WASHINGTON (Reuters) - Reebok International Ltd has agreed to pay $25 million to settle charges that it made unsupported claims that its "toning shoes" provide extra muscle strength, the U.S. Federal Trade Commission said on Wednesday.
The money will go toward consumer refunds.
Reebok advertisements said the shoes strengthened hamstrings and calves by up to 11 percent more than regular sneakers, and toned the buttocks by up to 28 percent more, the FTC said.
"To its credit, Reebok pulled these ads sometime in the middle of our investigation," David Vladeck, head of the FTC's Consumer Protection Bureau.
Toning shoes are designed to be slightly unstable. Makers of such shoes often say the instability requires the wearer to work harder, thus strengthening muscles.
"We did get consumer complaints. We watch TV. We read the newspapers," said Vladeck. "There is no such thing as a no-work, no-sweat way to a fit and healthy body."
Adidas, which owns Reebok, said in a statement that it disagreed with the FTC and stood behind the shoes.
"The (FTC) allegations suggested that the testing we conducted did not substantiate certain claims used in the advertising of our EasyTone line of products," Adidas said. "In order to avoid a protracted legal battle, Reebok has chosen to settle with the FTC. Settling does not mean we agreed with the FTC's allegations; we do not."
The company added, "We stand behind our EasyTone technology -- the first shoe in the toning category that was inspired by balance-ball training."
A variety of companies advertise toning shoes, including New Balance, Skechers, Ryka and Avia.
Skechers acknowledged in an August filing with the Securities and Exchange Commission that the FTC was looking at its advertisements for its Shape-ups and other toning shoes.
The FTC said Reebok began making the claims about its EasyTone and RunTone shoes in early 2009, and provided statistics about the purported benefits of the shoes.
The refunds to customers will be made available either directly from the FTC or through a court-approved class-action lawsuit, the agency said.
By Diane Bartz in Washington and Nivedita Bhattacharjee in Bangalore | Reuters
Wednesday, September 28, 2011
Friday, September 23, 2011
What Your Nails Say About You
Toenail and fingernail disorders may signal problems that reach far beyond your fingers and toes. Nail abnormalities often indicate an underlying medical condition or a deficiency in certain vitamins and minerals. Warning signs to look out for include yellow nail discoloration, nail splitting, nail cracking, black fingernails, ridges on nails, and white spots on fingernails. So even if you skip regular manicures and pedicures pay close attention to your nails and discuss any toenail or fingernail changes or disorders with your doctor.
Nail Splitting and Nail Cracking: Split nails or cracked nails can be problematic all on their own, but they can also be fingernail disorders that signal another health problem. Nail splitting and nail cracking can be due to a thyroid condition (hyperthyroidism or hypothyroidism) or psoriasis. If you find that your nails are brittle or split or crack easily and often, talk to your doctor about health conditions that may be responsible.
Soft or Brittle Nails: Fingernails that are soft to the touch or flake apart easily are commonly caused by a lack of the protein keratin. Keratin deficiency often results from crash dieting or some other sudden dietary changes. A protein-rich diet can reverse the damage, as can taking a daily supplement of biotin, a B vitamin. Other causes of soft or brittle nails include chemicals in products used as part of a manicure or pedicure (such as acetone and methyl acrylate), and health conditions, including Crohn’s disease and anemia.
Ingrown Nails: When nails grow into the skin instead of straight, an ingrown nail occurs. This painful toenail and fingernail disorder is most often caused by an injury to the nail — someone steps on your foot or you stub your toe — or from wearing shoes that don't fit properly. But nail disorders such as a nail fungus can also trigger an ingrown nail. Ask your doctor if you can attempt to treat an ingrown nail yourself; a severely ingrown nail may require antibiotics to prevent an infection or minor surgery to remove some or the entire ingrown nail.
Nail Fungus and Yellow Nails: Nails that crumble and break, turn yellow, or begin to smell may signal a fungal infection, also known as onychomycosis, which can affect fingers or toes. You may have picked up the toenail fungus in a public pool or locker room — any place that's moist and warm. Have your nails inspected by a doctor who can confirm the diagnosis and recommend treatment, either with an anti-fungal cream or a course of oral antifungal medication. Frequent fungal infections may indicate a weakened immune system, a health problem like diabetes, or poor circulation. To prevent toenail fungus, keep your feet clean and dry, and wear shoes or sandals in public places.
Black Lines in Nails: A black line or streak that appears in a nail is often from some type of injury. But if you don't remember accidentally whacking your index finger or stubbing your toe on a table leg, start looking elsewhere for an explanation. These black lines could be warning signs of melanoma, an extremely dangerous type of skin cancer, so you should see a doctor to have them checked out.
Blood under Nails: You can accumulate blood under a nail when the nail has been injured — hit against something, crushed, pinched, or otherwise traumatized. The nail may look black due to the blood that pools beneath it, and the nail may eventually fall off. Sometimes, to alleviate pain and pressure, it’s necessary for a doctor to puncture a small hole in the nail to allow the blood to drain. Splinter-like streaks of red may be caused by an injury, but they could possibly indicate an infection of a heart valve, which showers the bloodstream with debris that causes the marks to appear. If you see streaks of red in your nails when you haven't injured them, ask your doctor about it.
Ridges on Nails: Ridges on nails can be more than unsightly — they may indicate a nutritional deficiency. Ridges on nails can be a sign of malnourishment or a specific deficiency in iron, in which case you may also have depressed areas on the nail. Horizontal ridges on nails can also result from arsenic poisoning. See a doctor for evaluation if you notice ridges forming on your nails.
White Spots on Fingernails: White spots on fingernails are generally of no concern. They usually occur as a result of a minor injury to the nail that you may not even remember. Over time, they grow out and are clipped or filed off. But if you frequently see white spots on your fingernails and find that they don't go away, you may have an infection that requires medical attention.
Nail Splitting and Nail Cracking: Split nails or cracked nails can be problematic all on their own, but they can also be fingernail disorders that signal another health problem. Nail splitting and nail cracking can be due to a thyroid condition (hyperthyroidism or hypothyroidism) or psoriasis. If you find that your nails are brittle or split or crack easily and often, talk to your doctor about health conditions that may be responsible.
Soft or Brittle Nails: Fingernails that are soft to the touch or flake apart easily are commonly caused by a lack of the protein keratin. Keratin deficiency often results from crash dieting or some other sudden dietary changes. A protein-rich diet can reverse the damage, as can taking a daily supplement of biotin, a B vitamin. Other causes of soft or brittle nails include chemicals in products used as part of a manicure or pedicure (such as acetone and methyl acrylate), and health conditions, including Crohn’s disease and anemia.
Ingrown Nails: When nails grow into the skin instead of straight, an ingrown nail occurs. This painful toenail and fingernail disorder is most often caused by an injury to the nail — someone steps on your foot or you stub your toe — or from wearing shoes that don't fit properly. But nail disorders such as a nail fungus can also trigger an ingrown nail. Ask your doctor if you can attempt to treat an ingrown nail yourself; a severely ingrown nail may require antibiotics to prevent an infection or minor surgery to remove some or the entire ingrown nail.
Nail Fungus and Yellow Nails: Nails that crumble and break, turn yellow, or begin to smell may signal a fungal infection, also known as onychomycosis, which can affect fingers or toes. You may have picked up the toenail fungus in a public pool or locker room — any place that's moist and warm. Have your nails inspected by a doctor who can confirm the diagnosis and recommend treatment, either with an anti-fungal cream or a course of oral antifungal medication. Frequent fungal infections may indicate a weakened immune system, a health problem like diabetes, or poor circulation. To prevent toenail fungus, keep your feet clean and dry, and wear shoes or sandals in public places.
Black Lines in Nails: A black line or streak that appears in a nail is often from some type of injury. But if you don't remember accidentally whacking your index finger or stubbing your toe on a table leg, start looking elsewhere for an explanation. These black lines could be warning signs of melanoma, an extremely dangerous type of skin cancer, so you should see a doctor to have them checked out.
Blood under Nails: You can accumulate blood under a nail when the nail has been injured — hit against something, crushed, pinched, or otherwise traumatized. The nail may look black due to the blood that pools beneath it, and the nail may eventually fall off. Sometimes, to alleviate pain and pressure, it’s necessary for a doctor to puncture a small hole in the nail to allow the blood to drain. Splinter-like streaks of red may be caused by an injury, but they could possibly indicate an infection of a heart valve, which showers the bloodstream with debris that causes the marks to appear. If you see streaks of red in your nails when you haven't injured them, ask your doctor about it.
Ridges on Nails: Ridges on nails can be more than unsightly — they may indicate a nutritional deficiency. Ridges on nails can be a sign of malnourishment or a specific deficiency in iron, in which case you may also have depressed areas on the nail. Horizontal ridges on nails can also result from arsenic poisoning. See a doctor for evaluation if you notice ridges forming on your nails.
White Spots on Fingernails: White spots on fingernails are generally of no concern. They usually occur as a result of a minor injury to the nail that you may not even remember. Over time, they grow out and are clipped or filed off. But if you frequently see white spots on your fingernails and find that they don't go away, you may have an infection that requires medical attention.
Wednesday, September 21, 2011
Compression stockings: One size definitely does not fit all
Proper selection and sizing of compression hosiery can be confusing, but both are essential for control of edema and management of more serious vascular conditions in patients with diabetes. And then there’s the even more challenging issue of patient compliance.
By Shalmali Pal
Fit shoes in the afternoon and compression stockings in the morning. That’s the simple but effective rule that works for Bill Meanwell, CPed, founder, CEO, and director of the International School of Pedorthics in Broken Arrow, OK.
Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner at Foot and Ankle Associates of North Texas in Grapevine, also follows a similarly streamlined model.
“For diabetics, usually we use 15 to 20 mmHg compression for those with edema and 10 to 15 mmHg for those without. Anything higher than 20 mmHg compression, patients should be custom measured by a physician, especially if they have peripheral arterial disease,” she said.
Indeed, the application of compression stockings would seem to be fairly cut and dry: Take leg measurements, use the manufacturer’s guidelines for determining the level of compression, choose a style, and hand over to the patient.
But not all diabetic patients are created equal, and neither are compression stockings. At one end of the spectrum are patients who may benefit from support pantyhose for light pressure to prevent or reduce mild swelling, a condition that is not only uncomfortable but can delay wound healing in diabetic patients. At the other end are those who suffer from significant edema or venous leg ulcers who are candidates for prescription-strength compression stockings. And then there are patients with peripheral arterial disease (PAD) and peripheral vascular disease (PVD). Issues that need to be addressed when prescribing compression hosiery include proper diagnosis, accurate measurements, and, of course, patient compliance.
Spotting vascular issues
While it may seem obvious, PAD and PVD require consideration beyond a visibly swollen leg, said David G. Armstrong, DPM, MD, PhD, professor of surgery at the University of Arizona College of Medicine and director of Southern Arizona Limb Salvage Alliance (SALSA), both in Tucson.
Some, but not all PAD and PVD sufferers, will show signs of intermittent claudication. But if the patient never walks far or long enough for leg pain or cramps to set in, then claudication may not manifest. Other symptoms to look for include:
Weak or tired legs
Difficulty with walking or balance
Cold and numb toes or feet
Slow-healing sores
Foot pain even while at rest
The prescription for compression hosiery in diabetic patients with PAD or PVD needs to come from a clinician. Armstrong offered a general guideline for when compression hosiery are appropriate.
“As long as the patient doesn’t have tremendously low outflow pressure into the extremity, I think it’s safe for them to wear compression hose,” he said. “If their outflow pressure is below the relatively mild amount of pressure applied by a compression stocking–for example, if the outflow pressure is below 30 or 40 mmHg–then that’s significant ischemia and the person has bigger problems that just swollen legs. They should be evaluated promptly by a vascular surgeon. The key is knowing this and measuring it. As we often say at SALSA, ‘You can’t manage what you can’t measure’.”
Measure for measure
Improper compression hosiery usage and incorrect sizing has been a recognized problem in the foot health community, but not necessarily well documented. Graduated compression stocks that are sized incorrectly may actually increase the incidence of vascular disease and may even lead to skin breakdown, neither of which are ideal in any patient, diabetic or otherwise. In a study published in the August 2002 issue of Medsurg Nursing, a group of nurses was interviewed about their fit technique for graduated compression stockings, and only two of 15 said that they measured the patient’s leg to determine the correct size.
In a 2008 study, researchers at Presbyterian Hospital in Dallas sought to determine if healthcare practitioners were correctly sizing compression stockings, how the patients rated the comfort level of the stockings, and whether they understood the purpose of the hosiery. The study population was made up of hospitalized, postoperative patients, and nurses dispensed the stockings, but the results can be applied to diabetic patients as well, according to lead author Elizabeth H. Winslow, PhD, RN, FAAN.
While it is important to note that there are differences between postop patients and diabetic patients in terms of their compression needs, a good fit is a universal must. Additionally, many of the issues that Winslow’s group saw in their study population may also crop up with diabetic patients.
“Any patient who has compression stockings prescribed needs to wear the appropriate size; know how to size, and use the stockings correctly,” Winslow said. “Patients, and their family members, also need to realize that the leg size may change. If swelling significantly increases or decreases, the patient will need to be re-measured to determine if another size is needed.”
The final study group consisted of 142 patients, the majority of whom (74%) were overweight. The most common type of surgery was gynecological (53%) followed by orthopedic surgery (41%). Seventy-four percent of all patients were prescribed knee-length stockings, and 26% wore thigh-length stockings.
Winslow and coauthor Debra Brosz, MSN, RN, ONC, NEA-BC, found that the compression stockings were used incorrectly in 29% of the patients, with the most common problems being that the stockings were rolled down or too loose. The authors did not ascertain if the stockings were deliberately rolled down by patients, Winslow said. But diabetic patients will be tempted to turn down the band at the top of the stockings, especially if the leg swells and the hosiery feels tighter.
Also, patients with a thigh circumference of greater than 25 inches were given thigh-high stockings when knee-length would have been more appropriate. However, a larger size than appropriate was prescribed in 26% of the patients wearing knee-length hosiery. In patients with a body mass index of 25 or more, the thigh-length stockings were more likely to be used improperly than the knee-length stockings. The findings were published in the September 2008 issue of the American Journal of Nursing.
The authors acknowledged that, in some cases, stockings were initially sized correctly, but subsequent swelling brought on changes to the patients’ needs (see Tables 1 and 2). Winslow also pointed out that patients with neuropathy “may have difficulty feeling any pressure areas or problems from the stockings until serious skin damage has occurred.” Again, stockings need to be measured and re-measured to meet the patient’s evolving needs.
Nancy Elftman, CO, CPed, stressed the importance of obtaining Ankle-Brachial Index (ABI) measurements.
“You have to know the ABI to put the stocking on,” said Elftman, founder of Hands on Foot in La Verne, CA. “If the ABI is less than 0.6, then it’s an arterial disease, not a venous disease, and you cannot put compression on it.”
Compression can actually worsen the already limited blood flow in patients with peripheral arterial disease and potentially induce ischemia.
“If (the ABI) between 0.6 and 0.8, then it’s a combination of venous and arterial and for that, you can only use a 20 mmHg stocking. If it’s a 0.8 to a 1.0 ABI, then that’s purely venous and you can use a 30-40 mmHg,” Elftman added. (see Table 3).
Knee vs thigh
In Winslow’s study, patients expressed a preference for knee-high stockings over thigh-high ones. They also found that more problems arose when patients were given thigh-high stockings. Their findings led to a policy change at their institution: Nurses are encouraged to work with physicians and nurse practitioners to make sure that knee-length stockings are prescribed. In addition, “we have removed the thigh-length stockings from all of our buildings.”
A patient survey done at California State University in Sacramento found that knee-length sequential compression devices for preventing deep venous thrombosis were more comfortable for patients, encouraged a higher level of compliance with treatment, and were less expensive. That study was published in the July/September 2007 issue of Critical Care Nursing Quarterly.
A systematic review of 14 randomized trials in hospitalized populations and passengers on long haul flights found that knee-length stockings did not appear to be worse than thigh length in hospitalized patients. That study, published in the December 2006 issue of the European Journal of Vascular and Endovascular surgery, found that knee-length stockings were actually better in passengers in flight for preventing DVT.
An earlier study done at Semmelweis University in Budapest, noted knee stockings were less efficient at increasing venous outflow in postoperative patients, although they were deemed more comfortable and less likely to wrinkle. Those findings were reported in the February 2001 issue of Clinical Orthopaedics and Related Research.
But Elftman said that, in her experience, there are really only two circumstances where a thigh length stocking would be more appropriate in diabetic patients: If the patient has lymphedema, or if the patient prefers a longer stocking.
“Women, especially if they wear skirts, want [the stocking] to be up higher. Some patients have trouble with knee stockings rolling down so they’d rather have it go up higher. But as far as the physiological effects, the knee down is what you are working on,” she said.
Elftman pointed out that, according to noted vascular surgeon John Bergan, MD, founder of the Vein Institute of La Jolla in California, “it really doesn’t do any good in terms of compression to go to the thigh. There is so much volume in the thigh, it’s not really producing hydraulic compression. He says go to the knee unless they feel better having a higher stocking. It would be for patient preference, not for the compression.”
Armstrong said that at his institution, knee highs are preferred over thigh highs because many of the patients simply cannot manage longer stockings. The hemmed band can be difficult to negotiate over a thigh with a larger circumference, while the stockings that are attached with a bit may prove tricky to attach.
Compression and compliance
An October 2006 study published in the Journal of Vascular Surgery looked at the prevention of venous ulceration recurrence using class 2 and class 3 elastic compression. No surprise that the lowest recurrence rate was seen in patients who wore the highest degree of compression. The authors concluded that “patients should wear the highest level of compression that is comfortable.”
But the most effective level of compression and patient comfort don’t always jibe. One of the best ways to ensure compliance is to, once again, make sure that the stocking has been properly fitted. In Winslow’s study, one of the most common problems with the thigh-high stockings is that they were rolled down.
Another key is making sure that the patient understands what the intention is behind the compression stocking.
“As clinicians, you can’t assume that just because you said something, someone knows it and internalizes it. The key for clinicians treating people at high risk is to stay on-message. Every single person that sees a patient has to be talking to him with that same message. The more you drive home that message, the better adherence will be,” Armstrong said.
Elftman said she first does a trial run.
“We take the measurements together and then we put [the patient] in an Unna boot or an Ace wrap for a week,” she said. “They come back and we do the measurements again. Just during that week, they can see the difference, the decrease in the size of the leg. So by the time we measure for the stockings, [the patient has] seen the decrease and are much more compliant. You really have to build them up to it.”
Elftman also drives home that the stockings must be removed every night. Because the stockings can be difficult to put on, some patients prefer to leave them in place, but Elftman strongly discourages that, explaining to the patient that the small radius of compression in the heel could cause an ischemic ulcer.
Even if the patient comprehends the point of the stocking, clinicians also need to look beyond their vascular issues. Armstrong shared the case of a patient with mixed arteriovenous disease who needed to wear his compression hosiery. But Armstrong’s team had to overcome a major obstacle before they could get this patient into his stockings.
“(This patient) had some substance abuse problems,” Armstrong explained. “He was self-medicating when he initially came to see us and, in a fit of mania, he had ground a hole into his ankle and part of his foot with a PedEgg callus trimming device. He was committed to using that PedEgg on his calluses. We had to convince him that the hole in his skin was not a positive result of his PedEgg regimen. But when we tried to take the PedEgg away from him, he totally shut down. We were unable to communicate and he refused to even work with us. So instead of taking away the PedEgg, we focused on teaching him how to use it appropriately and safely—and checking in on him frequently.”
Once the wounds had healed, and Armstrong’s team were confident that the patient understood how to use his pedicure aid properly, the stockings were introduced.
“He is now very adherent, uses his hose diligently, and reports to us regularly and passionately about his stockings and his PedEgg use. He is now a partner rather than an opponent,” Armstrong said.
Compression stocking measurements: Dos and Don’ts
Do measure and fit the stockings according to the manufacturer’s recommendation.
Do document leg measurements and stocking size at baseline.
Do check the stockings to ensure correct usage and adequate perfusion.
Don’t assume that leg measurements are set in stone. Review measurements regularly to check for swelling and excessive pressure from the stockings.
Don’t let the patient go for more than one day without removing the stockings and performing a skin assessment.
Don’t monitor patients while they are lying down. Placing the patient in a seated position can help determine if the stockings are acting like a tourniquet.
Source: Adapted from Best Practice: Graduated compression stockings for the prevention of post-operative venous thromboembolism 12:4, 1-4, 2008, The Joanna Briggs Institute
Seven steps to obtaining the right measurements
1. Measure the circumference of the ankle around the narrowest part, above the ankle bone.
2. Measure the circumference of the widest part of the calf.
3. Measure the length of the calf from the back of the heel to the bend in the knee.
4. Measure the circumference of the widest part of the thigh just below the gluteal fold.
5. Measure the length of the thigh from the gluteal fold to the back of the heel.
6. Measure the circumference of the widest part of the hips.
7. Measure the circumference of the waist.
ABI measurements
Tools needed
Sphygmomanometer with appropriately sized cuff(s) for both arm and ankle
Hand-held Doppler ultrasound device with vascular probe
Conductivity gel compatible with Dipper ultrasound device
Calculating ABI
1. Measure brachial systolic pressure in both arms.
2. Measure posterial tibial and dorsalis pedis systolic pressures in both legs.
3. Divide each ankle systolic pressure by the brachial systolic pressure.
ABI key
Normal: 1.0-1.1
Borderline: 0.91-0.99
Abnormal: <0.9 or >1.3
Source: Adapted from Ankle-Brachial Index: A Diagnostic Tool for Peripheral Arterial Disease, American Academy of Nurse Practitioners
Compression cross-checked: Flight-related data and diabetes
The subject of vascular problems and long-haul flights has taken off in recent years. Multiple studies have shown that being airborne for more than 10 hours increases the risk of deep venous thrombosis (DVT) or edema. However, the risk of both conditions can be reduced with compression hosiery.
The question for lower extremity practitioners is: Is the research on “travel stockings” relevant for diabetic patients? Yes, according to Armstrong.
“I think these (results) apply equally to people with and without diabetes,” he said. “The key for the people with diabetes is that they are under the care of a diabetologist, a vascular specialist, and a foot specialist. You have to make sure that they’ve been properly assessed by one or all of those specialists in terms of their risk for DVT.”
Results from the LONFLIT4-Concorde study are the most relevant to diabetic patients. Conducted by the A San Valentino Vascular Screening Project in Chieti, Italy, the study evaluated edema during seven to eight hours flights and whether it could be controlled with compression stockings (20 to 30 mmHg). There were 144 subjects (74 in the stocking group and 76 in the control group), all of whom had edema-associated microangiopathy from diabetes, venous hypertension, or anti-hypertensive treatment.
The level of edema was comparable in the two groups at baseline. Post-flight, the stocking group’s average edema score was three times lower than in the control group (P < 0.05). Also, there were no cases of DVT in the stocking group, compared to a 3% incidence in the control group. The level of compression was well tolerated in both groups. The results were published in the March-April 2003 issue of Angiology.
By Shalmali Pal
Fit shoes in the afternoon and compression stockings in the morning. That’s the simple but effective rule that works for Bill Meanwell, CPed, founder, CEO, and director of the International School of Pedorthics in Broken Arrow, OK.
Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner at Foot and Ankle Associates of North Texas in Grapevine, also follows a similarly streamlined model.
“For diabetics, usually we use 15 to 20 mmHg compression for those with edema and 10 to 15 mmHg for those without. Anything higher than 20 mmHg compression, patients should be custom measured by a physician, especially if they have peripheral arterial disease,” she said.
Indeed, the application of compression stockings would seem to be fairly cut and dry: Take leg measurements, use the manufacturer’s guidelines for determining the level of compression, choose a style, and hand over to the patient.
But not all diabetic patients are created equal, and neither are compression stockings. At one end of the spectrum are patients who may benefit from support pantyhose for light pressure to prevent or reduce mild swelling, a condition that is not only uncomfortable but can delay wound healing in diabetic patients. At the other end are those who suffer from significant edema or venous leg ulcers who are candidates for prescription-strength compression stockings. And then there are patients with peripheral arterial disease (PAD) and peripheral vascular disease (PVD). Issues that need to be addressed when prescribing compression hosiery include proper diagnosis, accurate measurements, and, of course, patient compliance.
Spotting vascular issues
While it may seem obvious, PAD and PVD require consideration beyond a visibly swollen leg, said David G. Armstrong, DPM, MD, PhD, professor of surgery at the University of Arizona College of Medicine and director of Southern Arizona Limb Salvage Alliance (SALSA), both in Tucson.
Some, but not all PAD and PVD sufferers, will show signs of intermittent claudication. But if the patient never walks far or long enough for leg pain or cramps to set in, then claudication may not manifest. Other symptoms to look for include:
Weak or tired legs
Difficulty with walking or balance
Cold and numb toes or feet
Slow-healing sores
Foot pain even while at rest
The prescription for compression hosiery in diabetic patients with PAD or PVD needs to come from a clinician. Armstrong offered a general guideline for when compression hosiery are appropriate.
“As long as the patient doesn’t have tremendously low outflow pressure into the extremity, I think it’s safe for them to wear compression hose,” he said. “If their outflow pressure is below the relatively mild amount of pressure applied by a compression stocking–for example, if the outflow pressure is below 30 or 40 mmHg–then that’s significant ischemia and the person has bigger problems that just swollen legs. They should be evaluated promptly by a vascular surgeon. The key is knowing this and measuring it. As we often say at SALSA, ‘You can’t manage what you can’t measure’.”
Measure for measure
Improper compression hosiery usage and incorrect sizing has been a recognized problem in the foot health community, but not necessarily well documented. Graduated compression stocks that are sized incorrectly may actually increase the incidence of vascular disease and may even lead to skin breakdown, neither of which are ideal in any patient, diabetic or otherwise. In a study published in the August 2002 issue of Medsurg Nursing, a group of nurses was interviewed about their fit technique for graduated compression stockings, and only two of 15 said that they measured the patient’s leg to determine the correct size.
In a 2008 study, researchers at Presbyterian Hospital in Dallas sought to determine if healthcare practitioners were correctly sizing compression stockings, how the patients rated the comfort level of the stockings, and whether they understood the purpose of the hosiery. The study population was made up of hospitalized, postoperative patients, and nurses dispensed the stockings, but the results can be applied to diabetic patients as well, according to lead author Elizabeth H. Winslow, PhD, RN, FAAN.
While it is important to note that there are differences between postop patients and diabetic patients in terms of their compression needs, a good fit is a universal must. Additionally, many of the issues that Winslow’s group saw in their study population may also crop up with diabetic patients.
“Any patient who has compression stockings prescribed needs to wear the appropriate size; know how to size, and use the stockings correctly,” Winslow said. “Patients, and their family members, also need to realize that the leg size may change. If swelling significantly increases or decreases, the patient will need to be re-measured to determine if another size is needed.”
The final study group consisted of 142 patients, the majority of whom (74%) were overweight. The most common type of surgery was gynecological (53%) followed by orthopedic surgery (41%). Seventy-four percent of all patients were prescribed knee-length stockings, and 26% wore thigh-length stockings.
Winslow and coauthor Debra Brosz, MSN, RN, ONC, NEA-BC, found that the compression stockings were used incorrectly in 29% of the patients, with the most common problems being that the stockings were rolled down or too loose. The authors did not ascertain if the stockings were deliberately rolled down by patients, Winslow said. But diabetic patients will be tempted to turn down the band at the top of the stockings, especially if the leg swells and the hosiery feels tighter.
Also, patients with a thigh circumference of greater than 25 inches were given thigh-high stockings when knee-length would have been more appropriate. However, a larger size than appropriate was prescribed in 26% of the patients wearing knee-length hosiery. In patients with a body mass index of 25 or more, the thigh-length stockings were more likely to be used improperly than the knee-length stockings. The findings were published in the September 2008 issue of the American Journal of Nursing.
The authors acknowledged that, in some cases, stockings were initially sized correctly, but subsequent swelling brought on changes to the patients’ needs (see Tables 1 and 2). Winslow also pointed out that patients with neuropathy “may have difficulty feeling any pressure areas or problems from the stockings until serious skin damage has occurred.” Again, stockings need to be measured and re-measured to meet the patient’s evolving needs.
Nancy Elftman, CO, CPed, stressed the importance of obtaining Ankle-Brachial Index (ABI) measurements.
“You have to know the ABI to put the stocking on,” said Elftman, founder of Hands on Foot in La Verne, CA. “If the ABI is less than 0.6, then it’s an arterial disease, not a venous disease, and you cannot put compression on it.”
Compression can actually worsen the already limited blood flow in patients with peripheral arterial disease and potentially induce ischemia.
“If (the ABI) between 0.6 and 0.8, then it’s a combination of venous and arterial and for that, you can only use a 20 mmHg stocking. If it’s a 0.8 to a 1.0 ABI, then that’s purely venous and you can use a 30-40 mmHg,” Elftman added. (see Table 3).
Knee vs thigh
In Winslow’s study, patients expressed a preference for knee-high stockings over thigh-high ones. They also found that more problems arose when patients were given thigh-high stockings. Their findings led to a policy change at their institution: Nurses are encouraged to work with physicians and nurse practitioners to make sure that knee-length stockings are prescribed. In addition, “we have removed the thigh-length stockings from all of our buildings.”
A patient survey done at California State University in Sacramento found that knee-length sequential compression devices for preventing deep venous thrombosis were more comfortable for patients, encouraged a higher level of compliance with treatment, and were less expensive. That study was published in the July/September 2007 issue of Critical Care Nursing Quarterly.
A systematic review of 14 randomized trials in hospitalized populations and passengers on long haul flights found that knee-length stockings did not appear to be worse than thigh length in hospitalized patients. That study, published in the December 2006 issue of the European Journal of Vascular and Endovascular surgery, found that knee-length stockings were actually better in passengers in flight for preventing DVT.
An earlier study done at Semmelweis University in Budapest, noted knee stockings were less efficient at increasing venous outflow in postoperative patients, although they were deemed more comfortable and less likely to wrinkle. Those findings were reported in the February 2001 issue of Clinical Orthopaedics and Related Research.
But Elftman said that, in her experience, there are really only two circumstances where a thigh length stocking would be more appropriate in diabetic patients: If the patient has lymphedema, or if the patient prefers a longer stocking.
“Women, especially if they wear skirts, want [the stocking] to be up higher. Some patients have trouble with knee stockings rolling down so they’d rather have it go up higher. But as far as the physiological effects, the knee down is what you are working on,” she said.
Elftman pointed out that, according to noted vascular surgeon John Bergan, MD, founder of the Vein Institute of La Jolla in California, “it really doesn’t do any good in terms of compression to go to the thigh. There is so much volume in the thigh, it’s not really producing hydraulic compression. He says go to the knee unless they feel better having a higher stocking. It would be for patient preference, not for the compression.”
Armstrong said that at his institution, knee highs are preferred over thigh highs because many of the patients simply cannot manage longer stockings. The hemmed band can be difficult to negotiate over a thigh with a larger circumference, while the stockings that are attached with a bit may prove tricky to attach.
Compression and compliance
An October 2006 study published in the Journal of Vascular Surgery looked at the prevention of venous ulceration recurrence using class 2 and class 3 elastic compression. No surprise that the lowest recurrence rate was seen in patients who wore the highest degree of compression. The authors concluded that “patients should wear the highest level of compression that is comfortable.”
But the most effective level of compression and patient comfort don’t always jibe. One of the best ways to ensure compliance is to, once again, make sure that the stocking has been properly fitted. In Winslow’s study, one of the most common problems with the thigh-high stockings is that they were rolled down.
Another key is making sure that the patient understands what the intention is behind the compression stocking.
“As clinicians, you can’t assume that just because you said something, someone knows it and internalizes it. The key for clinicians treating people at high risk is to stay on-message. Every single person that sees a patient has to be talking to him with that same message. The more you drive home that message, the better adherence will be,” Armstrong said.
Elftman said she first does a trial run.
“We take the measurements together and then we put [the patient] in an Unna boot or an Ace wrap for a week,” she said. “They come back and we do the measurements again. Just during that week, they can see the difference, the decrease in the size of the leg. So by the time we measure for the stockings, [the patient has] seen the decrease and are much more compliant. You really have to build them up to it.”
Elftman also drives home that the stockings must be removed every night. Because the stockings can be difficult to put on, some patients prefer to leave them in place, but Elftman strongly discourages that, explaining to the patient that the small radius of compression in the heel could cause an ischemic ulcer.
Even if the patient comprehends the point of the stocking, clinicians also need to look beyond their vascular issues. Armstrong shared the case of a patient with mixed arteriovenous disease who needed to wear his compression hosiery. But Armstrong’s team had to overcome a major obstacle before they could get this patient into his stockings.
“(This patient) had some substance abuse problems,” Armstrong explained. “He was self-medicating when he initially came to see us and, in a fit of mania, he had ground a hole into his ankle and part of his foot with a PedEgg callus trimming device. He was committed to using that PedEgg on his calluses. We had to convince him that the hole in his skin was not a positive result of his PedEgg regimen. But when we tried to take the PedEgg away from him, he totally shut down. We were unable to communicate and he refused to even work with us. So instead of taking away the PedEgg, we focused on teaching him how to use it appropriately and safely—and checking in on him frequently.”
Once the wounds had healed, and Armstrong’s team were confident that the patient understood how to use his pedicure aid properly, the stockings were introduced.
“He is now very adherent, uses his hose diligently, and reports to us regularly and passionately about his stockings and his PedEgg use. He is now a partner rather than an opponent,” Armstrong said.
Compression stocking measurements: Dos and Don’ts
Do measure and fit the stockings according to the manufacturer’s recommendation.
Do document leg measurements and stocking size at baseline.
Do check the stockings to ensure correct usage and adequate perfusion.
Don’t assume that leg measurements are set in stone. Review measurements regularly to check for swelling and excessive pressure from the stockings.
Don’t let the patient go for more than one day without removing the stockings and performing a skin assessment.
Don’t monitor patients while they are lying down. Placing the patient in a seated position can help determine if the stockings are acting like a tourniquet.
Source: Adapted from Best Practice: Graduated compression stockings for the prevention of post-operative venous thromboembolism 12:4, 1-4, 2008, The Joanna Briggs Institute
Seven steps to obtaining the right measurements
1. Measure the circumference of the ankle around the narrowest part, above the ankle bone.
2. Measure the circumference of the widest part of the calf.
3. Measure the length of the calf from the back of the heel to the bend in the knee.
4. Measure the circumference of the widest part of the thigh just below the gluteal fold.
5. Measure the length of the thigh from the gluteal fold to the back of the heel.
6. Measure the circumference of the widest part of the hips.
7. Measure the circumference of the waist.
ABI measurements
Tools needed
Sphygmomanometer with appropriately sized cuff(s) for both arm and ankle
Hand-held Doppler ultrasound device with vascular probe
Conductivity gel compatible with Dipper ultrasound device
Calculating ABI
1. Measure brachial systolic pressure in both arms.
2. Measure posterial tibial and dorsalis pedis systolic pressures in both legs.
3. Divide each ankle systolic pressure by the brachial systolic pressure.
ABI key
Normal: 1.0-1.1
Borderline: 0.91-0.99
Abnormal: <0.9 or >1.3
Source: Adapted from Ankle-Brachial Index: A Diagnostic Tool for Peripheral Arterial Disease, American Academy of Nurse Practitioners
Compression cross-checked: Flight-related data and diabetes
The subject of vascular problems and long-haul flights has taken off in recent years. Multiple studies have shown that being airborne for more than 10 hours increases the risk of deep venous thrombosis (DVT) or edema. However, the risk of both conditions can be reduced with compression hosiery.
The question for lower extremity practitioners is: Is the research on “travel stockings” relevant for diabetic patients? Yes, according to Armstrong.
“I think these (results) apply equally to people with and without diabetes,” he said. “The key for the people with diabetes is that they are under the care of a diabetologist, a vascular specialist, and a foot specialist. You have to make sure that they’ve been properly assessed by one or all of those specialists in terms of their risk for DVT.”
Results from the LONFLIT4-Concorde study are the most relevant to diabetic patients. Conducted by the A San Valentino Vascular Screening Project in Chieti, Italy, the study evaluated edema during seven to eight hours flights and whether it could be controlled with compression stockings (20 to 30 mmHg). There were 144 subjects (74 in the stocking group and 76 in the control group), all of whom had edema-associated microangiopathy from diabetes, venous hypertension, or anti-hypertensive treatment.
The level of edema was comparable in the two groups at baseline. Post-flight, the stocking group’s average edema score was three times lower than in the control group (P < 0.05). Also, there were no cases of DVT in the stocking group, compared to a 3% incidence in the control group. The level of compression was well tolerated in both groups. The results were published in the March-April 2003 issue of Angiology.
Tuesday, September 20, 2011
The shoe review: From high heels to low flats, local podiatrists analyze footwear
Tuesday, March 15, 2011
By Robyn Gautschy ~ Flourish
Women have been told that sometimes they have to suffer for fashion. That is certainly true when it comes to shoes.
Whether it's sky-high stilettos or the latest sandal trend, women's shoes are not often designed for function over fashion.
Local podiatrists give us the low-down on how our feet are affected by various styles of shoes.
Furry boots
How they affect your feet: "They're very comfortable and warm, but there's not much support in them," says Dr. Hugh Protzel, podiatrist at Foot and Ankle Centers of Southeast Missouri. Wearing these popular boots may lead to heel pain, foot aches and arch pain, especially if you have flat feet. "I wouldn't go for a long walk in them," says Protzel.
As for the furry lining, doctors don't see any relationship between the material and foot fungus.
"If someone already has a problem with excessive foot sweating, they could have a problem with foot fungus. But for the average person, there shouldn't be any kind of issue," says Dr. Robert Daugherty of Advance Foot & Ankle Center.
How to find a good pair: You may want to get a prescription insert for added support, says Protzel.
Flip flops
How they affect your feet: Flip flops are a good way to protect your feet when you're hanging out at the pool, says Protzel, but if you plan on going for any length of walk, they offer no support. "They don't allow for the proper gait cycle your foot should go thorough with each step," he adds. Protzel's flip flop-wearing patients have problems with heel pain and tendinitis.
How to find a good pair: Look for sturdier sandals. Protzel says Birkenstocks offer very good support.
Stilettos
How they affect your feet: "The visual, aesthetic things going on are nice, but functionally, they are potentially deforming," says Dr. Zenon Duda, podiatrist at Cape Foot Clinic. Stilettos alter the way the head and shoulders sit, increase the arch in the back, relax the calf muscles and cause the chest to protrude. As a result, you place excessive pressure on the balls of the feet, take unnaturally short steps, and struggle to maintain stability. With long-term wear, you're likely to see hammertoes, bunions, corns and red spots. Pointy-toed heels will eventually mold your feet into a triangular shape.
How to find a good pair: If you must wear stilettos, look for a pair made of soft leather and with not many stitches -- these will be more flexible and protective than heels made of man-made materials. Duda suggests wearing them in short bursts, with time in between for the feet to breathe and stretch.
Flats
How they affect your feet: "Most don't have any cushion or support, but then again, they don't cause any problems because they're nice and wide and are often made of soft leather," says Dr. James Main, podiatrist in Cape Girardeau. "Other than if you have a problem where you need cushion or additional support, these are probably not too bad. They're better than heels or pointy shoes." Daugherty thinks most women without foot problems can get by wearing flats, but he worries about the long-term effects. "If you wear them excessively over time, you might wind up with some problems. They have no support, especially for the arches, and people that stand a lot with their jobs will probably have some pain," he says.
How to find a good pair: Look for flats with enough room for an insert -- that way, you at least have some type of arch support, said Daugherty.
Wedges
How they affect your feet: "They're a good way to hurt your ankles," said Dr. James Main, podiatrist in Cape Girardeau. "Anytime you wear a heel, you shift your body weight forward to the front of the foot, and you're inherently unstable." Like heels, wedges place more weight on the front part of the foot, which can cause knee and lower back problems, says Main. Wedges usually have no support on the sides, making it easier to lose balance and topple over. "On a wedge, the weight is at least spread out over the heel," he concedes.
How to find a good pair: "A woman should go with the very lowest heel height that she can go with. The lower the better," says Main. Many wedges have a rubberized or corklike bottom, which Main believes may add more support than a hard material.
Platform heels
How they affect your feet: Platforms are better than stilettos, but still, "Any kind of shoe that puts abnormal stresses on the balls of foot can cause problems," said Daugherty. "Occasional wear is not a big deal, but this is definitely a shoe that I don't recommend."
How to find a good pair: A stable bottom should be the No. 1 concern, says Daugherty. Wood bottoms are probably more stable and will last longer.
By Robyn Gautschy ~ Flourish
Women have been told that sometimes they have to suffer for fashion. That is certainly true when it comes to shoes.
Whether it's sky-high stilettos or the latest sandal trend, women's shoes are not often designed for function over fashion.
Local podiatrists give us the low-down on how our feet are affected by various styles of shoes.
Furry boots
How they affect your feet: "They're very comfortable and warm, but there's not much support in them," says Dr. Hugh Protzel, podiatrist at Foot and Ankle Centers of Southeast Missouri. Wearing these popular boots may lead to heel pain, foot aches and arch pain, especially if you have flat feet. "I wouldn't go for a long walk in them," says Protzel.
As for the furry lining, doctors don't see any relationship between the material and foot fungus.
"If someone already has a problem with excessive foot sweating, they could have a problem with foot fungus. But for the average person, there shouldn't be any kind of issue," says Dr. Robert Daugherty of Advance Foot & Ankle Center.
How to find a good pair: You may want to get a prescription insert for added support, says Protzel.
Flip flops
How they affect your feet: Flip flops are a good way to protect your feet when you're hanging out at the pool, says Protzel, but if you plan on going for any length of walk, they offer no support. "They don't allow for the proper gait cycle your foot should go thorough with each step," he adds. Protzel's flip flop-wearing patients have problems with heel pain and tendinitis.
How to find a good pair: Look for sturdier sandals. Protzel says Birkenstocks offer very good support.
Stilettos
How they affect your feet: "The visual, aesthetic things going on are nice, but functionally, they are potentially deforming," says Dr. Zenon Duda, podiatrist at Cape Foot Clinic. Stilettos alter the way the head and shoulders sit, increase the arch in the back, relax the calf muscles and cause the chest to protrude. As a result, you place excessive pressure on the balls of the feet, take unnaturally short steps, and struggle to maintain stability. With long-term wear, you're likely to see hammertoes, bunions, corns and red spots. Pointy-toed heels will eventually mold your feet into a triangular shape.
How to find a good pair: If you must wear stilettos, look for a pair made of soft leather and with not many stitches -- these will be more flexible and protective than heels made of man-made materials. Duda suggests wearing them in short bursts, with time in between for the feet to breathe and stretch.
Flats
How they affect your feet: "Most don't have any cushion or support, but then again, they don't cause any problems because they're nice and wide and are often made of soft leather," says Dr. James Main, podiatrist in Cape Girardeau. "Other than if you have a problem where you need cushion or additional support, these are probably not too bad. They're better than heels or pointy shoes." Daugherty thinks most women without foot problems can get by wearing flats, but he worries about the long-term effects. "If you wear them excessively over time, you might wind up with some problems. They have no support, especially for the arches, and people that stand a lot with their jobs will probably have some pain," he says.
How to find a good pair: Look for flats with enough room for an insert -- that way, you at least have some type of arch support, said Daugherty.
Wedges
How they affect your feet: "They're a good way to hurt your ankles," said Dr. James Main, podiatrist in Cape Girardeau. "Anytime you wear a heel, you shift your body weight forward to the front of the foot, and you're inherently unstable." Like heels, wedges place more weight on the front part of the foot, which can cause knee and lower back problems, says Main. Wedges usually have no support on the sides, making it easier to lose balance and topple over. "On a wedge, the weight is at least spread out over the heel," he concedes.
How to find a good pair: "A woman should go with the very lowest heel height that she can go with. The lower the better," says Main. Many wedges have a rubberized or corklike bottom, which Main believes may add more support than a hard material.
Platform heels
How they affect your feet: Platforms are better than stilettos, but still, "Any kind of shoe that puts abnormal stresses on the balls of foot can cause problems," said Daugherty. "Occasional wear is not a big deal, but this is definitely a shoe that I don't recommend."
How to find a good pair: A stable bottom should be the No. 1 concern, says Daugherty. Wood bottoms are probably more stable and will last longer.
Monday, September 19, 2011
Bunion research focuses on patient quality of life
Lower extremity practitioners know the effect of hallux valgus on a patient’s quality of life starts with a frustrating inability to find fashionable shoes that fit—but evidence suggests it doesn’t end there. Pain, function, and self-image all play significant roles.
By Larry Hand
Recent studies have concluded that increasing severity of hallux valgus (HV) leads to a series of conditions or behaviors—increasing pain, decreasing functional ability, withdrawal from normal daily activities—that contribute directly to a progressive decline in health-related quality of life.
The chain reaction applies to men and women, but studies have shown that women are much more likely than men to develop HV and more likely to experience a drop in quality of life. And practitioners interviewed for this article said more and more younger people are being seen with juvenile-onset HV, a disorder that is most often inherited.
It’s logical to think that eliminating the deformity would necessarily reverse any downward quality of life trends. And recently published research does conclude that some surgical procedures are effective for correcting HV. What happens after surgery, however, can vary greatly, depending on the procedure done, the patient’s own tendency to stiffen after surgery, whether patients get physical therapy, and whether they comply with surgeons’ recovery instructions.
“The most common quality of life issue is they just can’t put on the kind of shoes they want to wear,” said Lowell Weil, Jr., DPM, of the Weil Foot and Ankle Institute in Des Plaines, IL. “A typical patient is a woman in her mid- to late-40s who has seen her bunion progressively get worse and she’s tried wider shoes, deeper shoes, and less-high-heeled shoes. While that works for a time, the shoes are becoming less and less comfortable because of the progressive pain. She could probably find an ugly orthopedic shoe that she could get into, but that just doesn’t work for her professionally or socially.”
As the bunion progresses, Weil continued, women start to become embarrassed by their feet.
“They don’t want to go barefooted. They don’t want to wear sandals or flip flops. It’s an ugly deformity to them, and some people even have concerns that the opposite sex find it unappealing,” he added.
Mounting evidence
In a study e-published ahead of print in November by Arthritis Care & Research, researchers at the Musculoskeletal Research Centre at LaTrobe University in Australia and Keele University in the U.K. concluded that a progressive reduction in both general and foot-specific health-related quality of life occurred in people with increasing severity of hallux valgus deformity, or greater HV angle. They analyzed the records of people aged 56 and older in a six-year follow-up of the North Staffordshire Osteoarthritis Project in the United Kingdom.
More than 36% of the study’s participants were affected by HV, which was more prevalent in females and older patients. However, after adjusting for age, sex, education, and body mass index, Medical Outcomes Study Short Form 36 (SF-36) quality of life scores decreased as HV severity increased. After the same adjustments, increasing HV severity also was linked to greater impairment on the pain and function subscales of the Manchester Foot Pain and Disability Index (MFPDI). The same type of association existed for bodily pain, general health, social function, reduced physical function, and mental health subscale scores after adjusting for pain in the back, hip, knee, and foot.
The researchers used survey questionnaires to obtain their self-reported data, and they used five validated line drawings that showed various degrees of HV, with angles ranging from 0° to 60°. They started with a population of more than 11,300 people registered with three general practices from the North Staffordshire Primary Care Research Consortium. The researchers reasoned that, since more than 95% of people are registered with a general practice in the UK, the registers provided a valid sampling population.
Almost 3600 people completed the first of two surveys three years after recruitment into the trial, and the second survey three years later returned about 2800 responses, for an adjusted 83.9% response rate. Those reporting HV were most likely to be female and older than others, and they generally had a lower body mass index and shorter stature. Just over 40% had unilateral HV and just under 60% had bilateral HV. Of the 2681 respondents who could be considered for foot deformity severity, just over 33% characterized their worst foot severity as a 30° angle or higher, while most (almost 45%) characterized their foot angle as at least 15°. Only 57 people said their angle was more than 60°.
An earlier study, published earlier in 2010 in Osteoarthritis & Cartilage, was the first study to assess quality of life’s association with HV and big toe pain in a general community population. (An association had previously been reported in small hospital-based studies.) Researchers at the University of Nottingham in the UK analyzed results of almost 3100 responses received from more than 13,600 questionnaires mailed to individuals registered with two general practices in Nottingham. They used the short version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF).
They concluded that concurrent HV and big toe pain—but not HV alone—is associated with overall dissatisfaction with health and low scores on the WHOQOL-BREF physical, psychological, and social domains. They also compared the significance of the association to that of patients with severe knee and hip osteoarthritis who are in line to have joint replacement surgery.
Research involving such large numbers of people relates well to individual patients being seen by practitioners in the United States.
“Much of it has to do with the types of shoes people have to wear and their activity levels,” said Vincent Marino, DPM, a podiatrist who practices in San Francisco, Novato, and Sacramento, CA. “Many of our professional women [patients] who have to wear fashionable shoe types during the day usually suffer more and at an earlier stage than someone who can wear more comfortable shoes. It becomes frustrating because they are in pain a great deal and it becomes an issue with work requirements.”
Often, the pain causes a person to forego activities that, under normal circumstances, they would be doing on a daily basis.
“A lot of times patients will say they’re not able to do the things they normally do, or they have to curtail it; if they usually go out for an hour or two, now it’s just a half hour,” said Althea Powell, CPed, LPed, OST, who operates Powell Shoes in Vero Beach, FL. “We’ve had patients who said they were just unable to exercise. They can’t go for a walk even though the doctor says they need to walk for exercise.”
And the effects go well beyond middle-aged and older women. In an article published last year in the Journal of Foot and Ankle Research, researchers from the University of Queensland reported HV prevalence of 36% in elderly women and 16% in elderly men, 26.3% in adult women and 8.5% in adult men, and 15% in juvenile (under age 18) girls and 5.7% in juvenile boys.
“The unsightliness of the deformity has an effect on many teenage girls and young women. They’re hesitant to wear open-toed shoes because they perceive their foot as being ugly,” Marino said. “They come in because they want to wear some open-toed sandals without having people stare, and it has an effect on their psyche. It also affects the ability of men and women to exercise. They lose the ability to run comfortably and do some of the activities that they put in their everyday lifestyle to help control their stress levels. They stop running. They stop using the elliptical. They stop doing aerobic activities. Every time they put a shoe on, they’re in pain.”
Just getting into a properly sized shoe makes a big difference for even minor bunions, said Chad Brown, CPed, of Brown’s Enterprises, a specialty shoe retailer in St. Louis.
“But in more severe cases, hallux valgus deformity can be just as debilitating as someone who suffers from migraines,” he said. “You’re going through excruciating pain, and it affects everything from going to the grocery store to taking vacations with your family.”
Even professional basketball players are susceptible.
“One player who was a patient of mine probably wore a size 20 or 21 shoe and he had two different-sized feet,” said Dennis Janisse, CPed, president and CEO of National Pedorthic Services and a clinical assistant professor of physical medicine and rehabilitation at the Medical College of Wisconsin in Milwaukee. “I actually had to cast his feet for a high-end dress shoe company so that they could make a shoe over the cast. Because he had such a big-sized shoe, it was so hard for him to get footwear anyway. He was cramming that bigger foot into a smaller shoe, and he ended up with a significant deformity on the one foot and the other foot was fine.”
Wide range of treatments
Treatment for HV, most often a hereditary disorder, ranges from just trying to control the symptoms with proper shoes and orthotics to surgery, often considered a last resort.
“Unfortunately there’s not a lot that really works,” Weil said. “For somebody who is developing a bunion, there’s nothing you can do to arrest the progression. No mechanical device or change of shoe gear is going to prevent the progression of the problem. Basically you treat it with finding wider and deeper shoes that are more amenable to the deformity. You change activities to make it more comfortable. Shoes and orthotics may make it less painful—until it gets bad enough to have surgery.”
More than 130 procedures have been described for HV as far back as the early 1900s, but in the last 20 years, techniques have improved and have been refined based on technological advances in surgery in general, Weil said.
In 2000, a Cochrane Database Systematic Reviews article cited a consistently high (25% to 33%) rate of dissatisfaction among osteotomy patients postoperatively. However, recent publications have pointed to different, highly positive results. A June 2007 paper published in Quality of Life Research concluded that surgery improves the quality of life for HV patients in terms of bodily pain, vitality, and mental health. A study to be published in the March 2011 issue of Clinical Orthopaedics & Related Research cites improvements in AOFAS pain and function scores from 61.5 to 90.3 in patients who underwent a unilateral scarf osteotomy combined with distal soft tissue alignment at the Hospital for Special Surgery in New York City.
Still, opinions vary as to the effectiveness of surgical procedures, depending on who you ask. Some pedorthists and physical therapists still see patients postoperatively who may be predisposed to stiffness in joints or otherwise have not fared well after surgery for various reasons, including not complying with surgeons’ instructions. Marino, however, said noncompliance is not a significant problem in his San Francisco practice.
“I personally drill into their heads that I won’t operate unless they know what they have to do afterward. I tell them, ‘If you don’t listen, then we’ll just end up doing this again,’ ” he said.
Some results depend on the reason for the surgery in the beginning, and the expectations of the patients, particularly with regard to wearing stylish shoes.
“In our neighborhood, people have surgery based on what they can’t wear and the amount of deformity, which is a lousy reason to do it, quite frankly,” said Stephen Paulseth, PT, DPT, SCS, ATC, in private practice in Los Angeles, near Beverly Hills.
He recommends the use of orthotics before and after surgery, as needed.
“We always try to get the patient in before they consider surgery, to see if we can get them a little bit more mobility, get them in some calf/soleus exercises and calf stretching, and to use their flexor hallucis during push-off. They tend to allow their foot to deviate at push-off, which drives their first-toe into abduction,” he said.
Most of the patients seen by RobRoy Martin, PT, PhD, assistant professor of physical therapy at Duquesne University in Pittsburgh, PA, are postoperative patients.
“A lot of them have inappropriate preoperative expectations, thinking they can go back to the shoes they wore before they had surgery,” he said. “The really fashionable shoes are just so bad. I’ll trace their foot and then put the shoe on top of the trace and ask the patients, ‘how can you possibly jam your foot back into that?’ ”
Other people, he added, are simply prone to stiffness after surgery. He tries to counter that with aggressive joint stretching and mobilization exercises, and he recommends a good cross-training shoe that is sturdier and stiffer than a running shoe to maintain forefoot stability.
If a person’s job requires a higher fashion, therein lies the rub. Although most shoes that are wide enough and deep enough to accommodate HV are functional, Powell said, “They’re not pretty. It does not matter the age group, whether someone is in their 30s or 80s, they are looking for function as well as aesthetic.”
That said, the footwear options available for patients with HV today are much better than in the past, Janisse said.
“You’re not going to find a three-inch spike heel or anything like that that’s going to accommodate something like a significant deformity. But a lot of the footwear out there today is much more accommodating and is acceptable, unlike it was years ago,” he said.
Still, shoe manufacturers “definitely need to keep their efforts strong in making shoes that are more fashionable, even though they have made a lot of progress in the past 10 years,” said Brown in St. Louis.
And the shoes need to accommodate all ages, he added.
“The younger people don’t want to look like they’re wearing the same pair of shoes their mom or grandmother wore,” Brown said.
By Larry Hand
Recent studies have concluded that increasing severity of hallux valgus (HV) leads to a series of conditions or behaviors—increasing pain, decreasing functional ability, withdrawal from normal daily activities—that contribute directly to a progressive decline in health-related quality of life.
The chain reaction applies to men and women, but studies have shown that women are much more likely than men to develop HV and more likely to experience a drop in quality of life. And practitioners interviewed for this article said more and more younger people are being seen with juvenile-onset HV, a disorder that is most often inherited.
It’s logical to think that eliminating the deformity would necessarily reverse any downward quality of life trends. And recently published research does conclude that some surgical procedures are effective for correcting HV. What happens after surgery, however, can vary greatly, depending on the procedure done, the patient’s own tendency to stiffen after surgery, whether patients get physical therapy, and whether they comply with surgeons’ recovery instructions.
“The most common quality of life issue is they just can’t put on the kind of shoes they want to wear,” said Lowell Weil, Jr., DPM, of the Weil Foot and Ankle Institute in Des Plaines, IL. “A typical patient is a woman in her mid- to late-40s who has seen her bunion progressively get worse and she’s tried wider shoes, deeper shoes, and less-high-heeled shoes. While that works for a time, the shoes are becoming less and less comfortable because of the progressive pain. She could probably find an ugly orthopedic shoe that she could get into, but that just doesn’t work for her professionally or socially.”
As the bunion progresses, Weil continued, women start to become embarrassed by their feet.
“They don’t want to go barefooted. They don’t want to wear sandals or flip flops. It’s an ugly deformity to them, and some people even have concerns that the opposite sex find it unappealing,” he added.
Mounting evidence
In a study e-published ahead of print in November by Arthritis Care & Research, researchers at the Musculoskeletal Research Centre at LaTrobe University in Australia and Keele University in the U.K. concluded that a progressive reduction in both general and foot-specific health-related quality of life occurred in people with increasing severity of hallux valgus deformity, or greater HV angle. They analyzed the records of people aged 56 and older in a six-year follow-up of the North Staffordshire Osteoarthritis Project in the United Kingdom.
More than 36% of the study’s participants were affected by HV, which was more prevalent in females and older patients. However, after adjusting for age, sex, education, and body mass index, Medical Outcomes Study Short Form 36 (SF-36) quality of life scores decreased as HV severity increased. After the same adjustments, increasing HV severity also was linked to greater impairment on the pain and function subscales of the Manchester Foot Pain and Disability Index (MFPDI). The same type of association existed for bodily pain, general health, social function, reduced physical function, and mental health subscale scores after adjusting for pain in the back, hip, knee, and foot.
The researchers used survey questionnaires to obtain their self-reported data, and they used five validated line drawings that showed various degrees of HV, with angles ranging from 0° to 60°. They started with a population of more than 11,300 people registered with three general practices from the North Staffordshire Primary Care Research Consortium. The researchers reasoned that, since more than 95% of people are registered with a general practice in the UK, the registers provided a valid sampling population.
Almost 3600 people completed the first of two surveys three years after recruitment into the trial, and the second survey three years later returned about 2800 responses, for an adjusted 83.9% response rate. Those reporting HV were most likely to be female and older than others, and they generally had a lower body mass index and shorter stature. Just over 40% had unilateral HV and just under 60% had bilateral HV. Of the 2681 respondents who could be considered for foot deformity severity, just over 33% characterized their worst foot severity as a 30° angle or higher, while most (almost 45%) characterized their foot angle as at least 15°. Only 57 people said their angle was more than 60°.
An earlier study, published earlier in 2010 in Osteoarthritis & Cartilage, was the first study to assess quality of life’s association with HV and big toe pain in a general community population. (An association had previously been reported in small hospital-based studies.) Researchers at the University of Nottingham in the UK analyzed results of almost 3100 responses received from more than 13,600 questionnaires mailed to individuals registered with two general practices in Nottingham. They used the short version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF).
They concluded that concurrent HV and big toe pain—but not HV alone—is associated with overall dissatisfaction with health and low scores on the WHOQOL-BREF physical, psychological, and social domains. They also compared the significance of the association to that of patients with severe knee and hip osteoarthritis who are in line to have joint replacement surgery.
Research involving such large numbers of people relates well to individual patients being seen by practitioners in the United States.
“Much of it has to do with the types of shoes people have to wear and their activity levels,” said Vincent Marino, DPM, a podiatrist who practices in San Francisco, Novato, and Sacramento, CA. “Many of our professional women [patients] who have to wear fashionable shoe types during the day usually suffer more and at an earlier stage than someone who can wear more comfortable shoes. It becomes frustrating because they are in pain a great deal and it becomes an issue with work requirements.”
Often, the pain causes a person to forego activities that, under normal circumstances, they would be doing on a daily basis.
“A lot of times patients will say they’re not able to do the things they normally do, or they have to curtail it; if they usually go out for an hour or two, now it’s just a half hour,” said Althea Powell, CPed, LPed, OST, who operates Powell Shoes in Vero Beach, FL. “We’ve had patients who said they were just unable to exercise. They can’t go for a walk even though the doctor says they need to walk for exercise.”
And the effects go well beyond middle-aged and older women. In an article published last year in the Journal of Foot and Ankle Research, researchers from the University of Queensland reported HV prevalence of 36% in elderly women and 16% in elderly men, 26.3% in adult women and 8.5% in adult men, and 15% in juvenile (under age 18) girls and 5.7% in juvenile boys.
“The unsightliness of the deformity has an effect on many teenage girls and young women. They’re hesitant to wear open-toed shoes because they perceive their foot as being ugly,” Marino said. “They come in because they want to wear some open-toed sandals without having people stare, and it has an effect on their psyche. It also affects the ability of men and women to exercise. They lose the ability to run comfortably and do some of the activities that they put in their everyday lifestyle to help control their stress levels. They stop running. They stop using the elliptical. They stop doing aerobic activities. Every time they put a shoe on, they’re in pain.”
Just getting into a properly sized shoe makes a big difference for even minor bunions, said Chad Brown, CPed, of Brown’s Enterprises, a specialty shoe retailer in St. Louis.
“But in more severe cases, hallux valgus deformity can be just as debilitating as someone who suffers from migraines,” he said. “You’re going through excruciating pain, and it affects everything from going to the grocery store to taking vacations with your family.”
Even professional basketball players are susceptible.
“One player who was a patient of mine probably wore a size 20 or 21 shoe and he had two different-sized feet,” said Dennis Janisse, CPed, president and CEO of National Pedorthic Services and a clinical assistant professor of physical medicine and rehabilitation at the Medical College of Wisconsin in Milwaukee. “I actually had to cast his feet for a high-end dress shoe company so that they could make a shoe over the cast. Because he had such a big-sized shoe, it was so hard for him to get footwear anyway. He was cramming that bigger foot into a smaller shoe, and he ended up with a significant deformity on the one foot and the other foot was fine.”
Wide range of treatments
Treatment for HV, most often a hereditary disorder, ranges from just trying to control the symptoms with proper shoes and orthotics to surgery, often considered a last resort.
“Unfortunately there’s not a lot that really works,” Weil said. “For somebody who is developing a bunion, there’s nothing you can do to arrest the progression. No mechanical device or change of shoe gear is going to prevent the progression of the problem. Basically you treat it with finding wider and deeper shoes that are more amenable to the deformity. You change activities to make it more comfortable. Shoes and orthotics may make it less painful—until it gets bad enough to have surgery.”
More than 130 procedures have been described for HV as far back as the early 1900s, but in the last 20 years, techniques have improved and have been refined based on technological advances in surgery in general, Weil said.
In 2000, a Cochrane Database Systematic Reviews article cited a consistently high (25% to 33%) rate of dissatisfaction among osteotomy patients postoperatively. However, recent publications have pointed to different, highly positive results. A June 2007 paper published in Quality of Life Research concluded that surgery improves the quality of life for HV patients in terms of bodily pain, vitality, and mental health. A study to be published in the March 2011 issue of Clinical Orthopaedics & Related Research cites improvements in AOFAS pain and function scores from 61.5 to 90.3 in patients who underwent a unilateral scarf osteotomy combined with distal soft tissue alignment at the Hospital for Special Surgery in New York City.
Still, opinions vary as to the effectiveness of surgical procedures, depending on who you ask. Some pedorthists and physical therapists still see patients postoperatively who may be predisposed to stiffness in joints or otherwise have not fared well after surgery for various reasons, including not complying with surgeons’ instructions. Marino, however, said noncompliance is not a significant problem in his San Francisco practice.
“I personally drill into their heads that I won’t operate unless they know what they have to do afterward. I tell them, ‘If you don’t listen, then we’ll just end up doing this again,’ ” he said.
Some results depend on the reason for the surgery in the beginning, and the expectations of the patients, particularly with regard to wearing stylish shoes.
“In our neighborhood, people have surgery based on what they can’t wear and the amount of deformity, which is a lousy reason to do it, quite frankly,” said Stephen Paulseth, PT, DPT, SCS, ATC, in private practice in Los Angeles, near Beverly Hills.
He recommends the use of orthotics before and after surgery, as needed.
“We always try to get the patient in before they consider surgery, to see if we can get them a little bit more mobility, get them in some calf/soleus exercises and calf stretching, and to use their flexor hallucis during push-off. They tend to allow their foot to deviate at push-off, which drives their first-toe into abduction,” he said.
Most of the patients seen by RobRoy Martin, PT, PhD, assistant professor of physical therapy at Duquesne University in Pittsburgh, PA, are postoperative patients.
“A lot of them have inappropriate preoperative expectations, thinking they can go back to the shoes they wore before they had surgery,” he said. “The really fashionable shoes are just so bad. I’ll trace their foot and then put the shoe on top of the trace and ask the patients, ‘how can you possibly jam your foot back into that?’ ”
Other people, he added, are simply prone to stiffness after surgery. He tries to counter that with aggressive joint stretching and mobilization exercises, and he recommends a good cross-training shoe that is sturdier and stiffer than a running shoe to maintain forefoot stability.
If a person’s job requires a higher fashion, therein lies the rub. Although most shoes that are wide enough and deep enough to accommodate HV are functional, Powell said, “They’re not pretty. It does not matter the age group, whether someone is in their 30s or 80s, they are looking for function as well as aesthetic.”
That said, the footwear options available for patients with HV today are much better than in the past, Janisse said.
“You’re not going to find a three-inch spike heel or anything like that that’s going to accommodate something like a significant deformity. But a lot of the footwear out there today is much more accommodating and is acceptable, unlike it was years ago,” he said.
Still, shoe manufacturers “definitely need to keep their efforts strong in making shoes that are more fashionable, even though they have made a lot of progress in the past 10 years,” said Brown in St. Louis.
And the shoes need to accommodate all ages, he added.
“The younger people don’t want to look like they’re wearing the same pair of shoes their mom or grandmother wore,” Brown said.
Saturday, September 17, 2011
Nicotine Raises Blood Sugar Levels in Lab
SUNDAY, March 27 (HealthDay News) -- Smoking is damaging to everyone's health, but the nicotine in cigarettes may be even more deadly for people who have diabetes.
In lab experiments, researchers discovered that nicotine raised blood sugar levels, and the more nicotine that was present, the higher the blood sugar levels were. Higher blood sugar levels are linked to an increased risk of complications from diabetes, such as eye and kidney disease.
"Smoking is really harmful for diabetics. It's even more harmful to them than to a non-diabetic," said study author Xiao-Chuan Liu, an associate professor in the department of chemistry at California State Polytechnic University in Pomona. "This study should encourage diabetics to quit smoking completely, and to realize that it's the nicotine that's raising [blood sugar levels]."
For that reason, it's also important to limit the use of nicotine replacement products, such as nicotine patches, Liu said.
"If you're using them for a short period of time to quit smoking, that's OK. But, if you still have this addiction to nicotine and are using this product long-term, it will do harm. Don't use electronic cigarettes or nicotine gum for a long time. You need to stop nicotine intake," he advised.
Liu is scheduled to present his findings Sunday at an American Chemical Society meeting in Anaheim, Calif.
It was already well-established that smoking increased the risk of problems in people with diabetes, Liu said. What hasn't been clear, he said, is if there is a specfic component of cigarettes that increases the risk.
To test whether or not nicotine, an addictive substance found in cigarette smoke, contributed to higher blood sugar levels, Liu and his colleagues added equal amounts of glucose (sugar) to samples of human red blood cells. They also added varying levels of nicotine to each sample of red blood cells for either one day or two days.
They then tested the hemoglobin A1C (HbA1C) levels of the samples. HbA1C is a measure of what percentage of red blood cells have glucose molecules attached to them. In diabetes management, the HbA1C -- sometimes referred to just as A1C -- test gives doctors an idea of average blood sugar levels for the past three months or so. Most people with diabetes strive for a level of 7 percent or less, based on American Diabetes Association guidelines.
The researchers found that nicotine raised HbA1C. The smallest dose increased HbA1C levels by 8.8 percent. The highest dose -- after two days of nicotine treatment -- increased blood sugar levels by 34.5 percent.
"Nicotine is a toxic substance, and our results show that nicotine caused an increase in HbA1C," said Liu. "This is important for the public to know, and for smokers to know. It's not just the cigarette smoke. If you think you can just use a nicotine replacement product indefinitely, there's still a risk, and your chances of getting complications will be a lot higher," he cautioned.
Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, said that the researchers showed that nicotine can significantly raise A1C levels in the lab, but it's important to also know if it does so in the body.
But whether or not nicotine is the specific reason that blood sugar levels are higher in smokers, he said, "Everybody -- whether they have diabetes or not -- should stop smoking. Patients with diabetes already have a much higher risk of cardiovascular disease, and smoking adds to that."
He said that using nicotine replacement products for a month or two is fine. "If nicotine replacement is used for a short period of time with smoking cessation as the goal, there's no risk. But it's not OK if someone plans to replace smoking with nicotine replacement products indefinitely," said Zonszein.
In lab experiments, researchers discovered that nicotine raised blood sugar levels, and the more nicotine that was present, the higher the blood sugar levels were. Higher blood sugar levels are linked to an increased risk of complications from diabetes, such as eye and kidney disease.
"Smoking is really harmful for diabetics. It's even more harmful to them than to a non-diabetic," said study author Xiao-Chuan Liu, an associate professor in the department of chemistry at California State Polytechnic University in Pomona. "This study should encourage diabetics to quit smoking completely, and to realize that it's the nicotine that's raising [blood sugar levels]."
For that reason, it's also important to limit the use of nicotine replacement products, such as nicotine patches, Liu said.
"If you're using them for a short period of time to quit smoking, that's OK. But, if you still have this addiction to nicotine and are using this product long-term, it will do harm. Don't use electronic cigarettes or nicotine gum for a long time. You need to stop nicotine intake," he advised.
Liu is scheduled to present his findings Sunday at an American Chemical Society meeting in Anaheim, Calif.
It was already well-established that smoking increased the risk of problems in people with diabetes, Liu said. What hasn't been clear, he said, is if there is a specfic component of cigarettes that increases the risk.
To test whether or not nicotine, an addictive substance found in cigarette smoke, contributed to higher blood sugar levels, Liu and his colleagues added equal amounts of glucose (sugar) to samples of human red blood cells. They also added varying levels of nicotine to each sample of red blood cells for either one day or two days.
They then tested the hemoglobin A1C (HbA1C) levels of the samples. HbA1C is a measure of what percentage of red blood cells have glucose molecules attached to them. In diabetes management, the HbA1C -- sometimes referred to just as A1C -- test gives doctors an idea of average blood sugar levels for the past three months or so. Most people with diabetes strive for a level of 7 percent or less, based on American Diabetes Association guidelines.
The researchers found that nicotine raised HbA1C. The smallest dose increased HbA1C levels by 8.8 percent. The highest dose -- after two days of nicotine treatment -- increased blood sugar levels by 34.5 percent.
"Nicotine is a toxic substance, and our results show that nicotine caused an increase in HbA1C," said Liu. "This is important for the public to know, and for smokers to know. It's not just the cigarette smoke. If you think you can just use a nicotine replacement product indefinitely, there's still a risk, and your chances of getting complications will be a lot higher," he cautioned.
Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, said that the researchers showed that nicotine can significantly raise A1C levels in the lab, but it's important to also know if it does so in the body.
But whether or not nicotine is the specific reason that blood sugar levels are higher in smokers, he said, "Everybody -- whether they have diabetes or not -- should stop smoking. Patients with diabetes already have a much higher risk of cardiovascular disease, and smoking adds to that."
He said that using nicotine replacement products for a month or two is fine. "If nicotine replacement is used for a short period of time with smoking cessation as the goal, there's no risk. But it's not OK if someone plans to replace smoking with nicotine replacement products indefinitely," said Zonszein.
Friday, September 16, 2011
Star QB has to have part of leg amputated following freak injury
One of the top quarterback prospects in Virginia is facing a difficult and uncertain future that will almost certainly not include college football after he was forced to amputate part of one of his legs at a hospital in suburban Washington, D.C.
As first reported by the Charlottesville Daily Progress, Woodberry Forest (Va.) School quarterback Jacob Rainey had part of one of his legs amputated on Saturday, just more than a week after he suffered a freak injury in a final preseason football scrimmage against Flint Hill (Va.) High.
According to the Daily Progress, Rainey suffered a broken knee cap when he was cleanly tackled from behind by a Flint Hill player. After he arrived at the nearest hospital, doctors discovered that he had suffered other complications from the injury, most drastically a ruptured blood vessel.
In a statement released by Woodberry Forest officials it was revealed that Rainey was moved to Fairfax Inova hospital when his condition failed to improve. There, Inova doctors determined that he had severed the main artery in one of his legs and that he had to immediately undergo vascular surgery to avoid further serious health issues. The only solution was to amputate part of one of his legs, a procedure which was carried out on Saturday, just a day after Woodberry Forest opened the season with a 16-13 victory at Richmond (Va.) Benedictine High without its expected starting quarterback.
Woodberry coach Clinton Alexander was given the unenviable task of telling the rest of the team that Rainey would have to lose part of his leg, a job which immediately transformed the program's buoyant mood following its season-opening victory to a somber discussion of how the team could keep Rainey -- one of the top junior quarterback prospects in the state who was being recruited by a number of ACC programs -- involved in their season.
Alexander said that his team was still dealing with the shock of learning that one of their closest friends had suffered such a dramatic injury on the field, though he said that the close ties that made them particularly sensitive to his injury also will help the team move on from it.
"I have had situations in my career were we have had a player's parent pass away during the season and have had two players on two different teams die in a car accident, but nothing like this," Alexander told Prep Rally in an email.
"Our players love Jacob very much and were very upset when it happened and were very worried about him after he was taken to the hospital. Our team is very close, one of the benefits of a boarding school football program. They get so much time together on dorm that the depth of the relationships they form is quite amazing. This has certainly helped our players understand how important it is to care about each other and attempt to overcome adversity together."
One of the ways Woodberry Forest plans to memorialize their missing leader is by passing around his jersey number each week. In the team's first game at Benedictine, Rainey's closest friend, Nate Ripper, wore his number 9 jersey. In each subsequent week for the remainder of the season, a different player will don it to honor Rainey's place with the program.
Fittingly, Rainey will even be part of the group that decides which player wears his own jersey each week.
"One of our parents gave us the idea to allow a different player each week to wear Jacob's number 9 jersey in each game so he will be with us," Alexander told Prep Rally. "Our leadership committee which Jacob is part of makes the decision."
Sadly, Rainey isn't the first prep football victim to have to undergo such a drastic surgery in the past calendar year. In October 2010, McLouth (Kan.) High's star running back Trevor Roberts had to have the lower segment of his left leg removed after it became infected following a compound break in a game.
Amazingly, the Daily Progress reported that Rainey remained in high spirits despite the tragic circumstances that have befallen him. It seems unlikely that he will continue to garner the kind of recruiting interest he had attracted to this point, but he can at least rest easy knowing that one of the programs which had forged a bond with him was thinking about him just after his operation.
"A young man playing at Woodberry Forest suffered a tragic thing where he lost his leg," Virginia coach Mike London said in his weekly press conference Monday. "Our thoughts and prayers go out to the whole Woodberry Forest football family and to this young man's family in particular. Wins and losses are important, but sometimes the realities of what's really important are the young men and the family members and the sons that we are responsible for."
Thu Sep 15
By Cameron Smith
As first reported by the Charlottesville Daily Progress, Woodberry Forest (Va.) School quarterback Jacob Rainey had part of one of his legs amputated on Saturday, just more than a week after he suffered a freak injury in a final preseason football scrimmage against Flint Hill (Va.) High.
According to the Daily Progress, Rainey suffered a broken knee cap when he was cleanly tackled from behind by a Flint Hill player. After he arrived at the nearest hospital, doctors discovered that he had suffered other complications from the injury, most drastically a ruptured blood vessel.
In a statement released by Woodberry Forest officials it was revealed that Rainey was moved to Fairfax Inova hospital when his condition failed to improve. There, Inova doctors determined that he had severed the main artery in one of his legs and that he had to immediately undergo vascular surgery to avoid further serious health issues. The only solution was to amputate part of one of his legs, a procedure which was carried out on Saturday, just a day after Woodberry Forest opened the season with a 16-13 victory at Richmond (Va.) Benedictine High without its expected starting quarterback.
Woodberry coach Clinton Alexander was given the unenviable task of telling the rest of the team that Rainey would have to lose part of his leg, a job which immediately transformed the program's buoyant mood following its season-opening victory to a somber discussion of how the team could keep Rainey -- one of the top junior quarterback prospects in the state who was being recruited by a number of ACC programs -- involved in their season.
Alexander said that his team was still dealing with the shock of learning that one of their closest friends had suffered such a dramatic injury on the field, though he said that the close ties that made them particularly sensitive to his injury also will help the team move on from it.
"I have had situations in my career were we have had a player's parent pass away during the season and have had two players on two different teams die in a car accident, but nothing like this," Alexander told Prep Rally in an email.
"Our players love Jacob very much and were very upset when it happened and were very worried about him after he was taken to the hospital. Our team is very close, one of the benefits of a boarding school football program. They get so much time together on dorm that the depth of the relationships they form is quite amazing. This has certainly helped our players understand how important it is to care about each other and attempt to overcome adversity together."
One of the ways Woodberry Forest plans to memorialize their missing leader is by passing around his jersey number each week. In the team's first game at Benedictine, Rainey's closest friend, Nate Ripper, wore his number 9 jersey. In each subsequent week for the remainder of the season, a different player will don it to honor Rainey's place with the program.
Fittingly, Rainey will even be part of the group that decides which player wears his own jersey each week.
"One of our parents gave us the idea to allow a different player each week to wear Jacob's number 9 jersey in each game so he will be with us," Alexander told Prep Rally. "Our leadership committee which Jacob is part of makes the decision."
Sadly, Rainey isn't the first prep football victim to have to undergo such a drastic surgery in the past calendar year. In October 2010, McLouth (Kan.) High's star running back Trevor Roberts had to have the lower segment of his left leg removed after it became infected following a compound break in a game.
Amazingly, the Daily Progress reported that Rainey remained in high spirits despite the tragic circumstances that have befallen him. It seems unlikely that he will continue to garner the kind of recruiting interest he had attracted to this point, but he can at least rest easy knowing that one of the programs which had forged a bond with him was thinking about him just after his operation.
"A young man playing at Woodberry Forest suffered a tragic thing where he lost his leg," Virginia coach Mike London said in his weekly press conference Monday. "Our thoughts and prayers go out to the whole Woodberry Forest football family and to this young man's family in particular. Wins and losses are important, but sometimes the realities of what's really important are the young men and the family members and the sons that we are responsible for."
Thu Sep 15
By Cameron Smith
Thursday, September 15, 2011
More evidence links diabetes, Parkinson's disease
NEW YORK (Reuters) – People with diabetes may be more likely to also develop Parkinson's disease - and this seems particularly true for younger patients, a new study suggests.
The findings, published online by the journal Diabetes Care, add to evidence linking diabetes and Parkinson's. One recent report said that U.S. adults with diabetes had a slightly higher risk of developing Parkinson's over a 15-year period, compared to nondiabetics.
Neither study, however, proves that diabetes itself causes Parkinson's.
Instead, researchers think it's more likely that the two disorders share some common underlying causes.
The new findings are from Denmark, where researchers compared close to 2,000 adults with Parkinson's disease and nearly 10,000 people the same age but without the disease (the "control" group).
Overall, 6.5 percent of the Parkinson's patients had diabetes for at least 2 years before they were diagnosed with the movement disorder. By comparison, just 5 percent of people in the control group had diabetes for at least 2 years.
Overall, the study found, having diabetes was linked to a roughly one-third higher risk of developing Parkinson's. That was after the researchers accounted for participants' age and sex, and any diagnoses of emphysema - which was considered a proxy for heavy smoking. (Studies have found cigarette smokers to be at lower risk of Parkinson's, for reasons that are not clear.)
In particular, diabetes was related to a higher risk of developing Parkinson's before the age of 60 -- which is about the average age at diagnosis.
Exactly what the findings mean is unclear, according to the researchers, who were led by Dr. Eva Schernhammer of Harvard Medical School in Boston.
But they say that for now, the "most plausible" explanation would be that diabetes and Parkinson's have some of the same biological underpinnings.
One possibility is continuous low-level inflammation throughout the body, which is suspected of contributing to a number of chronic diseases by damaging cells. There might also be a common genetic susceptibility.
However, even if people with diabetes have a relatively bigger risk of Parkinson's, that does not mean it is a high risk. For example, the recent U.S. study that tracked patients for 15 years involved nearly 289,000 older adults. The proportion of people who eventually developed Parkinson's disease was 0.8 percent among diabetics and 0.5 percent among nondiabetics - less than 1 percent in either case.
The researchers on that study said that people with diabetes should simply continue to do the things already recommended for their overall health -- eating a well-balanced diet and getting regular exercise.
More studies are needed, they said, to understand why diabetes is related to a higher Parkinson's risk, and what, if anything, can be done about it.
Diabetes arises when the body can no longer properly use the blood-sugar-regulating hormone insulin. Parkinson's occurs when movement-regulating cells in the brain die off or become disabled, leading to symptoms like tremors, rigidity in the joints, slowed movement and balance problems.
Researchers say it's possible that something about diabetes -- like a problem regulating insulin -- might somehow contribute to Parkinson's. But that remains unproven.
SOURCE: http://bit.ly/fWbB3u Diabetes Care, online March 16, 2011.
The findings, published online by the journal Diabetes Care, add to evidence linking diabetes and Parkinson's. One recent report said that U.S. adults with diabetes had a slightly higher risk of developing Parkinson's over a 15-year period, compared to nondiabetics.
Neither study, however, proves that diabetes itself causes Parkinson's.
Instead, researchers think it's more likely that the two disorders share some common underlying causes.
The new findings are from Denmark, where researchers compared close to 2,000 adults with Parkinson's disease and nearly 10,000 people the same age but without the disease (the "control" group).
Overall, 6.5 percent of the Parkinson's patients had diabetes for at least 2 years before they were diagnosed with the movement disorder. By comparison, just 5 percent of people in the control group had diabetes for at least 2 years.
Overall, the study found, having diabetes was linked to a roughly one-third higher risk of developing Parkinson's. That was after the researchers accounted for participants' age and sex, and any diagnoses of emphysema - which was considered a proxy for heavy smoking. (Studies have found cigarette smokers to be at lower risk of Parkinson's, for reasons that are not clear.)
In particular, diabetes was related to a higher risk of developing Parkinson's before the age of 60 -- which is about the average age at diagnosis.
Exactly what the findings mean is unclear, according to the researchers, who were led by Dr. Eva Schernhammer of Harvard Medical School in Boston.
But they say that for now, the "most plausible" explanation would be that diabetes and Parkinson's have some of the same biological underpinnings.
One possibility is continuous low-level inflammation throughout the body, which is suspected of contributing to a number of chronic diseases by damaging cells. There might also be a common genetic susceptibility.
However, even if people with diabetes have a relatively bigger risk of Parkinson's, that does not mean it is a high risk. For example, the recent U.S. study that tracked patients for 15 years involved nearly 289,000 older adults. The proportion of people who eventually developed Parkinson's disease was 0.8 percent among diabetics and 0.5 percent among nondiabetics - less than 1 percent in either case.
The researchers on that study said that people with diabetes should simply continue to do the things already recommended for their overall health -- eating a well-balanced diet and getting regular exercise.
More studies are needed, they said, to understand why diabetes is related to a higher Parkinson's risk, and what, if anything, can be done about it.
Diabetes arises when the body can no longer properly use the blood-sugar-regulating hormone insulin. Parkinson's occurs when movement-regulating cells in the brain die off or become disabled, leading to symptoms like tremors, rigidity in the joints, slowed movement and balance problems.
Researchers say it's possible that something about diabetes -- like a problem regulating insulin -- might somehow contribute to Parkinson's. But that remains unproven.
SOURCE: http://bit.ly/fWbB3u Diabetes Care, online March 16, 2011.
Wednesday, September 14, 2011
How Repetitive Foods Can Mean Weight Loss
Monotony at mealtime can reduce calorie consumption....
Want to lose weight? How about trying to bore yourself thin? According to a new study, monotony at mealtime might be a clever -- if unexciting -- way to reduce calorie consumption.
Human beings come pre-loaded with a sort of habituation threshold and it shows itself in a lot of ways. Hear the same pop song too often and you eventually want to fling the CD out the window. See the same sitcom re-run enough times and the jokes just aren't funny anymore. The same holds true for food -- even your favorites get boring if you eat the same thing over and over without shaking up the menu a little. It's not even necessary that the repetitive food be boring: you'll habituate to pizza almost as easily as you do to boiled chicken.
Straightforward as that simple idea seems, there's been surprisingly little hard research to measure it in any kind of empirical way. In the new study, University of Buffalo nutritionist Leonard Epstein and his colleagues recruited 32 women -- half of them obese, half nonobese -- and divided them into two groups, also with equal numbers of overweight and normal weight subjects. The women were instructed to perform an assigned task for 28 minutes, after which they were given 125-cal. portions of macaroni and cheese and allowed as many additional helpings as they wanted.
All of the women went through five such 28-min. sessions -- the only difference was, half of them did so on five consecutive days and half came back once a week for five weeks. By the end of all of the sessions, the once-a-day group had decreased its calorie intake of macaroni by about 30 cal. per session, while the once-a-weekers had increased theirs by 100 cal. The conclusion: the first group had simply gotten sick of the stuff.
Epstein writes that, "The study suggests a starting point for further research." "Repeated presentations once a day compared with once a week provide a reference point for the interval between food presentations that could lead to long-term habituation." In other words, adjust the sliding scale of lag time between repetitive meals until you find the point at which the food is not so over familar that you go running to some high-calorie alternative, but not so novel that you gorge on it when you see it.
Further research, the investigators believe, could also shed light on the link between overeating and addiction. Some nutritionists theorize that the obese may suffer from a too-high habituation threshold, taking much longer to get tired of a food than other people.
The American Journal of Clinical Nutrition, Aug 2011
Want to lose weight? How about trying to bore yourself thin? According to a new study, monotony at mealtime might be a clever -- if unexciting -- way to reduce calorie consumption.
Human beings come pre-loaded with a sort of habituation threshold and it shows itself in a lot of ways. Hear the same pop song too often and you eventually want to fling the CD out the window. See the same sitcom re-run enough times and the jokes just aren't funny anymore. The same holds true for food -- even your favorites get boring if you eat the same thing over and over without shaking up the menu a little. It's not even necessary that the repetitive food be boring: you'll habituate to pizza almost as easily as you do to boiled chicken.
Straightforward as that simple idea seems, there's been surprisingly little hard research to measure it in any kind of empirical way. In the new study, University of Buffalo nutritionist Leonard Epstein and his colleagues recruited 32 women -- half of them obese, half nonobese -- and divided them into two groups, also with equal numbers of overweight and normal weight subjects. The women were instructed to perform an assigned task for 28 minutes, after which they were given 125-cal. portions of macaroni and cheese and allowed as many additional helpings as they wanted.
All of the women went through five such 28-min. sessions -- the only difference was, half of them did so on five consecutive days and half came back once a week for five weeks. By the end of all of the sessions, the once-a-day group had decreased its calorie intake of macaroni by about 30 cal. per session, while the once-a-weekers had increased theirs by 100 cal. The conclusion: the first group had simply gotten sick of the stuff.
Epstein writes that, "The study suggests a starting point for further research." "Repeated presentations once a day compared with once a week provide a reference point for the interval between food presentations that could lead to long-term habituation." In other words, adjust the sliding scale of lag time between repetitive meals until you find the point at which the food is not so over familar that you go running to some high-calorie alternative, but not so novel that you gorge on it when you see it.
Further research, the investigators believe, could also shed light on the link between overeating and addiction. Some nutritionists theorize that the obese may suffer from a too-high habituation threshold, taking much longer to get tired of a food than other people.
The American Journal of Clinical Nutrition, Aug 2011
Tuesday, September 13, 2011
HEALTH LINE: Wearing Heels Could Lead to Arthritis Later in Life
CINCINNATI—Beauty is pain: We’ve heard women say that—joking or not—for decades.
This mantra helps you get through those agonizing last few miles on the treadmill or jazzes you up when going to the salon for an eyebrow wax or tweeze.
But some of the pain associated with society’s image of beauty could truly be harmful for health, says one UC Health primary care physician, and it doesn’t have to be as extreme—or as expensive—as surgery or injections.
"There are all sorts of products on the market that are truly unnecessary, but we are told we need these things to fit into society,” says Shyamala Jagtap, MD, who sees patients in the UC Health Physicians Office in West Chester, citing teeth whitener as an example and a new deodorant that is supposed to stop underarm hair growth in women. "These are not harmful, but they are not vital to our health. In some cases, what makes us fit in could not only mean pain now, but also health problems down the road.”
Specifically, Jagtap relates this to a fashion staple in most women’s closets: High heels.
A recent poll by the Society of Chiropodists and Podiatrists found that 25 percent of women who wear high heels are more likely to get arthritis.
"When you stand, the forces of gravity supporting your body go along your spine, then split into two along your pelvic bones to your hipbones, downward into your thigh bones, then down your leg bones to your heel, and then along the outer margin of your feet. The forces then spread throughout the rest of the foot, to your toes and finally to your big toe,” Jagtap explains. "If you change that alignment, causing weight to be borne on your toes instead of your heels, throwing your whole weight bearing system off and changing the line of gravity, it can affect your joints negatively, eventually leading to arthritis in your knees, ankles and back.”
She adds that more immediate problems could arise before the aches and pains of arthritis begin.
"Feet, like one’s ears and nose, keep growing throughout a lifetime,” Jagtap says. "In most women’s shoes, high heels in particular, the front of the shoe comes to a point at the center, causing the bigger toe—our longest toe—to get pushed towards the middle of the shoe, causing bunions.”
Jagtap adds that cramming your feet into the small and narrow shoe box of high heels can lead to hammer toe, in which the end of the toe is bent downward. High heels can also lead to Achilles’ tendonitis and additional back problems.
In addition to purchasing shoes with a large enough shoe box to allow toes to align side-by-side, Jagtap suggests:
Buy shoes at the end of the day. Feet swell throughout the day, and to avoid shoes that pinch, its best to buy when your feet are at their largest.
Measure the right and left feet separately and buy shoes to fit the larger one, providing padding for the smaller one.
Leave a little room in the shoe box, enough to slip an extra finger.
Buyshoes with good arch and heel support.
If you do buy heels, make sure they are no higher than an inch to an inch and a half.
Walk around in new shoes to make sure they fit correctly; shoes should have a slight give when you lift the foot, and the back of the foot should not feel tight.
"If you really want to wear the most fashion-forward stilettos, you can carry something more comfortable and foot-friendly to change into,” says Jagtap. "The older you get, the more you should think about comfort shoes, and you should always think about getting shoes that fit well. It’s OK to be fashionable, but we must keep our health in mind and try to decide which is more important or determine a way to be both trendy and healthful.”
08/09/2011
This mantra helps you get through those agonizing last few miles on the treadmill or jazzes you up when going to the salon for an eyebrow wax or tweeze.
But some of the pain associated with society’s image of beauty could truly be harmful for health, says one UC Health primary care physician, and it doesn’t have to be as extreme—or as expensive—as surgery or injections.
"There are all sorts of products on the market that are truly unnecessary, but we are told we need these things to fit into society,” says Shyamala Jagtap, MD, who sees patients in the UC Health Physicians Office in West Chester, citing teeth whitener as an example and a new deodorant that is supposed to stop underarm hair growth in women. "These are not harmful, but they are not vital to our health. In some cases, what makes us fit in could not only mean pain now, but also health problems down the road.”
Specifically, Jagtap relates this to a fashion staple in most women’s closets: High heels.
A recent poll by the Society of Chiropodists and Podiatrists found that 25 percent of women who wear high heels are more likely to get arthritis.
"When you stand, the forces of gravity supporting your body go along your spine, then split into two along your pelvic bones to your hipbones, downward into your thigh bones, then down your leg bones to your heel, and then along the outer margin of your feet. The forces then spread throughout the rest of the foot, to your toes and finally to your big toe,” Jagtap explains. "If you change that alignment, causing weight to be borne on your toes instead of your heels, throwing your whole weight bearing system off and changing the line of gravity, it can affect your joints negatively, eventually leading to arthritis in your knees, ankles and back.”
She adds that more immediate problems could arise before the aches and pains of arthritis begin.
"Feet, like one’s ears and nose, keep growing throughout a lifetime,” Jagtap says. "In most women’s shoes, high heels in particular, the front of the shoe comes to a point at the center, causing the bigger toe—our longest toe—to get pushed towards the middle of the shoe, causing bunions.”
Jagtap adds that cramming your feet into the small and narrow shoe box of high heels can lead to hammer toe, in which the end of the toe is bent downward. High heels can also lead to Achilles’ tendonitis and additional back problems.
In addition to purchasing shoes with a large enough shoe box to allow toes to align side-by-side, Jagtap suggests:
Buy shoes at the end of the day. Feet swell throughout the day, and to avoid shoes that pinch, its best to buy when your feet are at their largest.
Measure the right and left feet separately and buy shoes to fit the larger one, providing padding for the smaller one.
Leave a little room in the shoe box, enough to slip an extra finger.
Buyshoes with good arch and heel support.
If you do buy heels, make sure they are no higher than an inch to an inch and a half.
Walk around in new shoes to make sure they fit correctly; shoes should have a slight give when you lift the foot, and the back of the foot should not feel tight.
"If you really want to wear the most fashion-forward stilettos, you can carry something more comfortable and foot-friendly to change into,” says Jagtap. "The older you get, the more you should think about comfort shoes, and you should always think about getting shoes that fit well. It’s OK to be fashionable, but we must keep our health in mind and try to decide which is more important or determine a way to be both trendy and healthful.”
08/09/2011
Friday, September 9, 2011
More Muscle Mass Knocks Out Insulin Resistance and Prediabetes
Having more muscle mass can protect against insulin resistance and prediabetes, no matter overall body size, researchers said....
In a cross-sectional study, every 10% increase in the ratio of skeletal muscle mass to total body weight was associated with an 11% reduction in risk of insulin resistance and a 12% drop in risk of transitional, prediabetes, or overt diabetes. The findings point to the importance of gauging muscle mass, in addition to other established risk factors such as body mass index (BMI) and waist circumference, when assessing a patient's metabolic health, the researchers said.
The results may also have implications for the role of muscle-building exercises in preventing metabolic dysfunction.
It's known that very low muscle mass (sarcopenia) is a risk factor for insulin resistance, but it's unclear whether increasing muscle mass outside of the sarcopenic range can boost insulin sensitivity or protect against diabetes.
So to determine whether increases in muscle mass are associated with improved glucose regulation, the researchers looked at data on 13,644 patients from the National Health and Nutrition Examination Survey (NHANES) III, conducted from 1988 to 1994.
Patients had data on homeostasis model assessment of insulin resistance (HOMA-IR); glycated hemoglobin (HbA1c); prevalence of transitional, prediabetes, or overt diabetes (PMD); and prevalence of overt diabetes mellitus. These four factors served as the study outcomes.
Muscle mass was assessed via bioelectrical impedance, which measures opposition to the flow of an electric current through body tissues, determining total body water to estimate body composition.
The researchers found that all four of the outcomes declined across quartiles from lowest to highest skeletal muscle index, or the ratio of skeletal muscle to body weight. The smallest effect size was seen for HbA1c, with a 5.8% relative mean reduction between the highest and lowest quartiles.
On the other hand, the most striking effect was in diabetes prevalence, with a relative reduction of 63%. Prevalence was 14.5% in the lowest quartile compared with only 5.3% in the highest, the researchers reported.
After adjusting for confounders including age, ethnicity, sex, and obesity, the relationships persisted for insulin resistance and prevalence of transitional, prediabetes, and overt diabetes.
Specifically, each 10% increase in skeletal muscle index was associated with 11% relative reduction in HOMA-IR and a 12% relative reduction in the combined diabetes endpoint.
After excluding patients with diabetes, these relationships were strengthened. For every 10% increase in muscle mass ratio, there was a 14% reduction in HOMA-IR and a 23% reduction in combined diabetes prevalence.
They explained that the weaker associations when diabetic patients were included were likely due to the effects of diabetes on muscle mass and on pancreatic beta-cell mass.
The researchers concluded that the relationship between muscle mass and insulin resistance was not limited to sarcopenia, as "increases in muscle mass above even average levels were associated with additional protection against insulin resistance and prediabetes."
The study was limited by its cross-sectional nature, and by its use of bioelectrical impedance alone to estimate muscle mass. Also, there was no differentiation between type 1 and type 2 diabetes in the original survey, they said.
As well, patients with high muscle mass tend to have low fat mass, so any of the associations may be due to adipose tissue, they cautioned, although they attempted to control for this.
Despite these findings, prior prospective studies of short-term strength training programs in overweight and obese patients have been unclear in terms of their effects on metabolic abnormalities, they said.
They called for more work to determine the proper duration of exercise interventions needed in order to improve insulin sensitivity and glucose metabolism, and ultimately to have an effect on diabetes incidence.
In a cross-sectional study, every 10% increase in the ratio of skeletal muscle mass to total body weight was associated with an 11% reduction in risk of insulin resistance and a 12% drop in risk of transitional, prediabetes, or overt diabetes. The findings point to the importance of gauging muscle mass, in addition to other established risk factors such as body mass index (BMI) and waist circumference, when assessing a patient's metabolic health, the researchers said.
The results may also have implications for the role of muscle-building exercises in preventing metabolic dysfunction.
It's known that very low muscle mass (sarcopenia) is a risk factor for insulin resistance, but it's unclear whether increasing muscle mass outside of the sarcopenic range can boost insulin sensitivity or protect against diabetes.
So to determine whether increases in muscle mass are associated with improved glucose regulation, the researchers looked at data on 13,644 patients from the National Health and Nutrition Examination Survey (NHANES) III, conducted from 1988 to 1994.
Patients had data on homeostasis model assessment of insulin resistance (HOMA-IR); glycated hemoglobin (HbA1c); prevalence of transitional, prediabetes, or overt diabetes (PMD); and prevalence of overt diabetes mellitus. These four factors served as the study outcomes.
Muscle mass was assessed via bioelectrical impedance, which measures opposition to the flow of an electric current through body tissues, determining total body water to estimate body composition.
The researchers found that all four of the outcomes declined across quartiles from lowest to highest skeletal muscle index, or the ratio of skeletal muscle to body weight. The smallest effect size was seen for HbA1c, with a 5.8% relative mean reduction between the highest and lowest quartiles.
On the other hand, the most striking effect was in diabetes prevalence, with a relative reduction of 63%. Prevalence was 14.5% in the lowest quartile compared with only 5.3% in the highest, the researchers reported.
After adjusting for confounders including age, ethnicity, sex, and obesity, the relationships persisted for insulin resistance and prevalence of transitional, prediabetes, and overt diabetes.
Specifically, each 10% increase in skeletal muscle index was associated with 11% relative reduction in HOMA-IR and a 12% relative reduction in the combined diabetes endpoint.
After excluding patients with diabetes, these relationships were strengthened. For every 10% increase in muscle mass ratio, there was a 14% reduction in HOMA-IR and a 23% reduction in combined diabetes prevalence.
They explained that the weaker associations when diabetic patients were included were likely due to the effects of diabetes on muscle mass and on pancreatic beta-cell mass.
The researchers concluded that the relationship between muscle mass and insulin resistance was not limited to sarcopenia, as "increases in muscle mass above even average levels were associated with additional protection against insulin resistance and prediabetes."
The study was limited by its cross-sectional nature, and by its use of bioelectrical impedance alone to estimate muscle mass. Also, there was no differentiation between type 1 and type 2 diabetes in the original survey, they said.
As well, patients with high muscle mass tend to have low fat mass, so any of the associations may be due to adipose tissue, they cautioned, although they attempted to control for this.
Despite these findings, prior prospective studies of short-term strength training programs in overweight and obese patients have been unclear in terms of their effects on metabolic abnormalities, they said.
They called for more work to determine the proper duration of exercise interventions needed in order to improve insulin sensitivity and glucose metabolism, and ultimately to have an effect on diabetes incidence.
Thursday, September 8, 2011
Study Cites Eleven Risk Factors That Could Predict Amputation
Given that lower extremity amputation is a devastating consequence of diabetic foot infection, physicians must be vigilant for the signs that could presage amputation. In a new study in Diabetes Care, authors have developed a risk score of 11 factors that could predict amputation.
Researchers identified 3,018 patients who were hospitalized for culture-documented diabetic foot infection at 97 hospitals in the U.S. between 2003 and 2007. Among those patients, 21.4 percent underwent a lower extremity amputation.
The 11 risk factors for amputation, in ascending order of point value, are: chronic renal disease or creatinine >3 mg/dL; male sex; temperature <96°F or >100.5°F; age 50 or older; ulcer with cellulitis; history of amputation; albumin <2.8 g/dL; history of peripheral vascular disease; white blood cell count >11,000 per mm3); surgical site infection; and transfer from another acute care facility.
Authors note that treatment of a patient with a low score may require fewer medical resources than a patient with a high risk score. The study also says in an attempt to avoid amputation, healthcare providers should concentrate efforts on a patient with a risk score of more than 21 as they have a 50 percent chance of amputation.
Lead study author Benjamin A. Lipsky, MD, notes researchers developed the risk score specifically to use information that is present at (or soon after) the time of hospitalization. As he notes, this info includes findings from the history, physical examination or simple laboratory tests. He foresees “relatively minimal” organizational challenges for healthcare facilities implementing this scoring system. Dr. Lipsky says facilities would just need to educate providers about the score and perhaps provide a score sheet with explanations on how to use it.
Although the study used a database of patients who were hospitalized for their diabetic foot infection, this risk score would likely apply to the majority of patients who do not require hospitalization, according to Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the VA Puget Sound Health Care System. He and his co-authors would like to see the score validated in such a population.
David G. Armstrong, DPM, MD, PhD, cites the importance of the risk score system, saying it will be helpful to have a predictable system as another tool to predict outcomes. He compares this to a wound classification system, which is “highly predictive of good and bad outcomes” when a patient presents with a wound.
Dr. Armstrong has found the most critical predictors of amputation to be infection, ischemia and renal disease. He expresses surprise that renal disease was not more of a factor in the study.
“We believe that people on dialysis, people with end-stage renal disease and people with kidney disease are going to become increasingly important targets for aggressive intervention or hospice,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Lipsky would like to see if the score can be further simplified and refined so clinicians can remember it more easily. He would also like to see the risk score applied to patients in other countries and healthcare systems.
By Brian McCurdy, Senior Editor
Researchers identified 3,018 patients who were hospitalized for culture-documented diabetic foot infection at 97 hospitals in the U.S. between 2003 and 2007. Among those patients, 21.4 percent underwent a lower extremity amputation.
The 11 risk factors for amputation, in ascending order of point value, are: chronic renal disease or creatinine >3 mg/dL; male sex; temperature <96°F or >100.5°F; age 50 or older; ulcer with cellulitis; history of amputation; albumin <2.8 g/dL; history of peripheral vascular disease; white blood cell count >11,000 per mm3); surgical site infection; and transfer from another acute care facility.
Authors note that treatment of a patient with a low score may require fewer medical resources than a patient with a high risk score. The study also says in an attempt to avoid amputation, healthcare providers should concentrate efforts on a patient with a risk score of more than 21 as they have a 50 percent chance of amputation.
Lead study author Benjamin A. Lipsky, MD, notes researchers developed the risk score specifically to use information that is present at (or soon after) the time of hospitalization. As he notes, this info includes findings from the history, physical examination or simple laboratory tests. He foresees “relatively minimal” organizational challenges for healthcare facilities implementing this scoring system. Dr. Lipsky says facilities would just need to educate providers about the score and perhaps provide a score sheet with explanations on how to use it.
Although the study used a database of patients who were hospitalized for their diabetic foot infection, this risk score would likely apply to the majority of patients who do not require hospitalization, according to Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the Primary Care Clinic at the VA Puget Sound Health Care System. He and his co-authors would like to see the score validated in such a population.
David G. Armstrong, DPM, MD, PhD, cites the importance of the risk score system, saying it will be helpful to have a predictable system as another tool to predict outcomes. He compares this to a wound classification system, which is “highly predictive of good and bad outcomes” when a patient presents with a wound.
Dr. Armstrong has found the most critical predictors of amputation to be infection, ischemia and renal disease. He expresses surprise that renal disease was not more of a factor in the study.
“We believe that people on dialysis, people with end-stage renal disease and people with kidney disease are going to become increasingly important targets for aggressive intervention or hospice,” says Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Lipsky would like to see if the score can be further simplified and refined so clinicians can remember it more easily. He would also like to see the risk score applied to patients in other countries and healthcare systems.
By Brian McCurdy, Senior Editor
Wednesday, September 7, 2011
Diabetics are more prone to bone-related conditions
DUBAI - Diabetic patients suffer disproportionately from common musculoskeletal conditions in terms of increased prevalence, severity, and morbidity, according to a doctor.
“The high glucose, high insulin milieu of diabetic tissues affects many of the key cells,” said Dr Saleh Mohammed Kagzi, Orthopaedics Surgeon, Zulekha Hospital, Dubai.
Osteoarthritis is the most common form of arthritis in adults and as such would frequently co-occur with diabetes by chance alone, he said. “Peripheral neuropathy, a common complication of diabetes, may also adversely affect joints and increase the risk of advanced, aggressive forms of osteoarthritis.”
“Diabetes may also affect the outcomes of therapy in osteoarthritis. It was noted in a study that there is a propensity for diabetic patients to have more severe pain and radiographic changes both preoperatively and postoperatively, an increased risk of deep tissue infection as well as an increased revision rate compared with non-diabetic,” he added.
Although diabetes is not recognised as an independent risk factor for the development of rheumatoid arthritis (RA), many patients suffer from both conditions. “Carpal Tunnel Syndrome (CTS) is a common compression neuropathy of the median nerve associated with many conditions including diabetes.”
Diabetes may induce structural alterations of tendon, increase obesity, and produce metabolic abnormalities that result in proliferation or fibrosis of the connective tissues surrounding the nerve.
Metabolic conditions including diabetes are thought to impair bone homeostasis. Type 1 diabetes has been associated with abnormal bone formation or bone turnover, or both possibly leading to decreased bone mineral density (BMD) and increased marrow adiposity.
“Gout is an acute and chronic arthritis caused by monosodium urate (MSU) crystals. Hyperuricemia is a necessary condition for gout and is part of the constellation of lipid and non-lipid cardiovascular risk factors typically defined as the metabolic syndrome,” explained Dr Kagzi.
“Type II diabetes is also a part of this syndrome and as such, an association of gout and type II diabetes would be expected. Renal insufficiency, a common complication of diabetes, also predisposes to gout.”
In contrast, several of the musculoskeletal syndromes associated with the hydroxyapatite-like basic calcium phosphate (BCP) crystals such as calcific tendinitis are clearly associated with diabetes. Charcot arthropathy, which is also called neuropathic arthritis, is a serious complication of diabetes, he said.
“It is characterised by fracture, dislocation, and subluxation of the affected joint in the presence of a significant sensory deficit. Charcot arthropathy typically affects the foot in diabetic patients with peripheral neuropathy. Late stages are often complicated by refractory skin ulcers and may culminate in amputation.”
Tendinopathies occur frequently in patients with diabetes. Painful tendinopathies, including shoulder tendinitis, limited hand mobility (cheiropathy), tendon ruptures, and adhesive capsulitis affect 30-60 per cent of diabetic patients, and cause considerable disability among affected patients.
Flexor tenosynovitis in the hand is also quite common in diabetic patients with a prevalence estimated at 10-20 per cent of diabetic patients. Interestingly, diabetes and its control may also affect therapy, he said. Although inter-sheath injections are typically very successful for flexor tenosynovitis in the hand, high hemoglobin A1C levels, reflecting poor diabetic control, adversely affect results from this intervention. Tendon rupture may also be associated with diabetes.—news@khaleejtimes.com
“The high glucose, high insulin milieu of diabetic tissues affects many of the key cells,” said Dr Saleh Mohammed Kagzi, Orthopaedics Surgeon, Zulekha Hospital, Dubai.
Osteoarthritis is the most common form of arthritis in adults and as such would frequently co-occur with diabetes by chance alone, he said. “Peripheral neuropathy, a common complication of diabetes, may also adversely affect joints and increase the risk of advanced, aggressive forms of osteoarthritis.”
“Diabetes may also affect the outcomes of therapy in osteoarthritis. It was noted in a study that there is a propensity for diabetic patients to have more severe pain and radiographic changes both preoperatively and postoperatively, an increased risk of deep tissue infection as well as an increased revision rate compared with non-diabetic,” he added.
Although diabetes is not recognised as an independent risk factor for the development of rheumatoid arthritis (RA), many patients suffer from both conditions. “Carpal Tunnel Syndrome (CTS) is a common compression neuropathy of the median nerve associated with many conditions including diabetes.”
Diabetes may induce structural alterations of tendon, increase obesity, and produce metabolic abnormalities that result in proliferation or fibrosis of the connective tissues surrounding the nerve.
Metabolic conditions including diabetes are thought to impair bone homeostasis. Type 1 diabetes has been associated with abnormal bone formation or bone turnover, or both possibly leading to decreased bone mineral density (BMD) and increased marrow adiposity.
“Gout is an acute and chronic arthritis caused by monosodium urate (MSU) crystals. Hyperuricemia is a necessary condition for gout and is part of the constellation of lipid and non-lipid cardiovascular risk factors typically defined as the metabolic syndrome,” explained Dr Kagzi.
“Type II diabetes is also a part of this syndrome and as such, an association of gout and type II diabetes would be expected. Renal insufficiency, a common complication of diabetes, also predisposes to gout.”
In contrast, several of the musculoskeletal syndromes associated with the hydroxyapatite-like basic calcium phosphate (BCP) crystals such as calcific tendinitis are clearly associated with diabetes. Charcot arthropathy, which is also called neuropathic arthritis, is a serious complication of diabetes, he said.
“It is characterised by fracture, dislocation, and subluxation of the affected joint in the presence of a significant sensory deficit. Charcot arthropathy typically affects the foot in diabetic patients with peripheral neuropathy. Late stages are often complicated by refractory skin ulcers and may culminate in amputation.”
Tendinopathies occur frequently in patients with diabetes. Painful tendinopathies, including shoulder tendinitis, limited hand mobility (cheiropathy), tendon ruptures, and adhesive capsulitis affect 30-60 per cent of diabetic patients, and cause considerable disability among affected patients.
Flexor tenosynovitis in the hand is also quite common in diabetic patients with a prevalence estimated at 10-20 per cent of diabetic patients. Interestingly, diabetes and its control may also affect therapy, he said. Although inter-sheath injections are typically very successful for flexor tenosynovitis in the hand, high hemoglobin A1C levels, reflecting poor diabetic control, adversely affect results from this intervention. Tendon rupture may also be associated with diabetes.—news@khaleejtimes.com
Saturday, September 3, 2011
Real life: 'They think it's witchcraft'
The issue of diabetes in Haiti -- where one is 16 suffers from the illness -- has a unique set of problems
Monday August 01 2011
If Jean Bernadette (56) hadn't discovered she was diabetic, she would probably be dead by now. In Haiti, where the health focus remains fixated on infectious diseases like HIV, Non-Communicable Diseases (NCDs) like diabetes are often detected late, when patients need extensive and expensive hospital care.
Yet, cardiovascular diseases and diabetes rank first and fourth in Haiti respectively, while HIV-AIDS now sits well below them in 10th position.
Jean Bernadette got diabetes 15 years ago. However, like many Haitians, she hasn't had access to the right medication or treatment.
Pointing to a gap in her right foot she tells me: "Six months ago I had to go to hospital to have a surgeon cut it off."
A study released by the General Hospital in Port-au-Prince in 2009 shows that more than 50pc of patients in the capital have diabetic foot, with ulcers and infections in the feet standing out as the major source of death in these patients.
According to 2006 figures supplied by the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), a private organisation affiliated to the International Diabetes Federation (IDF), one in every 16 Haitians is diabetic.
To add to the problem, FHADIMAC's Vice-President Dr Philippe Larco explains, "the concept of a chronic disease is not understood in Haiti.
"People think that it is supernatural, some kind of witchcraft, and there is nothing you can do against it. This is a big challenge for our healthcare teams in terms of the compliance of the patient with the treatment."
In addition to such challenges lie a lack of proper funding, data collection, surveillance, available medication and treatment.
These vital pieces in the Haitian health puzzle are all scarce commodities for diabetics, as the country's health development continues to be tied almost exclusively to more visible and campaign-ready infectious diseases like HIV, malaria and tuberculosis.
Dr Larco explains that the "cost of medication is too high and patients simply cannot afford it".
"With more than 60pc of the population living on less than €1.50 a day, it is very difficult for a family to buy insulin on a regular basis and many of them let a parent die because the economic burden is too great."
Both of Jean Bernadette's parents were diabetics and died from cardiovascular-related complications. Her father developed chronic kidney disease and her mother died from a heart attack that she believes stemmed from years of high blood pressure.
She shows me a diabetic glucose monitor that FHADIMAC gave her last year when they began screening for diabetic patients in the post-earthquake camps.
Unfortunately she doesn't have any test strips to use with the monitor. "I can't check my sugars without strips but I can't afford them either," she explains.
Vicious circle
Dr Larco says that a vicious circle exists where the international community doesn't fund these silent, invisible diseases and thus "NCDs don't end up on the list of priorities for the Haitian Ministry of Health which in turn blocks funding activities related to NCDs," he says.
According to the charity UNAIDS, in 2010 up to $145m (€100m) was used to target HIV prevention, medication and management in Haiti.
As for diabetes, less than $15m (€10.5m) was used. The country has one of the lowest expenditure rates on diabetes in the Americas with only $48 spent per person.
Ironically, the earthquake at the start of last year did spark some positive change for diabetics in Haiti, with more funding becoming available for the cause.
In April this year, FHADIMAC began work on a two-year project in conjunction with the World Diabetes Foundation to open up 12 new diabetic clinics. Mobile clinics will also be set up for patients in remote rural areas. They will all carry out basic glucose testing along with eye and feet exams.
Following the earthquake, international organisations such as Medecins Sans Frontieres (MSF) have had a strong presence in the country. Dr Andre Munger, the medical chief at one of MSF's trauma hospitals in the outskirts of Port-au-Prince, says they "are now starting to take action because of the health catastrophe posed by non-communicable diseases like diabetes".
Later this year, MSF aim to carry out a new survey on the number of people suffering from diabetic and cardiovascular complications in Haiti. "Without proper data and statistics we'll never be able to address these issues properly," Dr Munger explains.
In order to bring this work on to the international stage and begin to tap into possible new sources of funding, FHADIMAC will present its plan at a UN summit in New York in September.
For many diabetics and other NCD patients like Jean Bernadette, such efforts could be the difference between life and death.
Monday August 01 2011
If Jean Bernadette (56) hadn't discovered she was diabetic, she would probably be dead by now. In Haiti, where the health focus remains fixated on infectious diseases like HIV, Non-Communicable Diseases (NCDs) like diabetes are often detected late, when patients need extensive and expensive hospital care.
Yet, cardiovascular diseases and diabetes rank first and fourth in Haiti respectively, while HIV-AIDS now sits well below them in 10th position.
Jean Bernadette got diabetes 15 years ago. However, like many Haitians, she hasn't had access to the right medication or treatment.
Pointing to a gap in her right foot she tells me: "Six months ago I had to go to hospital to have a surgeon cut it off."
A study released by the General Hospital in Port-au-Prince in 2009 shows that more than 50pc of patients in the capital have diabetic foot, with ulcers and infections in the feet standing out as the major source of death in these patients.
According to 2006 figures supplied by the Haitian Foundation for Diabetes and Cardiovascular Diseases (FHADIMAC), a private organisation affiliated to the International Diabetes Federation (IDF), one in every 16 Haitians is diabetic.
To add to the problem, FHADIMAC's Vice-President Dr Philippe Larco explains, "the concept of a chronic disease is not understood in Haiti.
"People think that it is supernatural, some kind of witchcraft, and there is nothing you can do against it. This is a big challenge for our healthcare teams in terms of the compliance of the patient with the treatment."
In addition to such challenges lie a lack of proper funding, data collection, surveillance, available medication and treatment.
These vital pieces in the Haitian health puzzle are all scarce commodities for diabetics, as the country's health development continues to be tied almost exclusively to more visible and campaign-ready infectious diseases like HIV, malaria and tuberculosis.
Dr Larco explains that the "cost of medication is too high and patients simply cannot afford it".
"With more than 60pc of the population living on less than €1.50 a day, it is very difficult for a family to buy insulin on a regular basis and many of them let a parent die because the economic burden is too great."
Both of Jean Bernadette's parents were diabetics and died from cardiovascular-related complications. Her father developed chronic kidney disease and her mother died from a heart attack that she believes stemmed from years of high blood pressure.
She shows me a diabetic glucose monitor that FHADIMAC gave her last year when they began screening for diabetic patients in the post-earthquake camps.
Unfortunately she doesn't have any test strips to use with the monitor. "I can't check my sugars without strips but I can't afford them either," she explains.
Vicious circle
Dr Larco says that a vicious circle exists where the international community doesn't fund these silent, invisible diseases and thus "NCDs don't end up on the list of priorities for the Haitian Ministry of Health which in turn blocks funding activities related to NCDs," he says.
According to the charity UNAIDS, in 2010 up to $145m (€100m) was used to target HIV prevention, medication and management in Haiti.
As for diabetes, less than $15m (€10.5m) was used. The country has one of the lowest expenditure rates on diabetes in the Americas with only $48 spent per person.
Ironically, the earthquake at the start of last year did spark some positive change for diabetics in Haiti, with more funding becoming available for the cause.
In April this year, FHADIMAC began work on a two-year project in conjunction with the World Diabetes Foundation to open up 12 new diabetic clinics. Mobile clinics will also be set up for patients in remote rural areas. They will all carry out basic glucose testing along with eye and feet exams.
Following the earthquake, international organisations such as Medecins Sans Frontieres (MSF) have had a strong presence in the country. Dr Andre Munger, the medical chief at one of MSF's trauma hospitals in the outskirts of Port-au-Prince, says they "are now starting to take action because of the health catastrophe posed by non-communicable diseases like diabetes".
Later this year, MSF aim to carry out a new survey on the number of people suffering from diabetic and cardiovascular complications in Haiti. "Without proper data and statistics we'll never be able to address these issues properly," Dr Munger explains.
In order to bring this work on to the international stage and begin to tap into possible new sources of funding, FHADIMAC will present its plan at a UN summit in New York in September.
For many diabetics and other NCD patients like Jean Bernadette, such efforts could be the difference between life and death.
Friday, September 2, 2011
Diabetes Linked to Tooth Decay
Research has found a link between diabetes and dental problems....
Doctors say that diabetics are more prone to periodontal diseases. More than 70% of diabetic patients suffer from a periodontal problem. Research has found a link between diabetes and dental problems. Doctors say that diabetics are more prone to periodontal diseases.
According to the results of the study, periodontal disease makes it harder for people who have diabetes to control their blood sugar.
"Research on 113 Indians suffering from diabetes showed that after treating periodontal infections, it became easier to manage their diabetes," said Dr. D. Gopalakrishnan, secretary general of the international clinical dental research organization.
Dental expert Dr. Vikas Goud explains the connection between the two: "In diabetic patients, due to the slow glucose metabolism rate and low immunity, high glucose level in the saliva leads to bacterial infection, resulting in diabetic oral manifestations like swollen gums. The insulin, which would have helped in glucose metabolism, is now used to fight infections. Therefore, the sugar level goes up further, posing a risk to diabetic patients. Once the sugar level comes down, again the swollen gums become normal."
More than 70% of diabetic patients suffer from a periodontal problem.
Dr. Sudheer Chowdhury, dental surgeon at Ameerpet Dental Hospital, Hyderabad, says the symptoms to look out for are bleeding while brushing teeth, swollen puffy gums, bad breath, tooth problems that require frequent use of tooth-picks and wobbly teeth
Doctors say that diabetics are more prone to periodontal diseases. More than 70% of diabetic patients suffer from a periodontal problem. Research has found a link between diabetes and dental problems. Doctors say that diabetics are more prone to periodontal diseases.
According to the results of the study, periodontal disease makes it harder for people who have diabetes to control their blood sugar.
"Research on 113 Indians suffering from diabetes showed that after treating periodontal infections, it became easier to manage their diabetes," said Dr. D. Gopalakrishnan, secretary general of the international clinical dental research organization.
Dental expert Dr. Vikas Goud explains the connection between the two: "In diabetic patients, due to the slow glucose metabolism rate and low immunity, high glucose level in the saliva leads to bacterial infection, resulting in diabetic oral manifestations like swollen gums. The insulin, which would have helped in glucose metabolism, is now used to fight infections. Therefore, the sugar level goes up further, posing a risk to diabetic patients. Once the sugar level comes down, again the swollen gums become normal."
More than 70% of diabetic patients suffer from a periodontal problem.
Dr. Sudheer Chowdhury, dental surgeon at Ameerpet Dental Hospital, Hyderabad, says the symptoms to look out for are bleeding while brushing teeth, swollen puffy gums, bad breath, tooth problems that require frequent use of tooth-picks and wobbly teeth
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