MTE 5 and 10 Diabetic Foot Disorders Seacliff CD, Bay Level Nicholas J. Lowery, DPM Saturday, March 5, 2016 2:00 p.m. – 3:30 p.m. and 3:45 p.m. – 5:15 p.m. Treatment of the diabetic foot poses a challenging clinical dilemma to all practitioners. While often overlooked, foot disorders are a major cause of morbidity to patients with diabetes, as well as cost to the health care delivery system. The patient with diabetes that is complicated by peripheral neuropathy and/or peripheral arterial disease is at high risk for diabetic foot ulcer, diabetic foot infection, and potential amputation. All practitioners that treat diabetic patients should be acutely aware of foot-related complications in this delicate patient population to avoid morbidity, mortality, and limb loss. It is the responsibility of all providers who care for diabetic patients to help prevent such instances through proper examination, education, preventative measures and appropriate treatment. This lecture will focus on disorders that affect the foot in diabetic patients. The attendee will learn how to properly examine the diabetic foot and stratify patient risk, how to recognize the atrisk diabetic foot, how to diagnose and treat diabetic foot ulcers and infections, and how to diagnose and treat Charcot neuroarthropathy. Real-life case scenarios will be provided to enhance learning and promote discussion.
155 Wilson Avenue, Washington, PA 15301
Disclosures • Soluble Systems - speaker
Diabetic Foot Disorders Nicholas J. Lowery, DPM UPMC Podiatric Surgical Residency Program Immediate Past Chairman, ADA Special Interest Group, Foot Care
www.whs.org 1
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetes and its Complications
Prevalence of Diabetes in USA is Rising
• “The era of coma has given way to the era of complications” • Eliott P. Joslin
People in Millions 30 23.8
25 20
25.8
29.1
18.3
15 10
People in Millions
5 0 2003
2007
2010
2012‐ 9.3%
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetes Mellitus in the USA
Diabetes Mellitus in the USA
• Other Facts:
• Diabetes in our YOUTH:
– – – – –
Incidence: 1.7 million new cases in 2012 Undiagnosed: 8.1 million cases in 2012 Seniors: 25.9% age 65 or older Prediabetes: 86 million in 2012 Deaths: 7th leading cause of death
– 208,000 under age 20 • 0.25% of under 20 population
– 2008-2009 – Annual Incidence • 18,436 with Type I Diabetes • 5,089 with Type II Diabetes
• 69,071 as underlying cause • 234,051 as underlying or contributing cause • American Diabetes Association 5
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetes Mellitus in the USA
Cost of Diabetes
Percent by Ethnicity
Cost In Billions 250 White 7.6%
245
200
176
150
Asian 9.0%
100 Hispanic 12.8%
69
50
Cost In Billions
0
Non‐Hispanic Blacks 13.2%
Total Cost of Direct Diagnosed Diabetes Medical Cost
American Indian 15.9%
Reduced Productivity
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Diabetes at the Local level
Diabetes on a Global level
• Pittsburgh Metro Area • 2.4 Million people – 223,000 with DM (9.3%) – 17,856 DFU (8%) – 4,014 Amputation (1.8%)
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Diabetes and the Foot
Diabetic Foot Disease – Fact Sheet • More than 60% of lower extremity amputations are in patients with diabetes • About 75,000 diabetic related amputations each year in U.S. • Estimated that somewhere in the world a limb is lost every 20 seconds due to diabetes • Following an amputation in a patient with DM:
• Very common – Foot ulcers, amputation, Charcot – >5% have ulceration – maybe higher
• 85% of amputations are preceded by ulceration – Reduce ulceration = reduce amputation
– 30% will have contralateral limb amputation within 3 years – 60% will die within 5 years 11
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
How do we raise Awareness?
Lower Limb Amputation Rates - USA
Non‐traumatic Lower Extremity Amputations in Diabetic Population (per 1000) 12
11.2
10 8.7
8
6.5
6 4
4.1
3.3
2 0 1990
1996
2000
2005
2009
Series 1
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Diabetic Foot is on the Radar
Economic Burden of Diabetic Foot Ulcer • Per patient with DFU = $33,000 – 1.5 admissions – 14 outpatient visits
• Per patient with LEA = $52,000 – 2 admissions – 12 outpatient visits
• Total direct cost = $9-13 billion • Margolis et al 15
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Foot-in-Wallet Disease
Foot-in-Wallet Disease
• AZ Medicaid eliminates podiatry 2009 • Est. $351,000 saved from $8.7 billion • Analysis to determine – admissions, charges, length of stay and severe aggregate outcomes – – – –
Percent Increase 50.00% 40.00% 30.00% 20.00%
Mortality Amputation Sepsis Surgical Complications
10.00%
36.50% 37.50%
49% 22.50%
Percent Increase
0.00%
• Skrepnek et al Diabetes Care Sept 2014
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Unadjusted, overall DFU hospitalizations among AHCCCS beneficiaries (6-month moving average).
155 Wilson Avenue, Washington, PA 15301
Cost Savings?? • $1 saved = $48 spent by eliminating podiatric services • $351,000 saved turns into $16 million incurred
Grant H. Skrepnek et al. Dia Care 2014;37:e196-e197
19 ©2014 by American Diabetes Association
155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Risk Factors for Foot Pathology
The Gift that Nobody Wants = PAIN
• • • •
• Peripheral Neuropathy
Rarely a single entity Neuropathy Arterial Disease Deformity
– – – – –
THE MOST IMPORTANT cause of ulceration Seven fold increase risk of amputation Sensory loss Musculoskeletal deformity/imbalance Skin changes – autonomic neuropathy
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155 Wilson Avenue, Washington, PA 15301
Peripheral Arterial Disease
Other Risk Factors
• • • •
• • • • •
Common in Diabetes Mellitus Calcification of large vessels Affects capillary perfusion Typically below the knee
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Foot deformity Plantar callus Long duration of Diabetes Peripheral Edema End-stage Renal disease
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
The Pathway To Ulceration
The Diabetic Foot Exam • History – – – – – – –
Type of diabetes and duration History of ulceration/amputation History of neuropathic symptoms History of vascular surgery Renal history Retinal history Cardiac history
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetic Foot Exam
Diabetic Foot Exam
• Physical Exam • Inspection of Skin – – – – –
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• Musculoskeletal Inspection – Deformity – Claw/hammertoes – Prominent metatarsal heads – Charcot Deformity – Muscle wasting
Skin condition Sweating Infection Ulceration Calluses
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155 Wilson Avenue, Washington, PA 15301
Diabetic Foot Exam
Diabetic Foot Exam
• Neurological Assessment
• Vascular Assessment – Palpation of pulses – Inspection of skin – temperature – Ankle/Brachial Index – Refer for advanced studies if necessary
– Achilles reflexes – Semmes‐Weinstein Monofilament – Vibratory Sensation – Light touch Sensation – Michigan Neuropathy Screening Instrument
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155 Wilson Avenue, Washington, PA 15301
Risk Assessment based on Exam
Diabetic Foot Ulcer
Risk Category
Definition
Recommendation
0
No Patient LOPS/PAD/Deformit Education/Advice y
Annual
1
LOPS +/‐ Deformity
Prescription Shoes, Prophylactic surgery, Education
3‐6 Months
2
PAD +/‐ LOPS
Prescription Shoes, Vascular consultation
2‐3 Months
3
History of Ulcer or Amputation
Same as 1, consider 1‐2 Months vascular consultation
• 60 – 85% of Lower Extremity Amputations • 75,000 Annual • Following Amputation
Suggested Follow Up
– 30% Contralateral amputation – 60% Mortality in 5 years
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155 Wilson Avenue, Washington, PA 15301
Normal Wound Healing
Chronic vs. Acute Wounds Healing Wounds • Low Inflammatory Cytokines • Low Proteases • Intact Functional Matrix • High Mitogenic Activity
Hemostasis
Inflammation
Chronic Wounds
Repair
• High Inflammatory Cytokines • High Proteases • Degraded ECM • Low Mitogenic Cells ‐ Senescent
Remodeling
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Managing the Chronic Wound Bed • • • •
Sheehan et al. Diabetes Care. 2003;26:1879‐1882.
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Nonviable Tissue Infection/Inflammation Moisture Regulation Tissue Margins
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155 Wilson Avenue, Washington, PA 15301
Wound Bed Preparation and TIME
Nonviable Tissue
Clinical Observations
Cellular/Molecular Problems
Clinical Actions
Effects of Clinical Actions
Clinical Outcome
Tissue
Defective ECM, cellular debris
Debridement
Restoration of wound base, functional ECM
Viable wound base
Infection
High bacterial load Prolonged inflammation
Remove infection Topical/systemic ABX
Lower bacterial load
Bacterial balance, reduced inflammation
Moisture
Dessication Excessive fluid
Moisture regulating Restore epithelial Moisture balance dressings migration, decrease maceration
Edge
Nonmigrating epithelial margin
Consider advanced therapy Debridement + bioengineered skin, etc
Migrating keratinocytes Responsive wound cells
Advancing epithelial margin
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155 Wilson Avenue, Washington, PA 15301
Infection/Inflammation
Moisture Imbalance
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155 Wilson Avenue, Washington, PA 15301
Edge – Margin nonadvancing/undermined
Diabetic Foot Ulcer Five Year Survival – Diabetic Foot Ulcer 60
50
40
30
20
10
0 Neuropathic Ulcer
Ischemic Ulcer Series 1
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetes is a Malignant Disease
Diabetic Foot Ulcer
100 90 80 70 60 50 40 30 20 10 0
• Neuropathy
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85 63
– – – –
Melanoma
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Breast
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Prostate Cervical 10
2/3 of patients with DFU have neuropathy as etiology Sensory, motor and autonomic components 10% of people with diabetes Nearly half of DM patients with disease > 7 years
Neuropathic Ulcer 3
Ischemic Ulcer Lung Pancreatic
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Diabetic Foot Ulcer ‐ Treatment
Diabetic Foot Ulcer • Vascular Disease – – – –
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• OFFLOAD!!! OFFLOAD!!! OFFLOAD!!!
Diabetes – independent risk factor Smoking, hyperlipidemia, hypertension Large and small vessel disease 1/3 of DFU have PAD as etiology • 50% of these have neuropathy
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155 Wilson Avenue, Washington, PA 15301
Diabetic Foot Infection
Diabetic Foot Infection • Major contributor to hospitalization and lower extremity amputation among patients with diabetes • 20-25% of all diabetic related admissions • Account for large number of hospital bed-days • Proper evaluation of infected diabetic feet is an essential first step in treatment
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155 Wilson Avenue, Washington, PA 15301
Major Risk Factors for Diabetic Foot Infection
Risk Factors for Diabetic Foot Infection
The Diabetic Foot Triad • Neuropathy – Sensorimotor, Autonomic
• Vasculopathy Neuropathy
– Macrovascular, microvascular
• Immunopathy • Miscellaneous Miscellaneous
Vasculopathy
– Renal failure, CHF, Deformity, Trauma
Immunopathy
Immunopathy IDSA Guidelines for Diabetic Foot Infections. Clin Infect Dis. 2004;39:885–910. 49
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Diabetic Foot Evaluation
Significant Independent Risk Factors for DFI • • • • • • •
• Edelson et al. evaluated 225 consecutively admitted patients with a diabetic foot infection
Ulcers that penetrate to bone Wound present > 30 days Recurrent wounds Traumatic wounds Peripheral artery disease Risk of Hospitalization is 56x Risk of amputation is 155x
• They found the initial evaluation of the patients was critically lacking
Abscess
• Lavery et al 2006 ARCH INTERN MED/VOL 156, NOV 11, 1996
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Classification of Diabetic Infection
ER and Hospital Records • 31% of patients did not have their LE pulses documented • 60% were not evaluated for presence of protective sensation • Radiographs were not performed on 1/3 of all patients • Only 8% of patients had depth, size and description of wound documented, with 57% having no wound description • 48% of patients did not receive specific instructions for home wound care
• Non Limb Threatening – – – – –
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Superficial Infection Less than 2cm from portal of entry/ulcer Minimal or no ischemia Medically stable No constitutional symptoms
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Limb Threatening Diabetic Foot Infections
Charcot Neuroosteoarthropathy • Non‐infectious destruction of bone associated with neuropathy • Initial recognition can be difficult • Can be devastating • Now common in diabetics with neuropathy
• Cellulitis extending beyond 2cm from initial ulceration • Constitutional Symptoms • Lymphangitis • Hyperglycemia • Ischemia • Probes to bone
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155 Wilson Avenue, Washington, PA 15301
Case 1: “Best Case Scenario”
Past Medical History
• CC: Swelling and redness of the right foot and ankle
• Type II Diabetes Mellitus for 34 years • Neuropathic pain and numbness in the LE • Medications
• HPI: 75 y/o female who noted the onset of redness, swelling and mild pain (3 out of 10) • No history of trauma or increased activity
– – – – –
Diovan Zocor Amitriptyline HCTZ Insulin
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155 Wilson Avenue, Washington, PA 15301
Initial Treatment
Physical Exam
• Saw a local physician who injected her foot with steroids • That did not work so she was prescribed oral steroids • She was prescribed exercises • She did not experience any relief • Referred to foot and ankle specialist
• • • • •
5’ 7” tall weighing 176 WD in No acute distress No ulcers or deformity Normal pedal pulses but 2+ edema Neurological exam – Absent sensation with monofilament – Decreased vibration – Absent Achilles reflexes
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155 Wilson Avenue, Washington, PA 15301
Radiographs – Normal!
Initial diagnosis – Stage 0 Charcot • Walking boot • Cane • Further diagnostic workup included an MRI
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MRI – Silent Bone Injury
Our Treatment • Protected weight-bearing in a removable boot for 3 months until inflammation subsided • Serial radiographs looking for any signs of collapse • Accommodative insert and shoes
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155 Wilson Avenue, Washington, PA 15301
15 Month Follow up – Asymptomatic!
Case 2: “Worst Case Scenario” • 55 year old female who complains of mild pain and soft tissue swelling, difficulty walking and inability to put her foot in her shoe • Presents to local ED • No history of trauma • Type II DM which is insulin dependent • End stage renal disease on hemodialysis • Dialysis three times a week
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155 Wilson Avenue, Washington, PA 15301
Initial Presentation ‐ ED Mild distress Ankle tenderness Soft tissue swelling Neurological reported as sensation and motor intact • Extremity was warm and erythematous • • • •
Initial Radiographs: Normal
• No vascular compromise was noted • Work up included a negative venous ultrasound • Radiographs are normal
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Initial Orthopaedic Evaluation
New Radiographs – NOT normal!
• Palpable pedal pulses • Absent sensation • Unilateral edema with severe valgus deformity • Subjective complaints of pain
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155 Wilson Avenue, Washington, PA 15301
Lateral Radiographs
Treatment - BKA
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Lessons Learned
The common denominator = Neuropathy • “The absence or decrease in pain sensation in the presence of uninterrupted physical activity”
• Early diagnosis • Early offloading before deformity develops • Excellent functional outcome can result • Better than any surgical outcome
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Diabetes Leprosy Myelomenigocele or Spina Bifida Chronic Alcoholism Transplant patients Chemotherapy
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Today’s Unified Theory
RANKL-OPG Balance
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Renal Osteodystrophy
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Tabes dorsalis Syringomyelia Congenital insensitivity to pain Spinal Cord Injury Peripheral Nerve Inj. Idiopathic neuropathy
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Who is at risk?
Diagnosis of Charcot
55‐60 years old (mean 57) Obese (mean BMI 33) Longer duration of DM (15) 80% have diabetes for 10 yrs Sensory neuropathy is always present Relationship between bone mineral density is unclear H/o transplant surgery
• Must have a high index of suspicion • Be wary of diabetic patient who is able to walk on a foot that looks like this • If you elevate the LE for 5 minutes you may resolution of erythema
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“The Perils of Procrastination”
The Perils of Procrastination • • • • • • •
• Nearly 80% of cases misdiagnosed, most being labeled as sprains • Additional imaging (MRI, CT and Bone Scans) facilitate early diagnosis • Early utilization of advanced imaging can prevent extended foot fractures and deformity •
Ankle sprain (6) Cellulitis (4) Osteomyelitis (3) Gout (3) Septic arthritis (2) Plantar fasciitis (2) DVT (2)
Chantelau. Diabetes Medicine 2005 81
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
ADA-APMA Task Force 2011
“The Consequences of Complacency”
• Convened in Paris in 2011 to review:
• 20 patients with Stage 0 Charcot • Initial diagnosis missed 19/20 • Less complications in those that did not collapse
– – – –
– 14% vs 66%
• Surgery required in 50% • No amputations •
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Definition Pathogenesis Diagnosis Treatment
Wukich et al, Diabetes Med, 2011
– Published in Diabetes Care and JAPMA
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Treatment Algorithm for Charcot – Task Force Recommendations
Conservative Treatment for Charcot • Stage 0 Charcot: Immobilize Immediately!! • Stage I Acute Charcot – Immobilize in TCC – CAM walker – Wait until signs of inflammation cease
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Conservative Treatment Progression
Goals for Surgical Intervention • • • • • • • •
Plantigrade foot Stable Shoeable/Braceable Heal any ulcers Prevent recurrences Decrease or eliminate pain Avoid amputation Maintain ambulation
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Do We Make a Difference? • Each $1 invested in care by a podiatrist for people with diabetes results in $27 to $51 of healthcare savings. (JAPMA 2010) • Podiatric medical care in patients with a history of ulceration can reduce high level amputation by 65-80% (Gibson, Int Wound Journai, 2013) • Instituting a structured diabetic foot program can yield a 75% reduction in amputation rate and four-fold reduction in inpatient mortality (Weck, Cardio. Diabetology, 2013)
Case Studies
www.whs.org 89
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Standard Issue DFU
#1. Standard Issue DFU
• Confirm – good pulses/inflow • Confirm – well managed DM • Confirm – No radiographic infection • Confirm – No clinical infection/healthy wound bed 91
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155 Wilson Avenue, Washington, PA 15301
#3. It takes a village
#2. “Minor” deformity = “Major” problem? • • • •
56 year old male Type I DM Peripheral neuropathy History of deep abscess left foot
• Had multiple debridements • NPWT • Other advanced therapies • HBOT • Now scheduled for 1st Ray Amputation
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155 Wilson Avenue, Washington, PA 15301
Clinical Presentation
Physical Exam
• Medial 1st MPJ exposed through 4.5x2.5 cm wound • No acute signs of infection • No gross deformity/instablility
• Vascular: – Palpable Pedal pulses, biphasic DP/PT with doppler – ABI 1.09 LLE, Non‐ invasives normal – CFT intact to digits
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• Neurologic: – Absent protective sensation – Absent vibratory sensation – Absent Achilles reflex
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Initial Labs/Cultures • • • •
WBC: 8.1 ESR: 97 CRP: 3.5 HbA1C: 7.2
Radiographs
• OR Bone Cultures: – MSSA from 1st metatarsal – On Cefazolin 2G IV Q8 for 6 weeks with PICC
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MRI
MRI
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155 Wilson Avenue, Washington, PA 15301
Initial Treatment Plan
Clinical Presentation
• Return to OR • Full thickness excisional debridement of wound, bone • Application of Advanced Skin Substitute • Application of NPWT
• 12/17/12 • Taken to OR, wound debridement, application of skin substitute and wound VAC • First PO visit – 1 week later
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155 Wilson Avenue, Washington, PA 15301
Clinical Presentation
Clinical Presentation
• 1 week return to wound center
• Skin Substitute #2 applied at 4 weeks
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Clinical Presentation
Progressive Improvement
• Two weeks s/p 2nd Skin Substitute
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Healed
#4. Insurmountable Deformity • Patient is a 56 year old female with non-healing ulcer of her left foot. • Ulcer is under lateral foot, present for 9 months • Local wound care provided, including offloading, local products, Skin Substitute application x8 • No pain – history of neuropathy • Referred due to nonhealing ulcer, consider operative management
• Ultimately healed in 12 weeks after OR debridement • Two applications of Skin substitute
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155 Wilson Avenue, Washington, PA 15301
155 Wilson Avenue, Washington, PA 15301
Past Medical History
Physical Examination
• Type II Diabetes Mellitus with known peripheral neuropathy • Back surgery x3, tethered cord • MRSA • History of brain injury – cause “from spinal cord stimulator, MRSA clot” • Chronic left leg pain/deformity • Partial vision loss after clot incident • SH: Denies smoking, EtOH, Drug use
• Vascular: Pedal pulses palpable 2/4 bilateral, CFT intact to all digits, skin temperature warm • Neurologic: Absent vibratory sensation and Absent monofilament exam. Achilles reflexes absent. • Musculoskeletal: Muscle strength left – 4/5 for eversion, inversion, plantarflexion. 2/5 dorsiflexion. Equinovarus deformity noted, unable to correct to neutral. 109
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Radiographs
Clinical Photo – 8/21/13
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Radiographs
MRI – Negative for Osteo
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155 Wilson Avenue, Washington, PA 15301
Labs
Diagnosis
• • • • •
• Non-healing diabetic foot ulceration • No radiographic/MRI/lab evidence of osteomyelitis • Chronic Equinovarus deformity left lower extremity
WBC 5.8 HbA1c 6.7 Glucose 122 ESR 28 CRP 1.2
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155 Wilson Avenue, Washington, PA 15301
Treatment Options??
Treatment Plan • Tibiotalocalcaneal Arthrodesis with intramedullary fixation – Obtain cultures intraoperative from bone
• Debridement of wound • Application of skin substitute
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Post Op Radiographs
Follow up visit – 9/11/13
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155 Wilson Avenue, Washington, PA 15301
Healed – 12/04/13
Radiographs – 5/14
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Radiographs
Successful result • Now ambulating in custom shoes, last follow up 5/15 • Recognition of Biomechanical forces that cause pressure • Combine deformity correction with local/advanced wound care
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155 Wilson Avenue, Washington, PA 15301
#5. Severe Diabetic Foot Infection
Severe Diabetic Foot Infection
• • • •
• Vitals
68 year old male in ICU – sepsis Unable to obtain history Severe diabetic foot infection right foot Ulcers sub 2 and sub 5, passively draining purulent discharge • Ulcer medial foot, passively draining as well • Fluctuance dorsal right foot
– – – –
Temp: 100.1 BP: 126/86 Resp: 20 Pulse: 102
• Labs – WBC: 22.7 – ESR: 120 – Glucose: 326 125
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155 Wilson Avenue, Washington, PA 15301
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Healed
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MRI 12/15/10
#6. “The Red, Swollen Ankle” • 56 year old female complains of redness and swelling right ankle • Painful, difficult to ambulate • Type 2 Diabetes Mellitus • Peripheral Neuropathy • History of left second digit amputation
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155 Wilson Avenue, Washington, PA 15301
Radiographs 1/25/11
Follow up • • • • •
Redness/swelling unresolved Right ankle remains painful Now feels unstable Non-healing arthroscopic portal Cultures growing VRE
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Treatment
First Step – Stabilize and treat infection
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Next step – TTC fusion with Ex Fix
3 Months – TCC
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155 Wilson Avenue, Washington, PA 15301
6 months – WB with CROW
12 months – WBAT with AFO
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One Day With Diabetes: • • • • •
5000 Diagnosed $670 million 280 Lives 200 Limbs We Can Do Better. Today. • ADA 2014 141
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