Negative Pressure Wound Therapy and Materials: Unclogging The System?

While this is not a new discussion for us at SALSA, we thought it appropriate to get the discussion out into the ether.

For so very long, we have been asking why NPWT with foam works so well-- particularly when compared with certain types of gauze. Is there some magic property between the two? After all, a vacuum is a vacuum-- and the most perfect way to have a vacuum might be to have nothing in contact with the surface?!

We have thought that the main reason that foam- particularly polyurethane (PU) foam- works well is because it stays porous and provides channels for even distribution of NPWT and won't "clog up the line" with wound debris.

Perhaps this holds true when we discuss our concept of "wound chemotherapy" by way of streaming fluid through the wound. When we stream that fluid through the wound, we are unclogging channels in the PU foam. This most certainly must have a positive therapeutic effect. It also partly explains why we see a reduction in maceration and a reduction in slough in the wound.

Finally, this explains why we often don't frequently see this change in the wound with intermittent streaming (ie instilling fluid with a "hold" period in NPWT). This might not have the same hydrodynamic effect.

Anyway, we look forward to your feedback as always.

Message from Ron Jensen, APMA President: Make Amputation Prevention a Priority

REPRINTS PRINT BOOKMARK & SHARE Healthcare Business News Ronald Jensen Make preventive care a priority By Ronald Jensen Posted: December 1, 2009 - 5:59 am EDT Over the course of their career, medical professionals often make decisions that permanently affect the lives of their patients. For me, as a doctor of podiatric medicine, nothing is more tragic than sitting down with a patient to inform them that he or she will have no other choice than to have a toe, a foot or even their entire leg amputated due to blood flow complications from diabetes. The most frustrating part? This situation is one that typically could have been prevented—time and time again. Amidst the wrangling over an agreeable healthcare reform solution, Americans are still trying to come to terms with reform's hefty price tag. For many, it is hard to imagine increasing funding for a healthcare system that has already proven to waste millions of dollars each year. Advertisement | Your Ad Here It has been widely publicized in the media that the U.S. spends more than twice on healthcare what other developed countries do—yet sees little return on this enormous investment. Lost in the media mix and debate of the issues is a fundamental principle that is not brought to the forefront of discussion often enough: prevention. As president of the American Podiatric Medical Association, I believe that access to preventive care outweighs the effectiveness of some of medical technology's greatest triumphs. Daily, my colleagues and I are on the front lines of diabetes management. Without the doctors to catch a person's blood flow problems to their lower limbs before the onset of serious complications, even the most advanced technologies are of little use to successfully treat the condition. Make no mistake, providing better preventive care for epidemics such as diabetes could help save our broken healthcare system billions of dollars every year. Diabetes is not only devastating to the entire body—it also hits the American healthcare system hard in the wallet, with direct and indirect costs reaching nearly $200 billion per year. Nearly 24 million people—8% of the U.S. population—are currently battling diabetes. Treating the disease and its many complications requires a complete management team, including a podiatric physician, to attend to the necessary foot care those with diabetes require. However, diabetic complications are frequently seen by a medical professional only after the sole treatment option is total amputation of a toe, foot or lower limb. Many of our nation's healthcare problems have evolved from a general lack of education. Studies have shown that simply creating greater public awareness of diabetic foot care could positively affect our healthcare system. According to an article published in the Journal of the American Podiatric Medical Association, comprehensive amputation prevention programs can reduce amputation rates from diabetic complications by as much as 70%. Detecting diabetic foot ulcers early and staving off tragic foot and leg amputations benefits more than just the individual whose foot or leg is spared. The entirety of amputation costs avoided with prevention—including actual procedural costs, necessary hospital stay and follow-up care—can save our healthcare system up to $8 billion each year. Complications from diabetes—including diabetic ulcers and amputations—are preventable, but only with the help of a diabetes management team, which includes a podiatrist, vascular surgeon and primary-care physician. Diagnosed cases of diabetes will continue to rise exponentially without an immediate intervention. Current statistics show that nearly 6 million Americans have diabetes and are not aware of their disease. Something must be done to encourage both those with diabetes and those at risk to seek out the critical preventive care that will save their limbs and their life. I urge our lawmakers to make diabetes prevention—and preventive care for all major health conditions—a top-level priority in the healthcare reform debate. The short-term payoff may not be seen overnight. The long-term successes, however, will be monumental—helping to keep doctors like myself from having to present patients with a heart-breaking, life-altering diagnosis far too often. Ronald Jensen, a physician, is president of the American Podiatric Medical Association. He resides and practices podiatry in Modesto, Calif. What do you think? Post a comment on this article and share your opinion with other readers. Submit your comments to Modern Healthcare Online at mheditorial@modernhealthcare.com. Please be sure to include your hometown and state, along with your organization and title.

Wound Measurement via Phone

From our colleagues at MedGadget:

Remote Wound Management With Help of Smart Phones

Filed under: Telemedicine

Wound patients typically get lots of care at home, either from visiting nurses or from home care providers. Now technology is coming to even this forgotten medical market. And not surprisingly, it is mobile phone technology with backing from a big gun: AT&T. What we know is that the Wound Technology Network, a telehealth-based wound management service, is giving out HTC smart phones equipped with iVisit software to many of its providers for sending images back to specialists for remote analysis:

Under a two year agreement with AT&T, Wound Technology Network will equip its clinical staff including physicians, nurse practitioners and physician assistants across South Florida and Southern California with HTC FUZE™ smart mobile devices when providing care in patient’s homes. Clinical staff will use the devices to access an application developed by iVisit which creates videoconferencing tools for mobile devices and PCs and speak live with a wound care specialist at Wound Technology Network’s tele-health center who will assist them to assess the patients’ wounds and perform the necessary treatment. To aid in the treatment process, clinical staff will also capture images of the patient’s wounds using the HTC FUZE™ and transmit the images to the wound care specialists to upload onto an electronic medical record which is immediately faxed to the patient’s primary care physician.

SALSAism entry: ManifesTOE

Here is another addition to our list of SALSAisms from our very own stellar fellow, Tim Fisher.

ManifesTOE: An operative report following an amputation prevention procedure (bypass or incision and drainage or graft/flap.

Skin Bacteria and the "Microbiome"- Misanthropic microbial communities?

I have been speaking (electronically) with my colleague Randy Wolcott-- the very talented clinician and widely acknowledged biofilm guru from Lubbock. He was telling me of his experience at the American Society of Microbiology meeting in Mexico recently, where the discussion has continued to focus not on one bug, but on "biomes" of bugs.

The more we discuss this, the more we realize that the possibility of what we refer to (tongue in cheek) as an "H. pylori" for a wound may be a good analogy-- but a simplistic one. I will quote good Dr. Wolcott:

"While, H. pylori possesses all the tools necessary to attach, form a biofilm and create a hyperinflammatory environment on which it can subsist, many bacteria choose to co-aggregate to have all the elements necessary for biofilm formation and the ability to produce a chronic infection.

"...most of the biofilm experts agree that the presence of numerous different species existing in the same host niche (wound) was sufficient to strongly suggest that a biofilm was present. This is based on the laboratory finding that it is very rare for planktonic bacteria to coexist in the same area while biofilms are almost polymicrobial.

I like your phrase [David] “misanthropic microbial communities” because it connotes bacteria abandoning their commensal roles and have turned to the dark side of harming humanity. "

This is really interesting stuff. I am so very fascinated where we're going!

Centers for Disease Control Maps: Foot Exams and Self-Exams

Many of you may know this, but the United States Centers for Disease Control and Prevention is a veritable treasure trove of important information regarding diabetes care trends in the United States. To that end, we share with you the number of documented diabetic foot examinations by state in this post. Enjoy!

As a bonus, here is the link for documented patient self-foot-exams. We can do a lot better.

More SALSAisms

When the chips are down, you need SALSA

FreeToes and SALSA

"One Stop Shop" For Amputation Prevention

Here is a terrific article from the Daily Mail from our friend and colleague Prof. Mike Edmonds' world-class unit at King's College Hospital, London.

______________

Thousands of diabetics could be saved from needless amputation, claims 'one-stop shop' specialist

By DAVID HURST
Last updated at 1:02 AM on 17th November 2009

• Comments (0)
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One of the great worries for diabetics is complications.

Nearly 800,000 are at risk of blindness, heart disease and kidney failure because their blood sugar levels are not under control, it was reported last weekend.

Every week 100 people lose a foot or limb through diabetes.

The amount of amputations through diabetes could be reduced if patients were seen at a specialist centre, a specialist has claimed

But according to a leading specialist, much more could be done to reduce the numbers who have an amputation - if only patients were seen at a specialist centre.

Retired nurse Valerie Robinson was destined to be another of the unlucky ones.

Last year, an ulcer on her left ankle became so badly infected that doctors told her it was highly likely to become gangrenous. The leg would have to be amputated or she would die. 'I was absolutely devastated,' she recalls. 'I'd never thought it would come to this. It was very depressing.'

Foot ulcers - the result of nerve damage and poor blood flow - are a common problem for diabetics. The nerves control blood pressure. Damage to them causes reduced blood flow to the extremities, leading to a loss of sensation.

Poor blood flow means the skin does not regenerate as quickly and becomes thin and easily damaged. The feet are particularly vulnerable. Even something as apparently benign as a shoe that rubs can cause problems, as no pain is felt.

Left untreated, a sore can develop.

The lack of blood flow means the skin takes longer to heal and doesn't heal as well - often resulting in an ulcer and infection. Up to 15 per cent of patients with foot ulcers end up needing amputation.

As well as great personal misery, this costs the NHS £252 million a year.

Diabetic Valerie Robinson was saved from having her leg amputated after seeing Dr Edmonds

But Valerie was spared drastic surgery thanks to the pioneering approach taken by Dr Mike Edmonds, a diabetes consultant at King's College Hospital in London. He runs what could be described as a one-stop shop for diabetics.

Unlike most hospitals, Dr Edmonds has a large team of experts, including orthopaedic surgeons, vascular surgeons, specialist nurses and chiropodists.

He believes that more than half of diabetic amputations could be avoided if all a patient's diabetic complications, from blocked arteries to bone problems, were treated, rather than just their feet.

'We're mainly a diabetic foot clinic, but we can also treat other damage caused by diabetes, such as kidney or heart failure,' he says.

'Our approach is different from most hospitals. The key is to ensure patients get speedy, aggressive treatment, provided by experts across a range of disciplines. As a result, we've managed to save the limbs of patients who were destined for an amputation.'

Valerie is typical of the patients Dr Edmonds sees. The retired nurse from Hastings, East Sussex, was diagnosed with type 2 diabetes in 1986.

'I knew, from being a nurse, how important it is for diabetics to look after their feet. I always wore shoes that fitted well. But two years ago I developed a condition called Charcot foot, where the bones in the feet soften and cause the foot to change shape.

'My left foot started getting flatter, and my ankle started to turn over unnaturally.

'Then, last year, I slipped and bruised my left foot, and just below my knee. I got the ulcer due to my bad circulation and the wound couldn't heal. I knew ulcers were bad news, so I went to my then local hospital in East London.'

There, to her horror, doctors told her she was at very high risk of gangrene. If her lower leg was not amputated, the infection could spread and kill her.

Then Valerie struck lucky. First, her leg did not become immediately gangrenous and, a few months later, during a check-up, one of her doctors mentioned King's College Hospital.

She asked to be sent there for a second opinion. Dr Edmonds and his team were confident her leg could be saved through a simple operation. 'I cried with relief when they told me,' she says.

The cause of Valerie's problems was the bone deformity, which made her vulnerable to falls and therefore ulcers. These kinds of bone deformities are common in diabetics because nerve damage causes the joints to deteriorate.

The nerve damage also means patients have little or no sensation, so they're less likely to notice when their feet are painful. It means they continue to walk and put pressure on the bones, making the injury worse.

Dr Edmonds explains: 'We're increasingly treating patients with "neuroischaemic feet" - that is, with both nerve damage and reduced blood supply.

'The main treatment is to improve the blood supply, either by opening up the artery in the leg with a balloon or stent, or performing a bypass around the blocked artery.'

Fortunately, Valerie still had a good enough blood supply to the leg, so rather than opening up the arteries, the team's orthopaedic surgeon corrected her misshapen foot to solve the problem for good. Valerie's ankle was straightened by the insertion of a special nail into the bones of the foot.

'Many hospitals think the sort of operation we did on Valerie is hazardous and doesn't work,' says Dr Edmonds.

'Working with the smaller arteries below the knee, including the foot, requires complex procedures which are not readily available to diabetic patients in most hospitals.'

But having a team ready to take an 'aggressive' approach to diabetic disease means this kind of option is possible at King's College Hospital.

clinic, which accepts referrals from around the country, sees between 20 to 35 patients every day and there are only about three amputations a year - ten times fewer than the national average.

'One lady came to us with severe gangrene in her big toe and an infection in the surrounding bone. She had blocked arteries in her lower leg and she'd been warned she might lose her leg.

'But the staff here performed an arterial bypass to her lower leg to save it. In the end, she lost only her toe.

'What makes our approach so successful is that we take a holistic approach,' says Dr Edmonds. 'Patients with an ulcer need their whole body treating, not just their foot.'

There are only a handful of other UK hospitals, including Ipswich, Edinburgh and Exeter, with anything close to a similar service.

'There should be teams such as our one at every hospital to help patients such as Valerie,' says Dr Edmonds.

Valerie knows how lucky she's been. 'I can't bend my ankle, and never will be able to - but my leg has been saved,' she says.

'I can stand and walk on my leg once again. Without the clinic, I'd be fitted with a prosthetic leg. It's a fantastic service.'

• DIABETIC Foot Clinic, King's College Hospital, 020 3299 3223. Diabetes UK, 020 7424 1000, www.diabetes.org.uk

Read more: http://www.dailymail.co.uk/health/article-1228373/Thousands-diabetics-saved-needless-amputation-claims-stop-shop-specialist.html#ixzz0X5O2sJTs

NASCAR and Diabetes: A Family Affair to Prevent Amputations

PHOENIX, Arizona. Jeff DeSantis, past President of the California Podiatric Medical Association and David G. Armstrong, Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance (SALSA) were pit-crew VIP's at the unveiling of the "Diabetes is A Family Affair" initiative supported by the American Podiatric Medical Association (APMA). "It is a privilege to be a part of this enormously important program in such a splendid venue like the Sprint NASCAR series", noted Professor Armstrong, "Nearly one in 5 of the population at this event will have diabetes and everyone here knows someone with the disease. What we need to tell them is that the problem is preventable-- and the most common of diabetic problems-- foot infections and amputations-- are even more preventable." The pair of podiatric leaders were guests of Hall of Fame Racing's number 96 Ask.com Ford, driven by Kevin Harvick. "We're grateful to Hall of Fame Racing's generosity and support and believe that this kind of program can do nothing but good to reduce the needless number of amputations in the USA and around the world."

Toemigo and Flowmigo

Two new self explanatory additions to the list of SALSAisms.

Are Diabetic Feet Less Cushy?

We at SALSA have been fascinated with a recent paper by our colleagues Hsu and coworkers from Chang Gung Memorial Hospital and National Taiwain University Hospital. Their evaluation of the plantar fat pad-- that specialized fat that exists on the sole of every one of us-- may undergo changes in people with diabetes. To make a long story short, fewer small "microchambers" of fat make it less cushy. We invite you to give the work a read. Perhaps this could open the way for more works in plantar fat pad augmentation?

UofA Surgery's Armstrong Named "Cure Award" Winner by American Diabetes Association

Tania and David Armstrong Arrive at the Awards Gala

TUCSON, AZ. David G. Armstrong, Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance at the University of Arizona College of Medicine was given the American Diabetes Association's "Cure" award at a black tie gala held this weekend for his group's work in Amputation Prevention. "This is a honor that I share with our SALSA team, our Department and with our University", noted Dr. Armstrong, a past board member of the American Diabetes Association. "We have found that putting people together really makes a difference. The secret sauce that makes up SALSA is teamwork." Armstrong, a podiatrist and researcher, has produced more than 270 peer reviewed manuscripts and helped to develop the key classifications and guidelines that serve to direct diabetic foot care around the world. His SALSA unit, co-directed by renowned vascular surgeon Dr. Joseph Mills, has served as a model for care regionally, nationally,and internationally.

Free Diabetic Foot Care...in Pakistan

120 patients receive free treatment at Diabetic Foot Clinic

Sunday, November 08, 2009 By Shahina Maqbool

Islamabad Ever since its establishment in March 2009, 120 patients with diabetic foot disease have received free treatment at the Diabetic Foot Care Clinic of the Pakistan Institute of Medical Sciences (PIMS). However, due to limited resources, patients do, at times, have to bear the cost of some drugs, specific tests not available at PIMS, and specialised foot wear necessary to prevent further damage to the affected foot. According to consultant medical specialist and diabetologist Prof. Dr. Jamal Zafar, under whose supervision the clinic was established, the hospital has complete data of 101 patients; 29 patients lost to follow-up and the remaining 72 patients continued the follow-up till their treatment was completed. Out of these 72 patients, 40 recovered completely and 29 recovered with disability i.e., they had minor or major amputations. Three patients died because of overwhelming sepsis developed due to delay in treatment; usually patients initially go to local quacks and general practitioners for treatment. The cumulative rate of major and minor amputations at the PIMS Diabetic Foot Care Clinic stands at 40.27 per cent. These data suggest a tremendous success in treatment of such patients as the rate of amputation varies between 70-80 per cent in the absence of specialised diabetic foot care treatment facilities. Apart from this, the clinic also offers counselling for patients regarding foot care, diet plans, exercises and literature. Minor debridements and dressing of wounds is done in the clinic, but if the wound is more complicated, then the patient is surgically managed by the Department of General Surgery under supervision of Prof. Dr. Tanvir Khaliq. A certified dresser is also available at the clinic to provide specialised dressing facilities to patients at their homes so that they don’t have to visit the clinic on a daily basis for dressing, which is usually required for months. “This facility can be made available to patients in Islamabad and Rawalpindi at a very nominal cost if some NGO or philanthropist gets involved in bearing the cost,” Dr. Jamal pointed out. The Diabetic Foot Care Clinic is working six days a week from 8 a.m. to 2:00 p.m. daily and registration is open for all diabetic patients, not only for treatment of patients having established diabetic foot disease, but also for counselling of diabetics regarding foot care, dietary and lifestyle modifications. A diabetes educationist is also available at the clinic every Monday and Thursday. The PIMS Diabetic Foot Care Clinic is increasingly being recognised as a unique initiative of its kind in the whole region of Northern Punjab, NWFP, Kashmir and Northern Areas. The clinic follows a multidisciplinary approach for provision of care to diabetic patients in terms of prevention and treatment of a very common and disabling complication of diabetes i.e., diabetic foot disease, which is the commonest medical cause of amputation of extremities worldwide. “The idea behind the establishment of the clinic was not only to create awareness amongst diabetic patients regarding foot care, but also to provide specialised services to them under a single roof in terms of diabetic physician, surgeon and podiatrist,” says Dr. Sohaib Ejaz; resident in General Medicine, who has been specially trained and has got certification in diabetic foot care management. He added that all residents in the unit have been trained by seniors and are actively participating in diabetic foot care.

Order up a SALSAchino: Wound Care to Order?

We have been discussing "wound chemotherapy" for some time at SALSA. That is: delivery of specific agents (antimicrobials, anti-inflammatories, pro-angiogenic factors, anti-biofilm agents, growth factors). In fact, it is now a daily treatment regime on our service through modified negative pressure wound therapy modalities.

As we do this more frequently, we liken ourselves to the barrista at the local coffee joint or a bartender or a "mixologist". Dr. Joe Mills just called me during ward rounds and, after criticizing my work ethic for not joining him (he is very needy, mind you), he delivered some SALSAism gems. Some new terms of art related to our SALSA mixology:

SALSAlatte (like salicylate, an antiinflammatory)

Podobarrista

Plantar Flappochino

Feel free to email us with your ideas and experiences as you embark on your own good works.

Armstrong/SALSA Tout Team Approach to Amputation Prevention at 35th Mexican Association for General Surgery International Symposium

Armstrong lecturing to Mexican Association for General Surgery's Symposium in Acapulco, Mexico from University of Arizona

David G. Armstrong, DPM, PhD, Professor of Surgery at the University of Arizona became the first podiatric surgeon to address the Mexican Association for General Surgery's International Symposium. The lecture, which was given by way of the University's biomedical communications unit to the congress in Acapulco, detailed the structure and function of the renowned Southern Arizona Limb Salvage Alliance (SALSA) and techniques to prevent amputation in people with diabetes. "We believe strongly that team trumps technology", noted Dr. Armstrong, "However, when both are combined, it is a really wonderful combination." The session, which was chaired by Surgeon Fermin Martinez de Jesus, President and Founder of the Mexican Diabetic Foot Society. This symposium was preceded by a pre-conference which included podiatric surgeon Stephanie Wu, Associate Professor of Surgery at Rosalind Franklin University of Medicine and Science as well as a "virtual" visit by Professor Armstrong.

From the APMA: Nearly 40% of African Americans Delay Preventative Diabetic Foot Care Because of Lack of Coverage

BETHESDA, MD -- 11/03/09 -- New national survey results show that nearly 40 percent of African-Americans with diabetes delay a visit to a podiatrist -- a critical member of a diabetes management team -- because they cannot afford the necessary medical care, according to the American Podiatric Medical Association (APMA).

The nationally balanced sample, which included 400 African-American men and women with and without diabetes, found that 38 percent of respondents with diabetes put off a visit to a podiatrist because they could not afford care, had no insurance, or care was not covered by their insurance plan. Additionally, while nearly all respondents (98%) agreed that proper foot care is vital, almost half (48%) admitted that they have never been to a podiatrist for a diabetic foot examination or treatment. African-Americans are twice as likely as Caucasian-Americans to develop diabetes.

"More than half of all African-Americans -- 54 percent -- reported in our survey that they have at least one family member with diabetes," said APMA President Ronald D. Jensen, DPM. "Diabetes has a tendency to be genetic, and the disease truly is a family affair. It is vital that our nation's health care reform plan include stipulations that ensure all Americans, both those with and at risk for diabetes, can afford the necessary diabetes care and management that they require."

Studies have shown that greater public awareness of diabetic foot care could positively impact the American health care system. According to an article in the Journal of the American Podiatric Medical Association, comprehensive amputation prevention programs have reduced amputation rates up to 70 percent -- saving the health care system up to $8 billion each year.

APMA's "Diabetes is a Family Affair" campaign -- which takes place during November's Diabetes Awareness Month -- encourages those with diabetes, as well as those at risk, to openly discuss the disease with family members. Diabetes, an American health epidemic, is often passed down from parents to children. While the survey found that 77 percent of African-Americans say they are willing to talk to their family about diabetes, those who do not have the disease are far less likely to do so than those who are currently suffering from it (59% vs. 95%).

Other results from the survey found that 47 percent of African-Americans with diabetes have experienced foot issues related to the disease, -- which can lead to a foot or leg amputation without treatment. For the results from the survey in their entirety, or more information about APMA's "Diabetes is a Family Affair" campaign, visit www.apma.org/diabetes.

Founded in 1912, the American Podiatric Medical Association (APMA) is the nation's leading and recognized professional organization for doctors of podiatric medicine (DPMs). DPMs are podiatric physicians and surgeons, also known as podiatrists, qualified by their education, training and experience to diagnose and treat conditions affecting the foot, ankle and structures of the leg. The medical education and training of a DPM includes four years of undergraduate education, four years of graduate education at an accredited podiatric medical college and two or three years of hospital residency training. APMA has 53 state component locations across the United States and its territories, with a membership of close to 12,000 podiatrists. All practicing APMA members are licensed by the state in which they practice podiatric medicine. For more information, visit www.apma.org.

Mills, Armstrong Bring Toe and Flow to Indian Health Service Symposium

Photo (from L)

Joseph L. Mills, MD, Professor of Surgery, University of Arizona

David G. Armstrong, DPM, PhD, Professor of Surgery, University of Arizona

The renowned Southern Arizona Limb Salvage Alliance (SALSA) service of
the Department of Surgery at the University of Arizona had their
teamwork on full display this weekend in a novel simultaneous lecture
at the Native American Cardiology Program/IHS Conference, held in
Scottsdale, Arizona. "This was a truly fun program.", noted Professor
Armstrong. "To be able to take the dynamic, debate, and camaraderie we
have in the clinic, on the wards and in the operating room to the
podium is a rare treat." Professors Armstrong and Mills described the
now well-known "Toe and Flow" concept for amputation prevention.
Armstrong went on to suggest "It is a sad fact that amputations are
several times higher amongst Native Americans in the USA than for
other Americans. The fact that it is a fact, though, doesn't make it
right or necessary. These problems are preventable. That's why we come
together in symposia like this." The program, chaired by noted
cardiologist Beth Malasky, included clinicians, scientists and
epidemiologists from throughout the nation.

SALSA adds "Sole" to Renowned Bioimaging Institute Program

David G. Armstrong, Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance (SALSA) joined six other renowned researchers to present at this year's Advanced Research Institute for Biomedical Imaging (ARIBI) workshop. "We have learned long ago that no clinician is an island when caring for a disease", noted Armstrong, "The same can be said for scientists. When people doing cutting edge optics and signal processing combine with clinicians asking basic questions, the result can be transformative." Armstrong presented a wide range of imaging technologies being developed and tested by SALSA, including 3-D imaging tools to, as Armstrong put it, "Tivo, or time-shift the physical exam" for later playback and analysis to new methods of measuring skin temperature by patients at home that have been shown to reduce risk for limb threatening diabetic foot ulcers. The program, coordinated by ARIBI's Director, Professor Ron Lynch, included topics ranging from cutting edge imaging of the nervous system to novel methods to monitor cardiac and oncologic therapies.

University of Arizona's SALSA Spices up the Palais Des Congres de Montreal for IDF World Diabetes Congress

The Southern Arizona Limb Salvage Alliance (SALSA) of the Department of Surgery at the University of Arizona College of Medicine was well represented at the largest diabetes symposium in the world today in Montreal. SALSA Scientist Dr. Manish Bharara is presenting three SALSA studies on Thermometry (used to predict wounds), the team approach to amputation prevention (commonly referred to as the "Toe & Flow"-- a term coined by SALSA) and Diabetes Related Amputations. These works were co-authored by SALSA clinician-scientists Prof. David G Armstrong, Prof. Joseph Mills, Prof. Horacio L Rilo and Dr. Ryan Fitzgerald. "I am enormously pleased with how well these have been received", noted Dr. Bharara. "It is an indication of the global epidemic we're in and the high quality work going on at centers, worldwide to stem the tide of amputations."

Photo caption:

SALSA's Manish Bharara, PhD and Professor Hermelinda Pedrosa, MD, of Brasilia during IDF Poster Session

Press Release: Latest diabetes figures paint grim global picture

International Diabetes Federation says epidemic out of control

The International Diabetes Federation (IDF) released new data today showing that a staggering 285 million people worldwide have diabetes. The latest figures from the IDF Diabetes Atlas indicate that people in low and middle-income countries (LMCs) are bearing the brunt of the epidemic, and that the disease is affecting far more people of working age than previously believed.

Read the full press release

"Aggressive Care Saved my Foot"

Message from the BBC:

by Jane Elliott Health reporter, BBC News

John Parker's foot was saved

This article contains a graphic image of an infected limb.

Pensioner John Parker, from Bromley, Kent, walks with a stick to help him balance.

But despite this John, who has type 2 diabetes, knows he is a lucky man.

For he has had months of diabetic ulcers and could have lost a few toes, or even his foot.

Thankfully, through aggressive treatment, doctors were able to save all John's toes.

But recent figures show that many are not as lucky.

The NHS spends £600m a year on treating foot problems in people with diabetes, and £252m of this is spent on amputation.

Diabetes can cause damage both to the nerves of the foot, and to the blood supply that keeps the foot tissues healthy.

I think I must have very good healing properties - my mother lived to 104 John Parker

Both can lead to foot ulcers and slow-healing wounds which, if they become infected, can result in amputation.

Professor Mike Edmonds, a diabetic consultant at King's College Hospital, London, treated John.

He said there are about 100 amputations a week in the UK because of foot ulcers.

But he believes at least half of these could have been prevented.

The key, he says, is to ensure patients get speedy, aggressive treatment, provided by experts across a range of disciplines.

It is an approach that Professor Edmonds has pioneered at his clinic, which takes on patients with the most severe of symptoms.

It has the facilities to offer interventions such as radiology to improve circulation in the legs, and bypass surgery to clear blockages in damaged blood vessels.

"Our remit is to get patients out of trouble quickly," said Professor Edmonds.

"It is all about preventing the natural disease progressing to an irretrievable state.

"It is about putting all these measures into use to preserve the limb."

Saving limbs

The clinic sees around 20-35 cases each day in the foot clinic, but only have about two to three amputations each year.

It compares very favourably with other units - particularly as some patients have been referred for a second, or even third, opinion.

John - who has had heart and renal problems - was admitted to the clinic as an emergency.

He realised he could lose some toes - but was not aware until after his treatment that his whole foot was at risk.

He underwent bypass surgery to clear the blockage in his leg and angioplasty to widen his femoral artery.

Diabetics can cause severe damage to foot tissues

"Possibly he would not have been considered for surgery in other places because of his heart problems," said Professor Edmonds.

"But here he had a package of multi-disciplinary care that saved his leg."

John's wife Sheila agreed that her husband had been a lucky man.

"They were a bit hesitant because of his heart trouble," she said.

"They very carefully explained all the pros and cons.

"They told us afterwards that he could have lost his foot - but it didn't sink in at the time."

John agrees that the hospital was vital in his recovery, but also credits his own genes for helping.

"The bypass has healed perfectly," he said.

"I think I must have very good healing properties - my mother lived to 104."

The 2010 SALSA Fellowship at University of Arizona is open for applications

Deadline for Applications: 1 January, 2010

The fellowship’s central aim is to train and develop future leaders in this field.

The Southern Arizona Limb Salvage Alliance (SALSA) in the Department of Surgery, University of Arizona, is currently seeking qualified applicants for the position of Diabetic Foot Fellow for the July 2010-2011 academic year. Foci of fellowships, depending on the applicant, range from basic research to clinical research to robust reconstructive foot and ankle surgical training in limb salvage techniques in a uniquely integrated "toe and flow" service model. Most candidates combine a hybrid of clinical and research foci.

Ideal candidates should possess an already strong academic background with a keen interest in academic development, inpatient and outpatient care, and research. While preference is given to podiatrists, we train fellows from a variety of medical, surgical, and research backgrounds.

This fellowship was developed to meet the unique and varied health, education and research needs of the field of diabetic foot care. SALSA and University Medical Center provides care for patients throughout the Southwest, with regular out of state and international consultations. SALSA is one of the most dynamic and productive clinical/research teams in the world dedicated to the diabetic foot, wound healing, and limb salvage.

Graduates of Armstrong-led fellowship programs include many of the leading clinicians and researchers in the field, worldwide.

Applicants should forward a letter of intent (preferably via email) with their curriculum vitae to the attention of:

David G. Armstrong, DPM, PhD

Professor of Surgery

Director, SALSA

Department of Surgery

University of Arizona College of Medicine

1501 North Campbell Avenue

PO Box 245072

Tucson, Arizona, 85724-5072

dga@email.arizona.edu

Der Dopplerganger and Toebama: SALSAisms

On our SALSA toe and flow service, we often operate in close quarters. This
has led to many appellations for and colloquialisms used by various team members. Here is a
partial (and running) list:

1. ManifesTOE: An operative report following an amputation prevention procedure (bypass or incision and drainage or graft/flap.
2. Toemigo/Flowmigo (self explanatory)
3. FreeToes with SALSA (mantra for limb salvage)
4. Toebama and Joe the Plumber (nicknames designed to politicize the Toe and Flow team-- however, there are no wedge issues in SALSA-- just wedge pressures).
5. Toe and Flowmance (bromance between podiatrist and vascular surgeon)
6. The Toebel "piece" prize: Award for prevention periodically given for keeping a person intact.
7. FloJoe (Armstrong's affectionate nickname for Mills)
8. Toe Bless Oblige (the obligation to improve foot care)
9. Podshine
10. Der DopplerGanger - referring to one's vascular partner
11. Sir I-Pod (international podiatrist)
12. PodCaster
13. Toe Mechanic
14. SALSA Bowl (for our laboratories)
15. Podiatric physician extender (given to our vascular surgical team)
16. SALSA Relay: handing off a particularly challenging patient between SALSA team members.
17. Non-life partner: one's professional SALSA partner
18. Marooned on the Pedal Peninsula: trying to heal a wound on the foot without sufficient blood flow.
19. Impaired Toemerular Filtration Rate (TFR): End Stage Renal Disease's ravages on healing.
20. MalaPodism: diagnosing a foot problem incorrectly-- or as something else.
21. EuTOEpia: A state of podiatric and vascular bliss.
22. Podtification: contemplation on a particularly difficult patient.
23. Podogenic: A particularly impressive foot photograph
24. Podigraphy: Medical imaging for the feet
25. The Sole Train: A typically busy Armstrong-Mills tuesday SALSA clinic
26. Sole searching: a particularly thorough foot examination
27. Filet of Sole: the proper way to drain an extensive plantar space infection
28. Plantar fascist: one who lines him or herself against a team approach to limb salvage.
29. Toereador: one who fights diabetic foot infections
30. Sourtoe roll: Patients with infections that tend to roll in on Friday afternoon.
31. Toeligarchy (Flowligarchy)/singular: Toeligarch: The "Toe and Flow" team, run by benign digital despots.
32. Podiatrust: faith in ones SALSA parter (from George Andros)

There are many more. We will try to update this list periodically. Any suggestions? Send a note to: armstrong@usa.net

The Wound Healing Spectrum: A Timeline for Utilization of Advanced Therapies

There has been a consistent request for some clarity on where various classes of wound healing modalities may fit along a timeline. Rather than adhere to a "one size fits all" concept, more clinicians have moved toward a multimodal approach. This manuscript, which was published today in the maiden voyage issue of the Journal of Diabetic Foot Complications (an open access journal) continues this discussion.

The Wound Healing Spectrum

APMA News Features Toe and Flow

The latest APMA News features a cover story on the APMA-SVS Toe and Flow Collaborative from its inception in Tucson with SALSA to plans for the future.

The article along with a related article on an up and coming LA-based Toe and Flow Unit under the aegis of Drs. George Andros, Lee Rogers and Nick Bevilacqua, is included here. Enjoy.

Apma News Oct 2009

Interview with Dr. Armstrong: "Meet the Masters"

For those of you who wanted a link to the recent "meet the masters" session, hosted by Dr. Bret Ribotsky, feel free to listen to it here.

Meet the Masters Series Enters the SALSA Bowl: Tuesday at 9PM Eastern/6 Pacific (http://bit.ly/1at8wN)

I'm honored to have been invited by the always compelling Dr. Bret Ribotsky to join him for a "Meet the Masters" interview Tuesday, 28 September at 9PM Eastern, 6PM Pacific. Go to www.PodiatricSuccess.com
For more information and join in!

SVS And APMA Alliance Provides Better Care To Diabetic Patients

The Society for Vascular Surgery® (SVS) and the American Podiatric Medical Association (APMA) announce formation of a strategic collaboration to help advance the care of patients with critical limb ischemia, especially in the diabetic population. The multidisciplinary team approach was outlined during a meeting between leaders of both associations in August.

The collaboration includes an agreement approved by the respective boards of SVS and APMA to identify clinical issues, questions important to both memberships, and to work together to find solutions that will benefit our patients. Specifically, in the August leadership meeting, it was agreed to:

1. Appoint a group representing both organizations to write a joint statement on the multidisciplinary team approach to the care of diabetic foot

2. Produce a supplement on the care of the diabetic foot that will be jointly published in the Journal of Vascular Surgery® and the Journal of the American Podiatric Medical Association

3. Establish joint postgraduate courses to be held at the annual scientific meetings of both organizations

4. Collaborate on practice guidelines and reporting standards dealing with the care of diabetic foot

5. Collaborate on advocacy and public awareness efforts in areas of common interest

"Vascular surgeons and podiatrists have always worked together to provide the best care for patients with diabetic foot problems," said Anton N. Sidawy, president, SVS. "We are pleased to formalize an alliance with APMA so that we can jointly work on the prevention and management of diabetic foot, which would positively impact the care of our patients. Our staffs will conduct public education programs to raise awareness and promote prevention."

A Management of the Diabetic Foot session was a highlight at the SVS' 2009 Vascular Annual Meeting®.

Toe and Flow: History in DC

Front (L-R): Anton Sidawy (President, SVS), Ron Jensen (President, APMA)

Back: Richard Neville (Georgetown), John Steinberg (Georgetown), David G. Armstrong (University of Arizona/SALSA), George Andros (Los Angeles), Christopher Attinger (Georgetown)

In the annals of amputation prevention, this will be remembered as a great day. The American Podiatric Medical Association (APMA) and the Society for Vascular Surgery (SVS) today ratified a historic collaboration that will continue efforts begun by many teams to enhance work toward amputation prevention.

Diabetes Foot Specialists Say Cost-Effective Wound Therapy Underused Due to Healthcare Reimbursement Incentives

WHAT: Every 30 seconds, across the globe an individual loses a limb due to poor diabetes management. In the U.S., diabetes affects nearly 24 million people. When poorly controlled, diabetes results in nerve damage and poor circulation to the legs and feet. When this occurs, patients lose the ability to sense foot pain injury, and, when left untreated, which leads to foot ulcers, reduced mobility and amputation. *Approximately 85% of amputations are preceded by a foot ulcer that doesn’t heal.

Preventive care makes the difference. Leading podiatric experts, Dr. John S. Steinberg of Georgetown University Hospital’s Department of Surgery, and Dr. David G. Armstrong, director of the Southern Arizona Limb Salvage Alliance (SALSA), are pioneers of the "toe and flow’’ approach, which they say is more effective than repeated endovascular stent procedures. They urge a team approach to diabetic foot care and argue that current health reimbursement incentives work against delivery of evidence-based guidelines and cost-effective care.

WHEN:		September 24-26 Georgetown Diabetic Limb Salvage Conference
WHERE:		JW Marriott Pennsylvania Avenue Hotel
		Washington, DC
WHO:		David G. Armstrong, DPM, PhD, Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance (SALSA), Arizona Health Sciences Center, Tucson, AZ. www.diabeticfootonline.com
		John S. Steinberg, DPM, FACFAS, Department of Surgery and Co-Director of the Wound Healing Center, Georgetown University Hospital, Washington, D.C.

From PNAS: Using Math to Heal Wounds

By Laura Sanders, Science News

A mathematical model may help clinicians speed the healing of persistent bedsores, diabetic ulcers and other types of chronic wounds, scientists report online September 21 in the Proceedings of the National Academy of Sciences.


Chronic wounds are a serious public health problem, affecting 6.5 million people in the United States, says study coauthor Avner Friedman of Ohio State University in Columbus. These wounds linger, often because they don’t get enough blood flushing them with oxygen and other healing factors. Friedman and his colleagues’ new model is the first to predict the healing behavior of such blood-deprived — or ischemic — wounds, he says.

Mathematician John Dallon of Brigham Young University in Provo, Utah, says that the new model is the “start of something that could give valuable insight to the wound healing problem in the future.”

Friedman and his colleagues started by modeling a simple, flat wound at the skin’s surface. First the team developed equations to represent the springy, elastic tissue near the wound. Another set of equations predicted when and how healing factors enter the wound. Such factors include pathogen-busting white blood cells, capillary sprouts, blood-vessel–forming proteins and oxygen concentrations. By tweaking the amount of oxygen near the wound, researchers could model the healing of nonischemic and ischemic wounds.

The model’s simulations agreed with wound healing times found in experiments, the authors say. An eight-millimeter–wide wound under normal conditions is predicted to completely heal in about 13 days. But an ischemic wound would be only 25 percent healed after 20 days. The model also predicts that under low-oxygen conditions, fewer white blood cells can reach the wound.

The new model may help clinicians pinpoint better ways to treat wounds, Friedman says, for example by providing guidance about when oxygen and pressure therapies will be most effective.

Although the model includes many variables, others remain unexplored. “Of course, wound healing is extremely complex, and even in their model they have, out of necessity, ignored many things,” Dallon says.

Friedman and his colleagues would like to include in the model the behavior of genes, microRNAs and proteins known to speed along healing. The team would also like to model the tissue underneath the surface of the wound. These kinds of complexities are needed “to really make a big dent into this serious problem,” Friedman says. “Of course, we won’t cure wound healing with mathematics, but we can suggest ideas to biologists.”

Against "Proceduralism"-- Can Team Trump Technology in the Evolving Healthcare Discussion?

Can teams trump technology in the new healthcare debate? I ask because I find myself frustrated by patient after patient we see in our SALSA unit, referred from elsewhere, who have been relegated to amputation. This is not because they haven't had access to technology. In fact, most have had extensive work done. What frustrates me, and I know my SALSA partners, as well, is the lack to access to team.

I am, as we speak, sitting in front of an x-ray of a patient who had extensive endovascular intervention-- but no follow-through to manage her complex wound when the isolated procedure failed. Why? The cynic would suggest that it is because the procedure was reimbursed well, but the necessary healing and preventative followup was perhaps less fiscally rewarding. Therefore, one may posit it easier to justify doing nothing or cutting the limb off.

The point is that our current healthcare discussion must work out some sort of balance to support medical and surgical teamwork instead of simply one-off fee for service proceduralism. I know there must be a way. Too many smart people are involved and committed for this opportunity to pass.

Common Foot Problems and Their Solutions

This was posted today on the outstanding patient website "Diabetes Self-Management"


by David G. Armstrong, DPM, PhD
People with diabetes are often told to pay close attention to their feet — and for good reason. While having diabetes doesn’t make it more likely that you’ll injure your feet in the first place, having certain common diabetes complications raises the risk of minor foot problems becoming major foot problems if not treated promptly.

One of those complications is peripheral neuropathy, or damage to the nerves in the feet and lower legs. Peripheral neuropathy can cause a loss of sensation in the feet, meaning that heat, cold, and/or pain may not be felt. As a result, a person becomes more vulnerable to getting burned if he steps into hot water or walks barefoot on hot pavement or sand, and he’s also more likely to let small blisters, cuts, and scrapes on his feet go untreated since he doesn’t feel them.

The other common diabetes-related complication that raises the risk of foot problems is reduced blood circulation to the feet. Blood carries oxygen and other nutrients and substances that are necessary for wound healing. When blood circulation is reduced, wounds heal more slowly and have more time to become infected.

The good news is that many if not most major foot problems are avoidable. How to do it? Maintain the best blood glucose and blood pressure control possible. Wear well-fitting shoes or slippers at all times (except for sleeping or bathing), and check inside them for foreign objects before putting them on. Check the tops and bottoms of your feet and between your toes every day, especially if you know or suspect you have either neuropathy or reduced blood circulation. Look or feel for any signs of rubbing, injury, or infection, such as redness, broken skin, or areas of unusual warmth.

If you develop a foot problem, attend to it immediately. Apply first-aid measures to small cuts or blisters, then check daily to see whether the wound is healing. Stop wearing any shoes or socks that rub on or bother your feet in any way. And call your diabetes care provider promptly if small wounds do not heal quickly or if you sustain a serious foot injury.

Resolving common problems
Having any kind of foot problem can interfere with your daily life. Here’s how to address some common complaints and keep your feet in good health.

I’d like to walk more for exercise, but my feet hurt when I walk.

Your feet may be hurting for a number of reasons, most of which can be prevented or treated by changing your activity, your shoes, or the insoles in your shoes.

In general, the more active you are, the better you will feel, and walking is a good choice of activity for many people. However, if you have diabetes-related foot problems, check with your doctor about how much walking is safe for you. It may be advisable to alternate between walking and activities that put less stress on your feet, such as bicycling, swimming, or water aerobics. (Be sure to wear water shoes when exercising in water.)

If walking is safe for you, choose walking shoes that are flexible enough to walk in easily but that also provide support and cushioning. Wear socks that provide some cushioning and that wick away sweat. Remember that even the best shoes won’t last forever, and the more you weigh, the faster your shoes will wear out. Generally, shoes will last for no more than 500 miles, which usually equals three to six months of regular walking. Plan on buying a new pair of walking shoes before the old ones wear out so that you can “break in” the new ones a little at a time. (Although shoes should fit well and be comfortable at the time of purchase, it’s recommended that you wear them for only short periods at first and gradually lengthen the time you walk in them.)

If your feet still hurt with well-fitting shoes, or your feet have changed shape so much that no pair of shoes fits well, a podiatrist or other foot expert may be able to recommend insoles or other shoe inserts to allow you to walk comfortably. However, you will still need to replace your shoes at 500-mile intervals (or earlier), and you will most likely need to replace your inserts as well.

I put moisturizing lotion on my feet every day, but the skin on them is still dry and itchy.

Try switching to a thicker lotion or cream, and apply the product more than once a day. For very dry skin, moisturizer should be applied two to four times a day. However, be careful not to put too much between your toes. Too much wetness in this area increases the risk of skin breakdown and infection.

If increased moisturizing doesn’t improve dryness, flaking, or itching, see your primary-care doctor or foot doctor. Very itchy skin is sometimes a sign of a fungal infection such as athlete’s foot.

I have thick calluses on the bottoms of my feet. How can I get rid of them?

Calluses are your body’s way of telling you that you are applying too much pressure to a given area. If you do not have neuropathy, you can use over-the-counter tools to “grate” or file down the callus. The Ped Egg, for example, works well. After reducing the callus, moisturize the skin with a high-quality cream.

If you have neuropathy, calluses are far more serious, because you run the risk of developing an undetected wound underneath the callus. Do not try to treat calluses yourself; instead, have your foot doctor check them regularly. You can prevent calluses in the future by modifying the shoes or insoles you wear to reduce the stress on the area getting callused. Over-the-counter insoles can sometimes work well. For more significant problems, your foot specialist may prescribe insoles or shoe modifications.

Rarely, surgery is required to correct the underlying deformity leading to calluses. This may be considered as an option if a callus puts a person at high risk for developing a foot ulcer.

I’d really like to get a pedicure so my feet look good in sandals, but I’ve heard that people with diabetes shouldn’t get pedicures. Why is this?

People with diabetes are often advised not to get pedicures because of the possibility that salon workers will create small (or large) breaks in the skin while performing the pedicure. Any break in the skin is an access point for dirt and germs, possibly leading to an infection. The other concern about pedicures is that the toenail clippers and other implements used will not be clean, also raising the risk of acquiring an infection at the nail salon.

This doesn’t mean that pedicures are completely off-limits for people with diabetes who have good foot health. Provided the salon is reputable and has a good record of safety, you can get pedicures. However, if you have neuropathy or significant vascular disease, it’s best to forego pedicures: The potential consequences of getting an infection are too high.

I have a hard time cutting my own toenails. Is this something my doctor or a nurse could do for me?

Yes. It is best if a trained medical professional does this, particularly if you have neuropathy or vascular disease. Neuropathy can cause you not to notice small cuts that may occur if toenails are cut improperly or too short, and vascular disease in the legs and feet make you more vulnerable to infection of wounds on the feet.

Your health insurance may cover this type of foot care, but only if your doctor or podiatrist provides evidence that it is medically necessary.

My doctor says I need to treat the fungal infection in my toenails, but I don’t want to take another drug. How important is it really to treat this?

Generally, nail fungus is a cosmetic problem. However, when you have diabetes, fungal infections of the toenails can put you at greater risk for other types of infections and skin problems, particularly as you age. These include bacterial and secondary fungal infections of the skin. For this reason, if your doctor recommends it, you may benefit from a local or systemic treatment for nail fungus.

I have seen advertisements for laser treatment of fungal nails. Is that a good idea?

While it may stand to reason that laser therapy might be effective at killing fungus, the products and treatments currently being advertised really have no data behind them to back them up. If you have otherwise healthy feet and money to spare, you may want to give it a try. However, if you have neuropathy in your feet, vascular disease, or other skin conditions on your feet, I would suggest speaking to your doctor about how best to treat a fungal nail infection.

My feet have changed shape over the years, and it’s hard to find shoes that fit.

It is normal for your feet to flatten very slightly and to change shape, becoming longer and wider, as you age. It’s possible for your shoe size to increase by one or even two sizes over time. That being the case, it is very important to have your feet measured each year to assess your shoe size. A study conducted some years ago by our team in Arizona suggests that three-quarters of people with diabetes wear shoes that are at least one size too big or too small. (Shoes that are too big may allow the feet to slide around, possibly leading to blisters.)

I recommend, at the minimum, an annual visit to your foot specialist for an evaluation. If you have or develop risk factors for diabetes-related foot problems, your specialist may recommend prescription shoes or specific types of over-the-counter shoes. It may also be worth seeking out the services of a certified pedorthist if you have hard-to-fit feet. These footwear specialists may work in medical offices that provide foot care or are sometimes on staff at retail shoe stores that specialize in comfortable shoes. The Pedorthic Footwear Association Web site (www.pedorthics.org) has a search function to find credentialed pedorthists by location.

Shop for shoes later in the day, because feet can swell — sometimes imperceptibly — throughout the day. A shoe that fits well in the morning may be too tight by late afternoon. Buy shoes that provide arch support where you need it and enough room in the toe box for your toes to wiggle a little. Your heel should not lift more than half an inch when you walk.

It’s important that socks fit, too. Look for seamless socks or socks with seams that do not run across the bottoms of the feet or along any bony parts where they can cause pressure. White or light-colored socks are recommended, because any bleeding from a wound on the foot will be noticed quickly.

My feet smell terrible when I take off my shoes. What can I do about this?

This is a very common problem that is generally caused by the growth of bacteria on your feet. Alternating between pairs of shoes so that each pair gets a chance to dry out completely, and changing your socks more than once daily may help. Sprinkling the insides of your shoes with ordinary talcum powder may also reduce odor. If these steps are ineffective, speak to your doctor about alternative approaches. Do not try any home remedies without speaking first to your doctor.

Other common concerns
Unfortunately, many people with diabetes eventually develop neuropathy in their feet, so it’s important to have your doctor examine your feet at least once a year and to know how to protect your feet if you develop it.

My feet are sometimes numb when I wake up in the morning. Does this mean I have diabetic neuropathy?

You may, and your diabetes care doctor or foot specialist can evaluate this with a few simple tests in his office. It’s important to know whether you have neuropathy, or “loss of protective sensation,” in your feet, because that allows you to be proactive about protecting your feet.

Why do doctors say I should check my feet every day?

A daily foot check is one of the best ways to prevent foot complications, including ulcers. It is especially important if you have neuropathy, since you may not feel small injuries to your feet, but it’s a good habit for anyone to check their feet daily for signs of shoe rubbing, blisters, cuts, and calluses. These signs can alert you to the need to change your shoes or socks or to apply first aid. Once you’ve attended to a minor foot problem, check it daily to see if it’s healing normally.

What if you can’t see the bottoms of your feet? Ask a member of your household to look for you, or use a mirror to look yourself. A product called the Insight Foot Care Scale is both a scale (to weigh yourself) and an illuminated, magnified mirror. It automatically lights up after you weigh yourself as a reminder to check your feet. (You should sit down before examining each foot in the mirrored surface.) You can also press a button to turn on the lighted mirror if you don’t wish to weigh yourself first. (Learn more about Insight products at www.focusonyourfeet.com.)

If you have vision loss and cannot see your feet even in a magnified mirror, feel them carefully with your hands. Rub the back of your hand (which is especially sensitive to temperature) along each foot to help you detect cool spots, which may indicate impaired circulation, or unusually warm areas, which could be signs of inflammation and infection.

I’ve had an ulcer on my foot, and I’d really like to prevent another one. How can I do this?

In addition to performing a daily visual or manual foot check, using a skin thermometer to detect areas of inflammation on the feet can be very helpful. The TempTouch is an example of such a thermometer. (Read more about using the TempTouch at www.temptouch.com.)

Inflammation is a sign that a wound may be developing. By measuring the skin temperature at specific points on both feet and comparing the corresponding points on each foot, inflammation can be caught early. A difference of more than 3–4 degrees indicates that a hot spot may need to be looked at by a doctor.

Reason for hope
Attending to minor foot problems early is the best way to prevent major ones. But if you develop a more serious problem, don’t give up hope. Each year, new products and methods are developed for treating diabetes-related foot problems. Take advantage of these medical advances by bringing your foot problems to your primary-care or foot doctor’s attention promptly. Then take an active role in following through with your foot professional’s recommendations. When you work together with your medical team, there’s good reason to hope that your feet will last a lifetime.



Dr. Armstrong is Professor of Surgery and Director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson, Arizona. You can follow Dr. Armstrong's blog posts and other writings via Twitter at www.twitter.com/dgarmstrong or go directly to the SALSA Web site, www.diabeticfootonline.com.

Editorial on PBS: SALSA, Limb Salvage and Diabetes

The following editorial aired this evening on PBS's Arizona Illustrated. The original link is here.

SVS/APMA Toe and Flow Collaborative Lectures Made Freely Available for View/Download

The historic combined "Toe and Flow" Symposium borne out of collaboration between the Society for Vascular Surgery and the American Podiatric Medical Association is now freely available for view or download. Feel free to click here to view.

Health Reform Should Include Diabetes 'War'

Thanks to Dr. Lee Rogers for Picking this up:

Health Reform Should Include Diabetes 'War'

By Mort Kondracke
It would be entirely fitting for Congress to rekindle the "war on cancer" in response to the death of Sen. Edward Kennedy (D-Mass.), but another disease worthy of a war is diabetes.

Cancer kills more people each year - 560,000, according to the Centers for Disease Control and Prevention, compared with 233,600 for diabetes and its complications.

But the CDC estimates that the diabetes figures are hugely underreported and that the actual numbers may be 65 percent higher, or 386,000.

Kennedy's death from glioblastoma, an aggressive brain cancer, is one reason for a renewed attack on cancer.

But, as Gina Kolata pointed out in an illuminating article in the New York Times, Kennedy called for a cancer war months before President Richard Nixon declared it in his 1971 State of the Union message.

Kennedy advocated a larger research budget than Nixon's and enhanced status for the National Cancer Institute - ideas Nixon agreed to support as long as Kennedy's name was not on the bill.

Kennedy agreed and Nixon signed a cancer bill in December 1971. Cancer has received one of the largest budgets at the National Institutes of Health ever since, but clearly it is still not conquered.

The reason for a war on diabetes is that, like some cancers, Type 2 diabetes - the most prevalent type - is heavily a "lifestyle disease" resulting from overeating and lack of activity. Therefore, it's preventable.

(Type 1, or juvenile diabetes, occurs when the body's own immune system attacks the pancreatic cells that produce insulin, the hormone that processes glucose.)

Diabetes can result in ghastly consequences for its 24 million victims, including heart disease, stroke, blindness, kidney failure, amputations and nervous system disease, and it is hugely expensive to the economy.

The CDC estimated the national cost of diabetes in 2007 at $174 billion, including $116 billion in medical expenditures and $58 billion in lost productivity.

According to a 2007 study by the policy research firm Mathematica, the federal government spent nearly $80 billion of that, 12 percent of all federal health spending.

Yet, Mathematica found, 19 different federal agencies spent only $3.9 billion on disease prevention or health promotion activities with some impact on diabetes.

If a "war on diabetes" were declared, it ought to begin with a war on obesity, the epidemic most responsible for rising incidence of Type 2 diabetes among both adults and, increasingly, children.

In 1980, the CDC estimated that 47 percent of U.S. adults were overweight. In 2006, it was an astounding 66 percent, and 34 percent were obese - 72 million people.

Insurance companies and employers have developed incentives for workers to lose weight and become fit such as insurance premium reductions or paid-for gym memberships, but fighting obesity ought to be a major focus of health care reform.

David Snow, CEO of the pharmaceutical distributor Medco, recommends that the government run TV ads to promote healthy lifestyles akin to its fried-egg "your brain on drugs" ads or Smokey Bear anti-forest-fire spots.

I'd go further - pushing videos in school health classes showing diabetes amputees and kidney disease victims the way drivers' ed classes used to scare kids with car wreck films.

Conservatives will surely scream "nanny state" at such moves, but the fact is, obesity costs - as much as 27 percent of recent increases in national health spending, according to health analyst Kenneth Thorpe.

Beyond combating obesity, there's a need for better diabetes screening in government health programs. Medicaid and Medicare ought to adopt the kind of intensive disease-management techniques that many insurance plans employ.

Many plans hire contractors employing nurses to routinely check on patients' blood sugar levels and monitor complications - and pay doctors to prevent complications, not just treat them.

There's increasingly a role for technology. The computer chip maker Intel has deployed a series of home monitoring and communications devices, but is stymied by Food and Drug Administration regulations from going as far as it could.

In Asia, for instance, cell phones are equipped with glucose-testing kits that transmit data to a monitor. Here, the FDA would have to re-approve such a device every time its technology was updated.

How much of the government's $80 billion annual diabetes outlay - expected to triple by 2020 - could be saved by intensive prevention and management? It's a disputed point.

The Congressional Budget Office only estimates costs and savings within a 10-year "window," whereas chronic disease management probably would show results over a longer period.

A new study in the journal Health Affairs estimated that what amounts to a "war" on diabetes, costing $800 million a year, would merely pay for itself over 25 years, not cut the actual costs to the government.

But such a war surely would prevent many strokes, heart attacks, leg amputations and kidney failures. It's hard to believe that wouldn't save money, too.

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Mort Kondracke is the Executive Editor of Roll Call, the newspaper of Capitol Hill since 1955. © 2007 Roll Call, Inc.

http://www.realclearpolitics.com/articles/2009/09/12/_health_reform_should_include_diabetes_war_98268.html at September 13, 2009 - 10:12:46 PM CDT

2009 British Medical Book Competition Awards

I just received word from my colleagues on the other side of the SALSA pond that  2 of the 3 shortlisted books for top awards at the BMA Ceremony this past were on the diabetic foot. As many of you know, this would have been unheard of even 10 years ago. Congratulations to Profs. Ben Lipsky, Lee Sanders, Mike Edmonds and Ali Foster!

Results of the competition announced at the Awards Ceremony 8 September:

First Prize
The Diabetic Foot: Essentials of Managing Infectious Complications
Benjamin A Lipsky - Current Medicine Group, August
2008 ISBN: 9781858734255

Highly commended
Practical Manual of Diabetic Foot Care.
2nd edition
Michael E Edmonds, Alethea VM Foster, and Lee
Sanders - Wiley-Blackwell, January 2008
ISBN: 9781405161473
 

From Diabetes Mine: A Foot Scanner To Prevent Amputations

Congratulations to the folks at MeDavinci for this device. We have long been advocating a "personal health network". This home foot portal is a definite first step.

________________

The Vincent 50 for Diabetic Feet
Speaking of taking care of your diabetic feet, I was contacted this week by a European company called MeDaVinci working feverishly on a high-tech home scanning device that they hope will prevent amputations in thousands of patients who already have neuropathy.

Their system is called the Vincent 50 — after the St.Vincent Declaration, a decree signed by global health organizations in 1989 that vowed to cut the rate of diabetes-related foot amputations by 50%.







Yes, it’s a chunky box that looks like something dreamed up for The Jetsons, but it is 2010 state-of-the-art, the company tells me. Meant to be used daily by patients with existing foot damage, it automatically takes images of the soles and a “temperature profile of the foot.” This precise information is then immediately transmitted to a call center, where trained nurses “can make an overlay with earlier images and distract the pixels, to see if there are changes in inflammation or callus formation. If so, the patient is called and urged to visit the doctor or podiatrist.”

Company spokesman Ger Biesbrouck writes to me from Amsterdam that his team was “quite surprised” to discover the video entry in this year’s DiabetesMine Design Challenge on the FootSafe foot scanner, because his team believed they had no competition with this type of foot scanner.

What’s different about the Vincent 50, I’m told, is that it makes “non weight-bearing” images of the foot, so professionals can get a better view of possible damages. “See what is happening if you press your hand against a glass,” Ger writes. “It turns white, but you would like to see the red aspect.“ When the patient has to stand on the scanner, the pressure itself alters the image. Without pressure, the image shows every aspect of the foot and skin, pure and simple.

MeDaVinci already has a European patent on the technology, and patents are pending in the US and Japan, expected to be granted early 2010. My question of course was consumer price point: will the US health plans really cover such a costly home device? If not, who can afford such a fancy home scanner?

“We only see a market with high-risk patients, with poor sight and stiff joints, who already had an ulcer or minor amputation. From statistics we know that within a year 50% will develop a new problem. Preventing this problem will justify the placement of a scanner,” Ger adds.

Well, in Europe that is probably the case. But no guarantees in this country, where health care has gone from a “hairball” to a national battlefield. Nevertheless, the financial case for an ultra-sensitive home foot scanner for people with diabetic foot damage is a strong one. Consider:

* According to the International Diabetes Federation, there are over 1 million amputations worldwide each year

* Every 30 seconds, a lower limb is lost somewhere in the world as a consequence of diabetes

* The risk of amputation is a life long threat to diabetic patients; following an amputation, 30 to 50% of patients will undergo a further amputation of (or part of) the other foot within 5 years

* The diabetic foot is now one of the major problems in health care for the coming decade



If you have neuropathy, I beg you to perform those daily checks. If you don’t, and you’re lazy like me, this might be a good wake up call to start paying attention to your diabetic feet!

Diabetic foot team lowers rate of major amputations

Incidence of major diabetic foot amputations decreased 41% in 10 years.

By Gina Brockenbrough
ORTHOPAEDICS TODAY EUROPE 2009; 12:17
Norwegian investigators discovered a significant decrease in the incidence of diabetic foot amputations in one town 10 years after the establishment of a diabetic foot team at the city’s only hospital.

“We have registered a 41% decrease in major diabetic amputations,” Eivind Witsø, MD, said during his presentation at the 10th EFORT Congress. “The decrease reflects the improved quality of the prevention and treatment of diabetic foot ulcers and a general improvement in public health.”

In a previous study of patients with diabetes in the city of Trondheim, Norway, Witsø and his colleagues identified a rate of 4.4 lower extremity amputations per 1,000 patients each year between 1994 and 1997 — a rate he considered high.

In response, the investigators established the Trondheim Diabetic Foot Team as part of the orthopaedic surgery department at St. Olav’s University Hospital. The team consisted of an orthopaedic surgeon, nurse, podiatrist, prosthetist and orthotist, and focused on preventative care and early treatment.

The investigators compared the incidence of diabetic amputations from 1994 to 1997 with information from 2004 to 2007.


Amputations

The investigators found that the overall incidence of diabetic amputations per 1,000 patients with diabetes per year significantly decreased from 4.4 to 2.8 in 10 years.

Although they found that the incidence of minor diabetic amputations also decreased, the difference was not statistically significant.

Witsø said the study revealed no significant difference in the number of vascular interventions performed on patients with diabetes during the decade. He also noted that the diabetic foot team screened nearly 750 patients and performed nearly 6,000 consultations between 1996 and 2006.

A global trend?

During the paper discussion, co-moderator Per Kjaersgaard-Andersen, MD, asked Witsø if there has been a global decrease in the incidence of diabetic amputation.

“No, it’s not a global observation,” Witsø responded. He noted that while some countries have seen a decrease, diabetic foot amputation remains a major problem in other nations. He added that other researchers have observed a decline in diabetic amputations due to preventative care and an increase in vascular interventions.

“Perhaps this is one of the first studies that has shown a decrease in amputations that cannot be explained by an increase in vascular interventions,” Witsø said.

For more information:
Per Kjaersgaard-Andersen, MD, heads the Section for Hip and Knee Replacement, Department of Orthopaedics, Vejle Hospital, DK-7100 Vejle, Denmark; +45-7940-5716; e-mail: pka@dadlnet.dk. He has no direct financial interest in any products or companies mentioned in this article.
Eivind Witsø, MD, can be reached at St. Olav’s University Hospital, Norwegian University of Science, Gate 17, N-7006 Trondheim, Norway, 7030; +47-738-68000; e-mail: eivind.witso@stolav.no. He has no direct financial interest in any products or companies mentioned in this article.
Reference:

Eivind W, Arne L, Stian L. Forty percent decrease in the incidence of diabetic amputations in 10 years. Paper F197. Presented at the 10th EFORT Congress. June 3-6, 2009. Vienna.

Spreading the SALSA: University of Arizona's SALSA and University of Cardiff's Transatlantic Healing Collaborative Well Underway

The University of Arizona's Southern Arizona Limb Salvage Alliance (SALSA), under the direction of Professor of Surgery David G. Armstrong, DPM, PhD, continued its goal of "spreading the SALSA" in its unique collaborative with the renowned Wound Healing Research Unit at the University of Cardiff United Kingdom. The Collaborative, which has contributed to research and education, took on a new arm this week with Armstrong's lecture to Cardiff University's Masters of Science program in Tissue Repair and Wound Healing. "As a graduate of that program, it is an absolute pleasure to work with them in this capacity." noted Armstrong. "Our Universities' collective Biocommunications units are absolutely world class on both sides of the Atlantic. Telemedicine and telemedical education are now part and parcel of SALSA's mission." The MSc program, founded and run by Cardiff University's Professor Keith Harding, is the first and only Masters program of its type in the world. 

Heat Shock Relevant Cascade: Building the Podiatrist's Armour Against Inflammation

Providing better outcomes for patients with diabetic foot ulcers is the key to reduce the burden of traumatic amputations. Recent work from Mir et al. (2009), Christian Medical College, Vellore (India), suggests that heat shock protein 70 gene polymorphism is associated with the severity of diabetic foot ulcer. This is a remarkable concept and we at SALSA bowl feel it could be another armour in our fight against inflammation.

Wikipedia defines Heat Shock Proteins as "Heat shock proteins (HSP) are a class of functionally related proteins whose expression is increased when cells are exposed to elevated temperatures or other stress". This may be directly related to the diabetic population with lower extremity complications. It is often the repetitive stress/trauma and increased temperature that precedes an underlying ulceration.

What is amazing is that, temperature (or inflammation) is not always bad! Although, inflammation precedes an underlying ulceration, it is also an essential permissive component of the healing cascade. We at SALSA are studying temperature patterns/profiles for both pre-ulcerous patients and patients with active ulcers. We often refer to temperatures as the "Flare response" at the plantar surface. The working hypothesis is that perhaps by identifying this flare at baseline and developing a "Thermal Index" we can predict healers Vs non-healers, much on the lines of Dr. Sheehan's work regarding identifying which wounds would benefit from the expensive wound care modalities and which ones could be healed with less expensive modalities.

We will continue to watch this space and perhaps, study the association between HSP and plantar temperatures to validate this theory. "Perhaps someone that already has a lot of inflammation doesn't mount the extra flare required to heal".

Labor Day on the Pedal Peninsula

Greetings from the SALSA Bowl. Busy as usual at the University. We thought we might share with you some thoughts as we labor on this Labor day.

Joe Mills and I were doing an interview this morning for one of our professional magazines and we were reflecting on why the foot in diabetes seems so remarkably rich-- largely because we're at the end of what I refer to as an "anatomic peninsula". For that reason, we're hostage to the supply from the "anatomic mainland".

When we were asked about our research projects, we remarked that we were presently laboring on 23 funded projects evenly distributed between industry, non-for-profit, and Federal. I started to describe the tremendously diverse topics on which we are fortunate enough to work. These span everything from fancy arch supports, to computer designed shoes, to collagen that is woven on a loom to intelligent textiles, to super-strong tinkertoy fixation devices to chemotherapeutics to skin temperatures to new-fangled vascular conduits to psychiatry to neurology to superbugs to stem cells. I realized that this diversity, in a way, formed a union-- each project's ultimate goal is to prevent us getting "cut off" from the mainland.

I suppose, then, that's our thought for the day. We labor to prevent the rising tide of amputation to wash over our peninsula. That's enough work for all of us. There is power in a (diabetic foot) union.

"Step by Step" toward amputation reduction: training in worldwide "hotspots"

‘Step by Step’ diabetes
foot care training starts

PHILIPSBURG--St. Maarten took a giant step forward in its diabetes care on Sunday when the “Step by Step” diabetes foot care training programme was introduced.

Step by Step is a diabetic foot care education programme aimed at training health care providers to become certified diabetic foot care assistants. “The goal is to improve diabetic foot care in St. Maarten,” Diabetes Foundation of St. Maarten explained.

The programme is divided into two phases: one year for the basic course and an advanced course in the compulsory second year.

Following the basic intense three-day course, participants will have to report on their experiences and complete assignments throughout the first year.

The local faculty consists of general surgeon Dr. Felix Holiday, who will present an assessment of the foot care situation in St. Maarten and the need for the Step by Step Programme, and Internal Medicine specialist Dr. Theo Jolles, who will discuss the topic “Own country perspective on infection and treatment.”

Also a member of the faculty is general practitioner Dr. Sonia Swanston, who will discuss the differentiation between neuropathic and neuro-ischemic foot problems.

Other subjects such as what goes wrong with the diabetic foot, painful feet diagnosis, management, history taking and record keeping, a practical session on callus removal, workshop sessions on examining the foot that include the use of a tuning fork and monofilament, and live practical demonstrations of wound care on patients will be conducted by an international faculty comprising Belgian Doctor of Internal Medicine Dr. Kristien van Acker; United Kingdom podiatrist Neil Baker and Slovenian Professor Dr. Vilma Urbancic.

The six participants from St. Maarten and Statia were drawn from St. Martin’s Home, St. Maarten Medical Center (SMMC), White and Yellow Cross Foundation, a wound care nurse from Statia, two physical therapists and one medical pedicurist.

“With this course at least basic foot care will become available to the diabetic community and others in St. Maarten. Taking into consideration the urgent strained economic times, receiving the much-needed Step by Step Diabetic Foot Care project entirely free of charge is a true gift for which all of us should be more than grateful,” the foundation said.




Copyright ©2008 The Daily Herald St. Maarten
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Thermometry, Activity & Patients: Notes for the Physicians

"What should a clinician do in regards with thermometry and activity monitoring, when seeing a diabetic patient?"

All the literature out there, suggests that thermometry is useful in "Preventing" foot ulcers and the proven "Delta T" that is considered pre-ulcerous, is 4 Deg F or 2.2 Deg C. However, whether this value of "Delta T" is not validated for newly diagnosed diabetics or diabetics without any history of ulceration. It may stand to reason that, a different "Delta T" value may be true for this population, because thermal receptors are damaged much like mechanical receptors at the onset of neuropathy. Whether, this damage is instant or time driven, needs to be answered in an independent research study. There is some related evidence in this area, but we need to connect the dots through more studies.

To simplify things, it may be better to discuss temperature monitoring with patients based on their duration of diabetes and history of prior ulceration.

1) If there is a history of prior ulceration, there are hand held thermometers and proven "Delta T" that can be used to assess any pre-ulcerous symptoms through serial temperature logs. It must be emphasized that this "Delta T" as a one time measure may not be a cause of concern, however, if there is a clear pattern over 3-4 days of high Delta T, patient should immediately be seen by the physician.

2) On the contrary, if you are managing a newly diagnosed diabetic, with or without neuropathy, the same criterion for "Delta T" can be used at this stage with the additional serial monitoring of neurological damage over time (as the German study suggests).

Physicians must be cautioned when dealing with patients with significant PVD and those who undergo vascular procedures to restore blood supply to the extremities.
This patient group should only be advised above thermometry monitoring, once the perfusion levels are ascertained to be normal.

Regarding physical activity, what we have learned from several studies by Drs. Armstrong & Lavery is that it is not the ABSOLUTE ACTIVITY, rather the VARIABILITY IN ACTIVITY that is a cause of concern. As we do not have validated thresholds of activities currently, we have to advice patients to be consistent in their daily activities and in the event of significant variation at a particular day, be vigilant for the subsequent week. There is a study planned by the SALSA unit to develop and validate this threshold for activity prescription. The underlying vision is to develop a software tool, which potentially can be integrated with patient management tools/EMR's to recommend physical activity and/or specific exercises depending on past history and patient profile.

UA / SALSA: Congrats to Joe Mills and Vascular Surgery

UA wins rare accreditation for vascular-surgery residency

ARIZONA DAILY STAR

Tucson, Arizona | Published: 09.02.2009

advertisement

The University of Arizona has won accreditation to train vascular surgeons, becoming the only college in the Southwest to do so and only the second in the West.

The UA department of surgery will admit one resident per year to a five-year program to specialize in treating diseases of the blood vessels.

The Accreditation Council for Graduate Medical Education has approved only 19 such programs. The only other one in the West is at Stanford.

In the past, students who finished medical school and wanted to become certified vascular surgeons had to complete a five-year residency and a two-year fellowship with a specialized focused. The UA has offered the fellowship component for 25 years.

Recent industry changes shortened the training time to five years.

There is a growing need for vascular surgeons to treat increased numbers of people with vascular disease as a result of the aging population, obesity and diabetes, surgery professor Joseph L. Mills Sr. said in a press release. About 100 new vascular surgeons are certified each year, and twice that many are needed, he said.

The first resident in the new program is Janice Thai, a 2009 graduate of Stony Brook University School of Medicine in Stony Brook, N.Y.

Toe and Flow on the Go: Society for Vascular Surgery News Release

SVS Pulse

August 31, 2009 A publication of the Society for Vascular Surgery®

SVS Pulse is available online atVascularWeb.org

SVS and APMA Working Together to Benefit Patients

Recognizing the beneficial impact of a multidisciplinary team approach on the care of patients with critical limb ischemia, especially in the diabetic population, the leadership of the Society for Vascular Surgery (SVS) and the American Podiatric Medical Association (APMA) held a meeting on Aug. 21 to discuss details of strategic collaboration between the two organizations.

Pictured below, SVS was represented by President Anton Sidawy, MD, MPH; President-Elect Robert Zwolak, MD, PhD; Vice President Richard Cambria, MD and Executive Director Rebecca Maron, CAE. APMA was represented by President Ronald Jensen, DPM, President-Elect Kathleen Stone, DPM; Treasurer Joseph Caporusso, DPM and Executive Director and CEO Glenn Gastwirth, DPM.

This meeting was undertaken as a first step to implement an agreement approved by the respective Boards of SVS and APMA to identify clinical issues and questions important to both memberships and to work together to find solutions that will benefit our patients. Specifically, it was agreed to:

Appoint a group representing both organizations to write a joint statement on the multidisciplinary team approach to the care of diabetic foot

Produce a supplement on the care of the diabetic foot that will be jointly published in the Journal of Vascular Surgery and the Journal of the American Podiatric Medical Association

Establish joint postgraduate courses to be held at the annual scientific meet ings of both organizations

Collaborate on practice guidelines and reporting standards dealing with the care of diabetic foot

Collaborate on advocacy and public awareness efforts in areas of common interest

Watch next month for new content on VascularWeb.org®, "Management of the Diabetic Foot," which will feature vascular surgeon and podiatrist presenters from the 2009 Vascular Annual Meeting.

Vascular Surgeons (SVS) Meet With Podiatrists (APMA)

APMA Daily eNews eNews No. 2,895 Monday, August 31, 2009 In This Issue Did You Know? Vascular Surgeons Meet With APMA Bylaws Propositions Due Did You Know?  Did you know APMA is the largest association of American Board of Podiatric Surgery (ABPS)-certified DPMs in the world?   The APMA Daily eNews is sponsored by Systagenix Wound Management Quick Links APMA Web site   Private Insurance Complaint Form   Private Insurance Resource Guide   New Residency Helpline: 1-800-372-0775               Vascular Surgeons Meet With APMA Recognizing the beneficial impact of a multidisciplinary team approach on the care of patients with critical limb ischemia, especially in the diabetic population, the leadership of the Society for Vascular Surgery (SVS) and APMA held a meeting on August 21, 2009, to discuss details of strategic collaboration between the two organizations.   (Left to right) Glenn B. Gastwirth, DPM, executive director and CEO, APMA; Robert Zwolak, MD, president-elect, SVS; Joseph M. Caporusso, DPM, treasurer, APMA; Ronald D. Jensen, DPM, president, APMA; Anton Sidawy, MD, president, SVS; Kathleen M. Stone, DPM, president, APMA; Rebecca Maron, CAE, executive director, SVS. (Not shown: Richard Cambria, MD, vice president, SVS.)   SVS was represented by President Anton Sidawy, MD, MPH; President-elect Robert Zwolak, MD, PhD; Vice President Richard Cambria, MD, and Executive Director Rebecca Maron, CAE. APMA was represented by President Ronald D. Jensen, DPM; President-elect Kathleen M. Stone, DPM; Treasurer Joseph M. Caporusso, DPM; and Executive Director and CEO Glenn B. Gastwirth, DPM. This meeting was undertaken as a first step to implement an agreement approved by the respective Boards of SVS and APMA to identify clinical issues and questions important to both memberships, and to work together to find solutions that will benefit our patients. Specifically, it was agreed to:   1. Appoint a group representing both organizations to write a joint statement on the multidisciplinary team approach to the care of diabetic foot.   2. Produce a supplement on the care of the diabetic foot that will be jointly published in the Journal of Vascular Surgery and the Journal of the American Podiatric Medical Association.   3. Establish joint postgraduate courses to be held at the annual scientific meetings of both organizations.   4. Collaborate on practice guidelines and reporting standards dealing with the care of diabetic foot.   5. Collaborate on advocacy and public awareness efforts in areas of common interest.   Bylaws Propositions Due APMA Bylaws propositions are due to APMA Executive Director and CEO Glenn B. Gastwirth, DPM, by October 1. Submissions can be mailed to the attention of Dr. Gastwirth at the American Podiatric Medical Association, 9312 Old Georgetown Road, Bethesda, MD, 20814. APMA's Bylaws and Procedures Committee will review the submissions and present them, with comment, to the regular meeting of the House of Delegates, March 21-22, 2010, in Washington, DC. Information in the APMA Daily eNews is intended for APMA members and is not a substitute for professional legal, financial, or medical advice-coding rules and payment policies in particular can vary from carrier to carrier. If you do not wish to receive the APMA Daily eNews, please inform the Association by replying to this message. For a free subscription or to change your e-mail address in APMA's database, please write to rddickson@apma.org. Previous editions of the APMA Daily eNews are available at www.apma.org/DailyeNews (members may log in by using their APMA member number as the username, and their case-sensitive last name for the password). ::

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Op Ed in Arizona Republic: Ignorance on Amputation Prevention

August 31, 2009 |

Shadegg showing health ignorance

9 commentsAug. 31, 2009 12:00 AM

In an Aug. 25 interview on FOX News, Rep. John Shadegg, R-Ariz., nationally misrepresented my profession. Comparing podiatry to aromatherapy and acupuncture, Shadegg referred to podiatric medicine as an "esoteric demand that most people don't [want] and don't need."

As president-elect of the American Podiatric Medical Association, I am appalled that my U.S. representative, who serves on a key House health-policy committee, is so uninformed about the essential health-care services I provide.

Arizona hosts one of the most respected and lauded podiatric medical schools in the country: Midwestern University. The head of the University of Arizona's Southern Arizona Limb Salvage Alliance, or SALSA, is a podiatrist who works with vascular surgeons to prevent amputations that result from diabetes. In just nine months, SALSA's work has reduced high-risk, lower-limb amputations by more than 50 percent.

According to an article in the Journal of the American Podiatric Medical Association, amputation-prevention programs have reduced rates of amputation up to 70 percent - saving the health-care system up to $8 billion each year. This is hardly "esoteric." It is vital to health care. - Dr.Kathleen Stone, DPM, Glendale
The writer is president-elect of the American Podiatric Medical Association.

Frustration drives two diabetes patients to suicide

MUMBAI: Depressed over their condition, two ailing senior citizens committed suicide in separate cases on Saturday.

A 70-year-old man, who had been suffering fromdiabetes for a long time, jumped from the bedroom window of his fifth floor house at Santacruz (E) on Saturday morning. Sources at Vakola police station said that Prabhakar Padwal had diabetes for the last 20 years, and had been taking treatment at a privatehospital. A couple of years ago, he had developed gangrene on his right leg and it had to be amputated from the knee level. As a result, he had been fitted with an artificial foot, the police said.

However, he had been acutely frustrated with this condition, and had told his family members that he wanted to end his life. He had even tried to attempt suicide once before, but was saved due to the presence of his family members, said an officer from Vakola police station. Since the last few days, he had been highly depressed and was not taking hismedicines on time.

Early on Saturday, Padwal's family members heard some noise from his bedroom and on entering found the bedroom window open. Looking outside, they saw him lying injured on the first floor ledge of the building. He was taken to VN Desai Hospital, where he was declared dead on arrival, and the cause of death was given as `haemmorhage and shock due to multiple injuries'.

In a similar incident, a 62-year-old diabetes patient from Borivli (W), also ended his life on Saturday, when he hanged himself in his house.

Police sources said that Shridhar Shivdekar, had diabetes for a long time and had taken treatment at various hospitals. Recently, he had developed injuries on his feet and had been advised by his doctors to get three fingers on his toe amputated, sources said.

The family went to sleep on Friday night after having a discussion on the subject, and the senior citizen appeared to be quite normal at that time. However, when the family woke up on Saturday, they found him to hanging from the ceiling, and was declared dead by a doctor, the police said. The cause of death was given as `asphyxia due to hanging', and an officer from the Borivli police station said that there is nothing suspicious in this case.

Dr Alka Deshpande, former head of medicine department, JJ Hospital, said diabetes patients often tend to get depressed because their injuries do not heal quickly. Such chronic ailments that do have any permanent cure often affect the morale of the patient, and amputation can further complicate this, she said. Therefore, it is important to have trained counsellors in the hospital who can talk to the patient and also attend to his queries on diet control, she suggested.

From the Times of India
Rajiv.sharma@timesgroup.com

Team Approach to Amputation Prevention: Notes from Thailand

Intriguing data from Chaing Mai University in Thailand continuing the theme that interdisciplinary teams dedicated to limb salvage reduce costs and improve quality of life amongst people with diabetes.

A multidisciplinary diabetic foot protocol at chiang mai university hospital: cost and quality of life.

Rerkasem K, Kosachunhanun N, Tongprasert S, Guntawongwan K.

Faculty of Medicine, Chiang Mai University, Chiang Mai,Thailand. krerkase@mail.med.cmu.ac.th.

The consensus is that a multidisciplinary approach for patients with diabetic foot ulcer is effective in reducing the number of leg amputations. Concern remains, however, about cost and health-related quality of life issues. From August 2005 to March 2007, a multidisciplinary diabetic foot protocol (DFP) was used at the authors' teaching hospital.There were devices to reduce pressure on the foot.After healing, there were custom-fabricated orthoses and footwear, and monitoring of progress in ambulation. All subjects were educated about diabetic foot disease and its complications and prevention.They were also instructed to call and visit the hospital if there were any signs of new lesions.This study compared responses to the short form 36 questionnaires (SF-36) about health-related quality of life and the cost of medical care for patients receiving DFP care from August 2005 to March 2007 and those who had standard care from August 2003 to July 2005.There were 56 and 40 diabetic foot ulcer patients on DFP and standard care packages, respectively. Their gender distribution and mean age were similar. The average total cost of DFP patients was significantly lower than that for standard care patients ($1127.02 and $1824.58, respectively, P = .02). DFP patients had significantly higher scores on the SF-36 for both the physical and mental health dimensions than standard care patients. It was concluded that DFP was less expensive and gave patients a better quality of life, compared to standard care. On the basis of this finding, DFP should be used by every hospital to improve outcomes for patients with diabetic foot ulcer.

Many diabetic foot amputations are preventable: Frustrated foot specialists find too many diabetics on stairway to amputation

August 25, 2009
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Many diabetic foot amputations are preventable
by THE ASSOCIATED PRESS

WASHINGTON August 24, 2009, 03:34 pm ET
It costs $1,400 to cover the oozing sore on the diabetic's foot with a piece of artificial skin, helping it heal if patients keep pressure off that spot. So when Medicare paid for the treatment but not the extra $100 for a simple walking cast to protect it, an artificial skin maker last year started giving free casts to some needy patients.

Without the right cushioning, "the person will walk to the bus stop and destroy it," fumes Dr. David G. Armstrong of the Southern Arizona Limb Salvage Alliance.

Limb-salvage experts say many of the 80,000-plus amputations of toes, feet and lower legs that diabetics undergo each year are preventable if only patients got the right care for their feet. Yet they're frustrated that so few do until they're already on what's called the stairway to amputation, suffering escalating foot problems because of a combination of ignorance — among patients and doctors — and payment hassles.

"There's no magic medicine right now for the diabetic foot," says specialist Dr. Lawrence Lavery of Texas A&M University, who bemoans that simple-but-effective preventive care just isn't attention-getting.

"People come in (saying), 'Hey, my wife noticed a bloody trail today as I was walking across the linoleum in the kitchen. What should I do?'"

President Barack Obama got a drubbing from surgeons this month after a confusing comment about how they're paid for foot amputations that cost $30,000 or more. That tab is the total cost, including hospitalization; surgeon fees range from about $750 to $1,000.

Obama's larger argument: Better payment for early-stage diabetes treatment, or even care to prevent diabetes, could save the nation money.

The money part's hard to prove but it's a lot of misery saved if it's your foot, and the spat highlights a huge problem. Some 24 million Americans have diabetes, meaning their bodies can't properly regulate blood sugar, or glucose. Over years, high glucose levels gradually damage blood vessels and nerves.

One vicious result: About 600,000 diabetics get foot ulcers every year. Poor blood flow in the lower legs makes those ulcers slow to heal. And loss of sensation in the feet, called neuropathy, makes patients slow to notice even small wounds that rapidly can turn gangrenous.

A mere nick while clipping nails, or a blister from an ill-fitting shoe, can begin the march toward amputation — and about half of patients who do lose a foot die within five years.

Saving those feet isn't cheap. Treating a slow-to-heal diabetic foot ulcer can cost up to $8,000. If it gets infected, $17,000. Worse, a fraction of patients gets multiple slow-to-heal ulcers each year.

What helps?

—Routine foot checkups. There's great variability in how insurers pay for foot screenings before someone's deemed at high risk, says Dr. Harry Goldsmith, a consultant on podiatric reimbursement. Yet some simple tests, like one that measures blood pressure at the ankle to predict circulation clogs, can signal later risk of ulcers. Medicare patients who do develop certain risk factors qualify for the next step, regular clinic visits to have a technician trim nails or smooth calluses, time that should include a quick check for any wounds, Goldsmith says.

—Gadgets like $20 telescoping mirrors let diabetics who can't move well check their numb soles for wounds between doctor visits, and infrared foot thermometers that cost up to $100 can detect changes in temperature that mean an ulcer's brewing before the skin breaks. Again, insurance payment varies.

—Taking pressure off the foot is key, starting with supportive shoes or insoles that target weak spots before an ulcer strikes. Medicare will help pay for certain therapeutic shoes although paperwork limits the diabetics who try them, says Lavery. He finds that an athletic shoe checked by a foot specialist for proper fit can help many patients.

When an ulcer demands more advanced care like grafting that artificial skin, Armstrong says removable walking casts — to-the-calf Velcro boots that injured athletes often wear — ease pressure best but seldom are covered. Worried that doctors wouldn't prescribe its wound healer Dermagraft if patients crushed it before it could work, Tennessee-based Advanced BioHealing has provided nearly 1,900 of the boots through a patient-assistance program since last year, said vice president Dean Tozer.

—The "toe and flow" approach, diabetic limb-salvage teams that pair specialists who otherwise seldom work side-by-side, like podiatrists and vascular surgeons. Wound care won't work well until clogged leg arteries are cleared to improve blood flow, notes Armstrong, whose team at the University of Arizona, Tucson, documented a drop in amputations in its first nine months. Such teams can eliminate some of the time diabetics wait for appointments to treat a festering foot, plus stress prevention.

———

EDITOR'S NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

Death Panels for Diabetic Feet? Why we have been blown off course

"Surgeons Rebuke Obama's $50k Per Amputation Claim, Media Mum"


This topic has been simmering for the last week or so and is still rather fresh, but I think it has been completely taken in the wrong direction by our colleagues at the AMA/American College of Surgeons and American Academy of Orthopaedic Surgeons-- all who have rather inexplicably harshly countered it (rather than taking the time to educate). In fact, amputations do cost at least $30-50k per episode-- it is just that the doctor is only reimbursed about $800. There are good data to support that teams put together focusing on prevention save legs, prolong life, and save money-- but prevention doesn't yet seem to pay. Perhaps this is something that might be explored by the media in a more thoughtful manner? The concept of procedure-based vs. prevention based systems is really at the heart of this healthcare debate. It is remarkable and, we believe, unfortunate that opportunities like this last one may have (very much like the "death panels" issue) blown us collectively off course.

Podiatry, Vascular Surgery and Limb Salvage Front and Center in Beijing

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>
>
> BEIJING, CHINA/ Hundreds of delegates from throughout Asia convened
> on the site of a former palace outside the Chinese capital to
> discuss methods to reduce diabetes related complications across the
> region. "This problem can't be overestimated." noted Dr. Robert
> Frykberg, Chief of Podiatric Surgery at the Carl T. Hayden VA
> Medical Center in Phoenix, "We need to continue to build teams to
> fight it". This topic was one that fit squarely with the subject
> matter broached by Frykberg's colleague, Prof. David G. Armstrong of
> the Department of Surgery at the University of Arizona. Armstrong
> noted, "What we have to understand, is that, in the fight for
> amputation prevention, teams trump technology. When we put people
> together that care about stemming the amputation tsunami, we can
> literally beat back the tide. "
>
>

Toe and Flow in Beijing

Greetings from the runway at Beijing international airport. We are
here for a very short visit to support the outstanding work of Prof.
Zhangrong Xu, host of the Pan Asian Symposium on the Diabetic Foot. We
look forward to world class talks and workshops from colleagues from
throughout Australasia, Europe, and beyond.

Wii Pulseoximetry Monitor?

From our friends at Medgadget:

Update on Wii's Pulse Oximetry Monitor

Filed under: in the news...


We were pretty excited when Nintendo announced at the E3 Expo in June that they would be releasing a pulse oximetry attachment for the Wii. Now, a few more details are emerging.

Nintendo president Satoru Iwata mentioned in a Q & A that Nintendo "would like to deliver the actual product not too late in the year next year." The software is said to consist of a relaxation or meditation theme, but Iwata did mention the possibility of "measuring how horrified a player is in a horror title." We cannot wait to start giving patients stress tests by playing Resident Evil.

American College of Surgeons Weigh in on Health Care Debate

The issue of diabetes-related amputation is again front and center in the health care debate

________

Statement from the American College of Surgeons Regarding Recent Comments from President Obama

CHICAGO--The American College of Surgeons is deeply disturbed over the uninformed public comments President Obama continues to make about the high-quality care provided by surgeons in the United States. When the President makes statements that are incorrect or not based in fact, we think he does a disservice to the American people at a time when they want clear, understandable facts about health care reform. We want to set the record straight.

Yesterday during a town hall meeting, President Obama got his facts completely wrong. He stated that a surgeon gets paid $50,000 for a leg amputation when, in fact, Medicare pays a surgeon between $740 and $1,140 for a leg amputation. This payment also includes the evaluation of the patient on the day of the operation plus patient follow-up care that is provided for 90 days after the operation. Private insurers pay some variation of the Medicare reimbursement for this service.

Three weeks ago, the President suggested that a surgeon's decision to remove a child's tonsils is based on the desire to make a lot of money. That remark was ill-informed and dangerous, and we were dismayed by this characterization of the work surgeons do. Surgeons make decisions about recommending operations based on what's right for the patient.


We agree with the President that the best thing for patients with diabetes is to manage the disease proactively to avoid the bad consequences that can occur, including blindness, stroke, and amputation. But as is the case for a person who has been treated for cancer and still needs to have a tumor removed, or a person who is in a terrible car crash and needs access to a trauma surgeon, there are times when even a perfectly managed diabetic patient needs a surgeon. The President's remarks are truly alarming and run the risk of damaging the all-important trust between surgeons and their patients.

We assume that the President made these mistakes unintentionally, but we would urge him to have his facts correct before making another inflammatory and incorrect statement about surgeons and surgical care.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 76,000 members and is the largest organization of surgeons in the world.

Sincerely,

L.D. Britt, M.D., FACS, Chair of the ACS Board of Regents
John Cameron, M.D., FACS, President of the American College of Surgeons
Andrew Warshaw, M.D., FACS, Chair of the ACS Health Policy and Advocacy Group
Christian Shalgian, ACS Director, Division of Advocacy and Health Policy

Holter Monitor For The Feet: We May Be Close to Reality

SALSA has been a long term proponent of "Holter Monitor" equivalent for the feet. This study from Madrid, presents a preliminary feasibility study from healthy volunteers. This study proves the concept; and we look forward to more progress in this area. Serial monitoring of the temperature is highly predictive of recurring foot ulcers and the availability as well as advances in this technology may provide early intervention modalities, specially for the newly diagnosed diabetics as well as pre-diabetics. What's interesting and perhaps, the key application is the ability to combine multiple interventions with temperature such as physical activity, pharmacy adherence etc once the platform is available.

Here's our call to fellow researchers to start suggesting unique names for the foot's "Holter Monitor". I start with the first one, "Dia-Polter Monitor"!

Holter monitoring of central and peripheral temperature: possible uses and feasibility study in outpatient settings

Varela et al. J Clin Monit Comput. 2009 Aug;23(4):209-16.

Foot Temperature Monitoring for Preventing Ulcers & (may be) Damage to Sensory Receptors

Foot sole skin temperature affects plantar foot sensitivity:

Interesting work from Germany, suggests plantar foot temperatures may be important during quantitative sensory testing. This work is complimentary to SALSA's publications (Cold immersion recovery responses in the diabetic foot with neuropathy & Warm immersion recovery test in assessment of diabetic neuropathy – a proof of concept study) last year, suggesting the degeneration of thermoreceptors in people with diabetic neuropathy.

This work definitely furthers the role of thermometry in assessment of diabetic feet. Perhaps, plantar temperatures are not just useful in preventing recurring ulcers, rather they may be indicative of sub-clinical neuropathy as well. This reinforces the role of monitoring foot temperatures not only for high risk patients, but also for diabetics to prevent loss of sensation and damage to mechanoreceptors as well as thermoreceptors. This work ties in well with SALSA's activity prescription philosophy!

It is time now to develop this interesting concept into deliverable metrics for helping people monitor their temperatures and prevent (or delay) neuropathic complications and predict onset of ulcerations.

Surgeon wins recognition for saving diabetic patients' legs

Here is a wonderful story about our friend and colleague, vascular surgeon Stella Vig.

_______________________

Surgeon wins recognition for saving diabetic patients' legs

Monday, August 10, 2009, 18:00

Comment on this story

by Aline Nassif

aline.nassif@essnmedia.co.uk

To her patients, surgeon Stella Vig is something of a phenomenon at Mayday Hospital.

Her gift is saving thousands of diabetic patients the agony of losing a leg.

The 42-year-old vascular surgeon and diabetes expert has received two prestigious awards in the last few weeks for her work.

The merited recognition has come about because, since December 2006, she has presided over a 30 per cent drop in the number of major amputations at the Thornton Heath hospital.

It is mainly down to a procedural innovation, where all diabetic patients are automatically fast-tracked to her department for treatment and advice.

She explained: "Surgically there's nothing different here at Mayday but, instead of having diabetic patients spread across the hospital, we keep them all in one place.

"With diabetics who get blood supply problems it could be a matter of 24 to 48 hours before they face amputation, so the sooner we see them the better chance they have of avoiding that."

Sufferers of diabetes are particularly prone to having to have their feet amputated.

Stella said: "Because they have such poor blood supply they're often completely unaware that their feet are in trouble, so it's up to us to act fast on their behalf.

"Diabetics feel nothing. They could have huge holes at the bottom of their foot and never know."

Stella's team comprises of co-consultant surgeon Josh Derodra, physiotherapists, podiatrists [chiropodists], occupational therapists, visiting social workers as well as nurses and other medical staff.

All 49 beds across her Fairfield Ward 1 and neighbouring Fairfield Ward 2 – which treats diabetics with medical as opposed to vascular problems – are usually full, so Stella's team are careful to prioritise the urgent cases.

She said: "We can't take everybody but we do ensure each patient gets the right treatment.

"People with simple problems get treatment in the community, with the support of district nurses and GPs.

"Otherwise, they are kept in the ward for as long as it takes to treat them properly so they don't come back with more problems."

Statistically, patients with "diabetic feet" have a 40 per cent chance of suffering a recurrence within five years, so Stella insists on regular check-ups.

"Losing a leg is like losing your mum or a first degree relative – it has the same psychological effect," she said.

"It dramatically affects your social life, your work and even family relations.

"I once had to perform an amputation on a self-employed builder who had failed to seek medical treatment for his foot in time – he effectively lost his life."

STELLA'S PATIENTS

Air stewardess Amanda Jones, from Waddon, suffers from type-1 diabetes.

Despite wearing sensible shoes, the 38-year-old's awkwardly-shaped broad size 7 feet swelled up and became ulcerated in several places.

After feeling the discomfort she went to see her GP two months ago, who put her on a course of antibiotics.

But an infection in her left foot deteriorated and she checked herself into Mayday. There Stella gave her an aggressive course of antibiotics for 10 days and drained the wounds.

Amanda was hours away from amputation. She said: "I can't thank Stella enough, she was absolutely fantastic. If I had lost my leg my life would have been ruined. It would have meant the end of my career and a really depressing future on crutches or wheelchair-bound."

Former police dog handler Tony Harding has mild type-2 diabetes and kidney failure.

The 70-year-old, from Warlingham, was receiving dialysis treatment when he noticed that his left foot had suddenly started to go cold.

When he sought help from Stella she found a blackened toe – the result of a cut-off blood supply – that he hadn't even noticed.

Tony only lost the dead toe and had to have an operation to unblock a major artery from his groin down to his foot.

He said: "Thanks to Stella I have complete independence. She is an amazing doctor and a wonderful, supportive and kind human being."

Retired civil servant Tom Butlin has type-2 diabetes and suffered a potentially life-changing infection in his ankle.

It was brought on by "Charcot Foot" disease, where the bones in the foot collapse.

The 78-year-old, from South Croydon, saw Stella in the nick of time, otherwise he would probably now be left with just one leg.

He explained: "It was a pretty shocking sight. It started with a skin infection which seeped into the bones of my ankle and made them collapse.

"I was in a pretty serious situation, but Stella made me feel at home and comfortable at all times.

"Stella's an incredibly generous person and treats her patients like her friends. I have a lot to thank her for."

ToeandFlow.com

Thanks to the terrific suggestion by many of you-- most specifically our former fellow Lee Rogers, we have now modified our SALSA blog's domain name to "ToeandFlow.com". Those of you who already have the other (blogspot) address bookmarked, feel free to keep it that way, as either will bring you to our little spot on the www.

From Medgadget: Smart Cane Helps Bring Rehab Out of Rehab

Properly using a crutch after an injury is important if healing is to be promoted, but monitoring a patient's proper movement outside the rehab center is next to impossible.

Now, a physiotherapist and a computer scientist from the University of Southampton have teamed up to create an "intelligent crutch" that features force sensors and accelerometers. This smart crutch can provide info on its own movement and calculate the pressure that is applied to the leg. By processing the data, the device supposedly provides visual cues to the user when improper usage is perceived.

More from the press office at University of Southampton:Intelligent crutch with sensors to monitor usage...

How to Make Dakin's Solution

Many have wanted a simple recipe for making the solution developed by the British Chemist Henry Dakin and the French Surgeon Alexis Carrel. To that end, we enclose the recipe, thanks to the terrific folks at the Ohio State University.

As background, the solution was first developed by the pair in mutual service to the war effort during WWI in response to the very high rate of morbidity and mortality during healing. Carbolic acid, popularized by Lister and then by Halstead, was highly caustic. Carrel-Dakin's solution, given as an intermittent irrigation, was much more wound-friendly.

MediSens aims to restore diabetics’ sensation, balance

Wednesday - August 5th, 2009 - 01:40pm EST by Brian Dolan | Diabetes | Dr. Patrick Soon-Shiong | MediSens | peripheral neuropathy | UCLA Wireless Health Institute | ULCA | wireless health | wireless sensors |

UCLA announced today that MediSens Wireless, a wireless healthcare start-up, has obtained an exclusive license from UCLA on patented technology developed by UCLA professor Majid Sarrafzadeh and his team. (Sarrafzadeh is also a founder of MediSense.) MediSens plans to use the real-time wireless monitoring technology to develop body monitoring systems that help diabetic patients with peripheral neuropathy, which causes a loss of sensation in the foot, and other patients with health issues that affect their balance.

UCLA will receive royalties from products developed by MediSens, and MediSens has rented lab space at the California NanoSystems Institute (CNSI), which gives it access to the Institute’s core lab facilities for research and development. This incubator program at UCLA “offers shared, flexible lab space dedicated to housing eight to 10 early-stage incubation projects for short periods of time,” the university said in a statement.

“We hope that this technology will help to reduce the large number of injuries caused by diabetic foot ulcers and by falls each year, both in hospital rehabilitation departments and in at-home care environments,” Sarrafzadeh stated.

Sarrafzadeh is also a co-director of the Wireless Health Institute (WHI) at UCLA, which is dedicated to improving the timeliness and reach of health care through the development and application of wireless, network-enabled technologies integrated with current and next-generation medical enterprise computing. The WHI is under the executive direction of Dr. Patrick Soon-Shiong, a UCLA visiting professor of bioengineering and of microbiology, immunology and molecular genetics,whom mobihealthnews interviewed soon after his recent appointment at WHI.

For more, read this press release about UCLA and MediSens

Comprehensive Diabetic Foot Examination: Video

Following our recent Australian and Taiwanese workshops, we have had a number of requests for "how to" diabetic foot examination techniques. Here we provide methods for use of the Semmes Weinstein 10 gram monofilament, the biothesiometer (Vibration Perception Threshold), and a Doppler and blood pressure cuff for performing the Ankle Brachial Index (ABI) measurement. Enjoy.

Ankle Brachial Index

Vibration Perception Threshold

10 gram monofilament

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Home > Agency > News Archive - World diabetic foot doctors to lead workshop World diabetic foot doctors to lead workshop Media note: A photo opportunity will be available of the surgeon's diabetic foot workshop in the Ellery Room, Alice Springs Convention Centre on Wednesday 29 July at 10.00 am. Every 30 seconds, somewhere in the world, a person loses a leg because of the effects of diabetes, according to Alice Springs Hospital's Dr Jacob Ollapallil who is helping to host more than 100 surgeons who will converge on the Central Australian town for a two-day conference on 'Infections in Surgical Practice'. Many of the attendees will undertake a special workshop on the management of high risk diabetic foot problems with one of the conference's keynote speakers, American paediatric specialist and international authority on diabetic foot management, Professor David G. Armstrong. "The official rate of Type 2 diabetes in Central Australia presently stands at 11.8 per cent and could even be higher," said Dr Ollapallil. "The rising rate of Type 2 diabetes has increased the incidence of patients with diabetic foot problems, which are becoming more common throughout the world and result in major economic consequence for the patients, their families and society. The condition is responsible for up to 50 per cent of diabetes related hospital admissions." Dr Ollapallil added that around one in ten diabetics will develop a foot ulcer after being diagnosed with the disease, with consequent infection and gangrene of the foot being relatively common because of the slow rate at which the wound heals. "We are fortunate to have Professor David Armstrong (University of Arizona, USA) and Professor Rob Fitridge (QEH Adelaide) to lead the diabetic foot workshop," Dr Ollapallil said. The workshop and convention are being held in the Alice Springs Convention Centre from Wednesday 29 July to Friday 31 July. Media contact: Cameron Jackson 0401 114 113 Release date: Wednesday 29 July 2009

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Australian Financial Review July 30th 2009 Focuses on Diabetic Feet, Amputations

As part of our visit down under, the Australian Financial Review laid out a sizable article on the prevalence of the disease for patients. 

"Therm Deal" for the Diabetic Feet: WarmFeet Relaxation Method

Excellent work from our colleagues at University of Minnesota's Epidemiology Clinical Research Center! "Dr. Rice's technique was tested in multi-site clinical trials at the University of Wisconsin. The medical outcomes were highly significant and positive for increased wound healing and pain relief. Of patients who practiced the technique, 87.5 percent completely healed their chronic ulcers, compared to 43.7 percent in the control group without the technique. (From Diabetes Health)"

Again emphasizing, the significance of plantar temperatures and activity prescription to diabetic patients, both of which are "key" tools from Southern Arizona Limb Salvage Alliance (SALSA)'s Armour against diabetic lower extremity complications! Complimentary techniques like WarmFeet Intervention, as proposed by Dr. Rice are definitely helpful. However, it must be stressed that our patients have lost the "gift of pain" and will not be compliant with such an intervention. But, this can be corrected by providing them dermal thermometers, which will prompt them to use the intervention, when the temperatures scale above the normal daily values upon physical stress, minor trauma or an active ulceration. The good news is that, a large number of our patients are already familiar with dermal thermometers. Now, that's what we call a "Therm Deal" for the Diabetic Feet.

The War Room: Lobbying for Diabetic Foot Care in Australia

Greetings from the 48th floor overlooking the Central Business District in Sydney. We're here with representatives from foot care and industry from throughout Australia lobbying for improvements in Diabetic Foot Care through a series of visits and teleconferences.