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Transcript of Diabetic Foot
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DR.MOHAMMAD ANWAR HAU B ABDULLAHHOSPITAL RAJA PEREMPUAN ZAINAB II.
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Global Prevalence of Global Prevalence of Diabetes Diabetes
2003: 194 million 2010: 265 million
2025: 333 million (predict) 2030: 366 million.(longer life expectancy, sedentary lifestyle and changing dietary patterns).
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‘Global diabetes tsunami ’ Adult population with
diabetes: About 5% in Europe 10-12% in Asia 30-40% in Pacific Island nation
‘Global diabetes will become the health crisis of 21st century’
(Prof Paul Zimmet. Director of WHO Collaborating Centre for Diabetes)
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International Diabetes International Diabetes Federation (IDF): 2010Federation (IDF): 2010
5 countries with the largest numbers of people with diabetes are India, China, the US, Russia and Brazil.
5 countries with the highest diabetes prevalence in the adult population are Nauru, the UAE, Saudi Arabia, Mauritius and Bahrain.
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Countries with the highest numbers of estimated cases of diabetes for 2000 and 2030
2000 2030Ranki
ngCountry No of
diabetes (million)
Country No of diabetes (million)
1 India 31.7 India 79.4
2 China 20.8 China 42.3
3 USA 17.7 USA 30.3
4 Indonesia
8.4 Indonesia 21.3
5 Japan 6.8 Pakistan 13.9
6 Pakistan 5.2 Brazil 11.3
7 Russia 4.6 Bangladesh
11.1
8 Brazil 4.6 Japan 8.9
9 Italy 4.2 Philippines
7.8
10 Bangladesh
3.6 Egypt 6.7
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Prevalence of diabetes Prevalence of diabetes in WHO Western Pacific in WHO Western Pacific regionregionCountry year 2000 year 2030China 20.76 million 42.32
millionJapan 6.76 8.91Philippines 2.77 7.78Korea 1.86 3.78Malaysia 0.94 2.48Australia 0.94 1.67Singapore 0.33 0.69New Zealand 0.18 0.31 Total 35 million 71 million
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SOUTH EAST ASIA REGION:BY 2025:Prevalence: 13.5%
Total no of DM: 145 million people
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DIABETES IN MALAYSIA
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1.6 Million Malaysian Adults May Have Diabetes
PUTRAJAYA, Aug 11,2009 (Bernama) -- It is estimated that one out of eight Malaysians aged 30 years and above has diabetes, which amounts to over 1.6 million adults, based on the Third National Health and Morbidity Survey (NHMS) 2006.Director-General of Health Tan Sri Dr Mohd Ismail Merican said the prevalence of diabetes also showed a drastic increase of 80 per cent over a period of just 10 years, from 8.3 per cent in 1996 to 14.9 per cent in 2006 for the same age group.Even more worrying, he said, was that one third of those who had diabetes were undiagnosed, and were not aware of their condition.
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PREVALENCE OF DM IN MALAYSIA NHMS I (1986) : 6.3%
NHMS II (1996) : 8.3%
NHMS III (2006) : 14.9% (1.6 m)
Now: > 20% (2 million)!!
(WHO- 2.48 million by 2030)
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Diabetes Risk for developing various serious
health problems that may affect: HeartsHearts Eyes Eyes
Kidneys Kidneys PregnancyPregnancy
NerveNerve Sexual functionSexual function
Skin and feet-----> ulcers and Skin and feet-----> ulcers and infectioninfection
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Foot ulceration is one of the most common complications in patients with diabetes.
The most common cause of admission to hospital for people with diabetes.
Shorten life expectance and increased mortality
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Facts about diabetic foot Facts about diabetic foot ulcerulcer Diabetic ulcer account for 85% of non-traumatic lower extremity amputation.
Diabetic patients is 15x more likely to undergo lower extremity amputation.
3%-4% of diabetes patients have foot ulcer or deep infection at any time.
12% - 24% of diabetes patients with foot ulcer require amputation.
3 -5 year risk of needing contra-lateral amputation is 50%
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Estimated every 30 (20) seconds a lower limb is lost to diabetes.
3 -5 year risk of needing contra-lateral amputation is 50%
• 69% of diabetic amputees will not survive past five years (2004).
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MALAYSIA- ESTIMATED:
48,000 to 64,000 of patients with diabetic foot ulcer (3% - 4%) at any time???
4,800 to 6,400 amputation (10% of foot ulcer patients require amputation)???
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DIABETIC FOOT-MALAYSIAN SCENARIO
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Observations- patients: Late presentation
Time for decision making
Bad general condition on admission (septicemia, severely dehydrated, anaemia, cardiac, electrolytes imbalance, DM not controlled, etc).
Alternative treatment
Refusal for treatment (AOR)
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Healthcare providers:Primary health-careTertiary health-care
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Observations- healthcare providers
Knowledge DM and foot care (NorAziana; Nur Azlina 2009)- 30-40% average to low; dressing materials
Attitude- not serious and aggressive enough (DM control)
Misleading- Diabetic treatment, direct selling etc
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Health-care system No dedicated diabetic foot-care team
(not glamorous work)
Not many – interested (junior doctors)
Lack of expert in various fields (vascular, endocrine, podiatric, prosthetic and orthotic)
Lack of facilities (angio etc).
Low priority- OT Wound-care in primary health (dressing,
etc)
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National Orthopaedic National Orthopaedic Registry Malaysia Registry Malaysia
(NORM)(NORM)
Diabetic foot/hand registryData on:
Second half of 2008 2009
17 sdp
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July- Dec 2008 2009
nn 909 1254
Mean Mean ageage
56.7 52.2
Sex (%)Sex (%) F: M= 53:47 F:M= 52: 48
Race (%)Race (%) M: 77C: 9
I: 14
M: 75C: 11 I: 12
ResidencResidence (%)e (%)
Urban: 56Rural: 42
Urban: 54Rural: 46
OccupatiOccupation (%)on (%)
H.W: 36Retired: 14
Unemployed: 11
H.W: 37Retired: 14
Unemployed: 10
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July- Dec 2008
2009
Education Education level (%)level (%)
Non: 13Primary: 44Secondary:
40Tertiary: 3
Non: 5Primary: 48Secondary:
42Tertiary: 5
Type of DM Type of DM (%)(%)
Type 1: 13Type 2: 87
Type 1: 16Type 2: 84
Duration of Duration of DM (year)DM (year)
Type I: 10.5Type II: 11.3
Type I: 11.9Type II: 10.4
Mean Mean duration duration
prior prior admission admission and stay and stay
(day)(day)
12.5
11.8
14.2
13.7
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July- Dec 2008
2009
nn 909 1254
On Rx (%)On Rx (%) 85 84
Compliance Compliance (%)(%)
56 40
Type of DM Type of DM treatment treatment
(%)(%)
Diet: 8OHA: 61 Insulin:
16Insulin + OHA: 7
Diet: 12OHA: 65
Insulin: 15Insulin + OHA: 10
Rx prior to Rx prior to admission admission
(%)(%)
Nil: 25Self: 4
Traditional: 3
Medical: 67
Nil: 25Self: 8
Traditional: 4
Medical: 62
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July- Dec 2008
2009
nn 909 1254
Co-Co-morbid morbid illness illness
(%)(%)
HPT: 56IHD: 12
H’cholesterol: 10
HPT: 55IHD: 8
H’cholesterol: 11
Family hx Family hx of DM (%)of DM (%)
41 43
ComplicatComplication (%)ion (%)
Retinopathy: 14
Vascular: 18Neuropathy:
45Nephropathy:
10
Retinopathy: 16
Vascular: 19Neuropathy:
39Nephropathy
: 8
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Health-awareness and Health-awareness and practicespractices 2008
(%)2009 (%)
Formal education
30 28.8
Aware of risk 61 64.6Wash feet 74.0 71.6
Inspect feet 51.0 51.6Apply
emollients24.0 23.8
Appropriate shoe
27.0 27.3
Keep diabetic booklet/record
25.0 23.1
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Clinical Outcome: Clinical Outcome 2008 (%)
N=9092009 (%)N=1254
Wound (Wd) healed 13 14.8Wd clean, granulate, discharged outpatient dressing 65 67.9
Amputation, stump healed 9 9.6Amputation, stump infected 2 1.2Death, due to septicemia 1 1.3Death, due to medical problem 0 0.2Discharged at own risk (AOR Discharged) 4 5.0
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NHMS III (2006):
4% to 7% of known diabetics had
undergone toe or leg amputations.
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Other aspects:
Healthcare cost Productivity Social-economic burden Psychological trauma Family tension and stess
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Centers for Disease Control and Prevention - USUnited States
1995: the cost to treat a DFU over a 2-year period was $27,987
2009: $46,841
Direct costs for a treating lower-extremity amputation: $22,700 to $51,300 (USD)
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2001: the estimated total cost of Rx of diabetic foot ulceration and amputation: $10.9b
2007: total cost of diabetic care $174 billion: $116 billion in direct costs and $58.3 billion in indirect costs (transportation, time etc).
70% of cost due to hospitalization
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Economic burdenEconomic burdenSweden (1998): Total direct costs for healing of
infected ulcers not requiring amputation are approximately $17,500 USD
Total costs for lower-extremity amputations are approximately $30,000-$33,500 USD depending on the level of amputation
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Financial costs
10 per cent of the NHS budget; around £9 billion a year based on 2007/2008 budget.– £173 million a week– £25 million a day– £1 million an hour– £17,000 a minute– £286 a second.
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Patients not using prosthesis/orthosis
Financial Does not fit/not comfortable
Home environment Heart unable to take it
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Energy expenditure for amputation:
Amputation level
% energy above baselin
e
Speed (m/mi
n)
O2 cost (ml/kg/
m)
Long BKA (>50%)
10 70 0.17
Average BKA 25 60 0.20Short BKA
(<20%)40 50 0.20
Bilateral BKA 41 50 0.20AKA (<1/3, >2/3) 65 40 0.28Wheelchair 0 - 8 70 0.16
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*Neuropathy (~80%)
*Vasculopathy (~47%) *Immunopathy (~58%)
PATHOGENESIS OF DFP
* Incidence based on Nather, Clarabelle et al 2005
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NEUROPATHY (30 – 50% with DM > 10 yrs)
• Major factor in diabetics leading to diabetic foot problems Sensory Autonomic Motor
•Root CauseRoot Cause of all of all diabetic foot diabetic foot problemsproblems
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IMMUNOPATHY• Diabetics have inherent susceptibility to infection
• Defects in leukocyte function
leukocyte phagocytosis neutrophil dysfunction deficient white cell chemotaxis and adherence
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VASCULOPATHY (6% to 23%)
• Microangiopathy Involving terminal arterioles (thickening of basement membrane of endothelium)
• Atherosclerosis Involving large and medium sized vessels Usually Crural Involvement Pattern - Anterior and
Posterior Tibial vessels in the leg. Dorsalis Pedis and Posterior Tibial vessels in the foot are usually patent (Pomposelli, 1995)
In Singapore, incidence of vasculopathy is in 46.8% based clinically on absence of pulses.
ABI < 0.8 is 31% using Doppler ultra sound probe(Adriaan, Nather et. al., 2005)
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FOOT AT RISK-
need periodic, thorough examination.
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FOOT AT RISK1. History of ulceration
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FOOT AT RISK 2. Presence of Peripheral vascular disease
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FOOT AT RISK 3. Presence of Neuropathy
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FOOT AT RISK 4. Presence of Deformity
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FOOT AT RISK 5. Inappropriate or No Footwear A B
C D
E F
•Over 70% of patients wear slippers or no footwear most of the time (Kathryn, Nather, Zameer A et. al., 2005)
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FOOT AT RISK:6. Skin Lesions
• Corn/Callus• Fungal Infection
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FOOT AT RISK:7. Nail Pathology
• Deformed Nail• Lesions – Ingrowing Toenail• Infected Nail
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General Risk Factors:
• Smoking
• Alcoholism
• Obesity
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General Risk Factors: CO-MORBIDITIES• Hypertension
• Hyperlipidemia
• Ischaemic Heart Disease
• Cerebrovascular Accident
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GENERAL RISK:
Occupation: Wet at work Prolonged walking or
standing.
Duration of diabetes
Education level
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Management Surgical drainage/ debridement
(repeated) - surgical, chemicals, ultrasonic, pulse jets
Dressing (materials and solutions).
Correction of deformity Off-loading amputation Rational use of antibiotics
(appropriate sample for culture; follow up on the laboratory result)
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Our roles?
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Diabetes and diabetic foot care
Make the diabetic patient/family members aware through continual education, self responsibility and self care that---->
it is possible to lead a normal life through healthy lifestyle, diet, exercises and control of blood sugar and care of the feet
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Health education Continuous and tirelessly About diabetes and its complications Important of good diabetic control (role
model) About foot-care How to recognised foot at risk/ trouble.
His/her responsibility for lifelong care of diabetes and feet Important: they must comply
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FOOT CARE1. Daily foot
inspection
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FOOT CARE
2. Use lukewarm (not hot!) water to wash feet
3. Be gentle feet washing/bathing.
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FOOT CARE4. Moisturize feet – be careful with the web space .
5. Nail cutting
6. Wear clean, dry socks (NEVER use heating pad or hot water
bottle)- keep foot warm
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FOOT CARE
7. Avoid walk barefoot.
8.Comfortable well fitting shoe
8.Shake out shoes and feel the inside before wearing
8.Never treat corns or calluses themselves.
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FOOT CARE11. Diabetic control
12. Stop smoking
13. Periodic foot examination
14. Keep the blood flowing to feet (ELEVATE, WIGGERS TOES, MOVING ANKLE) , avoid cross-leg or hanging leg/feet too long
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PREVENTION BETTER THAN
CURE
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Surgical procedures:
Prevent recurrent foot ulcer
Reduced / avoid amputation
Improved function
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THEME FOR DIABETES 2011:
“Leg for Life”
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SHARED RESPONSIBILITY!!
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THANK YOU VERY MUCH