Amputations: the politics behind limb loss

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A lovely writeup on diabetes and lim salvage by a seasoned HCP.

Do find time to read and enjoy

Cutting off people’s legs is never a pleasant job for the surgeon;

But many times there are, when it’s the only way forward;the only way to save a life.

Apart from limbs lost to trauma via accidents, or to cancers, today the leading cause of limb loss ‎across the world is chronic non communicable disease in one form or another and diabetes ranks a leading offender ;

Diabetes is not a disease until it is made to be.

it is made to be when high sugar is made into high grief ‎;

High grief when mere number set to a higher than normal level by regulatory defects in the body is allowed to hold the body hostage for too long.

A high sugar effectively beaten down and kept so keeps the diabetic away from diabetes : diabetes sans diabetes.

Each time I’ve come across a rotten leg from diabetes, the chances are more often than not

I always opine

there is more than diabetes to blame.

…there is the patient who might have been too slack or not compliant enough,

….the treatment regime that might ‎have become too unsuited to the challenges at hand

Or

….the diabetes that has become part of a larger complex ravaging the particular patient :

in clinical parlance,part of a multimorbidity transcending mere sugariness.

Diabetologists are the sugar experts but any clinician unable or unwilling to offer tangible help with the management of diabetes in its most general sense is likely to come to grief at some point in his career.

Surgeons are regularly sucked into the sugar issue but sadly often to bring bitter pills.

Uncontrolled sugar over a long enough period raids virtually every tissue of the victim, none less so than the blood vessels.
Increasing deterioration in calibre and reflex performance of the blood vessels lead to progressive interference in the circulatory status of the tissues, gradually compromising the nutritional transactions at the tissue interfaces.

Add to this, the simultaneous deterioration in the integrity of the nerves, compromising their sensory efficiencies,

….the stage is more than set for tissue death :

a death that may even be so painless

and thus unnoticed if and when any attendant nerve damage has also come to compromise the ability to feel.

Bacteria lurk everywhere: the good and the bad. When they smell luck, they rush to the spot, and their feeding frenzy only expedites the rate at which tissue is lost and the system beyond poisoned.

The ultimate compound effect is a sore, which no matter how small it started can fester into a huge crater, as deep as it is wide.

To have flesh eating bacteria ( saprophytes) in the vicinity of sugar laden tissues poses a particular danger to the uncontrolled diabetic:

not just to the limb, the entire system.

Any organ can be lost to diabetes but particularly the limbs.

As a clinician and surgeon, , I’ve always ‎favored saving a limb to sacrificing it.

But there are ironically too many patients who are their own worst enemies ‎.

When a bad leg ulcer presents itself to the surgical clinic, what is often required to heal it can involve far more ‎sacrifices than what is required to amputate the leg.

And though some Surgeons might be constitutionally reluctant for protracted involvement with ulcer care,opting instead to dovetail the drama into an amputation, some patients, inspite of the words dripping between their lips are often themselves too indisciplined to withstand the drawn out rigor attendant to limb saving protocols ;

they cheat on themselves or are frankly non compliant with limb saving regimes.

Or

sometimes the cost involved healing an ulcer ( daily dressing, antimicrobials, regular tissue trimmings, restricted activities, regular blood checks, upped dosages etc) might prove too prohibitive to the payer.

An ulcer is any break in the skin lining; But it can very rapidly progress to well beyond the skin to involve underlying fat, muscles and bones.

Surgeons have evolved various ways to classify these ulcers to facilitate communication between and betwixt handlers :

But by and large, most of the classification systems speak to depth or width or more commonly both along with notions about presence or absence of associated infections

For any ulcer to heal,the strategic aim is reverse the very process or processes that led to it in the first instance.

In many cases, such reversal is possible with or without difficulties.

In others, fixed damages to the support system in the particular part, like the blood vessels and nerves prevent reversibility ‎.

This latter group forms the bulk of cases that may lose limbs. There are many agents on the shelves that are aimed at countering the negatives inside an ulcer;

Those that will kill offensive germs

Or

improve blood flow

Or

expand oxygen supply

Or

bring vital elements to the arena

Or

prevent water logging

Or

retard tissue destruction.

Or

any number of petty but contributary roles towards recovery.

For many years, research has concentrated on stealing ideas from the body itself ;seeking to break into the secrets of the body regulatory pathways ; it’s innate checks and balances.

Luckily the body is getting to yield more and more of its secrets to those researchers who relentlessly knock at its many doors.

And through these unlocked secrets, the applied science at the bed sideis ‎getting richly and confidently relevant .
One thing is clear ; biologically nothing ever happens in the body unless pulled or pushed.

There are no happenstances where the body is concerned.

If my foot turns red,something has pushed or pulled the red to the foot or in the foot ‎.

Every cell is responding to something under a complex but well ordained set of traffic rules ‎.

For a cell to grow, it must be pushed to grow.

And the pushers of such growth are called growth factors.

But the pushers of growth( growth factors) are unable to push if the cell to be pushedhas no handles that can be engaged by pushers’ hands.

These handles when they exist ‎are called receptors.

So growth factors to be fully relevant must have growth receptors granting a hole into which reciprocal key can fit to unlock the handle to the transaction.

The pusher ( growth factor) engages the ‎handle ( growth receptor) on the pushed then the cell grows.

Growth often means multiplication when the process is unfettered.

If an ulcer is loss of tissue anywhere between the skin level and deeper, it also means if the area can be brought under the influence of growth factors, new cells can be produced to replace lost ones:

And like mortar filling up a hole in the floor, the new cells can fill up the hole in say the leg.

This is a simplistic analysis, but as true as it ever gets.

The new drive towards cure of stubborn leg ulcers is now the use of growth factors.

But their use is still patchy,by and large restricted to research centres.

Cuban scientists have for the past nine years been trying to get their newly found products

( herbeprotP) into the wider market but read through below ( in red) and see how politics can retard progress , leaving amputations at run away levels

HerbeprotP is drug formulation composed of epidermal growth factor ; the growth pusher that can stimulate cell production at depleted sites causing tissue defects to fill up and stave off amputation.

But standing in its path is politics.

The embargo is preventing the drug from getting out of Cuba to be tested for claimed impact on the wider market.

wish to know more about the polit‎ics standing in the path of ulcer healing and limb salvage ?
‎…………..

“I don’t know what’s going to happen, but I do know that it may be that American legs are being lost while Cuban legs are being saved because Washington agencies …won’t allow that medicine in,”

said Dr. I. Kelman Cohen, professor emeritus in surgery at Virginia Commonwealth University.

“I think all the American medical community really wants is for Heberprot to be allowed into the country for testing

…Let’s get it tested and see if it will really save the thousands of limbs that many believe it can,” Cohen said.

In December, 2013, 111 members of Congress petitioned the Treasury secretary to allow the drug to be tested in the U.S., but up to now there has been no sign of progress, according to several lawmakers who signed the letter.

Diplomatic talks between Washington and the Castro government on issues such as immigration, travel and commercial ventures are scheduled to start next week.

At a briefing today on Obama’s normalization plans, administration officials were asked about the status of Heberprot but were noncommittal.

A proven drug that will thwart flesh-destroying diabetic wounds is desperately sought by physicians throughout the world, according to Dr. David Armstrong, professor of surgery and director of the University of Arizona’s Southern Arizona Limb Salvage Alliance.

Diabetes researchers at Umeå University in Sweden reported in 2013 that worldwide, a limb is lost every 20 seconds because of a foot ulcer that doesn’t heal.

According to the American Diabetes Association, in the U.S. alone more than 73,000 diabetics undergo amputations every year, or about one every seven minutes.

“It just rips me apart to know that there may be something out there that has the potential to save limbs and we can’t get a chance to test it because of politics rather than public health,”

Armstrong said in an interview.

Each year, he and his team at the Tucson medical center spend hours in operating rooms trying to save the lower limbs of more than 11,000 patients from around the world.

“So far this year, there have been several patients who may have benefited from a study of the type needed for the Cuban drug,” he said.

Dr. Georges Benjamin, executive director of the American Public Health Association, said that “there is politics in everything” but putting public health before politics is of prime importance to his organization, which just last month signed a agreement to work more closely with its Cuban counterparts.

“We recognize that there is opportunity for allowing them to learn from us, but even more importantly, for us to learn from them and that would include any technological advances they may have made that still need to be studied and validated,”

Benjamin said.

There is nothing mysterious about the path between diabetes and the loss of a limb.

Untreated or poorly treated, diabetes often interferes with blood flow to the extremities, causing vascular disease, a failure in anti-bacterial defenses and nerve damage.

Because of this loss of protective sensation, diabetic ulcers form but often go undetected. Without a proper blood supply, the tissue around the ulcer becomes infected, continues to die and the wound grows.

Hyperbaric oxygen treatment is sometimes useful, say diabetes specialists, but surgical removal of the dead flesh is the typical treatment. And at a certain point, amputation becomes the only option to save the life of the patient.

Dr. Elof Eriksson, a Harvard University professor and chief of plastic surgery and a wound care expert at Boston’s Brigham and Women’s Hospital, last month returned from an international meeting of hundreds of wound specialists near Havana.

He called the results of studies presented at the conference on Heberprot’s effectiveness to treat severe diabetic ulcers “impressive.”

“The only definite answer can come from a large clinical trial,” Eriksson said.
‎.

‎When Republicans continue to threaten reversing obama ‘s thaw of US- Cuban relationship, the public health implications are numerous : this is just one.

Building walls between nations, the type Cruz and Trump want to do retard intellectual and scientific diffusion of knowledge and skills ; those of us who know this too well have no choice but fight against a Republican victory by any means.

Basil jide fadipe.
Justin fadipe centre.
He is a Surgeon in the Carribeans.
His hobbies includes writing on anything about life and living.
West indies.

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