Around 77% of people with Type 2 diabetes were aged 45 years and over when they were first diagnosed, compared with 16% of people with Type 1 diabetes. Pathology leading to amputation - Physiopedia, universal access to physiotherapy knowledge. Worldwide prevalence estimates of amputation are difficult to obtain, mainly because amputation receives very little attention and resources in countries where survival is low.
Peripheral Vascular Disease is also known or referred to as Peripheral Artery Disease or lower extremity occlusive disease. The peripheral vascular system consists of the veins and arteries beyond or distal to the chest and abdomen supplying the arms, hands, legs and feet. Atherosclerosis, which is the process of Peripheral Arterial Disease (PAD), affects several arterial beds including the coronary and peripheral circulation. Diabetes is also another condition that has an effect on the pathology that may lead to lower limb amputation.
Diabetes Mellitus (Type 2) Diabetes mellitus is also present in almost half of all cases, and people with diabetes mellitus have a 10 times higher risk of amputation.
Patients who suffer from Diabetes Mellitus are at a high risk of developing ulcers and associated complications. Studies indicate that diabetic patients have up to a 25% lifetime risk of developing a foot ulcer. Neuropathy in diabetic individuals affects the motor, sensory and autonomic components of the the nervous system. In the case of peripheral circulation where the the arteries of the lower limbs are affected, pain and tissue damage develop which may eventually lead to amputation in some cases. Peripheral arterial disease is one contributing factor to ischaemia involving the lower limbs.
Tissue viability is affected not only by internal factors such as PAD or Diabetes Melllitus but also by external stimuli such as smoking. Lower limb amputation can also occur due to systemic infections such as bacterial infections.
Learn about the shoulder in this month's Physiopedia Plus learn topic with 5 chapters from textbooks such as Magee's Orthopedic Physical Assessment, 2014 & Donatelli's Physical therapy of the shoulder 2012. The risk of South Asian women dying early from heart disease is 65% higher than the general population. British-Bangladeshi and -Pakistani people are five or six times more likely to have type 2 diabetes than the general population.
At birth, males and females in Richmond upon Thames can expect to live without a disability for more than 13 years longer than those in Newham.
All of the reasons for the high levels of ill-health from diabetes and heart disease haven't yet been precisely worked out. It's important for East London Bangladeshi and Pakistani communities and their healthcare providers to be aware of these issues. There is also a need for more research in order to work out in greater detail why individuals of Bangladeshi and Pakistani heritage are particularly affected in this way. Our East London Genes & Health study aims to help researchers to find out more, for example by looking at the health history of individuals with variants in genes to find out if there is any link between the gene and disease, or in response to treatments.
Most people know that diabetes has something to do with sugar and insulin, but many are unaware that there are actually two main types of diabetes – type 1 and type 2.
Insulin is a hormone that is produced by a gland called the pancreas (which sits just behind the stomach). In type 2 diabetes, the body doesn't produce enough insulin, or the body's cells don't react to insulin. Rather than being heart-shaped, the heart is in fact a fist-size organ that is responsible for pumping blood around our bodies via an intricate network of blood vessels.
Coronary heart disease (CHD), which is the leading cause of death both in the UK and worldwide, can result in heart failure, heart attacks, and more commonly, angina (chest pain related to exercise).
A heart attack (also known as myocardial infarction or MI) arises when blood flow to the heart is suddenly disrupted, causing damage to heart muscle. Cardiac arrest is when the heart actually stops pumping completely; it’s different from a heart attack, although it may result from such an attack. Angina is chest pain that usually occurs during activity or exercise and is the result of a reduced heart blood supply fue to narrowed heart arteries. It is worth noting that people in the East London Bangladeshi community are on average younger than some other populations in the UK.
Written by Julie N Reza and David van Heel, with advice from Tahseen Chowdhury and Andrew Wragg. We all know that eating too much can be bad for our health, especially if we become overweight or obese. Obesity is the medical term for the accumulation of excess fat, leading to adverse effects on health and reduced life expectancy.
Obesity can lead to increased risk of heart disease, type II diabetes, osteoarthritis and some types of cancer.
In the medieval period, obesity was a sign of status – only the wealthy were able to eat too much (and would have lower activity levels). It is very difficult to estimate the weight, and therefore the BMI of a skeletonised person, and because of that any estimates have wide error margins. There is eburnation (polishing) and flattening of the head of this femur (thigh bone), which is indicative of osteoarthritis of the hip.
The largest factor influencing the likelihood of having osteoarthritis is age – put simply, the older you are, the more wear and tear on your joints.
Diffuse Idiopathic Skeletal Hyperostosis (DISH; also known as Forestier’s disease) is a non-inflammatory joint disease which causes ossification (turning to bone) of the spinal ligaments and the regions where tendons and ligaments attach to bone (entheses). DISH is more commonly seen in males over the age of 50 and is associated with a rich diet, and with Type II diabetes, although the exact causes of the disease are unknown. This first metatarsal (foot bone) has a large hole at the distal end, caused by the build up of urate crystals in gout. Among Americans born in the US, nearly 40% of all tuberculosis cases are in African-Americans. On the other hand, although African-Americans are disproportionately likely to be poor, they are only a quarter of Americans living in poverty; whites make up about 41% of the poor. Most death sentences are handed out for killing white people, even though African-Americans make up 50% of murder victims (they are only 12% of the population). So if an African-American male had fired ten shots into the SUV of some white suburban kids playing their music too loud, killing one of them, I think we all know there would have been a murder conviction and almost certainly a death penalty imposed. In case of conviction for murder, African-Americans are 38% more likely to be handed the death penalty than members of other racial groupings.
Unfortunately for people of color around the world this inequality and its consequences are universal. Thank you to all of my supporters for your generosity and your encouragement of an independent press! Mortality is a direct measure of health care need reflecting the overall disease burden on the population, both in terms of the incidence and prevalence of diseases and the ability to treat them. The rate of all age all-cause mortality in Enfield has continued to decline in line with London and England. Despite the decline in all age all-cause mortality across the borough as a whole, there is significant variation in the rates of mortality between wards, as can be seen from the map below. The largest numbers of deaths in 2010 were due to circulatory (cardiovascular) diseases, cancers and respiratory diseases.
Preventable mortality is defined as deaths that are considered preventable if, in the light of the understanding of the determinants of health at the time of death, all or most deaths from the underlying cause (subject to age limits if appropriate) could potentially be avoided by public health interventions. As the graph below shows, Enfield had significantly lower overall (actual) mortality rates and preventable mortality rates for cancers and respiratory disease compared to England, and similar mortality rates and preventable mortality rates of liver disease and cardiovascular disease compared to England.
Cancer was the most recorded cause of actual and preventable death amongst people aged under 75 of the conditions considered both in Enfield and in England between 2009 and 2011. The new Public Health England tool 'Longer Lives' (4) ranks local areas by their under 75 mortality rate overall, and by under 75 mortality rates for cancer, cardiovascular disease, respiratory disease and liver disease. Deaths from causes considered ’amenable’ to health care are premature deaths that should not occur in the presence of timely, high quality healthcare. Enfield’s rate of healthcare-amenable deaths has continued to decline, and has remained closely in line with rates across London and England, particularly since 2004.
As can be seen from the graph below, there has been an on-going, but varying discrepancy between males and females in terms of potential years of life lost (PYLL), which is an estimate of the average years a person would have lived if they had not died prematurely, in this case, from causes that could be prevented by healthcare. 1 Directly standardised rates (DSR) of mortality are used to compare the number of deaths between areas with different age structures and population sizes.
2 Standardised mortality ratios (SMR) are a comparison of the number of the actual (observed) deaths in a given population with the number of expected deaths, once the local population structure and size has been factored in. 3 A full list of deaths considered as ‘preventable’ can be found on page 100 of the Public Health Outcomes Framework part 2. 5 A full list of causes considered amenable to healthcare can be found on page 10 of the NHS Outcome Framework technical appendix.
It may be referred to as hardening of the arteries where there is generalised degeneration of the elastic tissue and muscles composing the arterial system. It is characterised by chronic compensatory hyperglycaemia that results from progressive insulin resistance especially in muscle tissue together with insufficient pancreatic secretion of insulin to aid glucose uptake in tissues . Peripheral neuropathy and ischaemia from Peripheral vascular disease are two contributing factors to the development of foot ulcers. Autonomic neuropathy causes the reduction in sweat and oil gland function with the foot loosing its natural ability to moisturise the overlying skin.
Patients suffering from peripheral arterial disease present with pain referred to as Intermittent Claudication. The latter is one of the causal factors when amputation of the affected lower limb may be considered. Smoking is considered to be another or an added risk factor for lower limb amputation due to its effect on the circulation and potential for healing. Previously healthy individuals when affected by such infections are at a risk of amputation of limbs not only as a treatment of choice but also as a life saving measure. In order to facilitate scientific communication the International Organization for Standardization (ISO) developed a system of accurate classification. 2005, Major lower limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. However, we already know some of the differences in health are likely to arise from the combined effects of many factors, including genetic variation, socio-economic differences (affecting poverty, nutrition and housing conditions), and differences in social and cultural beliefs and lifestyle practices (e.g.
You can do already something yourself by stopping smoking, eating a healthier diet, taking more exercise, and having your blood pressure, glucose levels (or a test called haemoglobin A1C) and cholesterol levels checked (and treated if necessary)!
Although there are similarities, these two are actually quite different conditions in terms of how they develop and are managed. When we eat carbohydrates, these are broken down into a number of sugars – one of which is glucose. This type of diabetes is more common in the UK, but often symptoms can be controlled with good diet and exercise and regular monitoring of blood glucose levels. These include arteries (that lead away from the heart, generally carrying blood rich in oxygen to the body) and veins (that lead towards the heart, generally carrying blood low in oxygen) and capillaries (small blood vessels that join arteries and veins together). It usually is the result of a build up of fatty substances such as cholesterol in the coronary arteries (atherosclerosis) that affect or block the heart’s blood supply. It usually causes chest pain and other symptoms such as shortness of breath, sweating and vomiting.
It usually happens because the arteries supplying the heart have become hardened and narrowed due to atherosclerosis.
It's therefore important to age-standardise to make a fair comparison of rates of disease between populations.
Obesity itself does not cause pathological lesions in bone, however recent research has suggested that obesity can cause an increase in the size of bones, especially the width of the femur (thigh bone).
Strenuous activity, especially from an early age, will also increase the likelihood of developing osteoarthritis. Clinically, the patient initially suffers from pain in the mid back, and over time experiences increasing stiffness as the bones of the spine fuse together.
The vertabrae are fused together due to the ossification of a ligament running along the front of the spine. DISH has been observed to be particularly common in medieval skeletons from monastic cemeteries, suggesting that either these were monks who enjoyed a particularly rich diet or possibly that these were rich patrons who chose to be buried at the monastery. Lead was used as a sweetener and preservative in wine, and liquid containers often had lead glazes. The all-age all-cause mortality is a measure of the rate at which people are dying, and is also used as a proxy measure for life expectancy. Circulatory diseases, which include deaths from ischaemic heart disease and strokes, accounted for 32% of all deaths, while cancers and respiratory diseases (including deaths from pneumonia) accounted for 29% and 14% of all deaths respectively. The age groups for which a death is considered preventable varies by disease type, so the graph below look at all deaths considered preventable for all ages. A total of 307 deaths from cardiovascular disease, 462 deaths from cancer, 98 deaths from liver disease and 63 deaths from respiratory deaths between 2009 and 2011 were considered preventable. Compared to comparator areas with similar levels of deprivation, Enfield had the lowest rate of overall mortality, mortality from liver disease and mortality from cancer, and the second lowest death rates for cardiovascular disease and lung disease. In 2008-10, Enfield’s rate of ‘amenable’ deaths was 91.90 per 100,000 people (under the age of 75), which equated to a total of 743 deaths that during the three year period that could be considered amenable. A low DSR is a mark of positive performance, as this represents fewer deaths in the given population. The national rate is expressed as 100, so a local SMR higher than 100 implies an excess mortality rate whereas a number below 100 implies below average mortality.
Peripheral Vascular Disease is the most common cause of limb loss overall, with the rate of dysvascular amputation being nearly 8 times greater than the rate of trauma related amputations, the second leading cause of limb loss. This tissue is replaced by fibrous tissue and the elastic vessels become harder with stretching of collagen and calcium depositing in the walls of the arteries causing them to become hard and tortuous. Diabetes Mellitus usually has an insidious onset and presents as persistent hyperglycaemia.
Once a foot ulcer develops there is a high risk of wound progression that may lead to complications and amputation. The innervation of the intrinsic muscles of the foot is affected and damage leads to an imbalance between the flexors and extensors of the affected foot and therefore causing anatomic deformities. The skin becomes dry and susceptible to tears or breaks with subsequent development of infection. Neuropathy (with alterations in motor, sensation, and autonomic functions) plays the central role and causes ulcerations due to trauma or excessive pressure in a deformed foot without protective sensibility. It has a detrimental effect on wound healing due to the local and systemic processes that nicotine has. Infections include: Meningococcal Meningitis, Staphylococcus and MRSA infections and Necrotizing Fascitis. Whereas no other treatment but surgery is currently available for chondrosarcomas, osteosarcomas show an approximately 50–80% response rate to adjuvant chemotherapy. The mentioned classification is constructed on an anatomical bases due to a failure of formation.
Insulin’s role is to control the amount of glucose we have in our blood; too much glucose in the bloodstream can have serious effects on various organs and tissues, including the eyes, kidney and heart. However, the disease is progressive, which means it can get worse and require treatment in the form of tablets or insulin injections.
The heart is made up of chambers with valves that help the heart carry out its pumping action. In some cases an individual may have a silent heart attack – with vague or very few symptoms. Carrying too much weight can lead to type II diabetes and osteoarthritis of weight bearing joints, and certain diseases such as DISH (Diffuse Idiopathic Skeletal Hyperostosis) are also seen more often in obese individuals. It is well known that activity increases bone size and bone mass – and carrying around excess weight has a similar effect on bone.
Therefore very few researchers have investigated the prevalence of obesity in medieval populations. Once all of the cartilage has worn away, bone on bone contact occurs – which leads to polishing (eburnation) and porosity of the bone surface.
Obesity puts extra strain on the main weight bearing joints – especially the knees – and therefore also leads to an increased risk of developing osteoarthritis. Documentary evidence suggests that although monks ate a frugal diet at the start of the Middle Ages, they became adept at bending fasting rules and there are many accounts describing the rich and varied diet they enjoyed. When all age all-cause mortality rates improve, life expectancy can also be expected to improve, though the relationship between these two measures is not straightforward. However, Upper Edmonton has a SMR of 161.95, indicating that rates of all age all-cause mortality are more than 60% higher in this ward compared to the overall Enfield rate.
Deaths due to a wide range of causes are considered, including some infectious diseases, a range of cancers, alcohol or drug related deaths, transport accidents and suicide or homicide (3). In national rankings, Enfield had the 32nd lowest rate of overall under 75 mortality out of the 150 local authorities in England. Amenable deaths are generally agreed to occur amongst people aged 28 days to 74 years of age (though this does vary by disease type), and includes deaths due to a wide range of conditions including diabetes, epilepsy, various types of cancer and numerous infectious diseases, as well as deaths that occur due to problems with medical or surgical care (5). On analysing causal pathways for diabetic lower-limb amputation foot ulcers preceded around 84% of amputations. Such deformities include the toes being pulled up into a hammer toe or claw foot flexion deformity. Minor trauma is also a contributing factor to ulcers that may eventually lead to amputation. Once the protective layer of skin is broken, deep tissues are exposed to bacterial colonization. It is the first method of choice for arterial stenosis and occlusion, and for venous incompetence. Nicotine being a vasconstrictor reduces the blood flow to the skin and thus causes tissue ischaemia together with an impairment in the healing process. Examples of traumatic injuries include: compound fractures, blood vessel rupture, severe burns, blast injuries, stab or gunshot wound, compression injuries and cold trauma. Surgical removal of these tumours is currently mostly performed with limb salvage, but amputation may be required in some cases. A Review of Pathophysiology, Classification, and Treatment of Foot Ulcers in Diabetic Patients. Type 2 diabetes is associated with obesity, so maintenance of a healthy weight can help control or prevent the condition.
Importantly, the heart gets its own blood supply via blood vessels called the coronary arteries. Although patterns of obesity, dietary intake and skeletal pathology are far from simple and therefore difficult to interpret, there is plenty of evidence that being overweight can even affect our bones! According to the World Health Organisation, a BMI of over 30 is obese and a BMI under 18.5 is considered underweight.
Osteoarthritis of the knee, hip and possibly also the lower back and feet have all been associated with obesity in modern populations. Fat friars became famous through stories, including Friar Tuck, the rotund friend of Robin Hood, and Chaucer’s monk, described as a ‘fat and personable priest’.
High lead levels in the body cause kidney damage and this inhibits uric acid excretion, leading to hyperuricemia. Some, but not all of these conditions overlap with causes of ‘preventable mortality’ described above, but relate specifically to the access to and quality of primary and secondary healthcare. Foot ulcers are considered to be reasonably common and they not only affect the patient's funtional status and well being but can also identify individuals who may be at a higher risk of amputation. These will cause abnormal bony prominences and pressure points, such as on the tops of the toes or under the metatarsal heads, which may eventually lead to skin breakdown and ulceration.
Individuals suffering from peripheral vascular disease and diabetic peripheral neuropathy experience a loss of sensation that may exacerbate the development of ulcers.
Infection is facilitated by DM-related immunological deficits, especially in terms of neutrophils, and rapidly progresses to the deep tissues.
In individuals suffering from PAD the blood flow in the lower limbs is reduced due to processes causing stenosis. Ultrasonic imaging is non-invasive and can provide clinical information about the site and severity of narrowing of arterial vessels or of any blockages of main vessels. Nicotine also promotes an increase in the level of platelet adhesiveness which in result raises the risk of thrombotic microvascular occlusion leading to further tissue ischaemia. In cases of traumatic injury amputation of the limb is considered either as a life saving procedure or where the limb is so severely injured that reconstruction will be less functional than amputation.
In addition, the tumours have a risk of local recurrences adversely affecting the prognosis compared to the primary tumour"..
Transverse Deficiencies resemble an amputation residual limb, where the limb has developed normally to a particular level beyond which no skeletal elements are present. In the medieval period, obesity was an indication of wealth, and was also seen in monastic communities where a high-calorie diet and low levels of physical exertion led to problems we often associate with our modern, sedentary lifestyles. Waist circumference is strongly linked to obesity and these increased health risks – and it is understood that carrying excess weight around the waist is particularly harmful to health.
In archaeological populations we can see the changes on the bone joint surfaces of people who had osteoarthritis – but these are more advanced changes than those required to make a clinical diagnosis of osteoarthritis, which rely on identifying narrow joint spaces (the size of the gap between the bone ends in a joint) on x-rays. Osteoarthritis of the spine is very common in medieval populations, and is directly related to age. In peripheral arterial disease there is build up of fatty deposits in the walls of the arterial system. Many times diabetic individuals are unable to detect trauma to an affected area such as the foot. Blood circulation is usually sufficient when one is at rest, however when one starts walking and the demands are greater the blood supply is not sufficient to the lower limb muscles causing cramps and pain. Where multiple stenoses are present such imaging can determine which stenosis is causing more restriction to blood flow. In the case of trauma limb amputation can also take place months or years after the actual trauma when reconstructive procedures or healing hava failed. Osteoarthritis of the major joints is less common, but is still seen quite often – especially in the knees, hips, elbows and shoulders. This variation in SMRs are reflected in the variation of life expectancy seen across Enfield, as described in the Enfield JSNA ‘People’ Chapter. These fatty deposits, also known as atheromas, cause a reduction in the lumen of the arteries. In diabetic individuals the hyperglycaemic-induced metabolic abnormalities cause a conversion of intracellular glucose to sorbitol and fructose.
This may result in injury with wounds either going unnoticed or progressively worsen when the affected area is exposed to repetitive pressure or forces such as shear forces during ambulation. Thus such pain gets worse with greater demands example: when walking uphill and improves or is relieved after a short rest. Again, this is directly associated with age; however, one study has suggested that osteoarthritis was more common in older individuals (estimated to be over 45 years of age) predicted to be obese compared with older individuals with a normal BMI. The reduction in the lumen causes stenosis and restricts the blood flow and supply to the particular area affected. The accumulation of these sugars cause a reduction in the synthesis of products required for normal nerve conduction and function. Poor healing of such wounds, due to compromised circulation, will eventually lead to amputation of the involved limb. The chemical conversion of glucose will also increase the oxidative stress on nerve cells and lead to further ischaemia and thus causing further nerve cell injury and death. The skin surface is located at the top of the image whilst markers on the right indicate depth in cms.
Diabetes type 2 starting insulin|
Diabetes type 2 injection medication name
Free diabetes awareness wristband
Type 1 diabetes potential cure 2014