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1362577835 preventive foot clinics dr gopalka
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Transcript of 1362577835 preventive foot clinics dr gopalka
Preventive Foot Clinics
Sanjeev Kelkar
Why Preventive Foot Clinics?
• Need• Concept• Actualization• Experience• Learning
Preventive Foot Clinics
• Ulcer – gangrene – amputation – going on for long across the world and our country
• Energy and resources spent – huge• Treat as you can, send when it complicates• An Attitude for early detection when no co-
morbidities are present difficult to inculcate both among the HCPs and patients
• Treating an unborn future that does not get conceived
Diabetic Foot Statistics
• Estimated life time risk of diabetic foot - 15%• • 5-10% of all diabetic patients have or have had
foot ulceration of various degrees and about 1% have undergone amputation
• Diabetes accounts for up to 50% of non traumatic leg amputations*
• Of all the diabetic amputees about 50% will lose their life or their other leg by 3 years
Major Problem in India• Neuropathic ulcer ( 85--95 %), Eminently preventable• Patients are younger, • Mean age of amputation earlier, • Far too many amputations for neuropathic ulcer. • Neuropathy that is significant enough to cause foot
ulceration may affect 40% of diabetic population, especially elderly with type 2 diabetes.
• Upto 35% of all diabetic patients have asymptomatic neuropathy
• Diabetic Neuropathy affects 70% of the Diabetes patients –
The Compounded Problem
• Component causes leading to foot ulcers• Peripheral neuropathy : 78%• Minor trauma : 77%• Deformity : 63%• Edema : 37%• Peripheral ischemia : 35%• Callus : 30%• Infection : 01%
The Compounded Problem
• Contra-lateral amputation rate of 12 to 28% between 1 to 3 yrs
• Mortality - 16 to 38% :1 year• - 35 to 65% :3 year• - 75 to 80% : 5 year
Preventive Foot Clinics
Concept
Concept
• Assembly line operation• Multiport data entry• End to end solution• Skill transfers
CLINICAL EXAMINATION
1
2
3
1. Monofilament 2. Doppler
3. VPT
Overview
DIABETES EDUCATORS AT FOOT CLINIC
DIABETES EDUCATORS AT FOOT CLINIC
PREVENTIVE FOOT CARE, AID, KMCH, CHENNAI, INDIA
INDIVIDUAL COUNSELING
EDUCATOR’S COUNSELING THE PATIENTS
FOOT CARE - THE 10 COMMANDMENTS
THE 10 COMMANDMENTS OF FOOT CARE EXPLAINED BY NURSE EDUCATOR
Preventive Foot Clinics - Assets
• Enablers: Aware profession, available infrastructure within the country
• Need: People from the lower economic strata have much higher levels of complications across the board –
BUDS, CODI, NUDS,
Preventive Foot Clinics• Data entered online by three different
persons – baseline at the reception, clinical by the doctor, SW MF, VPT, HCP in VPT negative patients by trained techs,
• Doppler for PVD
Preventive Foot Clinics• Footwear inspection by a trained podiatrist,
advice given, • Second phase of preventive foot clinic – • Aims at establishing capacity to manufacture in
house foot wear, outsource it• The clinic charges for an extended period, not on
a visit to visit basis,• People pay –tariff low
Preventive Foot Clinics
These trained but non medical persons, they handle different jobs
eg baseline clinical data work at reception, help manage data entry etc.
• Understand the problems
Preventive Foot Clinics
• We can’t treat all, all along with the complications and all the works associated with it – let us face it
• But we can teach and prevent• The real solution is prevention prevention
and prevention
PREVENTIVE FOOT CARE CLINICDr. AMBEDKAR INSTITUTE OF DIABETESKILPAUK MEDICAL COLLEGE HOSPITAL
Summary Statistics
TOTAL NUMBER OF PATIENTS SCREENED : 6800 AS ON 14.7.2005
Number of patients examined : 6800
Number of patients with Foot problem : 5700
P. Neuropathy : 83.8%, PVD : 3.5 %,
Foot ulcers : 4.5% Preventive foot care education : All 6800Number of patients undergoing Minor / Major Amputations : 36
43
57
0
10
20
30
40
50
60
MALE FEMALE
MALE FEMALE
TOTAL SCREENED - n = 6800
%
FOOT EXAMINATION IN DIABETES
83.8
36.4
47.4
0102030405060708090
TOTAL MALE FEMALE
% OF MALES & FEMALES WITH FOOT PROBLEMSn = 6800
1) 16.2 % Did not have foot Problems2) Problems were more in Females
FOOT PROBLEMS AT SCREENING - AID KMCH - CHENNAI
0Ulcer
Amputation
GangreneCornClawtoesFissures
Calluses
Fung. Inf IngrownToe Nails
(n = 6800)%
of F
oot P
robl
ems
57.8
45.849.8
13.8
3.3 2.9 4.50.5 0.8
0
10
20
30
40
50
60
MONOFILAMENT EXAMINATION - n = 6800
60.5%
39.5%
0
10
20
30
40
50
60
70
P. Neuropathy in Diabetics - 1
NORMAL
ABNORMAL
% o
f pro
blem
s
Monafilament test is less reliable than VPT
16.2
83.8
24.531.8 27.5
0
20
40
60
80
100
Normal Total VPT+ve
Mild Moderate Severe
Normal Total VPT +ve Mild Moderate Severe(n = 6800)
P. Neuropathy in Diabetics - 2
Loss of VPT is more reliable test than MF
1.5
8.2
34.7
54.3
1.30
10
20
30
40
50
60
Non DM <5 6 to 15 16 to 25 >25
DURATION OF DM – WITH FOOT PROBLEMS(n = 6800)
Foot
pr o
blem
s %
Duration in Years
> 256 to 15< 5
More than 50% have foot problems at < 5 years
16-25
FOOT WEAR IN DIABETICS - n = 6800
41
20.816.7 15.9
3.81.8
05
1015202530354045
Hawai Plastic Others Bare FootedLeatherHawai MCR Plastic Others
Foot Problems are more with Hawai & Plastics even with MCR – Great Toes / Little Toes were outside the Foot Wear.
Foot
Wea
r %
34.7%
83.8%
3.5%
n = 6800
NEUROPATHY Vs VASCULAR PROBLEMS IN DIABETICS
NEUROPATHY
VPT MF DOPPLER AB INDEXVASCULAR
PVD is very minimal in this study
Action
• Evaluate the findings
• Pass the patient through an education session, put relevant educational material in vernacular in the hand
• Monitoring advised, • Revisit fixed, drugs prescribed
What Paul Brand Said - We did
• The single most important intervention to reduce amputation is to remove the footwear and see the feet of a diabetic
• Paul Brand as told to the Americans
Educate, educate and educate
Effect Of Patient Education On Amputation Rates
Knee & Above
12%
15%
5%
46%
35%
60%
Toe & Metatarsal
Below KneeNo Education
Education
University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.