In an exclusive interview given to Citizen News Service onsite at the Amrita Endocrinology, Diabetes and Diabetic Foot Conference (AEDFC 2012) held recently at the Amrita Institute of Medical Sciences (AIMS) in Kochi, two renowned and senior stalwarts of the institute’s Department of Endocrinology, Diabetic Lower Limb and Podiatric Surgery, Dr Harish Kumar and Dr Ajit Kumar Varma, shared some of the latest developments that have taken place at AIMS in the field of diabetic foot management.
Statistics indicate that 15% of all people living with diabetes will develop foot problems related to the disease and if not treated timely, one in 6 patients with diabetic foot ulcer will require amputation. Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. In India and other developing countries the amputation rate is about 45% for diabetic foot problems. However at Amrita Institute this is as low as 8.5% with a limb salvage rate of 91.5% in diabetic foot and ankle diseases.
Diabetic foot conditions develop from a combination of causes including poor circulation and diabetic neuropathy which can cause a loss of ability to feel pain, heat, and cold. People living with diabetes and suffering from neuropathy can develop minor cuts, scrapes, blisters, or pressure sores that they may not be aware of. If these minor injuries are left untreated, serious limb and life threatening infections may occur. Preventing foot complications is more critical for the patient living with diabetes and with peripheral obstructive vascular disease. However, in selected patients with foot wounds, revascularization techniques, including peripheral angioplasties, bypass surgeries and negative pressure wound therapy can be carried out to improve wound healing.
Diabetic peripheral neuropathy is a very disabling problem causing numbness and pain and preventing the patient from sleeping at night. Even high doses of medication are not able to give complete relief. For better management of this problem, anodyne therapy (which is widely used in the West and USA, but relatively new to India) has been introduced in AIMS a few months back. It consists of a machine which converts electrical energy into deep penetrating infra red rays and relieves the disabling neuropathic symptoms to a large extent. The pad with electrodes is kept on the soles of the feet and deep penetrating infra red light goes into the tissues. Nitric oxide from the cell is released which helps in cellular function. Moreover it helps in regeneration of new blood vessels (angiogenesis) improving the nerve function. Even a short period of 7 to 10 days of this therapy has benefitted a large number of patients who had chronically been on long term medication without much relief. Each sitting is of 40 minutes duration costing Rs 500 and normally there are 10 to 14 sittings in one complete course. Sometimes it may need to be repeated after 6 or 8 months. It gives very good relief to the patient and medications are reduced and even stopped completely after a year or so. It is a one of its kind facilities in Kerala and even in the whole of India only 5 or 6 machines have been sold as of now.
Another recent surgical intervention started at AIMS (which is yet to be used anywhere else in the world) is prosthetic foot bone replacement technique for destroyed Charcot bones. Charcot foot is a disabling condition in diabetes in which the bones become soft, powdery and get destroyed completely. Conventionally, these Charcot bones are managed conservatively but in cases where the bone is completely destroyed the patient has to be surgically treated with compression screws and external fixtures. But as the bones are very soft even after reconstruction, the compression screws do not hold well and once the patient walks for a year or so re-collapse occurs. So reconstructing an already soft bone is not of much help. To improve upon this, podiatric surgeons at AIMS are using prosthetics made of a material called poly methyl methacrylate (PMMA). PMMA has a bony consistency and when shaped with the mixer it hardens within 10 minutes. On the surgery table, after removing the destroyed foot bones, the surgeons shape it within this time period like a clay model in the form of the foot bone which is to be replaced. This artificial bone is then fixed to the foot or the tibia with compression screws. In the past two years around 8 such surgeries have been performed at AIMS successfully on patients in whom amputation was otherwise inevitable. The first patient underwent this surgery 2 years ago and continues to walk comfortably. The last patient was operated upon 4 months back. He is from Oman and when advised amputation in his country he came here and got his foot bone replaced with prosthetics and is doing fine. A paper on this unique replacement of destroyed foot bones technique has been sent by the Institute for publication in the journal for diabetic foot complications.
Another researcher at AIMS has found for the first time that fungi are actually colonizing the deep tissues in diabetic foot and many of the deep tissue infections are fungal in nature. Classically, in diabetic foot one thinks of bacterial infections which are treated with antibiotics. But to treat with anti fungal medicines is a new concept. This research shows that not only the fungi are present in the deep tissues, but also that if one treats the fungi then the wounds heal faster. In the study conducted at AIMS, it was found that invasive fungal infections accounted for about 29% of diabetic lower limb infections. This far reaching discovery in the field of management of the diabetic foot problems will alter the way in which diabetic foot infections were being investigated and treated till now.
Another very interesting phenomenon noticed in one of the studies conducted two years ago at AIMS was a marked increase in the number of hospital admissions and the number of surgical diabetic foot procedures during the rainy season, indicating that diabetic foot infections increase sharply during the monsoon period. The culprit is the dirty water overflowing from the drains and flooding the roads of most Indian cities during heavy rains due to faulty drainage systems. This dirty water is full of fecal bacteria. When anyone having even a small lesion or cut in the foot walks through this water, infection is likely to set in. So, during the monsoons there is a sharp increase in the number of patients with diabetic foot problems. Thus insanitation and water logging problems add to the woes of patients living with diabetes.
The incidence of diabetes is very high in Kerala. A study conducted at AIMS a few years ago found it to be as high as 17.5% (against the national average of 9%) in and around Kochi in the adult population and the numbers have gone up since then. Kerala has all the markers of a developed world. One does not find any rural areas there. They are all urban/semi urban regions which have all the urban facilities. Unfortunately, this also means that the incidence of life style diseases, like diabetes, increases.
Diabetes is indeed one of the most challenging health problems of the 21st century. However, despite loud promises, the Indian government and its public health planners still remain indifferent to the serious health implications of diabetes and its complications. The main drivers of the epidemic are economic development and urbanisation, which bring changes in lifestyle, and increasing life expectancy. The health systems of our country do not seem to be currently equipped to meet the rising demand of diabetes and non-communicable diseases. There is an immediate need for awareness programmes to educate people about the methods to prevent diabetes and care of diabetic foot problems.
Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)
