The SA Journal Diabetes & Vascular Disease Vol 11 No 4 (November 2014)

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162 VOLUME 11 NUMBER 4 • NOVEMBER 2014
CURRENT TOPICS SA JOURNAL OF DIABETES & VASCULAR DISEASE
Key messages
Diabetes patients should be:
• made aware of their foot risk and signposted to the foot-
protection team.
• empowered to optimise self-care of the feet
• referred rapidly to a MDfT in the event of a ‘foot attack’
Early intervention reduces complications and amputations.
Conclusion
An integrated structured foot-care service between primary and
specialist care is essential in reducing the risk of both minor and
major amputations. Commissioners should be aware of the com-
missioned service within their area and aspects to be improved to
reduce the cost of care for these high-risk patients.
The current rate of major amputation is too high. It is vital that
healthcare professionals understand the importance of performing
good-quality annual foot checks, providing patients with the tools
they need to understand their risk of a ‘foot attack’ and, if necessary,
enable patients to access specialist help as quickly as possible.
Conflict of interest None
Funding sources None
References
1. Day C. Foot guide. Br J Diabetes Vasc Dis 2006; 6: 139–40.
2. Campbell IW. Diabetic foot disease – new thoughts on prevention and treatment
Br J Diabetes Vasc Dis 2011; 11: 53–54.
3. Nag S, McCulloch A, Razvi S. Foot trauma due to foreign bodies – out of sight,
out of mind? Br J Diabetes Vasc Dis 2004; 6: 421.
4. NHS Atlas of Variation in Healthcare, 2010. NHS Right Care,
nhs.uk/atlas/downloads/EndocrineMaps_AoV_201 1.pdf (Accessed May 2014).
5. Kerr M. Foot Care for People with Diabetes: The Economic Case for Change.
Insight Health Economics. March 2012.
nhs-diabetes/footcare/foot-care-for-people-with-diabetes.pdf (Accessed May 2014).
6. The Information Centre for Health and Social Care. Hospital Episode Statistics
2007/08-2010/11 (Accessed May 2014).
7. State of the Nation. England. 2013.
About%20Us/What%20we%20say/0160b-state-nation-2013-england-1213.
pdf (Accessed May 2014).
8. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of
amputation of the lower limb in England. Diabetologia 2012; 55: 1919–1925.
9. Ipsos MORI. Survey on awareness of Diabetes and Diabetes UK amongst
the general public, conducted on behalf of Diabetes UK 2007.
10. Year of care. Report of findings from the pilot programme. June 2011 http://
pdf (Accessed May 2014).
11. Putting feet first. Commissioning specialist services for the management and
prevention of diabetic foot disease in hospital. June 2009. .
org.uk/Documents/Reports/Putting_Feet_First_010 709.pdf (Accessed May 2014).
12. Tobalem M, Uckay I. Evolution of a diabetic foot infection. New Engl J Med 2013;
369: 2252.
13. Vascular Society of Great Britain and Ireland. Quality Improvement Framework for
Major Amputation Surgery. March 2012.
category/audit-qi/ (Accessed May 2014).
14. The National Confidential Enquiry into Patient Outcomes and Deaths. http://
(Accessed May 2014).
15. All-Party Parliamentary Group on Vascular Disease. Tackling peripheral arterial
disease more effectively: saving limbs, saving lives.
media/reports/2014-03-tackling_peripheral_arterial_disease_more_effectively__
saving_limbs__saving_lives.pdf (Accessed May 2014).
Bariatric surgery has better outcomes after 15 years
Bariatric surgery comes out ahead with greater weight loss,
more incidents of diabetes remission and fewer cardiovascular
disease (CVD) complications than standard medical care. Fifteen
years after undergoing bariatric surgery, 30% of patients no
longer had diabetes, but only 7% of patients who received usual
care were in diabetes remission.
These long-term findings from the Swedish Obese Subjects
(SOS) prospective, matched-cohort study by Dr Lars Sjöström
from Sahlgrenska University Hospital in Gothenburg, Sweden,
and colleagues (J Am Med Assoc 2014; 311: 2297–2304, 2277–
2278) were published to coincide with the American Diabetes
Association conference in San Francisco.
The study also shows that ‘obese diabetics whose diabetes was
of shorter duration or who had the greatest weight loss between
the time of surgery and two years later were the most likely to
have a sustained remission at 15 years. These patients likely had
bariatric surgery before the failure of the insulin-producing cells
of the pancreas was irreversible’.
The SOS study enrolled 4 047 obese patients in Sweden between
1987 and 2001. The current analysis looked at those who had
diabetes at baseline, 260 patients, who then received usual medical
care, and 343 patients who underwent bariatric surgery – vertical
banded gastroplasty (227 patients), non-adjustable or adjustable
banding (61 patients) or Roux-en-Y gastric bypass (55 patients).
The patients had a mean age of about 50 years, a mean
body mass index (BMI) of about 41 kg/m2 and about 60% were
women. They had had diabetes for approximately three years.
The researchers tracked microvascular complications of the
kidney,eyesandperipheralnerves,andmacrovascularcomplications
– coronary heart disease, heart failure, stroke andperipheral arterial
disease – after a median of about 17 years. Diabetes remission
was defined as having a blood glucose level below 110 mg/dl
(6.11 mmol/l) and not taking antidiabetic medication.
Bariatric surgery was associated with higher diabetes remission
rates and weight loss compared with usual care, although these
rates declined over time in both groups. Bariatric surgery was also
associated with a significantly decreased risk for microvascular
and macrovascular complications (hazard ratios: 0.43 and 0.74,
respectively).
Additional follow up of newer studies is required to answer the
question of which bariatric procedure is best for inducing long-
term remission of diabetes, but those data will not be available
for another five to 10 years.
Source
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