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3/2/2016
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3/2/2016
Track 1 Breakout Session-
Cost Effective Clinical Tools
for Improved Diabetic Foot Outcomes
(Hands- on session)
R. Gary Sibbald, MD, M.Ed, D.Sc (Hons)
FRCPC (Med, Derm), FAAD, MAPWCA
Elizabeth A. Ayello, PhD, RN, ACNS-BC,
CWON, MAPWCA, FAAN
Kathya Zinszer, DPM, MPH FAPWCA
Participants Will:
Describe an evidence based 60- second screening tool for the high risk diabetic foot
Demonstrate the use of infrared thermography in the care of persons with diabetes mellitus
Identify areas of high pressure and shear on the diabetic foot that can lead to ulceration
Global Type 2 Diabetes Tsunami
IDF Atlas 5th edition diabetes
prevalence (age 20-79)
Guyana
15%
Year Persons with
Diabetes
Comment
2011 365 million • 4.6 million DM related deaths annually
• Spending on DM 465 million US
2030 552 million • 50% increase
• Additional 398 million at high risk
75% of people with diabetes now live in low-and middle-income countries
1) Narayan V, et al. Diabetes: The Pandemic and Potential Solutions. In:
Jamison D, et al., editors. Disease Control Priorities in Developing
Countries. 2nd ed. Washington, DC: World Bank; 2006. p. 591-603.
Plantar Pressure Redistribution
You do not need a lot of money
or resources to make a big difference
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Plantar Pressure Redistribution
Standards of Care - Affordable
In Canada250 patients treated for
less than $7000 Canadian
In Guyana$150-200
$20-25
A Variety of Standard Offloading
Boots and shoes
$20-25
Darco Forefoot & Heel Offloading
Shoe & GlobalPed
$20-25
Forefoot OffloaderRearfoot Heel Offloader
Posterior Heel and Achilles Tendon offloader
Bledsoe & Pneumatic Walking Boots
$20-25
Total Contact Cast: Gold
Standard for Plantar Diabetic
Foot Ulcers
$20-25
Felted Foam: Lower risk for
Plantar Diabetic Foot Ulcers with
severe PDN
$20-25
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Every 20 seconds a lower limb is lost to diabetes somewhere in the world
Vast majority are preventable through patient centred interprofessional care (integrated, coordinated)
Diabetic foot screening (high risk foot) is one of the three most cost-savings diabetes interventions – yet the most neglected (others- HbA1c, blood pressure)
Diabetic Foot – Global View
Source: Williams, International Working Group for the Diabetic Foot & Narayan KV, Zhang P, Kanaya AM, DE, Engelgau MM, Imperatore G, et al. Diabetes: The Pandemic and Potential Solutions.
Disease Control Priorities in Developing Countries [Internet]. Washington D.C. World Bank; 2006 Available from: http://www.ncbi.nlm.nih.gov/books/NBK11777/
Benchmark HbA1c Data
• GPHC: 4302 1st tests – April 2010 to Feb
2013
• 295 F-up tests - 65% adherent to
protocol
• Percentage with HbA1c > 9%
o All persons with diabetes 38%
o Diabetic Foot patients 44%
Mean HbA1c from DFC patients 13% higher than from other facilities
High risk foot status is associated with poor glycemic control
Phase 1- Developed Center of Excellence at GPHC –
Diabetic Foot Centre
Interprofessional teams MD, Nurse, Rehab
Develop Key opinion leaders
4 levels of education – multi faceted,
longitudinal strategies
Focus on Prevention
Wound Bed Preparation Paradigm (Sibbald et al. 2011)
In clinic preceptorships:Doppler, infra-red thermometer, footwear
Provides an early warning sign with patient self monitoring of repetitive
trauma
Acute stage may be 10-15 degrees Fahrenheit warmer than the mirror image on the other foot
Temperature normalization may allow gradual re-ambulation with plantar
pressure redistribution devices
Armstrong DG, Lavery LA: Predicting neuropathic ulceration with infrared dermal thermometry. J Am Podiatr Med Assoc 87:336–337, 1997David G. Armstrong and Edgar J. G. Peters (2002) Charcot’s Arthropathy of the Foot. Journal of the American Podiatric Medical Association: July 2002, Vol. 92, No. 7, pp. 390-394.
EXERGEN scanning thermometer
Charcot foot –Neurological Exam
• Sensory –
– Semmes - Weinstein 5.07 monofilament
– Vibratory test - Diminished
• Autonomic- Dry skin (R/O Tinea)
• Motor-
– Reflex - ankle jerk diminished
Stage Management
0 – Prodromal
? 4-8 deg. F
Non-weight-bearing cast
Minimum immobilization: 8–12 weeks
1 - Developmental, acute
?8-15+ deg. F
Non-weight-bearing cast
Immobilization or graduate to a removable
cast walker
2 - Coalescence, subacute
? 4-8 deg. F.
Patellar tendon-bearing brace (PTB)
Charcot restraint orthotic walker (CROW
walker)
3 - Reconstruction, chronic
Normal/ similar mirror image
Custom-made shoes with or without a brace54
Management of the Charcot Foot:Use the infrared thermometry to measure stages
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Pillars of Charcot Treatment
1. Early recognition
2. Off-loading to reduce
the deformity that will
result from continued
weight-bearing and
3. Management of
complications
Validation of Commercially Available Infrared Thermometers for Measuring Skin Surface
Temperature Associated with Deep and Surrounding Wound Infection
Asfandyar Mufti MD (c)Pat Coutts RN, IIWCCR. Gary Sibbald MD
Advances in Skin + Wound Care Jan 2015
Infrared Thermometer Screens
OBJECTIVE:
• Compare 4 less expensive, commercially available non-contact infrared thermometers to the scientifically accepted Exergen DermaTemp 1001™.
DESIGN, SETTING, AND PARTICIPANTS:
• observational study design• Consenting participants with open wounds were sequentially selected from a chronic wound clinic (n=108). • Skin temperatures were recorded using five non-contact infrared thermometers under consistent
environmental conditions.
MAIN RESULTS:
• No statistical difference was reported between the “ΔT” values for the five different thermometers (F(4, 514) = 0.339, p=0.852)
• intraclass correlation showed high reliability and agreement between raters, as the ICC values for all thermometers were >0.95.
Validation Commercially available low cost infrared thermometers
OBJECTIVE: Non- Contact Infrared Thermometer Comparison: • “whole wound” continuous scanning technique vs. • “head-to-toe/4 perimeter spot point” technique To detect the maximum wound temperature
DESIGN, SETTING, AND PARTICIPANTS:• Observational study design, • Participants with open wounds were randomly selected
from a chronic wound clinic (n=100). • Skin temperatures were recorded using four non-contact
infrared thermometers under consistent environmental conditions.
Infrared Thermometry – Scanning TechniqueRESULTS – “Mean Temperature Gradients”
• average blood sugar over 3 month period– Lifespan of red blood cell
(RBC)
• Glycation of hemoglobin irreversible– average level of glucose to
which RBC exposed
Nathan DM et al. Diabetes Care 31 (8): 1473–8
What is the A1C?
Blood test
which shows
average blood
sugar over
past 3 months
What is
your
A1C (%) ?
Your Average Blood Sugar
13 18 - 19 324-342
12 16 - 17 288-301
11 14 - 15 252-270
10 13 - 14 234-252
9 11 - 12 198-216
8 10 - 11 180-198
7 8 - 9 144-162
6 7 126
mmol/L mg/dl
Translating the hemoglobin A1c assay into estimated av erage glucose v alues
Dav id M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, Dav id Schoenf eld, and Robert J. Heine, f or the A1c-Deriv ed Av erage Glucose
(ADAG) Study Group. Diabetes Care 2008 . Av erage Blood Glucose (mmol) = 1.59 x A1C - 2.59
MH CCACCWCA 2012-Diabetes Related Data
19.3
25.655
Client with Foot Ulcers: Has the client had HbA1c
assessment in the last year
Yes
No
Toronto Regional Wound Healing Clinic Inc2016-03-02
HbA1c blood test measures the percentageof red blood cells that have glucose attached. Normal levels for people with Diabetes is <7.0%.HbA1c should be monitored regularly by physician and patient.
VIPS of Treat the Cause
Vascular
Insufficiency
Inflammation and /
or Infection
Pressure
downloading
Sharp Surgical
debridement
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Diagnostic tests VASCULAR SUPPLY AND HEALING ABILITY