Cath Lab Digest

The prevalence of diabetes is rapidly increasing and is expected to reach epidemic proportions over the next decade. Today, nearly 246 million people worldwide are diagnosed with diabetes, with India accounting for almost 45 million of those diagnoses. This number is expected to increase to 73 million by the year 2025 and India was deemed the diabetic capital of the world at the International Diabetes Federation Conference in Copenhagen in November 2006. Diabetes is associated with a plethora of complications with foot ulcerations being the most common. An estimated 15% of all patients suffering with diabetes will develop foot ulcers and about half of these ulcers will become infected resulting in 20% of patients left to face some form of a lower extremity amputation.

In India there are very few organized diabetic foot-screening programs. Podiatric services are only available in major centers and the multi-disciplinary team approach is mostly lacking. Proper diabetic shoes and orthotics are not readily available while socio-economic factors encourage barefoot walking, inappropriate footwear utilization, and an overall lack of awareness to the seriousness of diabetic foot problems. This unawareness is shared among both doctors and patients and subsequently referrals to specialty centers are late — causing even further concerns. Seventy percent of the population in India lives in rural areas and 40% reside in one-room tenements. Inadequate sanitation and improper foot offloading due to a lack of facilities and awareness are commonalities. Moreover, very few people in India have health insurance. The vast majority of patients with diabetic foot problems have to pay out of pocket for the cost of medical care, which hinders most from seeking prompt treatment.

The Amrita Institute of Medical Sciences and Research Centre (AIMS) in Kochi, Kerala, India (www.aimshospital.org), is a large, tertiary, 850-bed super-speciality hospital that is run under the guiding grace of their ‘Satguru,’ Mātā Amritanandamayī Devi. There is also an adjacent 600-bed general hospital. The Endocrinology Department at AIMS is the only full-fledged endocrinology department in the state of Kerala. Among the major endocrinology centers in the country, this department has the highest number of endocrine specialists. It provides full facilities for investigation and treatment of endocrine problems among adult, pediatric, and adolescent patients (including in-house hormone assays) and all the complications of diabetes. The department consists of a dedicated and well-qualified team of healthcare professionals comprised of consultant endocrinologists, an endocrinology specialist, several diabetic foot surgeons, diabetic educators, a physiotherapist, a psychologist, podiatry assistants, a medical social worker, a dietician, and other support staff such as nurses, administration, and research personnel.
Tertiary level healthcare is provided to patients with diabetes as well as other complex
endocrine problems. In addition, the department oversees a number of speciality clinics and has the support of allied specialties like neurology, nephrology, ophthalmology, neurosurgery, cardiology, nuclear medicine, and urology within the institute.

AIMS also formed a division of podiatric surgery (the largest in India) that focuses on diabetic lower limb surgical problems. The division of Podiatric surgery is associated with the department of Endocrinology and diabetes with strong support from vascular surgery and interventional radiology departments. This integrated team approach is crucial in the proper management of diabetic lower limb pathology. It is only available in a few centres worldwide. Furthermore, the hospital also has a footwear factory housed close to the center with trained staff developing and creating diabetic footwear, thus providing high-quality preventive, postoperative, and rehabilitative footwear. Amrita Diabetes Welfare Association (ADWA), a patient association was also created and has over 1,500 members and publishes Diabeat, a patient education magazine. Statistics show that the rate of major amputations for diabetic foot problems in developing countries is 45% and close to 8.7% in developed nations. The integrated team approach to the diabetic foot at AIMS has served as an efficacious model for limb salvage and has maintained their major amputation rate at a mere 9.2%.

The diabetic foot is a major healthcare concern on a worldwide scale. The implementation of a multi-disciplinary team such as the AIMS centre brings us one step closer in treating and preventing the deleterious effects of this arduous disease.