limb preservation: #actagainstamputation - diabetes update. dr. zaina albalawi_archi… · in...

Limb Preservation: #ActAgainstAmputation

Presented by:

Zaina Albalawi, MD, MSc, FRCPCEndocrinology and MetabolismClinical Assistant Professor, Memorial UniversityEmail: [email protected] May 2, 2020

Diabetes Update 2020

Additional Disclosure

NL photo credits: Mark Gray photography of NL @GrayMarker99

Image courtesy of: @YELLOWBELLYBREW Image courtesy of : my home office, signed by the original cast

Objective and Outline

Navigate how to act against preventable amputations in diabetes

Overview of amputation trends in Canada, morbidity and mortality

Prevention Strategy: rationale and overview

Technology and innovations in diabetic foot care (Prevention)


Amputation Trends In Canada, Morbidity and Mortality

Photograph by: Mark Gray


Amputation Rates Per 100,000 Population (Age –Adjusted)

National Average: 22.9 amputations per 100,000

Diabetes-related Amputations: >65%

Trends over 6-year period:

-Decrease (exception: BC, AB), however, total # of new amputations increased (2ry pop. growth)

-The # of new diabetes-related amputations increased by 13%!

Imam et al, Can J Public Health 2017Data: 2006-2012


Diabetes-Related Amputation Rates On The RiseMajor or minor lower-extremity amputations related to diabetes, PAD or both

in Ontario, Canada

Hussain MA et al. CMAJ Sep, 2019

HEALTH CARE SYSTEM

In Canada, annual cost of Diabetic Foot Ulcer (DFU) related care is approximately CAN $39 000 per incident case (Cost ranks 2nd to CVA)

GEMINI Group [Ontario]: mean in-patient cost for treatment of a DFU is $22,754 per hospital stay and $48,808 if a major amputation is required

RehabilitationLavery 2003

Ziegler-Graham 2008DAD 2012

Hopkins 2014IDF 2015

HEALTH CARE SYSTEM


Clinically Important & Meaningful Numbers

In people with diabetes:

What proportion will develop peripheral neuropathy in their lifetime?

What proportion will develop a diabetic foot ulcer?

Of those who have had one amputation, what proportion will develop another amputation?

Of those who end up with an amputation, what is mortality in 1-year, 2-years, and 3-years?

50%

15-25%

15-30%

48%,61%, 71%

Stern et al, Ann Vasc Surg. 2017Brennan et al, J Diabetes Complications 2017

Morbach et al, Diabetes Care. 2012

“In Diabetes, what you can’t feel can hurt” -David G. Armstrong


5-year Mortality: An Update

Armstrong DG et al. Journal of Foot and Ankle Research, 2020

80%

30.5%

56.6%

9%

29%

46.2%

31%

PREVENTION STRATEGY:

Rationale and Overview



Rogers LC, Armstrong DG. Podiatry Care. 2010.

Prevention Strategy: Rationale

Natural History: Diabetes-related Amputations

##ActAgainstAmputationLimb Preservation=Ulcer Prevention


Prevention Strategy: Overview

🔑🔑 SCREENING: identifying the “at-risk” foot

🔑🔑 REGULAR INSPECTION: and examination of the at-risk foot

🔑🔑 EDUCATION: the patient, family and healthcare providers

🔑🔑 FOOTWEAR: ensuring routine wearing of appropriate footwear

🔑🔑 TREATMENT: timely treatment of risk factors for ulceration/amputationBus et al. Diab Metab Res Rev. 2020Jeffcoate et al, Diabetes Care. 2018Crawford et al, Health Technol Assess. 2015Dorresteijn et al, Cochrane Database of Systematic Reviews. 2014

The 5 Key Principles of amputation/ulcer prevention:


Evidence-basedCost-effective

Accessible

Multidisciplinary Teams

www.woundscanada.ca

Screening: Risk Stratification


#ActAgainstAmputation

Bus et al. Diab Metab Res Rev. 2020Crawford et al, Health Technol Assess. 2015

With limited health resources, risk

stratification is essential to

appropriately allocate resources


Risk Stratification: Alternate Option

Prediction of risk: Strong recommendation based on high level evidence

Education: Clinically Meaningful Conversations

“You are currently at ____ risk for foot ulceration. Here

is some important educational material to reduce your risk of an

ulcer/amputation/death. Here are community resources. Next follow up in ------

months”


Technology and Innovations In Diabetic Foot Care: Prevention


Guideline RecommendationsInternational Working Group on the Diabetic Foot (IWGDF)

IWGDF 2019 guidelines on prevention: “Consider instructing a person with diabetes who is at moderate or high risk of foot ulceration…to self-monitor foot skin temperatures once per day to identify any early signs of foot inflammation and help prevent a first or recurrent plantar foot ulcer. If the temperature difference is above-threshold between similar regions in the two feet on two consecutive days, instruct the patient to reduce ambulatory activity and consult an adequately trained health care professional for further diagnosis and treatment.” (Weak; Moderate)

IWGDF 2019: “In a person with diabetes who has a healed plantar foot ulcer (IWGDF risk 3), prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent a recurrent plantar foot ulcer; furthermore, encourage the patient to consistently wear this footwear. (Strong; Moderate). Bus et al. Diab Metab Res Rev. 2020

Wijlens AM et al. Int Wound J. 2017Skafjeld A et al. BMC Endocr Disord. 2015 Lavery LA et al. Diabetes Care. 2004


Early Detection: Maximizing Ulcer-free Days

Areas of interest and recent developments:


Najafi B, et al. Diabetes/Metabolism Research and Reviews. 2020

a) Images (computer vision algorithms) high sens+spec. b) ThermographyEarly detection of inflammation. e.g.

infrared probe, smart mats (Podimetrics Mat) high sen.(97%) but spec. 43%. Average lead 37 days, Smart Socks (Siren Care)

Technologies to identify high-risk patients for triage and early intervention

• Home monitoring of plantar pressure and gait (FeetMe, Surresense Rx [Orpyx])

Technologies for effective and personalized prescription of offloading

Objective monitoring of adherence e.g. @monitor, Orthotimer sensor

• Real-time alerting systems• PAMTag

Technologies to improve adherence to protective footwear

Technology Innovations In Foot Care*: Prevention


Najafi B, et al. Diabetes/Metabolism Research and Reviews. 2020*Products shown as an example of available technologies, no specific product is endorsed

In Conclusion


In Summary: Take Away Points Amputations carry significant morbidity and mortality Rates are

mostly on the rise in Canada Action needed to halt the rise and ultimately decrease amputation rates

Limb Preservation= Ulcer prevention (1ry & 2ry) Investment in prevention strategies upstream is essential to reduce

amputation rates (Key principles: risk stratification, education, footcare, footwear, early identification & treatment) –Multidisciplinary Teams

There is a role for all of us involved in diabetes care to #ActAgainstAmputations

Some technologies and innovations are available to support prevention strategies many underway



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