In response to rising rates of diabetes and related amputations, the co-directors of UCSF’s Center for Limb Preservation – which has a limb salvage rate of 92 percent – present a quick guide to detecting amputation risk. They include COVID-specific advice to prevent delays in diagnosis and referral.
Mhm. Hi, I'm Mike Conte. I'm chief of vascular surgery at UCSF Medical Center and co director of the UCSF Center for Limb Preservation in the Diabetic Foot. Hello, My name is Alex Reyes Lemon. I'm the co director of a limb preservation center in Diabetic Foot at UCSF, and I'm a podiatrist. The topic of our conversation today is titled Crisis Within a Crisis. Limb Preservation, Diabetic Foot Care and The Cove in 19 Pandemic. The crisis that we're going to be discussing today are the lower extremity, amputations performed and die patients with diabetes and peripheral arterial disease. Let's share some of the statistics that make diabetes and P a D a global epidemic. There are 30 million patients with diabetes in United States that makes up approximately 9.4% of the entire U. S. Population. There are over 300 million patients with diabetes worldwide, nearly 70% of amputation. The United States are performed in patients with diabetes Age adjusted risk for amputation is 28 full higher in patients with diabetes. We estimate that there is a diabetic undergoing lower extremity amputation every 20 to 30 seconds around the globe. Diabetic foot ulcer tends to be the strongest predictor for limb loss. Among patients with diabetic foot ulcers that heal, 28 to 83% will have a recurrence within one year. One out of three diabetics older than the age of 50 have peripheral arterial disease. And diabetic patients with peripheral arterial disease are significantly increased risk for mortality and limb loss. And this has made this a major public health expenditure and growing rapidly. This is a graph from C. D. C. Looking at patients with diabetes and patients on percentage of patients with diabetes from 1958 to 2015. What we're seeing here is aesthetic incline of patients with diabetes from 1958 to 19 nineties, and then sometime in 19 nineties. Towards the end of 19 nineties. The incline has six is significantly worsened, and that goes towards 2015 and to present time. What about California? What's going on in our state? Well, the recent data that has been published within the past year shows the diabetes prevalence and lower extremity amputation since in California have significantly increased. There are more than 15.5 million adults, or 55% of all California adults that have pre diabetes or diabetes. More than one third of adults of color have pre diabetes, and in California, lower limb amputations have increased by greater than 35 31% from 2010 until 2016. Now we can break that down further county by county, and you can see that majority of counties in California have a rise in amputation rates, including counties such as Moran, that have seen an increase of 32% from 2010 to 2016. Now this is an important slide. I'm going to spend a little bit of time on this because this data is compelling. This data has been published within the last year or updated within the last year, and it talks about the five year mortality rate, comparing cancers to complications of lower extremity from diabetes and powerful arterial disease. So if we look at the first bar graph and pink breast cancer, five year mortality rate is roughly 10%. The next yellow bar and the red bar are shark. Oh, and diabetic foot ulcer Shark Oh is a foot complication of diabetes, and you can see that the five year mortality raid is approximately 30%. The next bar is an average of all cancers with a five year mortality rate again pretty comparable to diabetic foot ulcers and complication of diabetes. Such a shark go as we move on the bar, and blue is a minor amputation. So are patients who are patients who have lost parts of their toes or parts of their foot. Their five year mortality rate is approaching 50%. The bar and pink and black. Our patients with critical limb ischemia or severe Ph. D. And patients who have lost one of their limbs. Their five year mortality rate is approaching 60% and the only cancers that have a higher mortality rate. Adriatic cancer. So to summarize this data, we need to really think of this in a different way. That should be a paradigm shift as to how we approach patients with diabetic foot complications and P A. D. And we really should be approaching them with much more vigilance and much more urgency. And we should approach them as though they have cancer to understand the best ways to evaluate and treat patients with diabetic foot ulcer. It's important to first understand the fundamental basis of the path of physiology of the disease and its key components. We talk about the permissive triad of diabetic foot ulcer being this combination of peripheral neuropathy, basketball apathy and in Manama, the of these. The peripheral neuropathy is usually considered the key inciting factor, whereas patients who have lost protective sensation and have the combination of motor neuropathy with foot deformities are placed at high risk for skin breakdown in minor wounds that can then proceed to become chronic ulcers with repetitive trauma. On injury to the area, there is subcutaneous hemorrhage. There's callous formation and eventually their skin breakdown that also destroys the barrier toe infection and then creates a wounds environment where vascular compromise can also assume an important role. Many patients with diabetes, as we've already said, have coexist in perfect arterial disease. In some case cases, they have had no previous symptoms of peripheral arterial disease, often because their vascular disease is distributed in such a way that it doesn't necessarily cause walking pain. But once they have an open wound, an additional circulation is required to achieve healing. The underlying vascular disease becomes a second permissive component of the chronic diabetic foot ulcer and then finally, the reduced infection fighting capacity that is associated with diabetes and its effects on the immune system also plays a permissive role in allowing for bacterial colonization and inadequate resolution of inflammation and infection that promotes a cry necessity of the problem. It's the recognition of these interlacing elements of path of physiology that also dictates the multidisciplinary expertise that you really need to appropriately evaluate and treat patients with these limb threatening conditions. This classic article that appeared a little over a decade ago summarized the concept of the so called steroid amputation, which begins with neuropathy and ulceration, compounded by infection, and then in the presence of vascular disease. Major limb amputation, and supports the importance of concurrent and cohesive intersection between podiatry and vascular assessment as the two key aspects to the evaluation and treatment of these patients. So while the team approach requires expertise from other domains as well, including endocrinology, infectious disease, plastics and reconstructive surgery, and rehabilitative medicine, among others, many centers have sent have focused their efforts on the joining of dietary investor surgery as a two critical elements to bring together Ah center of excellence around amputation prevention. The other important thing to understand is why this is critical to improving the overall care in the community for patients who have or at risk for, diabetic foot ulcers. First, there still remains Avery low level of public and community physician awareness to the nature of the problem, how it can be indolent and another appreciated in individual patients once it's recognized. Often these patients are referred to multiple different providers in sequence. As a result, their care gets fragmented and delayed as they're referred first, potentially to a surgeon or podiatrist and then maybe eventually to an infectious disease specialist and then maybe eventually to have ask your specialist. This leads to delays in treatment and often leads to adverse outcomes. There is also a lack of standardization, of approaches for therapies and diagnostics across the professional community. The most important aspect of this, though, is that rapid recognition and treatment of those with the most advanced ages is absolutely critical for success in preserving not just a limb but a functional limp and our goal, or are sort of driving force around. This is the notion that time is tissue when patients reach a certain stage of acuity every day. Lost potentially results in a lower chance of successful limb salvage, And this really is what drives us to stress the importance of having a cohesive and patients Senate approach. In addition, once treatments air started upon, they need to be followed up closely by the multi disciplinary team to assess if things were progressing in the correct direction or if there's stalemated or if they're actually going in the reverse direction. And even after healing, surveillance and re intervention are often required based on those driving forces. In 2011, we decided to create a center at UCSF that was really the first of its kind in the Bay Area to focus and providing integrated in both disciplinary center for patients with lower extremity alterations, particularly those with diabetes. It was established as a basically between vascular surgery and podiatry at that time, but also embraces and involves many other outstanding referral groups that U. C S F for some of the other specialties, our center trees, patients with foot ulceration of any cause, peripheral arterial disease and diabetes, and those at risk for developing these conditions. Our primary goal is not just to preserve limbs, to preserve function, and our multi disciplinary team provides the expertise and the advanced technology to assess each patients clinical situation and to develop an individualized treatment plan which sometimes requires reevaluation and change over time. It's also very important that we closely coordinate this care between the outpatient and inpatient settings and between our own providers and are referring providers as it often takes quite a bit of time to achieve resolution of these wounds, and many patients need to be treated closer to home. We aim to provide a functional unit in our center between inpatient outpatient so that everybody knows the patients and where they are in their treatment course. Our Center for limb preservation Diabetic Foot has been operational now for nine years. We see approximately 2000 plus annual patient visits per year, and we see approximately 250 to 300 new patients a year are limb. Salvage rate is about 92%. What makes us special and unique is there were able to combine the expertise of podiatrists and vascular surgeons and onside diagnostic lower extremity evaluation at the same time, which is really different than what occurs in the real world. Typically, what you see is different specialties working in silos. There's vascular surgeons who do what they do their podiatrist toe do, who do what they dio. And by the time the patient makes it from one office to the next, valuable time is lost. And as we said earlier, time is tissue. So the typical visit here in the Center for Limb preservation is when the patient comes in, they get a diagnostic arterial evaluation on the spot. They get seen by a vascular surgeon and a podiatrist at the same time. And at that point we develop a treatment plan, and sometimes that requires revascularization to be done first. Sometimes it's podiatric procedure to be done first, or sometimes it's a combination of both specialties working together under one surgical time. We've also developed amputation risk and screening guide, and this is an easy way for providers medical providers to triage patients with diabetic foot complications. So, for example, somebody with diabetes who comes in without any symptoms they should be seen on an annual basis by a primary care and be given self management plan and foot and diabetic education. However, if the patient presents with numbness, tingling, burning of their feet in other words, symptoms of purple neuropathy. Now that becomes a moderate risk for amputation. And these patients should, at the very least, be seen annually by a podiatrist who will perform a screening test and to decide what type of risk they are for amputation or screen them for peripheral arterial disease. At that point, podiatrist will give diabetic foot education and reappoint the patient. If the patient presents with a history of ulceration or an imputation, or symptoms of intermittent qualification or pain in their feet at night, or they may present with a callous that has bleeding in it, that automatically puts them in the high risk for amputation, and they should be sent to a center for limb preservation in the diabetic foot. At that point, we will get that patient in within a week. If the patient presents with an active ulcer, cellulitis, gangrene or foot and ankle swelling with or without pain, that automatically bumps the patient up to a severe risk for amputation, and that patients should be sent to our center, which, in which case we will see the patient within 24 to 48 hours. Care of patients with advanced perfect order disease and diabetic foot alterations has suffered, as many other diseases have during the Kobe 19 pandemic. Not surprisingly, patients with diabetes, cardiovascular disease, advanced age and other co morbidity is that air seen in our population are known to be at higher risk for aggressive Kobe 19 infections. And so they have been potentially nervous about coming in to seek care. And the messages and communications that have gone out there have made it more challenging to deliver care for their patients. For these patients and others with non covert 19 illnesses, we were struck by a recent increase in major amputations that we saw during the shelter in place period between March and May. I hear it. Our center here on this slide data that's about to be published shows that in our own center during those two months, compared to two months in the fall, we had a notably reduced clinic and consultation visit for limb preservation by about 50%. At the same time, those patients that we did see using a typical staging system that we employ for these patients demonstrated higher acuity, particularly higher rates of significant foot infection that were evident on presentation of the patients. Unfortunately, we saw a 50% relative increase in the total number of amputations in these two months periods compared to historical controls, with a more than doubling of our major to minor amputation ratio during this period of time. So the increase in major amputations was significant and notable. We believe, based on our observations, that late presentations and or delayed referrals were the most likely cause of the increase major amputations that we saw during shelter in place. And that has prompted us to increase the education and call out into the public domain to pay more attention again, two diabetic foot ulceration and to the prevention of amputation. Even during this time, when we are obviously heavily distracted by the pandemic. A couple of other things we wanted to point out about our unit and about our team. Today, one is like you might expect from a tertiary care center of excellence. We have a very active clinical trials program focused on diabetic patients, diabetic foot ulcers and vascular disease. Our unit at UCSF was selected to be one of the six founding members of the n i H N I. D D K Diabetic Foot Consortium, which was established in 2018 with the goal of launching clinical trials to improve the standard of care and evidence in this field. Currently, we have to study studies that are actively enrolling subjects, to test novel biomarker measurements of diabetic foot ulcer and to predict recurrence. Our unit also has ongoing vaster device trials, currently a new drug eluting stent and also a Venus artillery realization procedure for patients with advanced the Meskhi Mia, who may lack other good options. Our team investigators air also leading studies in micro sensor technology to measure foot profusion on a chronic outpatient basis and biological and gene therapies for wound healing and diabetic foot ulcer. Many patients may be eligible for some or all of these studies, and our research team is easier to identify potential research subjects. Our team consists of seven vascular surgeons, three podiatrists for nurse practitioners at its core. We also have advanced trainees fellows from the vascular surgery and from the podiatry program that are focused on limb preservation. We have a dedicated patient care coordinator and our overall clinical manager, Joanne, and along who actively triage is the incoming referrals prioritizes the patients to be seen as quickly as possible, and our direct physician referral lines, as well as Joanna Cellphone are shown on this slide to provide the information for referring physicians. So in summary, in our nine years of existence, we have created a program that I think is unique in the Bay Area in cohesively bringing together vaster surgery and podiatrists who are very focused and dedicated to the improvement of care of patients with diabetic foot ulcer and vascular disease and the preservation of functional limbs. Our message to you today is to refer patients early, when there's concerns and thio contact us with any concerns or questions at any time for patients that you are seeing. We're happy to provide not only in person consultation but also phone consultations and anything that we can do together to reduce the burden of amputation in the Bay Area and in Northern California. During the past year, we've been able to open up opportunities for patients to come see us and be screened for purple arterial disease or diabetic foot complications outside of San Francisco. Closer to home, what makes our center unique is that we combine the expertise of vascular surgeons and podiatrists who are passionate in treating limb salvage every day. Uh huh.