������ϱ�

Alya Niang

Every day, 40 amputations are performed in Canadian hospitals. These Canadians are losing a toe, a foot, or even an entire leg, and the leading cause of these amputations is diabetes. High blood sugar levels can accumulate, whether type 1 or type 2, triggering inflammation and damaging blood vessels and nerves.

A new report from the Canadian Institute for ������ϱ� Information shows that diabetes is not only one of the most widespread chronic conditions in Canada, with numbers on the rise. Worrying signs also show that amputations are more frequent among people living in low-income areas, those with a lower level of education, and those in rural or remote regions.

We’ll hear from Dr. Laura Drudi about amputations linked to diabetes, and solutions aimed at improving early detection and access to care for vulnerable populations.

Laura Drudi

We’re really working to provide culturally supportive health care for Indigenous populations and homeless populations, who are particularly vulnerable to amputations due to a lack of access to preventive care. And finally, as a vascular surgeon and researcher, I work on solutions aimed at improving early detection and access to care for these populations.

Alya Niang

Hello and welcome to the Canadian ������ϱ� Information Podcast, or CHIP, the platform that brings you real experiences on health topics that matter to all of us. I’m your host, Alya Niang.

Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of CIHI, but this is a free and open discussion.

And today’s discussion paints a disturbing picture. Doctors estimate that nearly a million Canadians are exposed to complications which could cause them to lose an arm or a leg, or even their lives.

Hello, Dr. Drudi. Welcome to the podcast.

Laura Drudi

Thank you for having me.

Alya Niang

So, Dr. Drudi, I’ll ask you to please introduce yourself.

Laura Drudi

So, my name is Laura Drudi. I’m a vascular surgeon at the Centre hospitalier de l’Université de Montréal. I’m also a surgeon scientist at the CHUM Research Centre.

Alya Niang

Thank you. Dr. Drudi, if someone is suffering from a foot infection, how long has diabetes been present without being sufficiently controlled?

Laura Drudi

In general, when someone develops a serious foot infection, or diabetic foot, their diabetes has often been present and poorly controlled for a number of years, sometimes over 10 years. But it’s extremely variable. Prolonged hyperglycemia damages the nerves. We call that diabetic neuropathy. And then there are the blood vessels, where we can see peripheral vascular disease which increases the risk of infection and complicates treatment and healing of the feet.

Alya Niang

Okay. And so what happens when a person has diabetes that isn’t detected or treated?

And what happens in the body to cause that?

Laura Drudi

Right. So, when diabetes is not detected or treated, chronic hyperglycemia causes progressive damage to the nerves and blood vessels. That reduces blood circulation in the lower extremities and affects foot sensitivity, making injuries difficult to detect because the patients can’t feel their feet. So that’s diabetic neuropathy.

Those wounds can then become aggravated and develop infections, and without appropriate treatment, that can lead to gangrene and amputation.

Alya Niang

Got it. Dr. Drudi, the data shows that 3 times more men than women wind up getting an amputation. Why is that?

Laura Drudi

I’d say the answer is multidimensional. There are many factors that can explain that difference.

They can be explained by various biological, behavioural and even systemic differences between the sexes. So, first of all, biologically, when men develop atherosclerosis, or blockages, they develop earlier and are more severe. Whereas for women, estrogen can protect them before menopause. That also slows the progression of cardiovascular disease, including peripheral vascular disease, in women.

In addition, women tend to adhere more closely to preventive care, to monitoring their feet and even to seeing a doctor more quickly in case of any problem. Whereas men are often slow to seek treatment, which can aggravate those complications.

Behaviourally, men more frequently adopt high-risk behaviours like smoking.

Socio-economic factors also contribute to these sex disparities, for example by contributing to unequal access to care, differences in medical follow-up and also certain biases in research, which has historically focused on men rather than women. So, more proactive treatment of men, including better screening and raising awareness of [indiscernible], as well as adapting prevention strategies to men and women’s specific needs, could help to reduce that gap.

Alya Niang

Indeed. And one of the things I’ve heard from the medical community is that there seem to be more amputations. And that certainly seems to be reflected in CIHI’s data, where we reached a total of 14,000 in the course of last year. According to my calculations, that comes to something like 40 amputations per day nationwide.

Is that right?

Laura Drudi

So, the apparent increase in many amputations, as you say, is a really complex phenomenon that can’t really be attributed to just one factor. CIHI’s data does indeed suggest an increase, but it’s vital to look at this trend from a variety of perspectives.

On the one hand, tertiary and quaternary centres certainly play a key role in preventing amputations, or “limb salvage” as we call it, by offering treatments that are maybe more aggressive or advanced, like complex revascularization treatments and multidisciplinary care like the work I do in vascular surgery with my multidisciplinary team at CHUM.

However, access to these centres is unequal across our province and the country, and not all hospitals have the same resources to set up effective prevention strategies. So, patients living in remote regions, for example, or in vulnerable communities, may not be treated in time, which limits people’s salvage options and leads to amputations in our province.

Alya Niang

I understand. Maybe there are more amputations because fewer family doctors are detecting them in time and because there aren’t enough resources to monitor the people who have injuries or wounds on their feet.

Do you have the impression that some people get an amputation because it’s easier and faster?

Laura Drudi

That’s not an easy question to answer. It’s certainly a very complex question, but the stage at which the disease is detected has a considerable influence on the trajectory of care. So, in many cases, in remote regions that don’t have access, patients arrive at an advanced stage with critical ischemia, which means gangrene, rest pain, diabetic foot infections. And amputation then becomes a damage control measure, rather than a failure of prevention.

So that delay may be due to inadequate screening in first-line medical care, a lack of follow-up for diabetic patients, or inequalities in access to specialized care, particularly for marginalized populations.

Alya Niang

So the decision to amputate is really made after careful consideration, and it’s not because it’s easier or maybe faster, but because it’s the only solution.

Laura Drudi

Yes, I think everyone is making decisions focused on the patient, focused on the cases in front of us, and as I said, I think, after extensive conversations that we have with the patient. We make the decision together; it’s a shared decision. And amputating a leg is not easy — it’s difficult for their quality of life, and their subsequent rehabilitation. So everyone makes these decisions and thinks about them in depth.

Alya Niang

Okay. Amputations are expensive, Dr. Drudi, and the data shows that the cost is typically between 25 and 45,000 dollars per amputated patient. But I imagine it must also be emotionally costly for patients.

What would you say the effect of all these amputations is for individual patients?

Laura Drudi

Beyond the financial cost, amputations really have a major emotional and psychological impact on the patient, and on their caregivers and loved ones as well. They often lead to a loss of autonomy, a reduction in quality of life, and an increased risk of depression. We see that fairly often in the clinical setting. Many patients also feel a sense of social isolation, stigmatization, and difficulties in returning to an active life, including in their professional lives.

Alya Niang

And I imagine there’s follow-up with patients for that, psychological follow-up work?

Laura Drudi

Absolutely. So if we’re not screening for that, maybe we should be. But when they come in post-operatively or even on the ward, I talk with them about the psychological aspects. And if I see that there are elements of depression, anxiety or adjustment disorder, then I’ll definitely consult with my colleagues in psychiatry, either during their admission or externally.

Alya Niang

Okay. And the risk of death is also higher for amputated patients? Is that right?

Laura Drudi

Yes, that’s true. The mortality rate after a major amputation is really high, and we’ve seen that in recent years in studies and in the clinical setting. It’s estimated that about 50% of patients who undergo an amputation for vascular reasons die within 5 years after the procedure.

So that risk is especially high for patients with comorbidities like cardiovascular disease and renal failure, which is most of our population that gets amputations. And that reflects not only the extreme fragility of these patients, but in certain cases, also a lack of access to optimal cardiovascular care earlier on. Amputation is often the end result of delayed or inadequate treatment of [indiscernible] pathologies, suggesting that an overall improvement in the prevention and treatment of cardiovascular disease could potentially reduce the burden of amputations and improve the subsequent patient survival rates.

Alya Niang

I see. One of the other very worrying conclusions is that among the homeless population, the number of people suffering from frostbite who undergo amputations is almost 4 or 5 times higher.

Is that something you’re seeing?

Laura Drudi

Yes, unfortunately that’s a well-documented trend. People experiencing homelessness are faced with extremely unstable living conditions that increase their risk of severe medical complications, including amputations. Prolonged exposure to the cold, limited access to health care, high rates of undiagnosed diabetes followed by infections that are inadequately cared for, and untreated wounds all contribute to an active risk of amputation in this population.

I have an arrangement with several homeless shelters in Montréal: Projets Autochtones du Québec, PAC, Chez Doris, and also a clinic in Montréal, the Indigenous ������ϱ� Centre of Tiohtià :ke, which is really a clinic dedicated to Indigenous people, both those who are homeless and those who aren’t, and those have allowed me to directly observe the challenges these communities are facing. We’re really working to provide culturally supportive health care for Indigenous populations and homeless populations, who are particularly vulnerable to amputations due to a lack of access to preventive care.

And finally, as a vascular surgeon and researcher, I work on solutions aimed at improving early detection and access to care for these populations. We’ve also started a small diabetic foot clinic once a month in those shelters to reduce the problems linked to amputations.

Alya Niang

And my last question is, what advice would you give to people with diabetes to avoid amputations, and what solutions do you see for the future?

Laura Drudi

Absolutely. The most important thing is that people with diabetes should have their feet examined by a family doctor or specialist a minimum of once per year. Normally, it’s family doctors who will take care of that.

Other than that, the patient or a family member can look at their feet every day before going to bed to make sure there are no scars, injuries or cracks in their feet, because a small scar can progress and develop into a major problem like a diabetic foot ulcer. And even a small ulcer can lead to an amputation.

So patients or their caregivers can look at their feet every day and if there’s anything that’s not normal, they should see their family doctor or a specialist for a more detailed evaluation. But our requirements in first-line care are to evaluate all patients with diabetes, and to evaluate every year.

Alya Niang

And what solutions do you see for the future?

Laura Drudi

For me, the solutions are to develop multidisciplinary clinics for diabetic foot and peripheral vascular disease. Having all the specialists on site at the same time to treat our patients is a major issue in the big tertiary and quaternary centres. But CHUM and its Centre d’expertise du diabète are now developing a multidisciplinary clinic to reduce the amputation rate at our centre. And my goal as a researcher is to set up these clinics in regions all across Quebec to provide screening for people with diabetes so that we can really reduce amputations in the years to come.

Alya Niang

Great. Thank you very much, Dr. Drudi.

Laura Drudi

Thank you. My pleasure.

Alya Niang

It’s important to point out that the federal government says it’s working to make essential diabetes drugs free to patients as part of the first phase of a national universal drug insurance program. Let’s not forget that diabetes doesn’t only lead to loss of limbs. It also causes blindness, renal failure and heart disease.

If you’d like to learn more about the report, Advancing equity in diabetes prevention and care, the full document is available online at cihi.ca, along with lots of other information about CIHI’s work on equity in health care.

A big thank-you for taking time to listen in. Our executive producer is Kevin O’Keefe, and special thanks to Heather Balmain, our production assistant, and Avis Favaro, the host of the ������ϱ�podcast in English. Please subscribe to the CHIP wherever you get your podcasts. I’m Alya Niang. Talk to you next time.