diabetic ulcers

According to the CDC, almost 24 million Americans have diabetes, and it is estimated that six million of those individuals are undiagnosed.¹ In 2007, financial costs attributed to diabetes totaled $174 billion.² Additionally, comorbidities linked with diabetes may lead to serious complications and create additional economic and individual burdens. The development of diabetic foot ulcers (DFUs) is one such complication.

DFU treatment utilizes a considerable portion of health-care dollars and may also lead to significant disability and a decrease in quality of life. Patients with diabetes have a 15%-25% lifetime risk for developing a foot ulcer.^3,4 When ulceration occurs, the risk for infection is present and may range in severity from a superficial area to one that pervades the bone. About 25% of diabetic foot infections will extend to deeper subcutaneous tissue or bone, and up to 50% of those individuals will have a recurrent ulcer within the next few years.⁵ Infection is the leading risk factor for amputation among those with DFUs.⁶

Considering the prevalence of diabetes, it is conceivable that most primary-care providers (PCPs) will encounter patients with foot ulcers. Practitioners treating patients with diabetes must focus on prevention of ulcerations, prompt diagnosis, treatment initiation, and appropriate referrals to preserve optimal functioning. Given the number of uninsured or underinsured individuals, adhering to this seemingly straightforward strategy can prove difficult. Lack of access to primary care leads many patients to delay care, which prevents detection or delays diagnosis until the advanced stages of disease.

The following case illustrates the challenges faced by many PCPs when caring for an underinsured patient with type 2 diabetes mellitus (DM) and a DFU.

Case study

Mr. J, aged 45 years, was hospitalized for two weeks with cellulitis and a left plantar foot ulcer. Incision and drainage (I & D) revealed three purulent sinus tracts extending from the superficial to the deep space of the left foot involving the first and second metatarsal heads. An MRI established the presence of osteomyelitis, but fortunately the bone was viable, and amputation was avoided. Culture was positive for group B Streptococcus and methicillin-susceptible Staphylococcus aureus, and the patient was treated with antibiotics for six weeks. Ankle-brachial indexes (ABIs) and toe waveforms were within normal limits. On admission, Mr. J's blood sugar was 312 mg/dL and hemoglobin (Hb) A1c was 12.9%. He was diagnosed with type 2 DM and started on insulin therapy. Mr. J achieved good glycemic control, extensive diabetes education was provided, and he was discharged to follow-up in the primary-care setting.

Post-hospitalization follow-up

Over the next six months, Mr. J lost 83 lbs, his HbA1c dropped to 5.5%, and his foot ulcer healed. He kept regular appointments with a podiatrist and maintained routine foot care. A small blister was discovered near the site of the previous left plantar DFU (Figure 1). Antibiotic therapy was ordered along with an OTC antimicrobial ointment to be applied to the wound site. While the culture showed no infection and x-ray did not reveal osteomyelitis, the ulcer continued to extrude a small amount of nonodorous serosanguinous drainage. After caring for Mr. J for two months, the PCP referred him to a hospital outpatient wound-care clini

high heels are harmful?

Nearly three million women suffer high-heels related injuries which need medical attention, a recent study suggests. The Sun reported that 3000 women in the age group of 18 to 65 were studied by Hot Shoes, makers of comfort footwear.

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A model displays a creation as part of the Prada Fall/Winter 2010/11 women's collection during Milan Fashion Week February 25, 2010.

Most women twisted an ankle or tore a tendon but there were serious cases also of smashed teeth, broken bones and nasty falls. Yet, even this is not enough to dissuade 60 per cent of those interviewed for the study who said that they will continue wearing heels.

Almost 90 per cent of participants reported discomfit and ruined nights because of high heels. And 61 per cent reported sitting the night out due to the pain.

Only two per cent of those interviewed said that they did not wear high heels. Medical reports suggest that high heels could lead to foot deformities, posture problems, neck injuries and permanent damage in some cases. A 2001 Harvard study also found that high heels can set the stage for osteoarthritis of the knees.

Another study done by the shoe firm MBT claims high heel-induced injuries like twisted ankles, bunions and ingrown toenails cost the UK £29 million a year. The MBT study that included 1,000 women found that four in 10 women suffered an injury in their heels, such as falling over or twisting their ankles from wearing glamorous footwear.

A worrying trend is that women are getting cosmetic surgeries to fit into their Manolo Blahniks and Jimmy Choos. More than half of the 175 members of the American Orthopedic Foot & Ankle Society who responded to a recent survey by the group said that they had treated patients with problems resulting from cosmetic foot surgery.

The society will soon issue a statement condemning the procedures, said Rich Cantrall, its executive director.

Celebrities routinely undergo such surgeries as they more than anyone develop foot problems and ugly bunions and toes due to constant wearing of high Heels. Victoria Beckham was recently in the news for such a surgery.

High heels have been in fashion as far back as 1000 BC. They were a social status symbol. Women in the 16th and 17^th century took it to great heights and teetered around in 5-8 inches high shoes. They had attendants to help them move and sometimes carried stylish canes to support them. It is only in the 20^th century that demand for comfortable, fashionable shoes came from liberated women. Whatever the evidence to the contrary, it is still very difficult to separate women from their high-heels as history relates.