Use broad spectrum antibiotics in high doses for longer duration for treatment of foot ulcers-Prof. Basit


Diabetic Foot Symposium

Use broad spectrum antibiotics in high
doses for longer duration for treatment
of foot ulcers - Prof. Basit

We should train physicians in Diabetic Foot Surgery
to make it cost effective as podiatrists are too expensive

KARACHI: Prof. Abdul Basit, Executive Director of Baqai Institute of Diabetes and Endocrinology (BIDE) who is also chairperson of Pakistan Working Group on Diabetic Foot gave a plenary talk at the Diabetic Foot Symposium held here recently. This session was jointly chaired by Dr. A. Samad Shera and Prof. Jamil Ahmad Dean Faculty of Medicine at Baqai Medical University. The topic of his presentation was “History of Diabetic Foot Care in Pakistan: From Stone Age to Space” wherein he traced the history of diabetic foot care in Pakistan during the last eighteen years.

Pakistan, Prof. Basit said has about 7.1 million people with diabetes and the number of diabetic foot is estimated to be 0.4 million. To begin with we had no podiatrist, no diabetes educator. These patients used to shuttle between physicians, surgeons and orthopaedic surgeons. There used to be no Diabetic Foot Care Assistants. Doctors used to look at the ulcer and treat it with manual examination. Dressings used were Polyfax and the target used to be glucose only. Narrow spectrum antimicrobial agents were used and that too for five days. Little did the physicians realize that diabetic foot needs a long term treatment? All energies used to be spent on preventing death. Patients were asked to put pressure on foot ulcer so that the pus should come out. It was in 1996 that we started the first Diabetic Foot Clinic in Pakistan. Doctors were trained. We also trained Diabetic Foot Care Assistants because podiatrist was too expensive for us.

Prof. Ejaz Ahmad Vohra from Ziauddin Medical University along with
Prof. Zaman Sheikh from Sir Syed Medical College and Prof. Jamal Zafar
from PIMS chairing one of the scientific sessions during the
Diabetic Foot Symposium held at Karachi recently.

Pakistan Working Group on Diabetic Foot (PWGDF) was established in 2006. The doctors were told to look at the foot not only at the ulcer. They were asked to aim at metabolic control, blood pressure control, look at lipid profile, ask for cessation of smoking, start anti platelet therapy and also start Insulin from Day-I. We started using low cost dressing with Pyodine solution and Eusol solution. No specialized dressing was used as they are quite expensive. We started using broad spectrum antibiotics in high doses for longer duration. After identification, we aimed at removal of infection. Bed rest was suggested to the patient and they were also advised to use low cost off loading devices. The result was that amputation rate at BIDE reduced by 75%. With the advances in technology, we have been able to establish one hundred fifteen diabetic foot clinics in Pakistan and there has been an overall 50% reduction in amputation rate. We have so far trained 199 teams in diabetic foot care. We organized basic course in Diabetic Foot Care and foot examination. Prof. Basit suggested that we need to train physicians in Diabetic Foot surgery to make it cost effective. Our country cannot afford podiatrists as they are too expensive. What are Podiatrists, in fact they are leg surgeons, he remarked.

Continuing Prof. Basit said that so far BIDE has trained one hundred three Diabetic Foot Care Assistants. I am a member of the 80-Member Core group which is preparing the guidelines on diabetic foot care. We suggest that the physicians should look at the patient as a whole and not foot only. They must have a holistic approach. In collaboration with NICVD, we have started the Peripheral Artery Disease (PAD) Clinic. We are delivering integrated care to prevent diabetic foot complications. We now use collagen, silver dressing which are good for infected wounds. He also talked about Charcot arthropathy and the specialized off loading devices. Air cast boots are now available but they are quite expensive. Our aim should be to prevent the ulcer in the first place instead of treating ulcers. Patients are given foot care advice to prevent infections. We aim to establish seventeen hundred diabetic foot clinics in Pakistan by the Year 2016. We have formed an Advisory Board for Diabetes Care and hope to prepare guidelines useful and practical in the local environment. We have already published Guidelines on Self Monitoring of Blood Glucose. We have included diabetic foot care in primary care, secondary care and tertiary care level. We intend to start Masters Programme in Podiatry who will be trained in teaching hospitals. We also plan to organize an international Diabetic foot Symposium in Pakistan in 2015. We are looking at the community. BIDE has been included in the International PAD registry.

Talking about Foot Care enhancers Prof. Basit said that VAC and Maggots are the new developments in the treatment of diabetic foot ulcers. They will also come to Pakistan soon. He also referred to the stem cell therapy while leuco Patel is also available. Then we have specialized dressings. Corrective surgery is being performed to correct the foot deformities. We also plan to produce cost effective foot wear. He also referred to Insole for foot wear. Insole development will be used to produce foot wear, he added.

During the discussion when one of the participants said that he was using the maggots already, Dr. Zahid Miyan remarked that Maggots therapy is not only difficult but one also has to use sterilized maggots to get good results. They are quite expensive at present. When the participant said that he was using the maggots of the patient and also using plain water to wash the wound instead of using Pyodine, Prof. Basit remarked that if you have published your results, do let us know or we can have a comparative trial and in an era of evidence based medicine, we should come out with solid evidence about what we say. Dr. Samad Shera commended the contributions made by Prof. Basit in the field of Diabetic Foot and said that while examining patient with diabetes, we should start from the foot and then go upward.
Earlier Mr. Bates a podiatrist from Texas made a brief presentation on the role of podiatry through video link. He talked about sensory neuropathy and said that the causative factors could be alcohol, nutritional deficiency, leprosy or diabetes which can all cause neuropathies. He then showed some foot ulcer slides.

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