Monday, March 31, 2008

Foot care on the go

Foot care on the go

Pair of Richmond nurses offer medical treatment for your ailing feet, right in your home

Philip Raphael, Staff Reporter

Got a problem with your heart, make an appointment to see a heart specialist. Need some help with a sore back, go to a chiropractor.

Experiencing some nagging problems with your poor old feet?

Well, you'll deal with that yourself, when you get around to it, right?

That's the scenario played out by many people who give their feet the brush off instead of getting proper care.

But thanks to a new service, professional medical attention to those painful callouses, in-grown toenails, or more serious problems like poor circulation and feeling due to diabetes, can walk right through your front door because a pair of Richmond nurses are offering in-home foot treatments.

And it is starting to catch on, especially since waits to see a foot specialist (podiatrist) can be as long as eight weeks, and a foot care nurse like Michelle Jackson or Shamim Murji can be on your doorstep literally the next day.

Started in September, Jackson's M.J. Footcare, and Murji's Shmamim's Foot Care Clinic provide professional treatment and advice that goes beyond just keeping a pair of feet looking their best.

"It's not about pedicures," explains Jackson, who has been a registered nurse since 1965, and has spent the last seven years working with patients at Minoru Extended Care facility. "It's about proper care for your feet, which a lot of people tend to overlook."

"For some reason or another, people don't seem to take the extra effort to take care of their feet," adds Murji. "For some of our older clients, perhaps it's a question of mobility...Now, we can come out right to their homes."

For Jackson, starting the service was a way of charting a new career path. Knowing that her position was being phased out and replaced by staff with licenced practical nurse qualifications, Jackson decided to seek another line of work that would take her extensive medical experience, and work with the elderly, into account.

And she found it when she came across the Foot Care Course offered by the Victorian Order of Nurses, a four-day program that teaches how to assess a patient's condition and recognize certain problems.

"We see some pretty horrible things out there because people have spent a good part of their lives wearing shoes that are probably too small for them, or living with things like callouses, corns, or simply haven't had their toenails trimmed properly in quite a long time," Jackson says. "Many of the conditions we find people in could have been prevented if they had looked after their feet properly at the beginning."

Tools of the trade include special burrs, and even a hand-held power grinder like a Dremel tool fitted with a special foot care disc, to help quickly and easily remove built up layers of skin.

"Some clients I see have callouses that are half an inch thick, and with the special training we have, a foot nurse can take that down gradually," she explains.

In more serious conditions, like those brought on by diabetes, prompt medical attention from a foot care nurse can head off potentially dire consequences.

Jackson says when diabetes patients lose proper circulation and feeling in their feet, even slight foot discomfort due to ill-fitting shoes, or even socks, can create dangers.

"Damage can be done sometimes just by wearing the wrong type of shoes, or even socks with seams that put pressure on parts of their feet."

While they are prevented from any type of invasive procedures, Jackson and Murji said they can tell clients what problems to look for that may require the hand of a specialist.

"We want the (clients) to be well-educated on the health of their feet," Murji says.

Aside from the hands-on treatment during their home visits, Jackson and Murji can also help customers dispel some foot care fallacies, such as putting moisturizing cream between their toes, which is a big "no-no," Jackson says, because it can provide the perfect habitat nurture and spread harmful bacteria.

One of the most common conditions they see is a fungal infection that can get under the nail bed of the toe and discolour the nail. Proper foot cleansing techniques to inhibit the fungus spread are provided, and, "We can teach them to treat themselves by making a solution of water and either Dettol or Pine-Sol, soaking a rag in it, and then placing the rag in their shoes overnight to help kill off any further fungus problems," Jackson says.

The treatments are not covered by B.C.'s Medical Services Plan, and cost clients $35 for the initial visit which includes getting a complete medical history. Subsequent sessions are $30 each.

"You can't even get a plumber come out to your house for that," Jackson quips.

So far, the clients span most age groups and walks of life.

"What we're finding is that people don't know that this type of service exists. But when they do, they are very thankful," Jackson says.

The trend for foot treatment specialists is more commonplace in Victoria where a larger retirement age population has given rise to as many as 30 full-time foot care nurses in that city. In the Lower Mainland, White Rock, with its large retirement age base, has spawned a small group of foot care nurses with whom Jackson and Murji hope to strike an informal alliance.

But the ultimate plan is to establish a stand alone foot clinic where clients could visit on a regular basis.

Until then, Jackson said she will work on the goal one foot at a time.

nFor more information on foot care, call M.J. Foot Care at 604-340-3916 or Shamim's Foot Care Clinic at 604-218-4220.

Wednesday, March 26, 2008

NEFCA 17th Annual Footcare Conference

“Step into the Future” Conference Registration Form

April 11 & 12, 2008

Days Inn Kingston Hotel & Convention Centre

33 Benson St., Kingston, ON K7K 5W2

Phone (613) 546-3661 Fax (613) 544-4126

Friday Registration @ 4:00 pm – Saturday Registration @ 7:30 am

Dates

Member

Non-Members

March 3, 2008

$175.00

$200.00

Cheques must be postmarked by the above dates.

Send Conference Fee to:

NEFCA

C/O Ann Moore

237 Pineland Court

Waterloo, Ontario

N2J 2S3

Member □ Non-Member □

Name:

Business Name:

Street Address:

City/Town:

Postal Code:

Phone:

Refund Policy

Full refunds, less $50.00 processing fee will be given for cancellations received in writing

10 days prior to the conference / program date.

Refunds will not be issued for non-attendance.

NSF cheques – There will be a $35.00 charge.


NEFCA 17th Annual Footcare Conference

“Step into the future”

Friday, April 11th, 2008

4:00 - 5:30 p.m.

Registration / Shopping / Networking

5:30 – 6:30 p.m.

Welcome from the President / AGM

6:30 – 7:30p.m.

Dinner

7:30p.m. – 8:30p.m.

Networking with Jack McAlpine, Walkwel Shoes

8:30p.m.

Break / shopping / networking

Saturday April 12nd, 2008

7:30 - 8:30 a.m.

Registration / Breakfast / shopping / networking

8:30 - 8:40 a.m.

Welcome from the President

8:40 - 9:00 a.m.

Exhibitor Introductions /Announcements

9:00 - 10:30 a.m.

Nail Pathology, Graham Curryer, Chiropodist

10:3011:00 a.m.

Break / shopping / networking

11:00 a.m.– 12:00 p.m.

Compression Therapy, Sigvaris

12:00 – 1:00 p.m.

Lunch / shopping / networking

1:00 - 2:30 p.m.

Disinfection, Sterilization Ministry of Health, Clare Berry

2:30 – 3:00 p.m.

Break / shopping /networking

3:00 – 4:30 p.m.

Infection control putting into practice, Jeanne Boniface

4:30p.m.

Closing and thanks from President

Foot Care Canada- Sunday April 13,2008. Kingston Ontario

FOOT CARE CANADA

Sunday April 13, 2008. Kingston, Ontario

Invitation:

The newly appointed committee of FOOT CARE CANADA would like to take this opportunity to invite any interested foot care nurse, regulatory body, educator and/or policy maker to attend a workshop April 13, 2008 from 9:00 am – 3:15 pm, held at St. Lawrence College in Kingston, Ontario (detailed below). Nurses wishing to be considered as a Provincial /Territorial Advisor should attend this workshop and submit their resume (details attached) and a position statement to the committee for consideration. This workshop will follow a foot care conference on April 11-12th.

Background:

On September 22, 2007, a group of 60 foot care nurses, educators and managers from across Canada met in Winnipeg, Manitoba to discuss how to introduce national foot care nurse guidelines for skills, education and certification. All 60 participants supported a draft position statement proposed by an Ad Hoc committee and a consensus was reached to begin the development of a national communication strategy that could reach an estimated 3,000 – 6,000 foot care nurses in Canada. It is understood that this is a huge undertaking, and there are many steps that need to happen in order for the ultimate goal of national guidelines and certification for foot care nurses to occur.

How do I register for Foot Care Canada’s workshop on April 13th?

There will be no cost to attend! Updates on this workshop will be posted in the ‘Foot Care Canada’ section, on the following website http://www.cawc.net/open/library/clinical/specialty.html.

Currently, we are a volunteer committee without funding or office support, so if you are interested in attending the April 13th workshop, we kindly ask that you please email your name and contact information directly to our new email address at footcarecanada@yahoo.ca and we’ll look forward to meeting you! See attached agenda and mission statement.

How do I register for the foot care conference on April 11 – 12th?

Our workshop will follow a local foot care conference in Kingston, Ontario at the Day’s Inn. To register for the conference contact Linda Heber at hebers@sympatico.ca (NEFCA).

Please share this memo with any and all who may be interested.

We hope to see you there!

Foot Care Canada Committee:

Cindy Lazenby RN (Kingston, ON),

Pat MacDonald LPN (Winnipeg, MB),

Donna Schofield RN, CNephC (Cornwall, ON),

Mary MacKay RN, IIWCC (Halifax, NS)

Sandra Bird LPN (Winnipeg, MB).

FOOT CARE CANADA

Sunday April 13, 2008. Kingston, Ontario

Location: St. Lawrence College, 100 Portsmouth Avenue, Kingston Ontario.

(go to www.stlawrencecollege.ca/?iPageID=69&iMenuID=5 for virtual directions)

Flying? Book a flight directly to Kingston (it’s an easy transfer from the Toronto Airport).

Workshop Agenda

9:00 am: Welcome and Introductions:

Ø National & Regional Co-Chairs

Ø Collaboration with other Organizations

o Canadian Association of Wound Care (CAWC)

o Provincial and territorial registering bodies and nursing associations

9:30 am: Past and Present of Nursing Foot Care

10:00 am: Networking & refreshment break (Tim Horton is in the building!)

10:30 am: Nursing Foot Care: Barriers and Solutions

Ø Interactive exercise led by Pat MacDonald LPN

11:30 am: Future of Nursing Foot Care:

Ø Foot Care Canada’s Mission Statement and Goals (see attached)

Ø What can You do?

o Send us your contact info

o Attend Foot Care Canada events

o Provincial /Territorial Advisors

o Clinical or evidenced-based articles

12:15 pm: Networking & lunch (cafeteria style)

1:15 pm: What is Evidence-Based Practice and How do we Implement it?

Ø Interactive exercise led by Cindy Lazenby RN

3:15 pm: Closing


Foot Care Canada Position Statement (Jan 2008)

The Mission of Foot Care Canada is to advance the practice of foot care through a collaborative and networking process for all individuals providing foot care.

Goals:

Collaborate with health care professionals across Canada to promote optimal care and improve client outcomes.

Develop educational opportunities, national guidelines and a certification process for nursing foot care.

Promote public awareness of the benefits of foot care and of the role of a foot care nurse within the health care team.

Facilitate the development and publication of clinical and research based articles related to the advancement of nursing foot care.

What Can You Do?

  1. Send us your contact information at our new email address footcarecanada@yahoo.ca.
  2. Attend Foot Care Canada’s events. Go to www.cawc.net (Canadian Association for

Wound Care) for updates on the following upcoming events:

    1. April 13, 2008 workshop in Kingston ON.
    2. September 28-29, 2008 foot care conference/workshop in Halifax NS.
    3. November 2009 foot care/wound care conference in Quebec City, Quebec. (date TBA)
  1. Apply/submit to one of the following (go to www.cawc.net for job descriptions and specifications):
    1. Provincial/territorial advisor
    2. Conference speaker
    3. Conference sponsor
    4. Conference exhibitor
    5. Clinical or evidence-based article
  2. Spread the word…tell two colleagues and they’ll tell two colleagues…

2008 Organizational Chart:

Ø 1 Chair: Cindy Lazenby

Ø 4 Co-Chairs: Northern (Sandra Bird, acting)

Western (Pat MacDonald)

Central (Donna Schofield)

Eastern (Mary Mackay)

Ø 12-24 Provincial/Territorial Advisors (TBA) Organization Chart

Saturday, March 22, 2008

Blog Questions

Q: Hi Always Foot Care and welcome to Askablogr. I had hoped this tool would be useful to resource sites like yours, so I'll be eager to hear any feedback, your readers and patients have on the product.
Posted by Chris DeVore

A: Hi Chris, thanks.  We look forward to seeing how things work out here.  We are sure our readers will benefit from this resource.

 

 

Thursday, March 20, 2008

Saving diabetics’ feet

Saving diabetics’ feet

Diabetic foot syndrome (DFS) is one of the most serious sequela of diabetes mellitus - Disease management programmes (DMP) yield first results

article image
DFS, described in the Wagner classification system by six grades from the initial wound to amputation, is a slowly developing condition that presents a major challenge for the medical team, which should include podiatrists and orthopaedic technicians. In Germany alone, current estimates indicate 29,000 diabetes mellitus-induced amputations annually, most of these following an infection – particularly MRSA. 10% of all diabetics with DFS will undergo a major amputation of the lower extremities, and 20% of these patients will not survive the surgical intervention.

The problem and causes of DFS
The crucial issue with DFS is the sensor and motor polyneuropathy that affects about 60% of these patients. Sensor polyneuropathy reduces pain sensitivity, which means the patient or the family notice a weeping wound on the sole of the foot only because socks or shoes are wet. Fairly often, it is only upon discovery of such a wound and subsequent consultation with a doctor that the patient realises s/he suffers type II diabetes mellitus that needs treatment. In many such cases the patients had not paid much attention to their feet and overlooked previous symptoms, such as reduced sweat secretion, excessively warm, dry, chapped and callous feet and even deformations caused by motor neuropathy. The latter atrophies the short foot muscles and causes changes in the form of the plantar arch, which in turn leads to a different distribution of pressure when walking and, consequently, to callus formation on the foot where the pressure is most intense. Often, these physical developments are ignored because they are taken as normal signs of ageing. According to a Health Care Monitoring study, patients take their bodies for granted, or maybe fall into one of the following categories:

article image
l 21% of adults take only the most basic measures to maintain health; they consider a visit to the doctor’s surgery is an easy way out and tend to reject self-medication
l 15% of adults feel healthy; they talk and think little about their health; they know that their personal healthcare is inadequate but see no point in changing their behaviour
l 17% of adults are not interested in their individual health; they feel healthy and rarely see a doctor (Source: Health Care Monitoring, a German study involving 3,000 people.

Details: www.psychonomics.de)

According to this study 46.6% of the adult population have little or no interest in their health and react too late to a condition that would have prompted the other half of the population to see a doctor. This disinterest might explain why so many patients present with severe medical conditions.

article image
A further consequence of neuropathic disorders is diabetic neuropathic osteo-arthropathy (DNOAP or ‘Charcot foot’), which causes the plantar arch to collapse, leading to deformities due to increased pressure and callus formation.

About 30% of these patients suffer a combination of peripheral arterial disease (PAD) and diabetic neuropathy, 10% have ischaemia. In both cases the prognosis is even worse than for neuropathy due to the vascular situation and poor circulation. Vascular diagnostics and reconstruction are imperative – a fact that underlines the necessity for close cooperation between diabetologists and vascular surgeons, if the patient is to have a chance to avoid amputation.
Even better: the patient can be convinced to participate in a disease management programme (DMP).

In Germany, such programmes have shown very promising results. In December 2006, the first data analyses to provide an indication as to the effectiveness of DMPs became available. In one German Federal State the condition of 44,995 patients with type II diabetes mellitus were recorded for six months (April to September) in 2006, and the study showed that very few cases of diabetic keto-acidosis had been reported. This means that diabetics in Germany are quite well prepared to avoid this dreaded life-threatening metabolic disorder. After all, 30.1% of them could get rid of typical diabetes symptoms, such as fatigue, polyuria and polydipsia (excessive thirst). High blood pressure was under control in almost 40% of them. 92.9% of the patients underwent a foot examination but only 48.6% participated in diabetes training.

These figures show that the education issue requires much more attention. This might well be the most difficult task for the medical team: The patient has to understand that he will benefit from that education and learn to control the disease and its consequences rather to be controlled by it.
Source: Phasengerechte Versorgung beim Diabetischen Fußsyndrom, Coloplast GmbH, Hamburg)

This article was published on 08/31/2007

Putting feet first: diabetic foot care worldwide

he International Diabetes Federation Consultative Section and International Working Group on the Diabetic Foot (IWGDF) publishes its fourth document in the Time to Act series to coincide with the 2005 Year of the Diabetic Foot. Diabetic feet tend to be under-recognised as a health issue, despite the fact that ulceration, gangrene, and amputations are more common complications of diabetes than dialysis and blindness. The statistics are startling: one in six diabetic patients will have a foot ulcer, with even more patients affected in developing countries; over 1 million amputations for diabetes-related complications occur every year.

A worldwide increase in type 2 diabetes means that health-care planners and professionals are facing an ever growing tide of patients with diabetes-related complications. Better prevention, restructuring of diabetes care, and advances in treatment are all needed. Diabetes and Foot Care: Time to Act aims to educate people with diabetes, health-care professionals, and policymakers about the disease and ways to prevent amputations. This is both its strength and its weakness. The concentration on organisation of care, education, and structures is exactly what is needed in countries and centres without structured foot care. But each chapter has to cover such a broad range of topics that some sections are disjointed and occasionally baffling. I would have preferred a separate section for each of the three target audiences, although the colour-coding key for each of the interest groups is useful.

The prevention and treatment of diabetic foot disease is challenging. I would, however, take issue with the statement that foot care problems are the easiest of all the diabetic complications to prevent. Surely, if it were true then rates of recurrent ulceration would not exceed 50% in most series. This is not to decry screening and preventative treatment. They are vital and have probably had a major role in the changing nature of foot ulceration. As the book makes clear, the number of peer-reviewed publications about the diabetic foot has increased ten-fold in the past decade. Despite this progress, there is still no clear evidence for the effectiveness of most individual interventions. The clearest evidence—and even this is from case-control studies—is for secondary sector multidisciplinary foot care teams. For this reason, and rightly, the book devotes as many pages to developing such systems on local and national scales as to the minutiae of ulcer treatment.

The section on treatment of foot ulceration is the weakest part of the book. There is an evidence gap about the specifics of such treatment. A Cochrane review has concluded that debridement of ulceration is a good thing, but there is no guidance on how much, how often, and for which ulcers. The control of infection is important, since infection plays a large part in tissue destruction leading to amputation. However, there is no evidence about the best antibiotic regimen or for how long it should be taken. The IWGDF steers a middle ground of consensus. Their document informs this book and so cannot be expected to be different. Offloading is, once again, stated as the most important aspect of care for diabetic foot ulcers. Although recent evidence suggests that non-removable devices are most effective, the book again has to take a broader view because of the diversity of its audience and so the advice is diluted. Various devices are presented as solutions for offloading, but few if any are validated by more than small case series. Medicine is often described as being as much of an art as a science, and this is particularly true of the care of diabetic foot ulceration. The evidence gap means that local services find their own solutions, informed where possible by the published literature and their own experiences. Most clinics see too few ulcer patients to do more than this. This book varies between prescriptive rules and generalised advice; this is a difficult balance and is partly successful.

The remit of the International Diabetes Federation is to raise standards in diabetes care globally and the sections on worldwide initiatives focus on each region. These initiatives are inspiring and give clues about how to set up your own service, but to use half the book to do this is surprising. A shorter section would have sufficed and allowed more space to address service requirements—from basic provision to centres of excellence. Such information would perhaps have met the organisational aspirations of those wishing to develop foot care services.

This is an ambitious book that succeeds in its main goal of raising awareness. The message that is clearly learnt from the book is that structured care can reduce the number of amputations in diabetic patients by at least half. This is the key message for people with diabetes, health-care professionals looking after them, and policymakers organising diabetes care. Although the book does not impart much new information to established practitioners, it highlights the seriousness of diabetic foot problems around the world and underlines how far each region needs to go to reach a common standard for the good of all patients.

Diabetes Prevalence

Diabetes is a serious condition for the individual and society. Its rapidly increasing global prevalence is a significant cause for concern.

In 2007, it is estimated that there are 246 million people with diabetes in the adult population in the seven regions of IDF. In 2003, the total was 194 million.

Type 2 diabetes constitutes about 85% to 95% of all diabetes cases in developed countries and accounts for an even higher percentage in developing countries. The epidemic nature of diabetes continues to affect ever-increasing numbers of people around the world while public awareness remains low.

In 2007, it is estimated that 7.3% of adults aged 20-79 in all IDF member countries have diabetes. The Western Pacific Region and the European Region have the highest number of people with diabetes, approximately 67 and 53 million respectively. The highest rate of diabetes prevalence is to be found in the North American region (9.2%) followed by the European Region (8.4%).

Diabetes: a forecast

The number of people with diabetes is expected to increase alarmingly in the coming decades. In 1985, an estimated 30 million people worldwide had diabetes; in 2000, a little over a decade later, the figure had risen to over 150 million. By 2025, the figure is expected to rise to 380 million.

The prevalence of diabetes is higher in developed countries than in developing countries, but the latter will be hit the hardest by the escalating diabetes epidemic. Increased urbanization, westernization and economic development in developing countries have already contributed to a substantial rise in diabetes.

The prevalence of diabetes in adults is projected to rise in both developed and developing countries. While diabetes is most common among the elderly in many populations, prevalence rates are significantly rising among comparatively young and productive populations in the developing world.

Causes of the rise

The alarming increase of diabetes prevalence is projected to occur because of:

  • Population ageing
  • Unhealthy diet
  • Overweight and obesity
  • A sedentary lifestyle

All over the world, traditional lifestyles and dietary patterns that have sustained people over generations are disappearing. Socio-economic realities mean that families are often forced to move away from rural areas and into urban areas to seek employment. Diabetes is primarily concentrated in urban areas and this characteristic is destined to increase in the future as a result of rapid industrialization in many countries.

The Cost of Diabetes

The human, social and economic impact of diabetes

The global diabetes epidemic has devastating human, social and economic effects. The largest costs of diabetes worldwide are its devastating effects on families and national economies.

Impact on families and people with diabetes

Diabetes is expected to cause 3.8 million deaths worldwide in 2007, about 6% of total global mortality, about the same as HIV/AIDS. Using World Health Organization (WHO) figures on years of life lost per person dying of diabetes, this translates into more than 25 million years of life lost each year.

The International Diabetes Federation (IDF) estimates that the equivalent of an additional 23 million years of life are lost to the disability and to reduced quality of life caused by the preventable complications of diabetes.

People living with diabetes and their families feel the impact of diabetes most directly. They feel the often crushing expenses of diabetes treatments as costs are not subsidized, and family income is frequently reduced when diabetes interferes with work.

It is often the case that caring for diabetes steals valuable time from education, paid work and leisure. In many countries, individuals and families fear and experience the disability, reduced quality of life, and the lost years of life that untreated diabetes brings.

  • People with diabetes face the near certainty, in many countries the stark reality, of premature death.
  • Type 1 diabetes is particularly costly in terms of mortality in poor countries, where many children die because access to life-saving insulin is not subsidized by governments (who instead tax it heavily), and is often not available at any price.
  • Studies recently carried out in Zambia, Mali and Mozambique highlight a stark reality: a person requiring insulin for survival in Zambia will live an average of 11 years; a person in Mali can expect to live for 30 months; in Mozambique a person requiring insulin will be dead within 12 months.
  • In the poorest countries, people with diabetes and their families bear almost the entire cost of whatever medical care they can afford.
  • In Latin America, families pay 40-60% of diabetes care costs out of their own pockets.
  • In India, for example, the poorest people with diabetes spend an average of 25% of their income on private care. Most of this money is used to stay alive by avoiding fatally high blood sugar levels.

Impact on national economies

Diabetes affects all people in society, not just those who live with diabetes.

WHO estimates that mortality from diabetes, heart disease and stroke cost about 250 billion international dollars (ID) in China, ID225 billion in the Russian Federation, and ID210 billion in India in 2005. Much of the heart disease and stroke in these estimates was linked to diabetes.

WHO estimates that diabetes, heart disease and stroke together will cost about:

  • $555.7 billion in lost national income in China over the next 10 years
  • $303.2 billion in the Russian Federation
  • $333.6 billion in India
  • $49.2 billion in Brazil
  • $2.5 billion even in a very poor country like Tanzania

These estimates are based on lost productivity, resulting primarily from premature death. Accounting for disability might double or triple these figures.

  • If nothing is done, diabetes threatens to subvert the gains of economic advancement globally.
  • Government budgets worldwide will face the immense strain of diabetes care on disability payments, pensions, social and medical service costs, and revenue.
  • Private health insurers and employers will face the spiralling costs of treating the growing number of people with diabetes.

Because diabetes is increasing faster in the world’s developing economies than in its developed ones, it is the developing world that will bear the brunt of the future cost burden.

Disparities developed – developing world

  • More than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries.
  • Less than 20% of expenditures are made in the middle- and low-income countries, where 80% of people with diabetes will soon live.
  • One country, the United States of America, is home to about 8% of the world’s population living with diabetes and spends more than 50% of all global expenditure for diabetes care.
  • Europe accounts for another quarter of spending on diabetes care.
  • The remaining industrialized countries, such as Australia and Japan, account for most of the rest.
  • In the world’s poorest countries, not enough is spent to provide even the least expensive life-saving diabetes drugs.
  • IDF’s new (and probably generous) estimates of national diabetes-care spending for 2007 include USD6 per person with diabetes in Burundi, USD10 in Tajikistan, USD78 in Guyana and USD48 in Haiti. Some of these amounts could not cover the annual wholesale price of a generic oral agent capable of preventing acute, life-threatening high blood sugar.
  • The economic opportunities that the United Nations want to create for developing countries with its Millennium Development Goals, will be greatly undermined by the economic impact of diabetes.

If nothing changes, the disparity in spending for diabetes care between the industrialized countries and the rest of the world will only increase. Overall, world treatment costs for diabetes are growing more quickly than the world population.

Dramatic rise in medical care costs for diabetes

Diabetes is costly even before it is diagnosed. This is true both in industrialized and developing countries. In 2007, the world is estimated to spend at least US$ 232 billion to treat and prevent diabetes and its complications. By 2025, this lower-bound estimate will exceed US$ 302.5 billion.

Where the costs lie

  • In industrialized countries, about 25% of medical expenditures for diabetes go to treating elevated blood sugar; 25% goes to treating long-term complications, largely cardiovascular disease, and 50% is consumed by the additional general medical care that is associated with diabetes.
  • The cost, for example, of a person with diabetes who has end-stage kidney disease is 3 to 4 times higher than the cost of a person with diabetes and no complications.
  • In the USA, acute hospitalization consumes 44% of diabetes-attributable costs; followed by:
    • 22% for outpatient care
    • 19% for drugs and supplies
    • 15% for nursing care
  • Similar proportions are reported for other high-income countries such as Finland.
  • In middle-income countries, half of diabetes medical expenditures are used for blood sugar control, which is essential for the prevention of acute life-threatening hyperglycaemia. The remainder is split between general medical care and chronic complications.
  • In Latin America and the Caribbean, for example, drugs to reduce blood sugar levels are believed to account for about 50% of all spending.
  • It is believed that in low-income countries almost all expenditure for diabetes is directed towards drugs to prevent death from high blood sugar.

Access to care

Although the medical care costs of diabetes are much higher in industrialized countries, nearly all of these countries have organized medical care insurance systems and/or governmental provisions for medical services. This allows families to survive financially when diabetes strikes. However, costs in these countries are much higher than they need to be because insufficient money is invested to prevent expensive complications such as heart disease, stroke, kidney disease, and amputations.

In developing countries, however, people living with diabetes bear the brunt of the medical costs out of their own pocket because many countries lack an adequate healthcare infrastructure.

Source: All economic impact data are drawn from the Diabetes Atlas, third edition, International Diabetes Federation 2006.

Did You Know?

Did You Know?

  • Diabetes currently affects 246 million people worldwide and is expected to affect 380 million by 2025.
  • In 2007, the five countries with the largest numbers of people with diabetes are India (40.9 million), China (39.8 million), the United States (19.2 million), Russia (9.6 million) and Germany (7.4 million).
  • In 2007, the five countries with the highest diabetes prevalence in the adult population are Nauru (30.7%), United Arab Emirates (19.5%), Saudi Arabia (16.7%), Bahrain(15.2%), and Kuwait (14.4%).
  • By 2025, the largest increases in diabetes prevalence will take place in developing countries.
  • Each year a further 7 million people develop diabetes.
  • Each year 3.8 million deaths are attributable to diabetes. An even greater number die from cardiovascular disease made worse by diabetes-related lipid disorders and hypertension.
  • Every 10 seconds a person dies from diabetes-related causes.
  • Every 10 seconds two people develop diabetes.
  • Diabetes is the fourth leading cause of global death by disease.
  • At least 50% of all people with diabetes are unaware of their condition. In some countries this figure may reach 80%.
  • Up to 80% of type 2 diabetes is preventable by adopting a healthy diet and increasing physical activity.
  • Diabetes is the largest cause of kidney failure in developed countries and is responsible for huge dialysis costs.
  • Type 2 diabetes has become the most frequent condition in people with kidney failure in countries of the Western world. The reported incidence varies between 30% and 40% in countries such as Germany and the USA.
  • 10% to 20% of people with diabetes die of renal failure.
  • It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy.
  • Diabetic retinopathy is the leading cause of vision loss in adults of working age (20 to 65 years) in industrialized countries.
  • On average, people with type 2 diabetes will die 5-10 years before people without diabetes, mostly due to cardiovascular disease.
  • Cardiovascular disease is the major cause of death in diabetes, accounting for some 50% of all diabetes fatalities, and much disability.
  • People with type 2 diabetes are over twice as likely to have a heart attack or stroke as people who do not have diabetes. Indeed, people with type 2 diabetes are as likely to suffer a heart attack as people without diabetes who have already had a heart attack.

Sources:

Diabetes Atlas, third edition, International Diabetes Federation, 2007.
Diabetes and Cardiovascular Disease: Time to Act, International Diabetes Federation, 2001.
World Health Organisation Diabetes Unit - www.who.int/diabetes.

International Working Group on the Diabetic Foot

Foot Note Zanzibar PDF Print E-mail
In July of 2004 my 18 year old daughter Clare and I accepted an invitation to learn of the conditions for people with diabetes in the developing world. Our extensive diabetes advocacy efforts for the last 11 years and recent appointment to the IDF Consultative Section on Childhood and Adolescent Diabetes enhanced our desire to learn more and perhaps share what we found with others.

Our diabetes journey took us to a hospital ward “foot clinic” on Zanzibar . I stress the term "foot clinic" in quotation marks for a reason. If there was ever a hell on earth, this had to be it. With one dedicated Dr. who makes under $100 a month and works 20 hour days, this was purgatory at it's worst. Thirty or more men lay in hospital beds in an open air room awaiting amputation. Their feet overwhelmed with gangrene ( dead and decay of tissue), and the flies and smell almost unbearable. Yet, Clare sat on beds, holding the hands of these men, listening to their stories. Nothing she could tell them would ease their pain...pain which was mental because the blessing in this is, diabetes kills the nerves first and they really did not recognize their blackened limbs.

As I watched my daughter with these men, my own protective instincts played havoc with my heart. Clare also has diabetes. She was diagnosed with Type 1 at age seven. Without quality diabetes education and support, Clare too could face this fate.

Then I turned from the scene before me to observe a nurse in a stark white, perfectly pressed uniform, change a dressing on a wound of the patient in the next bed. Her skill was flawless. Tenderness and compassion foremost in her every move. She shared with me that this man has six children. If he loses the foot he will no longer be able to provide for them. She is honored to help because she can make a difference in his life. Her wish would be that education and supplies could be made available earlier so her job would not be so difficult.

There are remarkably dedicated health care professionals in remote areas in the developing world. There are committed organizations and corporate partners who are making progress as well. My observation is these efforts are dwarfed by the magnitude of this problem and help is genuinely needed. Quality diabetes education, access to supplies and treatment as well as encouragement of others to join in this endeavor is paramount if we are to make real progress.

The decision to provide this opportunity for education, to allow us to see first hand the plight of these people, was insightful. The knowledge that any person should face amputation caused by a disease that is treatable is unacceptable. Armed with this new education, Clare and I are even more committed to spreading the word of our findings. We welcome any and all who wish to join in this advocacy effort.

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Thursday, March 13, 2008

Iran finds herbal diabetic foot cure

Iran finds herbal diabetic foot cure
Sat, 02 Feb 2008 22:57:49
Iranian scientists have successfully produced a new anti diabetes herbal medication which can effectively treat diabetic foot ulcers.

'Angipars' has passed animal and human testing without any reported side effects.

Scientists claim that the drug did not cause any genetic and DNA changes or other acute complications during tests on lab animals.

In addition, its topical, oral and intravenous forms have successfully been tested on human volunteers.

Diabetes is the leading cause of death in all industrialized nations. Diabetic foot is one of its most frequent complications resulting in amputation in the majority of the patients.

Having a healthy lifestyle and balanced diet and regular exercise can control blood sugar levels and prevent or minimize the complications secondary to the disease.

PKH/HGH

Charcot Foot: A Story of Foot Reconstruction

Before and AfterCharcot Foot: A Story of Foot Reconstruction

Josephine Kulman has had type 1 diabetes for 45 years, ever since she was five years old. For much of her life, her blood sugars were rarely in control.

Before she went on the pump a few years back, her A1c used to hover around 10%, and she'd often drag herself to work with blood glucose levels of up to 600 mg/dl.

In her forties, it all started to catch up with her. She got gastroparesis, lost vision in one eye, suffered a left-foot ulcer, and developed carpal tunnel syndrome and kidney problems.

On December 8, 2006, while walking in Manhattan, Josephine tripped. Three days later, she couldn't get her right shoe on. Looking down, she was appalled to find that her right foot was three times its normal size. In mid-December she entered the hospital for tests to discover why her foot was so inflamed.

Cellulitis was suspected, but eventually x-rays revealed that Josephine had Charcot foot. "My foot was shaped like an S," she says. "My ankle bone on the inside of my leg was underneath my arch. The one on the outside of my leg was in front of my foot. My foot was split from the big toe straight up, so half of my foot was going one way and half of it was going the other way."

Charcot foot is a softening of the bones of the foot that occurs in people with severe peripheral neuropathy. Their muscles lose the ability to support the foot, leading to a slackness of ligaments, dislocation of joints, damage to bone and cartilage, and deformity.

The bones slip out of position and then push on the soft tissue, breaking it down and leading to ulcers. The patient, unable to feel the pain that warns healthy people of injury, continues to walk on the broken foot, exacerbating the damage. That's exactly what happened to Josephine.

Amputation has always been a very real threat in cases of Charcot foot. But Josephine's story has a different ending, largely because she was fortunate enough to come under the care of Dr. Andrew Sands. Dr. Sands, the chief of foot and ankle surgery at St. Vincent's Catholic Medical Centers in Manhattan, is one of an innovative group of surgeons who is breaking new ground in the treatment of Charcot foot.

Dr. Sands was inspired to help people with diabetes by his cousin, who had type 1 diabetes and died at age 38 from a heart attack. "I went through everything with him," says Dr. Sands, "including partly amputating his foot." As a result of his cousin's influence, "I stay involved with diabetes and do new and exciting things for people with diabetes to save their feet."

In the past, says Dr. Sands, "people were very afraid to operate on diabetic feet, and a lot of people treated them in casts or in bulky boots or shoes. Wound care centers can treat the ulcers, but if the bone malposition isn't addressed, the foot is going to break down again the instant the patient starts walking on it again. More and more, people like me are operating on them and fixing the deformities. We're developing new and better implants, which are metal screws that fit inside the bones. Basically, it's like when a foundation collapses and then the walls start collapsing. You can shore it up with implants and allow the patients to keep their foot. Suddenly, a lot of people who before would have become wheelchair-bound or had an amputation are staying active on their own feet."

In Josephine's case, says Dr. Sands, "her forefoot was basically swept away from the rest of her foot. One row of bones 'bayoneted' over another row, shifting up, over, and on top of other bones. To get that back into alignment, you have to bring it all down and hold everything with screws. We took her forefoot and brought it around and lined it up again, and put big stainless steel screws through her bones to hold everything. The most important screw, which was about 4-1/2 inches long, went from the base of her big toe up into the big bone under her ankle. We recreated her entire arch."

These new operations are the product of a change in philosophy over the past ten to fifteen years, away from conservative treatments like casts and boots and toward more aggressive reconstruction. The trend has been fueled by advances in technology.

The older implants were too bulky to work well in a foot, but now the screws have been redesigned, says Dr. Sands, "to have a smaller head and a stronger shaft, so that they are strong enough to use in a foot, which bears the entire weight of the body."

"It used to be," says Dr. Sands, "that if someone had a terrible deformity in their hind foot or their ankle, the only option was to amputate. Now we have new implants that we can put through the heel and up through the sole of the foot, and we can lock the foot to the leg and save the foot. Sometimes the heel bone is still intact and the bones around it are destroyed, but now we can fix it."

Dr. Sands emphasizes that to benefit from foot reconstruction, patients must be "good partners" in the process. They must have good control of their blood sugar, and they must definitely not smoke.

"If you have a foot ulcer and you smoke," says Dr. Sands, "stop. If you're not a smoker and you have good circulation, if your foot is warm, then chances are strong that we can at least try to save your foot. Even if you have numbness up to your knee, as long as you have good circulation, we can get you to heal."

With regard to smoking with diabetes, Dr. Sands is adamant. "We guarantee very little in medicine," he says. "But to the degree that it is possible to guarantee anything in medicine, I can guarantee that if you have diabetes and you are a smoker, you will have an amputation. It's just that bad." Stop smoking, he advises, and then "keep your hopes up and keep your health up, because we're going to be able to do a lot more" when it comes to saving feet.

As for Josephine, she will be required to wear a special boot for about six months, but she expects to be fully healed once the boot comes off. Her best advice to people with a similar dilemma is to find the very best doctor they can.

"That was the key," she says. "It took time to get to Dr. Sands, but nobody else would have even considered doing a foot reconstruction. The foot would have eventually healed in an S shape, and I would have had problems for the rest of my life."


Disorders of the Diabetic Skin

Skin Care:
Disorders of the Diabetic Skin

- Robert A. Norman, DO, MPH


Diabetes is a disease that has a huge impact on our culture. It is estimated to account for 15% of all healthcare costs in the United States.1 It has been implicated as the chief cause of nontraumatic lower extremity amputations, 35% of new cases of end-stage renal disease (ESRD), and a significant amount of cardiovascular disease. It has also been said that 100% of all diabetic patients have their skin affected in one way or another.2 When you consider the elderly population, this effect is even greater.
As many as 16 million people are affected with diabetes3; the tremendous impact of the cutaneous manifestations of diabetes is obvious. The pathogenesis of these skin diseases is becoming clearer as more research is conducted. Even without that knowledge, some disorders are characteristically associated with diabetes. For example, diabetic bullae, the syndrome of waxy skin and limited joint mobility, and diabetic dermopathy are virtually pathognomonic.


Diabetic dermopathy is one of the most common skin abnormalities affecting persons with diabetes.

Disorders of the diabetic skin that contribute to its pathology include microangiopathy, infection, and metabolic disturbances of the tissue. These problems cause disease in other parts of the body as well. Consequently, it is important to understand the dermal manifestations of diabetes to effectively manage these common comorbidities.

Necrobiosis Lipoidica Diabeticorum

Necrobiosis lipoidica diabeticorum (NLD) is not exclusive to diabetes. Actually, it is relatively rare and has an incidence of 0.7% in patients with diabetes.4 The disorder has a greater incidence in women and is 4 times more common in Caucasians. Although the average age of those affected is 34, there is a predominance of presentation in the young.5 One paper reports that at the time of diagnosis, two-thirds of patients will have diabetes, and all but 10% of the rest will develop it within 5 years; the rest will have an abnormal glucose-tolerance test or first-degree relative with diabetes.3
Initially, NLD presents as an erythematous, nonscaly plaque on the pretibial and malleolar areas of the legs. Eventually, these areas enlarge and coalesce into larger plaques that then develop yellow, atrophic centers. The borders of NLD are irregular and enlarge slowly. The atrophy extends down into the dermis. Additionally, there are prominent telangiectasias, and approximately one-third of the lesions ulcerate. Slightly more than half of the patients diagnosed with NLD have associated retinopathy and/or other signs of microvascular compromise.6 The time required to see improvement varies from 3–4 years. Spontaneous resolution is sometimes noted. The mainstay of treatment is tight diabetic control. Topical and/or injected corticosteroids are also indicated. Intralesional injection of 0.1 ml triamcinolone 2.5–10mg/ml every 2–4 weeks has been found to be effective in severe cases.5

Granuloma Annulare

The cause of granuloma annulare is unknown. It is a benign condition that has several clinical forms. The classic type is most common. The less common forms include generalized, multiple, perforating, and subcutaneous forms. This condition has lesions similar to NLD without the atrophic center. Lesions are common over trauma areas, such as the dorsum of the hand and elbows. It begins as papules and expands into annular borders with central areas of hyperpigmentation. In spite of its appearance, there are few other symptoms. There are several forms of treatment, including liquid nitrogen, to ablate the annular borders of the lesion.

Diabetic Dermopathy

Diabetic dermopathy has been called one of the most common skin signs of diabetes, but it can be seen in non-diabetics as well. Prevalence is most noted in men with diabetes who are 60 years of age or above.5
The exact cause of this disorder is unknown. Some theories about the pathogenesis include post-traumatic atrophy due to a thermal or mechanical insult or post-inflammatory hyperpigmentation in poorly vascularized skin.5 There is little evidence of angiopathy or its relationship to other diabetic angiopathies, but its incidence does correlate well with the severity of diabetes.6
Diabetic dermopathy begins as pink patches approximately 0.5–1 cm in diameter on the pretibial and lateral leg areas. Eventually, they become hyperpigmented brown papules with a fine scale and surface atrophy. They are round, circumscribed, shallow, bilateral, and usually not symmetrical. They finally heal, forming scars. Treatment is episodic; these lesions often resolve spontaneously.

Acanthosis Nigricans

Acanthosis nigricans is a disorder that can be found in disorders of insulin resistance, such as diabetes, obesity, and paraneoplastic syndromes. It has been reported to occur with an incidence approaching 74% in healthy obese adults, 66% in primary school children who weigh 200% of the ideal body weight, 28% of children weighing 120% of ideal body weight, and 71% in an unselected population of primary school children.7-8 It has also been demonstrsted to occur with increased frequency in certain ethnic populations. American Indians have an incidence of acanthosis nigricans of 54%, and it occurs at an incidence of 40% in Hispanic populations.9
Most authors have causally linked acanthosis nigricans to pathology related to the insulin growth factor (IGF) receptors found in the epidermis.10 The defect has been postulated as being related to defects in the receptor itself, postreceptor function, antibodies, or obesity.11 Additionally, there are 3 lines of evidence that associate this disorder with high plasma levels of insulin. These include the finding of classic insulin receptors and IGF receptors in fibroblasts and keratanocytes in the epidermis. Second, acanthosis nigricans has also been found locally at the site of injection of insulin. Finally, as previously mentioned, most of the conditions associated with the disorder have a form of insulin resistance.
Symptoms include velvety, hyperpigmented plaques. These are found on the flexural areas and the back of the neck. Additionally, there can be an associated papillomatosis. These lesions can range from shallow to deep. Histologically, the lesions show marked hyperkeratosis and papillomatosis, and they are mildly acanthotic.12 Some also display atrophy and increased amounts of melanin in the basal epidermis.
There are several ways to treat this disorder. One way is to use keratolytic agents like salicylic acid. Some success has also been found using omega-3 fatty acids and a diet rich in fish oils. Finally, good success has been found using weight control and exercise.1 A combination of these, with good serum glucose control, is most likely to help.

Cutaneous Infections

Cutaneous infection is the area of diabetic skin disease that is most often thought about. Actually, well-controlled patients with diabetes probably are no more susceptible to infection than the normal population. However, poor control (especially ketoacidosis) compromises resistance. The poorly controlled get more severe, protracted, and resistant infections. Once serum glucose control is reestablished, resistance usually returns to normal. Contrary to logic, hyperglycemia contributes little to the growth of most cutaneous organisms. In support of this, topically applied sugar and honey have actually been used in healing ulcers of the skin.13 A well-known exception involves Candida. It has been shown to have a direct correlation between growth and sugar concentration in the saliva.