Study Links Depression With Diabetes Development

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By Brian McCurdy, Senior Editor

Can depression spur the development of diabetes? A recent study in the Archives of Internal Medicine concludes that older patients who are depressed have a higher risk of developing type 2 diabetes.    The 10-year study consisted of 4,681 patients over the age of 65 who did not have diabetes at the beginning of the study in 1989. Researchers performed annual screenings and assessed the patients for symptoms of depression related to mood, concentration, sleep and other symptoms.    The study concluded that each measure of depressive symptoms had a significant association with diabetes. Elderly people who reported a higher number of symptoms of depression were 60 percent more likely to develop diabetes, according to the study, although the researchers caution that the association is not fully explained by diabetes risk factors.    Guy Pupp, DPM, has a practice with a disproportionate number of patients with diabetes, over 75 percent of whom have type 2 diabetes and many of whom are over the age of 60. He says many patients convey symptoms of depression like sleep disturbances, problems with concentration, abrupt mood swings and occasional irritability.    “Many of these patients seem not to tend to their physical well being and fitness,” says Dr. Pupp, the Clinical Director of the Kern Foot and Ankle Clinic at Southeast Michigan Surgical Hospital in Warren, Mich. “Frequently, they are not physically active and tend to gain weight, a high risk factor for diabetes.”    How can depression lead to diabetes in older patients? Dr. Pupp notes that researchers have suggested that depressed patients have higher levels of the stress hormone cortisol. He says cortisol may decrease insulin sensitivity with the subsequent high levels of blood glucose that occur among patients with diabetes.    Kathleen Satterfield, DPM, says there can be a “mix of denial and depression” among patients with diabetes in terms of how the disease impacts daily function and whether patients can continue working or enjoying leisure activities without worrying about shoes and other concerns of disease.    Dr. Satterfield recalls two patients, both of whom were security guards with uncontrolled diabetes and Charcot. With an exacerbation of the disease, neither could care for his family, according to Dr. Satterfield.

Averting The Risks Of Diabetes Complications

How can DPMs spur patients to care for themselves and avert the potential complications of diabetes? Dr. Pupp cites patient education, which he reinforces at each visit. However, getting patients to care for themselves can be a challenge. “I have long fought to try to get patients to take ‘ownership’ of their disease but often to no avail,” says Dr. Satterfield.    Dr. Pupp makes frequent referrals to appropriate healthcare practitioners such as internists, endocrinologists, cardiologists, peripheral vascular specialists, counselors, diabetes educators and dieticians. Dr. Satterfield concurs with the importance of a multidisciplinary approach.    “I think that even more important is the need for DPMs to recognize depression and then make appropriate referrals,” says Dr. Satterfield, a Clinical Associate Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center at San Antonio. “Sometimes, we think our responsibility ends at the ankle and that is just not the case. We have to think about the entire patient.”

Can Ultrasound Facilitate Chronic Ulcer Healing?

By Brian McCurdy, Senior Editor Ultrasound has a variety of applications for healing and a recent study in the Journal of the American Podiatric Medical Association relates some potential in using noncontact low-frequency ultrasound on chronic foot and leg ulcers.    The study examined 51 patients with lower extremity ulcers, 20 percent of whom had a history of amputation and 65 percent of whom had diabetes. The wounds were chronic and nonhealing, and had a duration of between three and 18 months.    Patients received non-contact low-frequency ultrasound via the MIST Therapy system (Celleration), which uses continuous ultrasonic energy to atomize saline and convey continuous ultrasound to the wound site. Researchers say patients received standard of care therapy followed by ultrasound three to five times a week. The authors of the study note that 26 of the chronic wounds achieved closure during ultrasound treatment. The wound volume reduction was 37.3 percent (+18.6 percent) in the standard of care group as opposed to 94.9 percent (+9.8 percent) in the ultrasound group, according to the study.    Study author Steven Kavros, DPM, says the patients he typically sees for MIST ultrasound treatment have failed standard of care treatment and have recalcitrant ulcers. Despite the patients having to come into the office several times a week for treatment, he says this is not an issue for the most part.    “We do not have much of a problem with compliance because there is high motivation in getting these healed,” notes Dr. Kavros, who is affiliated with the Department of Orthopedic Surgery and Gonda Vascular Wound Healing Center at the Mayo Clinic in Rochester, M.N. He adds that his facility gets a good number of referrals for ultrasound treatment from other clinics.    Researchers are “just scratching the surface” of the potential of noncontact low-frequency ultrasound, according to Dr. Kavros. He notes the Mayo Clinic is researching the use of noncontact low-frequency ultrasound in biofilms, which he notes are generally accepted to be a factor in poor wound healing.

Studies Examine Efficacy Of Ankle Implants

By Brian McCurdy, Senior Editor A recent study grants high marks to a total ankle replacement while an advisory panel recently recommended that the Food and Drug Administration (FDA) approve a second ankle replacement device in the United States.    A recent study published in the Journal of Foot and Ankle Surgery examined 34 patients with osteoarthritis who had received 35 uncemented Buechel Pappas (Endotec) total ankle replacements between 1990 and 2005. Follow-up revealed 97 percent of patients were happy with their operation and 97 percent thought it was successful. The study notes that 66 percent of patients had no pain or occasional pain, all patients were mobile and 45 percent of patients did not require walking aids. Only 3 percent of patients required two walking aids.    In other news, the Orthopaedic and Rehabilitation Devices advisory panel to the FDA recently recommended FDA approval of the Scandinavian Total Ankle Replacement System (STAR, Link America). One can use the device, a mobile-bearing ankle prosthesis, to replace a painful arthritic ankle due to rheumatoid arthritis, primary arthrosis or posttraumatic arthrosis, according to the FDA.    A 24-month follow-up revealed a patient success rate of 45.1 percent for patients treated with the STAR implant in comparison to a 13.7 percent success rate in the control group, according to orthosupersite.com. The Web site noted an efficacy success rate of 58.5 percent in the STAR group versus 14.9 percent in the control group.    Mark Feldman, DPM, has implanted 100 patients ages 15 to 83 with the Buechel Pappas ankle implant since 1998 and was involved in the clinical trials for the device. In Europe, he has scrubbed in for over 30 STAR procedures with other doctors. Dr. Feldman notes that both implants have been used extensively in Europe for over 20 years.    “Buechel Pappas and STAR are the hallmarks of the second generation mobile bearing prostheses,” says Dr. Feldman, who practices privately in Miami.    Dr. Feldman notes that both devices have an “exceedingly high success rate.” As he says, the Buechel Pappas is easier to put in and can be used in patients with avascular necrosis while the STAR cannot be used in patients with that condition.

Can A New Treatment Be Beneficial With Congenital Vertical Talus?

By Brian McCurdy, Senior Editor While traditional treatment for idiopathic congenital vertical talus consists of manipulation and casting followed by surgical reduction, one may see complications including stiffness, incomplete reduction of the deformity and total recurrence of the deformity. A recent study in the Journal of Bone and Joint Surgery (JBJS) examines the effectiveness of a new treatment method based on Ponseti’s treatment for clubfoot.    The study was a retrospective review of 11 patients who had 19 feet with idiopathic congenital talus deformities. Researchers initially treated patients via serial manipulations and casts. This was followed by limited surgery that included percutaneous Achilles tenotomy, fractional lengthening of the anterior tibial tendon or the peroneal brevis tendon, and percutaneous pin fixation of the talonavicular joint. Researchers note that the principles of manipulation and plaster cast application were similar to the Ponseti clubfoot method but the forces were applied in the opposite direction.    Researchers obtained initial clinical and radiographic correction for all 19 feet requiring a mean of five casts. The final evaluation revealed a mean ankle dorsiflexion of 25 degrees and a mean plantarflexion of 33 degrees. The study notes the latest follow-up showed a significant improvement in all the measured radiographic parameters compared to pre-treatment values, and all the measured angles were within normal values for the patient’s age.    The study concluded the serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provide “excellent results” in regard to the foot’s clinical appearance and function as well as deformity correction.    Edwin Harris, DPM, says congenital vertical talus is a “very rare” condition, 10 to 15 times less common than talipes equinovarus. He notes that most cases of syndromic congenital convex pes valgus (congenital vertical talus) are seen in institutional practice due to the existence of other comorbid conditions, although a few cases may escape early detection and are treated in community practice.    Dr. Harris’ initial treatment involves the use of manipulation and serial casting. Although he uses techniques similar to those of Dobbs, Purcell, Nunley and Morcuende, he says he has not achieved the success rate of the JBJS study. He says the poor results are most likely due to the fact that the children are seen past the age of 2 and have already been walking on deformed feet. Dr. Harris also notes their joint surfaces may have suffered irreparable damage that even surgical release cannot correct.

Assessing The Potential Of The Treatment In Practice

In regard to the treatment described in the study, Dr. Harris says it would be effective with some qualifications.    “If one sees the infant early enough and if the head of the talus and the deep surface of the navicular have the potential for remodeling, this technique should work just as well as the manipulating techniques work for club feet,” he opines.    The study’s manipulation technique permits reversal of the abnormal anatomy, according to Dr. Harris, a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill. As he points out, the positioning of the surgeon's hands allows one to stabilize the talus while pulling the rest of the foot into a more anatomically correct position.    Due to the nature of this deformity, Dr. Harris notes there is almost always equinus deformity as a component of the overall problem. He has performed simple tenotomy of the tendo-Achilles for infants under six months, noting the necessity of re-operating on the tendo-Achilles later. He says the tendon looks pristine upon the second exploration.    However, Dr. Harris recalls operating on a 17-month-old with clubfoot who had failed a Ponseti reduction. He says the tendo-Achilles was so scarred that he needed about 35 to 40 minutes of valuable tourniquet time to gain access to the posterior compartment.    Dr. Harris also cites the issue of keeping the cast in place. He uses plaster of Paris over synthetic cast taping, adding that some surgeons use Soft Roll casting (3M). Though parents can unroll the material at home to bathe the baby, Dr. Harris notes the downside of parents being able to take the cast off any time. He says one can solve this by using materials parents cannot remove.

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