International Diabetic Foot Seminar

Transcription

1 In the name of God Proceedings of the International Diabetic Foot Seminar Tehran, November 15-17, 2007 Imam Khomeini Hospital Conference Center

2 Organizer: ENDOCRINOLOGY & METABOLISM RESAERCH CENTER TEHRAN UNIVERSITY OF MEDICAL SCIENCES PHONE: (+9821) FAX: (+9821) WEBSITE: 2 International Diabetic Foot Seminar November 2007 Tehran- Iran

3 Chairman of the Seminar: Larijani,Bagher MD Gary Sibbald MD Scientific Secretary: Mohajeri Tehrani,Mohammad Reza MD Executive Secretary: Amini,Mohammad Reza MD Executive Committee: Aalaa, M BSc Amini, MR MD Khazraei, Z BSc Parvizi, M MD Tabatabaei, O MD Taheri, E MSc., Pharm.D. International Diabetic Foot Seminar November 2007 Tehran- Iran 3

4 Scientific Committee: - Aghaei, HR MD (Iran) - Alavi, A MD (Canada) - Azizi,F MD (Iran) - Bahrami, A MD (Iran) - Behjati Ardakani, JMD (Iran) - Boutros, M RN (Canada) - Coelho, S RN (Canada) - Dowlati, Y MD (Iran) - Esfahanian, F MD (Iran) - Esteghamati, A MD (Iran) - Ghaharí, A MD (Canada) - Ghanaati, H MD (Iran) - Khatib, O MD (Sa ud i Ara bia) - Khoshniat, M MD (Iran) - Kitabchi, A MD (USA) - Landis, S MD (Canada) - Lankarani, M MD (Iran) - Larijani, B MD (Iran) - Mohajeri Tehrani, MR MD (Iran) - Nakhjavani, M MD (Iran) - Omrani, GH MD (Iran) - Orsted, H RN (Canada) - Pajouhi, M MD (Iran) - Rajabian,R MD (Iran) - Sharghi, S MD (Iran) - Shojaie fard, A MD (Iran) - Sibbald, G MD (Canada) - Soltani, A MD (Iran) - Taheri, E MSc., Pharm.D. (Iran) - Tahmasebi, M MD (Iran) - Taitoon, K.J.A (Bahrain) 4 International Diabetic Foot Seminar November 2007 Tehran- Iran

5 Organizing Committee: - Aalaa, M - Adibi, H - Aghamohammadi, M - Amini, MR - Babaei, Z - Cheraghi, M - Danesh D - Ghobadi, R - Hasankhani, A - Hamidi moghadam, A - Haratti, H - Kamazani, M - Khazraei, Z - Mohammadgholi, M - Mohammadzadeh, N - Moshaver, A - Parvizi, M - Sadeghian, M - Salimi, Sh - Sanjari, M - Sarafraz, L - Sharif, A - Tabatabaei, O - Taheri, E International Diabetic Foot Seminar November 2007 Tehran- Iran 5

6 Thursday, November 15, 2007 Opening ceremony Holy Quran 8-8:15 am Registration 8:15-8:30 am Recitation of holy Quran 8:30-8:35am Welcome Mohajeri Tehrani MD Introduction Larijani MD, Khatib 8:35-9 am MD, Sibbald MD 9-9:20 am 9:20-9:40 am 9:40-10 am 10-10:20 am Session 1 Chairs: Dr. Larijani, Dr. Sibbald, Dr. Khatib, Dr. Dowlati Overview of Diabetic foot and Novel therapy in diabetic foot Larijani MD Epidemiology of Diabetic Foot and Changes (DF) Khatib MD Local Skin care and Prevention Sibbald MD, Coehlo RN, Orsted RN Development of Non- Rejectable Live Skin Substitute for Non healing ulcers Ghahary MD Break 10:20-10:50 am Session 2 Chairs: Dr. Larijani, Dr. Nakhjavani, Dr. Kitabchi, Dr. Mohajeri Tehrani 10:50-11:15 am Diagnosis & Evaluation of Diabetic Foot and Ulcers Boutros RN, Sibbald MD 11:15-11:40 am The molecular basis of wound healing in Diabetes Kitabchi MD 11:40-12 am The pathogenesis of Diabetic Foot Sharghi MD Lunch & Exhibition pm pm pm Workshop Workshop Topic: The role of the foot care specialist and nurse in the Diabetic Foot Clinic Workshop in Persian: Case presentation of Diabetic Foot Canadian Team Botros, Coelho, Landis Khoshniat MD 6 International Diabetic Foot Seminar November 2007 Tehran- Iran

7 Friday, November 16, :30-8:50 am 8:50-9:10 am 9:10-9:30 am 9:30-9:50 am Holy Quran Session 3 Chairs: Dr. Sibbald, Dr, Sharghi, Dr. Rajabian, Dr Behjati Foot Examination in persons with diabetes New approaches to diabetic foot care: The whole patient before the hole in the patient Diagnosis of Osteomyelitis & role of bone probing Management of Diabetic Foot Infections (Cellulitis, Osteomyelitis) Break 9:50-10:20 am Session 4 Mohajeri Tehrani MD Sibbald MD Nakhjavani MD Landis MD Chairs: Dr. Sibbald, Dr. Pajouhi, Dr. Mohajeri Tehrani 10:20-10:45 am Dermatopathy of Diabetic Foot Dowlati MD 10:45-11:10 am The role of Angioplasty in DF ulcer healing Ghanaati MD 11:10-11:35 am Off loading methods in DF management Boutros RN 11:35-12 pm Advanced and Active therapies for the treatment of Diabetic Foot Ulcers Sibbald MD Lunch & Exhibition pm pm pm Workshop Workshop Topic: foot care / practical Workshop in Persian The diagnosis of osteomyelitis in Diabetic Foot kawthe J. Al Taitoon RN Aghaei MD ' International Diabetic Foot Seminar November 2007 Tehran- Iran 7

8 Saturday, November 17, 2007 Holy Quran Session 5 Chairs: Dr. Sibbald, Dr. Landis, Dr. Khoshniat, Dr. Alavi 8:30-8:50 am Neuropathic Diabetic Foot Esteghameti MD 8:50-9:10 am Empowering shared decision making in patients with diabetes Alavi MD 9:10-9:30 am The role of Orthopedic surgery in prevention and management of DF Tahmasebi MD 9:30-10 am The care following Amputation in Sibbald MD, Coelho RN DF patients, Boutros RN Break 10-10:30 am Session 6 10:30-11 am 11-11:30 am 11:30-12 am Chairs: Dr. Sibbald, Dr. Zakeri, Dr. Bahrami, Dr. Lankarani Evidence informed practice on local wound bed management Prevention of Diabetic Foot ulcers and amputations The role of vascular surgery in DF management Lunch & Exhibition pm Landis MD, Alavi MD, Coelho RN Sibbald MD, Boutros RN Shojaeefard MD pm pm Workshop Workshop Topic: Modern dressing in the treatment of Diabetic Foot Ulcers Workshop in Persian The prevention of Diabetic Foot Canadian Team Botros, Coelho, Landis Behjati MD 8 International Diabetic Foot Seminar November 2007 Tehran- Iran

9 TABAL OF CONTENTS INTRODUCTION SCIENTIFC SESSIONS WORKSHOPS International Diabetic Foot Seminar November 2007 Tehran- Iran 9

10 Introduction Diabetes is a serious condition for the individual and society. Its rapidly increasing global prevalence is a significant cause for concern. The prevalence of diabetes mellitus is reaching epidemic rates globally and the number of adults with diabetes is projected to reach 300 million worldwide by the year According to WHO forecast, prevalence of diabetes mellitus in Iran in years was 5.5 and 5.7% and in 2025 will be 6.8%, that means more than 5 million people in Iran will suffer from diabetes and its complication. Diabetic Foot lesions and amputations as one of the most serious diabetes complications are significant health and socioeconomic problems. It is a major cause of morbidity, disability, as well as emotional and physical costs for people with diabetes. Foot ulcers develop in 15 percent of diabetic patients during life long and 15 percent of them may lead to amputation. Diabetic foot is the most common cause of non traumatic amputation in the world. Currently, every 30 seconds someone somewhere in the world undergoes amputation for a diabetic foot ulcer. So, the Endocrinology & Metabolism Research Center as a collaborative center of WHO with assistance of the university of Toronto has tried to hold International Seminar of Diabetic Foot in November 2007 in Tehran. We tried to invite experts in the pertinent fields to share with us their knowledge and views on the advanced and active methods in the prevention of diabetic foot ulcers and amputations and also diabetic foot management. The topics discussed in this seminar will cover clinical, diagnostic and preventive strategies as well as role of angioplasty, orthopedic surgery and offloading methods in prevention, management and healing of diabetic foot. It is hoped, God willing, this seminar will help to improve significantly our knowledge of diabetic foot, and ultimately to provide diabetic patients improving levels of foot care in order to prevent amputation as the major complication of foot ulcer. Prof. Bagher Larijani Chairman of the Conference 10 International Diabetic Foot Seminar November 2007 Tehran- Iran

11 Thursday, November 15, 2007 Opening ceremony Holy Quran 8-8:15 am Registration 8:15-8:30 am Recitation of holy Quran 8:30-8:35am Welcome Mohajeri Tehrani MD 8:35-9 am Introduction Larijani MD, Khatib MD, Sibbald MD 9:00-9:20 am 9:20-9:40 am Session 1 Chairs: Dr. Larijani, Dr. Sibbald, Dr. Khatib, Dr. Dowlati Overview of Diabetic foot and Novel therapy in diabetic foot Epidemiology of Diabetic Foot and Changes (DF) 9:40-10:00 am Local Skin care and Prevention 10-10:20 am Development of Non- Rejectable Live Skin Substitute for Non healing ulcers Break 10:20-10:50 am Session 2 Larijani MD Khatib MD Sibbald MD, Coehlo RN, Orsted RN Ghahary MD Chairs: Dr. Larijani, Dr. Nakhjavani, Dr. Kitabchi, Dr. Mohajeri Tehrani 10:50-11:15 am Diagnosis & Evaluation of Diabetic Foot and Ulcers Boutros RN, Sibbald MD 11:15-11:40 am The molecular basis of wound healing in Diabetes Kitabchi MD 11:40-12 am The pathogenesis of Diabetic Foot Sharghi MD Lunch & Exhibition pm Workshop Workshop pm Topic: The role of the foot care specialist and nurse in the Diabetic Foot Clinic pm Workshop in Persian: Case presentation of Diabetic Foot Canadian Team Botros, Coelho, Landis Khoshniat MD International Diabetic Foot Seminar November 2007 Tehran- Iran 11

12 Bagher Larijani is Professor of Endocrinology and Internal medicine who is Chancellor, Tehran University of Medical Sciences, former Vice Chancellor of Research, Tehran University of Medical Sciences. Professor Larijani has been Director and Chief Scientific Officer, Endocrinology & Metabolism Research Center which has won the first rank in research and education among research centers. This center has been recognized as WHO Collaborating Center for Research and Education on Management of Diabetes and Osteoporosis. He is also the Chief of Endocrinology & Metabolism Ward of Dr. Shariati General Hospital Since Larijani earned his MD in 1987, Internal medicine specialty in 1990, post doctorate in Endocrinology and Metabolism in 1993 from Tehran University of Medical Sciences. He is full member of many known international associations and federations such as ADA, IDF, AACE, Endocrine Society, and Society for Endocrinology and IOF. He implemented countrywide networks of Diabetes and Osteoporosis in Iran. Prof. Larijani is co-editor and editor of thirty six books in medicine with focus on Endocrine Disorders, Osteoporosis and Medical Ethics and has published over 200 national and international articles. He is Editor in Chief of Medical journals: Scientific Journal of Medical Council of IRI, Medicine and Purification Journal and International Journal of Osteoporosis and Metabolic Disorders and also a member of editorial board of several medical journals such Iranian Journal of Diabetes and Lipid Disorders which is published seasonally in Iran. He has conducted multiple workshops, courses and lectures worldwide and has received multiple awards including Kharazmi Festival Best Researcher in 2004, Avicenna Festival, Best Medical Research Center in 2003, Rhazi Festival Best Medical Research Center in and Avicenna Festival, Best Books in 2002, Professor Larijani is recently co-director of the International Interdisciplinary Wound Care Course (IIWCC) in Tehran-Iran with collaboration of University of Toronto and University of Tehran. This course is the first University of Toronto continuing education course that is performing in Iran for health care professional with accreditation from both universities of Tehran and Toronto. 12 International Diabetic Foot Seminar November 2007 Tehran- Iran

13 F Overview of Diabetic Foot; Novel Treatments in Diabetic Foot Ulcer Larijani, B oot ulcers are one of the main complications in diabetes mellitus, with a 15% life time risk in all diabetic patients. The rate of lower extremity amputation among diabetic patients is times higher than in non- diabetics. The problem and features are infection, ulceration, or gangrene. Neuropathy, poor circulation, and decreased resistance to infection are the three major contributors to the development of diabetic foot; which when present, foot deformities or minor trauma can readily lead to ulceration and infection. Not all diabetic foots are preventable, but appropriate preventive measures can dramatically reduce their occurrence. In our assessment of diabetic foot ulcer the cost to treat one simple ulcer is $5000 to $8000. Awareness of physicians about foot problems in diabetic patients, clinical examination and Para clinical assessment, regular foot examination, patient education, simple hygienic practices and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50%. Many different methods have been proposed and their goal is to accelerate the wound healing. These treatments include local epidermal growth factor, vacuum-compression therapy (VCT), hyperbaric oxygen and peripheral Stem cell injection. All these treatments have a partial effect in ulcer improvement and amputation rate; so more effective treatments are essential. A novel way in treatment of this complication is an herbal extract (SPLGP) that has been studied in all steps of clinical trial. This new treatment by local, oral and intravenous routs has had beneficial effects in the treatment of diabetic foot ulcer after one month. Angiogenesis is one of the mechanisms of action of this drug. Results of these clinical trials showed that this treatment can be superior to other treatments. International Diabetic Foot Seminar November 2007 Tehran- Iran 13

14 Oussama Khatib Dr Ossama khatib is a specialist in Internal medicine, Endocrinologist and Diabetologist. He has obtained FFPHM, FRCP, MFPH in Royal colleges of physicians, London. He is regional Adviser Non-communicable Diseases, EMRO/WHO and International Adviser to the Royal college London, UK physician. He is currently in Saudi Arabia in king Fahad Medical School as port of endocrinology and diabetes. Dr Khatib has recently published more than 80 papers on diabetes, general medicine and public health. He is a member of editorial Board of Eastern Mediterranean Health Journal/WHO, Cairo, Egypt and Public Health Medicine Journal, London, UK. MEMBERSHIPS - Research Fellow- London University UK, Royal Post Graduate Medical School - Full Professional Membership of American Diabetes Association, 1991, USA. - Full Professional Membership of American Endocrine Society, 1991, USA. - Full Professional Membership of American Thyroid Society, 1991, USA. - Full Professional Membership of European Endocrine Society, 1991, UK. RECENT PUBLISHED BOOKS Clinical guidelines for management of hypertension, EMRO/WHO Technical publications Series Regional guidelines for screening and detection of breast cancer, EMRO/WHO Technical publications Series Regional guidelines for management and care for breast cancer, EMRO/WHO Technical publications Series Regional guidelines for management and prevention of diabetes, EMRO/WHO Technical publications Series Regional guidelines on diabetes and dyslipidaemia management and care EMRO/WHO Technical publications Series Diabetes in the Arab World, 2005, FSG Communications Ltd, Reach, Cambridge, UK 14 International Diabetic Foot Seminar November 2007 Tehran- Iran

15 D Epidemiology of Diabetic Foot Changes (DF) Khatib, O iabetes among Eastern Mediterranean (EM) population above age of 20 years is around 10.5% and is ranked among the leading causes of blindness, renal failure and lower limb amputation. While 50% of EM people with diabetes will die of cardiovascular diseases. This means that in our region, there are pandemic trends in prevalence of diabetes and associated complications. Globally, people with diabetes are 25 times more likely to have a leg amputated than those without the condition, and up to 70 percent of all leg amputations happen to people with diabetes. Somewhere in the world, a leg is lost to diabetes every 30 seconds. Foot ulcer is the most common single precursor to lower extremity amputations among diabetics. Hyperglycemia, impaired immunologic responses, neuropathy, and peripheral arterial disease are the major predisposing factors leading to limb-threatening diabetic foot infections Diabetic foot represents a health problem and economic burden among majority of EM Countries. Infection in a diabetic foot is limbthreatening and must be treated empirically and aggressively. Treatment of infected foot wounds is the most common reason for diabetes- related hospitalization. The good news is that up to 85 percent of diabetic amputations can be prevented. As to above challenge, the best approach for EMR is education, community awareness and prevention of diabetic foot. The public approach and education that emphasize on proper footwear and foot care are best preventive and cost-effective modalities that can be easily implemented among EM Countries. EM Countries need to strengthen national health services that promote the concept of prevention and tight control of diabetes in order to prevention diabetes complications. Preventing diabetes by means of lifestyle intervention is likely to be highly cost effective. This also necessitates building/strengthening diabetes registry and complications. International Diabetic Foot Seminar November 2007 Tehran- Iran 15

16 Heather Orsted Heather began her career as a Certified Nursing Aide in 1975 then went on to become a Registered Nurse graduating at Mount Royal College in She attended the Cleveland Clinic for her certificate in Enterostomal Therapy in In 1996 she completed a Bachelor of Nursing at the University of Calgary and went on to completer a Masters of Sciences in Wound Healing and Tissue Repair in 2005 from University of Wales, Cardiff. Heather, though a nurse since 1975, has worked in the nursing education field since 1981 but has been a Clinical Specialist for Ostomy, Skin & Wound Management: since 1987: regionally, nationally and internationally. She is Co-Director and Course Coordinator for the International Interdisciplinary Wound Care Course (IIWCC), University of Toronto, Faculty of Continuing Education, Department of Medicine, Toronto, on. Heather is a founding board member and former President of the Canadian Association of Wound Care (CAWC) and Co-chair for the 2008 World Union of Wound Healing Societies (WUWHS) meeting in Toronto. 16 International Diabetic Foot Seminar November 2007 Tehran- Iran

17 Local Skin care and Prevention Orsted, H Participants will: F Identify the role of screening in diagnosing the risk factors for developing a foot ulcer in a person with diabetes(pwd) Identify common skin changes in persons with diabetes(pwd): fungal infection, dry skin and other abnormalities Develop an approach to prevention of foot ulcers in PWD oot ulcers are the most common cause of hospitalization in persons with diabetes. A complete foot examination is essential for all diabetic patients due to circulatory and neuropathic manifestation of diabetes. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. To reduce the number of foot amputations, it is important to identify high risk PWD and correct predisposing factors. This session will examine an everyday practice approach to improving the outcomes for PWD and foot ulcers. International Diabetic Foot Seminar November 2007 Tehran- Iran 17

18 Aziz Ghahari Aziz Ghahary, Ph.D. Professor and Director; BC. Professional Burn and Wound Healing Research Group. Department of Surgery, 351- Jack Bell Research Center University of British Columbia Dr. Aziz Ghahary, has been a full professor in the Departments of Surgery and Medicine at the University of Alberta until July 1, He then joined the Department of Surgery, Division of Plastic Surgery to be become the Director of BC Professional Firefighter Burn and Wound Healing Research Lab. His lab is considered to be the first and the only Burn and Wound Healing Research Laboratory in British Columbia. His research interest is to understand the mechanism of normal and pathologic healing process. He is exploring the role of growth factors and cytokines in wound healing, as well as the keratinocyte-fibroblast interaction in pathological conditions frequently seen as a result of surgical incision, deep trauma, and thermal injury. Recently, he has identified a keratinocyte Derived Anti-fibrogenic Factor (KDAF) for dermal fibroblasts which could function as a stop signal for the dynamic healing process in skin. His research activity sheds new light on why some wounds become fibrotic; while others fail to heal. He later demonstrated that KDAF is involved in regulating the expression of several proteases such as MMP-1, 2, 3 and membrane type 5 MMP that are needed for slowing down the dynamic healing process and tissue remodeling. Another aspect of his research interest is to develop a shelf ready biological nonrejectable skin substitute to be used not only as a wound coverage bur also as rich source of wound healing promoting factors. His group has already used IDO as a local immuno-suppressive factor to protect allogenic live skin substitute as a wound coverage in an animal model. Using the same system, Dr. Ghahary is also interested in preparing and application of a non-rejectable allogenic islets embedded within an autologous fibroblasts populated collagen-gag scaffold to protect allogenic islet transplantation. In fact, his group successfully transplanted these islets in diabetic mouse model and showed a normalization in the glucose level without use of insulin administration. His findings have frequently been publicized by both local and national media such as CBC television, CFRN, the Vancouver Sun, the Edmonton Journal, the Faculty of Medicine and Dentistry News at the University of Alberta, and the CIHR website. In September 2004, he was recognized as the CIHR researcher of the week. He has recently described his discoveries in both the Vancouver Sun and CTV news. Dr. Ghahary has received his research funding from different local, national and international granting agencies such as the BC Professional Firefighter Fund, Canadian Institute of Health Research, Toronto Hospital for Sick Children and International Firefighter Fund. 18 International Diabetic Foot Seminar November 2007 Tehran- Iran

19 Development of Non- Rejectable Live Skin Substitute for Non healing ulcers Ghahari, A Introduction: The need for alternative, immediate and permanent wound closure materials has promised potential applications for the treatment of cutaneous wounds. One approach postulated by our research group is to generate a functional collagen-gag skin equivalent with a local immunosuppressive factor such as indoleamine 2,3-dioxygenase (IDO) incorporated to genetically modify either allo- or xenogeneic skin cells (1). IDO is a rate-limiting enzyme that converts tryptophan to N-formylkynurenine (2). This unstable product is further catabolized to kynurenine. It has been suggested that IDO plays a key role in the prevention of the immune rejection of the semi-allogeneic fetus (3) and in the immune resistance of tumors (4). In a co-culture system, we have recently demonstrated that depletion of tryptophan by IDO jeopardizes the survival of CD4+ lymphocytes and THP-1 monocytes (1). Thus, the aim of this study was to evaluate the effects of local IDO expression on xenogeneic graft take in an in vivo rat model. Materials and Methods: Type I collagen was isolated and purified from fetal bovine skin by repeated salt precipitation. Human fibroblasts were isolated from skin samples taken during elective surgeries. To make an IDO expressing skin substitute, cells were transfected with adenoviral vector bearing full length of IDO cdna using empty vector as control. IDo expressing cells were then embedded within GAG-type I collagen. Upon a successful transfection, the whole composite was grafted on the back of Sprague- Dawley (SD) rats. Wound closure analysis on day 4 and 8 post-surgery were carried our and samples taken were stained with H & E to determine the epithelialization gap. Immunohistochemical staining was also carried out to detect IDO expressing cells on day 8 and 28 post wounding. Immunostaining of CD4+ cells in sections of wound samples taken at day 14 and 28 post transplantation was carried out to determine the presence of infiltrated immune cells within xeno-graft skin substitute relative to that of control. Results and Discussion: To assess the effect of IDO on wound healing, the size of wounds margin was evaluated by measuring the wound gaps on day 8 post transplantation of skin substitute. The results showed that the wounds received engraftment of IDO adenovirus infected fibroblasts were significantly smaller compared to either non-treated, grafts with non-treated human fibroblasts, or grafts with mock recombinant adenovirus infected human fibroblasts (7.0 ± 5.0% vs ± 5.2% vs ± 3.7% vs ± 4.9%, IDO vs. non-treated vs. fibroblasts vs. mock, p<0.01). Examination of H&E stained wound sections revealed a dramatic difference in thickness of the epidermal layer between IDO collagen gels and all other control wounds. More rapid re-epithelialization was observed in wounds that received IDO adenovirus infected human fibroblasts compared to other groups on day 8 posttransplantation. To assess whether IDO plays a role in the prevention of grafted skin cells from host immune rejection, the number of CD3+ T infiltrated cells were determined. As shown in Table 1, there was no significant difference in the number of infiltrated CD3 + T lymphocytes in wounds that received IDO expressing human fibroblasts compared to either non-treated wounds, wounds that received uninfected human fibroblasts, or mock adenovirus infected human fibroblasts on day 8, however, these differences become significant on day 14 and 28. In conclusion, the finding of this study show a significant reduction in the number of infiltrated CD3 + T lymphocytes on day 14 and 28 post-transplantation in the wounds receiving IDO expressing fibroblasts relative to those of controls. Thus, the IDO expressing non-rejectable fibroblast-populated collagen-gag gel provides a migrating bed for the wound edge keratinocytes to migrate faster and epithelialize the wound surface earlier than control. Day 8 Day 14 Day 28 Untreated wounds 23.2 ± ± ± 7.5 Untreated fibroblasts 19.8 ± ± ± 15.1 Mock Ad fibroblasts 18.3 ± ± ± 21.2 IDO Ad fibroblasts 17.5 ± ± ± 5.1c References 1. Li Y, Tredget EE, Kilani RT, Iwashina T, Karami A, Lin X, Ghahary A: J Invest Dermatol 122: , Taylor MW, Feng GS. FASEB J 5: , Munn DH, Zhou M, Attwood JT,. Science 281: , Uyttenhove C, Pilotte L, Theate I, Stroobant V, Colau D, Parmentier N, Boon T, Van den Eynde BJ. Nat Med 9: , 2003 International Diabetic Foot Seminar November 2007 Tehran- Iran 19

20 Gary Sibbald Dr. Sibbald is a professor of Public Health Sciences and Medicine at the University of Toronto. He trained as a dermatologist and internist with special interest in wound healing and education. He is currently the director of medical education for Women s College Hospital and chair faculty of Medical Education Committee. Dr. Sibbald is a board member and current President of the Canadian Association of Continuing Health Education and chair of the Accreditation Committee for The Royal College of Physicians and Surgeons of Canada. He is a past chair of the Cambridge Conference on Medical Education. Presently, Professor Sibbald is the director Wound Healing Clinic at the Women s College Hospital. He established an interprofessional education model for wound care as co-founder, previous chairman and a five-time annual meeting chair of the Canadian Association of Wound Care. Professor Sibbald established the International Interdisciplinary Wound Care Course (IIWCC) at the University of Toronto in This course is the first University of Toronto continuing education course to offer a certificate of completion and combine residential weekends with self-study and a selective that relates new knowledge to everyday practice. This course is currently part of a new Master s Sciences/ Community Health Program in the Department of Public Health Sciences. He is co-editor of the Fourth Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Dr. Sibbald is the chairman and president elect for the 3 rd Meeting of the World Union of Wound Healing Societies to be held in Toronto in June 4 th to 8 th, 2008.Dr. Sibbald has published over 150 articles and book chapters. 20 International Diabetic Foot Seminar November 2007 Tehran- Iran

21 Diagnosis & Evaluation of Diabetic Foot and Ulcers Sibbald, G Participants will: Assess Sensory, Autonomic, Motor (SAM) components of neuropathy Evaluate clinical and laboratory investigations to document arterial circulation Identify callus, blisters and deformity as a cause of ulceration P eople with diabetes are at risk of nerve damage. The most common risk factors for foot ulceration include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. Foot ulcer evaluation should include assessment of neurological status, vascular status, and evaluation of the wound itself, including superficial or deep infection. It has been documented that 40 to 70% of all lower extremity amputations are related to diabetes. This means that the majority (85%) of all diabetes-related amputations are preceded by foot ulcers. Assessing the patient as part of the interdisciplinary team, clinicians must assess the whole patient, the wound and determine the severity of the infection to target the appropriate management and attempt to salvage the limb. International Diabetic Foot Seminar November 2007 Tehran- Iran 21

22 Abbas E. Kitabchi Dr. Abbas Kitabchi is Professor of Medicine and Molecular Sciences, and Director of Division of Endocrinology, Diabetes & Metabolism at the University of Tennessee Health Sciences Center (UTHSC) in Memphis, Tennessee, a position he has held since Dr. Kitabchi completed his graduate and medical degrees (M.S., Ph.D., M.D.) at University of Oklahoma and received his postdoctoral fellowship in Biochemistry at Oklahoma Medical Research Foundation where he was the first to isolate the product of lipid peroxidation, malonaldehyde (MDA) from liver of vitamin E deficient animal (Kitabchi et al J. Biol Chem., 1960). After completion of his clinical fellowship in Endocrinology with the late Dr. Robert H. Williams at University of Washington in Seattle in 1968 he was recruited to the UTHSC in Memphis, first as Director of Research at the Veterans Administration Hospital and then to the present position since 1973.Dr. Kitabchi has received multiple NIH grants as principle investigator, including Diabetes Control and Complications Trial (DCCT) and its follow-up (EDIC), Diabetes Prevention Program (DPP) as well as Look AHEAD. Dr. Kitabchi's pioneering work on the hyperglycemic crises regarding pathogenesis and various treatment modalities in DKA has provided evidence-base guidelines for the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) where Dr. Kitabchi's method of treatment has become standard of therapy. Dr. Kitabchi has served or is serving on the editorial board of Diabetes, Journal of Clinical Endocrinology and Metabolism, Metabolism, Diabetes Care, Endocrinology, International Journal of Osteoporosis and Metabolism, and Iranian Journal of Diabetes and Lipid Disorders. Dr. Kitabchi is author and co-author of more than 250 peer review articles, chapters and reviews in subject of diabetes, endocrinology and acute and chronic complications of diabetes and mechanism of insulin resistance. He is member of numerous prestigious societies including ADA, AACE, The Endocrine Society, ASCI, AAP, ASBMB, AIN, EASD, FACE, FACP, and IDF. He has served on the Research Grant and Program Committees of the ADA and is on the Task Force Committee of AACE for the Study of Obesity. 22 International Diabetic Foot Seminar November 2007 Tehran- Iran

23 O The molecular basis of wound healing in Diabetes Kitabchi, A ne of the major complications of Type 1 or Type 2 diabetes (T 1 DM and T 2 DM) is non-traumatic amputation of the leg. Worldwide, amputation secondary to diabetes mellitus occurs once every 30 seconds. In the U.S. the number of amputations in 2002 was 80,000, which was higher in men and ethnic minorities. The cost is about 60,000 per amputation, with a total annual cost of 2 billion dollars. Foot ulcers in diabetes are the cause of 85% of amputations. The Rule of 15 states that: 1) 15% of diabetic patients develop foot ulcer in their lifetime 2) 15% of foot ulcers develop into osteomyelitis, and 3) 15% of foot ulcers result in amputation. The tragic Rule of 50 applies to amputations in diabetes: 1) 50% of amputations are at the trans-femoral or trans-tibial level 2) 50% of patients require a second amputation in 5 years 3) 50% of patients die in 5 years or less. Axiom: The Team Care approach reduces ulcers/amputations by: 1) Integrated, risk-stratified interventions a) Identification of high-risk patients with exams b) Prompt multidisciplinary treatment of ulcers 2) Efficacy of Team Care (50-80% reduction in ulcers or amputations) Causal pathway for foot ulcers: 1) Neuropathy: 78% 2) Minor trauma: 79% 3) Deformity: 63% 4) Behavioral issues:? Neuropathy + Deformity + Minor Trauma Poor self foot care International Diabetic Foot Seminar November 2007 Tehran- Iran 23

24 Kitabchi, A Sensory neuropathy in diabetes consists of loss of protective sensation in feet. A painless skin injury can be detected with 5.07/10g Semmes- Weinstein monofilament superior predictive value. But up to 50% have no neuropathic symptoms. Peripheral arterial disease in diabetes (ABT<0.9) occurs in 20-30%. a) 10-20% in T 2 DM at Dx b) 30% in diabetes mellitus patients 50 years or older c) 40-60% in diabetics with foot ulcers Complications a) Claudication and functional disability b) Increased risk for concurrent CAD and CVD c) Delayed ulcer healing How to detect PAD in diabetes mellitus: Claudication at less than 1 block suggests severe ischemia. Buttock and thigh pain suggest aorto-iliac level. Calf pain suggests femoral level. Foot/ankle pain suggests tibioperoneal level. Rest pain indicates critical ischemia. Interpretation of the ABI: Normal: Mild obstruction Moderate obstruction* Severe obstruction* 0.40 or less **Poorly compressible greater than to medial Ca** *Poor ulcer healing with ABI 0.50 or less High risk feet require: a) An annual comprehensive foot exam. b) Regular prophylactic care. c) Intensive patient education. Basic foot care concepts include: a) Daily foot inspection. b) Commitment to self care. c) Protective behavior. 24 International Diabetic Foot Seminar November 2007 Tehran- Iran

25 Kitabchi, A Diabetic foot ulcers (DFUs), a leading cause of amputations, affect 15% of people with diabetes. A series of multiple mechanisms, including decreased cell and growth factor response, lead to diminished peripheral blood flow and decreased local angiogenesis, all of which can contribute to lack of healing in persons with DFUs. In this issue of the JCI, Gallagher and colleagues demonstrate that in diabetic mice, hyperoxia enhances the mobilization of circulating endothelial progenitor cells (EPCs) from the bone marrow to the peripheral circulation (see the related article beginning on page 1249). Local injection of the chemokine stromal cell derived factor 1α then recruits these EPCs to the cutaneous wound site, resulting in accelerated wound healing. Thus, Gallagher et al. have identified novel potential targets for therapeutic intervention in diabetic wound healing. Endothelial progenitor cells (EPCs) are essential in vasculogenesis and wound healing, but their circulating and wound level numbers are decreased in diabetes. This study aimed to determine mechanisms responsible for the diabetic defect in circulating and wound EPCs. Since mobilization of BM EPCs occurs via enos activation, we hypothesized that enos activation is impaired in diabetes, which results in reduced EPC mobilization. Since hyperoxia activates NOS in other tissues, we investigated whether hyperoxia restores EPC mobilization in diabetic mice through BM NOS activation. Additionally, we studied the hypothesis that impaired EPC homing in diabetes is due to decreased wound level stromal cell derived factor 1α (SDF-1α), a chemokine that mediates EPC recruitment in ischemia. Diabetic mice showed impaired phosphorylation of BM enos, decreased circulating EPCs, and diminished SDF-1α expression in cutaneous wounds. Hyperoxia increased BM NO and circulating EPCs, effects inhibited by the NOS inhibitor N-nitro-l-argininemethyl ester. Administration of SDF-1α into wounds reversed the EPC homing impairment and, with hyperoxia, synergistically enhanced EPC mobilization, homing, and wound healing. Thus, hyperoxia reversed the diabetic defect in EPC mobilization, and SDF- 1α reversed the diabetic defect in EPC homing. The targets identified, which we believe to be novel, can significantly advance the field of diabetic wound healing. International Diabetic Foot Seminar November 2007 Tehran- Iran 25

26 Kitabchi, A Chronic wounds, such as venous ulcers, are characterized by physiological impairments manifested by delays in healing, resulting in severe morbidity. Surgical debridement is routinely performed on chronic wounds because it stimulates healing. However, procedures are repeated many times on the same patient because, in contrast to tumor excision, there are no objective biological/molecular markers to guide the extent of debridement. To develop bioassays that can potentially guide surgical debridement, we assessed the pathogenesis of the patients wound tissue before and after wound debridement. We obtained biopsies from three patients at two locations, the nonhealing edge (prior to debridement) and the adjacent, nonulcerated skin of the venous ulcers (post debridement), and evaluated their histology, biological response to wounding (migration) and gene expression profile. We found that biopsies from the nonhealing edges exhibit distinct pathogenic morphology (hyperproliferative/hyperkeratotic epidermis; dermal fibrosis; increased procollagen synthesis). Fibroblasts deriving from this location exhibit impaired migration in comparison to the cells from adjacent nonulcerated biopsies, which exhibit normalization of morphology and normal migration capacity. The nonhealing edges have a specific, identifiable, and reproducible gene expression profile. The adjacent nonulcerated biopsies have their own distinctive reproducible gene expression profile, signifying that particular wound areas can be identified by gene expression profiling. We conclude that chronic ulcers contain distinct subpopulations of cells with different capacity to heal and that gene expression profiling can be utilized to identify them. In the future, molecular markers will be developed to identify the nonimpaired tissue, thereby making surgical debridement more accurate and more efficacious. During embryonic development, the vasculature is among the first organs to form and is in charge of maintaining metabolic homeostasis by supplying oxygen and nutrients and removing waste products. As one would expect, blood vessels are critical not only for organ growth in the embryo but also for repair of wounded tissue in the adult. An imbalance in angiogenesis (a time-honored term that globally refers to 26 International Diabetic Foot Seminar November 2007 Tehran- Iran

27 Kitabchi, A the growth of new blood vessels) contributes to the pathogenesis of numerous malignant, inflammatory, ischemic, infectious, immune, and wound-healing disorders. This review focuses on the central role of the growth of new blood vessels in ischemic and diabetic wound healing and defines the most current nomenclature that describes the neovascularization process in wounds. There are now two welldefined, distinct, yet interrelated processes for the formation of postnatal new blood vessels, angiogenesis, and vasculogenesis. Reviewed are recent new data on vasculogenesis that promise to advance the field of wound healing. International Diabetic Foot Seminar November 2007 Tehran- Iran 27

28 Sassan Sharghi Dr sharghi is an Endocrinologist. He trained as an internist and endocrinologist in Tehran University of medical sciences (TUMS). He is a graduate of the islet transplantation course at the university of Alberta, Edmonton, Canada, 2003 and islet Isolation course, Milan, Italy. He has passed scientific writing, research methodology primary, intermediate, and advanced courses in TUMS, EMRC. Dr sharghi is Assistant professor and researcher of internal medicine and endocrinology in endocrinology and metabolism research center, shariati hospital. He is a member of diabetes research group, research council, education council and director of education group in EMRC. Dr sharghi works as the director of clinical part of islet transplantation program in Iran and manager of diabetes clinic of special diabetes center. He is also a member of Iranian CPC development group. Dr Sharghi is also one of the mentors in IIWCC which held with collaboration of TUMS with university of Toronto. He is an advisor of Iranian journal of Diabetes & Lipid. He published articles in different endocrine fields esp. Diabetes, osteoporosis, thyroid disorders sport endocrinology medicine. 28 International Diabetic Foot Seminar November 2007 Tehran- Iran

29 The Pathogenesis of Diabetic Foot Sharghi, S Diabetic foot problems are common throughout the world, resulting in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable. A clear understanding of the etiopathogenesis of ulceration is essential if we are to succeed in reducing the incidence of foot ulceration and, ultimately, amputation. As the vast majority of amputations are preceded by foot ulcers, a thorough understanding of causative pathways to ulceration is essential if we are to reduce the depressingly high incidences of ulceration and amputation. In addition, as lower limb complications are the most common precipitants of hospitalization of diabetic patients in most countries, there are potential economic benefits to be gained from preventative strategies. Finally, a successful screening program based on early identification of those at risk should impact on the appreciable morbidity, and even mortality, of diabetic foot disease. The breakdown of the diabetic foot has been traditionally considered to result from peripheral vascular disease, peripheral neuropathy, and infection. More recently, other causes such as psychosocial factors, and abnormalities of pressures and loads under the foot, have been implicated. There is no compelling evidence that infection is a direct cause of ulceration: it is likely that infection becomes established once the skin break occurs. Foot ulcers rarely result from a single pathology. It is rather the interaction of 2 or more contributory causes that lead to the breakdown of the high-risk foot. The neuropathic foot, for example, does not spontaneously ulcerate; it is the combination of insensitivity and either extrinsic factors (eg, walking bare foot and stepping on a sharp object, or simply wearing ill-fitted shoes) or intrinsic factors (eg, patient with insensitivity and callus who walks and develops an ulcer) that ultimately results in ulceration. Neuropathy is the most important contributory cause in the pathway to ulceration, discussed along with other causes. At the molecular level, there are at least six metabolic abnormalities that appear to be major factors in the development of the chronic complications of diabetes and most are directly related to the elevated blood glucose, free fatty acid concentrations, and/or proinflammatory cytokines: International Diabetic Foot Seminar November 2007 Tehran- Iran 29

30 Sharghi, S 1) Increased oxidation of glucose and free fatty acids which produces mitochondrial reactive oxygen species (ROS) such as super oxide 2) A deficiency of myo-inositol leading to abnormal phosphoinositide metabolism 3) Increased metabolism of glucose through the sorbitol pathway 4) Non-enzymatic glycosylation of proteins and DNA (covalent attachment of arbohydrate molecules to proteins and DNA) 5) Abnormal extracellular matrix, especially reductions in heparan sulfate with an increase in collagen 6) In patients with the Metabolic Syndrome, there is the added impact of adipose tissue derived compounds such as: leptin, TNFa, angiotensin II, PAI-1, free fatty acids, and many more. These all, play in concert to cause vasculopathy, neuropathy skin disturbances and susceptibility to infections, and ultimately the situation known as "The Diabetic Foot". 30 International Diabetic Foot Seminar November 2007 Tehran- Iran

31 Workshops International Diabetic Foot Seminar November 2007 Tehran- Iran 31

32 The role of the foot care Specialist and Nurse in the Diabetic Foot Clinic Boutros, M RN Coelho, S RN Landis, S MD 32 International Diabetic Foot Seminar November 2007 Tehran- Iran

33 Boutros, M- Coelho, S- Landis, S M anagement of a diabetic foot ulcer can be complex and challenging. One in every six people with diabetes will have an ulcer during their lifetime and every 30 seconds a leg is lost to diabetes somewhere in the world. However, the introduction of multidisciplinary teams to treat diabetic foot ulcers has been shown to decrease amputation rates by as much as 50 to 85 percent. This workshop will review the factors that influence team performance and how effective teams function. This workshop will illustrate the roles of the nurse coordinator, foot care specialist and physician in improving patient outcomes. International Diabetic Foot Seminar November 2007 Tehran- Iran 33

34 Mohsen Khoshniat Nikoo Dr Khoshniat is an endocrinologist. He trained as an internist in Tehran University of medical sciences (TUMS) and as an endocrinologist in Shahid Beheshti University of medical sciences. He has practiced Endocrinology for 10 years. He is Assistant Professor and Researcher of Internal Medicine and Endocrinology in Endocrinology and Metabolism Research Center, Shariati Hospital. Recently, He focuses on Medical Ethics and spends half of his time in Medical History and Medical Ethics Research Center of TUMS. Dr Khoshniat is presently involved in diabetes research programs and Medical Ethics Researches, and Education of internal medicine residents and endocrinology fellowships. He published 20 articles in different Endocrine fields esp. Diabetes, GDM and endocrine complication of bone marrow transplantation and hyperthyroidism in breast-feeding mothers. 34 International Diabetic Foot Seminar November 2007 Tehran- Iran

35 Workshop in Persian: The diagnosis of osteomyelitis in Diabetic Foot P eripheral neuropathy and vascular disease alone do not cause foot ulceration. It is the combination of the factors that act together in the vast majority of cases. Trauma from either the patient s shoes or from external causes and loss of protective sensation and peripheral vascular disease are among the major contributors to foot ulceration. Diabetic neuropathy is the common denominator in almost 90% of diabetic foot ulcers. Trauma initially causes minor injuries, which are not perceived by the patient with loss of protective sensation. As the patient continues his activities, a small injury enlarges and may be complicated by infection. CLASSIFICATION SYSTEMS: Meggitt Wagner classification of foot ulcers Khoshniat Nikoo, M International Diabetic Foot Seminar November 2007 Tehran- Iran 35

36 Khoshniat Nikoo, M The University of Texas classification system for diabetic foot wounds Advantages It is simple to use and more descriptive It has been evaluated and shown to predict more accurately the outcome of an ulcer (healing or amputation) than the Meggitt Wagner classification. Cases with infection and/or ischemia are taken into account in this system It provides a guide for planning treatment Disadvantages Patient-related factors (poor foot care, emotional upset, denial) and foot deformities are not evaluated The location of the ulcer is not described CLINICAL PRESENTATION: 1- Neuropathic Develop at areas of high plantar pressures (metatarsal heads, plantar aspect of the great toe, heel or over bony prominences in a Charcottype foot). Are painless, unless they are complicated by infection. There is callus formation at the borders of the ulcer. Its base is red, with a healthy granular appearance. On examination evidence of peripheral neuropathy (hypoesthesia or complete loss of sensation of light touch, pain, temperature, and vibration, absence of Achilles tendon reflexes, abnormal vibration perception threshold, and loss of sensation in 36 International Diabetic Foot Seminar November 2007 Tehran- Iran

37 Khoshniat Nikoo, M response to 5.07 monofilaments, atrophy of the small muscles of the feet, dry skin and distended dorsal foot veins) is present. However, the pattern of sensory loss may vary considerably from patient to patient. The foot has normal temperature or may be warm. Peripheral pulses are present and the ankle brachial pressure index is normal or above Ischemic Develop on the borders or the dorsal aspect of the feet and toes or between toes. They are usually painful. There is usually redness at the borders of the ulcer. Its base is yellowish or necrotic (black). There is a history of intermittent claudication. On examination indications of peripheral vascular disease (skin is cool, pale or cyanosed, shiny and thin, with loss of hair, and onychodystrophy; peripheral pulses are absent or weak; the ankle brachial index is <0.9) are present. Non-invasive vascular testing (duplex or triplex ultrasound examination. 3- Neuro-Ischemic Neuro-ischemic ulcers have a mixed etiology, i.e. neuropathy and ischemia, and a mixed appearance. International Diabetic Foot Seminar November 2007 Tehran- Iran 37

38 Friday, November 16, :30-8:50am 8:50-9:10 am 9:10-9:30 am 9:30-9:50 am Holy Quran Session 3 Chairs: Dr. Sibbald, Dr, Sharghi, Dr. Rajabian, Dr Behjati Foot Examination in persons with diabetes New approaches to diabetic foot care: The whole patient before the hole in the patient Diagnosis of Osteomyelitis & role of bone probing Management of Diabetic Foot Infections Cellulitis,Osteomyelitis) Break 9:50-10:20 am Session 4 Mohajeri Tehrani MD Sibbald MD Nakhjavani MD Landis MD Chairs: Dr. Sibbald, Dr. Pajouhi, Dr. Mohajeri Tehrani 10:20-10:45 am Dermatopathy of Diabetic Foot Dowlati MD 10:45-11:10 am The role of Angioplasty in DF Ghanaati MD ulcer healing 11:10-11:35 am Off loading methods in DF management Boutros RN 11:35-12:00 pm Advanced and Active therapies for the treatment of Diabetic Foot Ulcers Sibbald MD Lunch & Exhibition pm 13:00 15:00 pm 13:00 15:00 pm Workshop Workshop Topic: foot care / practical Workshop in Persian The diagnosis of osteomyelitis in Diabetic Foot kawthe J. Al Taitoon RN Aghaei MD 38 International Diabetic Foot Seminar November 2007 Tehran- Iran

39 Mohammad R. Mohajeri Tehrani Dr Mohajeri is an Endocrinologist. He is an assistant professor of internal medicine and endocrinology of Tehran University of Medical Sciences and works as a researcher in endocrinology & metabolism research center, (EMRC), Shariati hospital. He trained as a General Practitioner and Internist in Tehran University, school of medicine and earned Board degree of Internal medicine in 2001, then he passed fellowship course of endocrinology and obtained the Board of Endocrinology in 2003 in Tehran University of Medical Sciences (TUMS). His fellowship research topic was Burden of diabetes mellitus estimation in IRAN. He involves in education of medical students and internal medicine residents and endocrinology fellows. Dr mohajeri is a member of Diabetic research branch of EMRC, he is also reviewer of Iranian Journal of Diabetes & Lipid since He is dealing with designing of clinical presentation curriculum of hyperglycemia with the assistance of WHO. He is one of the mentors of wound care course which is held in Tehran by TUMS with collaboration of Toronto University. Recently, he focuses on diabetic foot ulcer. He is also works as the director of diabetic clinic in shariati hospital. He published more than twenty articles in different aspects of endocrinology, esp. diabetes, diabetic foot, osteoporosis. International Diabetic Foot Seminar November 2007 Tehran- Iran 39

40 Mohajeri Tehrani, MR Foot Examination in persons with diabetes F oot problems are an important cause of morbidity in patients with diabetes mellitus. It may be affected by neuropathy and vascular diseases. The lifetime risk of a foot ulcer for diabetic patients (type 1 or 2) is approximately 15 percent. Foot amputations, many of which are preventable with early recognition and therapy, are all too often the outcome. For evaluation of diabetic foot ulcer it is better to pay attention to the cause of the ulcer (neuropathy, vascular diseases and infection) as well as to the ulcer bed itself. Screening for diabetic neuropathy: An abbreviated history and physical examination can usually establish the presence and severity of diabetic neuropathy. It is recommended to screen diabetic neuropathy by simple method such as use of monofilament; vibration testing. Screening with simple vibration testing, a monofilament examination, or superficial pain sensation appears to have a similar sensitivity and specificity for diabetic neuropathy. Evaluation of the diabetic foot: In examination of the diabetic patient it should noticed to the appearance of foot and evaluate these abnormalities such as signs of current or previous ulcers, lesions between adjacent toes due to pressure from tight shoes cramming them together, macerated areas between the toes ("athlete's foot"); bunions (callused areas). The physical examination may reveal several abnormalities that result from diabetic neuropathy, such as claw toes and Charcot arthropathy. These deformities may increase pressure to some areas and cause foot ulceration. The associated autonomic neuropathy can lead to several additional problems. Sweating is diminished or absent; as a result, the skin of the feet remains dry and has a tendency to become scaly and cracked, thereby allowing infection to penetrate below the skin. The presence of a diabetic foot infection is usually presumed if there is: At least two of the following: Erythema, warmth, tenderness, or swelling AND Pus coming out of an ulcer site and/or a nearby sinus tract. 40 International Diabetic Foot Seminar November 2007 Tehran- Iran

41 Mohajeri Tehrani, MR Diabetic foot ulcers can be graded according to a scheme proposed by Wagner: Grade 0 No ulcer in a high risk foot. Grade 1 Superficial ulcer involving the full skin thickness but not underlying tissues. Grade 2 Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. Grade 3 Deep ulcer with cellultis or abscess formation, often with osteomyelitis. Grade 4 Localized gangrene. Grade 5 Extensive gangrene involving the whole foot. There is another classification of diabetic foot named University of Texas classification (UT) in which etiology of the ulcer incorporated to the staging of the disease. Recommendation : It is recommended to perform a comprehensive foot examination annually on patients with diabetes to identify risk factors predictive for ulcers and amputation and perform a visual inspection of the feet at each routine visit. The comprehensive foot examination can be accomplished in the primary care setting and should include the use of a Semmes- Weinstein 5.07 (10-g) monofilament at specific sites to detect loss of sensation in the foot. Screen for peripheral arterial disease by asking about a history of claudication and assessing the pedal pulses. Consider obtaining an ankle brachial index in patients who are suspected to peripheral arterial disease. Patients should be considered at particularly high risk for future plantar ulceration if they have: previous history of foot ulceration or amputation, neuropathic foot deformities, especially with overlying bunions or calluses, no sensation of pressure from a 5.07 U monofilament. International Diabetic Foot Seminar November 2007 Tehran- Iran 41

42 Gary Sibbald Dr. Sibbald is a professor of Public Health Sciences and Medicine at the University of Toronto. He trained as a dermatologist and internist with special interest in wound healing and education. He is currently the director of medical education for Women s College Hospital and chair faculty of Medical Education Committee. Dr. Sibbald is a board member and current President of the Canadian Association of Continuing Health Education and chair of the Accreditation Committee for The Royal College of Physicians and Surgeons of Canada. He is a past chair of the Cambridge Conference on Medical Education. Presently, Professor Sibbald is the director Wound Healing Clinic at the Women s College Hospital. He established an interprofessional education model for wound care as co-founder, previous chairman and a five-time annual meeting chair of the Canadian Association of Wound Care. Professor Sibbald established the International Interdisciplinary Wound Care Course (IIWCC) at the University of Toronto in This course is the first University of Toronto continuing education course to offer a certificate of completion and combine residential weekends with self-study and a selective that relates new knowledge to everyday practice. This course is currently part of a new Master s Science/Community Health Program in the Department of Public Health Sciences. He is co-editor of the Fourth Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Dr. Sibbald is the chairman and president elect for the 3rd Meeting of the World Union of Wound Healing Societies to be held in Toronto in June 4th to 8th, 2008.Dr. Sibbald has published over 150 articles and book chapters. 42 International Diabetic Foot Seminar November 2007 Tehran- Iran

43 New approaches to diabetic foot care: The whole patient before the hole in the patient Sibbald, G By the end of this session participants will: Review the benefit of a trans professional model for optimal patient outcomes Implement the wound bed preparation model as an enabler to improving patient outcomes Emphasize the importance of the patient s perspective through patient centered concerns T he development of a Diabetic foot ulcer has a long term impact on the health of persons with diabetes. Cares of these persons require a systematic team approach from health care professionals. This session will update the practitioners on new advances in the management of diabetic foot ulcers. In order to improve health outcomes for persons with diabetic foot ulcers and decrease the burden on health care system a, comprehensive health care plan should be applied. International Diabetic Foot Seminar November 2007 Tehran- Iran 43

44 Manouchehr Nakhjavani Dr nakhjavani is an endocrinologist. He trained as internist and endocrinologist in Tehran university of Medical Sciences (TUMS). He is a graduate of a course in myoclinic. Canada. Dr nakhjavani is professor of TUMS. He is a head of Endocrine & Metabolism ward of Valiaser hospital. Dr nakhjavani is a member of endocrine & metabolism research center (EMRC), educational committee of Imam Khomeini hospital, scientific Associations, medical group, and endocrinologist associations. He is also responsible of internist exam (endocrine physiopathology) and OSCE exam of internists. 44 International Diabetic Foot Seminar November 2007 Tehran- Iran

45 Diagnosis of Osteomyelitis & role of bone probing D Nakhjavani, M iabetes is the leading cause of nontraumatic lower extremity amputations. Today, more than 85% of lower extremity amputations in patients with diabetes are preceded by foot ulcers. Determination of which diabetic foot lesions have underlying osteomyelitis is a difficult but important clinical issue, because failure to diagnose and treat osteomyelitis increases the risk of amputation Not all diabetic foot ulcers become infected, but determining which ulcers are infected and which have underlying osteomyelitis is difficult. The accuracy of clinical diagnosis of osteomyelitis in this setting is poor. Clinical diagnosis is complicated by the frequent absence of local signs of infection, such as purulent drainage and local erythema, warmth, and tenderness. Often, the only systemic sign of diabetic foot osteomyelitis is recalcitrant hyperglycemia; fever and chills are absent in up to two thirds of patients. Several findings suggest the presence of underlying osteomyelitis in the diabetic patient with a foot ulcer. Ulcerations present over bony prominences for more than 2 weeks are at high risk for contiguous bone involvement. Ulcer size and depth are also predictive of concomitant osteomyelitis. An ulcer area greater than 2 cm2 has a sensitivity of 56% and specificity of 92% for the diagnosis of osteomyelitis, and in one series, 82% of patients with ulcers more than 3 mm (1.2 in) deep had osteomyelitis. The ability to gently probe to bone at the base of an ulcer also is highly predictive of osteomyelitis. If bone can be reached during the probe of an ulcer, no other studies are needed to diagnose osteomyelitis. However, the negative predictive value of 56% for this test suggests that a negative result does not exclude a diagnosis of osteomyelitis. Laboratory studies Laboratory studies are notoriously unhelpful in diagnosis of osteomyelitis. The white blood cell count may be normal, and the erythrocyte Sedimentation rate (ESR) has limited sensitivity. One study found that an International Diabetic Foot Seminar November 2007 Tehran- Iran 45

46 Nakhjavani, M ESR greater than 100 mm/hr had a sensitivity of only 23% for the diagnosis of osteomyelitis in the diabetic foot. Diagnostic imaging Although bone biopsy is the definitive test for documentation of both the pathologic and microbiologic diagnoses of osteomyelitis, physicians often have to rely on imaging to make the diagnosis. However, choosing the appropriate study can often be confusing, and previous surgery, concomitant neuropathic osteoarthropathy (Charcot's foot), the duration of infection, and the cost of the study need to be considered Radiographs Plain radiographic films of the foot are obtained easily and are the least expensive study. Findings of osteomyelitis include cortical erosion or periosteal elevation in the area underlying an ulcer. Unfortunately, osteomyelitis usually must be present for at least 10 days to 3 weeks before the infection becomes detectable on plain films. It also is difficult to diagnose in patients with severe neuropathic bone disease, because the radiographic findings are very similar. Nuclear medicine scans Nuclear medicine studies, such as triple-phase bone scans, can also be used for evaluation of suspected osteomyelitis in diabetic patients with foot ulcers. The diagnosis of osteomyelitis requires increased focal activity in bone beneath an ulcer on both early and late phases of the scan. Because this study does not depend on anatomical changes in the involved bone, it can detect osteomyelitis up to 2 weeks earlier than plain films. The main drawback of this test is a high false-positive rate in patients with diabetes, which is due to the presence of neuropathic osteoarthropathy. Other causes of false-positive results in triple-phase bone scans include fractures and previous surgery. Radionucleotidelabeled white blood cell scans also are used for evaluation of suspected osteomyelitis. In this study, the leukocytes migrate to the area of infection, and an image is obtained with a gamma camera 24 hours after injection. The main advantages of this study are that neuropathic joints rarely cause false-positive scans and that because the results of the scans normalize with healing, the study can be used 46 International Diabetic Foot Seminar November 2007 Tehran- Iran

47 Nakhjavani, M to follow treatment response. Major drawbacks include limited spatial resolution, which makes differentiation of infection in bone compared with soft tissue problematic, and a completion time of more than 24 hours. Computed tomography Computed tomography remains a diagnostic option when other studies are not available. However, the main limitation of this study is its inability to differentiate between soft tissue changes secondary to suppurative infection, fibrosis, chronic ischemia, neuropathic changes, or osteomyelitis. Magnetic resonance imaging Recently, magnetic resonance imaging (MRI) has become widely available and provides an excellent means for differentiation between infections of soft tissue and bone. Overall, MRI has performed better than plain films, bone scans, and tagged leukocyte scans in diagnosing osteomyelitis in diabetic patients with soft tissue infections of the foot. Its sensitivity and specificity were 99% and 83%, respectively, in one study. The main limitation of MRI in this setting is its expense. Conclusion Osteomyelitis of the diabetic foot is a serious problem and is partly responsible for the high rate of lower extremity amputations in this diabetic population. Thoughtful sequential use of the physical examination and appropriate imaging techniques can help physicians to diagnose and treat osteomyelitis in diabetic patients with foot ulcers during early stages of infection. International Diabetic Foot Seminar November 2007 Tehran- Iran 47

48 Stephan Landis Dr. Stephan Landis is an infectious diseases internist, currently practising Hospital Medicine at the Guelph General Hospital, Guelph, Ontario. After practicing at the Hamilton General Hospital, McMaster University, as Associate Clinical Professor of Medicine for 21 years, he completed 5 years as Head of the Division of Internal Medicine at the Shaikh Khalifa Medical City in Abu Dhabi, United Arab Emirates (UAE). He practiced internal medicine, infectious diseases and developed the ambulatory wound care program, which was the only multidisciplinary service of its kind in the UAE. He has been actively involved, as chair and co-chair, in all three of the Middle East Wound Congresses held at Arab Health, Dubai, from He has given numerous presentations on wound management in Canada, United Arab Emirates, India, Qatar and Europe. 48 International Diabetic Foot Seminar November 2007 Tehran- Iran

49 Management of Diabetic Foot Infections (Cellulitis, Osteomyelitis) Landis, S Following this session, the attendee will be able to: A Identify and treat increased surface bacterial burden and deep surrounding skin infection Assess clinical parameters and investigations to follow the progress of infected foot ulcers Define the steps required for an integrated approach to the treatment of patients with diabetic foot ulcers person with diabetes is an immune compromised host, that is at an increased risk of developing infection. Case studies will be used to illustrate this concept, and to show, in a practical way, how to tackle the problem of successful management at the bedside. International Diabetic Foot Seminar November 2007 Tehran- Iran 49

50 Yahya Dowlati He was born at October 31, 1934 in Hamadan, Iran. He graduated from School of Pharmacy, Tehran University as PharmD (1959) and from School of Medicine, Tehran University as MD (1966).He did his Internship in Tehran University, ( ) and again Bon Secours Hospital, Grosse Pointe, Michigan, USA (1968). He did his Residency in Hahnemann Medical College & Hospital, Philadelphia, ( ) Now called Hahnemann University. PA, USA and Fellowship, in the same place (1972). He returned to Iran and has been involved in teaching, research and private practice.he has Experience of teaching in Dermatology and Dermatopathology at Razi Hospital, Tehran University of Medical sciences, Beheshti University of Medical Sciences, Iran University of Medical Sciences, Occasionally Isfahan, Tabriz, Kerman and Urmia (Tehran, Iran). As well as he is responsible for the teaching all the dermatology residents in the country at Center for Research and Training in Skin Disease and Leprosy. He is Member of Iranian Board of Medical Specialties Since 1989, President, Iranian Society of Dermatology, Since 1995, Chairman Iranian National Leishmaniasis Research Committee, Since 1992, Board of Directors, International Society of Dermatology: Tropical, Geographical & Ecological Since 1993, and his main job at present is Director, Center for Research and Training in Skin Diseases and Leprosy, Since March He is member of American Academy of Dermatology, American Societies of Dermatologic Surgery and Dermatopathology, International Societies of Dermatology,Association, Dermatopathology, Leprosy and Tropical Dermatology, International Leprosy Iranian Medical Council and Dermatological Association. He has gotten Silver award, American Academy of Pediatrics 1972, Gold award for election as the top clinical researcher, 5 th Ave Sina Scientific Award, Tehran University of Medical Sciences, Tehran, Iran, February, Honorable Mention, American College of Cardiology 1972 and Southern Medical Association 1972 and many other national and international certificates and awards. He has 50 scientific exhibits and posters and more than 50 papers that has been presented in international congresses. He has edited ten books and published 90 articles in national and international journals and there are more than 20 thesis that have been conducted with his directions and advises. Till now he has chaired several international congress sessions. "Treatment of acute Old World cutaneous leishmaniasis: a systematic review of the randomized controlled trials" Is the title of an article that is the first evidence based systematic review about treatment of acute old world cutaneous leishmaniasis This article has been written by Dr Dowlati and his coworkers in Center for Research and Training in Skin Disease and Leprosy and is under press in Journal of the American Academy of Dermatology. 50 International Diabetic Foot Seminar November 2007 Tehran- Iran

51 , Y Dermatopathy of Diabetic Foot Dowlti D irector, Center for research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences and Health Services Diabetes mellitus (DM) is a heterogeneous group of disorders characterized by high levels of serum glucose. It is a chronic disease which affects millions of people in both developed and developing countries. About 80% of DM cases are living in low and middle income countries. More than 30% of DM patients have some type of skin manifestation during the course of their disease. The aim of this presentation is to provide an overview of skin manifestations of DM. To achieve this purpose, cutaneous manifestations of DM are discussed in four categories: (1) skin diseases that have an association with DM, (2) DM-associated skin infections, (3) cutaneous manifestation of diabetic complications and (4) skin reactions to the treatment of DM. Diagnosis and management of different conditions in each category will be discussed. International Diabetic Foot Seminar November 2007 Tehran- Iran 51

52 Hossein Ghanaati Dr Ghanaati is an radiologist. He trained as a radiologist in Tehran university of medical sciences (TUMS), Dr Ghanaati is also a graduate of the observer fellowship in CT.scan 2005 observer fellowship in MRI London St bard hospital 2006, and Iranian national. Board of radiology sep He is associate professor of radiology in TUMS since Dr Ghanaati works as director of medical imaging center of Imam Khomeini hospital chairman of Iranian journal of radiology, founder & manager of computer center is Imam Khomeini hospital, manager of educational & research programming office of Imam Khomeini hospital, chairman of the 17th Iranian congress of radiology 2002, distinguished national radiologist by Iranian medical council, secretary of radiology strategic planning committee of ministry of health and medical education. He is a member of Iranian national educational committee of residency in training in radiology, Iranian journal of radiation research, ACTA media Iranian, scientific committee of the Neuroradiology journal. He successfully supervised eight projects for the first time in Iran. He has published so articles and 28 presentations. 52 International Diabetic Foot Seminar November 2007 Tehran- Iran

53 The role of Angioplasty in DF ulcer healing Ghanaati P eripheral vascular disease is an increasing common problem in developed contries. Ageing population, life style & increased incidence of diabetes & hypertension are important risk factors: Involvement of infra-popliteal arteries is leading to critical limb ischemia in some cases. Critical limb ischemias define as chronic ischemic limb at risk of amputation within a year %25 of patient will die & %25 will require major amputation. Successful treatment leads to instant relief of such severe disability & returns the limb to a chronically ischemic but viable state. Infra popliteal angioplasty could be considered a suitable technique with less complication in compare to surgery with remarkable benefits. Including prevention of major amputation, technical success in some series of infra popliteal angioplasty have been %70. Angioplasty is considered as effective treatment option in critical limb ischemia to effect limb salvage. International Diabetic Foot Seminar November 2007 Tehran- Iran 53

54 Miriam Boutros Miriam Boutros is a foot specialist at the wound healing clinic at Women s college Hospital.Her background is a Chiropodist (1994) with a specialty in biomechanics and sports medicine. She worked at Bay-crest centre for geriatric care for several years where she developed an interest in managing diabetic foot wounds. In 1999 she completed her IIWCC followed by a two year of clinical perceptorship at the wound healing clinic. After completing her training, she was inspired to develop The high risk foot course for the chiropody students. Mariam Boutros worked at the Michener Institute for health applies sciences ( ) training chiropody students both theoretically and clinically in managing the high risk foot. She is presently a clinical instructor at women s college Hospital and part of the Interdisciplinary team at the wound healing clinic. She is also a faculty member of the Canadian and Iranian IIWCC. 54 International Diabetic Foot Seminar November 2007 Tehran- Iran

55 Off loading methods in DF management Following this session, the attendee will be able to: F Assess the biomechanical devices that are important for diabetic foot care Evaluate a toolkit of options for plantar pressure redistribution. Select an appropriate device depending on individual patient characteristics oot ulcers are one of the major complications of neuropathy especially in persons with diabetes. The loss of protective sensation secondary to neuropathy often results in changes to the foot structure and skin breakdown as a result of abnormal ambulatory mechanical loading. Abnormal foot pressures can be reduced using several different approaches, including callus Debridement and prescription of specialty devices. Pressure redistribution of the Diabetic foot (especially periwound area) is a key factor in successful wound healing. Plantar pressure relief can be achieved using various off-loading modalities including contact cast, removable and irremovable cast walkers, walking splints, ankle-foot orthosis and surgical shoes. International Diabetic Foot Seminar November 2007 Tehran- Iran 55

56 Gary Sibbald Dr. Sibbald is a professor of Public Health Sciencess and Medicine at the University of Toronto. He trained as a dermatologist and internist with special interest in wound healing and education. He is currently the director of medical education for Women s College Hospital and chair faculty of Medical Education Committee. Dr. Sibbald is a board member and current President of the Canadian Association of Continuing Health Education and chair of the Accreditation Committee for The Royal College of Physicians and Surgeons of Canada. He is a past chair of the Cambridge Conference on Medical Education. Presently, Professor Sibbald is the director Wound Healing Clinic at the Women s College Hospital. He established an interprofessional education model for wound care as co-founder, previous chairman and a five-time annual meeting chair of the Canadian Association of Wound Care. Professor Sibbald established the International Interdisciplinary Wound Care Course (IIWCC) at the University of Toronto in This course is the first University of Toronto continuing education course to offer a certificate of completion and combine residential weekends with self-study and a selective that relates new knowledge to everyday practice. This course is currently part of a new Master s Sciences/Community Health Program in the Department of Public Health Sciencess. He is co-editor of the Fourth Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Dr. Sibbald is the chairman and president elect for the 3rd Meeting of the World Union of Wound Healing Societies to be held in Toronto in June 4th to 8th, 2008.Dr. Sibbald has published over 150 articles and book chapters. 56 International Diabetic Foot Seminar November 2007 Tehran- Iran

57 Advanced and Active therapies for the treatment of Diabetic Foot Ulcers Sibbald By the end of this session participants will: Evaluate the role of wound bed preparation in the healing of chronic wounds and diabetic foot ulcers: DIM before DIM-E Formulate an approach to the use of advanced therapies for diabetic foot ulcers when healing is stalled. Select appropriate treatment based on individual patient characteristics T he concept of wound bed preparation was designed to optimize the healing of chronic wounds. Local wound care consists of tissue debridement, control of persistent inflammation or infection, and moisture balance before considering advanced therapies (DIME). Advanced therapies (ex: Biologicals) should be considered as options for wound management when healing is stalled. International Diabetic Foot Seminar November 2007 Tehran- Iran 57

58 Workshops 58 International Diabetic Foot Seminar November 2007 Tehran- Iran

59 Kawther J.Al-Taitoon Mrs.Taitoon a graduated of the University of Texas Medical Branch of Galveston-Texas-USA. She is a full time faculty, Ass. Professor at the College of Health Sciences-Bahrain. She is a Diabetic Clinical Specialist and the IDF/ EMME Region Supervisor for Diabetic Education. Besides, the broad experience in diabetic education; conducted around the world various research, workshops; courses, seminars in the area of diabetic education. Also, she is talented artist and conducted various art exhibitions. International Diabetic Foot Seminar November 2007 Tehran- Iran 59

60 Al-Taitoon, K Diabetic Education-Client Readiness D iabetic education is a modality that is prescribed similar to a drug prescription. It consisted of phases which includes assessment, planning; implementation; evaluation and modification. Prior to the education it is important for the educator to consider the client's assessment of readiness. The client's readiness included physical, emotional; cognitive readiness and client's behavior. Upon recognizing the readiness problems than the educator develop the plan and these includes---use simple language, place priority information, use media for sensory stimulation, encourage interactions; plan time ;place and implement; evaluate and modify the whole plan to fit the readiness needs and wants. 60 International Diabetic Foot Seminar November 2007 Tehran- Iran

61 Hamid Reza Aghaei Meybodi Dr Aghaei Meybodi is an endocrinologist. He trained as an internist in Tehran University of medical science (TUMS) and as an endocrinologist in shahid Beheshti University of medical science. He is Assistant Professor and Researcher of Internal Medicine and Endocrinology in Endocrinology and Metabolism Research Center (EMRC), Shariati Hospital. He passed scientific writing, research methodology Primary, Intermediate, and Advanced courses in TUMS, EMRC. He is also director of Osteoporosis group in EMRC and responsible for Osteoporosis and GDM clinic in Shariati Hospital. Dr Aghaei is presently involved in two clinical trials which are related to Diabetes control with new insulin and High dose of Vitamin D. His future plan includes the development of the BMD course for the endocrinologists in four month later. International Diabetic Foot Seminar November 2007 Tehran- Iran 61

62 Aghaei Meybodi, HR Workshop in Persian: The diagnosis of osteomyelitis in Diabetic Foot C ase 1- A 50-year-old male patient with type 1 diabetes diagnosed at the age of 11 years was admitted because of infected foot ulcers. He had a mild fever and a history of proliferative diabetic retinopathy and microalbuminuria. Diabetes control was poor (HbA1c: 9.5%). He reported a trauma to his left foot 2 months earlier when an object fell on his feet while working. A superficial ulcer had developed on the dorsal aspect of his toe; the ulcer had become infected because the patient felt no pain and therefore did not seek medical advice. On examination, pedal pulses were normal but severe peripheral neuropathy was found. Case 2- A 57-year-old obese male patient with type 2 diabetes diagnosed at the age of 40 years, was referred to the outpatient diabetic foot clinic because of a chronic ulcer under his right foot. He was being treated with insulin and metformin with acceptable diabetes control (HbA1c: 7.5%). He had a history of background retinopathy and cataract in both eyes. On examination, the patient had severe diabetic neuropathy with loss of sensation of pain, light touch, temperature, vibration, and monofilaments. Achilles tendon reflexes were absent. Questions: 1. How do you evaluate these patients to R/O osteomyelitis? 2. What imaging study do you request? 3. How do you manage these patients? 62 International Diabetic Foot Seminar November 2007 Tehran- Iran

63 Saturday, November 17, 2007 Holy Quran Session 5 Chairs: Dr. Sibbald, Dr. Landis, Dr. Khoshniat, Dr. Alavi 8:30-8:50 am Neuropathic Diabetic Foot Esteghameti MD 8:50-9:10 am Empowering shared decision making in patients with diabetes Alavi MD 9:10-9:30 am The role of Orthopedic surgery in prevention and management of DF Tahmasebi MD 9:30-10:00 am The care following Amputation Sibbald MD, Coelho in DF patients RN, Boutros RN Break 10-10:30 am Session 6 Chairs: Dr. Sibbald, Dr. Zakeri, Dr. Bahrami, Dr. Lankarani 10:30-11:00 am 11:00-11:30 am 11:30-12:00 am Evidence informed practice on local wound bed management Prevention of Diabetic Foot ulcers and amputations The role of vascular surgery in DF management Lunch & Exhibition pm Landis MD, Alavi MD, Coelho RN Sibbald MD, Boutros RN Shojaeefard MD 13:00-15:00 pm 13:00-15:00 pm Workshop Workshop Topic: Modern dressing in the treatment of Diabetic Foot Ulcers Workshop in Persian The prevention of Diabetic Foot Canadian Team Botros, Coelho, Landis Behjati MD International Diabetic Foot Seminar November 2007 Tehran- Iran 63

64 Alireza Esteghamati Dr Esteghamati is an Endocrinologist. He trained as an internist and Endocrinologist in Tehran University of Medical Sciences. He is Associate Professor of Internal medicine and Endocrinology and Metabolism Department, vali-asr hospital. Dr Esteghamati is also a member of national committee of diabetes, member of board of directors of Iran endocrine society and board of directors of Iranian society of internal medicine. 64 International Diabetic Foot Seminar November 2007 Tehran- Iran

65 Neuropathic Diabetic Foot T E steghamati he number of patients with diabetes mellitus is increasing, by epidemic proportions, and the disease can lead to end-organ damage due to many years of hyperglycemia, which results in a major burden on health-care providers. Diabetic foot ulceration represents a major medical, social and economic problem all over the world. The lifetime risk for a person with diabetes of developing a foot ulcer could be as high as 25% and it is believed that every 30 s a lower limb is amputated somewhere in the world as a consequence of diabetes. Foot problems in diabetic patients account for more hospital admissions than any other long-term complications of diabetes, and also result in increased morbidity and mortality. Diabetic neuropathy and peripheral vascular disease are the main etiologic factors in foot ulceration; they act together and in combination with other factors such as unrecognized trauma, biomechanical abnormalities, limited joint mobility and increased susceptibility to infection. The diabetic foot syndrome encompasses a number of pathologic conditions including diabetic neuropathy, peripheral vascular disease, Charcot s neuroarthropathy, foot ulceration, osteomyelitis and the potentially preventable end point, amputation. The main focus of this article will be neuropathic foot ulceration (i.e. ulceration that penetrates the full thickness of the dermis in a person with diabetic neuropathy) and its prevention, All patients with diabetes should have a thorough foot examination at least annually; those at risk of ulceration require more frequent monitoring. Patients with sensory loss require regular podiatric care and should be educated in preventive foot care. We recommend shoes with adequate depth and width. Noninfected neuropathic foot ulcers require debridement and reduction of pressure over the ulcer area. Although the frequency of visits to the clinic depends on the severity of the ulcer and the response to therapy, weekly visits for wound debridement and assessment are initially reasonable. The benefit of removing pressure from a neuropathic foot ulcer is well established, and is the cornerstone of management of such ulcers. International Diabetic Foot Seminar November 2007 Tehran- Iran 65

66 Esteghamati, A KEY POINTS Diabetic foot problems result in major medical, social, and economic consequences for patients, their families, and society Neuropathy is the major contributory factor in the pathogenesis of diabetic foot ulcers Removing pressure from the diabetic neuropathic plantar ulcer is a major part of management of such ulcers Repetitive pressure on the wound, permitted because of trauma or insensitivity, may be a major contributory factor in persistence of diabetic foot ulcers The presence of unilateral heat and swelling in the feet of a neuropathic diabetic patient should be presumed to be caused by acute Charcot s neuropathy until proven otherwise All patients with diabetes should have a thorough foot examination at least annually 66 International Diabetic Foot Seminar November 2007 Tehran- Iran

67 Afsaneh Alavi Dr Alavi is a Dermatologist and has a 2 year appointment as a wound healing fellow at the University of Toronto. Her wound care expertise has grown from the completion of the International interprofessional wound care course (IIWCC) in Dr. Alavi trained as a dermatologist in Kerman Iran and practiced dermatology for 8 years including three years at the Kerman University Neuroscience researcher center. Her current activities include privileges as wound care and dermatology consultant at the trillium Hospital in Mississauga Ontario. Her fellowship duties include the participation in the care of patients, research and educational programs through the wound healing centers at Women s College and Mississauga wound healing clinic. Dr Alavi is also a graduate of the Teaching and Learning course for health care professionals at the University of Toronto. Dr Alavi has co-authored four chapters in the fourth Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals and a chapter in the American Diabetic Federation book (diabetes and skin). She was also a co-investigator on a primary care reform project for the comprehensive treatment of leg and foot ulcers in a home care population for the Ontario Government ministry of health and Long Term Care. Dr Alavi is presently involved in clinical trials in chronic wound care. She has presented for international wound conferences and has been published in wound care and dermatology Journals. Her future plans include the development of the IIWCC course for the Middle East through the collaboration of the University of Toronto and the University of Tehran. Dr. Alavi is a coordinator for a wound care course in collaboration with the University of Toronto and University of Tehran in Iran. She is currently enrolled in a new program at the University of Toronto as part of a new professionals Master s Program in the Department of Public Health Sciences with focus on education. International Diabetic Foot Seminar November 2007 Tehran- Iran 67

68 Alavi, A Empowering shared decision making in patients with diabetes (Patient-centered concerns) Learning objectives Participants will: Discuss the patient perspective for the treatment of Diabetic Neurotrophic Foot Ulcers (DNFU)/Diabetic Neuroischemic Foot Ulcers (DNIFU) Identify the barriers for treatment adherence Recognize the role of patient practitioner collaboration in improving patient outcomes including activities of daily living and gold standard care T reatment of chronic wounds has become increasingly focused on patient participation in the interprofessional decision making process.the concept of the patient practitioner relationship as a foundation for a collaborative, shared decision making process will be the discussed. The aim of this approach is to motivate patients to become knowledgeable about their disease and treatment options. The more motivated the patient is, the more likely they are to be adherent with the treatment plan. However, the more a practitioner confronts the patient, the more resistance develops. The patient physician relationship provides a foundation for this collaboration and had been described as the most important factor in patient adherence. The four E communication model (Engage, Empathize, Educate, and Enlist) for physicians and patients is useful to improve outcomes. 68 International Diabetic Foot Seminar November 2007 Tehran- Iran

69 Mohammad Naghi Tahmasebi Dr Tahmasebi is an Orthopedist. He trained as General physician & Specialty of orthopedics surgery in Tehran University of Medical Sciences (TUMS) and as specialist of knee Arthoplasty in London University, 1995.He is Associate Professor of orthopedics surgery in TUMS. He has 13 published articles in international medical journal. Dr Tahmasebi presented 39 in international national congress. He passed successfully 13 courses in Japan, Switzerland, Kuwait, Dubai, Saudi Arabic, Qatar, Uk. He was manager of Shariati hospital in pervious years. He is the member of editorial Board of Hakim, Acta medica iranica, Bone & joint magazines. Dr Tahmasebi is also the responsible of scientific Bone Bank International Diabetic Foot Seminar November 2007 Tehran- Iran 69

70 Tahmasebi, M N D The role of orthopedic surgery in prevention and management of DF iabetic foot ulcer is the reason of about 80% of nontraumatic lower extremity amputations. About 15% of diabetic patients will develop ulcers during their lives and the risk of amputation will become more than eight times for every diabetic ulcer. 36% of diabetic patients who undergo transtibial amputation due to diabetic ulcer will die in the following two years. There are three main risk factors for the development of a diabetic foot ulcer which consist of peripheral neuropathy (sensory, motor, autonomous dysfunction), peripheral vascular disease and immunodeficiency. Repetitive pressure and micro trauma over bony prominences in these diabetic patients will lead to blister and ultimately to full thickness skin breakdown. Losing this great defense mechanism (skin) accompanying peripheral vascular disease and immunodeficiency will make a perfect media for microorganisms to produce deep-seated infection. It is important to note that most of these risk factors do not act independently to produce foot ulceration. Instead, a combination of these risk factors triggers a pathway leading to ulceration. At the moment, the main concentration of diabetic foot management is the prevention. The preventive strategies constitute of education and justification of the patient about the disease and potential serious complications, instructing them how to keep their foot clean and how to check their foot every day with a mirror and the importance of clean and loose shoes which they wear. Face to face education of the patient by a physician who is trained in the field of diabetic foot is of paramount importance. It must be stressed for these patients that even the mildest problem in their feet, like a minor wound or even a blister could be followed by serious complications, so early medical consultation is a very important step in preventing the ulcer. All individuals with diabetes should have an annual review, which should include examination of the feet by a trained physician. 70 International Diabetic Foot Seminar November 2007 Tehran- Iran

71 Tahmasebi, M N In the management of a patient who comes with a diabetic ulcer, the first and the most important factor to be considered, is the general condition of the patients who are usually malnourished, suffering from renal insufficiency and who are ill of systemic infection due to immunodeficiency and who have been unable to control their blood sugar properly. About 60% of diabetic ulcers are primarily neuropathic, about 20% ischemic and 20% mixed. This means that about 40%of diabetic ulcers have an ischemic component which will affect the plan of treatment. These two types can be differentiated by a good physical examination. Surgical treatment includes tissue debridement followed by an appropriate dressing and removal of pressure for neuropathic ulcers and planning for peripheral vascular angioplasty for ischemic ulcers. If amputation is contemplated, it must be stressed that the main goal is to preserve maximum function and not only to eliminate the infected tissue. It means helping the patient to ambulate as soon as possible with proper orthotics. International Diabetic Foot Seminar November 2007 Tehran- Iran 71

72 Sunita Coelho 1999 Mrs Coelho is graduated from nursing in She worked on a medical inpatient unit at women's college hospital in Toronto until 1995 and then started as nurse coordinator in the wound clinic. She was one of the students of the first graduating class of the IIWCC in 72 International Diabetic Foot Seminar November 2007 Tehran- Iran

73 The care following Amputation in DF patients Coelho, S Following this session, the attendee will be able to: Discuss the complications associated with lower limb amputations in persons with DM Recognize the role of Interdisciplinary team in the management of persons with diabetes post amputation. T he pathogenesis of Lower extremity amputation in diabetes is multifactorial, resulting from peripheral neuropathy, ischemia and deformity, but infection is often the complication that requires surgical intervention. Lower extremity amputation in persons with diabetes results in the loss of part of the toe, foot or the entire limb. The goal of treatment post amputation involves preventing the events that lead to future proximal amputations in the same limb, or preserving the other extremity. A second amputation will result in further impaired mobility and a longer rehabilitation period. Post-amputation care can be optimized through an interdisciplinary approach to treatment, which includes the management of the person with diabetes as a whole with a holistic approach (glycemic control, pain management, local wound care, infection control, offloading, vascular reassessments and continued foot care). International Diabetic Foot Seminar November 2007 Tehran- Iran 73

74 Stephan Landis Dr. Stephan Landis is an infectious diseases internist, currently practising Hospital Medicine at the Guelph General Hospital, Guelph, Ontario. After practicing at the Hamilton General Hospital, McMaster University, as Associate Clinical Professor of Medicine for 21 years, he completed 5 years as Head of the Division of Internal Medicine at the Shaikh Khalifa Medical City in Abu Dhabi, United Arab Emirates (UAE). He practiced internal medicine, infectious diseases and developed the ambulatory wound care program, which was the only multidisciplinary service of its kind in the UAE. He has been actively involved, as chair and co-chair, in all three of the Middle East Wound Congresses held at Arab Health, Dubai, from He has given numerous presentations on wound management in Canada, United Arab Emirates, India, Qatar and Europe. 74 International Diabetic Foot Seminar November 2007 Tehran- Iran

75 The Evidence Informed Practice on Local Wound Bed Management Landis, S- Alavi, A- Coelho, S At the end of this session the participants will: 1. Assess the three fundamental components of local wound care including debridement, infection control (bacterial balance) and moisture balance (DIM) 2. Evaluate the existing guidelines that focus upon the evidence based approach to wound management A chronic wound is one in which the orderly sequence of repair is disrupted at one or more points of the inflammatory, proliferative, epithelialisation or re-modelling stages. Wound bed preparation has become the primary approach to effective wound management that includes holistic care and a team approach. International Diabetic Foot Seminar November 2007 Tehran- Iran 75

76 Gary Sibbald Dr. Sibbald is a professor of Public Health Sciences and Medicine at the University of Toronto. He trained as a dermatologist and internist with special interest in wound healing and education. He is currently the director of medical education for Women s College Hospital and chair faculty of Medical Education Committee. Dr. Sibbald is a board member and current President of the Canadian Association of Continuing Health Education and chair of the Accreditation Committee for The Royal College of Physicians and Surgeons of Canada. He is a past chair of the Cambridge Conference on Medical Education. Presently, Professor Sibbald is the director Wound Healing Clinic at the Women s College Hospital. He established an interprofessional education model for wound care as co-founder, previous chairman and a five-time annual meeting chair of the Canadian Association of Wound Care. Professor Sibbald established the International Interdisciplinary Wound Care Course (IIWCC) at the University of Toronto in This course is the first University of Toronto continuing education course to offer a certificate of completion and combine residential weekends with self-study and a selective that relates new knowledge to everyday practice. This course is currently part of a new Master s Science/Community Health Program in the Department of Public Health Sciences. He is co-editor of the Fourth Edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. Dr. Sibbald is the chairman and president elect for the 3rd Meeting of the World Union of Wound Healing Societies to be held in Toronto in June 4th to 8th, 2008.Dr. Sibbald has published over 150 articles and book chapters. 76 International Diabetic Foot Seminar November 2007 Tehran- Iran

77 Prevention of Diabetic Foot lcers and amputations Sibbald, G - Boutros, M At the end of this session the participants will: Identify the need for preventative foot maintenance in persons with Diabetes Evaluate the risk of amputation in the presence of a diabetic foot ulcer Assess the importance of an inter-professional collaboration to identify the gaps in services for persons with diabetes D iabetes-related amputations form a tremendous personal and societal burden. Foot ulcers are a complication of diabetes mellitus and often precede lower-extremity amputation. The underlying aetiologies are neuropathy, trauma, deformity, and high plantar pressure. The lack of protective sensation, combined with foot deformities, exposes patients to sudden or repetitive stress that leads to ulcer formation with a risk of infection and possible amputation. Amputation reduction programs include Recognition of risk factors, detection of early problems, preventive foot care, periodical foot examinations, appropriate therapeutic footwear, continual patient education and prompt multidisciplinary treatment in cases of foot ulcers. International Diabetic Foot Seminar November 2007 Tehran- Iran 77

78 Abolfazl Shojaie fard Dr Shojaiefard is an Vascular Surgeon. He trained as a General and Vascular surgeon in Tehran University of Medical Sciences (TUMS). Dr Shojaiefard is an Assistant Professor of vascular surgeon in TUMS. He has published a Book of Nutritional Support, Enteral and parenteral Nutrition TUMS Press. He has also involved in published six articles. Dr Shojaiefard presented following topics as a lecturer: 1. Liver Trauma: Approach and Management/ June Vascular Trauma of Lower Extremity/ Oct Popliteal Artery Aneurism: Assessment and Treatment/ Nov Varicose Vein of Lower Extremity/ Dec International Diabetic Foot Seminar November 2007 Tehran- Iran

79 The role of vascular surgery in DF management Shojaie fard, A P atients with diabetes mellitus are afflicted with a combination of chronic ischemia due to vascular occlusive disease and peripheral neuropathy that places them at significant risk for injury to the integument, invasive soft tissue infection, chronic ulceration and gangrene. Obstructive damages of the peripheral arteries in diabetes mellitus patients are known to occur 4 times more often than in patients not having diabetes. Vascular occlusive disease in diabetic patients afflicts arteries in a different distribution. In the diabetic population the aortoiliac segments are frequently free of disease. The ravages of atherosclerosis most severely affect the distal popliteal segment; the tibial and metatarsal vessels. The vascular involvement is extremely diffuse and particularly severe in tibial arteries, with high prevalence of long occlusions. A palpable pedal pulse does not preclude the possibility of the presence of limb-threatening ischemia. Additional non-invasive vascular studies should be undertaken for these patients. It is necessary for the surgeon to differentiate the more common neuropathic ulcerations from the truly ischemic ulceration. Symptoms of rest pain or claudication are not often helpful because many of these patients are asymptomatic as a result of the presence of their neuropathy and inactivity. It is often difficult to assess the severity of ischemia by history and physical examination alone; a combination of different types of noninvasive laboratory testing may be necessary. Pulse-volume recordings and segmental pressures should be routinely obtained. If questions persist, an anatomic study is warranted. Duplex ultrasonography can provide accurate information with little risk to the patient and so should be readily obtained. Because of increased vessel wall calcification in medium-sized and small arteries, it is difficult to compress the vessels when arterial segmental limb pressures are measured. International Diabetic Foot Seminar November 2007 Tehran- Iran 79

80 Shojaie fard, A Among the three risk factors for amputation in diabetic patientsneuropathy, ischemia, and infection-ischemia is the most difficult to quantify. Thus, functional and/or distal foot arteriopathy may be present without any clinical symptoms long before trophic changes occur. Mediacalcinosis alters ankle pressure. Toe pressure is the most reliable test for quantifying ischemia of the diabetic foot. Studies reported successful healing of local amputations when toe pressures were greater than 30 mmhg. Toe pressures have also been helpful in evaluating patients who have combined popliteal and tibial occlusive disease and occlusive disease of the small vessels of the foot. By quantitating the digital blood pressure, we can determine who will require bypass surgery sooner and avoid time-consuming attempts at more conservative therapy that ultimately would prove unsuccessful. A normal toe-brachial index is 0.75, and an index of less than 0.25 represents severe occlusive disease. By calculating the toe-brachial index and measuring segmental pressures, the surgeon can evaluate the various segments of the vascular tree, from the femoral artery to the digital artery, and can quantitate the relative contribution of arterial obstruction at each level. Early aggressive drainage, debridement, and local foot amputations combined with liberal use of revascularization results in cumulative limb salvage of 74% at 5 years in high-risk groups. Each year, 82,000 limb amputations are performed in patients with diabetes mellitus. Aggressive surgical care offers the best chance of avoiding major amputation. Diabetic foot infection does not imply that the blood supply to the soft tissues of the foot is compromised or that the foot cannot be salvaged; however, angiography should be performed when the patient's healing potential is poor. 80 International Diabetic Foot Seminar November 2007 Tehran- Iran

81 Shojaie fard, A Vascular reconstruction, when technically feasible, is recommended for patients with chronic neurotrophic ulcers associated with critical ischemia. Angiologic investigation must be undertaken, as well as an arteriography, in order to plan the revascularization. The treatment options are angioplasty with or without stenting and surgery. Depending on the extent of lesions, percutaneous transluminal angioplasty (PTA) and stent placement in iliac or femoral arteries and PTA of infrapopliteal artery stenoses and occlusions is considered as an effective therapy modality to avoid limb loss in diabetics with critical ischemia. Such as other patients with atherosclerosis if aortic and iliac artery occlusion is present, aorto-femural bypass with prosthetic graft should be considered. In diabetic patients sometimes superficial femoral artery in the adductor canal is severely stenosed or occluded and if good run off according to angiography is present, femoral-popliteal bypass with saphenous vein or vascular prosthetic graft should be performed. The pattern of arteriosclerotic disease allows construction of pedal bypasses especially by the use of short autologous vein grafts employing distal origin of the bypass. Indication and performance of the bypass procedure rely on a complete angiographic evaluation of the arterial system of the diseased limb. Improved foot perfusion will allow necessary minor amputations with safe wound healing. Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere "angiographic" absence. Pedal bypass grafting is a safe method with very good long-term outcomes and patency rate. International Diabetic Foot Seminar November 2007 Tehran- Iran 81

82 Workshops 82 International Diabetic Foot Seminar November 2007 Tehran- Iran

83 Modern dressings in the treatment of Diabetic Foot Ulcers Boutros, M- DCh Coelho, S- RN Landis, S MD International Diabetic Foot Seminar November 2007 Tehran- Iran 83

84 Boutros, M- Coelho, S- Landis, S T he Preparing the Wound Bed paradigm was first described by Sibbald et.al. and Falanga in The paradigm described by Sibbald et.al. included local wound care as an integral part of the management of a chronic wound in addition to treating the cause of the wound and addressing patient centered concerns. The goal of local wound care is to optimize the local conditions of the wound to facilitate healing. Local wound treatment includes the removal of dead tissue, maintaining a moist environment by controlling the excudate, preventing infection as well as addressing patient comfort. For wounds that do not have the ability to heal, conservative debridement, moisture reduction and bacterial reduction are the key elements with a different toolkit of local therapies. A variety of dressings are available on the market. The choice of an appropriate dressing can be confusing. This workshop will guide you through the various classes of modern dressings that are available. Through case study illustrations, the pros and cons of various dressings will be discussed based on the local condition of the wound and the goals of treatment. Samples of dressings will also be available during and at the end of the session. 84 International Diabetic Foot Seminar November 2007 Tehran- Iran

85 Javad Behjati Dr Behjati is an endocrinologist. He trained as an internist & Endocrinologist in Tehran university of Medical Sciences (TUMS). He is Associate Professor of Enternal medicine and endocrinology in TUMS. He actively involved in publishing articles about diabetes & thyroid disorders. He is also a graduate of the endocrine course in Toronto, Canada. International Diabetic Foot Seminar November 2007 Tehran- Iran 85