August 2009

Online Poll Examines Vascular Workup For Patients With Diabetes

By Lauren Grant, Editorial Assistant

   Slightly more than one-third of podiatrists surveyed in a recent online poll said they refer 10 to 20 percent of their patients with diabetes for further vascular workup.

   The poll on posed the question, “What percent of your patients with diabetes do you refer for further vascular workup?” Out of 126 total respondents, 45 DPMs (36 percent) refer 10 to 20 percent of patients with diabetes to vascular specialists. Thirty podiatrists (24 percent) refer 21 to 40 percent of diabetes patients to the vascular team. Only 10 percent of the survey respondents refer more than 80 percent of their patients with diabetes for further vascular testing.

   The poll results did not surprise Alexander Reyzelman, DPM, FACFAS.

    “For the majority of our diabetic patients we treat, the vascular workup can be performed by podiatrists in the office,” notes Dr. Reyzelman, who is an Associate Professor and the Chairman of the Department of Medicine at the California School of Podiatric Medicine at Samuel Merritt University.

   Andrew Rice, DPM, FACFAS, notes that he will perform non-invasive studies in the office but his patient results tend to indicate the need for referral to a vascular specialist.

    “My referrals average in the 41 to 60 percent range with the true number closer to 50 to 60 percent,” says Dr. Rice, who has been in private practice for 22 years in Norwalk, Ct.

   Both doctors cite key findings from non-invasive vascular testing and the clinical exam that would trigger a referral for further vascular work-up.

    “I look for toe pressures of less than 40 mmHg and a toe-brachial index (TBI) of less than 0.4 or an ankle-brachial index (ABI) of less than 0.5 before I refer the patient to the vascular surgeon,” points out Dr. Reyzelman. “My philosophy is to refer the patient who will need to be revascularized. The patient should either have an ischemic non-healing wound, gangrene or disabling intermittent claudication.”

   In addition to absent or diminished pedal pulses, the presence of a non-healing wound and/or an ABI of 0.75 or less, Dr. Rice says pulse volume recordings (PVR) and waveform analysis can reveal the absence of the dicrotic notch in early vascular disease.

    “Occlusions will show a decreased slope of the ascending and descending segments and rounding of the systolic peak, and flattened waveforms,” notes Dr. Rice, a Clinical Instructor in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine.

   Both physicians note the critical importance of appropriate vascular testing in this high-risk patient population.

    “Early recognition of limb-threatening ischemia can be the deciding factor in saving or losing part or all of the foot,” maintains Dr. Reyzelman.

   Dr. Rice says these patients would benefit from receiving care from a multidisciplinary team lead by a DPM and vascular specialist. Dr. Reyzelman adds that he would like to see more collaboration between the two specialties at conferences.“I would like to see more forums where vascular and podiatry are presenting and sharing information,” suggests Dr. Reyzelman.

Could Ultrasound Of The Fifth MPJ Help Diagnose RA Earlier?

By Brian McCurdy, Senior Editor

   A recent study in Arthritis Care and Research suggests that targeted ultrasound imaging of the fifth metatarsophalangeal joint (MPJ) may facilitate an earlier diagnosis of rheumatoid arthritis (RA) than radiographs.

   The study involved 30 patients, 17 of whom had RA and 13 of whom had undifferentiated arthritis (UA). Patients underwent lab tests, radiographs and ultrasound imaging of both fifth MPJs.

   Of the 30 patients, researchers noted 10 had ultrasound evidence of synovitis associated with a positive power Doppler signal. Seven had radiographic erosions of the fifth MPJ while ultrasound uncovered evidence of fifth MPJ erosions in 17 patients, according to the study. In addition, authors noted that a positive power Doppler signal was present in nine RA patients and in one UA patient.

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