Wednesday, July 29, 2009

Alternatives to Amputation

Amputation of an arm or leg should always be a last resort. That’s why Florence Davis of Hillside, NJ sought the help of a talented team of doctors at Newark Beth Israel Medical Center in an effort to save her leg.

For over a year, Davis struggled with a persistent foot wound that restricted blood circulation in her leg. The problem became so severe that doctors were considering amputating the leg. However, the vascular specialists at Beth Israel had other plans for their 81 year-old patient. Doctors applied a new ultra-cold catheter technique to open several blockages in the arteries—a technique that would save her leg without any surgery.

If you’ve ever sough medical advice for the treatment of a wound, you know that wound care can be a tricky ailment that can often spiral into other diseases due to complications and infections. Davis suffered from peripheral artery disease (PAD), but wasn’t aware that the condition could be life-threatening and seriously debilitating. If left untreated, people who exhibit symptoms of PAD are four to five times more likely to get a heart attack or stroke. The pain in Ms. Davis’ foot became so severe that she could barely walk. To make matters worse, she got a cut on her toe that refused to heal, so she turned to the Advanced Wound Care and Hyperbaric Institute at Newark Beth Israel Medical Center for help.

Doctors began aggressive wound treatment, but tests show that she had three blockages in the artery that runs from her hip to her toe. Circulation had to be restored, but Davis was not a candidate for the traditional vascular bypass surgery that transplants blood vessels from a healthy limb to replace blocked vessels. The wound care specialists at Beth Israel referred Davis to Madhu Salvaji, DO, one of a handful of New Jersey doctors who uses the Polarcath system to treat patients. This sophisticated form of treatment combines cold therapy and angioplasty (a procedure that involves using a balloon to open clogged arteries) to help prevent future blockages.

“Cooling the blood vessel down to -10 degrees Celsius as the balloon is inserted in the clogged artery, causes targeted cell death and alters the new cells that will replace them, greatly reducing the chances of a future blockage,” explained Dr. Salvaji. Altogether, Dr. Salvaji opened three blockages using a combination of cold catheter, stent placement and artherectomy, a delicate process of removing plaque from the artery walls.

“All I had to do was lie still,” said Mrs. Davis about the three minimally invasive procedures that were performed in stages. Within two weeks, the swelling in her foot disappeared, her toe was healed and she was back to her daily walking, shopping, and gardening.

For more information about advanced wound care or treatment for peripheral artery disease at Newark Beth Israel Medical Center, please call 1-888-SBHS-123.

Thursday, July 23, 2009

Peripheral Arterial Disease (PAD)

Peripheral Arterial Disease (PAD) is also known as atherosclerosis, poor circulation, or hardening of the arteries. PAD progresses over time at variable rates in each individual depending on the area of circulation effected and one's health and family history. The signs and symptoms of PAD may not arise until later in life. For many, the outward indications will not appear until the artery has narrowed by 60 percent or more.

One method the body uses to adapt to the narrowed arteries is the development of smaller peripheral arteries that allow blood flow around the narrowed area. This process is known as collateral circulation and may help explain why many can have PAD without feeling any symptoms.

When a piece of cholesterol, calcium or blood clot abruptly breaks from the lining of the artery or a narrowed artery blocks off completely, blood flow will be totally obstructed and the organ supplied by that artery will suffer damage. The organs in PAD most commonly affected and researched are the legs.

What happens if the disease worsens?

The severity of PAD depends on when it is detected and any pre-existing health factors; especially smoking, high cholesterol, heart disease or diabetes. In the later stages, leg circulation may be so poor that pain occurs in the toes and feet during periods of inactivity or rest. This is especially true at night. This is known as rest pain, which usually worsens when the legs are elevated and is often relieved by lowering the legs (due to the effects of gravity on the blood flow).

Critical Limb Ischemia

The most advanced stages of PAD can lead to Critical Limb Ischemia (CLI) . Here the legs and feet have such severe blockage that they do not receive the oxygen rich blood required for growth and repair of painful sores and even gangrene (dead tissue). This condition, if left untreated, may require amputation.

Wednesday, July 22, 2009

Workshop on Surgery cure for Peripheral Vascular Disease organised by Ruby Hall

(I-Newswire) - Workshop on Surgery cure for Peripheral Vascular Disease organised by
Ruby Hall
- Surgeries performed on five patients -
Pune, Tuesday 20th July 2009: In a bid to spread awareness about breakthrough treatments of Peripheral Vascular Disease ( PVD ), also known as Peripheral Arterial Disease, Ruby Hall had organised a day-long workshop recently.
The workshop, conducted under the supervision of Dr Bhagat Reddy from Georgia, USA. Dr Shirish ( M.S ) Hiremath, Dr Dhanesh Kamerkar and Dr Chandrashekhar Makhale actually performed Endo vascular procedures on five patients, who were suffering from PVD.
For cases of PAD, someone requiring surgery the newly developed device called the Frontrunner is now available which works in a similar way like an excavator, which bore through the mud and sludge causing the blockage. “It is like an angioplasty and a by-pass surgery performed on the leg,” says Dr Kamerkar.
Dr. Shirish ( M.S. ) Hiremath, Director, Ruby Hall Clinic said, “Lower limb PVD is a serious threat to the Indian population especially because of our susceptibility to Diabetes. Since people with diabetes frequently have high blood pressure and high cholesterol levels, it further accelerates the development of atherosclerosis. Given that PVD in diabetes is largely asymptomatic, patient education plays a key role in preventing major complications later. While 82,000 people have diabetes-related leg and foot amputations each year in India, timely treatment can significantly reduce this number”.

The new technique of surgery, prevalent in the West for a couple of years has now been brought to India to help patients who have a high risk of surgery. By the use of a Frontrunner, surgeons can avoid major cuts and incisions on the patient’s body and open up the blockage with just a puncture, as in conventional Coronary Angioplasty.
The workshop, which has already been held at major cities like Bengaluru, Hyderabad etc. aimed to instruct doctors about new tools and techniques that they can learn to deal effectively with the threat of PVD .
PVD, a widely prevalent, progressive atherosclerotic disease that carries a high risk of limb loss, stroke, and premature death, which can affect anyone. It occurs when the arteries ( blood vessels ) that supply blood to various parts of the body become narrow because of the buildup of fatty deposits on the inside walls of the blood vessels of the heart ( coronary artery disease ), brain ( cerebrovascular disease ) and kidney ( renal artery disease ). Because of this, people with PVD have a higher risk of heart attack, stroke or kidney failure.
Dr. Shirish ( M.S. ) Hiremath who has the largest volume of Angioplasties, explained how cardiologists have got involved in managing leg issues.” Basically the process of atherosclerosis ( aging of the arteries ) is same all over the body. Measures taken to avoid atherosclerosis help both “Heart and Health.” Also, with enormous expertise in Heart arteries, Dr. Shirish ( M.S. ) Hiremath, feels they are very adapt to performing leg Angioplasties.
The doctors warn that people with PVD, if not treated are likely to undergo amputation of the limbs. “If people have better tools available to them, the results in treating patients can improve drastically. Thus, the workshop is beneficial not just to doctors and a boon to patients suffering from PVD, but to the whole society at large,” acts Dr Kamerkar.
One of the patients, Suhas Patil, who got operated said, “ I was suffering from daibetes from a very long time but I was not aware of PVD. When the doctors informed me about it, I had lost all hopes. There are many such people like me who are not aware of such consequences Such kind of workshops should be organized on a regular basis to make people aware about the disease. I would like to thank all the doctors who helped me in understanding the effects of the disease and guided in the right direction.”

Tuesday, July 21, 2009

PAD | Are You at Risk for Peripheral Arterial Disease?

PAD | Are You at Risk for Peripheral Arterial Disease?
Tuesday, July 21, 2009

You walk a block, then clutch your leg with what feels like a charley horse. You stop, and the pain does too. The discomfort may be a warning of a common yet serious condition called peripheral arterial disease (PAD).
In PAD, the same fatty material that can clog heart arteries builds up in the arteries of the legs, blocking blood flow. The risk for death from heart attack or stroke is six to seven times greater in people with PAD is equivalent to the risk of someone who has had a heart attack or stroke. Without prompt treatment, one in four people with the condition will suffer a heart attack, stroke or amputation or die within five years.
PAD is most often recognized when it causes claudication and fatigue, cramps, tiredness or pain in the leg or buttock muscles that goes away when you stop walking. Less frequently, it can cause ulcers or slow-healing wounds on the feet or toes, or pain in the feet or toes that disturbs sleep. However, as many as half to two thirds of those with the condition have no symptoms.
As with coronary heart disease, key risk factors for PAD are having diabetes, smoking or having smoked, and being over age 50. “If you have no other risk factors, age alone will increase risk and yet risk rapidly increases even in younger people who smoke or have diabetes,” says Alan T. Hirsch, M.D., professor of epidemiology at the University of Minnesota School of Public Health in Minneapolis. “We want people to recognize that if you are over 50 and have any other risk factor, you have a one in four chance of having this disease.”
Also at risk are African Americans and anyone with chronic kidney disease, high blood pressure, high blood cholesterol or a personal or family history of vascular disease, heart attack or stroke. An estimated 8 to 12 million people in this country have PAD.
If you have risk factors, talk to your doctor, whether or not you have symptoms. The PAD Coalition, a consortium of health organizations and government agencies, recommends that those at risk get a quick, painless, accurate and inexpensive diagnostic test called an ABI (ankle-brachial index).
The good news: PAD is both preventable and is very treatable. “PAD is a common and serious disease, which merits immediate and lifelong attention,” says Dr. Hirsch. “Become informed and take actions to protect your health.” Arms for Legs While exercise is helpful for people with PAD, walking is a typical workout for sufferers but can also be painful. Diane Treat-Jacobson, R.N., Ph.D., assistant professor at the University of Minnesota in Minneapolis, has done studies on the effects of exercise on people with this disease.
She recently discovered that supervised training using aerobic arm exercise was as beneficial as treadmill walking in improving walking distance. Treat-Jacobson notes that while results are preliminary, arm exercise might be a pain-free option that can “help break the cycle of disability or enable patients to start exercising sooner after a surgical procedure.”
Remember that peripheral arterial disease is both preventable and very treatable, but it is a a common and serious disease which merits your attention if you have any of the symptoms addressed in this article.
It is up to you to become informed about this disease and take active action to protect your health.

Monday, July 20, 2009


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HEART TO HEART: Understanding PVD

HEART TO HEART: Understanding PVD
Monday, July 20th, 2009 02:52:00

STAND up. Feel the ground beneath you. Is it firm? Walk around and jump up and down. Go kick a ball. Now look at your feet. Look at them hard.
Why have I asked you to do this? What is my point?

For most people, this is not something that we think of consciously. The ability to stand and walk is what all of us learned to do months after birth. It is a natural part of our everyday life.
Unfortunately, the same cannot be said of Ibrahim (not his real name). He had his left leg amputated above the knee in March this year. His right leg followed two weeks ago. His life will never be the same again.

Ibrahim is a 60-year-old man with peripheral vascular disease (PVD). It is an occlusive arteriosclerotic disease affecting the arteries to his legs.

He also has diabetes, hypertension and high cholesterol.

Although he does not smoke, he has the other risk factors for severe PVD.

His problem started in the middle of last year. He complained of cramp-like feeling at the back of both calves when walking. The medical term for this symptom is intermittent claudication.

After a few weeks, he began to notice the walking distance it took for the claudication pain to come on was becoming less.

In late November, he noticed a small wound on the sole of his left foot. He had no recollection of how he sustained it. He had been having numbness in his feet for some time before that and he attributed it to his longstanding diabetes. When he sustained the wound to his foot, he had no knowledge of it till later.

Ibrahim has had diabetes, hypertension and high cholesterol for more than 10 years. He was not diligent in taking his medications or clinic follow-up appointments.

Instead, he resorted to traditional treatment to help heal the wound. By the middle of February, the wound had become worse. It was bigger and the whole foot was in pain even at rest.

When he eventually came to the hospital two weeks later, all his left toes were black and gangrenous. Infection had already spread to the bones of his foot. He had osteomyelitis.

He initially refused medical advice to have a below-knee amputation. He insisted on the medical team to perform a miracle to save his leg. Unfortunately, despite aggressive treatment with intravenous antibiotics and regular wound care, his leg could not be saved. As I am writing this, Ibrahim is recovering in the hospital from his second amputation. Sadly, his case is not isolated.

He is just 1 of about 10,000 diabetics whose legs are amputated in Malaysia every year, where 40 to 50 per cent of these cases are preventable.

Did you know that patients with PVD have a four-fold risk of death from heart attack and heart-related diseases, and a two to three times greater risk of stroke?

Diabetics are two to four times more likely to get PVD and for those who also smoke, the risk of having an amputation is 30 per cent in the next five years. With the rising number of diabetic patients, which currently stands at 14.9 per cent in Malaysia for those above 30 years of age, PVD is fast becoming an epidemic.

As a clinical condition, PVD is grossly neglected, vastly underdiagnosed and badly managed. As with Ibrahim
and thousands others, severe PVD leading to critical limb ischaemia (painful leg at rest, non-healing wounds and gangrene) is the first presentation to the doctor. Chances of a good recovery will be smaller at this stage.

For some, it may even be too late.

Ignorance is the main cause of the rising number of PVD cases worldwide. Perhaps we place too much concentration on the symptoms and signs of heart attack and stroke that we tend to neglect PVD, the third commonest manifestation of cardiovascular disease.

To halt the growth of this serious disease, drastic measures need to be instituted before the situation gets out of hand.

Early identification of patients at risk of PVD, aggressive risk factor modification and timely referral to the vascular surgeon in severe cases is vital.

If you are diabetic or at high risk of getting PVD, please consider the following:
● Watch your diet. It has to be low in sugar and fat.
● Take your medicines as prescribed. Follow the advice of your doctor.
● Stop smoking.
● Exercise regularly.
● Take care of your feet. Make sure they are clean and dry at all times, especially in the spaces between
the toes.
● If numbness develops on the soles of your feet, take appropriate measures to protect your feet from accidentally having a cut.
● If you have any of the PVD symptoms and signs (claudication or critical limb ischaemia), see a doctor straight away.

Once you see a doctor, he may order an ankle-brachial pressure index (ABPI) test. It is a measure of the fall in blood pressure in the arteries supplying the legs compared to the pressure in the arms. A reduced ABPI (less than 0.9) is consistent with PVD. Values of ABPI below 0.8 indicate moderate disease and below 0.5 severe disease.

These days, CT angiogram which is a non-invasive imaging test, is being used on a wider basis to visualise the extent of the disease. Based on this and the clinical picture, the vascular surgeon will advise on the best treatment from the available options which are:

● Conservative measures with medicines and life style modification only.
● Angioplasty, which is the opening up of narrowed arteries using special balloons inserted through the groin. This is the preferred option in certain cases especially in those at high risk of surgery.
● Bypass surgery using either the saphenous vein from the leg or an artificial graft to circumvent the blockage in the artery.

If you have any questions or comments, feel free to write to me at See you next Monday.

Sunday, July 19, 2009

Saving limbs with drug-eluting stents

July 16, 2009
Saving limbs with drug-eluting stents
Filed under: Uncategorized — reducedapmiami @ 1:55 pm

Attempts to explore deprecatory limb ischemia in peripheral arterial disorder (PAD) patients with unworthy of-the-knee angioplasty are still thwarted by restenosis (the re-narrowing of the artery at the situate of angioplasty or stenting), the extremity due to the fact that replay treatments and the continued progression of atherosclerotic complaint, leading to tissue death (gangrene) and amputation.

Interventional radiologists have been studying a potential solution - the use of drug-eluting stents - and have found that these types of stents lessened the rate of repeat procedures to open these small arteries, according to results presented at the Society of Interventional Radiology’s 34th Annual Scientific Meeting.

“This is encouraging news for PAD patients with critical limb ischemia. The smaller blood vessels below the knee are more difficult to treat due to their size (3 millimeters) and are more prone to reclog than larger vessels. The use of drug-eluting stents in the tiny infrapopliteal arteries of the leg may significantly impact their care,” said Dimitris Karnabatidis, M.D., assistant professor of interventional radiology at Patras University Hospital in Rion, Greece. “Drug-eluting (or drug-coated) stents have emerged as a potential solution to the limitations of endovascular treatment of PAD patients with critical limb ischemia,” he added. An interventional radiologist performs a balloon angioplasty to open a clogged blood vessel and then places a drug-eluting stent in that artery. The stent acts as scaffolding to hold the narrowed artery open. Drug-eluting stents slowly release a drug for several weeks to block cell proliferation or regrowth, thus inhibiting restenosis.

Researchers from a single center studied 103 patients in a double-arm prospective registry who had critical limb ischemia and who underwent infrapopliteal revascularization with angioplasty and placement of either a drug-eluting stent (with sirolimus, an immunosuppressant drug) or a bare-metal stent (without a drug coating). The patients had regular follow-ups up to three years, and researchers studied how they did by stent type. In the first group, 41 patients (75.6 percent diabetics) were treated with bare-metal stents, and in the second group 62 patients (87.1 percent diabetics) were treated with drug-eluting stents.

At three years, those patients with drug-eluting stents had “significantly higher patency” (length of time the blood vessels stayed open and moved blood flow efficiently); reduced restenosis of the vessels; and consequently less clinical recurrence requiring repeat angioplasty, said Karnabatidis. “In the drug-eluting stent group, an estimated 60 percent of the treated arteries remained open at three years. This is significantly longer than the bare-metal stent group, where the arteries remained open only approximately 10 percent at 3 years,” said Karnabatidis. “This corresponds to a more than 5 times increased risk of vessel reclogging when bare metal stents were used,” he added. “Because of the reduced vessel restenosis, repeat angioplasties were necessary in only 15 percent of the patients in the drug-eluting stent group versus almost 35 percent in the bare-metal stent group up to 3 years - this being the equivalent to an almost 2.5-fold risk of repeat procedures in the case of bare metal stents,” noted Karnabatidis. “These statistical results are based on three-year adjusted survival analysis after application of a Cox model for multivariable analysis,” he explained.

If a person has critical limb ischemia, it means he or she is at great risk for tissue death due to lack of blood flow, which carries oxygen and nutrients to the cells. The severely restricted blood flow results in severe pain in the feet or toes, even while resting, and sores and wounds that will not heal. Tissue death (gangrene) and amputation are imminent at this advanced stage of PAD, which is caused by atherosclerosis, the hardening and narrowing of the arteries over time due to the buildup of fatty deposits called plaque.

“Multicenter randomized trials are necessary to support these promising results and build on the level of clinical evidence supporting the integral value of infrapopliteal drug-eluting stents in critical limb ischemia treatment,” he added. In the United States, drug-eluting stents are FDA-approved for the coronary arteries but not for infrapopliteal arteries. In Europe, drug-eluting stents have CE Mark approval for below-the-knee use.

Thursday, July 16, 2009

Critical Limb Ischemia


Critical Limb Ischemia

Laura Bolton, PhD, FAPWCA

Dear Readers:
Critical limb ischemia (CLI), the most severe stage of peripheral arterial disease, affects 250,000 new patients annually in the United States with an estimated 40% requiring amputation within 12 months of a CLI episode, in addition to an annual mortality rate of more than 20%.1,2 Distal bypass surgery prompts healing of lower extremity ulcers associated with CLI if resulting arterial patency supports skin perfusion pressure of at least 35 mmHg.3 Surgical bypass of the occluded arterial segment improves3,4 and extends primary arterial patency, though there is insufficient evidence to support improved amputation rates or mortality compared to most other modalities.4 What options are available to the individual for whom bypass surgery is no longer feasible? This month’s Evidence Corner reviews two studies evaluating efficacy of modalities for treating CLI in patients without further vascular surgery options, as the search for an effective treatment of CLI continues.
Critical Limb Ischemia
Reference: Kavros SJ, Delis KT, Turner NS, et al. Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study with 18-month follow-up. J Vasc Surg. 2008;47(3):543–549.
Rationale: Intermittent pneumatic compression (IPC) is a noninvasive method of increasing arterial circulation and ameliorating intermittent claudication in patients with peripheral arterial disease (PAD).
Objective: Evaluate clinical efficacy of IPC in patients with chronic CLI, nonhealing foot ulcers, and minor toe or transmetatarsal amputation after further options for arterial revascularization had been exhausted.
Methods: This retrospective cohort study compared two similar groups, each consisting of 24 consecutive patients, for whom further surgical bypass was not an option, and were cared for in a multidisciplinary community clinic from 1998–2004. Resting ankle-to-brachial ratios of systolic blood pressure (ABI), sitting transcutaneous oximetry (TcPO2) duplex graft surveillance, and foot radiography confirmed vascular status. Both groups received weekly debridement and biologic dressings for tissue loss and nonhealing amputation wounds of the foot due to CLI. Intermittent pneumatic compression allocation was based solely on a patient’s willingness to use it. The IPC inflation pressure was 85 mmHg to 95 mmHg and was applied for 2 seconds with a 0.2-second rise, 3 cycles per minute, for three 2-hour daily sessions. Adherence was monitored closely. Healing outcomes were “favorable” if complete healing with limb salvage occurred during 18 months. Outcomes were considered “adverse” if nonhealing caused below-knee amputation during that time.
Results: Groups were comparable at baseline on all arterial and wound parameters; prior amputation and comorbid factors were assessed. Four patients (17%) in the control group and 14 IPC (58%) patients healed (P < 0.01). The likelihood of limb loss in the control group was 7 times that of IPC subjects who also increased in TcPO2 (P = 0.0038).
Authors’ Conclusions: When used within a protocol of standard wound care, IPC significantly improves clinical healing and below-knee amputation outcomes of patients with inoperable CLI. This research sets the stage for rigorous prospective, multicenter, randomized, controlled trials (RCTs) of IPC to establish its role in healing while clarifying its indications for use.
FGF-1 Gene Therapy Decreases Amputation Rates in Patients With CLI
Reference: Nikol S, Baumgartner I, Van Belle E, et al. Therapeutic angiogenesis with intramuscular NV1FGF improves amputation-free survival in patients with critical limb ischemia. Mol Ther. 2008;16(5):972–978.
Rationale: Although controversial, with its long-term effects under scrutiny, angiogenic growth factor therapy has been proposed for treatment of critical limb ischemia in end-stage PAD. Acidic fibroblast growth factor (FGF-1) is a potent mitogen for vascular endothelial cells, inducing blood vessel formation in vitro and in vivo. A plasmid-based gene transfer delivery system for FGF-1, NV1FGF with “Conditional Origin of Replication” (pCOR), reduces the potential for propagation in the host environment while sustaining local FGF-1 production permitting less frequent treatment.
Objective: A Phase 2b, double blind, randomized, placebo-controlled clinical trial investigated the efficacy and safety of intramuscular NV1FGF versus placebo in subjects with CLI at high risk of amputation.
Methods: A European multicenter trial screened 125 patients with CLI ineligible for revascularization as confirmed by a vascular surgeon. Each patient had at least 1 nonhealing ulcer, a TcPO2 £ 20 mmHg, ankle pressure
£ 70 mmHg, and toe pressure £ 50 mmHg. Patients were randomly assigned to receive 8 intramuscular injections of 2.5 mL NV1FGF in a 0.2 mg/mL solution (n = 59) or similar placebo injections (n = 56) on study days 1, 15, 30, and 45. Percent of patients with at least 1 ulcer completely healed at week 26 was the primary outcome. Secondary outcomes TcPO2, ABI, amputation, and death were evaluated at week 52.
Results: Among 107 subjects evaluated for healing, 19.4% of NV1FGF-treated and 14.3% of control patients healed during 26 weeks (P = 0.514; not significant). Likelihood of amputation or of major amputation was reduced in the NV1FGF group (P = 0.011), which also experienced improvement in time to death or major amputation. No other secondary outcomes were statistically significant. Adverse events were comparable in both groups, supporting the safety of NV1FGF.
Authors’ Conclusions: This was the first double blind, prospective RCT in patients ineligible for bypass surgery. Despite the fact that no improvement in wound healing was seen it showed the potential for NV1FGF to significantly reduce amputation risk, potentially lowering mortality rates in these high-risk patients.

Clinical Perspective
Both publications aim to improve the lot of patients with serious vascular impairment, using either biochemical or physical modalities. Plasmid gene transfer of NV1FGF administered once every 2–3 weeks for the first 7.5 weeks of care appears to save limbs, though its effect on ischemic ulcer healing remains uncertain. Other plasmid growth factors either lack healing and amputation effects5 or heal wounds without reducing amputation.6 The capacity to save limbs in high-risk patients for whom surgery is no longer an option is equally compelling for NV1FGF and IPC. Limb salvage plus the healing benefits of properly applied IPC are unprecedented, although it was a small retrospective study and was potentially biased by selection of IPC-willing patients. Larger prospective RCTs on patients with CLI, perhaps comparing IPC with and without NV1FGF, would seem necessary. As a physical modality, IPC may be compatible with gene or biochemical therapy. These studies open potential care options for patients with CLI who are faced with possible amputation.

1. Dormandy J, Heeck L, Vig S. The fate of patients with critical leg ischemia. Semin Vasc Surg. 1999;12(2):142–147.
2. Dormandy J, Mahir M, Ascady G, et al. Fate of the patient with chronic leg ischaemia: A review article. J Cardiovasc Surg. 1989;30(1):50–57.
3. Tsuji Y, Hiroto T, Kitano I, Tahara S, Sugiyama D. Importance of skin perfusion pressure in treatment of critical limb ischemia. WOUNDS. 2008;20(4):95–100.
4. Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD002000.
5. Powell RJ, Simons M, Mendelsohn FO, et al. Results of a double-blind, placebo-controlled study to assess the safety of intramuscular injection of hepatocyte growth factor plasmid to improve limb perfusion in patients with critical limb ischemia. Circulation. 2008;118(1):58–65.
6. Kusumanto YH, van Weel V, Mulder NH, et al. Treatment with intramuscular vascular endothelial growth factor gene compared with placebo for patients with diabetes mellitus and critical limb ischemia: a double-blind randomized trial. Hum Gene Ther. 2006;17(6):683–691.

Diabetic Footwear

From: Living and Coping with Diabetes

Diabetic Footwear
Jul 16th, 2009 by diabetes-blog
Foot pain affects many diabetics…

We received a tweet a from someone who wanted to recommend a brand of diabetic socks and foot wear that was very helpful in alleviating foot pain for his dad. We have not tried this brand personally… however, we wanted to share this information with you all in case someone may find a benefit from this type of product. Below you will find a brief synopsis of information along with the website.

Celliant/Health Sport socks and support braces, elbow sleeves are a newly created product. The Celliant yarn is patented and has been clinically proven to increase oxygen in the body, reduce pain, and help regulate body temperature.

Increased oxygen is known to promote quicker muscle recovery and healing. Increased circulation is a great thing for DIABETICS. My father is a Type II diabetic and he swears by the socks. Our product increases oxygen levels by up to 12%. You can look at the test and research results on our site

-Nick Lyle

If you find this information helpful or if you know someone that may benefit from this type of service please pass this link on.

Here 2 Serve U


Tuesday, July 14, 2009

PVD Study

Objective: We studied the effectiveness of a screening program for peripheral vascular disease (PVD) carried out by trained renal nurses in patients with and without diabetes on continuous ambulatory peritoneal dialysis (CAPD).

Patients and Methods: We recruited 30 stable diabetic and 30 stable non diabetic CAPD patients into this cross-sectional study. Trained renal nurses measured the patients' ankle-to-brachial systolic pressure index (ABI) using a Doppler ultrasound machine and their foot vibration perception (VPT) using a biothesiometer, and administered a questionnaire on foot symptoms. An ABI < 1.0 was regarded as abnormal and suggestive of the presence of PVD. An ABI < 0.7 or > 1.3 was regarded as severely abnormal. Findings for VPT were classified as normal or abnormal. Patients were then followed for 1 year for any overt development of clinical PVD, leg complications, and other vascular complications and for clinical outcome.

Results: The mean age of the patients was 63 ± 9 years, and the ratio of men to women was 1:1.3. An abnormal ABI was seen in 22 patients (37%). The questionnaire detected clinical PVD symptoms in 3 patients. Abnormal ABI and VPT findings were more frequent in diabetic patients. After 12 months of follow-up, patients with an abnormal ABI (and particularly those with a severely abnormal ABI) were more likely to develop leg complications and any type of cardiovascular disease than were patients with a normal ABI. Foot vibration perception had no predictive value on subsequent development of leg complications. When risk factors including age, ABI, and VPT were analyzed by logistic regression, only ABI was a significant independent predictor of subsequent lower-limb vascular complications [odds ratio (OR): 21.0; 95% confidence interval (CI): 2.35 to 187.0; p = 0.00064]. The OR for moderately abnormal ABI was 13.0 (95% CI: 1.015 to 166.3); for severely abnormal ABI, it was 27.4 (95% CI: 2.35 to 187.0, p = 0.0045).

Conclusions: Measurement of ABI by Doppler ultrasound is a useful and effective screening test for PVD in CAPD patients. In this study, VPT was not shown to be predicative of future leg complications, indicating that peripheral neuropathy plays a less important role in the development of such complications. Our results proved that trained renal nurses can play an active role in detecting foot problems in renal patients by ABI measurement.

Thursday, July 9, 2009

Foot Screenings - Saving Limbs, Lives, and Money

Foot ulcers are a common complication of diabetes, and as a result of their condition, diabetics are 15 times more likely to have an amputation of a lower extremity. The American Diabetes Association estimated that more than one-half of amputations could be avoided, which would result in a costs savings of $24,000 to $40,000 for each prevented amputation.

Encompass Network Partners is a new company that has set out to meet the challenge of diabetic foot screenings in dialysis patients. They have developed a Web-based application that aids clinic staff in performing foot checks and connects clinics with a network of foot-care specialists.

The crux of the service is prevention and treating the condition before there is a major issue down the road. "The biggest thing who we found in interviewing and going in and out of clinics was they wanted help for patients who already had black toe or had lost one toe maybe, and they were wanting limbs salvaged," said Clay Bullard, Encompass president. "But secondarily, we found that they don’t do any type of screening ahead of time. It’s kind of one of those elephants in the room that everybody knows is there but nobody wants to talk about."

Encompass recognized that dialysis centers and nephrologists wanted to help their patients, and that vascular physicians knew the patient load existed, said Bullard. So it set out to create a network that could connect the two sides.

The biggest advantage to diabetic foot screening is that it is standardization of care, said Bullard. He added that Encompass also provides an entire network of physicians who specialize in treatment of peripheral vascular disease. "There is a system of email alerts and really what the clinic can do is seamlessly become empowered at the source of treatment, and by that I mean, if they input the data and hit ‘refer’ they can literally know that they have given the patient a better chance of saving their limbs and having better vascular care."

~Article, Renal Business Today, February 2008