Podiatrists often face the challenge of patients with diabetes who are unaware they have the disease. A new survey commissioned by the American Podiatric Medical Association (APMA) discovers that such problems are particularly challenging among Hispanic-American patients, finding that a significant percentage of this patient population exhibits the warning signs of the disease.
One-third of Hispanic Americans without diabetes report foot and leg problems, according the APMA survey. These lower-extremity problems include numbness, tingling or burning, as well as cramping calves, which are all precursors of diabetes, according to the survey of 600 patients. The APMA says the survey results are in line with statistics from the Centers for Disease Control and Prevention, which estimates that almost half of the 2.5 million Hispanic Americans with diabetes do not know they have the disease.
Although diabetes is often a delayed diagnosis among Hispanic-American patients, Kathleen Satterfield, DPM, says the diagnosis “is not an unexpected one.
“When that lab result comes back and the patient is told, nine times out of 10 the response was, ‘Yeah, I thought so,’” says Dr. Satterfield, a Clinical Associate Professor at the University of Texas Health Science Center at San Antonio. “After all, so many of these people live with diabetes in their families each and every day. They have watched their aunts and uncles, grandparents and parents lose limbs and eyesight due to the ravages of the disease. They know when it hits.”
Furthermore, the U.S. Census Bureau notes that Hispanic Americans are nearly 50 percent less likely to visit a physician than non-Hispanic whites, according to the APMA. The association notes that in the Medicaid program, access to podiatric care is optional and nearly a million Hispanic-American patients are enrolled in Medicaid. Accordingly, David Schofield, DPM, the President of the APMA, in an APMA press release, says many visits to podiatry practices “may not be covered under the current system …” and notes this may contribute to lower-extremity complications of diabetes being underdiagnosed.
While Dr. Satterfield notes economic and geographic factors that contribute to a lack of access to the healthcare system, she says the biggest barrier to care may be a state of denial. While some patients may have a lack of awareness of the disease process, Dr. Satterfield says some Hispanic-American patients “have seen what diabetes can do and they do not want to admit that they have it because that would mean a change in lifestyle.”
To spur early diabetes detection, Dr. Satterfield suggests reaching children first. She cites a program by researcher Robert Trevino, MD, who set up a program for hundreds of kids with diabetes in San Antonio. The program rewarded the children for good behavior and Dr. Satterfield says the kids exercised, watched what they ate and also influenced their families’ behavior.
“Children are amazing motivators and I think that by concentrating on this population, we can do the most good,” says Dr. Satterfield.
By Brian McCurdy, Senior Editor
As wound care methodology and technology continues to evolve, one research team is utilizing genetic technology for the purpose of healing wounds. The Center for Lower Extremity Ambulatory Research (CLEAR) at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago is working with the science of proteomics, which may help DPMs better determine the ability and the rate with which patients can heal their wounds.
Proteomics has been defined as the study of large-scale protein expression patterns in cell/tissue and is the “new genomics,” according to David G. Armstrong, DPM, PhD, the Director of CLEAR. CLEAR partners with the renowned Midwest  Proteome Center under the direction of Marc J. Glucksman, PhD. The center partners with numerous other institutions, including the Argonne National Laboratories.
As Dr. Armstrong explains, proteomics identifies the various proteins that genes code for. He says this process is “highly intricate, and at the same time, highly practical for identifying meaningful proteomic fingerprints.”
What are the practical implications of proteomics? Seminal questions in the wound healing field include which patients will heal quickly, which will not heal quickly, and how practitioners can rapidly discover who will heal quickly, according to Dr. Armstrong. He notes that DPMs often ask why one patient receiving a certain wound healing therapy healed while the other patient did not.
Dr. Armstrong, a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine, says his team strongly believes that “work in (proteomics) can shed some light on these questions and do so in a way that brings a great deal of positive attention to this field. Our unit has renamed this highly directed area ‘podiomics.’ We will see where it leads.”
Furthermore, Dr. Armstrong says work on proteomics may spur the development of an area of molecular diagnostics delivered either at the point and time of the initial care or continuously, such as in negative pressure wound therapy. As Dr. Armstrong notes, clinicians could then pay further attention to patients who fail therapy by modifying either the technology they are using or their approach, and accordingly target these therapies to those who need it the most.
By Brian McCurdy, Senior Editor
The first in a new class of dipeptidyl peptidase-4 (DPP-4) medicines recently garnered FDA approval to treat type 2 diabetes. Sitagliptin phosphate (Januvia™, Merck) is indicated as a monotherapy or as combination therapy with either metformin or thiazolidinediones to improve glucose control in patients with type 2 diabetes who struggle to achieve glucose control with diet and exercise alone, according to the company.
Januvia addresses both reduced insulin due to beta-cell dysfunction and the liver’s uncontrolled production of glucose due to alpha-cell and beta-cell dysfunction, according to the company.
In two double-blind, placebo-controlled studies of a total of 769 patients with mild to moderate baseline A1C levels, Merck says 100 mg of Januvia once a day demonstrated significant mean differences in A1C from the placebo. The FDA cautions that clinicians should not use Januvia in patients with type 1 diabetes or to treat diabetic ketoacidosis. Merck notes that Januvia will cost $4.86 per tablet and the recommended dosage is 100 mg once a day.
“Januvia may become a revolutionary medication for the management of hyperglycemia,” says Eric Feit, DPM. He cites initial studies showing that the drug is effective in lowering HgA1c levels as a monotherapy and that it may be even more effective as a complementary medication to metformin and pioglitazone.
Although he feels Januvia shows promise, Dr. Feit says more long-term studies are needed to further define the drug’s safety profile. Furthermore, although Januvia is designed for patients who have difficulty controlling blood glucose with exercise and diet alone, Dr. Feit cautions that some patients may use Januvia “as an excuse not to eat well or exercise enough.”
With these cautions in mind, Januvia may provide another option for prescribing physicians to help keep blood glucose levels under control and reduce diabetic complications  such as foot and leg amputations, eye diseases, heart attacks, stroke and kidney disease, notes Dr. Feit, the Past President of the Los Angeles chapter of the American Diabetes Association.
Editor’s note: For related articles, see “Is Inhaled Insulin A Viable Alternative For Patients With Diabetes?" in the October 2006 issue or visit the archives at www.podiatrytoday.com .
The product Naftin Cream® (see New Products, October issue) should have been discussed as an antifungal agent, not a moisturizer. We regret the error.
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