Effective intervention strategies and collaboration at all level are needed - Prof. Kashif Shafiq



Diabetes FootCon 2022 Proceedings-I
Effective intervention strategies
and collaboration at all level are
needed - Prof. Kashif Shafiq
HbAIc is not a diagnostic test for diabetes
as s we have lot of people with
anaemia - Prof. Abdul Basit

KARACHI: Prof. Feroz Memon, Prof. Iftikhar and Dr. Hakeem Jokhio jointly chaired the first session during the Diabetes Foot Conference 2022 held here from October 14-16th 2022. Prof. Kashif Shafiq from DUHS was the first speaker who made a presentation on “Diabetes- A real Public Health Problem.” He discussed in detail the importance of life style modifications and dietary changes in management of diabetes. Almost 75% of people with diabetes, he said, live in low and middle income countries. All the estimates about its prevalence have been underestimates.

Prof. Feroz Memon from Indus Medical Colelge alongwith others chairing one of the sessions during NADEP’s Diabetes FootCon 2022.

Reviewing literature and IDF announcements from time to time, he said, it is estimated that by 2045, there will be seven hundred eighty million people with diabetes in the world. Almost 35.5% deaths of under sixty years of age are due to diabetes. We spend too little on treatment of diabetes. In Pakistan it is estimated that a patient with diabetes spends six to seven thousand rupees per month on treatment Cost of treatment of diabetic foot ulcer is very high. Hence it is essential that we opt for routine screening programme for diabetes in general population as survival matters a lot. There is a need to intensify awareness programmes about diabetes and pre-diabetes. Diabetes, he further stated, was a real public health emergency for which we need effective intervention strategies for which collaboration at all levels was essential.

Prof. Abdul Basit Director BIDE highlighted the Diabetes Prevention Programme in Pakistan. It lays emphasis on prevention. Type-2 diabetes, he said, affects everyone above fifteen years of age. All known risk factors are multiplying. Referring to a study on Metabolic Syndrome in Children by Dr. Zafar Hameed he said, it showed that 8.9% of all children between the ages of 8-10 years were overweight. 4.3% were suffering from obesity. Low Birth Weight babies are pre disposed to develop diabetes. Life style modification and metformin reduces the risk by 71-76%. Dr. Musarrat Riaz from BIDE has developed a risk score calculator and it just takes thirty seconds to calculate one’s risk score. HbAIc Prof. Basit sated was not a diagnostic test for diabetes as we have lot of people with anaemia. His advice to the patients was to help themselves by adopting healthy lifestyle. Over the years now the concept of public health, he said, has changed and we need to do some preventive work. We have been trying to get tax enhanced on sugary drinks but the vested interests are too powerful. We need to start training of nurses, midwives and lady health workers so that all healthcare workers could join to create awareness about this disease and help in its management.

Dr. Saiful Haque, Dr.Zahid Miyan alongwith others charring one of the scientific sessions during NADEP’s Diabetes FootCon 2022 held at Karachi recently.

Dr. Zahid Miyan Chairman of the organizing committee of the conference was the next speaker who talked about Diabetic Foot in Pakistan. He pointed out that there are over three million people who suffer from diabetic foot in Paksitan and it is an under estimation since many people do not come to the diabetic clinics. Simple infection leads to amputation. Mortality from diabetes is worse than cancer but it does not get the same attention and importance. Direct and indirect cost of treatment of diabetic foot has increased too much. It results in not only absenteeism from work but also loss of lives. He also referred to lack of education among patients and lack of available facilities. There is not much money in treatment of diabetic foot, hence not many doctors are interested in this specialty. He also disclosed that there are only eight countries in the world where clinical podiatry facilities are available. Many countries like Pakistan cannot afford qualified podiatrist’s hence Prof. Basit came up with the idea of training Diabetic Foot Care Assistants which was appreciated by Prof.Carl Baker the former chairman of International Working Group on Diabetic Foot. Then it was decided that some guidelines should be developed but when it was accomplished, not many people are using these guidelines.

Prof. Tahir Hussain alongwith Prof. Jamil Ahmed chairing one of the scientific sessions during NADEP’s Diabetes FootCon 2022 held at Karachi.

He then talked about wound debridement and pointed out that delay in referral is the worst enemy. Delay in referral in diabetic foot has its impact on prognosis. Delayed debridement can lead to amputation. It all starts with a small abscess, inadequate wound healing and delayed referral leads to gangrene. Time to referral Dr.Zahid Miyan opined was key to avoid amputation. Time is tissue in diabetic foot. Death from diabetic foot is increasing the world over, complications are increasing. Hence Fast Track Pathway has been developed to manage diabetes. This programme is being started in Pakistan. We hope it will achieve 50% reduction in minor amputation, 40% reduction in major amputations and almost 80% reduction in hospitalization and it will increase survival. We have also brought to Pakistan the D. Foot International programme through Baqai Medical University. The aim is to reduce avoidable amputations. We are aiming at evidence based standardized diabetic foot care. For this we need trained people. We aim to establish three hundred diabetic foot clinics in Pakistan in three years.

We have developed a Mobile App for this to collect data. He discussed in detail the concept of this project, training of the team for data collection. It consists of a proper referral system from primary care to secondary care and tertiary care. It offers interlinked collaboration for the doctors and it will be ensured that the patient referred from primary care physicians will come back to them and they will not lose the patient. So far eighty one such facilities have been owned by the pharma industry who are helping us. It includes forty eight in Sindh province, twenty five in Punjab, five in KPK and three in Baluchistan province. With the help of our corporate partners, we are hopeful that we will achieve the desired results, he remarked.

Prof. Jamil Ahmad alongwith Prof. Karim Kamaruddin chairing one of the sessions during NADEP’s Diabetes FootCon 2022.

Prof. Feroze Memon in his concluding remarks said that for us cardiologists time is muscle. We need to do whatever we can to ensure that people with diabetes do not meet with premature death. Dr. Jokhio emphasized on creating awareness about diabetes, starting awareness programmes in schools. It was also emphasized that in school curriculum healthcare subjects should be included. Prof. Iftikhar said that despite all the work being done, if we are not yet achieving the results, we need to look into it.

Management of chronic venous insufficiency

Ms Catherine Steer from South Africa discussed management of chronic venous insufficiency. This Satellite symposia was sponsored by AGP pharmaceuticals. She discussed in detail the edema, venous issues, ulcers and described her experience of looking at legs of patient’s in South Africa with reflux, obstruction or combination of both. These patients are suffering from hypertension but most often have no diabetes. They suffer from lower limb venous insufficiency which can be caused by venous disease or venous insufficiency. The objective is to encourage more blood flow to the heart. She then referred to high venous pressure, inflammation, hemodynamic factors, and endothelial dysfunction. Prevention and treatment are added parameters. She also talked about wound bed preparation, diagnosis needs to be made to continue in prevention. Of vascular changes. Efforts needs to be made to prevent complications and treatment depends on severity of disease. Speaking about the grade of clinical signs she mentioned Co, C6 and C3 edema. Disease progresses from Co to C6. More than two third of population is affected by chronic venous insufficiency. Overweight and pregnancy also leads to venous insufficiency.

Management strategies include life style modifications, weight control, regular exercise and avoiding prolonged standing. Compression is effective in 20-33%, Veno active drugs are also found to be quite safe and effective. Symptoms are high in people over the age of fifty years and females suffer the most. Over weight and pregnancy leads to venous insufficiency. Use of Veno active drugs are the first choice in the management while low grade compression is the second choice and Life style modifications remains the third choice in its management. She then highlighted the safety and efficacy of Doxium and said it manages the integration of vascular system. Pain and heaviness are reduced. It also improves CVI symptoms pain, heaviness improves, leads to increased flow and decreased obstruction is noted. Reduction in edema is noticed after twelve weeks of treatment. It also minimizes the risk of DVT, suffering from cardiovascular disease and results in improvement in quality of life .It increases healing rate, reduces inflammation but she cautioned that still we have a long way to go. Venous insufficiency patients are dependent on their lower limbs.

Responding to a question Ms Catherine Steer said that uncontrolled diabetes was not a contraindication for these of this drug. It was also pointed out that venous component in these patients should not be ignored otherwise it will be difficult to manage ulcers. Their early referral to specialists will be helpful. One can also use this drug to control edema before planning surgery.

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