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
