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LABORATORY MEASURES IN DIABETIC FOOT

LABORATORY MEASURES IN DIABETIC FOOT. Dr. Ghanshyam Goyal ILS Multispeciality Clinic S. K. Diabetes & Research Centre, Kolkata. Logic of Foot Examination. DFU are expensive, potentially limb/life threatening but Highly Preventable DFU affect 15% of all Diabetic Subjects

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LABORATORY MEASURES IN DIABETIC FOOT

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  1. LABORATORY MEASURES IN DIABETIC FOOT Dr. Ghanshyam Goyal ILS Multispeciality Clinic S. K. Diabetes & Research Centre, Kolkata

  2. Logic of Foot Examination • DFU are expensive, potentially limb/life threatening but Highly Preventable • DFU affect 15% of all Diabetic Subjects • Pts. DPN have annual incidence of DFU 7.2% • DFU account for 20% of Diabetes-related hospital admission (USA) • Cause of DFU : 45 – 60 % Neuropathic, 25 – 45% are neuro-ischemic, ~10% ischemic

  3. Priorities of Physical Examination • Non-Diabetic Subject – English – Head – to – Foot Examination • Diabetic Subject - Sanskrit - APD ApadaMastak ( Foot – to – head ) Foot Examination is a priority in a Diabetic Subject

  4. High Risk Patients • Duration of Diabetes > 10 years • Male > Female • Poor Blood Glucose Control • Patients with Cardiovascular, Renal or, Retinal Complications John A. Colwell : Diabetes, p.38., 2003

  5. High Risk Foot - Causes • Neuropathies • Vasculopathies • Foot Architecture – Congenital / Acquired • Mechanical – Overweight, Shoes, Callus • Others – Poor vision, elderly, Chronic Hyperglycemia Examination and approach should address these issues.

  6. Sensory Neurons – Fibers Type

  7. Inspection • Skin, nails • Architecture – pes planus, claw toe • Palpation – ADP & Post. Tibial, Bones • Auscultation – bruit • Special • Monofilament • Tuning fork • Biothesiometry (VPT > 25) • Hand-held Doppler

  8. Sensorimotor nerve functions investigated by four bedside tests • Monofilament • Achilles Tendon reflexes • VPT • Tuning fork • Biothesiometer

  9. Lab Measures

  10. Semmes-Weinstein Monofilament • 5 g, 10 g, 75 g • Sites – not standardized (Recommended sites : Great toe, heels & MT heads) • Gently touch skin and apply pressure until filament buckles – ask patient • DO NOT apply on ulcers • Corns & Calluses are usually insensitive • Sensitivity 95%, specificity 87% (10g)

  11. Vibration Perception • 128 Hz Tuning Fork • Large diameter fibers • Sensitivity > 80 % • Specificity ~ 60 – 70 % • Site not Standardized – base of great-toe nail and on medial malleolus

  12. Biothesiometer

  13. Temperature Sensation • Warmth -- Smallest, unmyelinated C fibers • Cold – Small, myelinated Ad fibers • Heating / Cooling detector uses the Peltier principle (metal element is heated or, cooled according to the direction of electric current

  14. Neurotips • Disposable, made up of plastic with a sharp metal end and a blunt end • Marketed by Owen Mumford, Oxford, UK • Detects loss of touch sensation (superior to safety pins, needles or, hat-pins)

  15. HCP Sensitometer . • Assessment of Thermal (Hot/cold) perception threshold

  16. Hand-held Doppler • Excellent tool for vascular assessment at bed-side • Normal sound Biphasic or Triphasic • Atherosclerotic vessels – monophasic • Ankle Brachial Index : < 0.9 usually indicates angiogram positive disease (falsely high because of high S.P. in atherosclerotic vessels).

  17. Ankle / Brachial Pressure Index (ABI) Ankle / Brachial Pressure Index (ABI) • Normal ABI = 1 • Ischemia < 0.85

  18. VASCULAR DOPPLER REPORT

  19. Ankle/Brachial Index • > 1.0 Normal • 0.9-1.0 Minimal disease • 0.5-0.9 Claudication • <0.5 Rest pain, Severe arterial disease

  20. Who Undergoes Vascular Evaluation • All patients with foot lesions • Examination of pulses • ABPI • Duplex scan • Angiography

  21. Foot Pressure studies in DN • Semi Quantitative • Pressure stat • Harris mat • Quantitative • Foot Scan • In shoe technique • Bare foot technique

  22. Pressure Stat Harris mat

  23. Paromed • Static weight bearing • Dynamic Gait pattern • Dynamic Impulses • Quantum values • 3-D analysis of peak plantar pressures during the ambulation period 0 N/cm2 to 19 N/cm2 20 N/cm2 onwards

  24. X-ray Foot • Soft tissue swelling • Foreign body • Gas gangrene • Vascular calcification • Loss of foot arch • Charcot’s arthropathy • Amputations • Osteomyelitis

  25. Foot: MR Imaging • Anatomical details • Osteomyelitis (Abnormal marrow signal, soft tissue mass and cortical destruction) • Neuropathic joint - Disorganised destruction, dislocation, marrow edema, effusion, loss of joint definition

  26. Charcots Foot

  27. Selected Antibiotics Regimens for Initial Empiric Therapy of Foot Infections in Patients with Diabetes Mellitus

  28. Summary • Periodic Examination of Foot is Mandatory in all Diabetic Patients • Identification of Early foot problems can prevent major events & Cost • Identification of High Risk Foot is possible at Primary Care Setting • Education of Physician AND Patient is important for Prevention of Foot Complications

  29. Thank you

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