Tag Archives for " Diabetic foot "

Diabetes, Dialysis and the Diabetic Foot: a timely reminder

On July 28 2008, on this website I wrote about Dialysis and the diabetic foot, with a description of a foot ulcer patient.

Last week I was invited to speak to patients of the Cape Town Dialysis Clinics about foot care; during my preparation I came across some startling evidence proving that dialysis is an independent risk factor for foot ulceration if you have diabetes and require dialysis.

We already know that impaired kidney function increases the risk of foot ulcers – also referred to in my 2008 Blog – but this 2010 research proves that:

If you have diabetes and are receiving dialysis, you are 5 times more likely to develop foot ulcers, compared to someone with diabetes who is not on dialysis.

Scary but true clear evidence from a study completed at Manchester UK.

The research showed that patients on dialysis have more nerve damage, circulatory problems and a history of foot ulcers and amputations.

There is a 25% lifetime risk of people with diabetes developing foot ulcers so the key issue whatever your status is prevention.

Diabetic foot ulcers have multiple causes, some are: external trauma from footwear, neuropathy, arterial damage, poor self-care, lack of access to care, poor treatment.

However, as with all research you must ask – “so what?” This patient group did not include any people of colour, so it may not apply totally to South African patients.

So what to do? our objective is always to PREVENT complications.

Every person with diabetes must have an ANNUAL FOOT EXAMINATION so that they understand their level of risk for developing foot complications.

in addition individual education on self management of their diabetes. this is a team effort, paying attention to cardio-vascular health, eyesight, footwear selection and fitting, foot biomechanics (and possibly insoles or orthotics), plus probably the most important factor – can you invest in the care being offered?

Always “take care of your pair”.

Neglect your feet and patients at your peril!

Neglected feet can become a serious problem. So to0 can neglected patients or visitors using this website. Welcome back to all of you – feet as well as people!

Good time management has never been one of my strengths and over the past 2 months I have had a struggle to make time for this fascinating communication channel with my blog visitors as well as the core professional duties of my daily practice and some additional duties on behalf of the podiatry profession.

So, look out for replies to all the comments posted. Do keep posting comments – the warning is only there because one person posted a comment with too much personal detail – failing to realise that what you post EVERYBODY reads.

Anyway, what has been going on? The “chairpersonship!” of the SA Podiatry Association(SAPA) is proving to be an enormous task; fortunately the Executive are really dedicated people and have taken up the challenge of a new (& very different chair with enthusiasm). We are developing a new website that will be more interactive for podiatrists and public. You should see podiatry visibilty in future.

Podiatry has been featured on SABC 3 with Noleen, Talk Radio 702 with Redi, chai fm community radio in Johannesburg and I understand there is something in the November edition of ELLE magazine.

The University of Johannesburg has also been active, honouring the top achievers of 2008 – guess where the top podiatry student is – yes, you’re right, emigrated to Australia!

By the way, it’s not too late to apply for a place on the course for 2010. However, tomorrow sees the start of the exams – more time pressure as I am an examiner and moderator for a couple of subjects.

Then come some big events. First up is the birth of our second grandchild, due in 2 weeks, followed by a trip to Harrogate in the UK for the Society of Chiropodists and Podiatrists Annual Conference – I am presenting a Poster on the work we have done at Chris Hani Baragwanath Hospital, Paediatric Rheumatology clinic.

Meanwhile, in the practice recently a lady with a classic case of neglected feet was brought in by her daughter. The lady lives in Limpopo Province north of Johannesburg; she had no idea how she damaged her foot so badly that the tendons were showing through the top of her foot! She felt no pain either (undiagnosed neuropathy?).

X rays revealed the bones inside were infected and had collapsed to create a very fat, swollen shape. (Charcot neuroarthropathy). As there was no pain it had been left under the care of the patient and her GP. Basically because the lady had poor access to health care, but more importantly no insight into her diabetes what would you expect? A classic example of  poor communication all round.

Talking of communication, look out for activities associated with World Diabetes Day on November 14th. Check what your local podiatrist or clinic is doing. There is a big event in KZN, with a SAPA presence, there are events in Cape Town too.

As the Southern Hemisphere is into “exams  fever,” I’ll leave you with this thought from a postcard that I bought in Oxford some years back.

Why study?

The more I study, the more I know.

The more I know, the more I forget.

The more I forget, the less I know.

So why study?

May is World Foot Awareness Month – Diabetes & Crocs

Foot Health Awareness is vital for people with diabetes.

PEOPLE WITH DIABETES ARE 25 TIMES MORE LIKELY TO LOSE A LEG THAN PEOPLE WITHOUT THE CONDITION

Today I want to issue a timely reminder to people with diabetes who want to wear ‘Crocs’.

Last Friday, I saw a patient who “lived in her ‘Crocs’.” That was until she got splinters which penetrated the soles and stuck into her big toe, as she was walking across the university campus. The splinters were removed by her GP and today she told me there was a small remaining piece that also had to be removed. Fortunately, although she has neuropathy, the wounds are healing well.

Last Christmas, a family member (with no diabetes) also had a piece of metal go through the sole of  his ‘Crocs’, whilst walking across the garden.

Previously, I have not taken a strong stand on this, but these two events have prompted me to express my opinion in the form of a WARNING.

If you have diabetes, think very carefully about wearing ‘Crocs’. If you have poor circulation or reduced nerve sensation; do not wear them outside the home.

EVERY 30 SECONDS A LOWER LIMB IS LOST TO DIABETES SOMEWHERE IN THE WORLD

May is World Foot Health Awareness Month

The International Fedaration of Podiatrists, headquartered in Paris, France, has declared May to be World Foot Health Awareness Month. I join them in calling the attention of the public and health care providers to the importance of good foot and ankle care. It’s time for all South Africans to stop and take a look at their feet!

The importance of good foot health and the role played by the podiatrist cannot be overstated, since, most South Africans will develop some foot or ankle problem during their lifetime. World Foot Health Awareness Month is a marvellous opportunity to stop and consider the value and importance of our feet.

Winter is nearly here and we will be spending more time in closed shoes. Do last year’s boots really still fit? Are they going to cause pressure calluses?

Don’t wait for your foot problem to become severe. Remember that the average person takes about 8,000 to 10,000 steps per day and while you’re walking, your feet are taking a pounding; often enduring more than your body weight with each step.

As part of World Foot Health Awareness Month 2009, there is a special focus on Diabetes and the Diabetes Health Care Team. In support of this initiative, the South African Diabetic Foot Working Group (DFWG), will be presenting free patient-oriented symposia nationwide.
PRETORIA:
30th May. Contact: Andrika Symington: 012 548 9499
CAPE TOWN:
9th May.Contact: Anne Berzen 072 342 9558
BLOEMFONTEIN:
13th June. Contact: Dr Willem de Kock 082 379 6231
DURBAN:
to be confirmed. Contact: Dr Paruk 031 241000-ask for speed dial
JOHANNESBURG:
to be confirmed. Watch this space!

These symposia will offer a unique opportunity for people with diabetes and their families to ask questions of the members of the health team directly involved in foot care.

MAY 2009 is WORLD FOOT HEALTH AWARENESS MONTH

Foot Fit for Voting?

Are you ‘foot fit’ for voting? On Wednesday of this week South Africans go to the polls to elect a new government. Foot fitness could be important since the process can involve many hours of extra standing or walking.

Here are a few tips to help you through the day!

Try to get a lift to the polling station – this reduces the walking you have to do.
Take a folding chair or sit on the ground if your feet start to ache.
Wear comfortable shoes with thicker soles – trainers or lace ups are best, because they can be loosened if your feet and ankles start to swell.
Don’t stand in one position for too long – move from foot to foot, wriggle your ankles up and down to keep the circulation going.
Bend gently from the knees up and down a few times.

If you have diabetes and reduced sensation take extra care that you don’t rub a blister from your shoes.

Start talking to the people around you – it helps to pass the time!
(Try to avoid talking politics!).

Have something to eat before you go to vote. (Voting on an empty stomach is as risky as shopping on an empty stomach!).

Sometime it’s a good idea to go later to the polling station, since everyone wants to get there early!

Above all do vote. Remember that it is a Public Holiday, so rush home and put your feet up.

Annual Foot Examination for People with Diabetes

Every person who has diabetes, should have an annual foot examination. Feet, along with kidneys and eyes, form the “terrible triad” as it is sometimes called in medical circles; because people with diabetes can develop peripheral arterial disease or peripheral neuropathy(feet); nephropathy(kidneys) and retinopathy(eyes). I have spent the past two days conducting the Annual Foot Examination for people who attend the Potchefstroom Centre for Diabetes (CDE).

How many people with diabetes undergo this annual examination? Who knows? What is certain is that CDE members have to comply with rules which gives them access to all the basic health care professionals they need. (CDE is a Managed Health Care network of over 250 medical practices contracted to certain medical aid schemes).

The benefit of this annual examination is that patients, families and health carers know if the feet are at risk of developing futher complications associated with diabetes. The examination involves checking vascular, neurological, dermatological and orthopaedic status. Footwear is also checked and commented on. The International Consensus for managing the diabetic foot states that early identification of vascular insufficiency and referral to the vascular specialist does save many limbs.

Worldwide of course there is evidence that smoking damages your health, but even in the group at Potchefstroom there were smokers.  All of whom had diminished circulation, plus the typical signs of cool feet, absent hair, discoloured pink/blue feet – especially when hanging over the side of the examination couch – and a cough.

Checking the state of sensation is vital for good diabetic foot health. The loss of sensation – neuropathy – is often an insidious process, not being fully appreciated by the patient until they are aware of “funny feelings” in their feet. Patients describe sensations of “pins and needles,” “shooting pains,” “ants running over my feet,” “I thought my sock was folded over under my foot, but it wasn’t,” “it feels like I’m walking on cotton wool” and many others. This could be the first step to damaging the foot and developing an ulcer.

People with diabetes get all the conditions that affect the rest of us. However, if not identified and managed properly an area of callus(which indicates increased local pressure) can easily develop into an ulcer. Various nail conditions are common amongst people with diabetes, especially fungal infections and they are difficult to get rid of.

They structure of any foot affects its function and so in the diabetic foot assessment we look at the alterations in shape that could cause load increases and potential blister or ulcer sites. In addition disorders such as gout are very often associated with diabetes.

Footwear is responsible for at least 50% of foot ulcers, so this is examined very carefully. Unfortunately, many people do not have suitable footwear, so it’s important to check it  and give good advice.

Diabetes is a life-threatenting disease, but modern medicine has moved to early diagnosis and treatment and an important part of this is recognition by podiatrists of the signs in the feet. However for the person with diabetes one of the simplest acts to ensuring long life is to have your feet examined annually and know your foot status or risk.

Dialysis and the Diabetic Foot

The diabetic foot is often associated with patients who are on dialysis for kidney failure as a result of their diabetes. There is a well known ‘triad’ of eyes/kidneys/feet. What health professionals call retinopathy/nephropathy/neuropathy.

We are managing a gentleman who is suffering the effects of many years of poorly-controlled diabetes, acompanied by smoking. The effect of this has been serious damage to the circulation to his legs. As a result, he has needed arterial bypass surgery and now, three times a week he comes to the hospital for dialysis, because his kidneys are malfunctioning,so his specialist asked us to look after his feet.

On first view we got a real shock – the three outer toes on his right foot were dry, shrivelled and black – typical of dry gangrene. These toes will probably fall off by themselves! The back if the left heel is one large blood blister, fortunately it’s dry and not infected.

The principle of managing cases like this is to keep the areas clean and dry. For the patient they have to do their best to control their blood sugar. The targets for good blood sugar control for a person with diabetes are between 5.5 and 7.0 mmol/litre, so you can imagine my concern at the last visit when I found out that this gentleman was running 15mmol/litre.

Every time the dressings are changed there is the opportunity for bacterial infection and high blood sugar usually worsens the situation. Of course the state of the feet and limbs in an obvious potential cause for the raised blood sugar too.

So what’s the lesson?  Mismanage diabetes at your peril!  Damage to the nerves and circulation will have a major impact on your life the longer you live. The complications of diabetes are largely preventable, yet vast amounts of money are spent worldwide on managing the complications of diabetes.

Control of blood sugar and not smoking will protect both arteries and nerves from serious damage. Nephropathy or damage to kidneys is life threatening and not everybody can access a dialysis unit. Loss of sensation or neuropathy, where there is no sensation in the feet, allows for injuries to happen without the person noticing.

Don’t become a victim of circumstance – take control of your diabetes now – and avoid dialysis later.

More Diabetic Foot Disasters

Two more diabetic foot disasters arrived in the practice and at my Hospital clinic this weekend. Another hot water bottle burn, plus a corn paste induced abscess.

Loss of sensation and lack of foot health education contributed to the elderly lady with Type 2 diabetes burning her left little toe and the lower part of her calf, plus blistering her right big toe. The lower calf is about 2mm deep and the blisters were still covering intact skin.

If you are in any way involved with people with diabetes this winter please warn them of the dangers of hot water bottles, heating pads etc. Remind them of the tips I put out recently for winter foot care.

When diabetes causes loss of sensation in the lower leg then putting hot objects like hot water bottles next to the skin can lead to serious damage.

Medicated corn plasters and pastes have been around for years and are usually used by desperate people who don’t know that a podiatrist can give them relief from their painful corns and calluses.

Sadly my patient is also a Type 2 diabetic, but without complications and therefore was in great pain.

I drained the abscess, applied appropriate dressings and prescribed antibiotics. This lady is booked off work for 3 days plus the weekend and I will see her again on Thursday.

That’s a big penalty in lost working time for a lady who was simply trying to take care of her feet but did not understand the value of taking professional advice until it was too late.

So who is to blame for these disasters? If the patients concerned didn’t know, then I am for not getting the good foot health message across to enough people. On the other hand the patients did know who to come to for help.

A Fresh Start At The Practice?

Fresh from the long weekend we welcome Ms Lauretta Zikalala to our podiatry practice. Lauretta is our new receptionist and will be the voice of the practice from today. Back at the practice today, (not exactly fresh!) after a tiring but stimulating weekend at the Diabetic Foot Working Group (DFWG) Congress. Armed with some new knowledge and revision of existing, Tshidi and I feel that we have more to offer our patients with diabetes.

We know that Podiatry and diabetes is not just about managing the serious complications such as foot ulcers. The key issue is the prevention of this complication and research shows that multidisciplinary interventions can reduce both ulcers and amputations. There is a major challenge in South African health care to educate everybody involved in diabetes about the need for proper foot health care.

Just to get patients and professionals to look at feet could prevent many complications. So many patients do not feel pain and are therefore misled into thinking that there is nothing wrong with their feet. Meanwhile they develop blisters from footwear, ulcers from objects like drawing pins, stones and other foreign bodies and burns and scalds from heaters or hot water. It is clear that we will have to develop innovative and cost effective interventions to reduce the numbers of amputations and to improve foot health awareness in South Africa.

For any health professionals reading this; do you know what an angiosome is? I’ll publish some references tomorrow. (I think you will be amazed). For the lay person, angiosomes allow vascular specialists and podiatrists, in the context of patient examination, to accurately assess the quality of blood flow to every part of the lower limbs and feet. This enables really accurate identification of those areas at risk due to inadequate blood supply. Most of us are familiar with the dermatomes which map out the nerve supply, but angisomes are something new. (Well they are to me!).

Diabetic Foot Congress: Johannesburg 2008

Tomorrow morning sees the start of the first Diabetic Foot Working Group (DFWG) Congress in Johannesburg. In South Africa it is also a long weekend – meaning that Monday June 16 is a National Holiday, when we remember the youth of SA and their part in the struggle against apartheid. Especially the riots which broke out on June 16 1976.

For those of us dedicated to another great cause, we will spend the next 3 days learning, sharing and discussing the causes and effects of the diabetic foot, with a special emphasis on our local problems and solutions. We have speakers from Cameroon, the UK and USA, in addition to a variety of local speakers. The benefit of this type of congress is that you get to meet the members of the wider multidisciplinary team and the exchange of ideas and information will help to increase the core of health professionals available to manage the feet of people with diabetes in South Africa.

Recently I have been requested to try to assist with the development of training in foot health in Nigeria and have a new contact with an orthopaedic surgeon in Iraq. There are no podiatrists in Nigeria at all, where the population is more than 140 million. Furthermore there is no government support for foot care either.

I am very pleased to report that the lady featured in the ‘bean bag’ blogs, is making fantastic progress, thanks to the skill of my associate Tshidi Tsubane. We are also very proud of the fact we have had a paper published in a new journal – Wound Healing Southern Africa – Volume 1 No 1. visit www.woundhealingsa.co.za

Currently we are working onpapers concerning nail surgery for people with diabetes and the costs of ulcer care from a podiatrist.

Finally for Friday 13th! I spent the day as an examiner for the podiatry students at the University of Johannesburg. I’m not sure who was more tired the students or me. At the end of two sessions of assessing competency in clinical skills you actually feel quite sorry for them.

Have a great weekend.