Outcome the Diabetic Foot in shifa hospital on 2016. Dr. Tayseer Altanna Consultant vascular surgery and Diabetic Foot care.

D. Foot wisdom 1*Every hand can be make dressing of the wounds But not every eye can be to see the wounds . 2*In D. Foot you get the less of damage no the best of result .

Since 2010 years the D. F patients admitted in vascular Deportment *Since 2010 years the D.F patients admitted in vascular Deportment . After the head of department Al-Jadba decided that . Befor that date the D.F patients admitted in defferent departments so the shifa hospital the first in Palestine had D. foot unite .

Diabetes : It is Chronic -Epidemic - Costly –complex and serious diseases . D- Foot : one of the most chronic complication of DM due to neuro-angio-arthro-retino-pathy and infection . Every 10 sec detected -3- new cases of DM Every 60 sec detected -2-new cases of DF Every 20 sec detected -1- cases L.L amputation .

Prevalence of DM , DFP in the world Des 2016 Years 10% 170 millions 2000 15% 220 millions 2004 20% 300 millions 2008 30% 360 millions 2012 40%-50% 430 millions 2016 ????? 700 – 750 mill 2030

The first five countries with largest of DM . D-patients Country 55 millions India 52 million China 30 million USA 20 millions Russian 16 millions Germany

The first five counties highest of D-M patients ع D-patients Country 35%-40% KSA 35% UAE 32% Kuwait 30% Bahrain 28% Qatar

Diabetes in Palestine : Palestine presented in the 10 postion between the Arab countries . The Diabetes in Palestine prevalent about 16-18%but the DFP about 35-40% . In West Bank the Diabetic patients 250000 In Gaza strip the Diabetic patients 200,000

Amputation due to trauma Amputation L.L in DM : - Amputation L.L SMC 2010 12% Amputation L.L SMC 2016 7,6% Amputation due to D-F Amputation due to trauma In minute 3-limbs Every 30 minute 1- limb In hour 180-limbs In hour 2- limbs In day 4000-limbs In day 48- limb In year 1400,000 limbs In year 1800 limbs

D-Foot in SMC on Vascular department The total number of admission in vascular department Jan 2010 – Dec 2016 . 6892 3288 47% D-Foot cases 3604 53% Vascular cases

The number of admission the D-Foot patients in last seven years 3288 The number of admission the D-Foot patients in last seven years 3288 . Admission DF every (year- 470) ,(mounth-39,1),(day-1,3) % Total admission years 8,5% 272 2010 9,7% 320 2011 12,3% 404 2012 16,7% 551 2013 15,3% 506 2014 18,5 610 2015 19% 625 2016 100% 3288 Total

The total number D Foot patient admission on 2016 The total number D Foot patient admission on 2016 . Type 1 >>> Type 2 >> 625 Female 240 >>> 38,4% Male 385 >>> 61,6 % 12 ----1,9% 625 613----98%

The age in D foot patients 625 : under 18 years 2 0,9% 19 – 40 years 102 16,4% 41 – 60 years 442 70% 60 years 79 12,7% Duration of DM in DF patient 625: 0-5y 6-10y 11-15y 16-20y above 20 y 110 250 150 80 35 17,6% 40% 24% 12,8% 5,6%

The follow up in primary health care : zzzzx The follow up in primary health care : 625 regular 352----56% irregular 182----29,1% No follow up 91----14,65

Treatment of Diabetis .(DF patients) Oral 226 36% Insulin 258 41,1% mixt 106 17% no 35 5,65

The HbA1C level in DF patients (625) under 7 85 36% 7---8 112 18 9---10 288 46% 10 140 22,4% The control glucose level it is vary bad ❕❕❕

The Scientific and education level of DF patient vary good 153 24,5% Good 216 34,5% Bad 148 23,7% Vary bad 108 17,3% Education level about 41% vary bad❓

The DF patients with other chronic diseases Hypertension 362 58% Cardiac diseases 212 34% Renal diseases 285 45,6% Retino pathy 412 66% others ❓❓❓ DF patients who had history of DFU Yes 418—67% No 207---33%

The most common of risk factor in D Foot ulcer it is callus formation The most common of risk factor in D Foot ulcer it is callus formation . D Foot with callus 552 88,3% D foot without callus 73 11,7% So the Diabetic and D Foot patients need for education health and good follow up in primary health care .

Type of ulcers of D Foot patients : Neuropathic ulcers 415….66,4% Ischemic ulcers 210….35,6% 625

The D Foot ulcers presented in defferant site of the foot (625) -Toes (Fore foot) 295 ----47,2% -Planter (mid foot) 228----36,5% -Heel(hind foot ) 102----16,3%

The deformation one of the most high risk of D Foot ulceration (625) -Toes deformation 492 78,7% -charcot foot 76 12% -no deformation 57 8,3% so the risk of D foot ulceration : 1* Neuro pathy callus , Deformation . 2* Angiopathy micro , macro angio pathy.

Angio-CT, angiography , angioplasty , stenting and surgical managenment : started Angio-CT of D Foot patients # conservative treatment 8---2,9 % # Ballon-angioplasty 112---39,7% # Stents-angioplasty 104 ---36,9% # Surgical (By pass) 58---20,5% Normal study 3----1,1% Patholgy (positive) 279----98,8% 282

So the Diabetic patients in need angio-CT after five years duration of DM. When the distal puls palpaler by hand . For -Early diagnosis -Early treatment -Follow up after that -Document

The common causes D-Foot ulcers 625 Internal cases neuro – angio – retino – arther-pathy and Infection . Extrnal causes. The extrnal causes of D.Foot ulcers -625- Trauma callus Burns shoes 190 208 102 125 30,4% 33,3% 16,3% 20%

Duration of ulcers and infection pre admission 625 0-5 days 280 44,8% 6-10 days 182 29% 2 –weeks 108 17,3% Greater than 55 9% 2-weaks So one of the most causes of L.L amputation it is . Late of admission Neglection

The Infection of D Foot patients 625: -Infected 512 81,9% -Gangrenous 98 15,7% -noninfected 15 2,4 The recurrent infection in D Foot patients about 22%

The most microorganism in cultures swab -pseudemonus 180 28,8% -streptococcus 110 17,6% -staphylococcus 45 7,2% -E-coli 50 8% -no culture 240 38,4%

We treated the D Foot patients under the Guide lines of : 1 We treated the D Foot patients under the Guide lines of : 1 *Control of blood sugar and control of infection . 2*Massive and aggressive Debridement . 3*Off-loading-reduction of pressure .

The Diabetic Foot patients , it is emergency case according the guide lines need admission in hospital for limb or life saving . Management of D Foot patients : -Analysis C.B.C , K.F.T -culture minim two culture ❓❓ -vascular status and A/B index , Toe index ❔❔ -Angio- CT .

Treatment of D Foot patients - Conservation treatment 20 / 3,2% - Surgical debridment 398 / 63,7% - Amputation 207 / 33,1% Amputation due to D Foot ulcers 625 High Amputation BKA, AKA, D.A 40 -----6,4% 207 Low Amputation Toes, TMA , SA. 167-----26%

Amputation L. L (high) post follow up 24 3,8% Amputation L Amputation L.L (high) post follow up 24 3,8% Amputation L.L (high) neglected 16 2,4% Amputation L.L (high) due to Ischemia 32 5,1% Amputation L.L (high) due to infection and 8 1,3% neuropathy

Amputation rate (high) in the seven years Amputation L Amputation rate (high) in the seven years Amputation L.L before 2010 11-12% in the 2016 6,4% BKA 112/3,1% % N , Amputation T . Amputation years 10% 27 272 2010 10,6% 34 320 2011 7,7% 51 656 2012 7,1% 36 506 2013 5,8% 32 551 2014 8,3% 610 2015 6,4% 40 625 2016 AKA 153 /4,3% DA 6/0,16%

What we are using in the wound dressing ❔❔ 1 What we are using in the wound dressing ❔❔ 1* dressing by NS , H2O2 ,povidin solution. 2* K-step , disinfectant , antimicrobial . 3* hydro – hypoalginat - Kaltostat , New – gel 4* silveralginat silver cell , aqua cell , Indian promogran . 5* hydro polymer polymem of all types . 6* N.P.WT , PRP , maggot therapy . 7* Follow up in D Foot clinic .

Results : Decrease of the L Results : Decrease of the L.L amputation number between the 2010/11% 2016 /6,4% -Good follow up of D Foot patients during in the D Foot out clinic Recommendation: state her rule through the molt to work on the development of a comprehensive and binding plan or (project) with participation of all parties associations because the diabetes has become an epidemic spreading and it is complication elusive and terrifying result . 1*The rule of the media in all Branches for education level , Awareness and high light the seriousness of the diseases and the magnitude of the suffering and the consequent complication .

2* Work on the contract conference every years for diabetes and it is complication at the level of the nation to high light , what is new and what is the problem . Conclusion : every beginning is defficult but not impossible with the will determination and wisdom to get sensitive of diabetes and it is complication , become epidemic how and in appeal to all man of science and the owners of pronouns , homeland calls them and honesty in not surrender .

Where do we stand today from DM and it is complication Where do we stand today from DM and it is complication . Where are we heading today . Where stood and where we go❔❔ Say act of God will see work and his messenger and the believers the great truth of God .

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