DETECTING FOOT ULCERS
A callus or corn on your foot is a nuisance for anyone. But for a diabetic, they can easily turn to an ulcer, and can even result in amputation. Doctors are now studying new methods to identify patients at risk for these dangerous wounds.
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William Malcolm
"Cribbage and life run hand in hand because you have to deal with the hand you are dealt."
At age 40, William Malcolm was dealt an unexpected hand. He was diagnosed with diabetes.
William Malcolm
Has Diabetes
"It's just an insidious disease. It attacks every part of your body."
One major complication is a foot ulcer that can go undetected until it's too late. William developed an ulcer on his toe and had to have it amputated.
The only way to detect ulcers is to see them -- until now. Doctors at harvard are studying two new tests that identify which patients are likely to have ulcers.
The first uses MRI technology to measure muscle energy in the foot.
Aristidis Veves, M.D.
Research Director
Joslin-Beth Israel Deaconess Foot Center
Boston, MA
"The idea is if the muscles are not working properly, then these patients will be at risk for not healing from their ulcers."
Another method uses hyper-spectral imaging. Doctors use images of a patient's foot to measure blood flow and early changes in oxygen. Here, the blue represents oxygen. Patients with less oxygen in their skin may have a higher risk of having an ulcer that won't heal.
John Giurini, D.M.P.
Podiatrist
Beth Israel Deaconess Foot Center
Medical Center
Boston, MA
"If we can determine early on a patient's ability to heal an ulceration, then we can steer them in the right direction to get that ulcer healed."
That's good news for patients like William.
William Malcolm
"It doesn't have to be a train wreck. You can get the help you need. Early detection means prevention."
And he hopes that prevention will pay off.
Doctors say these tests are still in their investigational stages and recommend that diabetics get treated immediately if they get a foot ulcer. Foot ulcers result in 80,000 lower leg amputations each year in the United States.
BACKGROUND: Every 30 seconds, a lower limb is amputated somewhere in the world as a consequence of diabetes, according to researchers writing in the November 11, 2005 issue of The Lancet. The researchers report the world is facing an epidemic of type 2 diabetes, and the incidence of type 1 diabetes is also increasing. The lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25 percent. If left untreated, patients with the condition may have to have their leg amputated. Diabetic foot ulceration and amputations were estimated to cost the United States health care payers $10.9 billion in 2001. However, foot ulcers and amputation are preventable. Provision of foot-care services can be associated with a reduction in amputations and simple clinical tests can predict those at risk of ulceration.
THE PROBLEM: The root of the problem is often a condition known as peripheral neuropathy, which develops when uncontrolled high blood sugar damages the nerves of the legs and feet, resulting in greatly decreased sensitivity. "Peripheral neuropathy causes extreme numbness and a loss of protective sensation," explains Aristidis Veves, M.D., of the Joslin-Beth Israel Deaconess Foot Center and Microcirculation Laboratory and associate professor of surgery at Harvard Medical School. "As a result, even a minor foot injury [such as a corn or callus, a splinter, or pressure from an improperly fitting shoe] can go undetected by the patient until it has escalated into a chronic wound that won't heal." Once an ulcer has become infected it can lead to the onset of gangrene, and in the most serious cases, to amputation of the limb.
EARLY DETECTION: Knowing that changes in large vessels and the microcirculation of the diabetic foot play a central role in the development of ulcers and their subsequent failure to heal, Dr. Veves and colleagues set out to specifically identify what these changes are. Using a novel technology known as medical hyperspectral imaging (MHSI), researchers studied a total of 108 patients -- 21 control subjects who did not have diabetes, 36 diabetes patients who did not have neuropathy and 51 patients with both diabetes and neuropathy. They also measured foot muscle energy reserves using a magnetic spectroscopy, a new method that is based on magnetic resonance imaging (MRI). Results reveal there are indeed measurable differences in the skin of diabetes patients and, in particular, diabetes patients with peripheral neuropathy that can be detected before ulcerative foot disease develops. Dr. Veves says, "Our results indicated that the amount of oxygen that is available is reduced in the skin of patients with diabetes and that this impairment is accentuated in the presence of neuropathy in the foot." Furthermore, Veves says, their findings showed that energy reserves of the foot muscles are reduced in the presence of diabetes, suggesting that microcirculatory changes could [also] have a major role.
Bonnie Prescot
Beth Israel Deaconess Medical Center
330 Brookline Ave.
GZ-6
Boston, MA 02215
(617) 667-7306
bprescot@bidmc.harvard.edu
http://www.bidmc.harvard.edu
Copyright © 2006 Ivanhoe Broadcast News, Inc.
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