Understanding Diabetic Foot: A Comprehensive Guide For General Practitioners

Description

This book is written as a comprehensive and practical guide for General Practitioners who often manage patients with diabetic foot complications. Topics covered include Types of Diabetic Foot Complications, Basic Science involved, Examining a Diabetic Foot, Doing Investigations and Treating a Diabetic Foot, Endocrine Control, Nutritional Support, Choice of Wound Dressing and Choice of the appropriate Antibiotic. An important chapter, especially useful to the GPs is a practical guide on when to treat the patients in their clinics and when to send them to hospitals for management by Diabetic Foot Specialists. A special emphasis has also been given to guide GPs how to educate their patients on Care of Diabetes itself, Care of the Foot and Choice of Footwear. In addition, this Companion Book to GPs will also be useful to Nurses and Podiatrists who also provide care to Diabetic Foot patients. For the latter, a Supplement has been added. Relevant topics include Team Approach, Nursing a Diabetic Foot, Nutrition, Wound Dressings, Negative Pressure Wound Therapy, Maggot Debridement Therapy, Off-loading & Shoes, Hyperbaric Oxygen Therapy, Charcot Joint Disease and Rehabilitation. Contents Foreword Preface About the Editor List of Contributors Section 1 Introduction to Diabetes Chapter 1 Diabetes in the World Introduction Diabetes Hot Spots in the World India China South East Asia Singapore References Chapter 2 Diabetes in Singapore Today Introduction Changing Dynamics Facts and Figures (Figure 1 — Straits Times, 14 April 2016) Parliamentary Debate on Diabetes, 13 April 2016 War on Diabetes, April 2016 National Day Rally Speech, 2017 References Chapter 3 Prevention of Diabetic Foot: Role of Government Intervention Diabetic Foot Strategy Prevention is Key Patient Education Curriculum for Patient Education Annual Foot Screening Role of Government Involvement Conducting National Public Awareness Programme National Programme for Public Awareness Algorithm for Prevention of Diabetic Foot Summary References Chapter 4 Understanding Diabetes How Insulin Works? Normal Individuals Diabetic Individuals Risk Factors Symptoms Glossary Chapter 5 Complications of Diabetes Acute Complications Acidic Blood — Diabetic Ketoacidosis (DKA) “Thick” Blood — Hyperglycemic Hyperosmolar State (HHS) Low Blood Glucose — Hypoglycaemia Chronic Complications Heart Attack — Coronary Artery Disease Stroke Leg Pain — Peripheral Arterial Disease (PAD) Kidney Damage — Diabetic Nephropathy Eye Problems — Diabetic Retinopathy Nerve Damage — Diabetic Neuropathy Diabetic Foot Complications Glossary Section 2 Introduction to Diabetic Foot Chapter 6 Types of Diabetic Foot Complications Introduction Pathophysiology Neuropathy Vasculopathy Immunopathy Types of Diabetic Foot Problems Skin Infection — Cellulitis Abscess Necrotising Fasciitis Bone Infection — Osteomyelitis Joint Infection — Septic Arthritis Dead Tissue — Gangrene Joint Breakdown — Charcot Joint Disease Ulcers — Wounds Infective Wound Ischaemic Wound Both Infective and Ischaemic Neuropathic Wounds Pressure Wounds Classifying the Diabetic Foot Wound References Chapter 7 Know Your Foot: A simple Guide to Anatomy and Biomechanics of the Foot Introduction The Anatomy Bones of the Leg Bones of the Foot Muscles of the Lower Leg Muscles of the Foot Blood Vessels of the Leg and Foot Nerves of the Foot How We Walk — The Gait Cycle Glossary Section 3 Assessing Diabetic Foot Chapter 8 Examining Diabetic Foot in Your Clinic Introduction History Taking Patient Profile What is the Patient’s Profile? What is the Patient’s Socioeconomic Status? Symptoms Where is the Pain? Is There Vascular Claudication? Is There Rest Pain? Is There swelling? Is There Deformity? Is There an Ulcer? Site of Ulcer Contents of Ulcer Is There Gangrene? Is There Numbness? How Severe is the Numbness? Has the Patient had Recent Trauma? Has the Patient Sustained Self-inflicted Trauma? Does the Patient Self-medicate? What is the Type of Footwear Worn? Medical History What is the Type of Diabetes Mellitus Present? What is the Type of Diabetic Medication Used? Does the Patient Monitor His Diabetes? Does the Patient Know His HbA1C Level? What are the Symptoms of Poorly Controlled Diabetes? What are the Complications of Diabetes Present? What are the Co-morbidities Present? Are Risk Factors of Diabetes Present? Social History What is the Functional Status of the Patient? What is the Patient’s Occupation? Is There a Family History of Diabetes? Is There a Caregiver? Performing the Clinical Examination Position of Patient Perform Step-by-Step Examination General Examination Vital Signs Examine Cardiovascular System Examine Respiratory system Examine Abdomen Local Examination Examining an Ulcer Assessing Diabetic Foot Triad Assessing Vasculopathy Femoral Pulse Popliteal Pulse Dorsalis Pedis Artery (Figure 12) Posterior Tibial Artery (Figure 14) Assessment for Sensory Neuropathy Pinprick Test Position Sense Vibration Sense Ten-Points Semmes Weinstein Monofilament Test (SWMT) (Optional) Assessment for Immunopathy Probe Test References Chapter 9 Investigating Diabetic Foot in Your Clinic Introduction Blood Tests Markers of Infection Markers of Healing Markers of Infection Culture and Sensitivity (c/s) Studies Radiological Tests Chapter 10 Recognising Osteomyelitis in Diabetic Foot Introduction Location Clinical Examination Probe-to-bone Test OM in a Non-healing Ulcer Investigations Blood Investigations Plain Radiographs High Index of Suspicion References Section 4 Treating Diabetic Foot Chapter 11 Treating Diabetic Foot: A Holistic Approach Introduction Holistic Treatment Endocrine Control Nutrition Wound Bed Preparation Time Concept Types of Dressings Negative Pressure Wound Therapy and Negative Pressure Wound Therapy with Instillation Antibiotics References Chapter 12 Antibiotics for Diabetic Foot Infections: A Practical Guide for the General Practitione Introduction Diagnosis Skin and Soft Tissue Infections Osteomyelitis Local Microbiological Data Collection of Specimen for Culture Collecting a Wound Swab Severity of Infection Outpatient Management of Diabetic Foot Infections Choosing the Antibiotic Regimen Duration of Antibiotics Indications for Hospitalisation References Section 5 Dressing Diabetic Foot Wounds Chapter 13 Choosing the Appropriate Wound Dressing: A Practical Guide Introduction Basic Science of Wound Healing Inflammatory Phase Proliferative Phase Maturation Phase Take Home Message Functions of a Dressing Characteristics of An Ideal Dressing Types of Wound Dressings Summary Chapter 14 Dressing A Wound: A Step-by-Step Guide for the General Practitioner Introduction Components of a Wound Dressing Cleansing Solution Wound Product Disposable Dressing Set Procedure Section 6 Managing Patients with Diabetic Foot Wounds Chapter 15 Getting to Know the Operation Performed on Your Patient Introduction Surgical Debridement Split Skin Grafting Minor Amputations Classification on Amputations Ray Amputation Trans-Metatarsal Amputation Mid-foot Amputations Pirogoff Amputation Why Distal Amputation Preferred Major Amputations Below-knee Amputation Above-knee Amputation References Chapter 16 When to Refer Diabetic Foot Complications? Introduction Performing Diabetic Foot Screening What is Diabetic Foot Screening? History Examination Referring Abnormal Findings of Diabetic Foot Screening Patient Education Referring Diabetic Foot Complications that Present to Your Clinic References Section 7 Educating Patients with Diabetic Foot Wounds Chapter 17 Living with Diabetes What is Diabetes? Causes Symptoms Complications Diagnosis Treatment: Medication Insulin Injections — Type 1 Diabetes Oral Tablets — Type 2 Diabetes Monitoring Hypocount Self-monitoring HbA1c Test Eye Examination Foot Screening Healthy Lifestyle Diet General guidelines on diet Weight Exercise What types of exercises are suitable? No Smoking Tips to help you stop smoking No Alcohol Chapter 18 Taking Care of the Foot Introduction Step 1: Foot Hygiene Step 2: Skin Care Step 3: Nail Care Step 4: Inspecting Your Feet Step 5: First Aid for Foot Managing Abrasions or Minor Cuts Managing Insect Bites and Stings Managing Bleeding Managing Burns and Scald Common Misconceptions Summary Tips and Checklist Checklist for Daily Inspection When Travelling Flying to Your Destination Upon Arrival In Subtropical or Tropical Countries Foot Screening Frequency and Duration Where What to Expect: The Procedure What to Bring + Wear Chapter 19 Choosing Your Footwear Introduction What Makes a Good Shoe? Avoid These! Choosing Your Shoes — Do’s and Don’ts Before Wearing Shoes Fact or Fiction? Test Yourself! Checklist Chapter 20 Education Pamphlets 1. Knowing Diabetes 2. Happy Feet 3. A Patient’s Guide to Footwear Section 8 Supplement for Nurses & Podiatrists Chapter 21 Team Approach for Diabetic Foot Introduction A Multidisciplinary Team Members Function of a Multidisciplinary Team Weekly Team Round Multidisciplinary Teaching Sessions Clinical Pathway Surgery Outpatient Clinics Patient Education Outcome of a Multidisciplinary Team Approach (Figure 2) Amputation Rates Complication Rates Costs References Chapter 22 Managing Diabetic Foot Ulcers — A Nursing Perspective Introduction Identification of the At-Risk Foot History Holistic Assessment Skin Conditions Hygiene Nursing Consideration for Hygiene Deformity Nursing Consideration for Deformity Footwear and Device Nursing Consideration for Footwear and Device Qualities of a Good Dressing Protocol Patient Education on Foot Care Conclusion References Chapter 23 Nutrition and Diabetes The Role of Nutrition and Wound Healing Macronutrients Fluids Fat Carbohydrates Protein Micronutrients Vitamin A Vitamin C Vitamin D Other Micronutrients Zinc Iron Trace Elements Summary References Chapter 24 Dressings and Alternative Therapies Introduction Wound Bed Preparation Medical Management Endocrine Control Medical Nutrition Therapy Dressing of Diabetic Foot Ulcers Types of Wound Dressings How to Choose an Appropriate Dressing Adjunctive Therapies References Chapter 25 Negative Pressure Wound Therapy Basic Science Application of VAC Dressing Case Study Case Study 2 Innovative Techniques and NPWTi White Foam Veraflo Therapy (NPWTi) References Chapter 26 Maggot Debridement Therapy Introduction Basic Science Case Study 1 Case Study 2 References Chapter 27 Offloading Diabetic Foot Introduction Offloading Devices Specialised Footwear Ready-Made Diabetic Shoe Offloading Insoles Forefoot Wedge Offloading Shoe Heel Wedge Offloading Shoe Charcot Joint Disease (CJD) and Offloading Offloading Walking Devices Custom-made Footwear References Chapter 28 Footwear and Offloading for Diabetic Foot Persons Introduction Definition of Footwear Facts About Load on Foot DM Foot Cycle and Roles of Offloading Footwear 2019 IWGDF Guideline for Prevention and Offloading Footwear Offloading Modalities Total Contact Cast Ankle Foot Orthosis (AFO) Common Foot Orthosis for Diabetic Foot Patients Common Shoe Modification for Diabetic Foot Patients Custom Moulded Shoes Shoes for Diabetic Foot Patients Characteristics of Proper Shoes Characteristics of Improper Shoes Proper Shoes Fit 10 Tips to a Great Shoe Fit Socks Risk Category and Recommending Footwear Conclusion References Chapter 29 A Quick Look into Hyperbaric Oxygen Therapy Introduction Hyperbaric Oxygen Therapy Effects of HBOT on Wound Healing Case Study Normobaric Oxygen Challenge Test HBOT and Necrotising Fasciitis HBOT and Microangiopathy HBOT or no HBOT? — The Continuing Controversy References Chapter 30 Charcot Joint Disease Introduction Historical Background Epidemiology and Etiology Pathogenesis Neurotraumatic Theory Neurovascular Theory Modern Theory Medical History Clinical Phases of CJD Acute Phase Bone Destruction/Deformity Phase Stabilisation Phase Radiological Presentation Atrophic Hypertrophic Eichenholtz Classification System Stage 0: At Risk Stage — The “Charcot in Situ” Stage Stage 1: Developmental Stage — Acute Stage Stage 2: Coalescent (Quiescent) Stage Stage 3: Remodeling Stage Brodsky’s System of Classification Type 1: Tarsometatarsal (Lisfranc’s) joints Type 2: Hindfoot Type 3 Type 4: Multiple Regions Type 5: Forefoot Clinical Examination Investigations Hematological and Biochemical Studies Tissue Biopsy Radiographs Conservative Treatment of CJD Acute Phase Offloading with Total Contact Cast Offloading with Walking Devices Custom-made Footwear Adjunctive Therapy Operative Treatment of CJD Outcome of Treatment References Chapter 31 Necrotising Fasciitis Introduction Types of Necrotising Fasciitis History Profile of Patients Predisposing Factors Comorbidities History Pathophysiology Examination Clinical Findings Investigations Microbiological Tests Radiological Tests Bedside Finger Test Treatment Antibiotics Combination Therapy NUH Antibiotics Guidelines Medical Treatment Surgery Complications Mortality References Chapter 32 Rehabilitating the Below-knee Amputee Introduction Pain Control Wound Care and Oedema Control Contracture Prevention and Joint Range of Motion Physical Conditioning Psychological Support and Education NUH Below-knee Rehabilitation Programme Criteria for Discharge Plan for Discharge Follow-Up Clinic Appointments Stump Preparation for Prosthesis Fitting Cost of Prosthesis References Appendix A NUH Diabetic Foot Team Need for Diabetic Foot Service Research Teams for Diabetic Foot First Research Team, 2005 Second Research Team, 2006 Third Research Team, 2007 Fourth Research Team, 2008 Fifth Research Team, 2009 Sixth Research Team, 2010 Seventh Research Team, 2011 Eighth Research Team, 2012 Ninth Research Team, 2013 Tenth Research Team, 2014 Eleventh Research Team, 2015 Twelfth Research Team, 2015 Publications by NUH Diabetic Foot Team Books Book Chapter Publications in Journals Courses On Foot Screening First Training Course for Diabetic Foot Screening (2006) Second Regional Training Course for Diabetic Foot Screening (2007) Third Regional Training Course for Diabetic Foot Screening (2008) Fourth Regional Training Course for Diabetic Foot Screening (2010) Fifth Regional Training Course for Diabetic Foot Screening (2011) Conclusion Appendix B History of Asia Pacific Association for Diabetic Limb Problems Introduction Third APCDLP Fourth APCDLP Fifth APCDLP Sixth APCDLP Seventh APCDLP Eighth APCDLP Ninth APCDLP 10th APCDLP 11th APCDLP 12th APCDLP 13th APCDLP 14th APCDLP 15th APCDLP 16th APCDLP 17th APCDLP Next Three Conferences Office Bearers of APADLP from 2000 to 2002 Past Presidents of APADLP