Dm Ii And Vascular Disease

[harleyman]

Does anyone have referenes or experience in getting vascular disease of the lower limbs service connected as secondary to DM II?

Veteran is s/c for DMII and PN with loss of use of one of the lower extremity ( 2 K awards one for loss and the other for ED),and also s/c for IHD. But recent claim for DVT (blood clot and infection in lower leg secondary to DMII ,VA has denied stating the leg condition is not related to the DMII.

Might the veteran get the DVT (clot and or infection)s/c as secondary to IHD?

Thanks!

Edited July 27, 2013 by harleyman

[harleyman]

The Veteran can afford the IMO's or at least he now as coverage other than VA. So that is not an issue at this time. However, the infection did spread to the lymph sytstem as that is why he is still under the care of an infectious disease doctor and he still takes an oral anti-biotic. He is due to see the Vascular surgeon in December. It will be a year come Thanksgiving when all this started.

The surgeries were for draining infectous fluids and debridement of the area. It seems he developed infection in the leg that would not drain but stayed as "pockets" within the venus and muscular system. His leg is still discolored, which the examiner denied, and he has a tender scar about an inch deep and about 5 to 6 inches long and 3/4 to 1.5 inches wide.He had home care for 3 months from medicare. It is sort of shaped like a "v" in the back of his leg. He said the examiner did touch his leg but "not really" as they don't want to get an infection from examining a patient. I can understand that, but they should be on the side of the Veteran. Then again, they have to be mindful of where there paycheck is coming from.

I do plan on giving the information and studies to the Veteran to take over the the VAMC and leaving studies and information about this condition for the examiner. He can delever this through the patient advocate and they can deliver it to the doctor, who is a real dumb a** in my opinion. We never know what motivates others, until we have walked in their shoes, however, I will help to re-file this claim and give it one more chance rather than do an appeal. We could file an FDC claim and see what happens.-H

Edited October 6, 2013 by harleyman

[free_spirit_etc]

"I can understand that, but they should be on the side of the Veteran. Then again, they have to be mindful of where there paycheck is coming from."

They should be on the side of the truth. And when they distort the truth because of who is paying their paycheck - that is totally unethical. I know it is part of the game -- but that doesn't make it right. The VA examiners should have to give out disclaimers with their opinions. "This opinion does not necessarily reflect the views of a real doctor practicing real medicine. This opinion is more of a pseudo-opinion, written by someone who graduated from medical school who stopped practicing medicine when he agreed to accept paychecks from the VA..."

Edited October 6, 2013 by free_spirit_etc

[free_spirit_etc]

"He states his leg was red and hot to the touch and painful."

This is interesting because from looking at the Merek Manual Cellulitis and DVT often present with similar symptoms. One difference is that with Cellulitis, the skin is hot and red -- and with DVT the skin is cool and normal color or cyanotic.

http://www.merckmanuals.com/professional/dermatologic_disorders/bacterial_skin_infections/cellulitis.html

Article includes table:

Table 1

Edited October 6, 2013 by free_spirit_etc

[free_spirit_etc]

"Assesment: Massive calf abcess and possible osteomyelities"

That would be infection in the bone. Did this end up being part of his final diagnosis?

It seems like there is more going on than just the cellulitis.

Edited October 6, 2013 by free_spirit_etc

[free_spirit_etc]

This is just parts of this article:

http://emedicine.medscape.com/article/237378-overview

Foot infections are the most common problems in persons with diabetes. These individuals are predisposed to foot infections because of a compromised vascular supply secondary to diabetes. Local trauma and/or pressure (often in association with lack of sensation because of neuropathy), in addition to microvascular disease, may result in various diabetic foot infections that run the spectrum from simple, superficial cellulitis to chronic osteomyelitis.

Infections in patients with diabetes are difficult to treat because these individuals have impaired microvascular circulation, which limits the access of phagocytic cells to the infected area and results in a poor concentration of antibiotics in the infected tissues. In addition, diabetic individuals can not only have a combined infection involving bone and soft tissue called fetid foot, a severe and extensive, chronic soft-tissue and bone infection that causes a foul exudate, but they may also have peripheral vascular disease that involves the large vessels, as well as microvascular and capillary disease that results in peripheral vascular disease with gangrene.^{[1, 2, 3, 4, 5]}

In general, foot infections in persons with diabetes become more severe and take longer to cure than do equivalent infections in persons without diabetes.

Diabetes mellitus is a disorder that primarily affects the microvascular circulation. In the extremities, microvascular disease due to "sugar-coated capillaries" limits the blood supply to the superficial and deep structures. Pressure due to ill-fitting shoes or trauma further compromises the local blood supply at the microvascular level, predisposing the patient to infection, which may involve the skin, soft tissues, bone, or all of these combined.

Diabetes also accelerates macrovascular disease, which is evident clinically as accelerating atherosclerosis and/or peripheral vascular disease. Most diabetic foot infections occur in the setting of good dorsalis pedis pulses; this finding indicates that the primary problem in diabetic foot infections is microvascular compromise.

Impaired microvascular circulation hinders white blood cell migration into the area of infection and limits the ability of antibiotics to reach the site of infection in an effective concentration. Diabetic neuropathy may be encountered in conjunction with vasculopathy. This may allow for incidental trauma that goes unrecognized (eg, blistering, penetrating foreign body). Go to Diabetic Neuropathy for more complete information on this topic.

Microbial characteristics

The microbiologic features of diabetic foot infections vary according to the tissue infected. In patients with diabetes, superficial skin infections, such as cellulitis, are caused by the same organisms as those in healthy hosts, namely group A streptococci and Staphylococcus aureus. In unusual epidemiologic circumstances, however, organisms such as Pasteurella multocida (eg, from dog or cat bites or scratches) may be noted and should always be considered. Group B streptococcal cellulitis is uncommon in healthy hosts but not uncommon in patients with diabetes. In diabetic individuals, group B streptococci may cause urinary tract infections and catheter-associated bacteriuria in addition to cellulitis, skin and/or soft-tissue infections, and chronic osteomyelitis. Such infections may be complicated by bacteremia.

Globally, diabetic foot infections are the most common skeletal and soft-tissue infections in patients with diabetes. The incidence of diabetic foot infections is similar to that of diabetes in various ethnic groups and most frequently affect elderly patients. There are no significant differences between the sexes.

Mortality is not common, except in unusual circumstances. The mortality risk is highest in patients with chronic osteomyelitis and in those with acute necrotizing soft-tissue infections.

The prognosis for cases of cellulitis, skin and/or soft-tissue infections, and acute osteomyelitis depends on the adequacy of antimicrobial therapy and surgical debridement

Cellulitis

Cellulitis may involve tender, erythematous, nonraised skin lesions on the lower extremity that may or may not be accompanied by lymphangitis. Lymphangitis suggests a group A streptococcal etiology. If bullae are present, S aureus is the most likely pathogen, but group A streptococci occasionally cause bullous lesions. No ulcer or wound exudate is present in patients with cellulitis.

Deep-skin and soft-tissue infections

Patients with deep-skin and soft-tissue infections may be acutely ill, with painful induration of the soft tissues in the extremity. These infections are particularly common in the thigh area, but they may be seen anywhere on the leg or foot. Wound discharge is usually not present.

Diagnostic Considerations

Skeletal and soft-tissue infections of the foot are not limited to individuals with diabetes; therefore, other conditions may need to be considered in the differential diagnosis, depending on the infection and structures affected.

In cellulitis, differential diagnosis includes leukoclastic angitis, diabetic dermopathy, chronic venostatic change, and superficial thrombophlebitis.

[free_spirit_etc]

http://www.simondodds.com/pathology/microvascular.htm

ABC of Vascular Disease

Microvascular Disease

1. What is microvascular disease?
Microvascular disease is a process through which the very small branches of arteries throughout the body become damaged. Microvascular disease is a common component of other conditions, such as diabetes mellitus and autoimmune diseases.

2. What causes microvascular disease?
The very small branches of the arteries are delicate but very important structures. Damage to these vessels results in occlusion of the vessels and impairment of blood flow. In many situations the small arteries can re-grow and overcome the blockage, a process called angiogenesis. This is part of the normal healing process. In microvascular disease the commonest cause is chemicals within the blood that damage the very delicate lining of the small arteries and causes the blood to clot in the artery and block it. Sometimes these chemicals are produced by the body itself as part of the immune response and is called an autoimmune microvascular disease. Occasionally microvascular disease is the result of abnormalities in the cells that form part of the blood.

3. What are the symptoms of microvascular disease?
The commonest symptoms are pain and discoloration of the extremities, usually the fingers and toes, sometimes even leading to gangrene. These symptoms are very similar to those cause by occlusion of the larger arteries except that it is not associated with muscle pain on exercise (intermittent claudication) and the blood pressure in the larger arteries is normal.

4. What are the complications of microvascular arterial disease?
Microvascular disease usually affects the whole body to some degree and the most serious complications are caused by damage to the vital organs (e.g. heart, brain, kidneys, liver).

5 What can I do to prevent microvascular disease from getting worse?
Treatment for microvascular disease is directed at the underlying cause. Lifestyle changes to eliminate factors that aggravate the condition, such as smoking, should be the first line of treatment. A complete medical assessment is required to identify the underlying cause if possible. If there is an autoimmune element to the condition, then referral to a rheumatologist may be required. If there is an abnormality in the blood referral to a haematologist is required. Surgery plays only a secondary role in the management of microvascular disease.