Friday, December 31, 2010

CMS issues final rule for dialysis facility quality incentive program

The Centers for Medicare & Medicaid Services issued a final rule for the Quality Incentive Program that will establish performance standards for dialysis facilities and provide payment adjustments to individual End-Stage Renal Disease facilities based on how well they meet these standards.

The final rule establishes the ESRD QIP performance standards, sets out the scoring methodology CMS will use to rate providers quality of dialysis care, and establishes a sliding scale for payment adjustments based on the facilities performance.  CMS will assess each dialysis facility on how well its performance meets the standard for each measure and will calculate each facilities Total Performance Score. The maximum Total Performance Score a facility can achieve is 30 (10 points per measure).  Facilities that do not meet or exceed performance standards will be subject to a payment reduction of up to 2% depending on how far their performance deviates from the standards.

CMS finalized three measures as the initial measure set during the first program year.  Two of these measures are designed to assess whether patients hemoglobin levels are maintained in an acceptable range, while the third measures the effectiveness of the dialysis treatment in removing waste products from patients blood.   
In future years CMS may add quality measures and establish additional performance standards that facilities will need to meet to receive full payment for the services they furnish to Medicare beneficiaries.

Read entire article here

Tuesday, December 28, 2010

Dialysis Data, Once Confidential, Shines Light on Clinic Disparities

For years, the government has collected a rich store of data about the performance of individual dialysis facilities. But it has kept nearly all the information secret from those it might benefit most: Patients.

Now ProPublica has obtained this data under the Freedom of Information Act. We are making a comprehensive set of clinic records publicly available  for the first time on our website.

Patients and others can search for a clinic and see how it compares on 15 key measures, ranging from mortality and hospitalization to transplant rates and infection control. Also on the site are historical reports dating to 2002.

Release of the data is long overdue, patient advocates say.

"It gives you a snapshot of what a clinic is about," said Roberta Wager, a past president of the American Association of Kidney Patients who works as a nurse and patient educator at several dialysis clinics in Texas. "This is your life. Wouldn't you want to have everything in your favor?"

There are almost 400,000 Americans who depend on chronic dialysis to do what their failed kidneys cannot, a number that has grown swiftly over the past two decades, spurred by epidemics of obesity and diabetes.

More than 5,000 facilities have sprung up to provide them with care, stretching into the nation's most rural areas and competing for patients in urban and suburban areas.

Patients today have more choice than ever. Yet most pick centers based on convenience, or on what their doctors suggest, with little notion that even clinics within the same communities can have substantial disparities.

In more than 200 counties nationwide, the data show, the gap between facilities with the best and worst patient survival, adjusted for case-mix differences, is greater than 50 percent. In areas such as Allegheny County, Pa., or Franklin County, Ohio, each with upwards of two dozen clinics, the differences are even more substantial, exceeding 200 percent.

There is also wide variability in how often patients at different clinics are hospitalized for septicemia. Although septicemia cases can be unrelated to dialysis, it is a significant risk for patients, who typically have their blood cleaned of toxins three times a week. Nationally, the rate was about 12 percent a year for 2006 to 2008. But in dozens of counties, the spread between facilities with the highest and lowest rates was more than 25 percentage points.

Read entire article here

Monday, December 6, 2010

New York City to Start Organ Ambulances

Renal Business Todays editor Keith Chartier

New York City will start sending out a second ambulance to scenes in which someone may be in danger of dying in order to quickly harvest organs that can be used for transplant.

The federally funded five-month trial will be limited to Manhattan between 4 pm and midnight to adults between 18 and 60 years old, and to people who die of cardiac arrest outside of a hospital.

The development of the program was fraught with ethical concerns, but those behind it felt that organs needed to be obtained sooner outside the hospital before the organ becomes unusable.

To read entire article on Renal Bizblog, click here

Wednesday, December 1, 2010

Making Sugar Count During The Holidays

American Diabetes Association - If you like sweets, one of the most tempting parts of the holidays is the dessert. Even though you have diabetes, you can still fit sweets into your meal plan.

Eating high-sugar foods like cakes, candy, cookies, and pies will make blood glucose rise, so do not just add them to your diet. Instead, substitute small portions of these sweets for other carbohydrates already in your meal plan. For example, if you want a small serving of pumpkin pie, then pass on eating a dinner roll during the main course.
 To view Desserts During the Holidays, click here

Monday, November 29, 2010

Cost of diabetes could be $3.35 trillion by 2020

The number of Americans diagnosed with diabetes and the related costs of the disease could reach catastrophic proportions, according to new research by the UnitedHealth Group.

The new projections are alarming, as more than 50% of Americans could have prediabetes or diabetes by 2020, which could carry a healthcare price tag of $3.35 trillion over the decade. New estimates show diabetes and prediabetes will account for an estimated 10% of total healthcare spending by the end of the decade at an annual cost of almost $500 billion –– up from an estimated $194 billion this year, UnitedHealth said in its new report, “The United States of Diabetes: Challenges and Opportunities in the Decade Ahead.”
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, UnitedHealth noted.

Read more here

Monday, November 22, 2010

Survey: Most consumers turn to blogs, Facebook for health info

A social media go-to-market strategy is fast becoming a must-have for companies these days, especially those companies operating in the healthcare arena. It’s no longer enough to push patient education out through a branded online page anymore, not with the growing prominence of social media sites. Today, companies need to seed that education across Facebook and Twitter and/or actively engage bloggers and heavy users to successfully get that education out to the masses online.

An Accenture survey released Tuesday found that U.S. consumers seeking medical advice are turning to medical websites, social media sites, online communities and informational websites in far greater numbers than the websites of pharmaceutical companies. According to the survey, of the more than two-thirds (68%) of consumers who go online for health information, slightly more than 1-in-10 regularly turn to a pharmaceutical company’s website to seek information about an illness or medical condition, compared with 92% who more frequently look to other online resources.
That patient traffic helps illustrate the fundamental shift from a predominantly one-way company-to-patient dialogue to enabling a patient-to-patient — and even a patient-to-healthcare-professional dialogue — through the evolution of social networks and online communities.
“Pharmaceutical companies that embrace innovations, such as social networking and communications via mobile devices, and integrate and align their communication strategy across multiple channels will be positioned to have a much greater influence on their patients’ choices and, consequently, realize significant increases in revenue, profitability and sustained competitive advantage,” stated Tom Schwenger, global managing director for Accenture’s Life Sciences Sales and Marketing practice.

Read more here

Tuesday, November 9, 2010

Dialysis: An Experiment In Universal Health Care

Every year, more than 100,000 Americans start dialysis treatment, a form of chronic care given to people with failing kidneys. And for many, the cost is completely free. Since 1972, when Congress granted comprehensive coverage under Medicare to any patient diagnosed with kidney failure, both dialysis and kidney transplants have been covered for all renal patients.

But a new joint investigation between The Atlantic and ProPublica found many problems with dialysis in the U.S.: The cost of treatment is among the world's highest, while the U.S. mortality rate for dialysis patients is one of the world's worst. One in four patients will die within 12 months of starting treatment.

Investigative reporter Robin Fields, who spent the past year reviewing thousands of documents and interviewing more than 100 patients, doctors, policymakers and experts, found systematic failures in the way dialysis centers are set up in the United States.

"At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care," she writes in a piece that will be published in the December issue of The Atlantic. "Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. [And] the government withholds critical data about clinics' performance from patients, the very people who need it most."

Read more on A Growing Industry

Thursday, November 4, 2010

Advocating for Patients with Diabetic Nephropathy

Although no cure exists, pharmacologic and nonpharmacologic measures can help patients prevent onset or progression of diabetic nephropathy to preserve kidney function.

Diabetes is the seventh-leading cause of death in the United States and the primary cause of end-stage renal disease. Diabetic nephropathy is a longterm consequence of diabetes, estimated to affect 20% to 40% of patients with diabetes. Although there is no cure for diabetic nephropathy, by understanding the pathophysiology, preventative strategies, and interventions to slow the progression of this disease, the pharmacist can be better prepared to advocate for kidney function preservation.

Although the exact cause of diabetic nephropathy is unknown, several mechanisms have been hypothesized. Hyperglycemia, the formation of advanced glycosylation products, activation of the renin-angiotensin- aldosterone system, and activation of cytokines are all thought to be contributing factors to the progression of disease.

Hyperglycemia appears to cause expansion and injury of the glomerular basement membrane of the kidneys by increasing the renal mesangial cell glucose concentration. Initially, the glomerular mesangium expands by cell proliferation and later by cell hypertrophy. Transforming growth factor beta (TGF-beta) is particularly important in causing the expansion and later fibrosis by stimulating the production of both collagen and fibronectin. Other cytokines that are present in the kidney are also under investigation for their role in diabetic nephropathy.

Advanced glycosylation products are formed as glucose binds reversibly—and eventually irreversibly—to proteins in the kidneys. The glycosylation products can eventually form complex cross-links over time as the hyperglycemia continues and can contribute to renal damage by stimulation of growth and fibrotic factors.

In diabetic nephropathy, the local renin-angiotensin system is activated. Angiotensin II is stimulated and results in constriction of the efferent arteriole of the glomerulus, which results in increased glomerular capillary pressures. Angiotensin II also stimulates renal mesangium expansion and fibrosis through activation of angiotensin II type 1 receptors, and increases the expression of TGF-beta and other growth factors.

Microalbuminuria (30-300 mg/L) may contribute to renal injury associated with diabetic nephropathy. An increase in glomerular permeability causes plasma proteins such as albumin to be secreted into the urine. A portion of these proteins is absorbed by the proximal tubular cells, which can trigger an inflammatory response that contributes to kidney damage. Macroalbuminuria (>300 mg/L), nephrotic syndrome, and eventually renal failure may occur during the later stages of diabetic nephropathy.

Read entire article at Pharmacy Times

Monday, November 1, 2010

Most diabetics do not change oral health habits after diagnosis

Many active diabetes managers have not changed their oral care habits since being diagnosed, despite the fact they are at higher risk for developing serious complications from poor oral hygiene, according to a study by dLife, a multimedia network serving the diabetes community, and market research firm SoundView Research.

Furthermore, more than half of active diabetes managers surveyed had not been advised by their dentists to take extra care to brush, floss or rinse daily.
"The results of this study show the gulf that exists between perceptions and the connections between diabetes and oral health. Your dental health absolutely affects the control of your diabetes," stated Charles Martin, a dentist, author and founder of "Inflammation in the mouth coming from gum disease spreads to the whole body. This inflammation increases insulin resistance, cholesterol levels and C-reactive protein levels. So, uncontrolled oral disease can be the hidden factor working against those trying to maintain good control over their diabetes."

Click here to read entire article

Sunday, October 31, 2010

Kidney Transplant Numbers Increase for Elderly Patients

Elderly patients with kidney failure get kidney transplants more often than they did a decade ago, according to a study appearing in an upcoming issue of the Clinical Journal of the American Society of Nephrology (CJASN). The results suggest that the chances of receiving a kidney transplant are better than ever for an older patient who needs one.

Kidney failure afflicts nearly half a million individuals in the United States, and 48% of sufferers are 60 years of age or older. Kidney disease patients who obtain a transplant live longer than those that remain on dialysis. Fortunately, living and deceased organ donations are on the rise; however, transplant waiting lists have become increasingly long as more and more people develop kidney dysfunction.

Elke Schaeffner, MD (Charité University Medicine, in Berlin, Germany), along with Caren Rose and John Gill, MD (St. Paul's Hospital, University of British Columbia, in Vancouver, Canada) examined whether elderly patients with kidney failure have better or worse access to transplants now than they did in the past. The study included patients with kidney failure in the United States aged 60 to 75 years listed in the United States Renal Data System between 1995 and 2006.

The study revealed that elderly patients rarely receive a transplant, but they were twice as likely to get one in 2006 as in 1995. (In 2006, they had a 7.3% likelihood of getting a transplant within three years of their first treatment for kidney failure.) Elderly patients now benefit from greater access to organs from living donors and older deceased donors compared to a decade ago. They also die less frequently while waiting for a kidney than they did in the past.

To read entire article click here

Monday, October 25, 2010

Diabetes prevalence among Americans may increase to 33%

The rate of diabetes among Americans is on an upswing and likely will reach epic proportions by 2050, costing the government millions.

A new study by the Centers for Disease Control and Prevention and published in Population Health Metrics found that annual diagnosed diabetes incidence (new cases) will increase from about eight cases per 1,000 people in 2008 to about 15 in 2050. The authors also projected that — assuming low incidence and relatively high diabetes mortality — total diabetes prevalence (diagnosed and undiagnosed cases) is projected to increase from 14% in 2010 to 21% of the U.S. adult population by 2050, but noted that  if recent increases in diabetes incidence continue and diabetes mortality is relatively low, prevalence will increase to 33% by 2050.

Read entire article here

Tuesday, October 12, 2010

History of diabetes treatment chronicled in New York Historical Society exhibition

Recalling the desperate fight for life that once was waged by juvenile diabetes patients and commemorating the events of the 1921 discovery by Toronto physician Frederick Banting that inaugurated a new era of hope for them and their families, the New York Historical Society will present the exhibition "Breakthrough: The Dramatic Story of the Discovery of Insulin" from October 5, 2010 through January 31, 2011.

Highlighting the roles of science, government, higher education, and industry in the development and distribution of a life-saving drug, the exhibition will bring to life the personalities who discovered insulin and raced to bring it to the world, and will tell the story of one extraordinary girl — Elizabeth Evans Hughes, daughter of statesman and Supreme Court Justice Charles Evans Hughes — who was among the very first patients to be saved.

"This is a powerful story that deals with type 1 diabetes and the discovery of insulin in that very early period. You can imagine the number of desperate people all over the world who wanted [an effective treatment]," said Stephen Edidin, chief curator of the Society's Museum Division. 

Read entire article here

Gestational diabetes test may predict Type 2 diabetes among women

A new Tel Aviv University study found a test used to diagnose gestational diabetes in women could be a key indicator to diagnosing Type 2 diabetes.

The study -- led by Gabriel Chodick of Tel Aviv University's department of epidemiology and preventive medicine at the Sackler faculty of medicine -- found that women who "failed" the glucose challenge test, a series of four blood tests conducted over a single four-hour period, have a higher chance of developing adult onset diabetes later in life. Chodick and colleagues collected data on more than 185,000 women in Israel who took the glucose challenge test, then acquired information from the nation's health registry as to what percentage of these women contracted diabetes later in life.

Read more here

Friday, October 8, 2010

Diabetes and Kidney Disease

Diabetes mellitus, usually called diabetes, is a disease in which your body does not make enough insulin or cannot use normal amounts of insulin properly. Insulin is a hormone that regulates the amount of sugar in your blood. A high blood sugar level can cause problems in many parts of your body.

Are there different types of diabetes?

The most common ones are Type 1 and Type 2. Type 1 diabetes usually occurs in children. It is also called juvenile onset diabetes mellitus or insulin-dependent diabetes mellitus. In this type, your pancreas does not make enough insulin and you have to take insulin injections for the rest of your life.

Type 2 diabetes, which is more common, usually occurs in people over 40 and is called adult onset diabetes mellitus. It is also called non insulin-dependent diabetes mellitus. In Type 2, your pancreas makes insulin, but your body does not use it properly. The high blood sugar level often can be controlled by following a diet and/or taking medication, although some patients must take insulin. Type 2 diabetes is particularly prevalent among African Americans, American Indians, Latin Americans and Asian Americans.

Read entire article here

Monday, October 4, 2010

Air pollution may be linked to diabetes, study finds

Diabetes could partially be related to air pollution, according to a new study.

The study, conducted by researchers at Children’s Hospital Boston and published in this month’s issue of the journal Diabetes Care, found that diabetes in adults was consistently correlated with particulate air pollution even after adjusting for known risk factors, such as obesity and ethnicity.
The researchers based the study on fine particulates of between 0.1 and 2.5 nanometers, known as PM2.5, a component of haze, smoke and car exhaust, obtaining county-by-county data from the Environmental Protection Agency for 2004 and 2005. They then combined that data with diabetes data from the Centers for Disease Control and Prevention and the Census Bureau to find the prevalence of adult diabetes and adjust for such risk factors as obesity, exercise, geography, ethnicity and population density.

Read entire article here

Tuesday, September 28, 2010

5 Reasons That May Explain Why Type 1 Diabetes Is on the Rise

Type 1 diabetes rates are increasing in children. Here are possible reasons why...

It's no secret that type 1 diabetes is on the rise in children. If current trends continue, new cases in kids younger than 5 could double by 2020, according to a study published last year in The Lancet. What's up for debate are the reasons for this increase. Is it environmental? Genetic? Something preventable? Scientists aren't sure just yet, but a book published in January, called Diabetes Rising: How a Rare Disease Became a Modern Pandemic, and What to Do About It (Kaplan Publishing), by freelance medical journalist Dan Hurley, explores the possibilities.

"Type 1 diabetes seems to be going up at a level of 3 percent a year in the United States," says Hurley, himself a longtime type 1 diabetes sufferer. "If we can find out what is causing that, we can prevent a lot of people from getting it." Clearly, he says, there is something going on in the environment—in the way people live—that is partly responsible. U.S. News asked Hurley, of Montclair, N.J., to discuss the leading theories scientists have for explaining why more kids are falling prey to type 1 diabetes and why more are expected to in the future. Below are 5 hypotheses he includes in the book. All of them presume that the person has some genetic tendency towards developing type 1 diabetes, Hurley says. "Think of these things—growth, sunlight, cow's milk in infancy, etc.—as fertilizers. With them, the underlying genetic risk is boosted."

Read entire article here

Monday, September 27, 2010

Price Chopper expands Diabetes AdvantEdge program with free offerings

Insulin-dependent diabetics will be eligible to receive free syringes and pen needles from Price Chopper, the Northeast supermarket chain said.

Price Chopper said the expansion of its Diabetes AdvantEdge program meant that it could serve 100% of the population that manages diabetes with increased access to medication, supplies, support and information, as well as education on food, nutrition and diabetes management.

Read more here

Friday, September 24, 2010

National Limb Loss Information Center - Fact Sheet

In the United States, there are approximately 1.7 million people living with limb loss. It is estimated that one out of every 200 people in the U.S. has had an amputation.

Each year, the majority of new amputations occur due to complications of the vascular system (of or pertaining to the blood vessels), especially from diabetes. These types of amputations are known as dysvascular. Although rates of cancer and trauma-related amputations are decreasing, rates for dysvascular amputations are on the rise. Incidence of congenital (present at birth) limb difference has seen little or no change.

Incidence data represents the occurrence or number of people who become an amputee each year. This fact sheet represents this type of data. Prevalence data represents the total estimated number of people living with limb loss, both new cases of amputation and those living with the limb loss for many years. 

To view recent trends and read the entire article, click here

Wednesday, September 22, 2010

Peripheral Arterial Disease/ABI Screening

Peripheral arterial disease (PAD) is more commonly known as hardening of the arteries. Peripheral arterial disease screening is done by using the ankle-brachial index (ABI). This ABI screening is painless, quick, and non-invasive. It will identify most cases of peripheral arterial disease.

What you can learn

The ankle-brachial index measures the ratio between the pressure in your arms and that in your legs. This ratio indicates how well blood flows to the legs. A ratio of less than 0.90 indicates plaque buildup and possible peripheral arterial disease. A ratio of 0.90 or greater is considered normal.

The ABI screening is simple and painless. After removing your socks and shoes, you will have pressure cuffs placed around your upper arms and ankles. A small ultrasound device will then measure the systolic blood pressures in your limbs.

Read more

Tuesday, September 21, 2010

The Ischemic Foot

The term "ischemic foot" refers to a lack of adequate arterial blood flow from the heart to the foot. There are a wide variety of possible causes for poor arterial circulation into the foot including arterial blockage from cholesterol deposits, arterial blood clots, arterial spasm, or arterial injury. The ischemic foot is also referred to as having arterial insufficiency, meaning there is not enough blood reaching the foot to provide the oxygen and nutrient needs required for the cells to continue to function.
The result of insufficient blood supply to the foot can manifest itself in a variety of ways depending upon how severe the impairment to circulation. Early symptoms may include cold feet, purple or red discoloration of the toes, or muscle cramping after walking short distances (intermittent claudication). Later findings may include a sore that won't heal (ischemic ulcer), pain at night while resting in bed, or tissue death to part of the foot (gangrene).
The diagnosis of ischemia is made by reviewing the patient's symptoms, examination of the foot, and special testing to evaluate the circulation. The examination should reveal cold skin temperature, and skin atrophy that causes the skin to appear shiny or paper thin with loss of normal hair on tops of the toes and on the lower leg. There is often a color change associated with ischemic feet. This may show as a purple discoloration of the toes, white blanching of the toes when the foot is elevated, and red discoloration when the foot is hanging down. Additionally the two arterial pulses in the foot will not be as strong as normal, or may be entirely absent. Certainly the presence of a pale looking ulcer, or black gangrenous toes would be an ominous sign of poor circulation.

Learn more about The Ischemic Foot here

Monday, September 20, 2010

What is P.A.D.?

P.A.D. is short for Peripheral Arterial Disease. People have P.A.D. when the arteries in their legs become narrowed or clogged with fatty deposits, or plaque. The buildup of plaque causes the arteries to harden and narrow, which is called atherosclerosis. When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced. Some people call this poor circulation.

P.A.D. occurs most often in the arteries in the legs, but it also can affect other arteries that carry blood outside the heart. This includes arteries that go to the aorta, the brain, the arms, the kidneys and the stomach. When arteries inside the heart are hardened or narrowed, it is called coronary artery disease or cardiovascular disease.

The good news is that like other diseases related to the arteries, P.A.D. can be treated by making lifestyle changes, by taking medicines, or by having endovascular or surgical procedures, if needed.

Is P.A.D. serious?  Read more here

American Diabetes Association teams up with HearPO

A national strategic partnership between the American Diabetes Association and HearPO will provide additional resources to educate people with diabetes, medical practitioners and the general public about the connection between diabetes and hearing loss.

Read more here

Saturday, September 18, 2010

Green Leafy Vegetables Can Cut Risk of Diabetes

Eating more green leafy vegetables can significantly cut the risk of developing diabetes, British scientists have confirmed. The researchers reviewed six earlier studies on links between diabetes and the consumption of fruits and vegetables and found eating an extra serving a day of vegetables like spinach, cabbage, and broccoli reduced adults’ risk of getting type 2 diabetes by 14 percent. The findings don’t prove that the veggies themselves prevent type 2 diabetes which is often linked to poor diet and lack of exercise and is reaching epidemic levels as obesity rates rise.

People who eat more green leafy vegetables may also have a healthier diet overall, exercise more, or may be better off financially and any of those factors could affect how likely they are to get diabetes. But, "the data suggest that green leafy vegetables are key," said researcher Patrice Carter of the diabetes research unit at Leicester University. The review, published in the British Medical Journal, looked at six studies, which covered more than 200,000 people between 30 and 74 years old, in the United States, China and Finland. "Fruit and vegetables are all good, but the data significantly show that green leafy vegetables are particularly interesting, so further investigation is warranted," Carter said in a telephone interview. Green leafy vegetables contain antioxidants, magnesium and omega 3 fatty acids – all of which have been shown to have health benefits, she added. Each of the studies that Carter and her colleagues analyzed followed a group of adults over periods of 4-and-a-half to 23 years, recording how many servings of fruits and vegetables each participant ate on a daily basis then examining who was diagnosed with type 2 diabetes.

Read entire article here

Friday, September 17, 2010

Symptoms and Diagnosis of PAD

The most common symptom of PAD is a painful muscle cramping in the hips, thighs or calves when walking, climbing stairs or exercising.

The pain of PAD usually goes away when you stop exercising, although this may take a few minutes. Working muscles need more blood flow. Resting muscles can get by with less. If there's a blood-flow blockage due to plaque buildup, the muscles won't get enough blood during exercise to meet the needs. The "crampy" pain (called "intermittent claudication"), when caused by PAD, is the muscles' way of warning the body that it isn't receiving enough blood during exercise to meet the increased demand.

Many people with PAD have no symptoms or mistake their symptoms for something else.

To see the symptoms of severe PAD, click here

Monday, September 13, 2010

Are the days of kidney dialysis numbered?

There's no gentle way to put it. Chronic kidney failure is ugly and often deadly, and more people in the States are suffering from it every year, with increasing rates of diabetes and hypertension contributing to the problem.

What's more, the treatment that keeps many waiting for kidney transplants alive--dialysis--involves several sessions per week, at several hours per session, during which blood pumps through an external circuit for filtration to replace just 13 percent of kidney function, leaving many patients exhausted both physically and financially.

View entire article here

Friday, September 10, 2010

Study Finds Differences in Care for Patients Beginning on Dialysis

A study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN)says that kidney disease patients
insured by some federally sponsored national health care organizations are more likely to undergo an important predialysis procedure than patients with other types of insurance.

The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

To read entire article, click here

Monday, September 6, 2010

Daily Hemodialysis Improves Depression and Recovery Time

Hemodialysis patients who transitioned from in-center to daily home dialysis regimens experienced significant improvements in depressive symptoms and post-dialysis recovery times, according to a new report published today in the American Journal of Kidney Diseases, the official journal of the National Kidney Foundation.

Patients who made the switch from the normal, thrice weekly in-center treatment regimen to a daily schedule, defined as six times per week, reported more than a 30% decline in depressive symptoms and an 87% drop in post-dialysis recovery time over a 12 month period.

The research team assessed 128 patients making the treatment regimen switch. Patients were assessed upon enrollment and then again four months and 12 months afterward. The average training period to complete the transition was 27 days.

Click here to read entire article

Monday, August 30, 2010

Dialysis 101


Dialysis is a treatment that performs the functions of natural kidneys when the they fail (kidney failure). Most patients begin dialysis when their kidneys have lost 85%-90% of their ability to function, and will continue dialysis for the rest of their lives (or until they receive a kidney transplant). This is called end-stage renal disease (ESRD).

ESRD may be caused by a variety of conditions that can impair kidney function, including diabetes, kidney cancer, drug use, high blood pressure, or other kidney problems. Dialysis is not a cure for ESRD, but helps you feel better and live longer.

There are two types of dialysis:

* Hemodialysis
* Peritoneal dialysis

Parts of the Body Involved

Hemodialysis—veins in the arm, leg, or neck

Peritoneal dialysis—abdomen
Reasons for Procedure

The purpose of dialysis is to help keep the body's chemicals in balance, which the kidneys do when they are healthy. The main functions of dialysis are to:

* Remove waste and excess fluid from the blood to prevent build-up
* Control blood pressure
* Keep a safe level of chemicals in the body, such as potassium, sodium, and chloride

Dialysis may also be done to quickly remove toxins from the bloodstream, in cases of poisoning or drug overdose.

To read more, click on: Dialysis/Lifescript

Type 2 diabetes may have links to Alzheimer’s, study reveals

Those with Type 2 diabetes may be at greater risk of developing the brain plaques associated with Alzheimer’s disease, new research suggested.

According to a Japanese study, which appeared in the Aug. 25 online issue of the journal Neurology, those individuals with the highest levels of insulin resistance had nearly six times the odds of developing plaque deposits between the nerves in the brain, after adjusting for other risk factors, compared with those with the lowest levels of fasting insulin.

To read entire article, click here

Monday, August 23, 2010

JDRF wants Denver residents to be 'T1D Aware'

The Juvenile Diabetes Research Foundation launched an awareness campaign in the Denver area to shed light on key signs of Type 1 diabetes.

To view complete article, click here

Friday, August 20, 2010

Diabetes-related hospitalizations on the rise

Nearly 1-in-5 hospitalizations in 2008 were related to diabetes, according to a recent report by the Agency for Healthcare Research and Quality.

That means a total of more than 7.7 million hospital stays and $83 million in hospital costs, of which Medicare covered 60%, the report found. On average, diabetes patients paid $10,937 for hospitalization, while those without the disease paid $8,746.

To read the entire article, click here.

Thursday, August 19, 2010

Fistula Placement More Likely with Federal Insurance Programs

Kidney disease patients insured by some federally sponsored national healthcare organizations are more likely to receive a fistula for vascular access during dialysis than patients with other types of insurance, according to a study appearing online Aug. 12 in the Journal of the American Society Nephrology (JASN).

The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis, according to the study’s authors.

Experts recommend creating an arteriovenous fistula (AVF), to connect a vein and artery and allow access to the vascular system during dialysis. An AVF provides a long-lasting site through which blood can be removed and returned during the dialysis procedure, which patients must undergo three to four times per week.

To view entire article, click here

Monday, August 16, 2010

As diabetes rates grow, R&D pipelines flow

Research and development pipelines are flowing with a record number of drugs for treating diabetes and related conditions, according to a report from the Pharmaceutical Research and Manufacturers of America released in late May, which showed 235 medicines in development to treat the disease.

According to the American Diabetes Association, 24 million Americans are living with diabetes, up from 21 million in 2005. The most rapidly growing incidence of the disease, Type 2, has increased along with the incidence of obesity in the United States.

To read the entire article, click here.

Tuesday, August 10, 2010

Many diabetic foot amputations are preventable

It costs $1,400 to cover the oozing sore on the diabetic's foot with a piece of artificial skin, helping it heal if patients keep pressure off that spot. So when Medicare paid for the treatment but not the extra $100 for a simple walking cast to protect it, an artificial skin maker last year started giving free casts to some needy patients.

Without the right cushioning, "the person will walk to the bus stop and destroy it," fumes Dr. David G. Armstrong of the Southern Arizona Limb Salvage Alliance.

To read the complete story, click here.

Monday, June 28, 2010

Diabetes an independent risk factor for vascular disease

New data suggest that although diabetes doubles the risk of vascular disease, elevated fasting glucose has little effect on the risk of coronary heart disease (CHD) or major ischemic events. The results of a meta-analysis of 1.2 million patients in 120 randomized, controlled trials were presented Saturday morning at a special symposium cosponsored by ADA and The Lancet, which published the study in their June 26 issue.
“We’ve known for decades that diabetes is a risk for vascular disease,” said lead author Nadeem Sarwar, PhD, University of Cambridge, United Kingdom. “But how the risk varies by age, sex, and levels of other risk factors remains unknown.”
Sarwar represented the Emerging Risk Factors Collaboration, which designed and conducted the study. The collaboration represents more than 12 million person-years of risk, he said, with a mean follow-up of 10 years.
Analysis of contributed studies showed that diabetes roughly doubles the risk of cardiovascular events regardless of other factors. Having diabetes increases the risk of coronary death by 2.31 times and increases the risk of a nonfatal myocardial infarction (MI) by 1.82 times.
The presence of diabetes also increases the risk for ischemic stroke by 2.27 times, for hemorrhagic stroke by 1.56 times, and for other vascular deaths by 1.73 times.
Overall, the hazard ratios (HRs) for CHD were higher for women than for men and higher in younger (40-59 years) patients than in those 70 years old and older. The HRs were also higher for fatal events compared with nonfatal MIs.
Why diabetes produces a greater risk in groups that would be expected to be at lower risk is not clear, Sarwar said. Diabetes may be associated with more severe vascular lesions, but further study is needed.
“We did not see a linear relationship between fasting glucose and cardiovascular disease,” Sarwar continued. “The risk is essentially flat for serum glucose between 3.9% and 5.6%, then increases sharply.”
The analysis suggests that diabetes is responsible for about 10% of all vascular deaths, roughly 325,000 people annually in the developed world.
“Diabetes doubles the risk for vascular diseases independent of other factors,” Sarwar concluded. “In people who do not have diabetes, fasting glucose is not a useful predictor of vascular disease.”
~ Drug Topics ~

Sunday, June 27, 2010

Diabetes exposure in utero increases risk of early ESRD

Being exposed to diabetes in utero substantially increases the risk of premature end-stage renal disease (ESRD), found Robert G Nelson, MD (left).
The finding comes from a study of Pima Indians 5 to 44 years old with type 2 diabetes, 102 of whom were the offspring of diabetic mothers and 1,748 without diabetes exposure in utero.
“Pima Indians have the highest rate of type 2 diabetes in the world. We’ve been studying the population since 1965, so we have extensive longitudinal data that allows us to look not only at disease in the parents, but in the offspring, and follow them into adulthood,” said Nelson.
An earlier study by Nelson and colleagues showed that exposure to diabetes in utero caused a dramatic increase in the development of diabetes in youth. About one-third of cases of diabetes in young adulthood are attributable to diabetes exposure in utero, he said.
Genetic susceptibility from the mother can partially explain the early onset of diabetes in the offspring, Nelson said. Intrauterine exposure also is associated with higher birth weight and higher weight in childhood and adolescence compared with persons without such exposure.
In the current study, the participants were followed for a maximum of 40 years, from their onset of diabetes until either death, onset of ESRD, or age 45 years.
Fifty-seven of the participants who were exposed to diabetes in utero developed ESRD before age 45, which was 4 times the rate of ESRD compared with controls who were not exposed to diabetes in utero.
Twenty percent of ESRD that occurs in the population before age 45 is attributable to exposure to diabetes in utero,” said Nelson. Assuming this relationship is causal, “if you delayed the development of diabetes until after the onset of childbearing years, you would reduce the incidence of diabetic ESRD by about 20%,” he said.
If the offspring are exposed to diabetes in utero, diabetes prevention efforts in the form of lifestyle modifications (diet and exercise) are needed to slow or prevent the development of diabetes and its complications, Nelson said.
~ Drug Topics ~

Monday, June 14, 2010

Diabetes-related leg amputations could be prevented and need not be costly: IDF

Published: Apr 12, 2010 17:28

Of more than one million lower extremity amputations performed each year worldwide, 70 percent happen to people with diabetes. In India alone, almost 40,000 legs are amputated every year as a consequence of diabetes.

These figures were mentioned by Prof. Jean Claude Mbanya, president of International Diabetes Federation (IDF), in his message to the mid-term continuing medical education (CME) meeting on "high-risk diabetic foot" organized by the Association of Surgeons of India (ASI), UP Chapter and Indian Podiatry Association (IPA) in Kanpur last Sunday.

Mbanya's message, which was also handed out to the media, said the latest data from the IDF indicates that “diabetes affects 285 million people around the world, and is increasingly on the rise.”

“Of the many serious complications that can affect individuals with diabetes, it is the complications of the foot that take the greatest toll," Mbanya said.

On a positive note, he said, amputations could be prevented and need not be expensive.

"Many of these amputations can be prevented. Better education and improved management of foot care can be performed at relatively low costs and have been shown to reduce the number of lower extremity amputations by 50-85%," he said.

And this can be done through a concerted effort involving members of the global diabetes community to increase awareness in levels of health care services worldwide, Mbanya said.

"It is time to reduce the unnecessary suffering that foot complications can bring. With relatively low investment, it is possible to advance education and prevention that will result in lower rates of amputation, and better quality of life for people with diabetes. The time to act is now!" he said.

Mbanya is a professor of medicine and endocrinology at the University of Yaoundé I in Cameroon. He is also the director of the National Obesity Centre University of Yaounde, Cameroon, and chief of the Endocrinology and Metabolic Diseases Unit of Hospital Central in Yaoundé

Tuesday, May 11, 2010

The Diabetic Foot in End Stage Renal Disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5–10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies—neuropathy, ischemia, and infection—are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.
~ ~

Tuesday, May 4, 2010

Prevent diabetes problems: Keep your feet and skin healthy

What are diabetes problems?

Too much glucose in the blood for a long time can cause diabetes problems. This high blood glucose, also called blood sugar, can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. Heart and blood vessel disease can lead to heart attacks and strokes. You can do a lot to prevent or slow down diabetes problems.

This information is about feet and skin problems caused by diabetes. You will learn the things you can do each day and during each year to stay healthy and prevent diabetes problems.

How can diabetes hurt my feet?

High blood glucose from diabetes causes two problems that can hurt your feet:

* Nerve damage. One problem is damage to nerves in your legs and feet. With damaged nerves, you might not feel pain, heat, or cold in your legs and feet. A sore or cut on your foot may get worse because you do not know it is there. This lack of feeling is caused by nerve damage, also called diabetic neuropathy. Nerve damage can lead to a sore or an infection.
* Poor blood flow. The second problem happens when not enough blood flows to your legs and feet. Poor blood flow makes it hard for a sore or infection to heal. This problem is called peripheral vascular disease, also called PVD.

Smoking when you have diabetes makes blood flow problems much worse. For example, you get a blister from shoes that do not fit. You do not feel the pain from the blister because you have nerve damage in your foot. Next, the blister gets infected. If blood glucose is high, the extra glucose feeds the germs. Germs grow and the infection gets worse. Poor blood flow to your legs and feet can slow down healing. Once in a while a bad infection never heals. The infection might cause gangrene. If a person has gangrene, the skin and tissue around the sore die. The area becomes black and smelly.

To keep gangrene from spreading, a doctor may have to do surgery to cut off a toe, foot, or part of a leg. Cutting off a body part is called an amputation.

What can I do to take care of my feet?

Wash your feet in warm water every day. Make sure the water is not too hot by testing the temperature with your elbow. Do not soak your feet. Dry your feet well, especially between your toes.

Look at your feet every day to check for cuts, sores, blisters, redness, calluses, or other problems. Checking every day is even more important if you have nerve damage or poor blood flow. If you cannot bend over or pull your feet up to check them, use a mirror. If you cannot see well, ask someone else to check your feet.

If your skin is dry, rub lotion on your feet after you wash and dry them. Do not put lotion between your toes.

File corns and calluses gently with an emery board or pumice stone. Do this after your bath or shower. ~ NDIC ~

Wednesday, April 28, 2010

Foot Complications

People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications. Foot problems most often happen when there is nerve damage, also called neuropathy, which results in loss of feeling in your feet. Poor blood flow or changes in the shape of your feet or toes may also cause problems.

Although it can hurt, diabetic nerve damage can also lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You could get a blister and not feel it. You might not notice a foot injury until the skin breaks down and becomes infected.

Nerve damage can also lead to changes in the shape of your feet and toes. Ask your health care provider about special therapeutic shoes, rather than forcing deformed feet and toes into regular shoes.
Skin Changes

Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control the oil and moisture in your foot no longer work.

After bathing, dry your feet and seal in the remaining moisture with a thin coat of plain petroleum jelly, an unscented hand cream, or other such products.

Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, don't soak your feet — that can dry your skin.

Calluses occur more often and build up faster on the feet of people with diabetes. This is because there are high-pressure areas under the foot. Too much callus may mean that you will need therapeutic shoes and inserts.

Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself - this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.
Foot Ulcers

Ulcers occur most often on the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting ulcers can result in infections, which in turn can lead to loss of a limb.

What your health care provider will do varies with your ulcer. Your health care provider may take x-rays of your foot to make sure the bone is not infected. The health care provider may clean out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider may culture the wound to find out what type of infection you have, and which antibiotic will work best.

Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special shoe, brace, or cast on your foot to protect it.

If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon. Good diabetes control is important. High blood glucose levels make it hard to fight infecton.

After the foot ulcer heals, treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from returning.
Poor Circulation

Poor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don't smoke; smoking makes arteries harden faster. Also, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.

If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. Work with your health care provider to get started on a walking program. Some people can be helped with medication to improve circulation.

Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes, but don't walk when you have open sores.

People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation. Most amputations are preventable with regular care and proper footware.

For these reasons, take good care of your feet and see your health care provider right away about foot problems. Ask about prescription shoes that are covered by Medicare and other insurance. Always follow your health care provider's advice when caring for ulcers or other foot problems.

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

~ American Diabetes Association ~

Tuesday, April 6, 2010

Foot Screenings...How important are they?

There are no screening protocols in hemodialysis centers to identify the problem earlier on. As a result preventive strategies to reduce morbidity and mortality related to this issue remains unaddressed. The magnitude of this problem is unrealized until you add to the equation that majority of hemodilaysis patients are diabetics as well. As a result there remains a significant issue of lower extremity amputations in hemodialysis patients. Overall 40% of patients in United States starting chronic dialysis count diabetes mellitus as the primary cause of renal failure, making it the number one cause of CKD (Berman et al, 2001). Patients with diabetes and chronic renal disease frequently present with a combination of the devastations of diabetes including: nephropathy, retinopathy, and vasculopathy. The main focus of the care of these patients has been on the target organs like heart and kidneys. Therefore, early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation--a failure for both the patient and physician. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. However, of all the long-term complications of diabetes, foot complications may be the most preventable. In the United States, diabetes is the cause of 50% of nontraumatic lower extremity amputations and is increasing annually (Levin, 2002). The prevalence of lower extremity amputation for patients with diabetes and CKD is much greater than those without CKD. The rate of lower limb amputation for the population at large increased during a recent 4-year period from 4.8 to 6.2 /100 persons. During the same time frame, this rate of lower extremity amputation rose from 11.8 to 13.8/100 among persons with CKD attributed to diabetic nephropathy. The rate for patients with diabetes and CKD was 10 times greater than the diabetic population at large (Eggers, Gohdes, & Pugh et al, 1999). The cost of treating patients with diabetes is astronomical both financially and in terms of quality of life. The loss of a lower extremity or even part of a lower extremity greatly impacts quality of life.

by Zahid Ahmad, M.D.
University of Oklahoma
Asst. Professor of Medicine – Interventional Nephrology
Section of Nephrology & Hypertention

Thursday, April 1, 2010

Amputation and diabetes: How to protect your feet

Foot care is especially important if you have diabetes. Diabetes can impair blood flow to your feet and cause nerve damage. Without proper attention and care, a small injury can develop into an open sore (ulcer) that can be difficult to treat. Sometimes amputation is necessary if an infection severely damages the tissue and bone.

The good news is that with proper diabetes management and careful foot care, amputation may be preventable. Here's what you need to know about the link between amputation and diabetes — and how to keep your feet healthy.
Why does diabetes pose a risk of amputation?

Diabetes can cause two potentially dangerous threats to your feet.

* Nerve damage (diabetic neuropathy). When the network of nerves in your feet is damaged the sensation of pain in your feet is reduced. Because of this, you can develop a blister or cut your foot without realizing it.
* Reduced blood flow. Diabetes can also narrow your arteries, reducing blood flow to your feet. With less blood to nourish tissues in your feet, it's harder for sores to heal. An unnoticed cut or sore hidden beneath your socks and shoes can quickly develop into a larger problem.

Left untreated, a minor foot injury could become a serious infection — even leading to tissue death (gangrene). Severe damage might require toe, foot or even leg amputation.

~ ~

Thursday, March 18, 2010

Preventing amputations in patients with diabetes and chronic kidney disease

Foot lesions are the single most frequently mismanaged problem of patients with diabetes mellitus and chronic kidney disease (CKD). Foot problems are often viewed as a minor problem, yet frequently impact patient survival (Schomig, Ritz, Standl, & Allenberg, 2000). Recommendations for improving the survival of patients with diabetes and CKD include improvement in the foot care and education of both patients and nephrology health care providers regarding diabetic foot complications (Ritz, Koch, Fliser, & Schwenger, 1999).

Over 40% of patients in United States starting chronic dialysis count diabetes mellitus as the primary cause of renal failure, making it the number one cause of CKD (Berman, 2001). Patients with diabetes and chronic renal disease frequently present with a combination of the devastations of diabetes including: nephropathy, retinopathy, and vasculopathy. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. The main focus of the care of this patient has been on the target organs of the heart and kidneys. Therefore, early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation--a failure for both the patient and clinician. However, of all the long-term complications of diabetes, foot complications may be the most preventable.

In the United States, diabetes is the cause of 50% of nontraumatic lower extremity amputations and is increasing annually (Levin, 2002). The cost of treating patients with diabetes is astronomical both financially and in terms of quality of life. The loss of a lower extremity or even part of a lower extremity greatly impacts quality of life. Depression is common after amputation. Leisure activities as well as employment status are altered. The mortality rate after amputation in patients with diabetes is 11%-41% at 1 year, 20%-50% at 3 years, and 39%-68% at 5 years (Fritschi, 2001).

~ BNET ~

Wednesday, March 17, 2010

Foot Care

Inspect your feet every day, and seek care early if you do get a foot injury. Make sure your health care provider checks your feet at least once a year - more often if you have foot problems. Your health care provider should also give you a list and explain the do's and don'ts of foot care.

Most people can prevent any serious foot problem by following some simple steps. So let's begin taking care of your feet today.

Your health care provider should perform a complete foot exam at least annually - more often if you have foot problems.

Remember to take off your socks and shoes while you wait for your physical examination.

Call or see your health care provider if you have cuts or breaks in the skin, or have an ingrown nail. Also, tell your health care provider if your foot changes color, shape, or just feels different (for example, becomes less sensitive or hurts).

If you have corns or calluses, your health care provider can trim them for you. Your health care provider can also trim your toenails if you cannot do so safely.

Because people with diabetes are more prone to foot problems, a foot care specialist may be on your health care team.
Caring for Your Feet

There are many things you can do to keep your feet healthy.

* Take care of your diabetes. Work with your health care team to keep your blood glucose in your target range.
* Check your feet every day. Look at your bare feet for red spots, cuts, swelling, and blisters. If you cannot see the bottoms of your feet, use a mirror or ask someone for help.
* Be more active. Plan your physical activity program with your health team.
* Ask your doctor about Medicare coverage for special shoes.
* Wash your feet every day. Dry them carefully, especially between the toes.
* Keep your skin soft and smooth. Rub a thin coat of skin lotion over the tops and bottoms of your feet, but not between your toes. Read more about skin care.
* If you can see and reach your toenails, trim them when needed. Trim your toenails straight across and file the edges with an emery board or nail file.
* Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect your feet. Check inside your shoes before wearing them. Make sure the lining is smooth and there are no objects inside.
* Protect your feet from hot and cold. Wear shoes at the beach or on hot pavement. Don't put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. Never use hot water bottles, heating pads, or electric blankets. You can burn your feet without realizing it.
* Keep the blood flowing to your feet. Put your feet up when sitting. Wiggle your toes and move your ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross your legs for long periods of time. Don't smoke.
* Get started now. Begin taking good care of your feet today. Set a time every day to check your feet.

~ American Diabetes Association ~

Friday, March 12, 2010

Preventative Foot Care in Hemodialysis Patients

Comprehensive care of hemodialysis patients poses a significant challenge for nephrologists. Although protocol driven approaches by hemodialysis centers have significantly improved standardized care, significant gaps remain in overall medical care provided to hemodialysis patients. Admittedly, with improvement in care, mortality rate for dialysis patients has decreased by 10 percent from its peak in 1988; however, it still stands at a disturbing figure of 248 deaths per 1,000 patient-years. The life expectancy of ESRD patients is one-fourth to one-sixth of the age-matched general population, with cardiovascular disease being the most likely cause of death.

Diabetics on hemodialysis have even worse prognosis than other patients. Patients with diabetes and ESRD are admitted to the hospital on average 2.3 times per year, and only 27 percent of these patients will survive five years on hemodialysis. With improvement in overall care, mortality has improved in hemodialysis patient population, but perhaps not to the expected level for multiple reasons. One likely explanation is that although mortality may be less with improvement in one area of care, mortality in other neglected areas of care may negate these potential gains. It therefore remains imperative that the nephrology community does not lose sight of the fact that only comprehensive care of these patients will realize the goal of improvement in mortality and morbidity in this hemodialysis population.
Focus on Foot Care

One such area of care which remains under the radar is morbidity and mortality related to peripheral vascular disease and foot care. For the most part, at this stage, foot care attracts attention only after a problem has already arisen. There are no screening protocols in hemodialysis centers to identify the problem earlier on. As a result, preventive strategies to reduce morbidity and mortality related to this issue remain unaddressed. The magnitude of this problem is unrealized until you add to the equation that the majority of hemodialysis patients are diabetics as well. As a result, there remains a significant issue of lower extremity amputations in hemodialysis patients. Overall, 40 percent of patients in the United States starting chronic dialysis count diabetes mellitus as the primary cause of renal failure, making it the number one cause of CKD (Berman et al., 2001).

Patients with diabetes and chronic renal disease frequently present with a combination of the devastations of diabetes including: nephropathy, retinopathy and vasculopathy. The main focus of the care of these patients has been on the target organs like heart and kidneys. Therefore, early risk factors for diabetic foot complications may be disregarded, and this may lead to amputation—a failure for both the patient and physician. Diabetic foot complications, including amputation, add significantly to the morbidity and mortality of the patient with diabetes and CKD. However, of all the long-term complications of diabetes, foot complications may be the most preventable. In the United States, diabetes is the cause of 50 percent of nontraumatic lower extremity amputations and is increasing annually (Levin, 2002). The prevalence of lower extremity amputation for patients with diabetes and CKD is much greater than those without CKD. The rate of lower limb amputation for the population at large increased during a recent four-year period from 4.8 to 6.2/100 persons. During the same time frame, this rate of lower extremity amputation rose from 11.8 to 13.8/100 among persons with CKD attributed to diabetic nephropathy. The rate for patients with diabetes and CKD was 10 times greater than the diabetic population at large (Eggers, Gohdes, & Pugh et al., 1999). The cost of treating patients with diabetes is astronomical both financially and in terms of quality of life. The loss of a lower extremity or even part of a lower extremity greatly impacts quality of life. Depression after amputation is common. Leisure activities as well as employment status are altered. The mortality rate after amputation in patients with diabetes is 11 percent to 4 percent at one year, 20 percent to 50 percent at three years, and 39 percent to 68 percent at five years (Fritschi, 2001). The impact of disorganized foot care on overall morbidity and mortality in hemodialysis patients therefore can no longer be ignored. One could always argue the benefit of putting resources into such an endeavor.

Do diabetic foot examinations reduce the risk of amputation? For two decades, the United States Department of Health and Human Services (HHS) has used health promotion and disease prevention objectives to improve the health of the American people. The overall goal for diabetes in the Healthy People 2010 objective is, “Through prevention programs, reduce the disease and economic burden of diabetes and improve the quality of life for all persons who have or are at risk for diabetes” (HHS, 2000). A specific objective contained within this goal targets a 55 percent reduction in the rate of lower extremity amputations in persons with diabetes. This would amount to 1.8 lower extremity amputations per 1,000 patients with diabetes per year, down from 4.1 per 1,000 patients that occurred in 1997 (HHS, 2000). Several clinical studies in the nondialysis diabetic population have shown that coordinated programs to screen for high-risk feet and to provide regular foot care decreased lower extremity amputation rates. In a controlled study, 45 hemodialysis patients were assigned to intensive education and care management that included preventive foot care and 38 HD patients were assigned to usual care. Over the 12-month follow-up period, there were no amputations in the study group while there were five lower extremity amputations and two finger amputations in the control group. Mortality was unaffected over the short time of the study, but the morbidity benefit was obvious. Benefit from aggressive preventive care is therefore very likely if not proven through prospective randomized controlled trials.

Nobody would disagree that regular foot care is standard care for every diabetic, and diabetic patients on dialysis are no exception to this standard of care. The American Diabetic Association recommends, “All individuals with diabetes should receive a thorough foot examination at least once yearly to identify high-risk foot conditions.” The ADA goes on to recommend more frequent evaluation for people with one or more risk factors and a visual foot inspection at every visit with a healthcare professional for diabetic patients with neuropathy. “Examination of the foot is an obvious, fundamental step to identifying certain foot risk factors that can be modified, thus reducing the risk of ulceration and amputation” (Mayfield, Reiber et al. 1998). Foot lesions are the single most frequently mismanaged problem of patients with diabetes mellitus and chronic kidney disease (CKD). Recommendations for improving the survival of patients with diabetes and CKD include improvement in the foot care and education of both patients and nephrology healthcare providers regarding diabetic foot complications (Ritz, Koch et al. 1999).
Improving Foot Care

The real question is: Why is it so difficult to provide much needed foot care and how best to do it? One has to take into account the fact that it is not easy for a hemodialysis patient to keep multiple subspecialty appointments. Once-a-year visits for foot examination are not very likely to identify and trigger an early referral. Yet three times a week they are available to a hemodialysis nurse for simple inspection and basic exam of feet. It is logical to think that foot care protocols would be part of patient care. It is possible that it poses some legal and monetary issues for the hemodialysis companies in an era of shrinking reimbursements for hemodialysis patients. These concerns, for the most part, are not true. Legally, it is always safer to prevent than treat an issue after it has been allowed to manifest in medical care set up. Improving care of hemodialysis patients with foot care should theoretically keep patients out of hospitals and on a hemodialysis chair for monetary gains of the hemodialysis center.

Finally, of course one cannot put cost on saving a patients from morbidity and mortality associated with poor foot care. However, planning this care would require careful insight into all practical aspects of care and caregivers. To begin with, the screening process should be very basic level, which hemodialysis nurses are comfortable with. Time spent and protocol has to be very straightforward. It should simply identify and focus on confirming a “NORMAL” exam from “NOT NORMAL” requires physician evaluation. Hemodialysis nurses should then be able to pass that information in a quick computerized manner to nephrologists triggering referrals to podiatrist, interventional cardiologist/interventional radiologists committed to his/her group preferably again by the same computerized network. Unnecessary time spent on telephone calls have to be avoided using protocol driven care and computerized network. Information then would have to be exchanged seamlessly between hemodialysis centre nursing staff, nephrologists, interventionalist and podiatrist. The whole network would have to be HIPAA compliant and be easy to learn and adapt to the needs to dialysis facility and physician groups involved. Ideally the network should be able to blend in with existing networks involved in hemodialysis care as well as communicate with subspecialty groups.

In summary, preventive foot care for hemodialysis patients is lost in efforts and time spent to provide care in other much politicized areas of care. But ignoring prevention in this area leads to significant morbidity and mortality. There are no randomized controlled trials of intensive education and care management versus usual care of feet in diabetic dialysis patients. Nonetheless, diabetic dialysis patients are likely to benefit from examination of the foot as part of the routine dialysis care. Given the fact that prevention can be easily done in hemodialysis center by hemodialysis nursing staff, there is little reason not to introduce it. Three times a week contact between hemodialysis nurses and patient is a potential opportunity to assess risks, educate and provide early intervention for foot issues in CKD population. Simple measures such as routine foot screening and education for this high risk population can prevent ulcer-initiating events and detect small ulcers when they may heal with proper intervention. Preventive strategies should include protocol based strategy for referral to specialist. Computerized network should allow this to happen seamlessly and effortlessly to benefit all involved in hemodialysis care. In this regard, all involved in medical care of hemodialysis patients can no longer afford to ignore the importance of preventive care of hemodialysis patients.

~ Renal Business Today ~

Zahid Ahmad, MD.
Dr. Ahmad is an assistant professor of medicine of interventional nephrology at the University of Oklahoma’s Section of Nephrology & Hypertension. For more information visit

Monday, February 15, 2010

Hunterdon Medical Center among first to use artery cleaning device

By: Hunterdon County Democrat

February 14, 2010, 11:06AM

Scott Collins, 45, of Lambertville visited Dr. Andrey Espinoza, interventional cardiologist at Hunterdon Medical Center, last summer in an act of desperation. After suffering from peripheral arterial disease for the past seven years, Collins had grown accustomed to the pain and numbness in his legs that prevented him from walking more than 50 yards without having to take a rest.
Once his legs reached 100% arterial blockage, Collins began to accept the idea that he would likely be a candidate for amputation.
Peripheral arterial disease occurs when plaque builds up on the inside walls of blood vessels, causing a blockage of blood flow to the extremities, and is often associated with high blood pressure, diabetes, heart disease, stroke and aging.
After a short visit with Espinoza, Collins learned that a new device, Pathway Medical Technologie’s Jetstream, could fix his problem. Interventional Cardiologists at Hunterdon Medical Center is now treating patients using a newly FDA cleared device that clears away and removes potentially deadly artery clogging plaque in leg arteries for those suffering from peripheral arterial disease, a chronic condition that affects nearly 12 million Americans.
Collins came back for his procedure and the moment they finished their work, he knew that they had changed his life.
“I was still lying on the table, but I knew the procedure had worked,” Collins said. “My leg began to itch. I hadn’t felt anything in that leg for years.”
Working from his three-story home as an antique reseller is enjoyable again, Collins said, adding he has found freedom in what he deems his “new legs.”
“This treatment represents an innovative and minimally invasive solution to clear blockages in the peripheral arteries, restoring blood flow and effectively treating the disease without surgery,” explained Espinoza, who is the first physician to treat a patient using the device at Hunterdon Medical Center.
The Jetstream Atherectomy System is the first on the market capable of treating an entire spectrum of disease found in the PAD patient, including hard and soft plaque, calcium, thrombus and fibrotic lesions with consistent clinical results. The Jetstream catheter is equipped with tiny rotating blades and a vacuum that cuts through accumulated plaque in the legs and then vacuums away the debris left behind.
This treatment has the potential to reduce procedure time and minimize vessel trauma, which can mean fewer complications for patients. Removing the plaque that has been cut loose also minimizes the potential for that plaque to travel back through the leg’s arteries and cause another blockage.
PAD usually affects adults from age 60 to 80, but patients can be younger. Further, while people with elevated cholesterol, smokers or those with a history of heart disease can develop PAD, many people do not realize they have blocked arteries. Unfortunately, despite the large number of sufferers, traditionally invasive treatments for PAD, such as bypass surgery, coupled with a lack of consumer education, means that PAD is responsible for more than 150,000 leg amputations each year and only about 400,000 patients receive the endovascular intervention they need. In addition, many patients are poor surgical candidates for whom surgery can be life threatening.
Jetstream is now in use at more than 100 centers across the country, including New York-Presbyterian Hospital in New York, St. John Hospital and Medical Center in Detroit, Cardiovascular Consultants of Washington in Seattle, Wellstar Kennestone Hospital in Atlanta and Leesburg Regional Hospital in Leesburg, Florida, and has been used to successfully treat more than 600 patients suffering from PAD to date.
Jetstream offers renewed hope for patients and the benefits of a minimally invasive treatment option, including faster recovery and decreased systemic complications.
For more information on cardiac services at Hunterdon Medical Center call Registered Nurse Nicole Camporeale, heart and vascular care coordinator at Hunterdon Medical Center, at 908-237-5440 or visit