Every twenty second a lower limb is lost somewhere in the world-Dr. Zahid Miyan

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 Proceedings of Diabetic Foot Symposium by BIDE

Every twenty second a lower limb is
lost somewhere in the world-Dr. Zahid Miyan

Every hospital should have a team for immediate
response treating life threatening limb infections

KARACHI: Prof. Jamal Zafar from PIMS Islamabad was the first speaker on the second day of the Diabetic foot Symposium organized by Baqai Institute of Diabetes and Endocrinology on August 21-23, 2015. He pointed out that they see between twenty five to thirty diabetic foot patients every day which includes two to three new cases. The department has no Dietetician, no nutrition expert and no Diabetic educator. However, we do have a podiatrist. Off loading devices is a problem. We see patients coming from every where but there is hardly any referral. Patients have no place to stay. No transport and no facility of wheel chair in the hospital. Some patients donate but they are not many. Some of the patients are lost to follow up.

Continuing Prof. Jamal Zafar said that phone consultation is available for the patients about antibiotics. He then gave details of hundred patients which included sixty male and forty female. Duration of diabetes was more than fifteen years in 30% of the patients. Eighteen patients had diabetes for less than five years but they had diabetic foot problems. Causative organism for each diabetic foot patient is recorded after culture and sensitivity. Meropenam was found to be most sensitive. Seventy five percent of the patients were fully recovered, 15% had patrial disability while 10% had amputation. We have limited resources and there is no comprehensive care set up at PIMS at diabetic foot clinic. There is no referral system; patient follow up is not optimal. Since 2007, we have made some progress but the situation is not yet ideal. Soon we will have some diabetic footwear and there is a ray of hope for improvement, Prof. Jamal Zafar concluded.


Picture on left shows Dr. Zahid Miyan  presenting symposium memento to Prof. Jamil Ahmad while
on right the picture shows Prof. Jamil Ahmad presenting  mementoes to  Prof. Jamal Zafar from
PIMS and Prof. Bilal Bin Younis from Shalamar Medical College/Shalamar Hospital Lahore
during the BIDE symposium on Diabetic Foot.

Dr. Sobia Sabir from Lady Reading Hospital Peshawar was the next speaker who described the challenges they are facing as regards diabetic foot ulcers i.e. infections, off loading devices and Peripheral Artery Disease. Presence of a multidisciplinary team consisting of physician, surgeon, podiatrist, specialist nurse, orthopedist, radiologist, dietetician and diabetic educator, she said, is essential. She then talked about debridement of non viable tissue, wound dressing and use of antibiotics, pressure off loading, and management of PAD and management of glycaemic control.


She pointed out that the problem starts with higher blood glucose levels. Diabetes may not be diagnosed for quite some time. Lack of education and knowledge, poverty, fear, injury, trauma, getting bad news is some of the issues which need attention. We need a psychologist to convey the bad news. Patients do not take walking bare foot seriously. They have ischaemia, pain and neuropathy. One in seven patients develop diabetic foot ulcer and it is a major cause of death. One in every twelve ulcers lead to amputation. Almost 80% of amputations, Dr.Sobia said is preventable. About 25% of diabetic foot patients are admitted because of diabetic foot ulcers. Diabetic foot is the second major emergency seen during Hajj among patients with diabetes. Diabetic foot care facilities are now available at Lady Reading Hospital. We have injury prone feet because of incorrect foot wear. Quacks are also playing havoc because of the lack of awareness among the poor patients. Obesity, poor physician’s awareness, very little screening for PAD is other important issues. The prevalence of diabetes is reported to be 20% in Khyber PK. Endocrinology unit was established at Lady Reading Hospital in 1994. In 2013 a new unit was created to provide diabetic foot care services. In 2013 the number of diabetic foot patients was 8% which increased to 15% in 2014 and 20% in 2015. Now doctors as well as patients have become aware about the availability of this service at this center. More and more patients are being referred which has increased the number of diabetic foot ulcer cases over the years. We have twenty five people in the department which includes one surgeon, four diabetic foot care assistants, we have also put in place infection control measures, Dr. Sobia remarked.


Prof. Jamal Zafar from PIMS, Prof. Bilal Bin Younis from Shalamar Medical College Lahore, Dr. Abbas
Raza from Shaukat Khanum Memorial Cancer Hospital Lahore, Dr. Sobia Sabir from  
Lady Reading
Hospital Peshawar making presentations at Diabetic Foot Symposium organized by BIDE at
Karachi from August 21-23, 2015. On extreme right Prof. Zaman Sheikh and

Dr. Chaminda from Sri Lanka are chairing this session.

Dr. Abbas Raza from SKMT Lahore talked about Diabetic Foot, different faces of some problems relieving agony. He discussed in detail about neuropathy, Vasculopathy and opined that diabetic foot consultation requires about an hour for every patient. The prevalence of diabetic foot ulcers is about 10% and we need to do something before amputation. It is essential that we look at the feet of the patient with diabetes, abnormalities are there. Vascular disease is 30% more prevalent in diabetics. Vasculopathy is difficult to diagnose. Ankle pressure can be misleading. It can be best diagnosed by digital subtractions angiogram. He then talked about novel imaging techniques, tissue oxygenation in detail.


Continuing Dr. Abbas Raza said that diabetic neuropathy is most difficult to treat. Autonomic neuropathy accounted for 44% of the patient diagnosed during two years. He also referred to motor neuropathy, lab studies and said that once deformity is fixed, patient gets better. Almost 20% of diabetes mellitus patients will have some other cause of neuropathy. As soon as you fix it, the patients get better. Patient education, he stated, is extremely important. We must have adequate foot assessment in patients with diabetes and pick up high risk patients, send them to a podiatrist. Diabetic Foot, Dr.Abbas Raza opined is a neglected area and one cannot go hunting for diabetic foot centers. Replying to a question Dr. Abbas Raza said that 90% of the patients with diabetic foot do not come to me and they end up with the surgeon and most of the surgeons do amputations. He agreed that we need more diabetic foot clinics. Summing up the discussion Prof. Jamil Ahmad referred to the psychology of the physician. We must ensure to examine the foot of patients with diabetes which is extremely important, he remarked.

Prof. Bilal Bin Younis from Shalamar Hospital Lahore spoke about Charcot Foot and discussed its differentials as well as pathophysiology in detail.

Diabetic Foot Care in Sri Lanka

On last day of the symposium Dr. Chaminda Garusinghe from Sri Lanka was the first speaker and he talked about Diabetic Foot Care in Sri Lanka. The prevalence of diabetes in Colombo the capital of Sri Lanka, he said is about 18.6%. Thee are over one million patients with diabetes in Sri Lanka and 50% of them do not know they have diabetes. We have young population and high birth rate but now the fertility rate has reduced. Elderly population is increasing hence we will have more diabetes in the days to come. Lower limb amputation is most common.


They had 66 amputations and most of these patients were over fifty years of age. Type 2 diabetes is most common. Giving details of their study which included 638 patients with diabetes, he said that 11 of their patients had peripheral neuropathy, 37 had ulcers, and 17 had gangrene. Fifty two patients had below knee amputations, thirteen had above knee amputations which are most often done by the most junior member of the surgical team. High risk patients are advised to go off the field, give up farming and change the nature of their job. There are two diabetic foot clinics and a wound clinic. High risk patients are called every three months for follow up. We have no chiropodist and we also lack multidisciplinary team approach and no training programme for foot care. Lack of foot care off loading devices is other problems. We need an accredited foot care training programme and we also intend to start home dressing for diabetic foot patients and we are here to learn how it can be organized, he added. During the discussion, the importance of ensuring continuity of care and provision of domiciliary care was highlighted.


Prof. Abdul Basit presenting memento to Dr. Sobia Sabir and Dr. Chaminda,  a delegate from
Sri Lanka presenting memento to Dr. Musarrat Riaz during the BIDE symposium on
Diabetic Foot held at Karachi recently.

Dr. Darshini Karuppiah also from Sri Lanka was the next speaker who talked about Osteomyelitis: A medical or Surgical Problem, she said, is the fore foot in 90%of the cases. She then discussed the use of probe to bone test which has 90% sensitivity and specificity for diagnosis. Plain X-ray and even MRI are used for diagnosis of Osteomyelitis. For diagnosis bone biopsy is the gold standard. In pre antibiotic era, for management of diabetic foot, surgical procedures was the only option available. Howeve, now with the availability of most potent and effective antimicrobial agents, morbidity and mortality and even amputation in diabetic foot has decreased considerably. Staph Aureus is the most common pathogen found in diabetes. Antibiotic treatment may last from three weeks to three months depending on the severity of the infection. During surgery, one can reset the bone and avoid long residual disease. Previously antibiotics were used as an adjunct to surgical treatment but now studies have showed that antibiotics alone also give good results. Conservative treatment has many advantages like less hospital cost but risk of ulcer is there. Surgical intervention has advantages as well as disadvantages and one has to take a decision based on the healthcare set up in the country. She was of the view that 63-83% of diabetic foot patients can be treated successfully with antibiotics alone. However, 13-28% may worsen and these are the patients which may require surgery early. Studies have showed that there was no difference in wound healing in patients treated with antibiotics and those treated with surgery. However, she emphasized that proper selection of patients was important for antibiotic treatment and those who will need early surgery. Patients with bone necrosis, non ambulatory and those in high risk should be referred for surgery. In patients with high clinical suspicion bone specimen should be sent for culture and sensitivity. At present both medical and surgical treatment has acceptable outcome.

Commenting on the presentation Prof Abdul Basit said that they intend to start a multicenter study on diagnosis of Osteomyelitis and Sri Lankan friends are most welcome to join us in this study. Infection rate in UK is very low as compared to our high infection rate. Almost 90% of our patients do need some surgical help and we need a protocol which should define the criteria for medical and surgical treatment.


Dr. Zahid Miyan from BIDE made a presentation on management of diabetic foot infections in Pakistan. He pointed out that every year about four million people with diabetic foot develop ulcers and we used to have a very high amputation rate. Almost 85% of all amputations due to ulcers are preventable. Studies have showed that every twenty second a lower limb is lost somewhere in the world. After three years, 50% of these patients with amputation die and after five years this figures increased to 70%. Mortality rate from amputations is higher than from malignancies and cost of treatment of these patients is also very high. Almost 50% of the diabetic foot ulcer patients suffer from depression.

Continuing Dr. Zahid Miyan said that almost 50% of diabetic foot ulcers are clinically infected at the time of presentation and 85% of amputations start with diabetic foot ulcers. Recovery of diabetic foot ulcer is very important to save the lower limb amputation. Speaking about essential steps for hospitalized patients, in patient service Dr.Zahid Miyan mentioned palpation of vessel, tissue and bone culture. Hospital must have these facilities. There should be a team for immediate response treating life threatening limb infections. Hospital should have a good antibiotic protocol, post operative management plan, education plan for the patient. Talking about the diabetic foot infection classifications he said that Grade one are those which are not infected. Grade two which is mild includes patients with redness or cellulites and ulcer size less than 2cm. Grade three includes those patients who have moderate infection i.e. deep tissue infection up to bone, abscess and necrosis. Those patients with bone necrosis, discharging pus, bagful of pus, inflammation come in grade four and this is the most serious foot infection.

 

Prof. Abdul Basit and Dr. Zahid Miyan presenting mementoes to delegates
from Sri Lanka Dr. Chaminda,
Dr. Darishini and others.

At BIDE we have patients 60% of whom suffer form moderate infection while 37% account for severe infection. Most patients come with most severe infection and 4% have moderate infection. Patients with moderate to serve infection needs hospitalization. All these patients should receive in-patient care unless they cannot afford hospitalization. Moderate to severe infections have high hospitalization and amputations. All these patients should have routine blood tests, HbA1c and fasting lipid profile. About 38% of their patients had no fever, 31% had normal TLC count. He reiterated that all patients will not come with fever, nausea, vomiting. All patients should have deep tissue culture, bone culture and if you suspect Osteomyelitis ask for culture and sensitivity of bone specimen. Plain X-ray is the most cost effective imaging modality which gives lot of information of foot. Some of these patients, Dr. Zahid Miyan said, may need urgent referral. Almost 76% of these patients have gram negative bacteria in infections. Almost 34% of their patients were MDR, 26.7% were MRSA where economically priced drugs won’t work. The prevalence of MDR in the world is 5% as compared to 34% in Pakistan. One must evaluate the danger sign as some of these patients might need urgent interventions. Multidisciplinary team approach gives best results. Education of the patient about foot care is important to prevent ulcers. We at BIDE, Dr. Zahid Miyan said, are training physicians in foot infection surgery. We need to train physicians to cut down the cost and save limbs. With good care we have reduced our amputation rate in diabetic foot ulcer cases by 75%. Subcutaneous gas on radiograph is an emergency. Bullae, skin necrosis, necrosis soft tissue infections are also an emergency. Initial therapy should be parenteral for moderate to severe infections. Proper selection of antimicrobial agents is also important. Duration of therapy will depend on the severity of infection. Optimal time is still not clear. Some patients may require prolonged antibiotic therapy. To achieve metabolic control, antibiotics alone won’t work; it must be supplemented with patient education. To prevent amputation, education of the patient, the family and healthcare professionals is important, he added.


Prof. Jamal Zafar from PIMS then presented highlights from their original study of Radionuclide scintigraphy in the management of diabetic foot infections. For diagnosis of Osteomyelitis X-ray, CT and MRI are all used but Radio Nuclide imaging is the most cost effective modality. Forty three patients were enrolled in this study which included 32 male and 11 female. Their HbA1c was 9.2. Bone infection was confirmed on biopsy. Twenty two patients had confirmed Osteomyelitis. This radio nuclide imaging test used 99nTc. It had 100% sensitivity and 95.2% specificity. The study conclusions were that Radio Nuclide imaging is a highly sensitive and specific diagnostic test which was also quite economical.