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        <title>The Mayer Institute Articles</title>
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            <title>Statistic by Frykberg: Part 2</title>
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 <![CDATA[Robert Frykberg,&nbsp;DPM, MPHPRESENT RI EditorDiabetic Limb SalvageDescriptive StatisticsAs we discussed&nbsp;last month&nbsp;, I thought that we might start out with our Primer on Biostatistics from a clinicians standpoint.&nbsp; I know that statistics can be daunting for those of you who are like I was   having a dislike of mathematics and not having a clue about statistics. The amazing thing is that you can learn so much about a study simply by reading the tables, the numbers, graphs, and figures. Many readers might just go to the tables and figures if the abstract has gotten their interest.&nbsp; I can still remember one of my professors in graduate school telling us that he only read the abstracts of papers to digest their meaning and rarely did he actually read the entire paper.&nbsp; I am somewhere in between   if the abstract is not interesting, I dont really care to read the paper. If it is and has some good data to report, I will read the paper and specifically look at the tables and graphs to get a real insight into the methodologies as well as the important results.All of this, however, presupposes that the reader has a basic understanding of medical statistics and knows what he/she is reading.&nbsp; I cant say that I really did for all of my training and the first 14 years of practice   a real shortcoming.&nbsp;You need to be an educated consumer of the medical literature in this century if you are to stay abreast of developments.&nbsp;&nbsp;So lets make it as easy as possible and start with the basics first. Digest the information in this series in small quantities so that it is comprehensible and meaningful. Again, I am a clinician, so things need to be made clear to me in a simplified manner that I can understand. Ill try to do the same for you.To Start — Descriptive StatisticsDescriptive statistics will be our starting point because of their basic nature and fundamental importance to a discussion of statistics. Although we havent yet discussed Student t-tests, you have obviously heard of this basic analytical method for hypothesis testing.&nbsp; But you very likely do not realize that it is most often used inappropriately. This is because the users (or authors) did not pay attention to the descriptive attributes of their study data.&nbsp; In this regard, t-tests require that the data follows a normal distribution (bell curve or parametric) and not a skewed distribution (non-parametric). See&nbsp;Figure 1&nbsp;below. Specific to our point at this time, however, a t-test is used to test differences between&nbsp;means&nbsp;of two populations or matched pairs. Aside from frequencies (percentages or crude numbers),&nbsp;measures of central tendencies lie at the heart of descriptive statistics.&nbsp;&nbsp;The three measures of central tendency that describe populations are&nbsp;mean,&nbsp;median, and&nbsp;mode.&nbsp; Most of us are familiar with means  the mathematical average of a sum of values (divided by the&nbsp;count&nbsp;or number of values summed). This is a very simple concept that we have all mastered in grade school.&nbsp; However, the mathematical average value of a population/distribution does not always give an accurate picture of that population.Figure 1.&nbsp;Normal distribution or Bell curve (top).&nbsp; Skewed distribution (bottom)Remember that the&nbsp;mean&nbsp;follows the tail   this means that a single skewed or aberrant result way out of line (i.e. excessively large or small) will affect the average value by skewing that average toward that&nbsp;outlier&nbsp;value. While describing the mean is appropriate for a normally distributed population (where the mean lies in the center of the curve), it is not appropriate for a&nbsp;non-parametric&nbsp;dataset (population).&nbsp; For data that is not normally distributed but skewed, it is appropriate to measure the center of the data by its&nbsp;median. The median is defined as the&nbsp;middle&nbsp;value when the numbers are arranged in increasing or decreasing order.&nbsp; For instance, if we have the following five values of 2, 3, 5, 9, and 10, the median or middle value would be 5.&nbsp; This is fine for an odd number of individual values (half are larger and half are smaller), but for an even number of values (datapoints) the median is defined as the average of the two middle values.&nbsp; For instance, in the following data set of six values ( 2, 6, 10, 13, 17, and 20), the average of the two middle values (10 and 13) is 11.5   thus, it is the median value of this dataset. It best describes the center of this dataset.The final measure of central tendency is the&nbsp;mode.&nbsp;&nbsp;The mode is described as the most common value occurring in a set of numbers.&nbsp; If we have a set of five prices from five sources for a new statistical calculator, the&nbsp;iCalc, that includes: $150, $155, $150, $160, and $159.50, we can easily see that the mode is $150. This is the value (price) that occurs most frequently from these sources.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;The Three Measures of Central Tendency:Mean&nbsp;  the&nbsp;mathematical average&nbsp;of a sum of valuesMedian&nbsp;- the&nbsp;middle&nbsp;value when the numbers are arranged in orderMode&nbsp;- the&nbsp;most common&nbsp;value occurring in a set of numbersInterestingly, for a perfectly symmetric distribution (Bell curve, normal distribution), the mean, median, and mode will all fall at the center of the curve. For skewed populations, the mean will always follow the tail (outliers) such that it lies on one or the other side of the curve, adjacent at some level to the median value. The mode will usually be found toward the high point of the curve, reflecting the most commonly occurring value. (Figure 2)Figure 2.&nbsp;In the normal curve (top), the mean , median, and mode are all at the same point. In the negatively skewed curve below, the three measures of central tendency are at different points (values) along the curve.&nbsp;Thats it for now- we will keep things simple so you can assimilate these concepts. They will be your building blocks for the future.&nbsp; If I can understand statistics, so can you.&nbsp; I have provided references for you below and suggest that you do some reading on your own.My hope is that you too will be amazed at the Power of Numbers...See you next time.Robert Frykberg, DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb Salvage###&nbsp;REFERENCES:Statistics. Cliffs Notes, Lincoln Nebraska.&nbsp; David Voelker and Peter Orton.&nbsp; 1993Online Statistics Education: An Interactive Multimedia Course of Study (http://onlinestatbook.com/)Stanton Glantz. Primer of Biostatistics. McGraw   Hill, Inc.,&nbsp; New York]]>
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            <link>http://themayerinstitute.ca/articles/statistic-by-frykberg-part-2.php</link>
            <guid>http://themayerinstitute.ca/articles/statistic-by-frykberg-part-2.php</guid>
            <pubDate>09 Apr 2012 05:58:28 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Research]]></category>
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            <title>TED Talks: Rethinking Data Transfer to the Patient</title>
            <description>
 <![CDATA[Redesigning Medical Data]]>
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            <link>http://themayerinstitute.ca/articles/ted-talks-rethinking-data-transfer-to-the-patient.php</link>
            <guid>http://themayerinstitute.ca/articles/ted-talks-rethinking-data-transfer-to-the-patient.php</guid>
            <pubDate>28 Mar 2012 04:40:41 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Innovation]]></category>
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            <title>Diabetic Amoutation Epidemic in UK: It's Happening Here Too</title>
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 <![CDATA['Unacceptably high' number of diabetes amputations in WirralWe need to see an improvement in the way care is organised.12:25pm Friday 9th March 2012 in&nbsp;NewsBy Geoff BarnesMore people must get the care they deserve to drastically reduce the number of preventable amputations.The Putting Feet First campaign will highlight how good practice results in reduced amputation rates.'Unacceptably high' number of diabetes amputations in WirralA NATIONAL campaign group has criticised the unacceptably high number of amputations in Wirral involving people with diabetes.Diabetes UK has launched its Putting Feet First campaign this week aimed at lowering the number of preventable amputations.It reveals that Wirral Primary Care Trust has 1.17 major amputations per 1,000 adults with diabetes, compared to the national average of .99 per 1,000 and that from 2008 to 2011, Wirral had 66 major amputations per 1,000 adults living with diabetes.It disclosed further that during the same period 136 adults living with diabetes across Wirral had amputations and there were 850 episodes of care for diabetic foot disease accounting for 8,906 nights in hospital.Over the three-year period 366 patients were admitted across Wirral PCT for foot disease.Helen Pattie, Diabetes UK NW regional manager, said: A single preventable amputation is one too many and the number of amputations in Wirral PCT is unacceptably high.We need to see an improvement in the way care is organised.More people must get the care they deserve to drastically reduce the number of preventable amputations.The Putting Feet First campaign will highlight how good practice results in reduced amputation rates.It aims to reduce diabetes related amputations by 50% over the next five years and to raise awareness of people living with diabetes in understanding how important it is to look after their feet and having them checked regularly.]]>
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            <link>http://themayerinstitute.ca/articles/diabetic-amoutation-epidemic-in-uk-its-happening-here-too.php</link>
            <guid>http://themayerinstitute.ca/articles/diabetic-amoutation-epidemic-in-uk-its-happening-here-too.php</guid>
            <pubDate>28 Mar 2012 04:30:58 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Prevention]]></category>
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        <item>
            <title>Surgery Can Cure Type 2 Diabetes: There is Hope for Some.</title>
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 <![CDATA[Weight loss surgery can reverse, possibly cure Type 2 diabetes, new research findsWRITTEN BY CANADIAN PRESS ON MARCH 27, 2012Email&nbsp;Print&nbsp;Text size&nbsp;CommentCHICAGO | New research gives clear proof that weight-loss surgery can reverse and possibly cure diabetes, and doctors say the operation should be offered sooner to more people with the disease—not just as a last resort.The two studies, released on Monday, are the first to compare stomach-reducing operations to medicines alone for diabesity —Type 2 diabetes brought on by obesity. Millions of Americans have this and cant make enough insulin or use what they do make to process sugar from food.Both studies found that surgery helped far more patients achieve normal blood-sugar levels than medicines alone did.The most proper name for the surgery would be diabetes surgeryThe results were dramatic: Some people were able to stop taking insulin as soon as three days after their operations. Cholesterol and other heart risk factors also greatly improved.Doctors dont like to say cure because they cant promise a disease will never come back. But in one study, most surgery patients were able to stop all diabetes drugs and have their disease stay in remission for at least two years. None of those treated with medicines alone could do that.It is a major advance, said Dr. John Buse of the University of North Carolina at Chapel Hill, a leading diabetes expert who had no role in the studies. Buse said he often recommends surgery to patients who are obese and cant control their blood-sugar through medications, but many are leery of it. This evidence will help convince them that this really is an important therapy to at least consider, he said.There were signs that the surgery itself —not just weight loss—helps reverse diabetes. Food makes the gut produce hormones to spur insulin, so trimming away part of it surgically may affect those hormones, doctors believe.Weight-loss surgery has proven to be a very appropriate and excellent treatment for diabetes, said one study co-leader, Dr. Francesco Rubino, chief of diabetes surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center. The most proper name for the surgery would be diabetes surgery.The studies were published online by the New England Journal of Medicine, and the larger one was presented Monday at an American College of Cardiology conference in Chicago.More than a third of American adults are obese, and more than 8 per cent have diabetes, a major cause of heart disease, strokes and kidney failure. Between 5 million and 10 million are like the people in these studies, with both problems.For a century, doctors have been treating diabetes with pills and insulin, and encouraging weight loss and exercise with limited success. Few very obese people can drop enough pounds without surgery, and many of the medicines used to treat diabetes can cause weight gain, making things worse.Surgery offers hope for a long-term fix. It costs $15,000 to $25,000, and Medicare covers it for very obese people with diabetes. Gastric bypass is the most common type: Through keyhole surgery, doctors reduce the stomach to a small pouch and reconnect it to the small intestine.One previous study tested stomach banding, a less drastic and reversible procedure for limiting the size of the stomach. This technique lowered blood sugar, but those patients had mild diabetes. The new studies tested permanent weight-loss surgery in people with longtime, severe diabetesAt the Cleveland Clinic, Dr. Philip Schauer studied 150 people given one of two types of surgery plus standard medicines or a third group given medicines alone. Their A1c levels _ the key blood-sugar measure _ were over 9 on average at the start. A healthy A1c is 6 or below.One year after treatment began, only 12 per cent of those treated with medicines alone were at that healthy level, versus 42 per cent and 37 per cent of the two groups given surgery.Use of medicines for high cholesterol and other heart risks dropped among those in the surgery groups but rose in the group on medicines alone.Every single one of the bypass patients who got to 6 or less got there without the need for any diabetes medicines. Almost half of them were on insulin at the start. Thats pretty amazing, said a study co-leader, Dr. Steven Nissen, the Cleveland Clinics cardiovascular chief.An obesity surgery equipment company sponsored the study, and some of the researchers are paid consultants; the federal government also contributed grant support.The second study was led by Dr. Geltrude Mingrone at the Catholic University in Rome, with Rubino from New York. It involved 60 patients given one of two types of surgery or medicines alone. The researchers set as their goal an A1c under 6.5—the level at which someone is considered to have diabetes.Two years later, 95 per cent and 75 per cent of the two surgery groups achieved and maintained the target blood-sugar levels without any diabetes drugs. None of those in the medicine-alone group did.There were no deaths from surgery and only a few complications. Four patients in the Cleveland study needed second surgeries, and two in the Italian study needed hernia operations. Doctors note that uncontrolled diabetes has complications, too _ many patients wind up on dialysis when their kidneys fail, and some need transplants.An adult who has a body mass index (a calculation based on height and weight) of 30 or more is considered obese. Thats 203 pounds or more for a 5-foot-9 man, for example.The government recently lowered the criteria for use of gastric bands from a BMI of 35 down to 30 in diabetics or people with heart disease, opening the way for wider use of this and other procedures for obesity.Dr. Alvin Powers, director of the Vanderbilt University diabetes centre, said the results are very encouraging for people like those in these studies _ very obese, with diabetes that cant be controlled through less drastic means.We still dont know the long-term outcomes of these surgeries and whether the benefits will last for more than a few years, he said.Others were more positive.The studies are likely to have a major effect on future diabetes treatment, two diabetes experts from Australia, Dr. Paul Zimmet and George Alberti, wrote in an editorial in the medical journal. Surgery should not be seen as a last resort and should be considered earlier in treating obese people with diabetes, they wroteJon Diat is a success story. Diat, 50, who works at Citigroup and lives in New York, had been piling on pounds and pills for cholesterol and high blood pressure. After he needed an artery-opening procedure he was diagnosed with diabetes, but medicines for that failed to keep his disease under control and worsened his obesity.I was maxed out on the medications. It was very grim, he said. Two years ago, he had weight-loss surgery from Rubino.They told me, ‘Youre going to see rapid results, but it was amazing. I literally lost 70 pounds in the first three months, he said. I was off insulin within less than 72 hours of surgery. I am in complete, total remission of diabetes. My blood sugars are normal.Now he eats right, plays tennis and hockey, walks the two miles home from work and takes 12 flights of stairs to his apartment.I look at this as a second chance at life, he said. Its been liberating.Tamikka McCray, 39, who also lives in New York and works for the citys Human Resources Administration, also had success from her surgery a year and a half ago. When she left the hospital, her diabetes had disappeared before any major weight loss had a chance to occur.That was the crazy part, she said. I didnt understand that when they came in and they checked it. My sugars were normal. She added: I left the hospital with no medication. And I havent been on anything since.]]>
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            <link>http://themayerinstitute.ca/articles/surgery-can-cure-type-2-diabetes-there-is-hope-for-some.php</link>
            <guid>http://themayerinstitute.ca/articles/surgery-can-cure-type-2-diabetes-there-is-hope-for-some.php</guid>
            <pubDate>28 Mar 2012 04:17:24 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetes Management]]></category>
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            <title>Getting Acquainted with Each Other in the Clinic</title>
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 <![CDATA[Patient-Centred Care: Is It In the Cards?Submitted by&nbsp;Mark Wahba&nbsp;on March 20, 2012 - 18:09Topics:&nbsp;MASHtrading cardspatient-centred carecommunicationsMark WahbaEmergency Room Physician, Saskatoon Health Regionmywahba@mac.comRemember when you were a kid and you or a sibling collected sports cards? &nbsp;They came in wax paper packs with hard&nbsp;sticks of chewing gum (always broken). Whether they were hockey, baseball or football they were all similar: a photo of a player on the front with a write-up on the back. The photo was great: a cool&nbsp;action shot or perhaps the&nbsp;stock head and shoulders portrait.But the best parts were the biographical snippets on the back. Everyone knew what the player looked like. But what were they&nbsp;really&nbsp;like?Where were they born? Where did they start their career? Whats their nick-name?There were&nbsp;team cards. Cards with trophies on them. Special edition cards.These cards gave you a glimpse into the players lives. Made them human. Check out the Mets Gregg Jefferies card here. Who knew he loved baseball so much? Other cards gave you some background into a team's history. Some told the origins of a particular award and who had won it.They also connected you to a world that&nbsp;you watched from the outside - &nbsp;made you a part of the team. What does it mean to be an Oiler, a 49er or a member of the Red Sox? What does it take to win the Most Valuable Player award or the Most Sportsmanlike Player?&nbsp; How many times have the Canadiens won the Stanley Cup? (Twenty-four, but whos counting.)I wonder if patients feel the same way. Being an outsider in a hospital and watching the world around them from the inside. Wondering what the people are really like.How about this?&nbsp; Healthcare trading cards.Think of it. At each new patient encounter, the staff member would hand the patient one of their cards. All the doctors, nurses, support staff, everyone. The card would have the staff members first name and photo on the front with a little write-up on the back. Maybe something like:&nbsp;&nbsp;Richard. Team: Housekeeping.&nbsp;Started with health region in 1987. Wizard with the floor waxer. Takes pride in making the patient's stay as comfortable as possible. Easy to work with and always a smile on his face.&nbsp;Francis. Team: &nbsp;Nursing. Started with health region in 1996. Experience with surgical and obstetrical nursing. Has a special gift of&nbsp;comforting patients and families before and after surgery. Favorite part of nursing is getting to know her patients. Favorite technical skill is dressing changes.Team card. 5B: Surgery. 20 bed surgical unit: 16 regular and 4 high-level observation. 1 charge nurse with 5 nurses each shift. Our motto Excellent pre- and post-operative care. No pain shall be left unmanaged.Printing tens of thousands of cards to give to each patient coming through the doors would be expensive and not very environmentally friendly. So how about a virtual card for everyone? Each ID badge could have a QR code it. (That's one of those black and white boxes that you take a picture of with your phone which then takes you to a website.&nbsp;[1])Patients could scan the code and find out who their team is. Maybe even have a spot on the website to leave some feedback for the employees. It would be a great way to close the feedback loop so sorely missing in healthcare. Combine this idea with a fully functioning patient-centred electronic health record and Wow. Youd completely connect the whole team.What a great way to get patients involved and humanize the care experience. Instead of a crowd of anonymous&nbsp;white coats in the room during&nbsp;bedside rounds there would be:Rachel, 4th year medical&nbsp;student: studied education before medicine, wants to work with children.Fernando, junior resident: likes operating. Wants to develop a better technique to reduce post op infections.Heather, senior resident:&nbsp;Going to Ottawa for a vascular fellowship. Hopes her children will adapt well to the new school.Ivan, attending general surgeon: specializes in laparoscopic surgery. Volunteered his surgical skills&nbsp;in Haiti last year.These cards could become part of the patients personal health record. Based on their experiences, patients would have favourites, their own personal dream teams. The aide who played cribbage with you during his break might be your equivalent of a Wayne Gretzky or Reggie Jackson rookie card.The most valuable card of all would be the patient's, which reveals the person behind the case, the life that transcends the disease. No longer would it be the woman with colon CA&nbsp;in bed 12 or the guy in bed 2 with dementia waiting placement. Instead it would be Adele, mother of 3. Accountant. Likes to be called by her first name. Fears that the colostomy bag will leak when she's at work.&nbsp; And Maj. Richardson. Served in World War 2 spending time in the Netherlands. Owned a hardware store and is a skilled woodworker.Healthcare cards would give both staff and patients a glimpse into the person behind the face, the white coat, or the gown. In an often impersonal, high-tech, fast-paced medical world, maybe theres something to learn from the sports trading cards that helped kids who wanted to know, &nbsp;What are those people really like?]]>
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            <link>http://themayerinstitute.ca/articles/getting-acquainted-with-each-other-in-the-clinic.php</link>
            <guid>http://themayerinstitute.ca/articles/getting-acquainted-with-each-other-in-the-clinic.php</guid>
            <pubDate>24 Mar 2012 08:44:58 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Innovation]]></category>
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            <title>Moneyball for Medicine: A New Twist on You Can't Manage What You Can't Measure</title>
            <description>
 <![CDATA[INNOVATORS: ‘Moneyball for medicineResearchers look to a winning formula from the world of sports to improve health-care deliveryWRITTEN BY MARK CARDWELL ON MARCH 8, 2012 FOR&nbsp;THE MEDICAL POSTEmail&nbsp;Print&nbsp;Text size&nbsp;CommentThough not a baseball fan, Dr. Mark Wahba found inspiration in the bestselling book Moneyball, leading him to think of new ways in which medicine can use statistics to achieve better results.Two years ago, emergency physician Dr. Mark Wahba was searching for an innovative way to improve efficiency at the Royal University Hospital in Saskatoon as part of a provincial health-care quality control program he was taking.He finally found what he was looking for in a pub 500 kilometres away in his hometown of Estevan, on Saskatchewans border with North Dakota.I was having a beer with an old friend and he said, ‘Youve got to read this book,  recalls Dr. Wahba, a clinical assistant professor of medicine at the University of Saskatchewan.The book was American sportswriter Michael Lewiss 2003 book,&nbsp;Moneyball: The Art of Winning an Unfair Game, the bestselling story of how Billy Beane, general manager of the Oakland Athletics, used statistical analysis to build winning teams made up of low-budget players whose baseball talents were overlooked by big-market Major League Baseball competitors such as the New York Yankees and Los Angeles Dodgers.When I read it, I was amazed, absolutely floored, says Dr. Wahba. The similarities between the Oakland Athletics and our health-care system were striking: We were both trying to provide big-league services with restricted budgets.That epiphany prompted Dr. Wahba to approach Mary Smillie, a former consultant with the Health Quality Council of Saskatchewan, and Steven Lewis, a baseball fan and health policy professor at Simon Fraser University in Burnaby, B.C., to talk about if and how Canadas public health-care system could benefit from Beanes game-changing approach to baseball.The result of their discussions is a new blog called M.A.S.H.—Meaningful Analogies in Sports and Health.Launched on the Open Medicine website in October (to roughly coincide with the late-September release of the book-based hit movie&nbsp;Moneyball, starring Brad Pitt), the blog is devoted to exploring how medicine and health care can profit from the development, use and application of statistical analysis in sports.The similarities between the Oakland Athletics and our health-care system were striking: We were both trying to provide big-league services with restricted budgets.Our operative theory is that health care would get better if it used data as adeptly as baseball—and, increasingly, other sports—to improve decision-making and quality, the trio wrote in their first entry on the website (http://blog.openmedicine.ca/mash).We suspect that many others out there agree in principle.Though the site is open to sports-medicine analogies of all kinds, Dr. Wahba says he believes that baseball—a sport for which he says he has little affinity as a fan—was the perfect entry into the discussion because of its widespread and time-honoured use of statistics and analysis.Professional baseball by far predates all other sports in regards to data collection, he says.He notes, for example, that baseball managers, coaches, players and even fans routinely follow and compare in minute detail almost every aspect of the sport, from pitches thrown and the resulting strikes and balls, to batters hitting averages based on multiple factors including left- versus right-handed pitching, pitch counts and having runners in scoring positions.Numbers are in the very DNA of baseball, says Dr. Wahba. It is a series of highly discrete events, every one of which can be shown to affect the outcome of a game.He adds that other sports—notably professional hockey, football and basketball—are also now collecting and using analytical data in an effort to both gain competitive advantage and to select players who have the best chance of success in their sport.There is no doubt that the use of statistics is now widespread in sport, and that they are enhancing performance, says Dr. Wahba.Contrast that with health care, which has an enormous inventory of unexplored data, underused analysis and, in too many places, a culture that regards data with suspicion and even hostility.In their initial paper on the blog, the MASH founders write that in the world of professional sports, the difference between success and failure sometimes hinges on minor differences in capacity and execution.Health and health care are, of course, far more fundamental to the human condition. Often, people live because of evidence-informed practice or die because the evidence has been ignored.To date, the site has a handful of entries that explain what analogies might be drawn between sports and health data.Dr. Wahba, for example, considers which data could explain outcomes. The batting average explains less about a players performance than previously assumed; being overweight (but not obese) has less adverse impact on health status than previously assumed, he writes. But there are perils of focusing too narrowly on a performance metric. . . . Fielding average does not tell us much about fielding performance; 30-day postsurgical mortality or readmission rates may be less meaningful than one-year quality-of-life outcomes.He advances a similar possibility for the importance of case-mix adjustment.A pitcher who yields three runs a game in a hitter-friendly ball park may be better than a pitcher who yields 2.5 runs a game in a park with distance fences; a surgeon with a higher crude mortality rate may be more skilled than one with a lower rate who takes easier cases.Understanding luck or random outcomes (good or bad), he adds, a pitcher who strikes out few batters but gives up few runs may be living on borrowed time; a hospital with no hand-washing protocol but (with) no major infection outbreaks may be likewise rolling the dice.A recent MASH blog, which Lewis posted on Dec. 6, is entitled Do clinicians need spring training?Baseball, it reads, has spring training and no one is exempt from the drills, the repetitions (and) the fine tuning. It is not just a rite of spring; it is fundamental to the pursuit of excellence.Baseball assumes that skills are impermanent, mastery is fleeting, coaching is essential, and practice never ends. Health care assumes that skills, once achieved, are permanent, mastery comes with time, coaching is unnecessary and practice is for students. Baseball has it right.He notes that to succeed like Billy Beane, hospital and health-care stakeholders—everyone from administrators to medical staff—need to completely rethink their time-honoured approaches to chronic problems.For Dr. Wahba, the goal of the MASH blog is to stimulate debate, participation and enjoyment among readers and writers alikeThe first question we should be asking ourselves is, ‘What exactly are we trying to accomplish?  says Dr. Wahba. From there its a matter of working backward to figure out how to make it happen.He says he hopes the MASH blog will get people thinking along those lines.A measure of success, says Dr. Wahba, would be if it inspires a single person to do something that improves a patients experience or outcome.Mark Cardwell is a freelance writer in Quebec.]]>
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            <link>http://themayerinstitute.ca/articles/moneyball-for-medicine-a-new-twist-on-you-cant-manage-what-you-cant-measure.php</link>
            <guid>http://themayerinstitute.ca/articles/moneyball-for-medicine-a-new-twist-on-you-cant-manage-what-you-cant-measure.php</guid>
            <pubDate>21 Mar 2012 05:20:41 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Innovation]]></category>
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            <title>My Colleague and Mentor, Dr. David Armstrong and His Partner in the War on Feet,Dr. George Andros are the Real Hollywood Stars.</title>
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 <![CDATA[Medical Experts Converge In Hollywood To Discuss Diabetes&nbsp;CareMarch 15, 2012 6:50 PMShare this11 commentAdd CBS Los Angeles to your Timeline to share with your friends.Filed UnderHealth,&nbsp;Healthwatch,&nbsp;News,Syndicated LocalRelated TagsAmputation Prevention,Amputation Prevention Center,&nbsp;DFCon,&nbsp;Diabetes Care,&nbsp;Diabetic Foot Global Conference,&nbsp;Dr. David Armstrong,&nbsp;Dr. George Andros,&nbsp;Feet,&nbsp;Foot,Hollywood,&nbsp;Ulcer,&nbsp;University of Arizona,&nbsp;Valley Presbyterian HospitalHOLLYWOOD (CBS)&nbsp;— Leaders in the medical world met in Hollywood Thursday for a global conference on diabetes care.The Diabetic Foot Global Conference (DFCon) focuses on amputation prevention and foot and wound care.The conference, now in its tenth year, was started by Dr. George Andros, the Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital, and Dr. David Armstrong, Professor of Surgery at the University of Arizona.The conference is the largest of its kind in the world.The founding doctors said that there is a misconception among people with diabetes.If you take all the patients that come in and have this sore on their foot and the ulcer that puts them at risk for amputation, I ask them, ‘what do you think your chances of saving your foot are? And they say, ‘Aw, not very good doc   5 percent? Well I say, ‘You got the right number, but the wrong way around. We save 95 percent of the feet that come to us at risk of amputation, Dr. Andros said.So the patients come in quite despondent and depressed and I think after weve seen them and talked with them — but most importantly after weve treated them   I think they feel a lot less depressed and a lot happier about their lives, he added.The great news is that theres hope and that is what were seeing in meetings like this. We have folks now from 50 nations, all 50 states, from 15 different medical, surgical, nursing disciplines that are here at DFCon that are now going to go back to their country as delegates, as champions and try to make a difference, said Dr. Armstrong.There are only four specialized clinics, like the ones at Valley Presbyterian and the University of Arizona, in the country.The doctors said that more are needed and that is why the conference is so important.For more information, visit DFCon online at http://dfcon.com/]]>
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            <link>http://themayerinstitute.ca/articles/my-colleague-and-mentor-dr-david-armstrong-and-his-partner-in-the-war-on-feetdr-george-andros-are-the-real-hollywood-stars.php</link>
            <guid>http://themayerinstitute.ca/articles/my-colleague-and-mentor-dr-david-armstrong-and-his-partner-in-the-war-on-feetdr-george-andros-are-the-real-hollywood-stars.php</guid>
            <pubDate>16 Mar 2012 02:54:03 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetic Foot Ulcer Treatment]]></category>
        </item>
        <item>
            <title>We Want Tu PUMP, YOU, UP: Arnold et al may have been on to something.</title>
            <description>
 <![CDATA[Diabetics should lift weights before cardio: studyinShare16Share thisEmailPrintRelated NewsFDA adds diabetes, memory loss warnings to statinsTue, Feb 28 2012Analysis &amp; OpinionThe slippery slope of a sugar taxFitness first for the First LadyRelated TopicsHealth »By Lindsey KonkelNEW YORK&nbsp;|&nbsp;Fri Mar 9, 2012 4:55pm EST(Reuters Health) - People with diabetes may have better blood sugar control during workouts if they lift weights before doing cardio exercise, according to a new study by Canadian researchers.It's important to define the best way for people with type 1 diabetes to exercise so that blood sugar doesn't drop too low, yet they can still reap all the benefits of aerobic exercise, Dr. Ronald Sigal, an endocrinologist at the University of Calgary in Canada and lead author of the study told Reuters Health.Those with type 1 diabetes, a condition in which the body does not produce its own insulin, a hormone needed to convert food into fuel, risk low blood sugar during exercise. Blood sugar that drops too low can lead to poor coordination, unconsciousness or even coma.About five percent of all Americans with diabetes, or roughly 1.3 million people, have type 1, which is often diagnosed in childhood, according to the Centers for Disease Control and Prevention.Twelve fit people with type 1 diabetes, who already ran and lifted weights at least three times per week, participated in the new study. The 10 men and two women averaged 32 years old.They met researchers at the laboratory for two experimental exercise sessions, which were held at least five days apart.At one session, participants did 45 minutes of treadmill running followed by 45 minutes of weight lifting. They switched the order for the other session.Each workout started at five o'clock in the evening to simulate a common time of day people might exercise after work, said Sigal.Researchers measured blood sugar levels before, during and after exercise for each participant.In people with type 1 diabetes, target blood sugar levels can range from about 4 to 10 millimoles per liter of blood (mmol/L).Researchers interrupted participants before blood sugar became too low for safety reasons -- if it fell below 4.5 mmol/L, participants stopped and ate a snack.When participants did aerobic exercise first, blood sugar dropped closer to that threshold and remained lower for the duration of the workout than when they lifted weights first and ran second.Lifting weights first was also associated with less severe drops in blood sugar hours after exercise, and post-exercise drops that did occur tended to last a shorter period of time.The current study, published in the journal Diabetes Care, echoes previous research showing that aerobic exercise causes a more rapid decrease in blood sugar than weightlifting.&#147;Your muscles utilize sugar very quickly in aerobic exercise, Dr. Vivian Fonseca, chief of endocrinology at Tulane University Medical School told Reuters Health. He was not involved in the current work.The study was small, and the researchers acknowledge that other factors, which they did not measure, could be at work, rather than the exercise order. For example, they did not account for levels of a number of hormones that could also lead to changes in blood glucose during exercise.Nor did they have control over participants' food and activity choices prior to exercise --the authors wanted the study to reflect real-life conditions faced by people with type 1 diabetes.Because study participants were young, active people with type 1 diabetes, it's not clear whether the findings would apply to less fit people with type 1 diabetes or people with type 2 diabetes.&#147;While the study findings are very intriguing, they may have limited practical value until more studies are done, said Fonseca.Still, the authors conclude, those people with type 1 diabetes who tend to develop low blood sugar during exercise &#147;should consider performing their resistance exercise first.SOURCE:&nbsp;bit.ly/yItDRO&nbsp;Diabetes Care, online February 28, 2012.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/we-want-tu-pump-you-up-arnold-et-al-may-have-been-on-to-something.php</link>
            <guid>http://themayerinstitute.ca/articles/we-want-tu-pump-you-up-arnold-et-al-may-have-been-on-to-something.php</guid>
            <pubDate>16 Mar 2012 08:44:34 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetes Management]]></category>
        </item>
        <item>
            <title>Low Carbs for 2 Days?  No Problem.</title>
            <description>
 <![CDATA[Low Carbs for Just Two Days a Week Spurs Weight LossAdhering to a strict, low-carbohydrate diet two days per week led to greater reductions in weight and insulin levels when compared with standard daily dieting.Can you diet for just two days a week? You might be able to drop more weight if you cut back on carbs just two days a week.The study's lead author Michelle Harvie, a research dietician at the Genesis Prevention Center at the University Hospital in South Manchester, England stated that, We came up with the idea of an intermittent low-carb diet because it enables people to still have foods that are very satiating. Also, there's a lot of evidence from other studies showing that restricting carbohydrates has the same effect as restricting energy.British researchers found that women who essentially gave up carbs for two days and ate normally the rest of the time dropped about 9 pounds on average, as compared to the 5 pounds lost by women who cut back to around 1,500 calories every day, according to a new report presented at the CTRC-AACR San Antonio Breast Cancer Symposium.Harvie and her colleagues were spurred to find a diet that would be easier for women to follow because research has shown that obesity and the changes it causes in the body increase the risk for breast cancer. We know from our research in animal models that losing weight has the potential for reducing breast cancer risk, Harvie said.The researchers followed 88 women for four months. All the women were at high risk for breast cancer based on their family histories. One third of the women were put on a Mediterranean-type diet that restricted calories to about 1,500 per day. A second group was told to eat normally most of the time, but two days a week to cut carbs and also calories to about 650 on those two days. The third group was also to cut carbs two days a week, but there was no calorie restriction on those days.At the end of four weeks women in both of the intermittent dieting groups had lost more weight -- about 9 pounds -- than the women who ate low calorie meals every day of the week -- about 5 pounds.Women in the intermittent dieting groups also had better improvement than daily dieters in the levels of hormones -- insulin and leptin -- that have been linked with breast cancer risk, Harvie said. And, yes, this is something you can try at home, Harvie said. You just need to dramatically cut back carbohydrates two days a week and try to eat sensibly the rest of the time, she added.What that means, Harvie said, is that you can eat protein and healthy fats on the two low carb days, but skip bread, pasta, root vegetables like potatoes, carrots and parsnips to get to the 50g limit. The diet allows for one piece of fruit on the low carb days. Other foods on the menu include: nuts and green, leafy vegetables, peppers, mushrooms, tomatoes, broccoli, eggplant and cauliflower.Presented at the CTRC-AACR San Antonio Breast Cancer Symposium Nov. 2011]]>
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            <link>http://themayerinstitute.ca/articles/low-carbs-for-2-days--no-problem.php</link>
            <guid>http://themayerinstitute.ca/articles/low-carbs-for-2-days--no-problem.php</guid>
            <pubDate>06 Mar 2012 04:25:09 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetes Management]]></category>
        </item>
        <item>
            <title>Dr. Frykberg's 3rd Instalment on Diabetic Foot Infections</title>
            <description>
 <![CDATA[&nbsp;Robert Frykberg,&nbsp;DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb Salvage&nbsp;The Challenges of Diabetic Foot Infections&nbsp;(Part 3):A Brief Primer on Antibiotics&nbsp;In the last couple of issues of&nbsp;Footnotes,&nbsp;we have been discussing the assessment and non-pharmacologic management of diabetic foot infections. Certainly, infection is that complication that so often leads to tissue loss   and in the presence of ischemia, directly contributes to limb loss. Antimicrobial therapy is the third element of care for diabetic foot infections (DFI)   third because antibiotics should be considered&nbsp;adjunctive&nbsp;to surgical management, although this 3rd rail is crucial to effective eradication of bacterial pathogens in this difficult setting.I am a clinician, not an infectious disease specialist. But having been in the trenches with such patients for a good many years, Ive learned a little about antimicrobial management for DFIs. Granted, Ive made many mistakes to go along with the successes. Hopefully, those experiences have made me somewhat wiser in my approach to such patients. Relatively mild or non-limb threatening infections are generally straightforward to manage with oral agents. For the purposes of this Foot Notes, however, we will concentrate on the more serious DFIs requiring hospitalization (IDSA Grade 3-4).&nbsp;Simplification, while appreciating the magnitude of the problem at hand, is always best. Many years ago, the standard cocktail for hospitalized patients with DFI consisted of triple therapy with Gentamicin, Ampicillin, and Clindamycin (or cephalothin). This regimen would cover most Gram negative rods (GNR), Gram positive cocci (GPC), as well as anaerobes. MRSA was not the problem that it is today.&nbsp; As you have surmised, we must have done a lot of harm to the diabetic kidneys with the aminoglycosides.&nbsp; In the mid-seventies, we didnt have carbapenems or extended spectrum penicillins (with or without beta-lactamase inhibiting agent combinations). With the advent of Imipenem, Ticarcillin, amoxicillin-clavulanate, and then piperacillin, and piperacillin/tazobactam, our options expanded dramatically. Soon, we were able to treat even the most severe of infections with a single empirical agent in many cases. Of course, then as now, penicillin (PCN) allergic patients presented a little more difficulty. Clindamycin even today remains a mainstay of treatment for such patients, although the options are quite a bit more numerous than before.&nbsp; Hence, we can discuss antimicrobial management in terms of severity of infection, as well as in the setting of PCN-allergic patients. This is obviously a simplistic approach, but in most cases, this approach will be sufficient for the average clinician to provide for reasonable initial empirical therapy. As always, antibiotic regimens need to be fine tuned and adjusted, based on culture and sensitivity (C&amp;S) results, patient response, and renal function.Only three currently marketed antibiotics have a specific indication for diabetic foot infections: piperacillin/tazobactam, linezolid, and ertapenem. These are great agents, and found to be superior to their various comparators in clinical trials (see references). Nonetheless, these agents are not always effective for all patients or pathogens (or combinations of pathogens). Hence, we usually provide parenteral empirical therapy with combinations of agents, until our C&amp;S results have been returned.Common antibiotics used for the management of diabetic foot infectionsAside from the need to empirically cover GNRs, GPC (especially&nbsp;Staph aureus&nbsp;and Group B Streptococci), and anaerobes, we must now be vigilant for the predominance of MRSA in the United States. Since more than 50% of our staphylococcal isolates in my facility are MRSA, we always empirically cover for this organism. For this, we add Vancomycin to our broad spectrum agent, Piperacillin/Tazobactam. One could just as easily prescribe Vancomycin plus ertapenem to achieve very broad coverage (even in PCN allergic patients). Whereas amoxicillin/clavulanate previously was my combination agent of choice, it no longer has the Gram positive and Gram negative spectrum that it once enjoyed.&nbsp; I do not really like vancomycin, due to rising minimum inhibitory concentrations (MIC) required, as well as its nephrotoxicity in diabetic patients with acute renal failure. Linezolid is a far more effective drug (that can also be given orally), but with a rising number of patients on SSRI agents for depression   especially in the Veteran population- we must be cognizant of Serotonin syndrome. Therefore, we use this agent primarily for documented MRSA infections in patients&nbsp; who have failed or responded poorly to vancomycin. I suppose daptomycin would be an equally good choice in this regard. Again, once our initial cultures have been returned with sensitivities, we narrow our coverage accordingly- to the simplest effective agent. Nafcillin or cefazolin are the single agents most often used for methicillin-sensitive&nbsp;staph aureus&nbsp;(MSSA) or streptococcal infections. For purely streptococcal infections, (excluding enterococcus) we prefer intravenous Penicillin G until we can safely switch to the oral formulation. For&nbsp;Enterococcus faecalis, we prefer ampicillin in some format (or vancomycin if being used for MRSA).For the PCN allergic patient, we rely very much on Clindamycin, Ciprofloxacin, and vancomycin (or linezolid). While Ciprofloxacin will provide coverage for most GNRs, clindamycin will cover MSSA, streptococci (not&nbsp;enterococcus), and even anaerobes. Occasionally, it will even cover MRSA.&nbsp; Furthermore, it can be safely used in patients with impaired renal function. Vancomycin is a more certain coverage for MRSA (as well as MSSA) and enterococcus. We will generally start those with moderately severe infections on a combination of Vancomycin and oral Ciprofloxacin for fairly broad coverage (but not good anaerobic coverage). Hence, for severe infections and necrotizing infections, it makes sense to add clindamycin to this regimen or at least metronidazole. Linezolid can also be considered for excellent GPC coverage   MSSA, MRSA, streptococcal, and enterococcus (including VRE). Again, tailoring coverage to isolated pathogens once sensitivities are known will make your patients and pharmacists very happy.I have left many possible agents or combinations out of this discussion for the sake of simplicity. In managing your patients, however, you must always consider the severity of the infection, prior cultures, local antibiogram profiles, renal function, concurrent medications, and general allergy profiles. It is also wise to be familiar with the profiles of your favorite antimicrobial agents   know the pathogen coverage they provide as well as the gaps in coverage. Remember that if the patient dos not respond within 24 to 48 hours, you have missed something. This could be an undrained abscess, ischemia, or a resistant or untreated pathogen. For particularly difficult patients, infections, or pathogens, I will consult my infectious disease specialist for help. Things can go downhill awfully quickly in this patient population.&nbsp;Nothing says it better than this quote from Louis Pasteur in 1880:The germ is nothing.&nbsp; It is the terrain in which it is found that is everything###References are provided below that can expand upon many of the points made above. We welcome your opinions, concerns, and suggestions.&nbsp; If you have an interesting case or a troubling circumstance that you would like to share with fellow PRESENT Diabetes members, &nbsp;please feel free to comment on eTalk.Best regards,Robert Frykberg, DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb SalvageREFERENCESEneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.&nbsp;Foot Ankle Int.&nbsp;Nov 1997;18(11):716-722.Frykberg RG. An evidence-based approach to diabetic foot infections.&nbsp;Am J Surg.&nbsp;Nov 28 2003;186(5A):44S-54S; discussion 61S-64S.Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision).&nbsp;J Foot Ankle Surg.&nbsp;Sep-Oct 2006;45(5 Suppl):S1-66.Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections.Clin Infect Dis.&nbsp;Oct 1 2004;39(7):885-910.Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes.&nbsp;N Engl J Med.&nbsp;Sep 29 1994;331(13):854-860.Grayson ML, Balaugh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.&nbsp;J Am Med Assoc.1995;273(9):721-723.Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes.&nbsp;Diabetes Care.&nbsp;Jun 2006;29(6):1288-1293.Eneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.&nbsp;Foot Ankle Int.&nbsp;Nov 1997;18(11):716-722.Frykberg RG. An evidence-based approach to diabetic foot infections.&nbsp;Am J Surg.&nbsp;Nov 28 2003;186(5A):44S-54S; discussion 61S-64S.Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision).&nbsp;J Foot Ankle Surg.&nbsp;Sep-Oct 2006;45(5 Suppl):S1-66.Javier Aragón-Sánchez, Yurena Quintana-Marrero, Jose L. Lázaro-Martínez, et al: Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality.&nbsp;INT J LOW EXTREM WOUNDS&nbsp;2009; 8; 141Javier Aragón-Sánchez:&nbsp;Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections&nbsp;International Journal of Lower Extremity Wounds&nbsp;2011 10: 33Lipsky BA, Itani K, Norden C. Treating foot infections in diabetic patients: a randomized, multicenter, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate.Clin Infect Dis.&nbsp;Jan 1 2004;38(1):17-24.Lipsky BA, Armstrong DG, Citron DM, Tice AD, Morgenstern DE, Abramson MA. Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, double-blinded, multicentre trial.&nbsp;Lancet.&nbsp;Nov 12 2005;366(9498):1695-1703.Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis.&nbsp;Clin Podiatr Med Surg.&nbsp;Jul 2007;24(3):469-482, viii-ix.Warren Joseph: Handbook of Lower Extremity Infection. Data Trace Publishing]]>
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            <link>http://themayerinstitute.ca/articles/dr-frykbergs-3rd-instalment-on-diabetic-foot-infections.php</link>
            <guid>http://themayerinstitute.ca/articles/dr-frykbergs-3rd-instalment-on-diabetic-foot-infections.php</guid>
            <pubDate>28 Feb 2012 05:38:52 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Infection]]></category>
        </item>
        <item>
            <title>Part 2 of Dr. Frykberg's Great Synopsis on the Challenges in Treating Diabetic Foot Infections</title>
            <description>
 <![CDATA[&nbsp;Robert Frykberg,&nbsp;DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb Salvage&nbsp;The Challenges of Diabetic Foot Infections:(Part 2)&nbsp;In the&nbsp;last issue of FootNotes,&nbsp;we focused on what I consider to be the essential components in the assessment of patients presenting with diabetic foot infections. Although I concentrated on severe or limb threatening foot infections, the principles remain the same for even mild or moderate infections: always be suspicious, always look for ischemia, and always obtain appropriate laboratory tests and imaging procedures as essential parts of your evaluation. Also important, please recognize that just having a wound does not imply that it is infected; most, if not all, wounds are contaminated. Infection is a clinical diagnosis based on those classical signs we are all familiar with: rubor, tumor, dolor, and calor. Nonetheless, diabetes (like syphilis) has become the great masquerader in that typical signs and symptoms are masked   especially in the presence of neuropathy.&nbsp; Hence, my exhortation that one must always be suspicious in such patients who often do not respond to treatment the way one would expect them to under normal circumstances (i.e. persistent fever after several days of ostensibly appropriate therapy).&nbsp;So now let us focus on the&nbsp;management&nbsp;of established diabetic foot infections that have been appropriately evaluated. Our focus will always be aimed at limb salvage, a much harder task in many cases than primary leg amputation.Management of Diabetic Foot InfectionsAntibiotics are&nbsp;only part of the management strategies for these complicated patients, although a significant component, of course.&nbsp; In most cases, however, antimicrobial therapy becomes adjunctive to non-pharmacologic (surgical) therapy. An old adage from my years of training in Boston stipulates that diabetic patients cannot tolerate undrained infection (I believe this comes from an old friend and surgeon, Gary Gibbons). This is a good point to remember, since it is painfully driven home whenever it is forgotten. As I mentioned earlier, those patients not responding to antimicrobial therapy alone likely are failing due to an undrained abscess or retained necrotic tissue. This is a very common scenario and one that is seen especially frequently in those patients with necrotizing soft tissue infections (necrotizing fasciitis, necrotizing cellulitis, clostridial myonecrosis, etc.). These patients typically require several trips to the operating room before their infection is controlled- short of doing a primary major amputation. Last month, I presented a&nbsp;case of necrotizing soft tissue infection.&nbsp;(Figure 1&nbsp;)&nbsp; As in this case, such patients do not always present with gas in the soft tissues   that would be too easy. Gas easily identifies those individuals requiring an urgent trip to the operating room   few would miss this clinical clue. Nonetheless, many individuals present with severe cellulitis and some soft tissue necrosis even in the absence of purulent drainage.Fig. 1.&nbsp;Necrotizing soft tissue infection- no gas on x-rays but note the severe cellulitis, edema, and necrotic dorsal skin. The portal of entry was in the webspace at the base of the second toe. No ischemia was present.They may or may not be sick (IDSA Grade 4 or 3), but the severity of their infection is signified by recalcitrant hyperglycemia, leukocytosis, and failure to resolve cellulitis with broad spectrum antimicrobial therapy.&nbsp; These important clinical clues should indicate that, very likely, surgical debridement or partial foot amputation is necessary. Several procedures are often required prior to eventual control of infection and definitive closure. (Figures 2-4)Fig. 2.&nbsp;Same patient after initial extensive debridement and toe amputations. Although infection somewhat improved, further necrosis and persistent cellulitis required further debridement.Fig. 3.&nbsp;After further debridement and toe amputations, the infection came under control. A large soft tissue and osseous defect remained with residual necrosis at the midfoot, placing the limb at risk.Fig. 4.&nbsp;Definitive closure was obtained with a Chopart amputation.Equally important is the necessity for detecting and treating peripheral ischemia (PAD) when present. Many patients with pre-existing PAD have a foot infection as their first presenting sign of ischemia. In the presence of neuropathy, critical limb ischemia is often silent in that the usual symptoms of claudication or rest pain are absent.&nbsp; Therefore, in all patients presenting with acute foot infection it is prudent to look for underlying PAD and request appropriate vascular studies and consultations.&nbsp; That being said, ischemia does not preclude appropriate surgical management for the&nbsp;acute&nbsp;infection.&nbsp; It is still essential to drain abscesses or to perform emergent local amputations to control infection. Revascularization should be performed&nbsp;after&nbsp;immediate control of infection. A final, definitive procedure such as a closed amputation or skin graft should follow the revascularization and restoration of perfusion to the foot.We have previously discussed the management of osteomyelitis in&nbsp;Diabetic Footnotes Issue 18 - Osteomyelitis — Now What?,&nbsp;but it is worth mentioning again in the overall context of managing diabetic foot infections.&nbsp; I am of the (biased) opinion that in the diabetic foot, osteomyelitis is best managed surgically in most instances. While this is a matter of debate around the Globe, surgical debridement or bone resection (and sometimes local amputation) with adjunctive systemic antimicrobial therapy seems to more predictably affect a cure than treatment with just antibiotics. This is the course of treatment followed by most US surgeons until prospective studies can definitively identify those sites or patients best suited to medical therapy alone.&nbsp; Nonetheless, osteomyelitis very rarely, if ever, presents as an acute problem   it usually comes associated with an acute soft tissue infection.&nbsp;Once the acute infection has been managed, the bone infection can be definitively treated as appropriate for the circumstances. For instance, in a patient with an infected plantar ulcer of a metatarsal head without gangrene, a joint resection with a 4 to 6 week course of culture-directed oral antibiotics will most often result in a cure.I have not specifically addressed antimicrobial therapy thus far, because I think that we need to place a good deal of emphasis on the surgical management of limb threatening infections. Nonetheless, in our next issue, we will discuss my approach to antimicrobial management of diabetic foot infections   from a clinicians viewpoint. I have been in the trenches for many years in this regard and have made many mistakes. Hopefully, Ive learned from them and can offer some guidance to you as well.&nbsp;Until next time…###References are provided below that can expand upon many of the points made above. We welcome your opinions, concerns, and suggestions.&nbsp; If you have an interesting case or a troubling circumstance that you would like to share with fellow PRESENT Diabetes members, &nbsp;please feel free to comment on eTalk.Best regards,Robert Frykberg, DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb SalvageREFERENCESEneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.&nbsp;Foot Ankle Int.&nbsp;Nov 1997;18(11):716-722.Frykberg RG. An evidence-based approach to diabetic foot infections.&nbsp;Am J Surg.&nbsp;Nov 28 2003;186(5A):44S-54S; discussion 61S-64S.Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision).&nbsp;J Foot Ankle Surg.&nbsp;Sep-Oct 2006;45(5 Suppl):S1-66.Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections.Clin Infect Dis.&nbsp;Oct 1 2004;39(7):885-910.Javier Aragón-Sánchez, Yurena Quintana-Marrero, Jose L. Lázaro-Martínez, et al: Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality.&nbsp;INT J LOW EXTREM WOUNDS&nbsp;2009; 8; 141Javier Aragón-Sánchez:&nbsp;Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections&nbsp;International Journal of Lower Extremity Wounds&nbsp;2011 10: 33]]>
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            <link>http://themayerinstitute.ca/articles/part-2-of-dr-frykbergs-great-synopsis-on-the-challenges-in-treating-diabetic-foot-infections.php</link>
            <guid>http://themayerinstitute.ca/articles/part-2-of-dr-frykbergs-great-synopsis-on-the-challenges-in-treating-diabetic-foot-infections.php</guid>
            <pubDate>28 Feb 2012 05:33:34 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Infection]]></category>
        </item>
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            <title>Vascular Referral Rate Very Poor</title>
            <description>
 <![CDATA[Guideline neglect observed for limb ischemiaU.S. study uncovers substandard care for patients facing amputationWRITTEN BY ED SUSMAN ON FEBRUARY 27, 2012 FOR CANADIANHEALTHCARENETWORK.CAEmail&nbsp;Print&nbsp;Text size&nbsp;CommentMIAMI BEACH, FLA. | Despite recommendations that patients at risk of amputation be referred to vascular surgeons, barely one-third of doctors at one institution complied with those guidelines.But a review of patients charts also found the recommendation was just one of many American Heart Association/American College of Cardiology recommendations for patients with chronic critical limb ischemia that had poor compliance, according to Dr. Laura Harmon, a surgery resident at Scott &amp; White Hospital in Temple, Texas. She conducted the retrospective study at Texas Tech University Health Sciences Center in Odessa.Only 36% of our patients in this study got beyond the primary caregiver, Dr. Harmon said at her poster presentation during the 2012 International Symposium on Endovascular Therapy here. The problem is not that our facilities are isolated and dont have specialists available. We are just not getting the referrals to the appropriate people.Dr. Harmon and colleagues reviewed cases of lower limb amputation from 2006 to 2010 to determine how well doctors were doing at following the 2005 guidelines.She found that of the 314 patients in the study:• 26% were referred to institutional smoking cessation programs• 32% had surgical revascularization procedures• 34% underwent assessment of additional ischemic risk factors• 34% had endovascular revascularization procedures• 36% were referred to a vascular specialist• 38% were on statin prescriptions• 39% were given hemodynamic diagnostic studies• 56% were given prescriptions for antiplatelet therapy• 59% had imaging studies to define underlying vascular anatomy.Despite the guidelines for lower extremity arterial disease management, a substantial gap exists between current recommendations and clinical practice, Dr. Harmon said. Our goal in performing this study was to bring some attention to this situation in our home facility and say: ‘Hey, we are not doing this right.She said plans are in place to determine if greater compliance with guidelines can be achieved through the education of physicians and allied health-care professionals.]]>
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            <link>http://themayerinstitute.ca/articles/vascular-referral-rate-very-poor.php</link>
            <guid>http://themayerinstitute.ca/articles/vascular-referral-rate-very-poor.php</guid>
            <pubDate>28 Feb 2012 05:26:59 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Vascular Support]]></category>
        </item>
        <item>
            <title>innovation at its Best: Toronto Scientist Develops Low Cost Prosthetic Limb</title>
            <description>
 <![CDATA[A novel artificial knee joint for lower-limb amputations: a functional and affordable technology for low- and middle-income coun&nbsp;from&nbsp;Grand Challenges Canada&nbsp;on&nbsp;Vimeo.Toronto scientist develops artificial leg that costs just $50Published On Thu Feb 09 2012EmailPrint(17)RssArticleComments (17)Research scientist Jan Andrysek displays the L.C. (Low Cost) mechanical knee that was created at the Bloorview rehab centre over the last six years.RICK EGLINTON/TORONTO STARBy&nbsp;Megan OgilvieHealth ReporterIf a man loses his leg in Sierra Leone — from the blast of a land mine or in a horrific car accident — chances are he will not be able to get an artificial limb.Those used in Canada and the U.S. are too expensive, costing many thousands of dollars each. And if a limb were available, it would likely be too primitive for him to use.But Jan Andrysek, a scientist at Holland Bloorview Kids Rehabilitation Hospital, has developed a cheap and functional artificial limb for those who have had their leg amputated above the knee.It costs just $50. Comparable limbs have a $3,000 price tag.On Thursday, Andrysek received a $100,000 grant to further develop his innovative limb, prosaically dubbed the Low-Cost Prosthetic Knee Joint, or the LC Knee. The award is one of 15 handed out by Grand Challenges Canada, an independent non-profit organization funded by the federal government, to Canadian researchers working to improve global health conditions.Researchers whose ideas prove successful are eligible for an additional $1 million to help get their innovation to the people who need it most.Andrysek, a rehab engineer, says designing the limb had its challenges. It had to be simple, but robust enough to withstand rough terrain, whether unpaved roads or mountain paths. It had to be comfortable so those who use the limbs could go back to work, often the hard physical labour of farming. It also needed to be inexpensive, yet made of high-quality materials that could last for years without need of repair.A key component of the limb is its unique knee mechanism that functions much like the human joint.It automatically locks and unlocks itself based on how the person is putting their weight on the limb, Andrysek says, noting that many of the artificial limbs used in developing countries have outdated manual locks on the joints.The mechanisms and technologies used are based on designs from post-World War II. They have not changed in 50 years.In addition to the novel design, which cut costs, Andrysek made the LC Knee of low-cost thermoplastics which could be mass-produced using injection molding techniques.We can now mold all the pieces for a knee for about $15, he says. These are fairly complex parts that have a complex structure and integrity and strength.An added bonus of using plastic? The knee is waterproof, increasing its chances of working well in humid environments.Andrysek plans to use the $100,000 grant to further test the LC Knee in developing countries, including Ethiopia, Colombia and Nicaragua.Toronto Innovators15 Canadian researchers received $100,000 grants from Grand Challenges Canada. The money is to be used to help get innovative health solutions to people in the poorest regions of the world. Four grants went to Toronto researchers.Lu Chen from the University of Toronto is developing a low-cost, portable device to monitor HIV progression in patients, a service usually unavailable to those in resource-poor areas.Helen Dimaras from the University Health Network is working on a way to quickly evaluate the progression of cancer in patients living in rural Africa.Ophira Ginsburg from Womens College Research Institute is designing a mobile phone tool for community health workers to use to encourage women in rural Bangladesh to seek help for breast cancer, a disease for which many women do not get treated until it is too late.Toronto Scientist&nbsp;]]>
            </description>
            <link>http://themayerinstitute.ca/articles/innovation-at-its-best-toronto-scientist-develops-low-cost-prosthetic-limb.php</link>
            <guid>http://themayerinstitute.ca/articles/innovation-at-its-best-toronto-scientist-develops-low-cost-prosthetic-limb.php</guid>
            <pubDate>22 Feb 2012 05:40:38 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Innovation]]></category>
        </item>
        <item>
            <title>Doctors Often Lecture Non-Coompliant Patients Too Much</title>
            <description>
 <![CDATA[Study: Doctors often lecture noncompliant patients too muchMany physicians don't ask open-ended questions about medication regimens. Experts say simply telling patients what to do is not always effective.By&nbsp;]]>
            </description>
            <link>http://themayerinstitute.ca/articles/doctors-often-lecture-noncoompliant-patients-too-much.php</link>
            <guid>http://themayerinstitute.ca/articles/doctors-often-lecture-noncoompliant-patients-too-much.php</guid>
            <pubDate>21 Feb 2012 06:20:31 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Prevention]]></category>
        </item>
        <item>
            <title>Innovation at its Best: Calgary Company Produces Pressure Sensing Insoles that Train the Mind.</title>
            <description>
 <![CDATA[SurroGait RxThe ProblemOne of the main problems with diabetic peripheral neuropathy is that, when someone is affected with it, he or she is unaware when pressure-induced damage is being done.&nbsp;&nbsp;The result is tissue damage, leading to ulceration, and often, amputation.&nbsp;The patented SurroGait Rx is a high-tech, pressure-sensing insole that tells the user when damage is being done to the feet and provides substitute sensation for numb feet. The SurroGait Rx includes a high-resolution pressure-sensing insole and a low-profile, ergonomic back display. Pressure information collected in the shoe is wirelessly sent in real-time to the back display.&nbsp;&nbsp;The back display transposes sensation that would otherwise be felt on the foot onto the back, so that the user can feel his or her feet through the back. With practice, through the incredible phenomenon of neuroplasticity, the user will rewire his or her brain so that interpreting the feeling on the back is second nature.This device is intended to not only prevent and treat the complications of peripheral neuropathy, but also to enable improved gait and balance, and decrease the risk of falls inherent to the problem of not being able to properly feel the feet.Clinical trials will begin with the SurroGait Rx in early 2013.Our SolutionThe SurroGait System uses a sensor grid to measure pressure over the bottom of the foot. Using a wireless communication profile this data is then transmitted to a back-display. A low-power processor is then used to analyze the data and convert it into a signal that can be used to stimulate the lower back. Using this stimulus the patient is able to feel the pressure exerted on the feet in a 1-to-1 fashion. A lightweight battery and state-of-the-art electronics in the back display allow the system to be ergonomic and low-profile to reduce visual impact of the device. A wristband display or mobile device can be used to control the intensity of the stimulus, as well as monitor battery life and pressure information.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/innovation-at-its-best-calgary-company-produces-pressure-sensing-insoles-that-train-the-mind.php</link>
            <guid>http://themayerinstitute.ca/articles/innovation-at-its-best-calgary-company-produces-pressure-sensing-insoles-that-train-the-mind.php</guid>
            <pubDate>10 Feb 2012 10:26:50 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Prevention]]></category>
        </item>
        <item>
            <title>A Tri-Corder for your Smart Phone?</title>
            <description>
 <![CDATA[New device will detect infections, cancer in minutesCBC News&nbsp;Posted: Jan 26, 2012 11:00 AM ET&nbsp;Last Updated: Jan 26, 2012 8:02 PM ETThis is the prototype of the new detection device developed by Dr. Shana Kelley at the University of Toronto. (CBC)Facebook48Twitter3Share51EmailExternal LinksKelley Laboratory(Note:CBC does not endorse and is not responsible for the content of external links.)]]>
            </description>
            <link>http://themayerinstitute.ca/articles/a-tricorder-for-your-smart-phone.php</link>
            <guid>http://themayerinstitute.ca/articles/a-tricorder-for-your-smart-phone.php</guid>
            <pubDate>27 Jan 2012 08:34:32 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Theragnostics]]></category>
        </item>
        <item>
            <title>TMI Team Sends Patients on Road Trip to Revascularization</title>
            <description>
 <![CDATA[Joanna Frketich&nbsp;Sat Jan 14 2012&nbsp;2&nbsp;RecommendDiabetes patients head to Toronto or lose a limbDr Perry Mayer&nbsp;Dr. Perry Mayer treats patients with diabetic foot and wound issues in his Railway Street clinic. Many of his patients are on such a long wait list for surgery that they run the risk of loosing a limb. Mayer sends these patients to Toronto for surgery even though the surgery could be done here in Hamilton.Cathie Coward/The Hamilton SpectatorDiabetes patients in danger of losing limbs are being sent to Toronto for treatment because Hamiltons waits are too long.The Mayer Institute, which specializes in diabetes wound care, sends patients needing urgent treatment, within 30 days, to vascular surgeons at Sunnybrook Health Sciences Centre instead of waiting for diagnostics and surgery at Hamilton Health Sciences or St. Josephs Healthcare.In my world, I wait an inordinate amount of time, said the institutes medical director, Dr. Perry Mayer. Its a ridiculous situation in Hamilton. We have brilliant, gifted surgeons here, theyre second to none. But their hands are tied.Hamiltons lead vascular surgeon says the problem is that 90 per cent of patients referred to them are urgent, so it can be difficult to determine who gets the care first.A lot of us feel overwhelmed with the sheer volume of disease, said Dr. David Szalay, division head of vascular surgery at HHS, St. Josephs and McMaster University. The challenge can be to try to work through your list and make sure nobody dies of a ruptured aneurysm waiting for you, nobody has a stroke waiting and you can intervene on the leg quick enough to prevent limb loss.Szalay says the delays occur when patients are referred and waiting for their first appointment and again when surgeons order diagnostic tests. In contrast, Toronto has more vascular surgeons to share the load, so patients get their first appointment faster. The doctors at Sunnybrook also have access to their own angioplasty suite so they do the diagnostics themselves and immediately do the treatment.Their model is ideal but pretty unique, Szalay said of Sunnybrook.Angelo Maletta says he would have lost his foot if hed waited any longer for treatment. The 61-year-old Welland maintenance worker was told in August his right foot would have to be amputated because of a diabetic wound.His cousin knew someone whose leg was saved by Mayer and recommended the clinic on Railway Street. Many of Mayers patients tell the same story of finding the institute by chance from friends or family after being told theyd need an amputation.My cousin, who I hadnt seen in months, happened to be at my house the day they told me they wanted to amputate, said Maletta, who shudders to think what would have happened otherwise. It would have been terrible for me.Maletta saw Mayer at the end of August. Tests showed there was not enough blood flow in his foot, so he was referred to Sunnybrook in October and had surgery on Nov. 9.Everything was just boom, boom, boom, said Maletta, commenting on the speed of treatment.His foot is now healing well.Getting treatment fast is significant considering Wound Care Canada reports there is a small window of opportunity for therapies. More than 50 per cent of lower extremity amputations are due to non-healing foot ulcers and the long-term prognosis isnt good for amputees. The death rate is 39 per cent to 68 per cent over a five-year period.There is hope that waits will ease a bit in Hamilton as another vascular surgeon is being recruited — the equivalent of three fewer surgeons are practising in this area compared to seven years ago. A second vascular ultrasound opened last week to double diagnostic capacity, and other health professionals such as physician assistants are being added to the vascular team.But until then, Mayer says he will continue to send patients to Toronto: These people cant wait. The patients who dont get to me lose their limbs. They lose their limbs at an astonishing rate.jfrketich@thespec.com905-526-3349 | @Jfrketich]]>
            </description>
            <link>http://themayerinstitute.ca/articles/tmi-team-sends-patients-on-road-trip-to-revascularization.php</link>
            <guid>http://themayerinstitute.ca/articles/tmi-team-sends-patients-on-road-trip-to-revascularization.php</guid>
            <pubDate>13 Jan 2012 09:34:02 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Limb Salvage Teams]]></category>
        </item>
        <item>
            <title>Part 1 on Infection  by Frykberg</title>
            <description>
 <![CDATA[The Challenges of Diabetic Foot Infections:Part 1&nbsp;Ive had a particularly difficult (and frustrating) week caring for several patients with very severe diabetic foot infections. Ive been at this for about 35 years now, but it doesnt seem to be getting any easier. Perhaps the patients are just getting more complex and sicker or perhaps the pathogens are getting more virulent. Regardless, the infections just seem to be getting more difficult to control. While we have many more antimicrobial agents than we did years ago, antibiotics are only part of the solution to managing foot infections in the diabetic patient. We certainly need to have a very good understanding of the spectrum of coverage (and gaps in coverage) for a number of different agents. But the reality is, antibiotics alone can most often NOT be relied on to be the magic bullet for managing such complications. In fact, a good friend of mine who specializes in such matters is known to advocate that draino is the best (and perhaps the most important) agent for treating diabetic foot infections (DFI). Others can do a better job than I of discussing the multitude of antimicrobial therapies available for treating such infections (and perhaps it might be the subject of a future discussion).&nbsp;&nbsp;Hence, I will focus here on the non-pharmacologic principles of assessment and management that are critical to success in this regard. For the purposes of our discussion, we will concentrate primarily on limb threatening (moderate or severe) infections.The Physical ExamA systematic and thorough evaluation is absolutely essential to detect associated abnormalities that either directly lead to the infection or contribute to its severity. Medical history and evaluation is obviously important for antecedent injuries, comorbidities such as kidney disease, peripheral arterial disease, heart disease, diabetes control and medications, allergies, etc.A diabetic foot ulcer (DFU) is rarely&nbsp;caused&nbsp;by an infection but is perhaps the most frequent causal factor leading to diabetic foot infections. Sometimes it is just a blister or a burn (especially in the Summer heat of Arizona) or a puncture wound that breaks the skin envelope and opens the portal to infection. In the most severe presentations (necrotizing soft tissue infections) signs will include secondary blisters, bullae, or necrosis proximal to open wounds or gangrenous toes.Fig. 1.&nbsp;Necrotizing soft tissue infection- no gas on x-rays but note the severe cellulitis, edema, and necrotic dorsal skin. The portal of entry was in the webspace at the base of the second toe.Palpation of the foot might not only express purulence, but subcutaneous crepitance might be palpable as well. Ulcers of long duration or with bone exposure are at high risk for developing infections. Therefore, it is important to carefully examine such lesions - or to look for them when they might be between the toes. A sterile probe or even applicator stick can be used to examine the depths of any wounds to ascertain bone involvement or exposure or whether sinus tracts extend proximally along fascial planes or tendon sheaths. While this probe-to-bone test has been maligned as a good indicator for osteomyelitis, in hospitalized patients with severe infections, it actually has quite good predictive value for osteomyelitis. It is therefore a routine and essential part of my examination.While many, if not most, of hospitalized patients with DFIs have at least some degree of peripheral neuropathy and sensory loss, you must&nbsp;always&nbsp;look for underlying ischemia. I am quite impressed with the frequency of undetected peripheral arterial disease (PAD) that we first diagnose upon presentation with a rather severe DFI.&nbsp; Perhaps the frequency of neuroischemic wounds has risen over the years; certainly the number of foot infections in such patients has in my clinical practice. Hence, palpation of pulses (at least from the Popliteal to pedal arteries) is a key part of the examination as well. Too often, however, the foot is so swollen that pulses- even when present- are difficult to palpate. This is why I carry a Doppler ultrasound unit in my pocket. I will routinely ascertain the presence and quality of Doppler signals in the pedal vessels. While rarely finding triphasic signals in the affected feet, we will often find biphasic or monophasic signals in the dorsalis pedis and posterior tibial arteries. Monophasic signals portend peripheral arterial disease, although when intermetatarsal artery signals are present, there is less concern for critical ischemia.&nbsp; Nonetheless, we very liberally order Doppler Segmental Limb Pressures and ankle-brachial indices (ABI) or toe pressures for qualitative and quantitative evidence of peripheral perfusion. Pulse volume recordings (PVR) are also quite useful in this regard, especially in the presence of calcified arteries in this patient population. Vascular surgical consultation to assess the need for angiography and revascularization is necessary when significant abnormalities are found.Imaging&nbsp;X-rays, of course, must be taken to determine whether there are underlying foreign bodies, deformities (Charcot), or signs of osteomyelitis. Equally important, one must always look for the presence of subcutaneous gas. Necrotizing soft tissue infections, whether caused by anaerobes, gram negative bacilli, staphylococci, or Beta-hemolytic streptococci frequently demonstrate gas accumulations around and proximal to the original focus of infections. Accordingly, plain films of the leg must also be taken to ensure that the foot infection does not involve these fascial planes or tendon sheaths. There are obvious treatment implications  emergent treatment implications- when gas is found in the soft tissues. But air is not gas in this sense of the word- sometimes air is found in the periwound area from walking on the foot. This is called emphysema and this is really not an emergency. When undrained abscesses or osteomyelitis are suspected, MRI or other advanced imaging can assist in making the diagnosis.Fig. 2.&nbsp;Note the soft tissue defect adjacent to the first MTP joint and the gas at the lateral ankle in this other patient.&nbsp;Laboratory StudiesLaboratory studies are, of course, critical in determining the patients response to the infection and help determine its severity. While complete blood count (CBC), differential, serum glucose, glycohemoglobin, and sedimentation rate are routine labs in this scenario, one must recognize that leukocytosis does not always accompany a moderate or severe infection in the diabetic patient.&nbsp; Hence, the clinician cannot be lulled into a false sense of comfort upon not finding an elevated white blood count (or elevated temperature for that matter).&nbsp; Suspicion and caution are the best attributes of the provider caring for such patients. Routine assessment of renal function is also necessary, following serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate (eGFR). These values will obviously affect antimicrobial dosing as well as consideration for angiography and contrast for MRI studies.ClassificationOnce the patient assessment has been completed, classification of the infection will be helpful in guiding treatment. The Infectious Disease Society of America (IDSA) has put forth a DFI Classification scheme that has been almost universally adopted here and abroad. (See Table below) This scheme is an expansion of the former non-limb threatening/ limb threatening classification used several decades ago.The reader is referred to the references below for an in-depth review of the points discussed in this months ezine. Next month, in Part II, we will discuss&nbsp;treatment&nbsp;of the infected diabetic foot. &nbsp;As always, your comments are always appreciated and encouraged.###References are provided below that can expand upon many of the points made above. We welcome your opinions, concerns, and suggestions.&nbsp; If you have an interesting case or a troubling circumstance that you would like to share with fellow PRESENT Diabetes members, &nbsp;please feel free to comment on eTalk.Best regards,Robert Frykberg, DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb SalvageREFERENCESEneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.&nbsp;Foot Ankle Int.&nbsp;Nov 1997;18(11):716-722.Frykberg RG. An evidence-based approach to diabetic foot infections.&nbsp;Am J Surg.&nbsp;Nov 28 2003;186(5A):44S-54S; discussion 61S-64S.Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision).&nbsp;J Foot Ankle Surg.&nbsp;Sep-Oct 2006;45(5 Suppl):S1-66.Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections.Clin Infect Dis.&nbsp;Oct 1 2004;39(7):885-910.Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes.&nbsp;N Engl J Med.&nbsp;Sep 29 1994;331(13):854-860.Grayson ML, Balaugh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.&nbsp;J Am Med Assoc.1995;273(9):721-723.Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes.&nbsp;Diabetes Care.&nbsp;Jun 2006;29(6):1288-1293.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/part-1-on-infection--by-frykberg.php</link>
            <guid>http://themayerinstitute.ca/articles/part-1-on-infection--by-frykberg.php</guid>
            <pubDate>03 Jan 2012 06:55:59 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Infection]]></category>
        </item>
        <item>
            <title>Part 2 on DFU Infection by Frykberg</title>
            <description>
 <![CDATA[The Challenges of Diabetic Foot Infections:(Part 2)&nbsp;In the&nbsp;last issue of FootNotes,&nbsp;we focused on what I consider to be the essential components in the assessment of patients presenting with diabetic foot infections. Although I concentrated on severe or limb threatening foot infections, the principles remain the same for even mild or moderate infections: always be suspicious, always look for ischemia, and always obtain appropriate laboratory tests and imaging procedures as essential parts of your evaluation. Also important, please recognize that just having a wound does not imply that it is infected; most, if not all, wounds are contaminated. Infection is a clinical diagnosis based on those classical signs we are all familiar with: rubor, tumor, dolor, and calor. Nonetheless, diabetes (like syphilis) has become the great masquerader in that typical signs and symptoms are masked   especially in the presence of neuropathy.&nbsp; Hence, my exhortation that one must always be suspicious in such patients who often do not respond to treatment the way one would expect them to under normal circumstances (i.e. persistent fever after several days of ostensibly appropriate therapy).So now let us focus on the&nbsp;management&nbsp;of established diabetic foot infections that have been appropriately evaluated. Our focus will always be aimed at limb salvage, a much harder task in many cases than primary leg amputation.Management of Diabetic Foot InfectionsAntibiotics are&nbsp;only part of the management strategies for these complicated patients, although a significant component, of course.&nbsp; In most cases, however, antimicrobial therapy becomes adjunctive to non-pharmacologic (surgical) therapy. An old adage from my years of training in Boston stipulates that diabetic patients cannot tolerate undrained infection (I believe this comes from an old friend and surgeon, Gary Gibbons). This is a good point to remember, since it is painfully driven home whenever it is forgotten. As I mentioned earlier, those patients not responding to antimicrobial therapy alone likely are failing due to an undrained abscess or retained necrotic tissue. This is a very common scenario and one that is seen especially frequently in those patients with necrotizing soft tissue infections (necrotizing fasciitis, necrotizing cellulitis, clostridial myonecrosis, etc.). These patients typically require several trips to the operating room before their infection is controlled- short of doing a primary major amputation. Last month, I presented a&nbsp;case of necrotizing soft tissue infection.&nbsp;(Figure 1&nbsp;)&nbsp; As in this case, such patients do not always present with gas in the soft tissues   that would be too easy. Gas easily identifies those individuals requiring an urgent trip to the operating room   few would miss this clinical clue. Nonetheless, many individuals present with severe cellulitis and some soft tissue necrosis even in the absence of purulent drainageFig. 1.&nbsp;Necrotizing soft tissue infection- no gas on x-rays but note the severe cellulitis, edema, and necrotic dorsal skin. The portal of entry was in the webspace at the base of the second toe. No ischemia was present.They may or may not be sick (IDSA Grade 4 or 3), but the severity of their infection is signified by recalcitrant hyperglycemia, leukocytosis, and failure to resolve cellulitis with broad spectrum antimicrobial therapy.&nbsp; These important clinical clues should indicate that, very likely, surgical debridement or partial foot amputation is necessary. Several procedures are often required prior to eventual control of infection and definitive closure. (Figures 2-4)Fig. 2.&nbsp;Same patient after initial extensive debridement and toe amputations. Although infection somewhat improved, further necrosis and persistent cellulitis required further debridement.Fig. 3.&nbsp;After further debridement and toe amputations, the infection came under control. A large soft tissue and osseous defect remained with residual necrosis at the midfoot, placing the limb at risk.Fig. 4.&nbsp;Definitive closure was obtained with a Chopart amputation.Equally important is the necessity for detecting and treating peripheral ischemia (PAD) when present. Many patients with pre-existing PAD have a foot infection as their first presenting sign of ischemia. In the presence of neuropathy, critical limb ischemia is often silent in that the usual symptoms of claudication or rest pain are absent.&nbsp; Therefore, in all patients presenting with acute foot infection it is prudent to look for underlying PAD and request appropriate vascular studies and consultations.&nbsp; That being said, ischemia does not preclude appropriate surgical management for the&nbsp;acute&nbsp;infection.&nbsp; It is still essential to drain abscesses or to perform emergent local amputations to control infection. Revascularization should be performed&nbsp;after&nbsp;immediate control of infection. A final, definitive procedure such as a closed amputation or skin graft should follow the revascularization and restoration of perfusion to the foot.We have previously discussed the management of osteomyelitis in&nbsp;Diabetic Footnotes Issue 18 - Osteomyelitis — Now What?,&nbsp;but it is worth mentioning again in the overall context of managing diabetic foot infections.&nbsp; I am of the (biased) opinion that in the diabetic foot, osteomyelitis is best managed surgically in most instances. While this is a matter of debate around the Globe, surgical debridement or bone resection (and sometimes local amputation) with adjunctive systemic antimicrobial therapy seems to more predictably affect a cure than treatment with just antibiotics. This is the course of treatment followed by most US surgeons until prospective studies can definitively identify those sites or patients best suited to medical therapy alone.&nbsp; Nonetheless, osteomyelitis very rarely, if ever, presents as an acute problem   it usually comes associated with an acute soft tissue infection.Once the acute infection has been managed, the bone infection can be definitively treated as appropriate for the circumstances. For instance, in a patient with an infected plantar ulcer of a metatarsal head without gangrene, a joint resection with a 4 to 6 week course of culture-directed oral antibiotics will most often result in a cure.I have not specifically addressed antimicrobial therapy thus far, because I think that we need to place a good deal of emphasis on the surgical management of limb threatening infections. Nonetheless, in our next issue, we will discuss my approach to antimicrobial management of diabetic foot infections   from a clinicians viewpoint. I have been in the trenches for many years in this regard and have made many mistakes. Hopefully, Ive learned from them and can offer some guidance to you as well.&nbsp;Until next time…###References are provided below that can expand upon many of the points made above. We welcome your opinions, concerns, and suggestions.&nbsp; If you have an interesting case or a troubling circumstance that you would like to share with fellow PRESENT Diabetes members, &nbsp;please feel free to comment on eTalk.Best regards,Robert Frykberg, DPM, MPHPRESENT Editor,&nbsp;Diabetic Limb SalvageREFERENCESEneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.&nbsp;Foot Ankle Int.&nbsp;Nov 1997;18(11):716-722.Frykberg RG. An evidence-based approach to diabetic foot infections.&nbsp;Am J Surg.Nov 28 2003;186(5A):44S-54S; discussion 61S-64S.Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision).&nbsp;J Foot Ankle Surg.&nbsp;Sep-Oct 2006;45(5 Suppl):S1-66.Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections.&nbsp;Clin Infect Dis.&nbsp;Oct 1 2004;39(7):885-910.Javier Aragón-Sánchez, Yurena Quintana-Marrero, Jose L. Lázaro-Martínez, et al: Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality.&nbsp;INT J LOW EXTREM WOUNDS&nbsp;2009; 8; 141Javier Aragón-Sánchez:&nbsp;Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections&nbsp;International Journal of Lower Extremity Wounds&nbsp;2011 10: 33]]>
            </description>
            <link>http://themayerinstitute.ca/articles/part-2-on-dfu-infection-by-frykberg.php</link>
            <guid>http://themayerinstitute.ca/articles/part-2-on-dfu-infection-by-frykberg.php</guid>
            <pubDate>03 Jan 2012 06:54:16 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Infection]]></category>
        </item>
        <item>
            <title>The Cost of Diabetes Keeps Rising</title>
            <description>
 <![CDATA[Cost of Diabetes Will Be $3.35 Trillion by 2020The United States of Diabetes: New report shows half the country could have diabetes or prediabetes at a cost of $3.35 trillion by 2020.More than 50 percent of Americans could have diabetes or prediabetes by 2020 at a cost of $3.35 trillion over the next decade if current trends continue, according to new analysis by UnitedHealth Group's Center for Health Reform &amp; Modernization, but there are also practical solutions for slowing the trend.&nbsp;See this week's Tool for Your Practice.New estimates show diabetes and prediabetes will account for an estimated 10 percent of total health care spending by the end of the decade at an annual cost of&nbsp;almost $500 billion -- up from an estimated $194 billion this year.The report,&nbsp;The United States of Diabetes: Challenges and Opportunities in the Decade Ahead,produced for November's National Diabetes Awareness month, offers practical solutions that could improve health and life expectancy, while also saving up to $250 billion over the next 10 years, if programs to prevent and control diabetes are adopted broadly and scaled nationally. This figure includes $144 billion in potential savings to the federal government in Medicare, Medicaid and other public programs.Key solution steps include lifestyle interventions to combat obesity and prevent prediabetes from becoming diabetes and medication control programs and lifestyle intervention strategies to help improve diabetes control.Our new research shows there is a diabetes time bomb ticking in America, but fortunately there are practical steps that can be taken now to defuse it, said Simon Stevens, executive vice president, UnitedHealth Group, and chairman of the UnitedHealth Center for Health Reform &amp; Modernization. What is now needed is concerted, national, multi-stakeholder action. Making a major impact on the prediabetes and diabetes epidemic will require health plans to engage consumers in new ways, while working to scale nationally some of the most promising preventive care models. Done right, the human and economic benefits for the nation could be substantial.The annual health care costs in 2009 for a person with diagnosed diabetes averaged approximately $11,700 compared to an average of $4,400 for the remainder of the population, according to new data drawn from 10 million UnitedHealthcare members. The average cost climbs to $20,700 for a person with complications related to diabetes. The report also provides estimates on the prevalence and costs of diabetes based on health insurance status and payer, and evaluates the impact on worker productivity and costs to employers.Diabetes currently affects about 27 million Americans and is one of the fastest-growing diseases in the nation. Another 67 million Americans are estimated to have prediabetes. There are often no symptoms, and many people do not even know they have the disease. In fact, more than 60 million Americans do not know that they have prediabetes. Experts predict that one out of three children born in the year 2000 will develop diabetes in their lifetimes, putting them at grave risk for heart and kidney disease, nerve damage, blindness and limb amputation.Estimates in the report were calculated using the same model as the widely-cited 2007 study on the national cost burden of diabetes commissioned by the American Diabetes Association (ADA).The report also focuses on obesity and its relationship to diabetes. Being overweight or obese is one of the primary risk factors for diabetes, and with more than two-thirds of American adults and 17 percent of children overweight or obese, the risk is clearly rising. In fact, over half of adults in the U.S. who are overweight or obese have either prediabetes or diabetes, and studies have shown that gaining just 11-16 pounds doubles the risk of type 2 diabetes and gaining 17-24 pounds nearly triples the risk.Because diabetes follows a progressive course, often starting with obesity and then moving to prediabetes, there are multiple opportunities to intervene early and prevent this devastating disease before it's too late, said Deneen Vojta, M.D., senior vice president of the UnitedHealth Center for Health Reform &amp; Modernization, who helped develop UnitedHealth Group's Diabetes Prevention and Control Alliance.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/the-cost-of-diabetes-keeps-rising.php</link>
            <guid>http://themayerinstitute.ca/articles/the-cost-of-diabetes-keeps-rising.php</guid>
            <pubDate>03 Jan 2012 06:46:19 EST</pubDate>
            <dc:creator>PV mayer</dc:creator>
            <category><![CDATA[Economics]]></category>
        </item>
        <item>
            <title>Tackling Diabetic Foot Disease in China</title>
            <description>
 <![CDATA[Diabetic foot care in mainland ChinaDiabetic foot ulcers,&nbsp;Service delivery&nbsp;| Zhangrong XuDiabetes is a major non-communicable disease worldwide. There are now some 40 million people with diabetes   and a similar number with impaired fasting glucose or impaired glucose tolerance   in mainland China alone (China News, 2008). Among those with diabetes, diabetic foot disease is becoming a serious health burden, impacting negatively both on peoples quality of life and on healthcare budgets.The First and Second Diabetic Foot Groups of the Chinese Diabetes Society were founded in 1996 and 2002, respectively. The groups aimed to establish a campaign to improve diabetic foot care in China. This included the participation of the Second Diabetic Foot Group in the International Consensus on the Diabetic Foot, which was published by the International Diabetes Federation (International Working Group on the Diabetic Foot, 2003).The Third Diabetic Foot Group of the Chinese Diabetes Society was founded in October 2008 and is currently active. This group aims to recruit new members from fields not specifically diabetes related, such as orthopaedic and vascular surgery, but whose contribution to diabetic foot care is essential.Over the past 5 years, various national meetings on diabetic foot disease and its management and prevention have been held at both local and national levels in China. A number of international experts in the field of diabetic foot care have been invited to China for lectures and clinical visits.&nbsp;The International Forum on Diabetic Foot and Related Diseases was held in Beijing in 2005 and 2006, in Kunming in 2007, and in Chengdu in 2008. Some 400-500 delegates attended each of these 3-day meetings. Workshops where held, during which approximately 100 participants were divided into groups to learn how to conduct basic examinations of the diabetic foot and investigations for peripheral vascular disease.&nbsp;A range of topics were covered, including taking an ankle-brachial pressure index and ulcer dressing choice. The workshops were mostly attended by physicians and nurses from teaching hospitals. Many attendees asked the Diabetic Foot Group to hold similar workshops in the future. To date, more than 1500 healthcare professionals have participated in diabetic foot care training provided by the group.In August of this year, the 5th International Forum on Diabetic Foot and Related Diseases&nbsp; was held simultaneously with the 6th Asia-Pacific Diabetic Limb Problems Meeting in Beijing. More than 500 participants from 16 countries took part. Speakers included Professors Robert Frykberg, Andrew Boulton, David Amstrong, Bejamin Lipsky and Dennis Yue, as well as Marg McGill, Senior Vice-President of the International Diabetes Federation.There are now more diabetic foot clinics in China than ever before, with seven new centres established in the past 5 years. However, relative to the size of the population with diabetes, there remains too few diabetic foot centres. The clinic at which I work has treated more than 350 people with diabetic foot problems over 5 years. We have been able to achieve a reduction in the amputation rate from 11.5% 5 years ago to 7.2% (mostly minor amputations) today.Some newer techniques for the management of diabetic foot disease have been used in Chinese clinics. These include vascular intervention (stents, Figure 1), and the transplantation of autologous peripheral blood stem-cells for the treatment of peripheral vascular disease. Autologous platelet-rich gels and negative pressure therapy have also been used for the treatment of hard-to-heal ulcers, with some diabetic foot centres achieving positive results. Some Chinese physicians treat foot problems with a combination of Western medicine and traditional Chinese medicine.Figure 1. Ischaemic ulcer (a) upon admission to hospital and (b) shortly after. Reperfusion was undertaken, the vascular supply is shown (c) before and (d) after intervention. The ulcer (e) 2 weeks after the intervention, and (f) 2 months after the intervention.&nbsp;&nbsp;In an effort to increase the amount of literature available to healthcare professionals with an interest in the diabetic foot working in China, the Diabetic Foot Group has undertaken a number of initiatives. The International Consensus on the Diabetic Foot (International Working Group on the Diabetic Foot, 2003) has been translated into Chinese and is now in its second print run, with 6000 copies distributed to-date. The group has worked with experts from a range of fields to produce books that introduced topics on the care of the diabetic foot. The output of literature from China has likewise increased. The number of scientific articles published by practitioners working in diabetic foot care in China has risen dramatically, from 6 in 1996 to 360 in 2006.In 2004, the Diabetic Foot Group organised research involving 14 teaching hospitals located in cities around China. A range of topics were investigated, including the classification and pathogenesis of diabetic foot disease and peripheral arterial disease, and the cost of diabetic foot disease to hospitals. People (n=634) with diabetes and foot problems or peripheral arterial disease admitted from 1 January to 31 December 2004 were included in this research.&nbsp;Neuropathy was present in 68.0% of participants, hypertension in 57.4%, peripheral arterial disease in 28.7%, coronary heart disease in 28.5%, cerebral vascular disease in 24.3%, and 38.8% were smokers. Foot ulcers were, in the majority (82.2%) of cases, at Wagner stage 1 or 2. In 42.7% of cases, more than one ulcer was present, and 67.9% of ulcers were complicated by infection. Ulcers were commonly neuroischemic. The average direct medical cost to the hospital attributable to diabetic foot disease or peripheral arterial disease in people with diabetes was ¥RMB&#8239;14906/person ($US&#8239;1850/person). Our results were presented at the 5th International Symposium on the Diabetic Foot held in The Netherlands (Xu, 2007).Diabetic foot disease is becoming a serious health and economic burden in China and around the world. The First, Second and Third Diabetic Foot Groups of the Chinese Diabetes Society have looked to provide healthcare professionals working in China with more information on, and clinical skills in, the management of diabetic foot disease. Practitioners in China look forward to increasing national and international cooperation between those with an interest in the care of the diabetic foot, through knowledge-sharing and participation in research.&nbsp;REFERENCESChina News (2008)&nbsp;[Rapidly increasing prevalence of diabetes in China.]&nbsp;(In Chinese) Available from:&nbsp;http://tinyurl.com/yfnwsfz&nbsp;(accessed 26.10.09)&nbsp;International Working Group on the Diabetic Foot (2003)&nbsp;International Consensus on the Diabetic Foot and Practical Guidelines on the Management and the Prevention of the Diabetic Foot.&nbsp;International Diabetes Federation, AmsterdamXu Z (2007)&nbsp;The diabetic foot in China.&nbsp;5th International Symposium on the Diabetic Foot, 9-12 May 2007, Noordwijkerhout, The Netherlands]]>
            </description>
            <link>http://themayerinstitute.ca/articles/tackling-diabetic-foot-disease-in-china.php</link>
            <guid>http://themayerinstitute.ca/articles/tackling-diabetic-foot-disease-in-china.php</guid>
            <pubDate>20 Oct 2011 10:02:54 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Limb Salvage Teams]]></category>
        </item>
        <item>
            <title>Theragnostics on Steriods</title>
            <description>
 <![CDATA[Next Up for Artificial Intelligence: Real Biologyby&nbsp;BRIAN KLEIN&nbsp;on&nbsp;Oct 14, 2011&nbsp;•&nbsp;5:46 pmFirst, artificial intelligence trumped expert chess players at their own game. Then came Watson, a computer system that famously beat Jeopardy. champions Brad Rutter and Ken Jennings. Now, researchers are putting artificial intelligence to work to automate biological research—-specifically the reverse engineering of metabolic networks from experimental data.A team of scientists from Vanderbilt University, Cornell University, and&nbsp;CFD Research Corp.&nbsp;have shown that a computer can take raw experimental numbers from a biological data and derive equations from it that describe how the system functions. The modelling used in the research is said to be one of the most complex scientific modeling problems that artificial intelligence has solved completely from scratch.Check out the announcement from Vanderbilt University:The brains of the system, which [Vanderbilt professor John P. Wikswo] has christened the Automated Biology Explorer (ABE), is a unique piece of software called Eureqa developed at Cornell and released in 2009. [Michael Schmidt and Hod Lipson at the Creative Machines Lab at Cornell University] originally created Eureqa to design robots without going through the normal trial and error stage that is both slow and expensive. After it succeeded, they realized it could also be applied to solving science problems.One of Eureqas initial achievements was identifying the basic laws of motion by analyzing the motion of a double pendulum. What took Sir Isaac Newton years to discover, Eureqa did in a few hours when running on a personal computer.In 2006, Wikswo heard Lipson lecture about his research. I had a ‘eureka moment of my own when I realized the system Hod had developed could be used to solve biological problems and even control them, Wikswo said. So he started talking to Lipson immediately after the lecture and they began a collaboration to adapt Eureqa to analyze biological problems.Biology is the area where the gap between theory and data is growing the most rapidly, said Lipson. So it is the area in greatest need of automation.Wikswo believes that artificial intelligence could potentially be harnessed to generate and analyze biological data to such a degree that it could predict the behavior of biological systems under a variety of conditions.[Wikswo also] maintains that this approach will give scientists the ability to control biological systems even if [the researchers] cant completely explain how they work, and this capability can provide the basis for the development of significantly improved drugs and other therapies.According to Cornell professor Hod Lipson, the researchers might need to create another program to translate the meaning of the equations that the Eureqa program comes up with.This this video from a couple of years ago explains how the Eureqa software derived the fundamental equations of motion from observations of a double pendulum.Top image: The microformulator pictured enables the biological experiments to be performed without human intervention. Image credit: Wikswo Lab.Abstract in&nbsp;Physical Biology:&nbsp;Automated refinement and inference of analytical models for metabolic networksPress release:&nbsp;Robot biologist solves complex problem from scratch]]>
            </description>
            <link>http://themayerinstitute.ca/articles/theragnostics-on-steriods.php</link>
            <guid>http://themayerinstitute.ca/articles/theragnostics-on-steriods.php</guid>
            <pubDate>20 Oct 2011 10:01:19 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Theragnostics]]></category>
        </item>
        <item>
            <title>Amputation Rates Vary Widely Across US</title>
            <description>
 <![CDATA[Location, Location, Location: Geographic Clustering of Lower-Extremity Amputation Among Medicare Beneficiaries With DiabetesDavid J. Margolis, MD, PHD&#8659;,&nbsp;Ole Hoffstad, MA,&nbsp;Jeffrey Nafash, BA,Charles E. Leonard, PHARMD, MSCE,&nbsp;Cristin P. Freeman, MPH,Sean Hennessy, PHARMD, PHD&nbsp;and&nbsp;Douglas J. Wiebe, PHD+Author AffiliationsDepartment of Biostatistics and Epidemiology and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PennsylvaniaCorresponding author: David J. Margolis,&nbsp;margo@mail.med.upenn.edu.AbstractOBJECTIVE&nbsp;Lower-extremity amputation (LEA) is common among persons with diabetes. The goal of this study was to identify geographic variation and the influence of location on the incidence of LEA among U.S. Medicare beneficiaries with diabetes.RESEARCH DESIGN AND METHODS&nbsp;We conducted a cohort study of beneficiaries of Medicare. The geographic unit of analysis was hospital referral regions (HRRs). Tests of spatial autocorrelation and geographically weighted regression were used to evaluate the incidence of LEA by HRRs as a function of geographic location in the U.S. Evaluated covariates covered sociodemographic factors, risk factors for LEA, diabetes severity, provider access, and cost of care.RESULTS&nbsp;Among persons with diabetes, the annual incidence per 1,000 of LEA was 5.0 in 2006, 4.6 in 2007, and 4.5 in 2008 and varied by the HRR. The incidence of LEA was highly concentrated in neighboring HRRs. High rates of LEA clustered in contiguous portions of Texas, Oklahoma, Louisiana, Arkansas, and Mississippi. Accounting for geographic location greatly improved our ability to understand the variability in LEA. Additionally, covariates associated with LEA per HRR included socioeconomic status, prevalence of African Americans, age, diabetes, and mortality rate associated with having a foot ulcer.CONCLUSIONS&nbsp;There is profound region-correlated variation in the rate of LEA among Medicare beneficiaries with diabetes. In other words, location matters and whereas the likelihood of an amputation varies dramatically across the U.S. overall, neighboring locations have unexpectedly similar amputation rates, some being uniformly high and others uniformly low.Received&nbsp;April 29, 2011.Accepted&nbsp;July 28, 2011.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/amputation-rates-vary-widely-across-us.php</link>
            <guid>http://themayerinstitute.ca/articles/amputation-rates-vary-widely-across-us.php</guid>
            <pubDate>30 Sep 2011 02:48:45 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Prevention]]></category>
        </item>
        <item>
            <title>Early Insulin Use in the Progression of Diabetes by the Master,  Dr Aaron Vinik</title>
            <description>
 <![CDATA[Dr. Aaron I. Vinik on Early Insulin Use in the Progression of DiabetesOne of the leading diabetes researchers in the world, Dr. Aaron I. Vinik, Director of Research and Neuroendocrine Unit, EVMS Strelitz Diabetes Research Center, shares his views on early insulin initiation.The natural history of type 2 Diabetes (T2DM) is a progressive worsening of glycemic control as a consequence of progressive beta cell failure so that ultimately all patients with T2DM are equivalent to patients with type 1 DM and are insulin deficient. In addition the clock starts ticking for macrovascular complications such as heart attacks, strokes and peripheral vascular diseases before the advent of fasting or postprandial hyperglycemia indicating that there are, in addition to hyperglycemia, a host of risk factors conducive to macrovascular disease. In contrast, the glycemia milieu is the single most important determinant of microvascular complications&nbsp;Major studies in T2DM have indubitably shown a reduction of microvascular complications by good glycemic control and the effect persists despite failure to maintain A1c's near normal. This is in stark contrast with the recent attempts to show that intensive glycemic control in the ACCORD, ADVANCE and VADT studies reduce macrovascular events: somewhat disconcerting was the finding in the ACCORD study of an increase in sudden death by 22% in the intensively treated group. Thus, the window of opportunity to aggressively treat T2DM is early and&nbsp;patients can enjoy a 'legacy effect' or what has been reported as metabolic memory. Why then did we not see this benefit in the three studies above and what have we learned? The lessons were invaluable and suggest that there can be a bad metabolic memory or legacy effect in certain situations:1. If the diabetes has been there for &gt; 12-15 years;2. Older people and African Americans;3. Significant impairment of renal function;4. The presence of coronary calcification;5. The history of peripheral neuropathy and the findings of autonomic neuropathy.So the window of opportunity has to be early in the absence of kidney, somatic and autonomic dysfunction, established cardiovascular disease and there are gender and ethnic group sensitivities. Perhaps the only protective factor appears to be obesity but that is almost contrary to everything we are trying to achieve in T2DM.So armed with this information, why is it that we have developed a treat-for-failure approach trying several medications, diet and exercise and only when we have failed to reach goal do we make adjustments? The median delay of adjusting a sulfonylurea is 24 months and metformin is 36 months. Titration is a tardy task and treating for failure is doomed to failure. A fundamental change in physicians' management of T2DM is required and the traditional treatment algorithm should emphasize treatment for success not failure.Traditional oral hypoglycemic agents such as sulfonylurea, metformin, the glitazones and the Incretins and Gliptins are able to lower A1c's about 0.5 to 2.0 %. Combinations of these agents can under optimum conditions achieve an A1c reduction of 3%. Thus in people close to goal of 6.5% (AACE) or 7.0% (ADA) then exercise, diet and a single agent are appropriate. If the A1c is between 7.5% and 9.0%, combinations of oral agents&nbsp;are an appropriate first choice. When A1c is &gt; 9.0 we need the unlimited capacity of insulin to achieve goal. This can be accomplished in a number of ways which include addition to the oral regimen, use of a single long acting insulin analog, use of combinations of different forms of insulin and finally a basal long acting insulin together with a short acting bolus based upon the prevailing blood glucose and the anticipated carbohydrate intake. Data from the UKPDS indicate that after insulin is introduced either alone or in combination with oral therapy, the long term outcome is improved glycemic control. There is however a clinical inertia amongst generalists and even endocrinologists to make these change.The barriers to initiation of insulin therapy are legion. Physicians have a fear of hypoglycemia and imagine there are adverse health consequences of the insulin itself. They have misconceptions of the regimens as being too complex and that it should be the therapy of last resort or limited efficacy. They are indeed major contributors to the fear patients have of the needle. This is a paradox when the needle per se is more benevolent than, for example, a finger stick. Patient-related behaviors are fear of hypoglycemia, adverse health outcomes, medication errors, needles and pain, weight gain and the complicated regimens and scheduling of injections. Unfortunately patients have been brainwashed into thinking that use of insulin is a personal failure, their disease is too advanced, it is the therapy of last resort and it greatly increases cost. Our own studies comparing insulin with oral agents have shown that insulin is associated with improved quality of life, less fatigue, increase in energy and enhanced state of emotion.&nbsp;Patient education along with the use of insulin formulations that reduce risk of hypoglycemia and weight gain, simplified treatment regimens and easy to use insulin delivery systems, should help to reduce the barriers to early aggressive insulin use when the window of opportunity presents itself and clinicians need to overcome inertia and not allow the window to close upon them. Every day here at the EVMS Strelitz Diabetes Center we see patients who are grateful for the restoration of their quality of life as well as the anticipated reduction of the burden of diabetes complications.Dr. Aaron I. Vinik has written five books, published more than 250 papers in medical journals, and is recognized as a pioneer and scholar. Dr. Vinik has received research funding for his studies from the National Institutes of Health, the National Cancer Institute, the Kroc Foundation and the American Diabetes Association.&nbsp;&nbsp;He is a leader in research on the diagnosis and treatment of diabetic neuropathy with a particular expertise in the area of autonomic diabetic neuropathy,&nbsp;a complex and challenging condition.&nbsp;Dr. Vinik has also been a leader in research on new approaches to generate islet cell tissue from pancreatic duct tissue which may one day lead to a true cure for diabetes.For more information on Dr. Vinik and his groundbreaking work at the Strelitz Diabetes Center, just follow this link,&nbsp;Eastern Virginia Medical School Strelitz Diabetes Center.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/early-insulin-use-in-the-progression-of-diabetes-by-the-master--dr-aaron-vinik.php</link>
            <guid>http://themayerinstitute.ca/articles/early-insulin-use-in-the-progression-of-diabetes-by-the-master--dr-aaron-vinik.php</guid>
            <pubDate>29 Sep 2011 04:23:30 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetes Management]]></category>
        </item>
        <item>
            <title>Primer in Wound Preparation by Rogers</title>
            <description>
 <![CDATA[&nbsp;&nbsp;Current Concepts In Wound Bed PreparationVolume 24 - Issue 8 - August 2011&nbsp;3054 reads&nbsp;0 commentsAuthor(s):&nbsp;&nbsp;Lee C. Rogers, DPMProper preparation of the wound bed is essential to priming the wound for effective healing. Accordingly, this author discusses key principles from the literature and shares insights from his clinical experience in employing debridement and adjunctive modalities to help facilitate better wound healing and eventual wound closure.Wound bed preparation is a term that describes making the wound ready for closure by advanced means. If the wound is not properly prepared, even the most expensive products or devices are unlikely to produce a positive outcome. One does not usually perform wound bed preparation in a single visit. There is more of a process to prepare the wound to be closed. In addition to the wound itself, one must ensure the patient is prepared for wound closure.&nbsp;&nbsp;&nbsp;Podiatric physicians must manage infection, ensure adequate vascularity and remove external pressure from the wound.1&nbsp;One can confirm the patients vascular status via noninvasive testing since pedal pulses alone are not a good indicator of sufficient perfusion. If there is vascular impairment, podiatrists should consider an appropriate referral for an intervention to improve circulation.&nbsp;&nbsp;&nbsp;In regard to infection, patients with diabetes do not often mount systemic responses to infection. Therefore, clinicians must rely upon local signs. Is there erythema, purulent drainage or odor present? As infection is purely a clinical diagnosis, a culture cannot determine if the wound is infected. Cultures can only help to discern which bacteria are pathogens in that infection. Uninfected wounds should not be cultured.&nbsp;&nbsp;&nbsp;One can mitigate external pressure either by surgical intervention or by using devices such as a total contact cast or removable cast walker.2&nbsp;&nbsp;&nbsp;Completing the above process and creating a good wound healing environment is considered the standard of practice in most communities. One monitors the wound over four weeks. If the wound area does not reduce by at least 50 percent in that time period, the wound is unlikely to heal in 12 weeks and one should employ advanced therapies.3&nbsp;There are many advanced therapies, ranging from skin grafts and flaps to bioengineered tissues, but they all require the wound to be adequately prepared.A Closer Look At Key Factors That Can Affect Wound HealingWound bed preparation consists of far more than just a debridement and, in some cases, may take weeks to accomplish. The goal is to optimize the wound in order to promote healing with advanced means and remove the barriers to healing. Let us first consider the inherent factors that are detrimental to wound healing like bacteria, senescent cells and hyperkeratotic tissue.&nbsp; &nbsp;Bacteria.&nbsp;A wound is a break in the dermal envelope. It is usually contaminated by bacteria and may even have a biofilm present. Just because a wound is colonized does not mean that it is infected. If the wound becomes critically colonized with bacteria, an infection may develop. Researchers suggest that bacterial loads between 105&nbsp;and 106&nbsp;per gram of tissue in the wound bed may cause infection.4&nbsp;&nbsp;However, more virulent organisms may cause infection at lower concentrations. Biofilm itself is detrimental to wound healing and will hinder the process, but infection causes tissue destruction. Biofilm is difficult to treat. At this time, only thorough debridement has proven to be a definitive treatment.&nbsp;&nbsp;&nbsp;Senescent cells.&nbsp;Cellular dysfunction is common in diabetic foot ulcers and other chronic ulcers. Somatic cells can only divide 50 times before their DNA telomeres have shortened and they can no longer replicate full copies of the DNA. At that point, there should be apoptosis or programmed cell death.&nbsp;&nbsp;&nbsp;In some diabetic wound healing models, researchers have shown that the apoptotic mechanism is impaired. They note that these old (senescent) cells continue to live in the wound but do not replicate or produce growth factors.5&nbsp;The senescent cells impair the ability of the wound to heal.&nbsp;&nbsp;&nbsp;Hyperkeratotic tissue.&nbsp;This hardened tissue forms along the wound periphery and its formation is accelerated by pressure, either direct forces or shearing forces. Bearing weight on the hardened tissue causes subdermal tissue trauma and hemorrhage. Hyperkeratotic tissue acts as a barrier to epithelialization. This tissue can also undermine and collect fluid and debris, thus increasing the risk for infection.Using Debridement And Adjunctive Modalities To Prepare The Wound BedThe main goal of preparing the wound bed is to provide a healing surface, which would accept a graft. While wound bed preparation involves debridement, this is more than just debridement. It also includes consideration of the aforementioned factors such as bacteria, cell senescence and hyperkeratotic tissue. Debridement removes devitalized or contaminated material from within or surrounding the wound. Selective debridement stimulates the repair process. There are various methods of debridement including surgical (scalpel), hydrosurgical (Versajet, Smith and Nephew), biosurgical (maggots), enzymatic or mechanical (wet to dry dressings).6&nbsp;&nbsp;&nbsp;I have heard the axiom that debridement converts a chronic wound into an acute wound. However, acute and chronic are specifically terms that describe time. One cannot take a chronic wound that has been open for four months and convert it into an acute wound present for one day. However, I believe debridement can put an acute injury into a chronic wound, which may provide growth factors and speed healing.&nbsp;&nbsp;&nbsp;For the purposes of wound bed preparation, surgical or hydrosurgical debridement is preferred. It can occur at the same time as grafting or precede grafting by up to a week. Use a scalpel to remove the wound margins, saucerizing the tissue, and then use a curette or hydroscalpel to debride the wound bed. The goal is to obtain a bleeding granular wound. If you are preparing a wound in the operating room for grafting, ensure that bleeding is under control prior to applying the graft in order to avoid a hematoma. Hematoma between the wound bed and the graft is a leading cause of graft failure. One should avoid electric cautery, if possible, and employ pressure, epinephrine or thrombin if needed&nbsp;&nbsp;If the wound is not completely granular, one should consider using either platelet-derived growth factor (PDGF, Regranex, Healthpoint Biotherapeutics) or negative pressure wound therapy (NPWT, VAC therapy, KCI) to make the wound granular and level with the surrounding tissue. The VAC therapy works well in combination with debridement to prepare the wound for grafting. VAC therapy can also assist in managing wound exudate. If one uses VAC therapy in the OR setting, ensure that bleeding is under control before applying NPWT.&nbsp;&nbsp;&nbsp;&nbsp;Armstrong and Lavery studied 162 patients as part of a 16-week randomized clinical trial.7&nbsp;As part of the study, 77 patients received NPWT while 85 received standard moist wound care. They found that VAC therapy had a faster rate of developing granulation tissue in comparison to standard moist wound therapy.&nbsp;&nbsp;&nbsp;When choosing a biomaterial, foam is more effective than gauze at producing granulation tissue. Foam also compresses and contracts better than gauze, enhancing the wounds ability to contract. Employing a silver impregnated foam can help manage bioburden.&nbsp;&nbsp;&nbsp;When performing wound bed preparation a week prior to applying bioengineered tissue, one should perform an adequate debridement, saucerize the margins and promote a good wound healing environment with regular dressing changes until applying the tissue.&nbsp;&nbsp;&nbsp;The first photo on page 1 shows two wounds on the lateral surface of a foot that are fibrotic but uninfected. We performed debridement with a scalpel and curette, which uncovered a healthy bleeding base (see the second photo on page 1). The use of bioengineered tissue prepared the wound for grafting. This preparation occurred in a single stage. One can apply a silver dressing to the wound to manage bacterial load and prevent infection until the application of bioengineered tissue.&nbsp;&nbsp;&nbsp;Often, the wound requires a maintenance debridement at the time of grafting and during subsequent applications. Cardinal and colleagues retrospectively analyzed the results from two controlled, prospective, randomized trials of topical wound treatments on 366 venous leg ulcers and 310 diabetic foot ulcers over 12 weeks.8&nbsp;The study results suggest that frequent debridement of diabetic foot and venous leg ulcers may increase wound healing rates. Maintenance debridements usually involve removing any obvious debris, fibrosis or hyperkeratotic margins.&nbsp;&nbsp;&nbsp;In some cases, the purpose of bioengineered tissue application might be to aid wound bed preparation because the cellular therapy provides the wound with multiple growth factors.Case Study: When There Is An Ankle Wound With Exposed TendonA 71-year-old male with diabetes presents to the clinic with a small, painful, undermining wound on the anterior ankle with an exposed extensor digitorum longus tendon. The wound was caused by direct trauma from a water sprinkler head. The tendon was visibly moving in the wound when the patient dorsiflexed and plantarflexed the ankle. This is problematic because bacteria has access to the tendon and can spread to adjacent compartments. The moving tendon also prevents granulation tissue from adhering.&nbsp;&nbsp;&nbsp;The patient went to the operating room for a wide debridement and I removed all undermining tissue. The patient was admitted to the hospital&nbsp;&nbsp;We started the patient on a VAC Ulta, a new product by KCI that instills a fluid into the wound. In this case, I infused one-quarter strength Dakins solution for the anti-infective and anti-inflammatory properties. With the VAC Ulta, one can tightly control the infusion/suction rate. I set this to instill 50 mL of Dakins solution, hold for five minutes, then resume suction and repeat the process every two hours.&nbsp;&nbsp;&nbsp;After three days, the wound appeared to improve but the tendon was still exposed. The patient went back to the OR, where we performed debridement with a Versajet. I placed Integra (Integra Life Sciences) on the wound and used traditional VAC therapy with the Granufoam Bridge Dressing as a bolster. The patient wore a total contact cast (TCC-EZ, MedEfficiency) to keep the tendon from moving under the graft. I changed the TCC-EZ and VAC therapy twice per week. After two weeks of treatment, the wound became granular and the tendon was covered.&nbsp;&nbsp;&nbsp;The aforementioned process describes wound bed preparation. I debrided the margins with a scalpel and performed light debridement of the wound bed with a Versajet. A split thickness skin graft was harvested from the anterolateral ipsilateral thigh at a thickness of 0.020 inches. I meshed this at 1:1.5 ratio, placed it on the wound and stapled it in place. I used a Mepitel silicone dressing (Molnlycke) as an interface. I placed VAC therapy on the graft as a bolster dressing and set this to -125 mmHg continuous pressure for five days.&nbsp;&nbsp;&nbsp;After VAC therapy removal, I covered the wound with Mepilex Ag (Molnlycke) at that point. The graft interstices healed in about 10 days. I covered the donor site with a Mepilex Border (Molnlycke) and changed it as needed. The wound healed uneventfully.Final WordsProper preparation of the wound bed is vital to graft or tissue success. Wound bed preparation is much more than just a debridement and takes into account factors that impede wound healing.&nbsp;&nbsp;&nbsp;By creating a recipient wound bed that is well vascularized, free from infection and granular with even sloping margins, we can increase the chance of graft take and facilitate more reliable wound healing.&nbsp;&nbsp;&nbsp;Dr. Rogers is the Associate Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles1. Rogers LC, Bevilacqua NJ. Organized programs to reduce lower-extremity amputations.&nbsp;J Am Podiatr Med Assoc. 2010;100(2):101-104.2. Armstrong DG, Boulton AJ. Pressure offloading and advanced wound healing: isnt it finally time for an arranged marriage?&nbsp;Int J Low Extrem Wounds. 2004; 3(4):184-187.3. Snyder RJ, Kirsner RS, Warriner RA, Lavery LA, Hanft JR, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes.&nbsp;Ostomy Wound Manage. 2010; 56(4 Suppl):S1-24.4. Sen RK, Murthy N, Gill SS, Nagi ON. Bacterial load in tissues and its predictive value for infection in open fractures.&nbsp;J Orthop Surg. 2000; 8(2):1-5.5. Rogers LC, Bevilacqua NJ, Armstrong DG. The use of marrow-derived stem cells to accelerate healing in chronic wounds.&nbsp;Int Wound J. 2008; 51(1):20-25.6. Attinger CE, Bulan E, Blume PA. Surgical debridement: the key to successful wound healing and reconstruction.&nbsp;Clin Podiatr Med Surg. 2000; 17(4):599-630.7. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial.&nbsp;Lancet. 2005; 366:1704-1710.8. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds.&nbsp;Wound Rep Regen. 2009; 17(3):306-311.]]>
            </description>
            <link>http://themayerinstitute.ca/articles/primer-in-wound-preparation-by-rogers.php</link>
            <guid>http://themayerinstitute.ca/articles/primer-in-wound-preparation-by-rogers.php</guid>
            <pubDate>26 Sep 2011 11:08:21 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Debridement]]></category>
        </item>
        <item>
            <title>Suture-less Vascular Anastomosis:Entering a New Era in Limb Salvage</title>
            <description>
 <![CDATA[Researchers Develop Method of Joining Blood Vessels Without Suturesby&nbsp;SCOTT JUNG&nbsp;on&nbsp;Aug 29, 2011&nbsp;•&nbsp;3:08 pmNo CommentsFor 100 years, the process of vascular anastomosis has largely been the same. Surgeons take a needle and thread and delicately suture together the walls of the blood vessel. Though literally sewing together blood vessels is a widely utilized surgical procedure, it isnt without its issues. Intimal hyperplasia, a cell response to the trauma of the needle and thread, causes blood vessels to narrow which increases the risk of a blood clot or localized turbulence. Sutures may trigger an immune response that causes dangerous inflammation. Moreover, suturing becomes extremely challenging on blood vessels that are less than one millimeter in diameter.Microsurgeons at Stanford University have developed a new method of vascular anastomosis that is safer and faster. The key ingredient in this new process is Poloxamer 407, a unique, FDA-approved polymer whose properties can be reversed by heating. In the case of vascular anastomosis, Poloxamer 407 is injected at the site where the blood vessels are to be joined, and the area is heated. The unique properties of Poloxamer 407 cause it to become elastic and solid when heated above body temperature. This causes both openings of a severed blood vessel to become distended, allowing surgeons to precisely join the openings together with Dermabond, a commonly used surgical sealant. After the blood vessels have been joined, a decrease in temperature causes Poloxamer 407 to dissolve harmlessly into the bloodstream.The process has been successfully demonstrated on blood vessels as small as 0.2 millimeters. If successful, the process could ultimately improve patient care by&nbsp;decreasing amputations, strokes and heart attacks while reducing health-care costs.Press release from Stanford University:&nbsp;Stanford researchers invent sutureless method for joining blood vesselsJournal abstract in&nbsp;Nature Medicine:&nbsp;Vascular anastomosis using controlled phase transitions in poloxamer gels]]>
            </description>
            <link>http://themayerinstitute.ca/articles/sutureless-vascular-anastomosisentering-a-new-era-in-limb-salvage.php</link>
            <guid>http://themayerinstitute.ca/articles/sutureless-vascular-anastomosisentering-a-new-era-in-limb-salvage.php</guid>
            <pubDate>25 Sep 2011 04:38:23 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Vascular Support]]></category>
        </item>
        <item>
            <title>Oxygen MicroGenerators to Treat Ischemic Wounds?</title>
            <description>
 <![CDATA[Implantable Oxygen Generators Help Fight Cancerby&nbsp;BRIAN KLEIN&nbsp;on&nbsp;Aug 31, 2011&nbsp;•&nbsp;12:47 pm1 CommenA couple of days ago, we ran a blog post on&nbsp;an implantable oxygen sensor&nbsp;for monitoring tumor growth. In related news, researchers at Purdue University are developing an implantable device using a similar approach to treat tumors. But instead of monitoring oxygen, the device generates the gas in order to boost the effectiveness of chemotherapy and radiation treatment. The technology generates oxygen through water&nbsp;electrolysis.The device targets tumors that are hypoxic, meaning having low levels of oxygen. Hypoxic tumors are difficult to treat using radiation therapy because oxygen amplifies the effectiveness of radiation by helping to form free radicals, which damage a tumors genetic material. So the hypoxic areas [of tumors] are hard to kill, says Babak Ziaie, a Purdue professor who led the research. Pancreatic and cervical cancers are notoriously hypoxic. If you generate oxygen you can increase the effectiveness of radiation therapy and also chemotherapy, he adds.Ziaie reports that his father is a cancer survivor, who went through many rounds of painful chemotherapy treatment. This is a new technology that has the potential to improve the effectiveness of such therapy, he says.In testing on mice, the research group showed the oxygen generators are effective in treating pancreatic tumors. Measuring less than one centimeter in length, the generators were inserted into tumors using a hypodermic biopsy needle.Press release:&nbsp;Tiny oxygen generators boost effectiveness of anticancer treatmentAbstract in&nbsp;IEEE&nbsp;Transactions on&nbsp;Biomedical Engineering:&nbsp;An Ultrasonically-Powered Implantable Micro Oxygen Generator (IMOG).]]>
            </description>
            <link>http://themayerinstitute.ca/articles/oxygen-microgenerators-to-treat-ischemic-wounds.php</link>
            <guid>http://themayerinstitute.ca/articles/oxygen-microgenerators-to-treat-ischemic-wounds.php</guid>
            <pubDate>25 Sep 2011 04:34:33 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Diabetic Foot Ulcer Treatment]]></category>
        </item>
        <item>
            <title>Who Says That Wound Care Isn't Sexy: Wounds Get Wet Before They Get Hot</title>
            <description>
 <![CDATA[2 CommentsBruin Biometrics Sub-Epidermal Moisture Scanner Might Detect Decubitus Ulcers Before They Show Upby&nbsp;GAVIN CORLEY&nbsp;on&nbsp;Sep 6, 2011&nbsp;•&nbsp;No CommentsBruin Biometrics,&nbsp;LLC,&nbsp; a wireless health technology company,&nbsp;and researchers at UCLA have developed a device for measuring the risk of pressure ulcer formation. The Sub-Epidermal Moisture (SEM) scanner is a handheld device which measures the dielectric properties of the tissue being assessed and provides an estimation of the sub-epidermal moisture which is indicative of risk of decub ulcer formation. The SEM scanner is designed to overcome current difficulties with visual pressure ulcer assessments by detecting early pressure damage before it becomes visible on the skin surface.The scanner is intended for use in a point of care environment and can wirelessly transmit measured data for storage and analysis on Bruin Biometrics proprietary back end system. The video below gives a nice overview of the early&nbsp;clinical work&nbsp;on SEM that led to the development of the system. It also has some nice technical info and shots of the device itself (techies scroll to 3:30). The SEM scanner was officially unveiled in April of this year and is expected to be commercially launched in the coming months.Product page:&nbsp;Bruin Biometrics SEM Scanner…]]>
            </description>
            <link>http://themayerinstitute.ca/articles/who-says-that-wound-care-isnt-sexy-wounds-get-wet-before-they-get-hot.php</link>
            <guid>http://themayerinstitute.ca/articles/who-says-that-wound-care-isnt-sexy-wounds-get-wet-before-they-get-hot.php</guid>
            <pubDate>25 Sep 2011 12:29:56 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Prevention]]></category>
        </item>
        <item>
            <title>FREMS as a Novel Therapy for treatment of DFU</title>
            <description>
 <![CDATA[Case Presentation and Conclusion:&nbsp;A Novel Therapy for Treatment of a Diabetic Ulcerationby Conway T. McLean, DPM&nbsp;Conway T. McLean, DPMDirector of Podiatric SurgeryCottage ClinicsChicago, IL&nbsp;A diabetic patient presented to the office with a common presenting complaint, a non-healing wound. Like so many individuals with diabetes, this particular patient's level of self-care (as well as their understanding of the disease) was somewhat lacking. A limb-threatening infection had developed of the left foot, due, at least in part, to inappropriate care. Relevant medical history included a five year history of a charcot foot deformity of the right tarsus.The motor changes associated with this patient's neuropathy manifested in hammertoe deformities, which predictably led to a distal digit ulceration. A better informed diabetic would have sought care sooner, well before the ulcer had developed into osteomyelitis. Thus, a primary causative agent, it might be argued, was a lack of education.The patient presented to the office three weeks after the development of the digital ulceration. He had received minimal care prior to his arrival, consisting of simple wet-to-dry guaze dressing changes.click image set to enlargeUlceration at first post-op check following debridement of infected bone and non-viable soft tissue, appropriate wound care.Physical ExamInitial assessment naturally included evaluation of the wound, vascular status and neurological function, and radiographs. Arterial doppler studies revealed patent pedal vessels, although skin perfusion was reduced, likely due in part to excessive edema with induration of soft tissues. The ulceration itself was fairly typical for the clinical situation, with surrounding hyperkeratosis, the presence of mild amounts of purulence, and gross enlargment of the digit. No actual pain was reported by the patient secondary to neuropathy, nor were systemic signs of infection evident, as is so often the case with a localized diabetic infection.Musculoskeletal exam revealed contracture of the lesser digits with increased pressures to the distal aspect of the 3rd digit left. As is the pathogenesis of this condition, mild, non-infectious erythema led to the development of hyperkeratosis. The insensate patient will experience minimal to no symptoms, and only attuned health care specialists will be aware of impending events.Plain film radiographs revealed osseous changes consistent with osteomyelitis, including cystic changes, fragmentation and osteolysis.click image set to enlargeDigit after debridement and excision of osteomyelitic bone and one FREMS treatment.Treatment ConsiderationsUnfortunately for many diabetics, the terrible triad of immunopathy, neuropathy and vasculopathy combine to create very real and formidable obstacles to healing. We are held captive by the blood flow is a very apt saying, and though this individual had sufficient large vessel flow, signs of inadequate perfusion due to microvasculopathy were noted, included hair loss and atrophic epithelium.. The most obvious and accepted therapies, which were utilized here, include debridement of necrotic bone and soft tissue, moist wound healing, and appropriate antibiosis.click image set to enlargeUlcerated digit demonstrating progressive healing following seven FREMS treatmentsUnique TreatmentUtilized in this case was a very new, unique form of electrical stimulation, which employs high negative potential, single-phase electric current pulses, with suitably modulated frequencies and very short durations. These pulses are regulated in frequency, intensity, duration and potential, and act on the surface as well as the deep tissues. FREMS (Frequency Rhythmic Electrically Modulated Stimulation) was designed to take advantage of the belief that the summation of sub-threshold electrical stimuli, conveyed through the skin proximal to a motor nerve in a non-invasive system, would induce composite motor action potentials in excitable tissues.This is in stark contrast to a single, low-intensity impulse of brief duration, such as the one delivered by TENS. This is unable to overcome the dielectric skin barrier and thus will not excite the underlying nervous and/or muscle to elicit a recordable motor action potential (MAP). The signal of the FREMS is quite different. Through a specific sequence of weak impulses, with a rapid increase and decrease in pulse frequency and duration, there is a gradual recruitment of MAP in the stimulated tissues.The patient's wound closed quickly and progressively, without interruption. An additional benefit to this patient was the associated improvement in sensorium. Because the therapy was utilized to treat the ulceration, it was performed unilaterally. The increase in sensation, as compared to the untreated side, was reported by the patient with signs including improved two point discrimination, vibratory sensation, monofilament detection. Also importantly, this benefit continued, with minimal loss, for eleven months.The science and art of wound care has developed rapidly as a field of study in the last few decades. This is evidenced by the explosion of new products and materials now available. Many adjunctive treatments have been developed, with more recent advances including negative pressure wound therapy, hyperbaric oxygen therapy and biological living skin equivalents.The FREMS device has been shown through numerous double-blind studies to have several significant and important effects. For example, there are changes in the perfusion velocity in the microcirculation, as well as inducing a long-acting increase in vasomotor activity (with significant changes noted at four months post treatment).Some other effects are an increase in the release of growth factors including VEGF, increased blood flow and capillary density encouraging the formation of new granulation tissue. Additionally, there is a significant increase in nerve conduction velocity(MNCV) and a statistically significant reduction of pain after FREMS. On average, at the end of active treatment, MNCV was increased by almost 5 m/s; vibration perception threshold was reduced by more than 2 V; and the number of foot points insensitive to the Semmes Weinstein monofilament was decreased.In this case, healing progressed rapidly upon initiating the FREMS, while the usual armamentarium of antibiosis, appropriate debridement and proper wound care were employed. Osteomyelitic bone was resected during the course of FREMS treatments (typically consists of ten sessions). The presence of infection is not a contraindication to its use, and it seems likely that FREMS aids the process of bacterial eradication by increasing perfusion.click image set to enlargeOsteomyelitic metatarsal head excision site healing via secondary intention.Immunopathy is an important component of the lower extremity problems experienced so frequently by people with diabetes. Yet vasculopathy and neuropathy may be considered the more devastating mechanisms, which lead so often to limb loss, disability, and a drastic reduction in quality of life. Those studies performed to date appear to indicate that we have a new and powerful tool that may significantly alter the natural history of this condition, leading to morbidity and mortality. No side effects or complications from it's use have been experienced, and though perhaps not all will experience such dramatic effects as this patient did, it appears certain that this modality has the potential to drastically change the outcomes of diabetic patient care and maintanence.Sincerely,###REFERENCES:Barrella M, Toscano R, Goldoni M, Bevilacqua. Frequency rhythmic electrical modulation system (FREMS) on H-reflex amplitudes in healthy subjects. Eura Medicophys 2007, 43: 37-47.Bevilacqua M, Barrella M, Toscano R et al (2004) Disturbances of vasomotion in diabetic (type 2) neuropathy: increase of vascular endothelial growth factor, elicitation of sympathetic efflux and synchronization of vascular flow (vasomotion) during frequency modulated neural stimulation (FREMS). 86th Annual Meeting of the Endocrine Society, p 321, P 2 61 (abstract)Bevilacqua M., Baruffaldi L., Foddis L., Toscano R., Vago. Increase of&nbsp; Vascular Endothelial Growth Factor by Electrical Stimulation with High Varialbility in Frequency and Amplitude: a clinical study in non-insulin dependent diabetics with limb ischemia. 85th International Congress of Endocrine Society, Philadelphia, June 2003Bevilacqua M. et al.   Increase of Vascular Endothelial Growth Factor (VEGF) by FREMS. A clinical study in Non-Insulin Dependent Diabetics with Limb Ischemia. Presented at ENDO 2003   Endocrinology Societys 85th annual meeting   Philadelphia.Bosi E, Conti M, Vermigli C, et al. Effectiveness of a novel frequency modulated electro-magnetic neural stimulation in the treatment of painful diabetic neuropathy. Diabetologia 2005, 48: 817-23Ciancia, et al. Diabetic plantar ulcer treated with an innovative thearpy - FREMS (frequency modulated&nbsp; electro-magnetic neural stimulation).&nbsp; Italian Society of Gerontology and Geriatics, Florence; Palazzo Congressi 9-13 November 2005Combi F. Application of novel neuromodulation for skeletal muscle regeneration following chronic fobrosis process. The Rehabiliation of Sports Muscle and Tendon Injuries-Milano April 2004Conti M., Peretti E., Cazzetta G., Folini L., Vermigli C., Galimberti G. Frequency modualted electromagnetic neural stimulation enhances cutaneous microvascular perfusion in patients with diabetic neuropathy. 42nd Annual Meeting of the European Association for the Study of Diabetes, Copenhagen Sept. 2006Da Ros R., C. Vitale, R. Assaloni, A. Ceriello &nbsp;Neuromodulation FREMS in the treatment&nbsp; of diabetic peripheral arterial disease. 42nd Annual Meeting of the European Association for the Study of Diabetes, Copenhagen Sept. 2006Facchini M.G., Mambelli E., Checchia G., Gaggi R., Santoro A., The Lorenz Therapy: a new tool in the treatment of uremic neuropathy. European Dialysis and Transplant Association, Lisbona May 2004.Farina S., Casarotto M., Benelle M., Tinazzi M., Fiaschi A., A randomized controlled study on the effect of two different treatments (FREMS and TENS) in myofascial pain syndrome. EUR MED PHYS 2004; 40:293-301Guggi S, Cavina U. Experience of a novel transcutaenous neuromaodulation as first approach to muscle injuries. XIV International Congress on Sports Rehabilitation and Traumatology, Bologna 2005Kumar D, Marshall HJ (1997) Diabetic peripheral neuropathy: amelioration of pain with transcutaneous electrostimulation. Diabetes Care 20:1702 1705Scionti L., Conti M., Vermigli C., Cazzetta G., Galimberti G., Bosi E. A new treatment for painful diabetic neuropathy: the Frequency Modulated Neural Stimulation (FREMS). NEURODIAB, Resensburg, GermanyZhao M. Bai H, Wang E, Forrester J.V., McCaig CD. Electrical stimulation directly induces pre-angiogentic responses in vascular endothelial cells by signaling through VEGF receptors. J Cell Sci 2003:117.395-405.Lorenz NeuroVasc&nbsp;is a Canadian company operating as the exclusive supplier of FREMS™ technology to the North American healthcare industry.FREMS™&nbsp;technology is the product of Lorenz Biotech S.p.A. of Modena, Italy, and is rapidly being adopted as a preferred treatment option in the European markets.&nbsp;— Products —FREMS™&nbsp;is a composition of electrical signals characterized by negative and multi-modulated pulses which mimic different electrophysiological processes.Aptiva™&nbsp;Ballet&nbsp;is the ideal device for the treatment and clinical research of peripheral nervous and vascular systems diseases.Aptiva™&nbsp;Move&nbsp;is the portable and flexible choice in rehabilitation.To learn more about Lorenz Neurovasc and its products and services,&nbsp;visit&nbsp;www.lorenzneurovasc.ca&nbsp;or call toll free at&nbsp;1.866.443.8567.]]>
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            <link>http://themayerinstitute.ca/articles/frems-as-a-novel-therapy-for-treatment-of-dfu.php</link>
            <guid>http://themayerinstitute.ca/articles/frems-as-a-novel-therapy-for-treatment-of-dfu.php</guid>
            <pubDate>25 Sep 2011 12:18:56 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[FREMS]]></category>
        </item>
        <item>
            <title>You Can't Manage What You Can't Measure</title>
            <description>
 <![CDATA[Translation Tool Deepens Data PoolBY&nbsp;JOHN PULLEY&nbsp;&nbsp;&nbsp;07/13/11 02:56 pm ETA partnership between the Mayo Clinic and the minds behind IBM's Watson technology is close to completing development of tools to mine data from electronic health records that speak different digital languages.The goal is to safely and securely convert stores of electronic health records into a bottomless pool of real-world clinical knowledge, the Mayo Clinic says in a&nbsp;news release. Reaching that goal requires the ability to glean information from a variety of EHRs that tag and store clinical information in different, often proprietary, digital formats.So far, investigators with the Mayo-led team have used natural language processing tools to pull information from the records of 30 patients with diabetes and run it through computing systems developed with IBM's Watson Research Center, a process that transforms the data into 134 billion pieces of information, according to the clinic. (Watson is the language-recognition computer that recently won a Jeopardy. challenge against two of the game show's best human players.)HHS believes that mining EHRs for clinical information can lead to improved care by allowing researchers to learn from trends and treatment successes across the country.This gets to the heart of meaningful use, says Lacey Hart, Mayo's SHARP administrator, in the news release. It's one thing to meet the government requirement that you should have an electronic record, but it's another thing, once you have that record, to make meaning out of it.The project is one of four funded by the $60 million Strategic&nbsp;Health ITAdvance Research Project (SHARP) program, an initiative of the U.S. Department of Health and Human Services through its Office of the National Coordinator for Health IT.]]>
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            <link>http://themayerinstitute.ca/articles/you-cant-manage-what-you-cant-measure.php</link>
            <guid>http://themayerinstitute.ca/articles/you-cant-manage-what-you-cant-measure.php</guid>
            <pubDate>02 Sep 2011 06:48:26 EST</pubDate>
            <dc:creator>PV Mayer</dc:creator>
            <category><![CDATA[Research]]></category>
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