1362577835 preventive foot clinics dr gopalka
TRANSCRIPT
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Preventive Foot Clinics
Sanjeev Kelkar
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Why Preventive Foot Clinics?
• Need• Concept• Actualization• Experience• Learning
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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
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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
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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 –
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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%
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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
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Preventive Foot Clinics
Concept
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Concept
• Assembly line operation• Multiport data entry• End to end solution• Skill transfers
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CLINICAL EXAMINATION
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1
2
3
1. Monofilament 2. Doppler
3. VPT
Overview
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DIABETES EDUCATORS AT FOOT CLINIC
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DIABETES EDUCATORS AT FOOT CLINIC
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PREVENTIVE FOOT CARE, AID, KMCH, CHENNAI, INDIA
INDIVIDUAL COUNSELING
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EDUCATOR’S COUNSELING THE PATIENTS
FOOT CARE - THE 10 COMMANDMENTS
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THE 10 COMMANDMENTS OF FOOT CARE EXPLAINED BY NURSE EDUCATOR
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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,
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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
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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
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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.
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• Understand the problems
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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
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PREVENTIVE FOOT CARE CLINICDr. AMBEDKAR INSTITUTE OF DIABETESKILPAUK MEDICAL COLLEGE HOSPITAL
Summary Statistics
TOTAL NUMBER OF PATIENTS SCREENED : 6800 AS ON 14.7.2005
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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
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43
57
0
10
20
30
40
50
60
MALE FEMALE
MALE FEMALE
TOTAL SCREENED - n = 6800
%
FOOT EXAMINATION IN DIABETES
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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
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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
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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
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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
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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
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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 %
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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
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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
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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
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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.