Aspectos positivos y negativos de la programación televisiva y de publicidad

reduce cardiac stress during the preamputation and rehabilitation periods is also essential, more so in patients beginning to mobilise using an artificial limb. ⁹⁰

2.5.7: Other therapies

New information about wound biology has led to a number of new technologies (e.g., living skin equivalents and growth factors such as basic fibroblast growth factor) that may prove useful. Recombinant platelet-derived growth factor has some benefit and complements the therapies of off-loading, debridement, and antibiotics. Hyperbaric oxygen has been used, but rigorous proof of efficacy is lacking.

delaythe emergence of end stage complications of DM suchas blindness, the need for renal replacement therapy, or amputation but is also most cost effective as a "one stop" package. ⁹² Screening for Diabetic Foot Disease can be done by evaluation to identify the four classicrisk factors (deformity,neuropathy, ischaemia, and infection) for developing diabetic foot disease. ⁹²

2.6.2: Identification of the high-risk patient

High-risk patients should be identified during the routine foot examination through identification of the following risk factors from history and clinical examination:

 Lack of social support

 Lack of education

 Previous ulcer/amputation

 Inappropriate footwear

 Callus

 Foot deformities

 Impaired protective sensation (monofilaments)

 Impaired vibration perception

 Absent Achilles tendon reflex

Following clinical examination, the patient should be categorized according to a risk classification system as outlined in Table 6 below. ⁹³

Table 7: Risk categorization system for Diabetic foot ulceration ⁹³

Category Risk profile Check-up frequency

1

no sensory neuropathy once a year

2 sensory neuropathy once every 6 months

3 sensory neuropathy,

signs of peripheral arterial disease and/or foot deformities

once every 3 months

4 previous ulcer once every 1-3 months

2.6.3: Education of patient, family and healthcare providers

Patients whose feet have a high risk of ulceration or amputation need support and education about foot care and may benefit from early evaluation by a specialist multidisciplinary team; they also need to be given prophylactic foot care and special footwear. ⁹²

Foot – specific, individualized, patient education is the most important element of a comprehensive diabetic foot program. ⁹² The objective of education is to change the self-care behaviour of the person with diabetes and to enhance adherence to foot care advice. Furthermore, people with diabetes should be encouraged to recognize potential foot problems and

take appropriate action urgently (i.e. seek professional help). Education should be simple, relevant, consistent, and repeated. ⁹²

Furthermore, physicians and other healthcare professionals should receive periodic education and reinforcement of diabetes management skills to improve the care delivered to high-risk individuals.

Special approaches are needed for elderly patients who, due to poor vision and limited mobility, may not be physically able to examine their feet daily. In this case, help from family members or healthcare professionals should be sought. Socio-economic factors and cultural background should also be taken into account when, for instance, shoes are advised or prescribed. ⁹²

Foot care education should emphasize the following: ⁹²

 Careful selection of footwear. Non constrictive, soft leather or athletic footwear decreases the risk of tissue breakdown from direct pressure. Cushioned stockings are helpful, and white socks make identification of skin breakdown easier, especially in individuals with impaired vision.

 daily inspection of the feet to detect early signs of poor-fitting footwear or minor trauma,

 daily foot hygiene to keep the skin clean and moist. Nails should be cut transversely to decrease the risk of an ingrown toenail.

 avoidance of self-treatment of foot abnormalities and high-risk behaviour (e.g., walking barefoot), and

 prompt consultation with a health care provider if an abnormality arises.

In Nigeria lack of proper education, knowledge and skills by both patients and healthcare providers, as regards the care of the diabetic foot, has been noted to result in insufficient prevention and management in too many patients. ⁸² The need for adequate research in DFU in Nigeria cannot therefore be overemphasized. Simple efforts of identification of those at high risk for DFU, appropriate foot care practices and education of healthcare professionals, patients and their carers, have resulted in significant reduction of the morbidity, mortality and economic burden from DFU, even in resource poor countries, without the need for expensive equipment. ⁹⁴

2.6.4: Appropriate footwear

Shoes protect the diabetic foot against trauma, extreme temperatures and contamination. Patients’ shoes should be checked regularly for size, style and state of wear; and shoes should be assessed to ensure that they are adequate and suitable. Patients without loss of protective sensation can select off-the-shelf footwear by themselves.

For patients with neuropathy and/or ischaemia, extra demands need to be met with regard to the fitting of shoes, especially where foot deformities

are present. ⁹² The use of special footwear made for individual patients at risk is reported to be important in the prevention of recurrent foot ulceration. ⁷²

In the United States, the Medicare Therapeutic Shoe Bill of 1993 provides financial support for 1 pair of appropriate inlay-depth shoes and 3 pairs of custom foot orthoses yearly for individuals with diabetes. ⁹⁵ The non- availability of such footwear in Nigeria may be an important factor for high recurrence rate of DFU in this environment. The time has therefore come, for a concerted effort to provide an effective foot care Programme for patients with Diabetes mellitus in Nigeria.

2.6.5: Treatment of non-ulcerative pathology

There is no such thing as a trivial lesion of the diabetic foot; ⁹⁸ apparently minor lesions can lead to an ulcer and provide an entry point for rapidly ascending infection.

Patients categorized as being at high risk should be treated regularly by a trained foot care specialist. Other interventions directed at prophylactic foot care include callus management, nail care, and prophylactic measures to reduce increased skin pressure from abnormal bony architecture. Attention to other risk factors for vascular disease (smoking, dyslipidemia, and hypertension) and improved glycaemic control are also

important. These preventive programs have been reported to markedly decrease the rates of DFU and LEA by up to 30-50%. ⁹⁸ The items listed below are considered to be important in prophylactic foot care: ⁹²

 Hyperkeratosis (corns and callus)

These occur on sites of pressure and friction, and are often associated with unsuitable footwear. Regular sharp debridement with a scalpel is the treatment of choice; use of keratolytic agents and proprietary remedies are discouraged. Any callus showing signs of associated bleeding, discoloration or bulla formation should be regarded as a clinical emergency and footwear problems should be addressed.

 Tinea Pedis

About 6 - 10% of DFU develop between the toes due to maceration from excessive moisture and fungal infection.⁷⁸

The widespread hot and humid conditions in Africa contribute to a high incidence of fungal infections and provide an environment for the rapid spread of infection. ⁸¹ Fungal infections of the skin may provide an entry point for more serious infections. It presents as numerous, small, itchy vesicles (although the pruritus may be absent in individuals with neuropathy), as macerated hyperkeratosis associated with interdigital fissuring, or in a moccasin distribution of

hyperkeratosis. Topical antifungal treatment is usually successful.

 Onychomycosis

Fungal infection of nails (onychomycosis) is common in people with diabetes. This can be diagnosed by KOH technique. These infections are recalcitrant to topical treatment and systemic anti-fungals are often required. Other nail abnormalities commonly found in people with diabetes include Onychauxis (thickening of the nails), Onychocryptosis (nail deformities such as ingrown toenails), and Onychogryphosis (deformities of the nails).

In conclusion, an effective foot care programme should include the following important aspects elaborated below: ⁹²

 Multidisciplinary Team Approach

In an ideal setting, healthcare professionals from different specialties should be involved in providing care. This should include a diabetologist; surgeon (general, vascular, orthopaedic, and/or plastic);

rehabilitation specialist; physiotherapist; microbiologist; dermatologist;

psychiatrist; nurse; educator; podiatrist; and casting technician.

The multidisciplinary team approach to diabetic foot care has been shown to bring about a 49-85% reduction in amputation rates. This underlines

the need to provide funding and support to create new clinics along a step-wise approach; beginning with a basic model and gradually developing into centres of excellence. ⁹²

 Provision of Podiatry Services

Podiatry is a branch of medical science concerned with the provision of preventive foot care, health education as well as the diagnosis and management of a variety of foot injuries and disorders (local or related to a systemic disease like DM). ⁹⁶

Podiatrists, (also called by several other names, including chiropodist, podologues, podologist, and pedicure), play a pivotal role among the healthcare professionals involved in the multidisciplinary diabetic foot care team with reports of remarkably reduced amputation rates in centres where the service is provided. Unfortunately, this service is currently only available in some parts of Europe and the US; hence, there is an urgent need for podiatry training programmes in many other countries.

To ensure standardization and effective service delivery, podiatrists should be state-registered and regulated by government so that people with diabetes are not put at increased risk by unregulated, unqualified and poorly equipped practitioners. ⁹⁶

In Nigeria, several individuals with minimal or no formal training, ranging from self-acclaimed beauticians to itinerant young, and

middle-aged men claim to provide ‘manicure and pedicure’ services although, these are mainly for cosmetic rather than health-related reasons.

 Involvement of people with Diabetes and Diabetes-representative organizations

People with diabetes and their representative organizations should be encouraged to help establish realistic treatment goals that recognize success in terms of metabolic control, delayed onset or prevention of complications, and sustained or improved quality of life.

This involves collaborative educational initiatives to ensure that informed self-care actions are taken and appropriate lifestyle choices made.

 Provision of Materials and Equipment

Necessary equipment must be provided to diagnose and manage Diabetic Foot Diseases before they worsen and become more costly to treat. This is especially paramount in developing countries where the effects of a chronic lack of resources are manifested in many areas. ⁹⁶ The need for improved funding in the care of the Diabetic Foot is aptly captured in the words of a renowned philosopher, George Bernard Shaw who is quoted thus: ‘I marvel that society would pay a surgeon a large sum of money to remove a person’s leg - but nothing to save it.’ ⁹⁷

In addition, well-designed promotional and educational materials should be made available in sufficient quantities and at strategic locations in the community and hospital environment to inform and educate

patients, their families and carers. Given that most ulcers are caused by poor footwear, appropriate shoes should be readily available to people with diabetes.

2.7. Issues regarding the Diabetic Foot and Developing Countries All over the world, people with diabetes experience diabetic foot

diseases. The spectrum of foot lesions and success of treatment however varies widely depending on economic circumstances, practical limitations, and the availability of professional experience. ⁹⁸

There is an increase in the prevalence of DM worldwide, especially so, in developing countries as a result of urbanization, and adoption of western-type diets and sedentary lifestyle. As a consequence, there is increased DM- related morbidity and mortality. ⁴⁵ Thus, foot complications now

constitute a major public health problem for people with diabetes in these countries. The poor economic situation in these countries and lack of health insurance means that the cost of DM and its complications are too high to be met by most individuals and their families; for example, extreme poverty means the purchase of appropriate footwear is either not feasible or is not a high priority. ⁵¹

A major problem in most developing countries is the lack of data on aspects of healthcare delivery system. ⁵¹ More specifically, data on the burden of the complications of the diabetic foot are sparse or totally lacking in most areas. Even when data is generated, a good record-keeping system is not in place resulting in unnecessary loss of information. ⁵¹ Furthermore, because of a diverse range of ethnic groups with differing languages, culture, religious beliefs and practices, communication and exchange of ideas and information is limited. In addition, widespread illiteracy and common recourse to practices of traditional healing such as scarifications or packing herbal remedies into a diabetic ulcer are of obvious detriment to foot care.

Extreme weather conditions in the face of widespread poverty, poor working environment, and walking barefoot are responsible for damage to the insensitive neuropathic foot. The lack of well developed healthcare infrastructures, compounded by poor communication and inaccessible remote rural populations, presents many people in developing countries

with serious difficulties in terms of access to healthcare. Delays in reaching healthcare facility may result in progression to advanced disease before presentation. Added to this is the chronic shortage of healthcare professionals in most places. While specialist healthcare professionals in most fields are still lacking, the few available ones are located in urban areas. Gaps are filled by poorly trained, inexperienced care providers and sometimes untrained charlatans. ⁹²

In conclusion, the two most significant risk factors for the occurrence of foot ulceration in developing countries are social deprivation and limited access to healthcare. Education targeting healthcare workers and people at risk remains the most powerful preventive tool and should be an integral part of a comprehensive foot-care Programme. ⁹²

CHAPTER THREE: SUBJECTS, MATERIALS AND METHODS