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"You can never heal a diabetic foot ulcer...

Discussion in 'Diabetic Foot & Wound Management' started by Craig Payne, Mar 29, 2013.

  1. Craig Payne

    Craig Payne Moderator


    Members do not see these Ads. Sign Up.
    ...you can only put it in remission"

    I have seen and heard this interesting concept a number of times in the last few years, now Dave Armstrong has a publication on it:

    Toward a Change in Syntax in Diabetic Foot Care: Prevention Equals Remission.
    Armstrong DG, Mills JL.
    J Am Podiatr Med Assoc. 2013 March-April;103(2):161-162.
  2. Selwyn Firth

    Selwyn Firth Member

    It is an interesting supposition by Dr. Armstrong, however wounds are not like cancer and suggesting that they are is detrimentile to the patient as well as the care givers who are involved in their care and treatment.
    If a wound has completely healed then it is cured and not in remission. The fact that some people re-injure them selves does not take away from the fact that the original injury was in fact cured/healed.

    Suggesting that it is only in remission and will reoccure is detrimental and worrisome to the patient and the practice should be discontinued.

    Since most of the poor healing outcomes stem from poor circulation more doctors should be looking into mechanical methods of improving lower limb circulation. The company I work for makes the only proven portable circulation booster. I am prevented from naming it directly but it has been mention on this forum.

    If anyone is interested send me a message through the forum and I will respond. Over 200,000 needless amputations are performed annually because many doctors are unaware of the ability to improve circulation mechaniclly. Unfortunately the patients not the doctors suffer.
  3. cwiebelt

    cwiebelt Active Member

    Interesting proposition David Armstrong puts forward
    Tend to think he has a point a lot of time and resources are spent on treating diabetic foot wounds so they are healed (cured ?) only to find they re-ulcer again. Despite offloading, footwear and ongoing education.
    May treat and manage but cure, I am not so sure anymore
    There are more complex cases and problems presenting for treatment and management which present ongoing new challenges and complexity (MRSA, Charcot foot collapse with deformity) that often could be managed better.
    So I tend to agree may be remission of foot wounds is a better terminology
  4. NewsBot

    NewsBot The Admin that posts the news.

    Press Release:
    June 14, 2017
    UA Surgeon Armstrong Urges New Focus on Diabetic Ulcers
    Remission — rather than repair — needs to be the goal of treatment, according to Dr. David Armstrong, whose report on diabetic foot ulcers appears in the New England Journal of Medicine.

    Foot ulcers are a prevalent complication for millions of people with diabetes. Estimates indicate that as many as one-third of people with the disease will develop at least one foot ulcer over the course of their lifetime. These wounds can lead to further complications such as strokes, heart attacks, infections, loss of limbs and premature death.

    Yet, the morbidity and mortality directly associated with foot ulcers often go unrecognized by physicians and patients alike. Currently, the clinical focus is on repairing an ulcer's surrounding tissue and healing the wound.

    Instead, physicians and patients need to focus on ulcer remission — that is, extending the time between the formation of ulcers, says Dr. David Armstrong, professor of surgery and director of the Southern Arizona Limb Salvage Alliance at the University of Arizona College of Medicine – Tucson. Armstrong says extending patients' ulcer-free days using treatment and prevention is essential, according to a report from Armstrong and his co-authors.

    The manuscript appears in the June 15 issue of the New England Journal of Medicine.

    "This paper is the first of its kind to call attention to remission," says Armstrong, also a member of the BIO5 Institute. "The word 'remission' has been mentioned in the literature over the last few years. But this is the loudest call yet, and more than any other work before, (it) lays out data in a way that sort of flips the script from healing to what we do in between healed wounds."

    Indications of diabetic foot ulcers include a lessened ability to feel pain coupled with repetitive stress on specific areas of the foot. Once healed, as many as 40 percent of patients will have recurrence of some kind in a year. This rises to three-quarters of patients by five years.

    Armstrong likens diabetes to cancer because the morbidity and mortality are similar. But clinicians have yet to treat diabetes like cancer, he says.

    "Diabetes can be more significant than many forms of cancer," Armstrong says. "This is a concept that's misaligned right now in medicine. As we move toward diseases of decay, as I call them — things like cancer, cardiovascular disease, diabetes — our goal as physicians, surgeons, scientists and policymakers is to delay that decay."

    Diabetes is unique, Armstrong says, because people can unknowingly injure themselves. "People can wear a hole in their foot just as you or I might wear a hole in a sock," he says. "These sores are covered up by a shoe or a sock, and very often a person with diabetes may feel little or no pain."

    But developing a diabetic foot ulcer means a person's chances of living an additional 10 years are half that of someone who has not developed one, Armstrong says. What's more, foot ulcers and infections dramatically increase a person's chances of being admitted to the hospital.

    "We looked at the data from 5 billion outpatient visits and found that diabetic foot ulcers and diabetic foot infections were astonishingly high-risk factors for hospitalization," Armstrong says. According to the study in the New England Journal of Medicine and cited in the May issue of the journal Diabetes Care, the admission rate was comparable to, or exceeding, that of congestive heart failure, kidney disease, depression and most types of cancer.

    To realign the way in which diabetes is viewed and treated, Armstrong says physicians must begin talking with their patients about severe complications, the way they talk with their patients about cancer, and emphasize that with new technologies and continuous care, such as careful dosing of physical activity, remission can be prolonged.

    "The real idea here is for physicians to help people move through their world a little better and give them more ulcer-free days and more activity-rich days," Armstrong says. "We want to keep our patients moving, so they’re not on the sidelines of life."

    Dr. Andrew J.M. Boulton of the University of Manchester, United Kingdom, and Sicco A. Bus of the University of Amsterdam, Netherlands, are co-authors of the study.

    NEJM paper: http://www.nejm.org/doi/full/10.1056/NEJMra1615439

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