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MALIGNANT DIABETES AND ASSOCIATED MORTALITY

MALIGNANT DIABETES AND ASSOCIATED MORTALITY. CAN WE DO ANYTHING ABOUT IT?. Terri DeJohn, M.D. Medical Director Hyperbaric Medicine and Wound Treatment Center. OBJECTIVES. Identify factors which contribute to increased mortality in the DFU patient.

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MALIGNANT DIABETES AND ASSOCIATED MORTALITY

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  1. MALIGNANT DIABETES AND ASSOCIATED MORTALITY CAN WE DO ANYTHING ABOUT IT? Terri DeJohn, M.D. Medical Director Hyperbaric Medicine and Wound Treatment Center

  2. OBJECTIVES Identify factors which contribute to increased mortality in the DFU patient. Learn who to call for help and when to make that call.

  3. DIABETES IS INCREASING 26 million people in the U.S. have diabetes 1.9 million diagnosed in 2010 15% will develop Diabetic Foot Ulcers (DFU)

  4. AMPUTATIONS 71% are toe, TMA and Symes amputations 82% decrease in BKA or AKA • 15% of DFU’s End in Amputation

  5. AMPUTATION INCIDENCE IN MINORITIES per 10,000 Diabetics MEN have twice the incidence of amputation as women in all races

  6. MALIGNANT DIABETES Armstrong DG. Int Wound J. 2007;Dec;4(4):286-7.

  7. MORTALITY RISK IMPROVES WITH TREATMENT BY A MULTI-DISCIPLINARY TEAM In 5 Years Living Dead

  8. MULTIFACTORIAL ETIOLOGY Diabetes Amputation

  9. MULTIFACTORIAL ETIOLOGY Diabetes Amputation

  10. MULTIFACTORIAL ETIOLOGY Amputation Vascular Disease Infection Ulceration Deformity • Neuropathy Diabetes

  11. LIMB SALVAGE TEAM • Multiple problems contribute to critical wounds and potential amputation. • Multiple doctors with expertise in their area working together to save a leg.

  12. MULTIFACTORIAL ETIOLOGY Amputation Vascular Disease - CV Infection - IMMUNE Ulceration - DERMATALOGIC Deformity- ORTHOPEDIC • Neuropathy - NEUROLOGIC Diabetes - ENDOCRINE

  13. OUTCOMES OF MULTIDISCIPLINARY TEAMS

  14. Moving from aWound Clinicor Lone Practitioner to a Limb Salvage Team

  15. Rapid Referral to Multi-disciplinary Team Referral before 25 days resulted in a 79% reduction in amputations. • vanAcker, et al, DFCon2011 Establishing a National Diabetic Foot Model

  16. RECOMMENDATIONS FROM EVIDENCE CONSENSUS RECOMMENDATIONS ON ADVANCING THE STANDARD OF CARE FOR TREATING NEUROPATHIC FOOT ULCERS IN PATIENTS WITH DIABETES APRIL 2010 OSTOMY AND WOUND MANAGEMENT

  17. TREATMENT OF DFU’s DEFINE DISCUSS DEBRIDE (VESSELS AND BED) DEBUG DECIDE DE-LOAD

  18. DEFINE SKIN AND ULCER EXAM • Skin • Sensation • Deformity • Ulcer: Size, Location, Base, Wound edge, Tunnel, Necrosis

  19. DEFINE INFECTION • Drainage • Odor • Redness • Swelling • Probe Bone • If suspicious: ESR, CRP (If both are normal, Osteomyelitis is unlikely), Culture

  20. IMAGING Plain films MRI or CT

  21. VASCULAR EVALUATION A tiered approach is recommended : 1. Pulses, ABI, and/or TBI 2. Segmental pressure volume, SPP and TcPO2 3. Vascular consultation

  22. TISSUE HYPOXIA TcPO2 < 40mmHg suggests impaired healing Risk of amputation is 161 times greater if TcPO2 <20 rather than TcPO2 >40 Risk amputation is 55 time greater if ABI is <0.45 rather than >0.7

  23. DEFINE LABS CBC HgA1c Cholesterol, HDL, LDL Homocysteine (Hcy)

  24. Effects of Hyperglycemia on Cells 1. Decreased proliferation and differentiation of keratinocytes (1) 2. Inhibition of fibroblast proliferation (2) 3. Decreased response of cells to growth factors (2,3) 4. Decreased migration of keratinocytes and fibroblasts (4) (1) Sparvchikov N, ed al. Diabetes 2001; 50: 1627-635 (2)Hehenberger K, et al. Cell BiochemFunct 1997; 15: 197-201 (3)Fard A, et al. ArteriosclerThromVascBiol 2000; 20: 2039-2044 (4)Lerman OZ, et al. Am J Pathol 2003; 162:303-312

  25. HEMOGLOBIN A1C & WOUND HEALING Methods: A retrospective analysis of data gathered from multi-center, controlled, prospective, randomized FDA approved clinical trials is being conducted. Results: The final linear regression model (P<0.0001) found that higher HgbA1C levels were associated with lower percentages of wound healing (P=0.05). For every 1% increase in HgbA1c there is a decrease of 3% in expected healing area Hanft J, et al, South Miami Hospital & Harvard Medical School, APMA Scientific Meeting Abstract, 2009

  26. Wound Healing in the Diabetic

  27. DEFINE LABS CBC HgA1c Cholesterol, HDL, LDL Homocysteine (Hcy)

  28. Homocysteine (Hcy) Known risk factor for atherosclerotic vascular disease and is an inhibitor of nitric oxide (NO) bioactivity ↑ Hcy was observed in 50% of patients with chronic wounds 63% of patients with diabetic, neuropathic ulcers

  29. Figure 6.

  30. TREATMENT OF HYPER- Hcy METANX L-methylfolate Pyridoxal 5'-phosphate Methylcobalamin Results in 3X’s lower serum Hcy

  31. DEFINE NUTRITION • Nutrition Screen • Albumin, Pre-Albumin, Transferrin CONSIDER PROTEIN SUPPLEMENTS .5 - .75 gm / kg of body weight

  32. DEFINE SMOKING • Nicotine • Cyanide • Carbon Monoxide CONSIDER E-CIGARETTE

  33. DEFINED DISEASE PROCESSES ULCER DEFORMITY INFECTION VASCULAR STATUS DIABETIC CONTROL NUTRITIONAL STATE

  34. DEFINE & DISCUSS Initial definition to determine what issues contribute to the problem Discuss with appropriate specialists

  35. DEFINE AND DISCUSS Tissue Hypoxia Deformity Infection Diabetic Control Nutrition Vascular surgeon Ortho/ Podiatry/ Pedorthotist Infectious Disease Endocrinologist/ Diabetic Ed Dietician

  36. DEBRIDE • Debridement • Sharp • Mechanical • Chemical • Autolytic

  37. DE-BUG

  38. BIOFILMS Biofilms are present in 60% of chronic wound biopsies Only 6% of Acute Wound Biopsies Biofilms retard wound healing Schierle WWR 17:2009

  39. BIOFILMS Biofilms induce a chronic inflammatory response • Reactive Oxygen Species (ROS) • Proteases ( MMP, neutrophil elastase) Chronic inflammation leads to damage of proteins that are essential for healing. • Extracellular Matrix Proteins • Growth factors and receptors

  40. DECIDE: WHAT DRESSING Wound care dressing orders for 202 patients receiving home health or HMO care 42% Wet-to-Dry 7.5% Enzymatic 7% Dry Gauze Cowan L, Stechmiller J. Advances in Skin and Wound Care Dec, 2009

  41. DECIDE: WHAT DRESSING • TO DRY: • Alginates • Foams • ABD’s • Polymers • NPWT • TO MOISTEN: • Hydrogel • Medihoney • Ointments

  42. DECIDE: WHAT DRESSING ANTIMICROBIAL Silver Iodosorb Medihoney ACTIVE DRESSING Collagens Regranex Skin Substitutes

  43. DE-LOAD (Off- Load) OFF LOADING DEVICES

  44. OFF LOADING TOTAL CONTACT CASTING Only device proven to effectively off load REMOVABLE DEVICES ARE REMOVED Only 28% of daily activity done with device Armstrong, Diabetes Care 2003

  45. QUALITYCARE BENCHMARKING Off Loading is the #1 Benchmark Diabetic Control Vascular Exam

  46. DECIDE @ 4 WEEKS A 50% reduction in wound area at 4 weeks is a surrogate marker predictive of wound healing. % Area Reduction at 4 weeks

  47. Percentage of Area Reduction = (A1 - A2) ÷ A1 x 100 A = Length x Width

  48. FAILURE TO ACHIEVE 50% CLOSURE @ 4 WEEKS REQUIRES ADVANCED THERAPIES

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