Addressing The Ongoing Challenge Of Diabetes Care
Over 18 percent of people age 60 and over in the United States have diabetes. According to the American Diabetes Association, 1.3 million new cases of diabetes are diagnosed every year in people over the age of 20. Between 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage, a major contributing factor to lower-extremity amputation. Greater than 60 percent of nontraumatic lower-limb amputations in the U.S. occur among patients with diabetes. With these statistics in mind, we present our Fifth Annual Diabetes theme issue. Leading off the theme issue is the cover story, “MRSA: Where Do We Go From Here?,” by David G. Armstrong, DPM, MSc, PhD (see page 42). Dr. Armstrong discusses the increased prevalence of infections caused by methicillin-resistant Staph aureus (MRSA) organisms, noting the rise of both nosocomial and community-acquired strains of MRSA. Interestingly, Dr. Armstrong says the literature is mixed regarding the effect of diabetic foot infections with MRSA on mortality rates. One study shows MRSA infections have a significantly poorer response to conservative therapy than other diabetic foot infections, and higher rates of minor and major amputations. Yet Dr. Armstrong notes a separate study that found patients without systemic infection could be treated successfully as outpatients for MRSA and that MRSA did not increase the rate of hospitalization or osteomyelitis. Dr. Armstrong also takes a closer look at antibiotic therapy, exploring the merits of available medications and offering a glimpse at the data of other therapies that are starting to emerge for treatment of MRSA. Given that diabetic neuropathy plays a major role in lower-extremity complications from diabetes, Stephanie Wu, DPM, offers a thorough review of “Current and Emerging Options For Treating Diabetic Neuropathy” (see page 66). Dr. Wu assesses the benefits, drawbacks and the most recent research on current medications ranging from selective serotonin and norepinephrine reuptake inhibitors (SSNRI) to tricyclic antidepressants and supplements. She also evaluates the potential of emerging modalities such as aldose reductase inhibitors. Another intriguing article is the provocative Point-Counterpoint debate, “Active Charcot: Should You Proceed With Surgery?” (see page 74). While nonweightbearing immobilization has been a traditional mainstay of treatment for acute Charcot, Peter Wilusz, DPM, and Guy Pupp, DPM, cite risks of cast disease and osteopenia. They advocate early identification of the Charcot process and that surgical intervention should be considered as early as a Stage 0 Charcot foot. Molly Judge, DPM, counters this argument, noting that “acute and chronic phases of Charcot degeneration are amenable to conservative measures.” While external fixation has been in vogue in recent years, Dr. Judge cites greater risks in surgical treatment of Charcot and emphasizes the important role of patient compliance. Wrapping up the issue is the continuing education (CE) feature, “How To Manage Heel Ulcers In Patients With Diabetes,” co-written by Jonathan Moore, DPM, and Pamela Jensen, DPM (see page 90). They emphasize a thorough diagnostic workup of these patients and a multidisciplinary approach to treatment. To that end, they provide an informative, algorithmic approach to help guide clinical decision-making and achieve successful outcomes. Given the aging of the population and the alarming rise of obesity in the country, it stands to reason that diabetes and its associated lower-extremity complications will continue to be an increasingly daunting challenge for the podiatric profession. Hopefully, the informative articles in this month’s issue will provide fresh perspectives to help you provide optimal treatment solutions for your patients.