September 2012

Study: Long-Term Survival Of DFU Patients Is Poor

By Brian McCurdy, Senior Editor

A new study in Diabetes Care notes that despite favorable results in long-term limb salvage for patients with diabetic foot ulcers, long-term survival rates remain unfavorable with peripheral arterial disease (PAD) and renal insufficiency making for an especially poor prognosis.

   Researchers focused on 247 patients with diabetic foot ulcers without previous major amputation who consecutively presented to a single diabetes center between June 1998 and December 1999.

   The study authors note that during follow-up, a first major amputation occurred in 38 patients (15.4 percent), 51.4 percent of whom had severe PAD. Age and PAD were significant predictors for first major amputation, according to the study. Furthermore, the authors note that cumulative mortalities at one, three, five and 10 years were 15.4, 33.1, 45.8 and 70.4 percent respectively.

   Study co-author David G. Armstrong, DPM, PhD, MD, notes evidence that modifying certain risk factors early on can reduce the progression of vascular disease in general and also potentially reduce the risk of PAD. Desmond Bell, DPM, says smoking cessation would be the most vital step to prevention. For those who require invasive intervention, lower extremity bypass surgery and endovascular procedures, such as angioplasty, atherectomy and stenting, “are having a profound impact on limb preservation,” notes Dr. Bell.

   “In my opinion, one of the real issues patients are facing is that PAD is under-diagnosed and under-recognized among practitioners,” says Dr. Bell, the Co-Founder and Executive Director of the Save a Leg, Save a Life Foundation in Jacksonville, Fla. “If more providers were aware of the five-year mortality rate associated with PAD, which is approximately 64 percent, I believe we would see a greater sense of urgency surrounding PAD.”

   By way of comparison, Dr. Bell cites the five-year mortality rates of prostate cancer at 9 percent and breast cancer at 14 to 18 percent. “One has to wonder why there is such a general lack of recognition of (PAD),” notes Dr. Bell.

   “We’ve seen now in this study and in others that mortality for people with wounds — and especially for people with wounds, vascular disease and other end-stage complications of diabetes — is at least as bad as a bad form of cancer, well over 50 percent at five years or even worse than that,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).

   Dr. Bell calls for greater screening of those who are at high risk for PAD, especially when considering the link among PAD, heart attack and stroke. Similarly, Dr. Armstrong advises talking to patients and emphasizing aggressive risk factor modification and patient appropriate treatment.

   Dr. Bell also suggests a “major public awareness campaign” to make the public and primary care providers aware that that PAD is likely present in patients in diabetes. As he points out, most of the general population have never heard of PAD, let alone know that September is PAD awareness month.

   Dr. Armstrong stresses the importance of the interdisciplinary team and SALSA’s “toe and flow” philosophy.

   “We believe now that since more than half of our patients have wounds that we would now classify as neuroischemic … that these two specialties, those interested in the toe and those that are interested in the flow, get together — really get together — to make a difference,” adds Dr. Armstrong.

CMS Offers Limited Coverage For PRP Treatment Of Chronic Wounds

By Danielle Chicano, Editorial Associate

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