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1362465129 diabetic foot syndrome an indian perspective

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diabetic foot syndrome an indian perspective

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1362465129 diabetic foot syndrome an indian perspective

  1. 1. DIABETIC FOOT SYNDROME – An Indian Perspective – Apropriate technology DR. ASHOK KUMAR DAS DEAN, DIRECTOR-PROFESSOR & HEAD, DEPARTMENT OF MEDICINE, JIPMER, PONDICHERRY
  2. 2. AGENDA ISSUES COST CLASSIFICATION HIGH RISK FOOT CLINICAL EVALUATION  HISTORY  PHY EXAM LAB TECHNOLOGY MANAGEMENT  6 CONTROLS  INDIAN PROBLEMS & SOLUTIONS DIABETIC FOOT CLINIC CONCLUSIONS
  3. 3. INTRODUCTION FOOT PROBLEMS - AN IMPORTANT CAUSE OF MORBIDITY IN DIABETIC PEOPLE 2025 THERE EXPECTED TO BE 75 MILLION DIABETICS 150 MILION FEET
  4. 4. TYPES OF DIABETIC FOOT NEUROPATHIC FOOT (COMMONEST) ISCHEMIC FOOT
  5. 5. DIAGNOSIS OF A ‘HIGH RISK’ FOOT PERIPHERAL NEUROPATHY SOMATIC AUTONOMIC PERIPHERAL VASCULAR DISEASE PREVIOUS FOOT ULCERS FOOT DEFORMITY CLAW TOES CHARCOT ARTHROPATHY
  6. 6. PRESENCE OF CALLUS BLIND OR PARTIALLY SIGHTED NEPHROPATHY ELDERLY POOR UNDERSTANDING OF DIABETES INABILITY TO FEEL SEMMES- WEINSTEIN NYLON MONOFILAMENT
  7. 7. TECHNOLOGY & DIABETIC FOOT UTILISED MAINLY SCREENING DIAGNOSIS OF HIGH RISK FOOT DIAGNOSIS OF EXTENT OF INVOLVEMENT PROGNOSTICATION TREATMENT OF DIABETIC FOOT
  8. 8. TECHNOLOGY & DIABETIC FOOT… HI TECH EDUCATION AWARENESS & EDUCATION PERSONS WITH DIABETES & DIABETIC FOOT CARE PROVIDERS viz…diabetic foot pressures & its improvement with insoles etc.
  9. 9. TECHNOLOGY & DIABETIC FOOT… Quantification & research Natural history of Diabetes & its complications Drug trials Evidence based Diabetology Practice viz …diabetic Neuropathy
  10. 10. AREAS & APPLICATION OF TECHNOLOGY IN DIABETES PRACTICE 2004Diabetic foot pressure studies: out of shoe in shoe emed pedomed f-scan
  11. 11. Introduction of opticalpedobiographs & development of computing technology microprocessor like recording devices provide—possibility of identifying patients at risk of plantar ulceration give basis for foot wear prescription & adjustment surgical intervention Hi tech education
  12. 12. COST FOOT COSTS A MAJOR COMPONENT OF DIABETES RELATED HEALTH-CARE EXPENDITURE IN US, COSTS OVER $500 MILLION PER YEAR IN UK, OVER £13 MILLION PER YEAR
  13. 13. CLINICAL ALGORITHM R E V IE W R IS K F A C T O R S T A T U S A T L E A S T A N N U A L L Y G E N E R A L A D V IC E O N N A IL C A R E , H Y G IE N E , P O D IA T R Y , F O O T W E A R N O R IS K F A C T O R S R E V IE W F R E Q U E N T L Y A L W A Y S IN S P E C T F E E T F O O T C A R E E D U C A T IO N R E G U L A R P O D IA T R Y C O N S ID E R N E E D F O R S P E C IA L F O O T W E A R R IS K F A C T O R S ID E N T IF IE D A S S E S S E V E R Y D IA B E T IC F O R R IS K F A C T O R S
  14. 14. CLINICAL EVALUATION ALWAYS PRECEDES ANY LABORATORY INVESTIGATION GOOD HISTORY AND THOROUGH PHYSICAL EXAMINATION WILL REDUCE NEED FOR MANY UNNECESSARY AND COSTLY INVESTIGATIONS
  15. 15. HISTORY VASCULAR / NEUROGENIC CLAUDICATION PREVIOUS ULCERATION / AMPUTATION PATIENT UNDERSTANDING OF DM & COMPLICATIONS
  16. 16. PHYSICAL EXAMINATION SHAPE & DEFORMITIES  TOE DEFORMITIES, NAIL DEFORMITIES  HALLUX VALGUS, HALLUX RIGIDUS  PROMINENT METATARSAL HEADS  HAMMER TOE  CHARCOT DEFORMITY  CALLUS
  17. 17. SENSORY FUNCTION  VIBRATION (128 HZ TUNING FORK)  THERMAL PROPRIOCEPTION  JOINT POSITION SENSE
  18. 18. MOTOR FUNCTION  WASTING  WEAKNESS  LOSS OF ANKLE REFLEXES
  19. 19. AUTONOMIC FUNCTION  REDUCED SWEATING  CALLUS  WARM FOOT  DISTENDED DORSAL FOOT VEINS
  20. 20. VASCULAR STATUS  FOOT PULSES  PALLOR  COLD FEET  EDEMA
  21. 21. CLINICAL ASSESSMENT - EIGHT COMPONENTS NEUROPATHY ISCHEMIA DEFORMITY CALLUS OEDEMA SKIN BREAKDOWN INFECTION NECROSIS
  22. 22. STAGING THE DIABETIC FOOT STAGE CLINICAL CONDITION 1 NORMAL 2 HIGH RISK 3 ULCERATED 4 CELLULITIC 5 NECROTIC 6 MAJOR AMPUTATION
  23. 23. LABORATORY EVALUATION OF THE VASCULAR SYSTEM INDIRECT METHODS DIRECT METHODS
  24. 24. INDIRECT METHODS DOPPLER ULTRASOUND PHOTOPLETHYSM O GRAPHY PULSE VOLUME RECORDING LASER DOPPLER FLUX TRANSCUTANEOU S OXYGEN TENSION ISOTOPE CLEARANCE
  25. 25. DIRECT METHODS DUPLEX SCANNING MAGNETIC RESONANCE IMAGING ARTERIOGRAPHY
  26. 26. DOPPLER ULTRASOUND AND DOPPLER PRESSURES METHODS INCLUDE DOPPLER SIGNAL WAVE FORM ANKLE DOPPLER PRESSURE ANKLE - BRACHIAL INDEX DOPPLER SEGMENTAL PRESSURES
  27. 27. DOPPLER USG - MOST WIDELY USED DEVICE RANGES FROM A POCKET SIZE DEVICE TO LARGE, STATIONARY COMPLICATED DEVICE AUDIBLE SIGNALS EVALUATED BY HEAD-PHONES OR LOUD SPEAKER
  28. 28. DOPPLER SIGNAL WAVE FORM NORMAL ARTERIAL DOPPLER WAVE FORM IS TRIPHASIC SYSTOLIC UPWARD DEFLECTION DIASTOLIC DOWNWARD DEFLECTION SMALLER UPWARD AND DOWNWARD DEFLECTION (DIASTOLIC FORWARD FLOW)
  29. 29. ANKLE - BRACHIAL INDEX DOPPLER PROBE USED TO MEASURE SYSTOLIC PRESSURE AT BRACHIAL ARTERY AND DORSALIS PEDIS/POSTERIOR TIBIAL ARTERY NORMALLY, ANKLE PRESSURE / BRACHIAL PRESSURE = 1 OR SLIGHTLY ABOVE ABI CORRELATES WITH SEVERITY OF ISCHEMIA
  30. 30. ABI ABI OF 0.8 - 0.5 ---  INTERMITTENT CLAUDICATION ABI OF < 0.5 ---  REST PAIN A CHANGE OF 0.15 IS CONSIDERED SIGNIFICANT
  31. 31. SEGMENTAL PRESSURES USED TO LOCALIZE VASCULAR OBSTRUCTION MEASUREMENTS WITH PNEUMATIC CUFFS ARE MADE FROM HIGH THIGH LOW THIGH BELOW KNEE ANKLE LEVEL
  32. 32. PRESENCE OF GRADIENT BETWEEN MEASUREMENTS INDICATES A SIGNIFICANT STENOSIS OR A COMPLETE OCCLUSION IN THE ARTERIAL SEGMENT BETWEEN THE TWO CUFFS
  33. 33. EXERCISE FOR DIAGNOSIS CAN UNMASK OBSTRUCTION CAUSES A DROP IN DOPPLER PRESSURES DISTAL TO OBSTRUCTION, AFTER EXERCISE DIFFERENTIATES VASCULAR FROM NON-VASCULAR ETIOLOGY FOR CLAUDICATION
  34. 34. ANKLE DOPPLER PRESSURE SEVERITY OF LOWER EXTREMITY ISCHEMIA SYSTOLIC PRESSURE AT ANKLE APPROPRIATE SIZED CUFF IS USED POSTERIAL TIBIAL / DORSALIS PEDIS THE HIGHER READING IS TAKEN
  35. 35. ANKLE DOPPLER PRESSURE ABSOLUTE ANKLE PRESSURE IS THE BEST PREDICTOR OF LIMB VIABILITY > 60 MM HG = 86% OF VIABLE LOWER EXTREMITIES < 60 MM HG = 77% OF NON-VIABLE EXTREMITIES
  36. 36. PHOTOPLETHYSMOGRA PHY USES A DIODE THAT EMITS INFRA- RED LIGHT INTO THE TISSUE, WHICH IS REFLECTED BACK FROM THE BLOOD IN THE CUTANEOUS MICROCIRCULATION TWO MEASUREMENTS TOE BLOOD PRESSURE SKIN PERFUSION PRESSURE
  37. 37. TOE BLOOD PRESSURE FALSE HIGH DOPPLER PRESSURES IN CASE OF CALCIFIED VESSELS ESPECIALLY USEFUL WHEN THE PATHOLOGY IN VESSELS IS BELOW THE ANKLE  BUERGER’S DISEASE  RAYNAUD’S PHENOMENON LOWER LIMIT OF NORMAL FOR TOE PRESSURE IS 50 MM HG
  38. 38. SKIN PERFUSION PRESSURE A GOOD PREDICTOR OF HEALING OF ULCER AND AMPUTATION SITES SKIN PERFUSION PRESSURE OF 21 MM HG OR ABOVE FOUND TO CORRELATE WITH HEALING AND DECREASED COMPLICATION RATE OF THE AMPUTATION SITE
  39. 39. PULSE VOLUME RECORDER SEGMENTAL PLETHYSMOGRAPH IS USED CHANGES IN EXTREMITY OR DIGIT VOLUME THAT TAKES PLACE IN RESPONSE TO ARTERIAL PULSATION IS MEASURED
  40. 40. PULSE CONTOUR NORMAL WAVE PEAKED BRISK ANACROTIC AND DICROTIC DEFLECTIONS DICROTIC NOTCH ABNORMAL WAVE FLATTENED WAVE ABSENCE OF DICROTIC NOTCH REDUCED ANACROTIC / DICROTIC COMPONENTS
  41. 41. PULSE AMPLITUDE ARTERIAL OCCLUSIVE DISEASE IS MARKED BY DECREASE IN AMPLITUDE OF THE PULSE WAVE FORM AMPLITUDE < 15 MM - FOOT PAIN LIKELY ISCHEMIC AMPLITUDE < 5 MM - FOOT ULCER UNLIKELY TO HEAL
  42. 42. TRANSCUTANEOUS OXYGEN TENSION (TCPO2) MODIFIED CLARK ELECTRODE THAT MEASURES PARTIAL PRESURE OF O2 THAT DIFFUSES THROUGH SKIN GOOD ULCER HEALING IF TCPO2 > 35 - 40 MM HG POOR ULCER HEALING IF TCPO2 < 20 - 26 MM HG
  43. 43. LASER DOPPLER FLUX ALSO CALLED VELOCIMETRY PROVIDES A DIRECT & CONTINUOUS MEASUREMENT OF SKIN CAPILLARY BLOOD FLOW VELOCITY SENSITIVITY LESS THAN TCPO2
  44. 44. ISOTOPE CLEARANCE 133 XE GAS ISOTOPE TO MEASURE SKIN BLOOD FLOW FLOW RATES ABOVE 2.6 ML / 100 GM TISSUE CORRELATED WITH GOOD HEALING
  45. 45. DUPLEX SCANNING COMBINATION OF REAL TIME B MODE SONOGRAPHY AND A PULSE DOPPLER ALLOWS 2-D VISUALIZATION OF BLOOD VESSEL WITH SURROUNDING TISSUES DETECTS CALCIFIED PLAQUE, ULCER, THROMBI, ANEURYSMS
  46. 46. COLOUR FLOW DOPPLER DISPLAY OF FLOW IN VESSELS IN DIFFERENT COLOURS DEPENDING ON DIRECTION OF FLOW ACCURACY OF 77% - 97% TIME-CONSUMING AND NEEDS SKILL
  47. 47. MAGNETIC RESONANCE IMAGING 3-D RECONSTRUCTION OF VESSELS POSSIBLE LUMINAL NARROWING, CALCIFIED PLAQUES AND THROMBI CAN BE DETECTED MR ANGIOGRAPHY - ROLE BEING STUDIED
  48. 48. ARTERIOGRAPHY INDICATIONS INCLUDE DISABLING CLAUDICATION ISCHEMIC REST PAIN ICHEMIC ULCERATION ISCHEMIC GANGRENE
  49. 49. DIGITAL SUBSTRACTION ANGIOGRAPHY ADVANTAGES OVER ROUTINE ARTERIOGRAPHY HIGH CONTRAST RESOLUTION IMPROVED ARTERIAL VISUALIZATION LESS REQUIREMENT OF THE RADIOCONTRAST DYE REDUCED COST OF EXAMINATION
  50. 50. VASCULAR EVALUATION - INDIAN CONTEXTAT PRIMARY HEALTH CARE LEVEL, CLINICAL EVALUATION OF UTMOST IMPORTANCE “ALWAYS INSPECT THE FOOT OF A DIABETIC PATIENT” PALPATE FOR THE PULSE - DORSALIS PEDIS, POSTERIOR TIBIAL IDENTIFY & REFER A HIGH-RISK FOOT TO NEAREST TERTIARY CARE CENTRE
  51. 51. VASCULAR EVALUATION AT AN INDIAN TERTIARY CARE CENTRETHOROUGH CLINICAL EVALUATION ABI WITH DOPPLER ESSENTIAL AND AFFORDABLE INTEGRATED APPROACH- TO LOOK FOR OTHER RISK FACTORS
  52. 52. LABORATORY EVALUATION OF NERVE FUNCTION TESTS OF SENSORY FUNCTION TESTS OF AUTONOMIC FUNCTION
  53. 53. TESTS OF SENSORY FUNCTION VIBRATION PERCEPTION THRESHOLD 128 HZ TUNING FORK REIDELL-SEIFFER GRADUATED TUNING FORK BIOTHESIOMETER VIBRAMETER
  54. 54. TESTS OF SENSORY FUNCTION (CONTD) LIGHT TOUCH SENSATION VON FREY HORSE HAIR NYLON MONOFILAMENTS THERMAL THESHOLDS MARSTOCK STIMULATOR MEDELEC SENSORTEK THERMOTEST
  55. 55. TESTS OF AUTONOMIC FUNCTION CARDIOVASCULAR TESTS TESTS OF OTHER SYSTEMS GI SWEAT PUPILLARY NEURENDOCRINE
  56. 56. NERVE FUNCTION EVALUATION- INDIAN PERSPECTIVEAT PHC LEVEL, CLINICAL EVALUATION OF LIGHT TOUCH WITH COTTON HAIR VIBRATION WITH TUNING FORK AND TEMP WITH WARM / COLD WATER AT TERTIARY CENTRES, BIOTHESIOMETRY AFFORDABLE AS ALSO NYLON MONOFILAMENTS FOR AUTONOMIC NEUROPATHY, CARDIOVASCULAR TESTS WELL DESCRIBED & EASY TO PERFORM
  57. 57. CARDIOVASCULAR TESTS FOR AUTONOMIC NEUROPATHY HR RESPONSE TO VALSALVA MANOEUVRE HR RESPONSE TO STANDING UP HR RESPONSE TO DEEP BREATHING BP RESPONSE TO STANDING UP BP RESPONSE TO SUSTAINED HAND-GRIP
  58. 58. NORMAL AND ABNORMAL VALUES OF AUTONOMIC FUNCTION TESTING TEST NORMAL BORDER ABNORMAL LINE VALSALVA 1.2 1.11-1.2 <1.1 RATIO HR VARIATION WITH DEEP BREATHING 15/MIN 11-14/MIN <10/MIN HR RESPONSE TO STANDING 1.04 1.01-1.03 <1.0 BP FALL ON STANDING 10 MMHG11-29MMHG >30MMHG BP TO HANDGRIP 16MMHG 11-15MMHG <10MMHG
  59. 59. AUTONOMIC Fn TESTS… CARDIOVASCULAR TESTS EASY TO PERFORM NEEDS ONLY ECG, SPHYGMOMANOMETER COMPLICATED TESTS LIKE 24 HOUR HR VARIABILITY etc ONLY FOR ADVANCED RESEARCH, AND PRACTICAL UTILITY LIMITED
  60. 60. INTERPRETATION NORMAL - ALL FIVE NORMAL / 1 BORDERLINE EARLY- ONE OF 3 HR TESTS ABNORMAL/ 2 BORDERLINE DEFINITE- > 2 HR TESTS ABNORMAL SEVERE- + > 1 BP TESTS ABNORMAL / BOTH BORDERLINE ATYPICAL- ANY OTHER COMBINATION
  61. 61. ASSESSMENT OF FOOT PRESSURES SIMPLE FOOT PRESSURE PADS SOPHISTICATED PEDOBAROGRAPHY F.SCAN MAT SYSTEMS
  62. 62. AFFORDABLE INDIAN ALTERNATIVES PEDOBAROGRAPHY & F. SCAN MAT SYSTEMS NOT FEASIBLE IN MOST INDIAN HOSPITALS REASONABLE, AFFORDABLE ALTERNATIVES INCLUDE HARRIS MAT INKPAD SYSTEM VIEW BOX
  63. 63. HARRIS MAT PATIENT STEPS ON AN INKED MAT WALKS ON A LONG SHEET OF PAPER FOOTPRINTS ANALYZED WITH RESPECT TO PRESSURE POINTS
  64. 64. INKPAD SYSTEM LARGE INKPAD WITH A PLASTIC COVER ON TOP TO PREVENT STAINING OF PATIENT’S FOOT FACILITY TO INSERT A PLAIN PAPER BELOW THE INKPAD PRESSURE BY PATIENT’S FOOT IS TRANSMITTED TO THE PAPER AND A FOOTPRINT OBTAINED
  65. 65. VIEW BOX A VIEW BOX WITH A PLAIN GLASS ABOVE AND A MIRROR BELOW A TUBE-LIGHT IS PLACED IN THE BOX FOR ILLUMINATION WHEN THE PATIENT STANDS ON THE TOP, THE REFLECTION IN THE MIRROR CAN BE EASILY EXAMINED AND PRESSURE POINTS VISUALIZED
  66. 66. OTHER LABORATORY TESTS BLOOD GLUCOSE LEVELS, GLYCATED HEMOGLOBIN TBA METHOD IN MOST INDIAN SETTINGS COMPLICATED METHODS OF ASSESSMENT NOT AVAILABLE/AFFORDABLE
  67. 67. Lab tests… MICROPROTEINURIA POSITIVE CORRELATION WITH PVD ‘SIGMA CHROMOGEN BLUE’ USED COMMONLY FOR ESTIMATION COMPLEX TESTS LIKE MICRO- ALBUMINURIA, RIA, ELISA NOT AVAILABLE EVEN AT MOST TERTIARY CARE CENTRES IN INDIA
  68. 68. MANAGEMENT MULTI-DISCIPLINARY APPROACH ADVOCATED IN THE WEST TEAM CONSISTS OF  PHYSICIAN  SURGEON  PODIATRIST  SPECIALIST NURSE  ORTHOTIST  RADIOLOGIST
  69. 69. IN INDIA THE PRIMARY CARE DOCTOR IS THE ONLY HELP AVAILABLE ORTHOTIST, PODIATRIST, SPECIALIST NURSE ALL EXTREMELY SCARCE THEREFORE, BASIC ASPECTS OF ALL THESE FIELDS NEED TO BE KNOWN BY EVERY PHYSICIAN
  70. 70. SIX ASPECTS OF PATIENT TREATMENT WOUND CONTROL MICROBIOLOGICAL CONTROL MECHANICAL CONTROL VASCULAR CONTROL METABOLIC CONTROL EDUCATIONAL CONTROL
  71. 71. WOUND CONTROL DEBRIDEMENT REMOVES CALLUS & REDUCES PLANTAR PRESSURES TRUE DIMENSIONS OF ULCERS CAN BE MEASURED DRAINAGE OF EXUDATE ENABLES DEEP SWAB FOR CULTURE CONVERTS CHRONIC WOUND TO ACUTE WOUND
  72. 72. SKIN GRAFT DRESSINGS DAILY SHOULD BE EASY TO LIFT FOOT GOOD EXUDATE CONTROL
  73. 73. DRESSINGS - TYPES FILMS CLEAR, WOUND INSPECTION EASY FOAM CUSHIONING EFFECT HYDROCOLLOIDS PATIENTS CAN BATHE ALGINATES USEFUL FOR PACKING DEEP WOUNDS
  74. 74. MICROBIOLOGICAL CONTROL NO UNIFORM AGREEMENT ON ANTIBIOTIC POLICY CLOXACILLIN + 3RD GEN CEPHALOSPORINS COMMONLY USED CIPROFLOXACIN + CLOX - ANOTHER USEFUL COMBINATION
  75. 75. IN NEURO-ISCHEMIC ULCERS, MORE AGGRESSIVE ANTIBIOTIC THERAPY REQUIRED AS COMPARED TO PURE NEUROPATHIC ULCERS SEARCH AGGRESSIVELY FOR OSTEOMYELITIS
  76. 76. MECHANICAL CONTROL CORRECT FOOTWEAR TENDING TO MINOR FOOT PROBLEMS  ONYCHOGYPHOSIS (MONSTER NAIL)  ONYCHOCRYPTOSIS (INGROWING TOE NAIL)  ONYCHOMYCOSIS  TINEA PEDIS  CORNS, ETC
  77. 77. TREATMENT OF DEFORMITY & CALLUS REDISTRIBUTION OF PLANTAR PRESSURES IN NEUROPATHIC FOOT TEMPORARY OFF-LOADING THE SITE OF ULCER USE OF CASTS  AIRCAST (WALKING BRACE)  TOTAL-CONTACT CAST  SCOTCHCAST BOOT
  78. 78. VASCULAR CONTROL CAREFUL CLINICAL EXAMINATION MANDATORY SUPPLEMENTED BY ABI ANGIOPLASTY / BYPASS IN NON- HEALING ULCERS WITH DOCUMENTED ARTERIAL STENOSIS
  79. 79. METABOLIC CONTROL POOR GLYCEMIC CONTROL DELAYED HEALING IMMUNE SUPPRESSION IMPAIRED RESPONSE TO INFECTION LOOK FOR OTHER ASSOCIATED METABOLIC PROBLEMS HT, UREMIA, ACIDOSIS, ETC
  80. 80. EDUCATIONAL CONTROL CONTINUOUS EDUCATION OF PATIENT ESSENTIAL INFORMATION ACCORDING TO STAGE ENSURES PATIENT CO-OPERATION & COMPLIANCE LIST OF SIMPLE DOS AND DON’TS
  81. 81. DO WASH FEET DAILY WITH MILD SOAP & WATER CHECK FEET DAILY SEEK URGENT TREATMENT OF ANY PROBLEMS WEAR SENSIBLE SHOES CHECK SHOES INSIDE AND OUTSIDE BEFORE WEARING
  82. 82. Do… HAVE FEET MEASURED WHEN BUYING SHOES BUY LACE-UP SHOES WITH PLENTY OF ROOM FOR TOES KEEP FEET AWAY FROM HEAT SIT INSTEAD OF STANDING CHANGE SOCKS FREQUENTLY
  83. 83. DONT USE CORN CURES USE HOT-WATER BOTTLES WALK BAREFOOT CUT CORNS OR CALLUSES BY YOURSELF DELAY IN SEEKING HELP FOR ANY PROBLEM
  84. 84. MANAGEMENT PROBLEMS IN INDIA POOR PATIENT AWARENESS DELAYED SEEKING OF HEALTH CARE POVERTY, LACK OF AWARENESS/NEARBY FACILITIES CULTURAL BELIEFS
  85. 85. INJURY PRONE FOOT DIVERSE CAUSES  RAT-BITE, INSECT BITE, ETC  INJURY DURING AGRICULTURE/MANUAL LABOUR LACK OF SUFFICIENT FACILITIES LACK OF TRAINED PERSONNEL COST
  86. 86. SOME SOLUTIONS EDUCATION PRIMARY CARE PHYSICIAN PATIENT INNOVATE PRAGMATICALLY, EG:- WASHED X-RAY FILM FOR ULCER MEASUREMENT INKPAD FOR FOOT PRESSURE ASSESSMENT
  87. 87. HONING OF CLINICAL SKILLS EARLY IDENTIFICATION OF ‘HIGH RISK’ FOOT BY SCREENING EVERY DIABETIC FOOTWEAR FOR INDIA  AVOID BLACK COL (ASSO. WITH HANSEN’S)  APPROPRIATE LOCALLY AVAILABLE MATERIAL  TAKING PATIENT INTO CONFIDENCE
  88. 88. DANGER SIGNS - FOR PATIENT AWARENESS TO SEEK MEDICAL HELP IF SWELLING COLOUR CHANGE PAIN / THROBBING THICK HARD SKIN OR CORNS BREAKS IN THE SKIN, INCLUDING CRACKS, BLISTERS OR SORES
  89. 89. ORGANIZING DIABETIC FOOT CLINIC IDENTIFY DIAB ETIC FOOT AT RISK INSPECTION PALPATE FOOT PULSE ANKLE JERK CLASSIFY & STAGE CALLUS REMOVAL CONTROL
  90. 90. BARE MINIMUM INSTRUMENTATION SEMMES - WEINSTEIN MONOFILAMENT BIOTHESIOMETER POCKET DOPPLER INKPAD
  91. 91. CONCLUSIONS DIABETIC FOOT - A WIDELY PREVALENT & COSTLY COMPLICATION OF DIABETES CLINICAL EXAMINATION OF FOOT - A MUST IN EVERY DIABETIC PATIENT SUPPLEMENTED BY LAB EVALUATION FOR VASCULAR, NEUROLOGIC AND MECHANICAL STATUS
  92. 92. Conclusions… APPROPRIATE MULTI-DISCIPLINARY MANAGEMENT BASED ON STAGING MUCH WORK LEFT TO BE DONE IN INDIA FOR RECOGNITION, EVALUATION AND TREATMENT OF DIABETIC FOOT
  93. 93. India—Dr.Paul Brandt &TCC PB while working at CMC amongst leprosy patients saw TCC Transformed same exp. to diabetic foot Mx. To day TCC is universaly accepted for Neuropathic Diabetic Foot Ulcer
  94. 94. Evaluation of Sensory Function Large Fibre Function Vibration Perception Threshhold Indian Biosthesiometer Rs. 25,000 vs Rs. 50,000 Local Simmes Weinstein monofilament
  95. 95. QST… Assessment of small fibre function Heat & Cold sensation Heat Pain & Cold pain sensation Marstock Stimulator Thermal Discrimination Threshold measurement Indian Equipment Rs.2,00,000 vs Rs. 50,000
  96. 96. Net Working

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