Every 30 seconds, 2 people get their lower limb amputated globally and in Indian scenario, diabetic foot care is largely neglected. Also, healthcare providers too aren’t adequately aware of foot care. 65% of amputations could be prevented by proper foot care, early identification and treatment by people with diabetes mellitus. In an attempt to prevent this, under the World Diabetes Foundation in collaboration with Udupi district health authority project was implemented “Diabetic Foot Care Stepping Ahead” (WDF 15:941), we are trying to strengthen the diabetic foot care on a great scale. Capacity building trainings and workshops for different levels of health care providers on diabetic foot care, community survey of diabetic foot complications and screening of high risk population for diabetes, mass media awareness and development of IEC materials and establishment of diabetic foot clinics, have facilitated to render better care in this area. Advanced Centre for Diabetic Foot Care and Research in Kasturba Hospital, Manipal and other peripheral level foot clinics in few centres across the Udupi District has been started. Through this, we will strive to alleviate the suffering pertaining to foot complications among people with diabetes.

The approach is two pronged: Preventive care and advanced care and research

Microfluidic Based Detection of Microbial Communities and Antibiotic Responses in the Management of Diabetic Foot Ulcers (MIDARDI)

MIDARDI is an interdisciplinary program with international participation of academia and industry scientists from India and Germany. The participating institutions/industries are Manipal School of Life Sciences, Manipal Academy of Higher Education, Manipal, India, Achira Laboratories Pvt. Ltd., Bangalore, India, Fraunhofer Institute for Cell Therapy and Immunology IZI-BB, Potsdam-Golm, Germany and BiFlow Systems GmbH, Chemnitz, Germany. The key investigators include Dr. Kapaettu Satyamoorthy, Dr. Dhananjaya Dendukuri from India and Dr. Joerg Nestler and Dr. Harald Peter from Germany.  This program is funded by Indo-German Science and Technology Centre (IGSTC) from India and German Federal Ministry of Education and Research BMBF, Germany.

Europe and India face an epidemic of obesity and Type 2 diabetes (T2D). T2D is comorbid with several debilitating conditions such as retinopathy, neuropathy and foot ulcers. Chronic non-healing diabetic foot ulcers (DFU) are a major complication associated with T2D that is further exacerbated by pathogenic bacteria. Microbial burden in each wound displays diverse morphological and physiological characteristics with unique patterns of antibiotic resistance. The standard treatment regimen for DFU is a combination of various broad-spectrum antibiotics prescribed based on wound presentation (Wagner grade). However, such empirical decisions, implemented due to lack of rapid and sensitive point of care diagnostics has led to the rise of multidrug resistant bacteria. The need of the hour is expeditious, sensitive and specific culture independent methods that can aid the clinicians in their diagnosis and prescription. The current project aims to meet this need by developing a microfluidics-based lab-on-a-chip device that can provide an identification of the bacteria and their antibiotic resistant genes. This would aid clinicians in their decision-making process by tailoring their prescriptions specifically to microbes prevalent in the DFU scenario that would concomitantly improve wound healing.

The development of such devices require knowledge on the wound microbiome and development of the appropriate taxonomic biosignatures that can identify the pathogenic bacteria (via next generation sequencing), knowledge of the minimum number of microbial colonies required in a predefined sample input to be detected by the chip, choice of nucleic acids technology and standardization of the same. Following an identification of the dominant bacteria and their resistant patterns, current work focused on development of a robust methods to incorporate in the point of care device being developed. Isothermal amplification methods are a streamlined, exponential way of identifying the target nucleic acid sequences, without the need of an external thermal cycler to allow the device to be used in any healthcare setting without reliance on external machinery or specially trained personnel. Translation and adaptation of this method into a lab-on-chip format for recognizing targets other than 16S rDNA (resistance genes) is being developed.

Publications:

1.    Jnana A, Muthuraman V, Varghese VK, Chakrabarty S, Murali TS, Ramachandra L, Shenoy KR, Rodrigues GS, Prasad SS, Dendukuri D, Morschhauser A, Nestler J, Peter H, Bier F, Satyamoorthy K. (2020). Microbial Community Distribution and Core Microbiome in Successive Wound Grades of Individuals with Diabetic Foot Ulcers. Applied and Environmental Microbiology, 86:e02608-19.

2.    Warrier A, Mazumder N, Prabhu S, Satyamoorthy K, Murali TS. (2021). Photodynamic therapy to control microbial biofilms. Photodiagnosis and Photodynamic Therapy 33, 102090.

3.    Warrier A, Satyamoorthy K, Murali TS. (2021). Quorum-sensing regulation of virulence factors in bacterial biofilm. Future Microbiology 16, 1003-1021.

4.    Prasad ASB, Shruptha P, Prabhu V, Srujan C, Nayak UY, Anuradha CKR, Ramachandra L, Keerthana P, Joshi MB, Murali TS. Satyamoorthy K. (2020). Pseudomonas aeruginosa virulence proteins pseudolysin and protease IV impede cutaneous wound healing. Laboratory Investigation 100, 1532-1550.

5.    Kavitha S, Spoorthi J, Deepika VB, Raviraj A, Ramachandra L, Satyamoorthy K, Murali TS. (2016). Virulence determinants in clinical Staphylococcus aureus from monomicrobial and polymicrobial infections of diabetic foot ulcers. Journal of Medical Microbiology, 65: 1-13

6.    Shettigar K, Bhat DV, Satyamoorthy K, Murali TS. (2018). Severity of drug resistance and co-existence of Enterococcus faecalis in diabetic foot ulcer infections, Folia Microbiologica 63: 115-122.

7.    Streit, Petra; Nestler, Joerg; Shaporin, Alexey; Graunitz, Jenny; Otto, Thomas (2018) Design methodology and results evaluation of a heating functionality in modular lab-on-chip systems. J. Micromech. Microeng. 28.

DIABETIC FOOTCARE IN COMMUNITY-BEST PRACTICES

Project Activities: Capacity building for screening, prevention, identification and management of diabetic foot complications is the important goal of the project. Different health care professionals have been trained from across the Udupi district, predominantly from the government sector and few from private. Physicians (104), Nurses and Auxillary Nurse Midwives (ANM)s (226), Accredited Social Health Activists (ASHA)s(852), Physiotherapists(75) were the different health care providers trained. It is being found remarkable that a mean enhancement of average 18 percentage in knowledge is very significant. Ultimately capacity building among health professionals was endeavoured

IEC materials were distributed to all health care centres, the television and radio program was conducted and broadcasted on diabetic foot complications and reached approximately 150000 population through local community radio and television. Publications of newspaper informative articles and educative videos on diabetes and foot complication in local visual media telecasted regularly. Incidental and mass education was imparted on many occasions across the district. Comprehensive and simple manual for health professionals and modest manual for Accredited Social Health Activist (ASHA) workers on diabetic foot complications were developed to bridge the dearth of comprehensive manuals for the clinical and field practice

As per International Diabetes Federation (IDF) atlas 2015 more than 50 % of the people with diabetes are undiagnosed. It is an iceberg phenomenon of the disorder. Same is applicable to diabetic foot complications. Community screening for Diabetes Mellitus and Diabetic Foot Complications are the untainted service objective of the mission. Here the ASHAs and Auxiliary Nurse and Midwife’s (ANMs) are empowered to do the door to door screening for diabetes mellitus and diabetes mellitus. They are facilitated by training, reviews and mentoring. All the screened participants were imparted with health education on diabetes mellitus. Newly diagnosed participants and people with diabetes were called for the special camps organized at respective primary health centers of community health centers for advanced assessment and conservative management. Self-sustainability of care and assessment procedures were adopted through capacity building trainings of different health professionals and establishment of a diabetic foot clinic. At present, we have screened more than one lakh populations through door to door survey, various camps, in collaboration with Non Communicable Disease division of Udupi District, Government of Karnataka. All participants were screened free of cost and those who requires further investigation were referred to Non Communicable Disease (NCD) clinic of Udupi District, and Kasturba Hospital for further diagnosis. The 16 foot clinic (01 advanced clinic, 02 intermediate clinic and 13 peripheral clinic) were established at different part of Udupi district. Those who require further care were referred to secondary clinic or centre for excellence to prevent amputation.

It is being found that absolute minimum services are available for diabetic foot care at multi-specialty hospitals and absolute absence of diabetic foot care services in peripheral level. Service generation is the important priority of this mission through the establishment of diabetic foot clinics at different levels, adopting a model of public private partnership (PPP). Centre for excellence diabetic foot clinic is established in KH, Manipal intended to cater all complex diabetic foot cases of Udupi district and also functions as a research and resource centre. There are three secondary level clinics established in Udupi, Kundapura and Karkala to cater intermittent foot care for the people. Basic level diagnosis, care, support and treatment rendered at community set up through 13 basic level diabetic foot clinics at selected Community Health Centres and Private Hospitals of Udupi District. This is how the mission is trying to generate all levels of services at door steps to alleviate the suffering from diabetic foot complications. This is the till date triumph story of the mission, though there are challenges in the journey it was very enriching and encouraging beginning and experience of the unexplored avenues of new horizons of diabetic foot care in India. Impact of the project: This mission has strengthened the comprehensive care, support and treatment perspective of diabetes mellitus and diabetic foot care across the district in turn it has escalated Non-Communicable Disease division activities. Since the components of this mission encompassed primordial, primary, secondary and tertiary prevention of diabetes mellitus and diabetic foot complications primary beneficiaries of this project are general population and people with diabetes. Culturally and local language tailored IEC materials developed under the project, radio programs, television interviews and videos filed the gap in dearth of IEC materials and educational programs specially in the area of diabetic foot, also it has sensitized the people of the district on diabetes mellitus and diabetic foot complications. These IEC materials were used as tool for diabetes mellitus & foot care health education and counselling. Series of capacity building trainings on diabetes mellitus and diabetic foot care enhanced the knowledge, attitude and practice in care, support and treatment perspectives among health care providers. Enhancement in post test score are the good evidence of the same. Initiation of peripheral level diabetic foot clinics in Non-Communicable Disease Clinic includes assessment and conservative management of diabetic foot complications using simple gadget by health care providers made availability and accessibility of specialist care at very peripheral which are virtually absent even in majority of private hospitals. Centre for excellence in KH Manipal made availability of advanced care for diabetic foot complications with in the district. Development of referral system and camp based approach in the mission triggered and speeded the accessibility of treatment service for the diabetic foot complications. Community level screening was performed on more than one lakh individuals in Udupi. Further follow up of high risk individuals with Fasting Blood Sugar and referral to primary health centres revealed approximately 4% of total individuals are newly diagnosed for diabetes mellitus. 33.2% of people with diabetes who exhibited diabetic peripheral neuropathy symptoms were referred for further follow up and treatment.

 Publications:

1.       Jadhav, Radhika and Maiya, Arun G and Shashikiran, U and Shivashankara, KN (2021) Efect of physical activity promotion on adiponectin, leptin and other infammatory markers in prediabetes: a systematic review and meta‑analysis of randomized controlled trials. Acta Diabetologica, 58 (4). pp. 419-429. ISSN 0940-5429

2.       Nayak, Pradeepa and Kumaran, Senthil D and Babu, Abraham Samuel and Maiya, Arun G and Solomon, John M (2021) Levels of physical activity and quality of life among community dwelling adults with stroke in a developing country. European Journal of Physiotherapy, 23 (3). pp. 165-170. ISSN 2167-9169

3.       Matpady, Prabhath and Maiya, Arun G and Saraswat, Pallavi Prakash and Mayya, Shreemathi S and Pai, Mamatha S and Anupama, DS and Umakanth, Shashikiran (2020) Dietary self-management practices among persons with T2DM: An exploratory qualitative study from western-coast of India. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14. pp. 2161-2167. ISSN 1871-4021

4.       Anju ., M and Saleena, UV and Maiya, Arun G and Hande, Manjunath H (2020) Effect of photobiomodulation on serum neuron specific enolase (NSE) among patients with diabetic peripheral neuropathy e A pilot study. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14. pp. 1061-1063. ISSN 1871-4021

5.       Yadav, Hrishikesh K and Maiya, Arun G and Rao, Sharath K and Hande, Manjunath H (2020) Effectiveness of customized insoles on maximum plantar pressure in diabetic foot syndrome: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14. pp. 1093-1099. ISSN 1871-4021

6.       Anche, Parameshwar and Maiya, Arun G and Kamath, Shobha U and Shastry, Ananthakrishna Barkur and Ravishankar, N (2020) Lifestyle modification with physical activity promotion on leptin resistance and quality of life in metabolic syndrome - A systematic review with Meta-analysis. Current Diabetes Reviews, 16 (3). pp. 1-11. ISSN 1573-3998

7.       Arora, Esha and Korada, Hrishikesh and Devasia, Tom and Bhat, Rama and Kamath, Ganesh S and Maiya, Arun G (2020) Profile of peripheral arterial disease in type 2 diabetes mellitus – a hospital-based observational study in coastal karnataka. Diabetes Mellitus, 23 (4). pp. 313-317. ISSN 2072-0351

8.       Maiya, Arun G and Anche, Parameshwar and Hande, Manjunath H (2020) Relationship Between Glycated Hemoglobin and Vibration Perception Threshold in Diabetic Peripheral Neuropathy. International Journal of Lower Extremity Wounds, 19 (2). pp. 120-124. ISSN 15347346


DIABETIC FOOTCARE IN COMMUNITY-BEST PRACTICE