Expert Addresses Global Diabetes

By Brian McCurdy, Associate Editor

“Diabetic foot disease is truly a global problem. Every patient of whatever race, with diabetes of whatever type, is at potential risk for developing foot problems,” noted Andrew Boulton, MD, during his keynote address, “The Diabetic Foot: A Global View,” at the Annual Scientific Meeting of the American Podiatric Medical Association in Seattle.
Introduced by legendary Paul Brand, MD, Dr. Boulton cited rising prevalence rates of diabetes and alarming statistics in other countries. Dr. Boulton strongly emphasized the need for better education on the causes of diabetic foot ulcers, treatment and the importance of increasing the presence of podiatry in other parts of the world to help in the prevention and management of diabetic foot complications.
“The aims in managing diabetic foot problems should primarily be concerned with limb preservation at all costs,” noted Dr. Boulton, a Professor of Medicine at the University of Manchester in the United Kingdom and Visiting Professor of Medicine at the University of Miami School of Medicine Division of Diabetes.
“The need for a better understanding of the pathogenesis and treatment of diabetic foot ulceration is strongly supported by the literature and depressing statistics. Trends in amputations have not shown any tendency towards improvement in recent years and foot ulceration remains the (most common) cause for hospitalization of diabetic (patients) in many Western countries.”
In the United Kingdom, Dr. Boulton noted diabetic patients are four times more likely to be admitted to hospitals and those with peripheral neuropathy have a 16-fold risk of hospitalization. He points out the U.K. probably has no more than 20 specialist multidisciplinary diabetic foot clinics for a population of about 55 million.
Dr. Boulton noted the cost of healing for diabetic foot ulcers with hospitalization and surgery in Sweden was $57,300 per case, compared to $8,500 per case just for primary healing in 1990. The standard of screening and educational foot care is generally higher in Scandinavian countries than in the rest of Europe, Dr. Boulton noted. While he said podiatrists are available in all these countries, few diabetic patients have access. He added that Sweden, Norway, Finland and Denmark all have multidisciplinary foot centers. However, Dr. Boulton noted podiatric education and the definition of podiatry are very different in various countries.

A Stunning Lack Of Access To Podiatric Services
There is a severe lack of access to podiatric services in several countries that have rapidly escalating prevalence of diabetes, according to Dr. Boulton.
For example, 1 to 5 percent of India’s 1 billion people, about 30 million, have type 2 diabetes. The hallmark of diabetes is gross infection, according to Dr. Boulton. He says factors which contribute to late presentation include frequent barefoot gait, attempts at home surgery, trusting in faith healers and undetected diabetes. While India has a few specialized centers in major cities, Dr. Boulton said diabetic foot care is mostly disorganized and India lacks podiatrists and orthotists.
Diabetic foot care is also very problematic in South Africa. Ten percent of a country with 40 million people have diabetes. Dr. Boulton said there are only 200 podiatrists in the country, not all hospitals have podiatrists and the level of diabetic foot care varies greatly across the country.
“It appears that whereas the illusion of good global foot care remains, we have reason to be hopeful that improvements will continue,” said Dr. Boulton.
He cited the efforts of the Netherlands where well-trained podiatrists are available specifically for diabetic patients in 32 percent of the hospitals. He noted Belgium’s national training program in diabetic foot care for those who treat diabetic patients and doctors who work at multidisciplinary foot clinics. Dr. Boulton also praised Australia for its “well-developed healthcare system” and its efforts to establish a national diabetes foot care network to address the shortage of multidisciplinary clinics.

What Influential Educators Thought
Lee Sanders, DPM, Former President of Health Care and Education for the American Diabetes Association (ADA), says Dr. Boulton’s address signaled diabetes is a growing global problem.
Early diagnosis and treatment are essential to making inroads in reducing diabetes complications. Up to 10 percent of patients with diabetes are likely to have had past or present ulcerations and about 1 percent have already had amputations, according to Dr. Boulton. He said diabetes is the major cause of non-traumatic amputation in many Western countries and rates are as much as 15 times higher than in the non-diabetic population.
Dr. Boulton said sensorimotor and autonomic components of neuropathy may contribute to diabetic foot ulceration, and emphasizes that half of all patients with significant neuropathy have no symptoms. “Thus, the warm, insensitive foot is at high risk of ulceration,” noted Dr. Boulton.
“This was an enormously important lecture,” points out David G. Armstrong, DPM, who is a member of the National Board of Directors of the ADA.
“The combination of Dr. Paul Brand and Dr. Andrew Boulton addressing our profession at our national meeting signals that podiatry has indeed arrived. Professors Brand and Boulton are, in essence, the king and crown prince of care in the diabetic foot and have done more than any two people in the last century in this area. Their acknowledgement of the importance of our profession in the care of this problem has never been in doubt. This address clearly reinforced that.”

Will Federal Reform Resolve The Malpractice Crisis?
By Gina DiGironimo, Production Editor
As medical malpractice lawsuits continue to rise and settlement amounts increase, there is growing support for federal tort reform.
Earlier this year, the AMA identified 12 states in crisis, including Pennsylvania, Texas, Ohio and Florida, among others. Physicians at the meeting voted to make liability reform the “highest legislative
priority.” President Bush recently outlined a framework for federal legislation similar to pending bills (backed by the AMA) in the House and Senate. The president’s proposal consists of many of the key reforms advocated by the AMA, including:
• no limit on economic damages with noneconomic damages capped at $250,000;
• punitive damages would be limited to whichever is less: $250,000 or twice the economic damages;
• medical malpractice cases would include a statute of limitations;
• physicians would be able to pay awards to patients over time as opposed to paying in one lump sum; and
• physicians would only be required to pay the portion of damages which they are personally responsible for.
The president has called for a liability bill in the Senate and for Congress to send him a tort reform bill by late fall.
Stephen Monaco, DPM, a former president of the Pennsylvania Podiatric Medical Association, says “(federal reform) legislation is vital to the future of the healthcare industry and it must begin for the survival of the industry.” However, Dr. Monaco believes President Bush will have a hard time getting his proposal past the House and the Senate.

An Uphill Battle?
The president faces opposition from two major factions: trial lawyers and Senate Democrats. Many trial lawyers believe the president should refocus his attention toward the insurance industry, an industry that does not adhere to the same federal antitrust rules as other businesses.
David Mullens, DPM, JD, says the trial lawyers in his California law office are “very upset with the capping of noneconomic damages.” Placing a cap on “pain and suffering” and actual damages is significant because it “makes podiatric cases very unattractive to medical malpractice attorneys,” notes Dr. Mullens. Since medical malpractice cases are taken on a contingency fee basis, top law firms will only take on the cases if the economic and/or non-ecomonic damages are very high, according to Dr. Mullens.
With the exception of cases in which a relatively young plaintiff loses his or her leg, Dr. Mullens says actual damages in podiatry malpractice cases are “modest” in comparison to those in other subspecialties, such as neurosurgery and ob/gyn doctors, which may be at a higher risk of malpractice suits.
Senate Democrats have also resisted reforms in medical malpractice cases. In a recent article, Sen. John Edwards (D, N.C.) says Bush’s framework for liability reform goes against the administration’s usual stance that states should be in control, calling his reform efforts misguided.
Dr. Monaco feels the opposition to federal reform from the Democrats will be tough because “traditionally, they (the Democrats) do not like to limit a citizen’s right to monetary damages.” He sees support coming from the general public, the AMA, APMA and hospital associations but is interested to see what the final bills will look like after they’ve made their way through Congress and/or the Senate.
Like many physicians, Dr. Monaco supports federal reform first, but strongly believes each state “needs to follow through with tougher legislation” as well. Nevada recently enacted tougher tort reform laws similar to the proposals outlined by President Bush and the AMA. Some of the new laws place a $350,000 limit on noneconomic damages, establish a standard that holds physicians liable only for the damages for which they are responsible and creates a shorter statute of limitations. Dr. Monaco believes states such as Nevada may become leaders and examples for other states (in passing legislation).

A New Standard For Treating Painful Diabetic Neuropathy?
By Gina DiGironimo, Production Editor
Researchers are now suggesting the use of topical doxepin 5% cream (Prudoxin, Healthpoint) as a first line of therapy for painful neuropathy.
In a recent study, researchers followed 20 patients suffering from diabetic neuropathy for eight weeks to assess the effectiveness of doxepin 5% cream over the current standard of care. Patients received treatment three times a day for two weeks, then twice-daily application for two weeks and once-a-day application during weeks five and six. In the final two weeks, researchers took patients off the medication to see if symptoms had returned and if so, at what intensity.

Study results revealed that after two weeks of three times a day application of the cream, 17 out of 20 patients were asymptomatic. Given the cream’s “85 percent effectiveness in the study,” David A. Yeager, DPM, and Matthew G. Garoufalis, DPM, the co-authors of the study, believe doxepin 5% cream can be used as a first line treatment. At the Westside Veterans Affairs Medical Center in Chicago, Drs. Yeager and Garoufalis estimate between 60 to 70 percent of their diabetic population has some form of neuropathy.
Both doctors encourage the use of doxepin 5% cream versus other available medications due to its few complications and interactions with other medications. Dr. Yeager adds the cream is a good topical alternative “to most of the oral medications that are on the market for diabetic neuropathy.” Dr. Garoufalis says it is “relatively inexpensive, works quickly — sometimes within the first 24 hours — and is very easy to use.”
Both doctors are excited about the study’s early results and say they will be expanding the study in the near future.

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