งานนำเสนอเรื่อง: "Every 30 seconds, a lower limb is lost to diabetes somewhere in the world นำเสนอโดยนพ.เพชร รอดอารีย์ ประชุมเรื่องเบาหวานกับการดูแลเท้า ณ โรงแรมมารวยกาเด็นท์"— ใบสำเนางานนำเสนอ:
1Every 30 seconds, a lower limb is lost to diabetes somewhere in the world นำเสนอโดยนพ.เพชร รอดอารีย์ ประชุมเรื่องเบาหวานกับการดูแลเท้า ณ โรงแรมมารวยกาเด็นท์ กรุงเทพมหานคร วันที่ 21 พ.ย. 2548
2Diabetes Complication in the Thailand Diabetes Registry From 9414 subjects register in the project, we find that they have more common microvascular complication that the macrovascular diseases. This is probably due to method of diagnosis. The CVD is an symptomatic and have overt clinical diseases, whereas the microvascular disease in mostly in the early stage because we use screening test such as urine microalubumin as a diagnostic tool.But this information telling us that we will facing huge number of retinopathy and renal disease in very near future if we do nothing in term of preventive measurement.
3Risk of amputation Factors Without amputation With amputation Adjust OR (95% CI)P-value of adjust ORHbA1C > 7 (%)69.274.60.6( )0.082Present of retinopathy (%)3075.62.2( )0.004Blindness (%)2.613.91.7( )0.159History of foot ulcer (%)4.786.659.2( )< 0.001Absent peripheral pulse (%)3.440.15.3( )Insulin use (%)28.467.61.9( )0.023
4Lower limb amputation in Thailand Diabetes registry (TDR) Amputated1.5%Belowknee31.7%Toe64.1%A.K. 4.2%3.9% absence of pulse5.9% foot ulcerABI had not been done in the diabetes registry project. But we found that 3.9% had absence of pulse and 1.5% had been amputated. But luckily most of them is only toe amputation, and only 4% undergone above knee amputation. The major risk of amputation are history of foot ulcer and the absence of pulseHistory of foot ulcer 59.2( ) <0.001Absent pulse 5.3( ) <0.001OR: Hx of foot ulcer = ( )OR: absence of pulse = 5.3 ( )Diabetes Registry Project 2003The Endocrine Society of Thailand
5UNADJUSTED FREQUENCY OF PAD USING ABI BY GENDER AND COUNTRY 5101520253035KoreaIndonesiaThailandTaiwanChinaPhilippinesHong KongMaleFemaleAll%The last complication is peripheral artery disease. In and PAD epidemiologic study using ABI as a screening test test for PAD in diabetic patient age over 50 with another one risk factor for atherosclerotic disesae. We found that Thailand have anormal ABI less that 0.9 about 15 % which is again in an average of other asian countries.CountriesPAD Epidemiologic study (PAD-SEARCH)
6Screening and monitoring for diabetes complications in the past 12 months YesNoEyes exam.67.432.1Retinopathy34.2Cataract33Feet exam.58.141.8Any problems13.5SM blood glucose8.590.5SM urine glucose1.398.167% had eyes exam58% have foot examSMBG only 8.5%Achive standard of careRef: Diabcare-Asia 2003 Thailand (in press)
7PAD in Diabetes Over 1/2 are asymptomatic or have atypical symptoms About 1/3 have claudicationThe risk of PAD in diabetes is increased by age, duration of diabetes, presence of peripheral neuropathy and some ethnicsDiabetes Care 2003;26:
9Mortality Over a Period of 10 Years in Patients with Peripheral Arterial Disease N Engl J Med 1992;326:381-6
10PAD: symptoms & signs Absense Pulse Cold sensation Shiny skin Pallor Loss of hair on foot & toesIntermittent claudicationNocturnal & rest painGangrene , Ulcer
11Intermittent Claudication 0.00-0.40 Severe PAD ABI (Ankle Brachial Index)Systolic ankle blood pressureSystolic brachial blood pressure> Non compressibleNormalMild to moderate PADIntermittent ClaudicationSevere PADRest pain, Ischemic ulcerNEJM 2001:344:21:p
12Role of primary clinician Establish the diagnosis of PADsymptomatologyABIOther vasucular lab. TestDiscuss the risk/benefit of therapeutic alternativesModify risk factors of systemic atherosclerosisPerform treadmill stress testingRefer to exercise programmeNEJM 2002; 347(24);
13Treatment for claudication Dose/interventionEfficacysafetyExercise35-50 min/day3-5 time/wkTreadmill/track walking% improvement in max. walking distance and QoL.Well tolerated; CVD complications are rareAngioplastyBased on anatomyImprove max. walking distance equal to exercise; improve QoL equal to surgery<0.5% morbidity and mortalitySurgery75-100% improvement in max. walking distance;improve QoL.2-3% mortality;5-10% morbiditypharmacotherapyNEJM 2002; 347(24);
14Questions Question 1: Any change in the foot since the last evaluation Question 2: Does the patient have a foot ulcer now or a history of foot ulcer?Question 3: Is there pain in the calf muscles when walking--i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest?
15Toe Deformities (Hammer/Claw Toes) Bunions (Hallux Valgus) Foot ExamItem 1: Are the nails thick, too long, ingrown, or infected with fungal disease?Item 2: Foot DeformitiesItem 3: Pedal PulsesItem 4: Skin ConditionToe Deformities (Hammer/Claw Toes)Bunions (Hallux Valgus)Plantar View of Charcot Joint
16Sensory Foot ExamThe sensory exam should be done in a quiet and relaxed settingApply sufficient force to cause the filament to bendThe total duration of the approach approximately 1-2 seconds
17Risk Categorization Risk Category Definition Management Guidelines High RiskOne or more of the following:Loss of protective sensationAbsent pedal pulsesSevere foot deformityHistory of foot ulcerPrior amputationConduct foot assessment every 3 months.Demonstrate preventive self-care of the feet.Refer to specialists and a diabetes educator as indicated. (Always refer to a specialist if Charcot joints are suspected.)Assess/prescribe appropriate footwear.Certify Medicare patients for therapeutic shoe benefits.Place "High Risk Feet" sticker on medical record.
18Risk Categorization Risk Category Definition Management Guidelines Low RiskNone of the five high risk characteristics below.Conduct an annual foot screening exam.Assess/recommend appropriate footwear.Provide patient education for preventive self-care.
19Management Plan patient education, any diagnostic studies, footwear recommendations,referrals,follow-up care.
21Ischemic Ulcer Treatment Guideline Evaluate severity of ischemiaMildModerateSevereGoodEvaluateHealth StatusEvaluate status ofPeripheral arterieswith AngiographyPoorGoodPoorConservativeTreatmentArterial BypassSurgeryAmputation
22Risk factors for foot ulcer Peripheral neuropathyAutonomic neuropathyPeripheral Arterial disease (PAD)Limited joint motionFoot pressure abnormalitiesFoot traumaUncontrolled and Duration of diabetesBlindnessRisk for amputationPeripheral neuropathyVascular insufficiencyInfectionHx of fooot ulcer/amputationDeformitiesTraumaVision losePoor glycemic control