Exercise is the most cost effective therapy for Peripheral Artery Disease and Amputation is an epidemic which must be stopped-Dr. Khusro Niazi

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Diabetic Foot symposium by PWGDF and BIDE

Exercise is the most cost effective therapy for
Peripheral Artery Disease and Amputation is an
epidemic which must be stopped-Dr. Khusro Niazi

We must abridge the gap between cardiologists & diabetologists
and manage diabetic foot with a multidisciplinary team-Prof. Abdul Basit

KARACHI: Supervised exercise is the most cost effective therapy for the treatment of peripheral artery disease and venous disease. Amputation is an epidemic which must be stopped. This was stated by Dr. Khusro Niazi. He was making a presentation on Vascular Interventions with special reference to treatment of peripheral artery disease at a symposium on Diabetic Foot organized by Pakistan Working Group on Diabetic Foot in collaboration with Baqai Institute of Diabetes and Endocrinology(BIDE) on September 28-29th 2013. It was formally inaugurated on September 28th while on September 29th the first session was chaired by Prof. Abdul Basit Director BIDE and Dr.Basheer Haneef Chief of Cardiology at Taba Heart Institute, Karachi.

Dr. Shamad Shera along with Prof. Basit, Prof. Jamil, Dr. Zahid Miyan,
Dr. Qamar and other chairing a session during the diabetic foot symposium.

Continuing Dr.Khusro Niazi further stated that revascularization must be ensured. Every effort should be made to save the leg thrugh revascularization which has a good psychological impact. If need be patient can go for surgical therapy later. Speaking about endovascular procedures vs surgery he said that due to technological advances one should go for cost saving approach and reduced morbidity and mortality. Save the leg. Endovascular procedures are less complicated as compared to surgery. These patients suffer from cramps at night; have lipo pigmentation on leg which is a sign of insufficiency which is very common. Many patients do not get diagnosed in time. It is also more common in coronary artery disease. The leg is swollen. According to studies 5% of US population is suffering from leg vein abnormality and by the age of sixty years, two third of the population will have this disease. Hereditary is the main cause. All the patients with advancing age, female sex, obesity, pregnancy are likely to suffer from this disease. He then showed some venous anatomy slides depicting venous insufficiency, venous hypertension, and spectrum of varicose vein. Leg pain, aching, leg cramps and itching were mentioned as some of the symptoms. He also talked about Doppler test technique for checking venous insufficiency.

Pigmentation in these patients, Dr.Khusro Niazi said will never go away but wound should not come back. Surgical treatment is now considered obsolete as endovascular ablation is the treatment of choice. He also briefly talked about laser therapy and said that it was an office procedure. Once you get trained to do it, it is OK. One must avoid DVT which can be fatal and one must remember that there are some risks involved. It is not a simple procedure. Speaking about advances in medical management Dr.Khusro Niazi said that efforts are under way to develop valves which may become more effective. At present compressing stocking is good but there is no drug therapy available. Blood is coming backward and since valves are not working, it creates problems. He suggested that treating physicians should advise the patients to keep the legs elevated.
Commenting on the presentation Prof. Abdul Basit remarked that we must abridge the gap between cardiologists and diabetologists. We intend to form a National Foot Club wherein we can manage the diabetic foot together in a multidisciplinary team.
Dr. Tahir Sagheer was the next speaker who talked about early intervention in peripheral vascular disease at NICVD. He showed the retrograde access and also talked about the goals of therapy. After removing the tissue from inside the artery, a balloon is inserted to reconstruct the artery. He was of the view that peripheral angioplasty is good, it is complimentary to surgery but in future we have to focus on restenosis.

Consultants and staff of Baqai Institute of Diabetology and Endocrinology (BIDE) photographed along
with Prof. F.U. Baqai Chancellor and Prof. Mrs. Zahida Baqai Vice Chancellor, Prof. A. Basit
Director BIDE during the concluding session of the Diabetic Foot Symposium
organized by PWGDF/BIDE recently.

Participating in the discussion Dr.  Basheer Haneef said that one should avoid stenting at lower level but stents can be used above knee. We have a lot to offer for arterial diseases as regards medical therapy. Exercise is of course the best option. Critical ischaemia in diabetic foot is an indication for below knee intervention. Restenosis is very high in lower limb hence avoid it and try to control all the risk factors. We need to work together to prevent and treat the non- communicable diseases by working together, he added.

Prof. Abdul Basit was the next speaker who talked about past, present and future of diabetic foot in Pakistan. He pointed out that morbidity of diabetic foot is very high and results in high mortality. According to estimates there are 0.4 million foot ulcers in Pakistan. It was in 1996 that we started the first Diabetic Foot clinic with eight hours OPD with twenty four hour phone service. He was of the view that diabetic foot emergency service should be available round the clock. At that time we had a 27% amputation rate. It is important that home dressing service is provided to these diabetic foot ulcer patients because daily dressing is required. Consultation with orthopaedic surgeon is too costly and they are also not easily available. Hence, we must train foot surgeons and the diabetic foot patients will get the best treatment. Now in 2008 we have an amputation which is equal to many countries. We have low income but treatment cost of diabetic foot is very high.
We teach about the wound debridement. We have established one hundred fifteen diabetic foot care clinics all over the country and they have managed one lac seventy five thousand patients in three years. There are about thirty three thousand patients who are at risk and our amputation has now reduced from 12% to 6% in the last three years. The economic burden of diabetic foot is very high.
Speaking about the future programme Prof. Basit said that a National Diabetic Foot Club will be established. Twelve diabetic centers in teaching hospitals all over Pakistan are being interlinked with each other. Our major emphasis will be on prevention of foot ulcer. He laid emphasis that physicians treating diabetics must examine the foot of the patients. Use of simple foot wear and cost effective off loading devices will be promoted. We will also promote proper foot wear for diabetics, custom made shoes. We will urge the world community to benefit from the Asian experience and involve the multiple stake holders. We will advocate multidisciplinary approach to manage diabetic foot and eventually we plan to form a Peripheral Vascular Disease Society.

Prof. A.H. Amir from Hayatabad Medical Complex talked about diabetic foot infections in Khyber PK province. Foot ulcers, he stated, is the most distressing complication of diabetic foot in Pakistan. Almost 85% of amputations present with foot ulcers. Infections lead to sepsis and then amputation. Early treatment is effective and if diagnosed in time they can be managed in the OPD which is an ideal situation but it does not happen. Patients continue using herbal medications and alternate medications and when find no relieve eventually come to us when it is too late. Many patients come from Afghanistan as well. He suggested good washing of the wound, taking the swab and doing culture sensitivity test to find an appropriate antimicrobial agent since they have already been taking some antibiotics. Almost 95% of the patients they examined were suffering from Type two diabetes and the duration of disease was more than ten years. He showed data of 114 patients of which 52% were male. Mean duration of treatment was fifty two days which was very expensive. We need to treat these patients early. MRSA is a serious infection and we see it quite often, he added.
During the discussion it was stated that at times one might have to go for deep swab, tissue swab and even bone culture to see what type of infection it is and then treat it properly. In case of septic wounds and treatment after hospitalization the cost is very high. They had 6% major amputations. His conclusions were that one should try to salvage the limb as far as possible. If you will send the patient to an orthopaedic surgeon, amputation will be the result in most cases.
Prof. Bilal Bin Yusuf from Shalimar Medical and Dental College gave details of the work being done at SIDER as regards diabetic food disease. The prevalence of foot ulcers, he said, was about 10% and chronic complications account for about 7%. He laid emphasis on proper evaluation of the patient i.e. medical, vascular, neuropathic evaluation. Examination of foot in diabetics is extremely important. Studies have shown that only 14% of doctors ask the patient to take off the shoe and examine their feet. We need to recognize the foot deformities early. The prevalence of ulcers in their patients was between 4.-16 percent.
Prof. Jamal Zafar from Pakistan Institute of Medical Sciences in his presentation narrated the problems he and his colleagues have to face while working in a public sector healthcare facility. Data collection is a major problem. It was in March 2009 that Diabetic Foot Clinic was established at PIMS where we had four to five beds reserved for diabetic foot in a 48-bed ward. We had a very good dresser and so far we must have examined about two thousand diabetic foot patients. We have observed that there is 30% relapse. Mostly we see new cases. We have one diabetic educator but in a public hospital, the place of clinic can be changed at any time. No surgeon is prepared to work in this area. We have financial constraints, non-availability of insulin, drugs, postgraduates and doctors are other problems that we face. We have no support from the vascular surgeon. Off loading devices are not available. Venous insufficiency is a problem and similarly we also face the problem of non-availability of foot devices.
Dr. Samad Shera who was chairing this session in his remarks emphasized the importance of examining the foot of diabetics regularly. We do see neuropathy but not ulcers. In the West in old people homes, foot ulcers are very high. One must start antibiotics if ulcer is suspected and refer the patient to a diabetic center, he added.
Prof. Jamal Zafar along with Dr. Najmul Islam chaired the next session. Dr. Ittat Hussain Zaidi talked about systemic management of diabetic foot. He emphasized on preserving the limb functions and limb salvaging. Pre ulcer coetaneous pathology should be taught to the patients. One must ensure adequate debridement. Cyst should always be dried. He also talked about reconstructive surgery in diabetics i.e. mid tarsal arthodesis, limb lengthening, deformity correction, use and application of external fixators. Plastic surgery is also involved in diabetic foot. Surgeon, he stated, must know when to operate and when not to.

Prof. Yakoob Ahmedani from BIDE was the last speaker in this session. His presentation was on Put Feet First and prevents amputation. He pointed out that about 15% of patients with diabetes develop foot ulcers and 5-15% of them will need amputation. Almost 70% of lower limb amputations are in diabetics and most common cause is foot ulcers. Morbidity in these patients rises from, 30% in first year to 50% and 70% in the second and third year. It has an emotional and social impact and quality of life is low in these patients. Many patients are not aware of their wound. Almost 12% of foot ulcers are caused by healthcare professionals. Male, people with long duration of diabetes, prior history of diabetes, less educated are more prone to suffer from diabetic foot. We at BIDE, he said, have treated about four thousand diabetic foot ulcers. He also talked about preventive foot care practices. Most of these patients who suffer from foot ulcers are not properly controlled but have poor glycaemic control. He laid emphasis on controlling the risk factors for PAD, tight blood pressure control, lipid control, stopping smoking, starting ant platelet therapy and use of appropriate antibiotics for infections. He was of the view that with proper management even worse ulcers do heal. If off loading devices are not used, foot ulcers won’t heal. Non healing ulcers must be given off loading devices and they will heal. We need to promote cost effective off loading devices.
Surgical management consists of revascularization. Nutritional deficiency deteriorates the diabetic foot ulcers. Physiotherapy and rehabilitation services are very effective and useful. Out of 3731 diabetic foot ulcers that we saw at BIDE, almost 50% recovered fully. Toe amputation accounted for 5.8%, above knee amputation was 0.18% while major amputation was in 1.3%. Our overall amputation rate reduces from 27.5% to 8.4%, Prof. Ahmedani remarked.
Dr. Zahid Miyan, General Secretary of Pakistan Working Group on Diabetic Foot said that in diabetes, involvement of nerves cause loss of sensations in feet and people with diabetes do not feel the pain of injury, cut or a prick as result of which ulcer develops in the foot. People with diabetes should therefore examine their feet daily and look for a breech of skin or any injury.

Workshops

Apart from state of the art lectures the main highlight of the symposium was hands on workshops regarding screening of feet at risk for diabetic foot ulcer, use of proper antibiotics in foot ulcer, chiropody techniques, preventive foot care practices as well as dietary modifications needed for diabetic foot patients.
Participants were given the opportunity to assess real patients and practical aspects of foot care practices were demonstrated to the doctors and allied health care professionals. Different types of shoes were also shown and its advantages and disadvantages were discussed in detail. Similarly use of conversation maps as training tool for diabetic foot patients was also demonstrated during the workshops. The aim of these workshops was to bridge the gap between theoretical and practical application of knowledge regarding diabetic foot. These workshops were highly appreciated by the participants.
Prof. F.U Baqai in his concluding remarks applauded the efforts of BIDE in providing comprehensive diabetes care to patients and their families. He was of the opinion that we should all question ourselves as to what we have given to our homeland? Prof. Zahida Baqai vice chancellor Baqai University presented the shields.

Concluding Session

In the concluding session regional chapters of PWGDF with their regional heads were approved which are as under:

1) Federal Capital- Prof Jamal Zafar
2) KPK- DR. Sobia Sabir
3) Baluchistan- Dr. Irshad Khoso
4) Northern Punjab- Prof. Bilal Bin Younes
5) Southern Punjab- Prof. Qazi Masroor
6) AJK- Dr. Iqbal Waheed

It was also decided that PWGDF should be registered and have a proper constitution and continue holding seminars, symposia and conferences to improve diabetic foot care. A national symposium on diabetic foot will be organized at Islamabad in Mid-October in 2014 while an international diabetic foot symposium will be organized in Karachi in 2015.
PWGDF would concentrate on training of medical professionals, particularly training of podiatrists. Efforts would be made to establish a School of Podiatry at Islamabad. It has been agreed that Prof Jamal Zafar would lead and coordinate these efforts. Prevention of foot ulcers is more cost & time effective and better suits our resource constraint society as compared to treatment of foot ulcers. PWGDF would strenuously promote prevention of foot ulcers, across Pakistan.
The meeting also felt that awareness and foot care education is the key to the prevention and management of foot ulcers. PWGDF would concentrate on awareness strategies, would develop its own educational literature and distribute it across the country.
There was agreement on the concept of “Diabetic Foot Club”. It provides a good opportunity for sharing of experience and mutual learning. All colleagues were encouraged to constitute “Diabetic Foot Club” in all the cities of Pakistan and hold it’s regular meetings, preferably, once a fortnight.
PWGDF also recommended the following strategies for the management of diabetic foot, with a particular consideration of cost and affordability of our population.

• Multidisciplinary team approach
• Good glycaemic control
• Control of risk factors for PAD i.e. tight blood pressure control, Improving lipid profile, Cessation of smoking, Anti-platelet therapy.
• Simple and cost effective antibiotics for control of infection
• Wound debridement- debride to bleed
• Simple and cost effective dressings with normal saline, Pyodine and Eusol No specialized dressings
• No topical antibiotic
• Simple and locally made, cost effective offloading devices i.e. modified foot wear-Healing sandals, Bohler Iron, Modified Plaster of Paris Cast, Scotch Cast boot, Modified Rocker Bottom.