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Prof. Taj Jamshaid MBBS, FCPS, FPSIM, CHPE, MACG Professor of Medicine – Sharif Medical & Dental College/ Sharif Medical City Hospital, Lahore Executive Member – Pakistan Society of Internal Medicine.

3927100 IVOIaaw 3UOHV1 WWO. Module 1: Types of Diabetes, Screening and , Diagnostic criteria.

Objective of this Program:. Save the limbs because limbs are life.

1 in 4 adult have diabetes 33 Million people have diabetes Prevalence Undiagnosed 30% 26%.

50.9% Diabetic Foot Ulcer. 12-25% Increased risk of ulcer.

Types of Diabetes, Screening and , Diagnostic criteria (CME Already Done).

Key takeaways from ADA 2022 Standards of Care updates: o Comorbidities should be considered when determining first-line therapy All adults should be screened for diabetes beginning at age 35 years O Women with risk factors should be screened for diabetes within 15 weeks of pregnancy.

Microvascular Eye High blood glucose and high blood pressure can damage eye blood vessels, causing retinopathy, cataracts and glaucoma Kidney High blood pressure damages small blood vessels and excess blood glucose overworks the kidneys, resulting in nephropathy. Neuropathy Hyperglycemia damages nerves in the peripheral nervous system. This may result in pain and/or numbness. Feet wounds may go undetected, get infected and lead to qangrene. Macrovascular Brain Increased risk of stroke and cerebrovascular disease, including transient ischemic attack, cognitive impairment, etc. Heart High blood pressure and insulin resistance increase risk of coronary heart disease Extremities Peripheral vascular disease results from narrowing of blood vessels increasing the risk for reduced or lack of blood flow in legs. Feet wounds are likely to heal slowly contributing to gangrene and other complications..

D iet = 50 to 60% of carbohydrates, 25 to 35 % Fats, 15 to 20% Protein I nsulin A ntidiabetic agents B lood sugar monitoring E xercise T ransplant of pancreas or insulin E nsure adequate food intake S crupulous foot care.

Pathophysiology of DFU. Reproduced from [7], with permission from Elsevier, 2006..

Hammer Toe. Claw Toe. Flat feet. High Arched Feet.

Neuropathic Neuroischemic Ischemic.

Neuropathy- A Double Edged Sword. Di a betes EF A Dysmetabolism Dy slipidemia P0130. pathwQ flu: Ahls ct,-LiF0ic Acid A-V shumting Neurqaü-xy Huer4scemia Free transitim mæ.l ions PKCß A1-toxidaåon Inhbitor AGE finnaåon E mogenots scavergers Ractive spaies Ischemia} r.erfl-sim Nerve ard gan4icm bloo:l flow Erdoreurial hypoxia ONCO DAG PKC All NO PGI, EDHF Vascular dFf1-mction.

Semmes-Weinstein Monofilament Test Place Monofilarnent to Skin Testing Sites First Metatarsal Apply Pressure Until Monofilament Buckles Fifth Third Metatarsal Metatarsal Release Sites Show•n to Identify 90% of Patients With Abnormal Test" Other Recommended Sites.

Who can have an Ulcer-People at Risk. Risk Factors for Ulceration General or Systemic Contributions Uncontrolled hyvglycemia Duration of diabetes Peripheral vascular disease Blindness or visual loss Chronic renal disease • Older age Local Issues • Peripheral neuropathy • Structural deformi • Trauma and imprope fitted shæs • Callus • History of prior u amputation • Prolonged elevated 'pressures • Limited joint mobility.

Diabetic foot Infection and Osteomyelitis. S opeJO øpuo C opeuo Z ope-10 opeao O ope•o KJ0Js!q lumeN - unopxeuq 1001 lelnosensKa.

Toe and Flow PAD and Diabetes. About 50% of patients with (CLI), critical limb ischaemia the advanced stage of PAD associated with lower-extremity amputation and significant mortality, also have diabetes and they fare worse than non-diabetics..

Responder Non-responder Before operation 6th month after operation.

MODERN VASCULAR SIGNS AND SYMPTOMS OF PERIPHERAL ARTERY DISEASE PAD is the narrowing of the arteries due to atherosclerosis (plaque buildup on arterial walls) decreasing blood flow to legs, feet, and toes. Left untreated, PAD complications include critical limb ischemia, gangrene, and amputation. Legs get tired but improve with rest 90 Leg Cramps. hard to walk Foot wounds or sores Can't walk far that don't heal 40% of people with PAD don't have leg pain. ModernVascular.com MODERN VASCULAR..

The Diabetic Foot Wounds-Examination and Ulcer Assessment.

Charcot Foot-Still a Dilemma. STAGE O Clinical stage 1 Fragmentation stage 2 Coalescence stage 3 Reparative stage CHARACTERISTICS Erythema, edema, increased temperature to foot Periarticular fractures, joint dislocation, instability, deformed foot Reabsorption of bone debris Stable foot TREATMENT' Limited weight bearing (possibly TCC or PPWB), close observation TCC, limited weight bearing TCC followed by CROW Possible surgical intervention for removal of bony prominences associated with ulceration TCC = total contact cast; PPWB = prefabricated pneumatic walking brace; CROW = Charcot restraint orthotic walker Extra-depth shoes and pressure-relieving orthoses also may be needed. Adapted with permission from Keliklan AS Operative treatment of the foot and ankle. Stamford, Conn.: Appleton & Lange, 799n53..

DIABETIC FOOT CARE. RACGP - Diabetic foot ulcer.

Foot Wear-For Protection and management of foot Ulcers.

H e e l P h a s e / H e e l Str i k e : when we w alk, fi r st o f all t h e h e e l stri k es o n the g r o un d M i d stance P h a s e: t h e w h o l e f o o t i n cl ud i n g the m i dd le p o rti o n s trik e s o n the g r o un d and t h e f e e t bear t h e wh o l e o f t h e b o d y w ei g h t H e e l li f t ph a s e: The h e el r i ses f r o m the g r o un d a n d w e i gh t o f the b o d y is sh i ft e d t o wards t h e f o re f o o t. T o e o ff ph as e : the wh o l e f o o t rises fr o m the g r o u n d a n d b o d y mo v es f o rwar d ..

Foot Examination- Important Elements.

Limbs for Life- Multan Chapter Lecture No. Date Introduction to the Learning Program Types of Diabetes, Screening and , Diagnostic criteria 1 Complications of Diabetes 2 Management of Type 1 and Type 2 Diabetes 3 Diabetic Foot- the Mechanism 4 Who can have an Ulcer-People at Risk 5 Neuropathy- A double edged Sword 6 Diabetic foot Infection and Osteomyelitis 7 Toe and Flow PAD and Diabetes 8 Onsite Workshop- Identification of Neuropathy The Diabetic Foot Wounds-Examination and Ulcer Assessment 9 Wound Classification- Case Studies 10 Charcot Foot-Still a Dilemma 11 Foot Wear-For Protection and management of foot Ulcers 12 Offloading devices for management of Foot Ulcers 13 Standard of Care-Diabetic Foot 14 Onsite Workshop- Diab. Foot Ulcer Classification, Charcot Foot Anatomy of normal foot and ankle, foot arches, foot muscles, ligaments, fat pad, bursae, ankle joint 15 Intervention and circulation of foot, X rays interpretation 16 Foot Examination- Important Elements 17 Onsite Workshop- Foot Wear, Classic Cases of PAD Closing Ceremony.

Question-1: 1 in ______ adults have diabetes in Pakistan..

Question-4: Trauma, Neuropathy and ______ Leads towards foot ulceration..

Question-7: About ______% of patients with Critical Limb Ischemia the advanced stage of PAD associated with lower extremity amputation?.

21 ght. Taj Jamshaid Email: drjamshaid1@gmail.com.