The north region (Amazonian), however, still represents a complex problem, which hopefully will be solved in the near future when those clinics will be re-evaluated by the Brazilian Diabetic Foot Task Force (BDFTF), a very important initiative of the National Coordination of Diabetes and Hypertension (Ministry of Health).
The project has been implementing the Practical Guidelines since the International Con- sensus was translated into Portuguese and distributed free of charge among all professionals trained on foot examination and care.21 A pilot study was carried out involving the hospital and two health centres in Brasilia: of 82.3% of the 367 records analysed, 40.4% of the patients in hospital care and 26% of those in primary care were found to have loss of protective sensation.31 Applying the International Consensus21 risk category system, a remarkable finding was shown related to category 3 (previous amputation or ulcer): 57.7% at the hospital had had an ulcer in comparison with 9% at the health centres.8,31 This demonstrated that the referral system is functioning, although the situation remains suboptimal for footwear, which is not provided either by the public or by the private health system.
Individual analysis of all three centres verified that 35.8% of those attending the federal senate foot clinic, set up in 1999 to make the politicians more sensitive to DM problems, were found to have inadequate footwear, while it was verified that the patients from the hospital and health centre did not have appropriate footwear, 65.5% and 62.2% respectively, probably due to a lower socio-economic conditions.32 Another tool implemented by the project was a specially designed foot card (Figure 32.2) to be given to patients after being screened, which has proven to be useful at both hospital and health centres: the patients can keep it and show it at other services in a similar manner to what has been done with diabetes identification cards.31,32
ACHIEVEMENTS RELATED TO FOOT TEAM, AMPUTATION RATES AND INSOLE PROVISION During the period 1992, 2004, there have been encouraging developments in the Brasilia project, although many remain to be achieved: this relates to the development of a true inter- disciplinary cooperation when compared to the basic team back in 1992. The vascular surgeons
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ACHIEVEMENTS RELATED TO FOOT TEAM, AMPUTATION RATES 369
Foot Card
• Any insensitive site indicates absent protective sensation according to the Practical Guidelines , International Consensus [21]
Figure 32.2 Foot card: a useful tool to identify patients screened for neuropathic ulcer risk. The foot card has been designed to be given to patients after being screened for foot problems, and it was based on the Practical Guidelines of the International Consensus.21 The new original format8 has been changed and the number of areas of tests for protective sensation is only three: hallux, first and fifth metatarsal heads
have become an integrated part and are now having daily clinics, as do the social workers.
Other specialists regularly involved include dermatologists, infectious disease specialist, or- thopaedists, orthotists, physiatrist, physiotherapists, plastic surgeons and psychiatrists.
An important link has been obtained with the extension of the project to the family health programme and other health districts, as there are six other outpatient foot clinics at those regional hospitals, which integrate the public health system of Brasilia.
A retrospective analysis performed at the hospital in Brasilia showed that 45% of the amputations in period 1989, 1991 were registered among diabetic patients.17 Evaluating data from 1992 to 2000, there was a trend towards reduction, with an overall decrease of 77.8%, with decrease particularly among female patients.8 More recently, applying the Lower Extremity Amputation Study (LEAS) group protocol,33 after the diabetic foot centre was inaugurated and linked to the orthotics and prosthetics department, a significant statistical difference between above-knee and below-knee amputations (Figure 32.3), with a trend towards reduction in the major procedures, has been found.
The increase in the minor amputations was observed after the vascular team daily activities, which can be seen as good practice although increasing the overall number of amputations.
The LEAS protocol is expected to be applied to other hospitals where surgical procedures have been carried out since the project implementation, to verify its overall impact among amputations.
The orthotists have joined the diabetic foot team in 1999 and have integrated well with the nurses on the team.
The provision of free insoles in the early stages has increased significantly, as it is now not only involving hospital patients but encompassing all the other regional foot
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370 THE DIABETIC FOOT IN BRAZIL
Figure 32.3 Amputation rate according to level of procedure Note: Lower Extremity Amputation Study protocol and guidelines33 on data collection were restricted to the reference hospital where the diabetic foot centre is based: a trend towards major amputation (above ankle) reduction and an increase in minor procedures (below ankle) has been verified
clinics of other health districts of Brasilia: from 198 (1999) it reached 1249 (2004), with a little decline to 1138 (2005) reaching a total of 6279 in the whole period (Figure 32.4).
PROBLEMS TO BE SOLVED Despite many good achievements, many problems still exist.
The project faces a low investiga- tion and management of peripheral arterial disease: the more complex diagnosis or intervention that has been shown in recent studies in Rio de Janeiro34 is difficult to achieve due to a lack of vascular surgeons and resources in many public hospitals.
There is a need to re-evaluate the foot clinics in the country in order to provide them with a better structure and more quali- fied professionals, particularly concerning the implementation of casting clinics and including simple techniques to evaluate plantar pressures.
An interesting study recently performed at the diabetic foot centre in the Brazilian capital compared Pressure stat R and Harris mat, showing the former to take significantly less time (1.70 min versus 2.61 min, p < 0.05) and to be able to evaluate the requirement of insoles with its pressure calibration card.35 Extension of the links with the primary care and health family professionals in the rest of the country might be achieved with the inclusion of a foot workshop during the Diabetes and Hypertension National Training where nearly 4000 primary care health professionals are expected to be trained.
The application of the International Consensus questionnaire might be a way to verify these issues and is expected to be in the agenda of the BDFTF with the support of the Ministry of Health
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Figure 32.4 Free insole provision from the orthotic and prosthetic department. The insole provision was started in 1999 when the diabetic foot centre was inaugurated in Brasilia, linked to the orthotic and prosthetic department of the State Health Secretary. There has been an important increase in the number of free insoles given to the diabetic patients with either high plantar pressure or foot deformities8
in 2006.
The provision of free insoles and prosthesis must be included in other state health departments as it has been done in Brasilia.
Free customized footwear, at least for those with deformities, would represent a preventative approach, as it has been done in India,36 and could be reached due to the abundance of leather in Brazil.
The links with the International Working Group on the Diabetic Foot since 1998 have represented a great opportunity to consolidate Brazil in the international scene, but throughout the period of its early steps the project has maintained an enriching scientific integration with the Manchester Diabetes Centre.
Other academic links have been gathered with the Medical School and the Catholic University of Brasilia, which have both included medical and physiotherapy students37 activities which may help future professionals to be more aware about the diabetic foot problems.
The lack of podiatrists in the country is also an important issue to be resolved, and discussion has been conducted with well-known North American and British professionals for the possibility of a course in the near future.
The social deprivation and inaccessibility to health care does account for the difference be- tween management in developed and underdeveloped countries.8,37,38 During these 13 years of its activities, the Save the Diabetic Foot Project has made notable achievements that have contributed to change the concerning, perception and management of foot problems in the country.8 No sophisticated plan was ever made, and the crucial approach for a country with
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scarce resources was education of health professionals involving general clinicians, special- ists and nurses from distant Amazonian states, underdeveloped areas of north, northeast and centre-west to the more developed areas in the southeast and south of Brazil.
It seems that the lesson of interdisciplinary management and prevention6,7,12,13,39,40 has been learned by many of them, and this certainly will help to circumvent the difficulties still currently being faced.
The scientific support of the Brazilian Diabetes and Endocrine societies plus the re- cent involvement in Clinical Guidelines Task Force of the International Diabetes Federation,41 which is represented in the BTFDF, hopefully encouraged the diabetic foot not be seen as the Cinderella of all diabetic complications.
The financial support of the Brazilian government through the Ministry of Health certainly will help the patients to be given the opportunity to receive a proper foot care.