WORLD DIABETES DAY 16TH NOVEMBER 2011

1. WORLD DIABETES DAY16TH NOVEMBER 2011 KOCAELI UNIVERSITY KIRSTEN LARSEN COPENHAGEN

2. PODIATRY ANDFOOT ULCER PREVENTION KEYWORDS: ORGANIZATION EXAMINATION EDUCATION TREATMENT FOLLOW-UP

3. FEDERATION INTERNATIONALE DES PODOLOGUES AUSTRTALIA,BELGIUM, CANADA CYPRUS,CZECH,FINLAND, FRANCE,GERMANY,GREECE, HONG KONG,ICELAND,IRE- LAND,ISRAEL,ITALY,MALTA, MAROCCO,NEW ZEALAND, NORWAY,PERU,PORTUGAL,SPAIN, SOUTH AFRICA,SWEDEN, SWITZERLAND,THE NETHER- LANDS,GREAT BRITAIN, AMERICA, URUGUAYA

4. FIP CO-WORK WITH WHO WORLD CONGRESS EVERY 3 YEARS QUARTERLY MAGAZIN: � FOOTSTEPS� INTERN.EDUCATION AND RESEARCH SUBCOMMITTEE ACADEMY OF PODIATRIC MEDICINE ESPECIALLY for DIABETES MELLITUS

5. PODIATRY EDUCATION DENMARK: 18 MONTHS 30 HOURS/WEEK 40% THEORETICAL, 60% CLINIC AND HOSPITAL-TRAINING + WORKWHOP(INSOLES AND ORTHOTICS) 2 STATE-SUPPORTED SCHOOLS, 150/YEAR EDUCATION: FREE OF COSTS MOST STUDENTS ARE FORMER HEALTH CARE PROFESSIONALS, SOME FEW DIRECTLY FROM HIGH SCHOOL OR OTHER PROFESSIONS

6. CONTENT OF EDUCATION ANATOMY,FYSIOLOGY,INFECTIONS- PATHOLOGY,MICROBIOLOGY, ORTO- PEDY,DERMATOLOGY,PSYCOLOGY, HEALTH-PAEDAGOGIC,TREATMENT- PRINCIPLES,DOCUMENTATION, TREATMENT OF NORMAL/ABNORMAL SKIN/NAILS, NAILBRACES, INSOLES AND ORTHOTICS

7. STATE-AUTORIZATION AFTER EXAM POSSIBILITY FOR CONTRACT WITH NATIONAL HEALTH SYSTEM INSURANCE LIKE OTHER HEALTH PROFESSIONALS POST-GRADUATE COURSES WITH HEALTH CARE PROF.AND OUR ASSOCIASTION

8. THE GOAL ABLE TO DIAGNOSE DISEASES IN THE FOOT/LEG, EDUCATE THE PTT. IN SELFCARE, NON-INVASIVE TREAT- MENT, PROTECTION OF PRESSURE POINTS. IN DIABETIC FOOTULCERS DEBRIDE AND PROTECT ULCERZONE , CORRECT DEFORMITIES BY INSOLES AND SILICONE-ORTHOSES CORRECT INGROWN NAILS BY NAIL-BRACES.

9. THE MULTIDISCIPLINARY IWGDF ORGANIZING AND PUBLISHING AN INTERNATIONAL CONSENSUS ON THE DIABETIC FOOT AVAIABLE WWW.IDF.ORG/BOOKSHOP -------------------------------------------------------- REVISED BY IDF

10. 10TH SCIENTIFIC MEETING POTSDAM,GERMANY28TH � 30TH SEPTEMBER 2012

11. THE DIABETES TEAM IN DENMARK HAS INCLUDED PODIATRIST SINCE THE 1970-IES NOW MOST EUROPEAN COUNTRIES HAVE

12. ALARMING PROPORTIONS ABOUT 15% OF THE DIABETIC PATIENTS WILL SUFFER FROM A FOOT � ULCER ONCE OR MORE DURING THEIR LIFETIME

13. ORGANIZATION OF FOOTCAREIN DENMARK FOR DM GPs PRESCRIBE PREVENTATIVE FOOTCARE AND EDUCATION AT PODIATRISTS� STATESUPPORTED WITH 50% 1 � 6 TIMES/YEAR ACCORDING TO THE RISK-PROFILE.

14. PRESCRIBED FOOTWEAR STATESUPPORTED BY 90% INSOLES BY 100 % ORTHOTICS BY 50% PROSTHETICS FOR LEG AMPUTATION 100 % CO-WORK PODIATRIST/ SHOEMAKER

15. PODIATRY IS WHATPODIATRISTS DO FOOT STATUS: SENSATION, BLOODSUPPLY, JOINTFUNCTION, GAIT-ABNORMALITY, SHOE-CONTROL, CLASSIFICATION IN RISK GROUPS EDUCATION ACCORDING TO RISK FACTORS. TREATMENT OF CORNS/CALLUS, NAILPROBLEMS, PROTECTION OF PRESSURE POINTS BY INSOLES AND ORTHOTICS

16. MANY PODIATRISTS WORKPARTTIME IN AN OUT-PATIENT CLINICAND PARTTIME IN THEIRPRIVATE CLINIC, OFTENWITH 1-2 COLLEAGES

17. WHEN A FOOTULCER OCCUR PATIENTS ARE REFERRED TO A PUBLIC DIABETES OUT-PATIENT CLINIC FOR FURTHER EXAMINATION: CULTURE HbA1c X-RAY TOE-BLOOD-PRESSURE, ORTHOP.CONSULT. OFFLOADING DEBRIDEMENT BY THE PODIATRIST IN THE HOSPITAL TEAM

18. AFTER HEALING PATIENT RETURNS TO THE PRIMARY SECTOR�S PODIATRIST FOR RE-EXAMINATION OF FOOT-STATUS RE-EDUCATION � NEW RISK-PROFILE NEW SHOES/ INSOLES /ORTHOTIC REGULARLY FOOTCARE

19. COST-BENEFIT THIS 25 YEARS CONTRACT ARRANGEMENT HAS PROVED COST- EFFECTIVE NUMBER OF FOOTULCERS DECREASED MINOR AMPUTATIONS IN-CREASED MAJOR AMPUTATIONS DECREASED

20. RISK-GROUP PATIENTS FOOTULCER-PREVIOUS FOOTULCER PREVIOUS AMPUTATION NEUROPATHY FOOT-DEFORMITY CHARCOT-FOOT LACKING FOOTPULSES OEDEMA NEPHROPATHY NAIL ABNORMALITIES WEEK EYE-SIGHT/OLD AGE/LIVING ALONE

21. SURVIVAL IS REDUCED IN PATIENTS WITH INFECTED NEURO-ISCHEMIC ULCERS 50% DIED WITHIN THE YEAR OF INFECTION Pendry E & Edmonds M, DFSG, 2006

22. A PREVIOUS FOOT ULCER IS ASSOCIATED WITH A 10 � FOLD HIGHER RISK OF AMPUTATION INFECTION WITH A 6 � FOLD HIGHER RISK COMPARED TO NON-INFECTED Reiber GE et al Ann Intern Med 117,97-105,1992

23. MAJOR AMPUTATIONS 85% IS PRECEEDED BY A NON- HEALING FOOTULCER FOOTULCERS OCCUR WHEN PREVENTION FAILS

24. QOL FOOTULCERS MAY LEAD TO ISOLATION DEPRESSION (FEAR FOR AMP.) LOST INCOME DROP-OUT OF DIABETES-CONTROL ECONOMICAL BURDEN FOR THE SOCIETY

25. MOST FOOT ULCERS CAN HEALRELAPSES CAN BE PREVENTED REASON IS DIAGNOSED/TREATED TOE-BLOOD PRESSURE > 30 mmHg PATIENT IS WELL-EDUCATED ULCER IS WELL DEBRIDED INFECTION CONTROLLED FOOTWEAR IS SUITABLE PRESSURE POINTS OFF- LOADED/ PROTECTED

26. INFECTION? PAIN AND ERYTHEMA MAY BE ABSENT DUE TO NEUROPATHY, DIMINISHING AXON REFLEX AND FAILURE OF VASO- DILATATION FEVER AND LEUCOCYTOSIS MAY BE ABSENT EVEN IN OSTEOMYELITIS FREQUENT INSPECTION !

27. WAGNER GRADE 0 MOBILE:INSOLES � RIGID:ROCKERBARMOBILE:INSOLES � RIGID:ROCKERBAR

28. Localization of ulcers

29. DAILY LIFE FOR MANY TOES

30. SIMPLE METHOD FOR NEUROPATHIC PATIENTS

31. MIRROR � BOXEASY AND SIMPLE CONTROL .

32. INGROWN TOENAILS

33. TOE-BP-MEASUREMENT

34. AFTER TOE AMPUTATION

35. MALLEOLUS ULCER

37. AFTER MAJOR AMPUTATION

38.  PREVENTION AND TREATMENT OF ULCER-ATION OF THE FOOT IN UNI-LATERALLY AMPUTATED DIABETIC PATIENTS 11/20 PATIENTS HAD A NON-REPORTED FOOT ULCER! Larsen K et al Acta orthop.scand.53,481-85,1982

39. CONSEQUENCES OF TOE AMPUTATION

40. AFTER MINOR AMPUTATION

41. HEALING OR NOT SEVERITY OF ISCHEMIA AND INFECTION COOPERATION EXPERT-TEAM AVAILABLE FUNDING CONDITIONS

42. OEDEMA

43. BULLOSIS DIABETICORUM

44. THE CHARCOT FOOT I

45. THE CHARCOT FOOT II

46. MUSGRAVE PRINT

47. CHARCOT ANKLE

48. INFORMATION ABOUTRECURRENCE � BIG VARIATION 25-50% OF RECURRENCE EVEN IN INTERVENTION GROUPS UP TO 80% OF RECURRENCE HAS BEEN REPORTED

49. AIRCAST REMOVEABLE

50. CAUSES FOR RE-ULCERATION/NEW ULCERS NEUROPATHY FOOT DEFORMITY INSUFFICIENT FOOTWEAR WERE THE CAUSES IN 63% OF ULCERS �CONTROL YOUR STRATEGIES� Reiber GE, Lavery LA et al Diabetes Care 22, 157-162, 1999

51. CAUSES FOR RE-ULCERATION HEART DISEASE PERIPHERAL ARTERIAL DISEASE WERE THE MAJOR REASON IN 20% RECURRENCE IN AN INTERVENTION GROUP AND A MORTALITY RATE OF 51% FAGLIA ET AL, Diabetes Care 2001

52. CAUSES FORRE-ULCERATION - NEW ULCERS THE MOST OFTEN MENTIONED: RE-EDUCATION LACKING FOOTWEAR INSUFFICIENT PODIATRY LACKING ISCHEMIA INCREASING REPORT DELAYED DROP-OUT OFTEN REPORTED

53. COST-BENEFIT SPECIALIZED FOOT-CARE FACILITIES IMPROVED HEALING COST-REDUCTION OF 50% Pieber TR et al J.Eval.Clin.Pract.13,2007

54. RESULTS MINNESOTA, USA, A 3-YEAR STUDY FREE PODIATRY, EDUCATION AND SHOEWEAR: REDUCTION IN MAJOR AND MINOR AMPUTATION: 48% NUMBER OF 1ST AMPUTATION DECLINED FROM 21/1000 RISK-GROUP PTT TO 6/1000 - - Rith-Najarian S et al, Fam Pract, 1998 Aug; 47(2): 127-32

55. DOES MY PATIENT UNDERSTAND THECONSEQUENCES OFHIS NEUROPATHY?DOES MY PATIENT SUFFERFROM UNNESSESARY FEARFOR AMPUTATION?!!!!!!

56. BENEFIT OF EDUCATION THE PATIENTS PRESENT THEIR FOOTPROBLEM EARLY, REDNESS OR TEMPERATUR-DIFFERENCE MAY BE REASONS THE PATIENT LEARN TO ACT AS A MEMBER OF THE DIABETES-TEAM, RESPONSIBLE FOR BG, OFFLOADING REGIME ETC.

57. CONSENSUS-REPORT: GROUP EDUCATION FOR FOOT- ULCER PREVENTION IS OBSOLET SAVE THE TIME FOR A GOOD EXAMINATION AND A GOOD EDUCATION OF THE RISK-GROUP PATIENTS

58. RISK-GROUP PATIENTS FOOTULCER-PREVIOUS FOOTULCER PREVIOUS AMPUTATION NEUROPATHY FOOT-DEFORMITY CHARCOT-FOOT LACKING FOOTPULSES OEDEMA NEPHROPATHY NAIL ABNORMALITIES WEEK EYE-SIGHT/OLD AGE/LIVING ALONE

59. MANUFACTURED SHOESSPECIALLY DESIGNED 1-YEAR STUDY, ITALY 69 PATIENTS 27% RECURRENCE INTERVENTION GROUP 58% CONTROL GROUP Uccioli L et al Diabetes Care l8,1376-781995

60. PRESCRIBED FOOTWEARCOMMON PITTFALLS FORMER LAST USED WITHOUT NESSESARY MODIFICATIONS 2) TOE-BOX TOO LOW 3) SHOES TOO NARROW 4) SHOES TOO SHORT 5) SHOES SENT BY MAIL 6) NO GUIDELINES TO SHOEMAKER Larsen K et al DFSG 2004

61. PRESCRIBED FOOTWEAR CONTROL BEFORE WEARING BY PODIATRIST (HOSPITAL/PRIMARY SECTOR) 69% SATISFACTION AFTER CORRECTION S MOST SHOEMAKERS HAVE NOW CO- WORK WITH PODIATRIST IN THE PRIMARY SECTOR , Podiatry-study 2004

62. METHODS FOR PRESSURE RELIEF IN-DEPTH-SHOES (without individually made insoles) HAVE EFFECT ON DORSAL PRESSURE AFTER 6 MONTHS NO REDUCTION IN PLANTA PRESSURE Habershaw et al, l996

63. PRESSURE RELIEF SILICONE � INJECTIONS IN PLANTA PEDIS (Metatarsal heads) PRESSURE RELIEF AFTER 1 YEAR 50% - - - 2 YEARS 0% Van Schie, 2006

64. SUCCESS CRITERIA(?) A 3-YEAR STUDY, VERY EXPERIENCED UK CLINIC 370 ULCER PATIENTS 230 PTT BECAME ULCER-FREE 48 PTT DIED WITHIN 31 MONTHS 121 PTT BECAME NEVER ULCER-FREE 92 PTT HAD RECURRENT OR NEW ULCER WITHIN 4 MONTHS

65. SUCCESS CRITERIA? THE HEALING RATE OF ULCERS? THE ABSENCE OF RECURRENCE? REDUCTION OF MAJOR AMPUTATION? LOW MORTALITY RATE?

66. ULCER-FREE SURVIVALFOLLOWING MANAGEMENT OF FOOTULCERS IN DIABETES Pound N et al, Diabetes Med 22: 1293-94,2005

67. KEEPING DIABETIC PATIENTS MOBILEIS ENCOURAGINGBRAND THE DIABETIC FOOTTO YOUR YOUNG DOCTORS