulcers are the most reliable harbingers of future amputation: according to a study published earlier this year in the journal Diabetes Care, nearly 9 in 10 nontraumatic foot and leg amputations come after the development of these infected sores, which can spread and quickly destroy surrounding tissue.
Some of these amputations, like Ms. Fry’s, can be traced to ulcers resulting from edema or other conditions that affect blood flow to the lower extremities. Others — as many as 60 percent, according to some estimates — are due to a common complication of diabetes: lower-limb numbness resulting from nerve damage from the disease.
Dr. Michael S. Pinzur, an orthopedic surgeon at Loyola University in Chicago, has had diabetes patients who have lost so much sensation in their feet that they have been oblivious to large objects, like cigarette lighters or toy trucks, that have gotten lodged in their shoes.
“Normally, if you’ve got something as small as an ingrown toenail, you feel it,” Dr. Pinzur said. “These people can’t feel it.”
Because there is no pain to alert them to potential danger, these patients often continue walking on increasingly sore, infected legs until they resemble hunks of raw meat.
With proper education, observation and follow-up care, Dr. Bakker argues, most patients at high risk of amputation could be healed before reaching the point of no return. He envisions an across-the-board protocol of aggressive wound care that would function a little like early-stage cancer treatment, vanquishing relatively minor sores and irritations before they have a chance to become something more serious.
“Some people do go to clinics for their ulcers and have them treated, but there often isn’t any follow-up,” he says. “There’s no good recall system. If you have an ulcer, you should really be seen every three months.”
At present, he points out, only 14 percent of general practitioners perform foot exams during yearly patient visits. He hopes this percentage will increase greatly as doctors become more aware of the benefits of preventive foot care, which includes checking the feet for redness, cuts and sores.
The World Health Organization has also lobbied for better preventive foot care to eliminate the need for amputations.
“Any amputation, especially for conditions like diabetes, is a human tragedy and a gross failure of public health efforts,” said Dr. Robert Beaglehole, W.H.O.’s director of chronic diseases and health promotion. “We are failing desperately to prevent the most preventable conditions.”
Dr. Pinzur, however, thinks it is unrealistic to expect the levels of patient compliance needed to achieve the results that Dr. Bakker and Dr. Beaglehole envision. Many diabetics, he notes, have difficulty learning to administer proper wound care, and many other patients do not follow doctors’ orders or show up for scheduled visits. “ “One-on-one patient education is really the only solution,” he said.
But Dr. Vivian Ho, an economist at Rice University, said that raising awareness about amputation danger signs among patients and doctors only addresses part of the problem. Her 2005 analysis of Medicare claims data showed that adding one vascular surgeon for every 33,000 Medicare beneficiaries in a region yielded a 1.6 percent decrease in amputations.
These results suggest that in many poor or rural regions of the United States, there simply are not enough specialists available to perform foot- and leg-saving procedures.
“Whether or not you have an amputation is a function of who you get sent to,” Dr. Ho said. “If there are only six vascular specialists in the entire state, many patients won’t get told to see a vascular surgeon at all.”
While general practitioners are trained to perform amputations, they are not usually qualified to perform complex limb-saving operations like bypasses or balloon angioplasties.
Economically and socially marginalized groups, Dr. Ho adds, get the shortest shrift in the amputation lottery. Among diabetics in North America, Hispanics and African-Americans are 1.5 to 2.5 times more likely than whites to undergo lower limb amputations. “There’s no advocacy group for this condition the way there is for something like breast cancer,” she said. “It’s a disease of the lower class.”
Dr. Ho argues that Medicare reimbursement rates in underserved regions should be raised to create an economic incentive for specialists to move to those areas.
“There’s correlation between the supply of specialists and how attractive an area is in terms of culture and economy — all the factors you’d find in the Places Rated Almanac,” she said. “But doctors will respond to higher rates. Anywhere dollar signs come into play, you’ll see an effect.”
Some physicians, though, think Dr. Ho’s focus on the drought of specialists is misguided. “The obvious answer is, ‘Let’s get everyone to see a vascular surgeon,’ but that won’t solve anything,” Dr. Pinzur said. “Vascular surgeons only start seeing patients at the point when they already have nonhealing ulcers, and at that point a lot of the damage has been done.”
Even in areas where specialists are plentiful, said Dr. Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey, doctors may be performing amputations that are not absolutely necessary.
“Doctors have to decide whether to spend three or four hours doing a complicated salvage procedure, or 35 minutes for a short, quick amputation,” he said.
Still, doctors caution against viewing amputation as something to be avoided at all costs. “Some people say: ‘If you take my leg off, my life is over. I’m going to die’ ” Dr. Pinzur said. “But it’s not a black-or-white issue. You always have to ask, ‘Will a salvage outperform an amputation in this case?’ ”
One of Dr. Pinzur’s patients, vehemently opposed to amputation, had been in and out of the hospital for years as a recurring infection smoldered in his foot.
“Finally he said, ‘Enough is enough,’ ” Dr. Pinzur said, “and two weeks after his amputation, he was walking around with a prosthesis and asking, ‘Why did I wait so long?’ ”
For Elaine Fry, the recovery process has been slower — just healing her surgical wound took several months.
A year after surgery, she has been attending physical therapy to get used to a recently fitted prosthesis and has been learning to drive with a left-leg accelerator pedal.
“I’m looking forward to doing all the things I used to do,” she said.
by Elizabeth Svoboda at The New York Times, published on Nov 7 2006
Thursday, November 23, 2006
DIABETES ARTICLES - Rookie Is No Novice at Dealing With Diabetes
DIABETES ARTICLES
Rookie Is No Novice at Dealing With Diabetes
After a dismal shooting night, the Charlotte Bobcats rookie Adam Morrison sat in front of his locker, head bowed as he tried to explain a 1-of-8 performance. At his feet was a duffel bag of energy bars and apple juice, reminders of what he has overcome to get this far.
“It’s something I’ve got to work through,” Morrison said of his shooting problems. “I’ve worked through it before and gone through adversity.”
It was not that long ago that Morrison sat in a hospital room, a 14-year-old listening as a doctor told him he was a Type 1 diabetic — a diagnosis he figured would end his N.B.A. dreams. But as the doctor started to rattle off the diabetic athletes who played professionally — the hockey Hall of Famer Bobby Clarke, the nine-time baseball All-Star Ron Santo and the longtime N.B.A. player Chris Dudley — a new goal came into focus.
“Right after that, the nurse came in to give him the second insulin shot and he told her, ‘You better show me how to do this, because I’m going to be doing it for the rest of my life,’ ” recalled his father, John.
Today, the 22-year-old Morrison is the only known diabetic in the N.B.A.. Dudley, the league’s last active player with the disease, hopes that does not become an issue as Morrison struggles to improve a shooting percentage that has not moved above 40 percent and to get quicker as a defender, where he has often been a step slow.
But after going 10 of 43 during a five-game stretch, Morrison rebounded this week to score 21 and 27 points in back-to-back games.
“If he struggles in the midseason, people may talk about his diabetes,” Dudley said. “But every rookie goes through that. Every rookie hits the wall at some point. I hope people don’t blame the guy if he struggles.”
About 21 million Americans have diabetes, which affects the body’s ability to make or properly use insulin. Type 2 diabetes is the most common and involves the destruction of insulin-producing cells, in part because of obesity or poor diet. Morrison has the less-common Type 1. His body cannot make insulin, which it needs to convert sugar from food into energy.
If left untreated, diabetics can experience heart and kidney problems, blindness and even death. They are told to closely monitor their diet and get plenty of rest. Morrison set a daily routine and settled on having the same meal before every game: a steak and baked potato exactly two hours before tip-off.
It worked. Morrison went on to have a stellar high school career in Spokane, Wash., before starring at Gonzaga, where he was the top scorer in college basketball last season at 28.1 points a game. He did it while constantly testing his blood-sugar level, up to four or five times during the day and nearly every timeout during a game.
The Bobcats trainer Joe Sharpe got Morrison’s system down during the preseason and keeps the bench stocked with apple juice and energy bars. There is also insulin on hand should Morrison’s blood sugar get too high.
“I try to make it as quick as possible,” Sharpe said. “I have his kit ready to go. He sits down, pricks his finger and gets his reading. I then give him what he needs.”
Morrison took great care to make sure he would be ready to play at the pro level and deal with the disease. Earlier this year he met with Dudley, who spent 16 seasons in the N.B.A. before retiring in 2003.
“I told him you’re not going to be perfect, but you have to be careful,” Dudley said. “Talking to teams about Adam before the draft, I told them if Adam was the kind of player that you had to worry about being overweight during the summer and all those things, I’d be a lot more worried about him. I’m not worried about that with Adam. He’s the type of guy who knows his body and is going to take care of his body.”
When Dudley first entered the league in 1987, it took 45 seconds to test his blood sugar. The technology has improved. Morrison recently signed an endorsement deal with LifeScan, which makes a device that gives a reading in 5 seconds.
When Morrison’s blood sugar is too high or low, he feels sluggish on the court. But he feels he will be able to adjust to the grind of an 82-game N.B.A. schedule.
“Obviously, you have to take care of your body,” Morrison said. “It’s definitely different than college.”
After signing a rookie contract that pays more than $3 million a season, Morrison has taken advantage of his new wealth. He has hired a full-time chef, had meetings with a nutritionist, and his sister and 5-year-old niece moved to Charlotte, N.C., to help with his off-the-court responsibilities.
That maturity was one of the reasons the Bobcats did not shy away from selecting Morrison with the No. 3 pick in the draft. Dudley, who runs a foundation that helps children deal with diabetes, believes the high-profile Morrison will raise awareness for the disease.
“We all want a cure and we’re trying to get a cure, but in the meantime these kids have to deal with diabetes, and we try to get the message out that they can succeed,” Dudley said.
Morrison said he realizes the influence he can have, and spent time this summer on a promotional tour for the company that makes his blood sugar meter. Could the day come when, instead of being asked to autograph a shirt or a ball, a child with diabetes hands Morrison his blood-sugar meter to sign?
“That would be pretty wild, but you know, I think it would be cool if it could happen,” Morrison said. “I’ll try to give back and be a role model to kids and even adults.”
by The Assosiated Press at The New York Times, published on Nov 19, 2006
Rookie Is No Novice at Dealing With Diabetes
After a dismal shooting night, the Charlotte Bobcats rookie Adam Morrison sat in front of his locker, head bowed as he tried to explain a 1-of-8 performance. At his feet was a duffel bag of energy bars and apple juice, reminders of what he has overcome to get this far.
“It’s something I’ve got to work through,” Morrison said of his shooting problems. “I’ve worked through it before and gone through adversity.”
It was not that long ago that Morrison sat in a hospital room, a 14-year-old listening as a doctor told him he was a Type 1 diabetic — a diagnosis he figured would end his N.B.A. dreams. But as the doctor started to rattle off the diabetic athletes who played professionally — the hockey Hall of Famer Bobby Clarke, the nine-time baseball All-Star Ron Santo and the longtime N.B.A. player Chris Dudley — a new goal came into focus.
“Right after that, the nurse came in to give him the second insulin shot and he told her, ‘You better show me how to do this, because I’m going to be doing it for the rest of my life,’ ” recalled his father, John.
Today, the 22-year-old Morrison is the only known diabetic in the N.B.A.. Dudley, the league’s last active player with the disease, hopes that does not become an issue as Morrison struggles to improve a shooting percentage that has not moved above 40 percent and to get quicker as a defender, where he has often been a step slow.
But after going 10 of 43 during a five-game stretch, Morrison rebounded this week to score 21 and 27 points in back-to-back games.
“If he struggles in the midseason, people may talk about his diabetes,” Dudley said. “But every rookie goes through that. Every rookie hits the wall at some point. I hope people don’t blame the guy if he struggles.”
About 21 million Americans have diabetes, which affects the body’s ability to make or properly use insulin. Type 2 diabetes is the most common and involves the destruction of insulin-producing cells, in part because of obesity or poor diet. Morrison has the less-common Type 1. His body cannot make insulin, which it needs to convert sugar from food into energy.
If left untreated, diabetics can experience heart and kidney problems, blindness and even death. They are told to closely monitor their diet and get plenty of rest. Morrison set a daily routine and settled on having the same meal before every game: a steak and baked potato exactly two hours before tip-off.
It worked. Morrison went on to have a stellar high school career in Spokane, Wash., before starring at Gonzaga, where he was the top scorer in college basketball last season at 28.1 points a game. He did it while constantly testing his blood-sugar level, up to four or five times during the day and nearly every timeout during a game.
The Bobcats trainer Joe Sharpe got Morrison’s system down during the preseason and keeps the bench stocked with apple juice and energy bars. There is also insulin on hand should Morrison’s blood sugar get too high.
“I try to make it as quick as possible,” Sharpe said. “I have his kit ready to go. He sits down, pricks his finger and gets his reading. I then give him what he needs.”
Morrison took great care to make sure he would be ready to play at the pro level and deal with the disease. Earlier this year he met with Dudley, who spent 16 seasons in the N.B.A. before retiring in 2003.
“I told him you’re not going to be perfect, but you have to be careful,” Dudley said. “Talking to teams about Adam before the draft, I told them if Adam was the kind of player that you had to worry about being overweight during the summer and all those things, I’d be a lot more worried about him. I’m not worried about that with Adam. He’s the type of guy who knows his body and is going to take care of his body.”
When Dudley first entered the league in 1987, it took 45 seconds to test his blood sugar. The technology has improved. Morrison recently signed an endorsement deal with LifeScan, which makes a device that gives a reading in 5 seconds.
When Morrison’s blood sugar is too high or low, he feels sluggish on the court. But he feels he will be able to adjust to the grind of an 82-game N.B.A. schedule.
“Obviously, you have to take care of your body,” Morrison said. “It’s definitely different than college.”
After signing a rookie contract that pays more than $3 million a season, Morrison has taken advantage of his new wealth. He has hired a full-time chef, had meetings with a nutritionist, and his sister and 5-year-old niece moved to Charlotte, N.C., to help with his off-the-court responsibilities.
That maturity was one of the reasons the Bobcats did not shy away from selecting Morrison with the No. 3 pick in the draft. Dudley, who runs a foundation that helps children deal with diabetes, believes the high-profile Morrison will raise awareness for the disease.
“We all want a cure and we’re trying to get a cure, but in the meantime these kids have to deal with diabetes, and we try to get the message out that they can succeed,” Dudley said.
Morrison said he realizes the influence he can have, and spent time this summer on a promotional tour for the company that makes his blood sugar meter. Could the day come when, instead of being asked to autograph a shirt or a ball, a child with diabetes hands Morrison his blood-sugar meter to sign?
“That would be pretty wild, but you know, I think it would be cool if it could happen,” Morrison said. “I’ll try to give back and be a role model to kids and even adults.”
by The Assosiated Press at The New York Times, published on Nov 19, 2006
