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IWGDF Newsletter March 2015
ISDF 20-23 May 2015 World Forum, The Hague, the Netherlands.
Within less than 3 months 7 th international symposium on the diabetic foot will take place; so it is time to register!
Register as a delegate and take advantage of the reduced advance fees. Save 95 Euros! Advance registration closes May 14. We have already received over 700 registrations for ISDF 2015!
Over 350 high quality abstracts have been received and are scheduled for an oral or poster presentation.
This unique multidisciplinary symposium will cover the latest scientific developments, both findings from basic research and clinical insights important to everybody’s daily practice. A number of renowned specialists in the field will discuss the prevention, diagnosis and treatment of lower extremity problems in diabetes. Interactive workshops will provide you with useful information for your daily clinical practice and oral/poster presentations of submitted abstracts will inform you on the current status of research and foot care initiatives throughout the world.
For the latest update of the program please click here.
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Content
We start again with news of the ISDF 2015 in The Hague, Netherlands and a call to register for this quadrennial and unique symposium.
In the section 'News from the IWGDF' we report on new initiatives:
- The DIAFI-DATE Collection , a low cost system for data management in foot care clinics
- The Nordic Diabetic Foot Task Force
- The founding of a new IWGDF working group called FLIRT, Footwear project for Low-Income Regions Together
The IDF Consultative Section on the Diabetic Foot reports on
- The recently held Train-the-Foot-Trainer course in Bled, Slovenia for participants from Central Europe in 'Messages from Abroad' we read about
- Diabetic foot care initiatives in Peru
In the section 'New book publications" we pay attention to recently published books on foot care
- from Brazil, UK and Germany
- and a 'frontpage' story on foot care in India
The agenda on 'future meetings' has been updated
Foot notes
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News from the IWGDF
Diabetic Foot Information-Data collection (DIAFI-DATA system)
A low cost system for data management in foot care clinics
Dr Line Kleinebreil is a primary care physician for the Department of Medical Information Technology at the Hôpital Européen Georges-Pompidou in Paris, France. She has a special interest in diabetes and chronic diseases, and has been involved for many years as a board member on a number of major French patient associations for both adults and children. She currently serves as Chair of the Diabetes Education Study Group (DESG) and vice president of Université Numérique Francophone Mondiale (UNFM), and is an active member of the World Health Organization (WHO) and International Telecommunication Union (ITU) “Be healthy Be Mobile” program, using mobile technology to fight non-communicable diseases epidemics.
We have asked dr Kleinebreil to report on the Diafi-data collection system. She writes us:
Amputations are a major problem in developping countries. A number of centers have been trained by the IWGDF(Train-the-Foot-Trainer courses) in the SACA, Caribbean and Central European regions to implement risk stratification, prevention and adequate foot care. In parallel an IDF initiative trained footcare centers in 10 african countries. As the Health Care professional perfectly knows 'no matter what we do or say we do, it is virtually impossible to prove unless it is clearly documented.'
That is why, to support these diabetic foot centers, an international multidisciplinary team, IT specialists from the Université Numérique Francophone Mondiale (UNFM, Paris, France), diabetic foot care specialists from IWGDF and representatives from foot clinics in low-income countries set together to develop the DIAFI-DATA system (DIAbetes Foot Information-DATA collection). The Diafi-data system has been originally developed for the SACA region and it has been used there in a pilot phase. The result is a system running locally on a USB flashdrive of which nothing has to be installed on the computer and internet access is not required. It is designed for all type of centers, including remote areas. The software stores the data locally and give access to a dashboard of indicators. An international, national, or regional comparison for indicators is facilitated. The programme will be implemented in African diabetic foot care centers and hopefully shortly in other regions in the world.
From left to right: Thomas Baratier (IT UNFM), Line Kleinebreil (UNFM) and Nalini Campillo (Dominican Republic) working in Paris to test the Diafi-data software.
For demonstration and test only, a web version is available on http://diafi.unfm.org .Go to « DIAFI INTERNATIONAL », then fill: Login : admin, Password : diafiadmin. Your comments, suggestions are welcome.
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Nordic Diabetic Foot Task Force
The Nordic Diabetic Foot Task Force which was initiated in cooperation with EWMA and IWGDF, held its’ first biennial symposium in Malmö, Sweden, November 5-6 2014. The Symposium and the Task Force focus on guideline implementation in the Nordic countries.
The symposium attracted over 200 participants, and was a rather unique meeting in so far as the participants were a multidisciplinary mix of endocrinologists, vascular surgeons, plastic surgeons, orthopaedic surgeons, wound care nurses, diabetes nurses, podiatrists and people with diabetes.
The aim of the symposium was two-fold: 1) To enhance cross-disciplinary learning among the professions that ideally should take part in diabetic foot care. 2) To actively involve the participants in drafting national strategies that will improve further the implementation of guidelines in each of the 5 Nordic countries.
The Nordic Diabetic Foot Task Force Steering Committee.
From left to right: Tómas Þór Ágústsson, Iceland; Klaus Kirketerp-Møller, Denmark; Magnus Löndahl, Sweden; Tore Julsrud Berg, Norway; Vesa Juutilainen, Finland, and the EWMA representatives Henrik J. Nielsen, Director EWMA Secretariat and (in front) Jan Apelqvist (Immediate Past-President)
Magnus Löndahl, Chair of the Symposium, says: “On behalf of the Nordic Diabetic Foot Task Force I am deeply satisfied with the results produced at this symposium. The participants have engaged in the presentations and debates during the various common and national sessions with a lot of energy and motivation. What is revealed is the need and willingness to cooperate across disciplines in order to improve diabetic foot care. With the Symposium we have successfully put the diabetic foot on the agendas in each of the Nordic countries.”
For the implementation of guidelines on the national level a draft strategy has been laid out for each Nordic country during the symposium. It will be the task of each National Working Group under the Nordic Diabetic Foot Task Force to follow these strategies.
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FLIRT: Footwear project for Low-Income Regions Together
The founding of a new IWGDF working group
The importance of pressure relief in the prevention and management of foot ulceration in people with diabetes is well documented in the guidelines of the International Working Group on the Diabetic Foot (IWGDF). However, the availability of offloading devices in many parts of the world is sparse. We, as members of IWGDF, undertook several programmes to train health care professionals all over the world and identified that there is a global need for widely available pressure off-loading devices which can be used in the overall management of diabetic foot patients in the pre-ulcerative, ulcerative and post-ulcerative stages.
The guidelines published on our IWGDF website emphasise that adequate off-loading is the cornerstone of diabetic foot ulcer treatment. Although the total contact cast remains the gold standard approach, it is not widely available. Alternative methods include orthoses such as pneumatic walkers, vacuum assisted devices and special shoes. However, in many cases, these appliances are not frequent used in the management of diabetic foot ulcers as shown by the Eurodiale study and other observational studies. The main barriers are the availability of skilled health care providers and the costs of the prefabricated devices. At present, especially in low-income countries, empirical hand-made solutions with low-cost materials are predominantly supplied.
New IWGDF working group
To overcome these limitations, a group of IWGDF members decided to establish a new working group, called FLIRT: Footwear project for Low-Income Regions Together.
The ideas of founding the FLIRT working group actually took place earlier at a meeting during the last Pan-African Diabetic Foot Study Group (PADFSG) conference in August 2014 in Dar Es Salaam, Tanzania.
The first full 2-day meeting was held in Montebelluna, Italy, in January 2015 with participation of Zulfiqarali G.Abbas, Tanzania, Kristien Van Acker, Belgium, Camillo Buratto, Italy, Sicco Bus, The Netherlands, Malte Tredup, Germany, Luigi Uccioli, Italy, Vilma Urbancic, Slovenia and Vijay Viswanthan, India. Stephan Morbach, Germany was excused.
The FLIRT working group
Aim
The aim of the FLIRT project is to provide low-income countries with a standard, prefabricated, affordable off-loading device that would fulfil certain criteria, including foot pressure off-loading of at least 50% compared to a standard local shoe.
At this first expert meeting, the minimal technical, manufacturing and implementation requirements were defined and a preliminary study phase was set up.
Initially, it will include a biomechanical study to assess the ability of the identified off-loading device to reduce the foot pressures by 50%. This will be followed by a randomized clinical trial which will be conducted in two centers, one in Tanzania (Dar Es Salaam) and a second one in India (Chennai).
Availability
If we can demonstrate minimally the equivalence in efficacy of the study device to local standard offloading method, the new device will hopefully become widely available for low-income countries at affordable cost.
The next meeting of the FLIRT working group will be held during the ISDF meeting in The Hague in May 2015.
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News from the IDF Consultative Section on the Diabetic Foot
Train-the-Foot-Trainer course in Bled, Slovenia
From 17-21 February, 2015, the 3rd Train-the-Foot-Trainer (TtFT) course was held in Bled, Slovenia, for the Central European region. The course was organized by IWGDF and IDF CS DF, and financially supported by IDF and industry partners. The core TtFT team existing of Kristien Van Acker, Belgium, Organizing board chair, Vilma Urbančič, Slovenia, hosting Co-chair, Stephan Morbach , Germany, Co-chair, Neil Baker, UK and Zulfiqarali Abbas, Tanzania was supported by the new faculty members Nina Petrova, UK, Maureen Bates, UK, Anna Korzon-Burakowska, Poland, Alexandra Jirkovska, Czech Republic, Oleg Udovichenko,Russia, Arend-Jan Woittiez, Netherlands, Line Kleinebreil, France, Belma Malanda (IDF) and Martin Perry (Rotary Club of Ledbury, UK).
The faculty
The participants
Participants
Daniela Chinnici from IDF coordinated with the board the candidate selection and was very helpful in many practicalities. The course was attended by 38 participants and 8 observers from 17 countries (Albania, Armenia, Bosnia-Herzegovina, Bulgaria, Croatia, Estonia, Greece, Kosovo, Latvia, Lithuania, Poland, Romania, Serbia, Slovenia, Sweden, Turkey, Ukraine). Dr Evarist Bouenizabile, President of IDF Africa was invited as observer for preparing one of the next editions of a TtFT course in Africa. Dr Arend-Jan Woittiez, skilled in education, was of great help for “auditing” the course and the faculty members Line Kleinebreil and Thomas Baratier , from France were responsible for sharing the knowledge of data collection through the “DIAFI-DATA” collection system tool and taping all the lectures and workshops.
Broad endorsement
This European edition was endorsed by seven European associations, related to diabetes care and wound care: EASD, DFSG, DESG, FEND, UNMF, EWMA, IDF Europe. In a panel discussion the representatives of all those twinning organizations promised to sustain and support the project for the next 2,5 years. All together a letter of action points will be prepared for the European Parliament in cooperation with CHRODIS as a joint action on 'addressing chronic diseases and promoting health ageing across the life cycle project' (www.chrodis.eu).
The DFSG Europe was helping the organisation to work on a mentorship project. Eighteen centres of excellence in Europe offer their services to help the new centres to be connected with each other.
The participants were pleased to have participated in this Central Europe edition of the series of TtFT courses and the organisers were happy to had realised extra projects: as having new faculty members on board, having integrated twinning organizations and the mentorship project.
This successful course would not have been possible without the support of Podartis, Wound Care Circle, Darco, Flen Pharma, Novo Nordisk, Medis, Krka, Zaloker & Zaloker, BSN Medical and Medical Monofilament.
More details about the course can be found on the website http://www.ttft.org.
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Messages from Abroad
We have asked Ms Dr Olga Núñez Chávez to report about the diabetic foot care activities in her country Peru.
Olga is endocrinologist and diabetologist, with a Masters in
Health Economics. She represents her country as IWGDF Representative. She was responsible for coordinating the National Program of Social Security from1994 to 1998. She founded the first Diabetic Foot Unit at the Rebagliati Hospital in 1995. As President of the Peruvian Diabetes Association, she achieved to pass the Diabetes Law in 2005, which eliminated taxes on diabetes treatment medication. Since 2008, she is Executive Director of the Institute of Prevention and
Education in Diabetes and does awareness campaigns,
educational workshops, summer camps for kids and teenagers, and accomplish training courses for primary doctors in Peru's provinces. As the Peruvian representative of Gleped, she has realized 4 TFT courses in coordination with the Health Ministry authorities of Regions Piura, Ica and Ancash.
Epidemiology and Healthcare restraints in Peru
Peru's population counts almost 31 million and nearly 9 million people are living in and around the capital Lima. Peru is a multiethnic country, which means that it is home to people of many different historical backgrounds. The prevalence figure of diabetes is between 4-5%. The budget of the healthcare sector is very low: 4.5% of the national budget. There is a low insurance rate: 64.7 % of the population belongs to some kind of an incomplete insurance. Peru deals with a shortage of medical specialists/doctors: there are at present 6074 practicing (current demand is 11176) of which 60% is working in Lima. Unfortunately the management on diabetic foot care in Peru has a low priority.
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Recently, the government prioritized the implementation of an universal health Insurance system for all low-income groups of the population. It also boosts focusing on non-communicable diseases, including diabetes at all levels related to the current epidemiological transition.
Early diabetic foot units were implemented in 1995 in the hospitals of the Social Security: Guillermo Almenara and Edgardo Rebagliti. Subsequently, other units have been founded in the governmental hospitals. However they do not cover the full demand for clinical care nor at GP (primary) level. At the primary level there is not enough care for the treatment of diabetic foot ulcers neither for preventative or educational programs for the foot at risk.
Train-the-Foot-Trainer course
With this background information in mind, we were very much motivated to participate in the Train-the-Foot-Trainer course for the SACA region, the first of its kind, in December 2012 in Brasilia, Brazil (see also the Newsletter March 2013). We clearly wanted to install a trainings program for early detection of the foot at risk based on the guidelines of the International Working Group on the Diabetic Foot (IWGDF).
With the support of the Peruvian Institute of Diabetes Education we conducted in 2013 and 2014 four workshops for physicians and nurse practitioners together with the Directors of Health from Piura, Ica, Sullana and Chimbote. For each session of two days we had four prominent speakers, who gave the content of the basic course on the management of diabetic foot care as well as educational sessions on diabetes and its complications. All participants received educational material, monofilament and report- follow up cards.
Spin off
The first course in Peru was held, in March 2013 in ICA (325 km south from Lima, which means 5 hours by bus). One endocrinologist (later responsible as coordinator), 25 GP’s , 30 nurses and 10 nutritionists were trained.
The second edition of the TtFT course in ICA was held in July 2013. The number of participants were again impressive: 59 of which 1 endocrinologist, 28 GP's, 25 nurses and 5 technician nurses.
Left: March 2013 ICA, the 1st TtFt course: diabetic foot examination. Right: May 2013 Piura, TtFT course: nurses in training
In May 2013 the TtFT course in Piura (1050 km North from Lima) was performed. The number of participants was 57, consisting of 25 GP's and 32 nurses. All of them live in the surroundings of Castilla, Piura and Alto Piura
The fourth course which took place in Peru in Sullana (1090 km from Lima) and was held in November 2014 with the participation of one endocrinologist, 20 medical doctors, 22 nurses and two technicians.
In November 2014, around the World Diabetes Day (WDD) celebration we realized at our last course which was held in Chimbote (770 km from Lima) that we also had the opportunity to have chiropodists ( we don’t have podiatrists in Peru) participating in the campaign for the World Diabetes Day. We gave in Ghimbote a Press conference about the Diabetic Foot at the occasion of WDD.
Left: November 2014 Sullana, the TtFT course with GP's Right: November 2014 Chimbote the TtFT course with GPs and nurses
We couldn´t realize the training program in the Callao Region in July 2013 because of a medical strike, which lasted 6 months!
For all this courses personal money was invested and we had to struggle with medical strikes and many other barriers, as no show of the media and so on. The local nurses representing the non-communicable diseases programs were involved as much as possible.
Future
For 2015 it is planned to organize workshops in Cañete, Trujillo, Ayacucho, Pucallpa and Lima. Monofilaments not available in our country will be provided by 'Medical Monofilaments', a very nice gesture. We hope that this example will be followed by donations from other companies.
In conclusion we can say that for us, organizers and speakers, this experience was very enriching. We overcame and sometimes even ignored a lot of national and local barriers. At the end we saw that the State Health System was really working. But it is not yet involved in prevention programs, the corner stone of good diabetic foot care. Finally we were pleased to observe the eagerness of all participants to learn. Which hopefully improves the quality of life of the patients suffering of the diabetic foot syndrome in Peru and beyond.
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Miscellaneous
Book publications
Recently new books on the diabetic foot were published
Left: Hermelinda Pedrosa at all - Neuropatias e Pé Diabetico - Portuguese, 307 pages (2nd print)
http://www.grupogen.com.br/neuropatias-e-pe-diabetico.html
Center: Robert Hinchliffe at all - The Diabetic Foot - English, 374 pages,
http://www.jpmedpub.com/
Right: Hochlenert at all - Das Diabetische Fusssyndrome - German, 212 pages
http://www.springer.com/gp/book/9783662439432
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An interesting publication from India
The diabetic foot 'frontpage' news in India
From Dr Kshitij Shankhdhar, podiatrist in Lucknow, India.
English translation of part of the article:
"It is vital to prevent a foot attack in people with diabetes"
Chief correspondent reports:
[...] Ranchi: It is essential for people with diabetes to protect themselves from foot attack. If foot attack happens, many have to face amputation although through information and other associated efforts, prevention is quite possible. But due to lack of information and inadequate medical facilities, this is not being done, which is unfortunate. [...]
[...] The above information was shared by renowned Diabetologist cum Podiatrist, Dr Kshitij Shankhdhar from Lucknow during a special interaction with Jharkhand Jagran / Roz Ki Khabar. Dr Shankhdhar is guest speaker at an international diabetic foot conference, being held in Novobirsk, Russia on 22-23 April 2015. He shall share his research and experience in the field of diabetic foot care. His lecture shall be translated in Russian language also. [...]
The article continues that: [...] In research it has been observed that due to lack of sensation in feet, the people with diabetes often purchase smaller size footwear which leads to undue pressure leading to foot lesions and risk of foot attack. It is important that doctors managing diabetes should examine the footwear along with feet and recommend diabetes friendly footwear. [..]
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