Feature: Monofilament ??? A Tool In The Fight Against Diabetes

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Minister of Health, Donville Inniss, accepting the monofilaments from Simone McConnie of the??Diabetes Foundation of Barbados. Looking on are Chief Medical Officer, Dr. Joy St. John, and Chairman of the Foundation, Dr. Oscar Jordan. (C. Pitt/BGIS)

While a high degree of amputations as a result of the ???diabetic foot’ has, for years commanded the attention of health care providers in Barbados, the level of commitment and enthusiasm to treatment and care for diabetics by health care professionals has never waned.

This observation was made recently as Chairman of the Diabetes Foundation of Barbados, Dr. Oscar Jordan, donated the first-ever set of microfilaments to the island’s public health sector, on behalf of his organisation. Prior to the presentation to Health Minister, Donville Inniss, the Chairman and his Chief Operations Officer (COO), Simone McConnie commented on the causes and complications of the ???diabetic foot’ and the working partnership formed with Government.??

Dr. Jordan recalled that, in the 1970s, when he reviewed the numbers of amputations carried out by the Queen Elizabeth Hospital (QEH), there were approximately 200; and upon a review in 2010 the figure stood at 219.?? He noted that, while this did not necessarily represent an increase, it, nonetheless, meant "that we have made no impact on this massive public health problem – a problem which entails not only psychological and economic issues for the family but problems at the workplace and for Government and the economy as a whole".

He added: "Over the years, the Queen Elizabeth Hospital was unable to facilitate general surgical admissions because the beds were always full with patients suffering from diabetic foot problems.?? The diabetic foot being a syndrome or a collection of syndromes, where people either had their feet amputated or were waiting to have them amputated."??

The Chairman went on to explain that it was important that diabetic patients knew whether there was sensation or loss of sensation (neuropathy) in their limbs.???? As he pointed out, the lack of protective sensation was a major aspect of care. "Rather than waiting until the patient has lost sensation completely, it is important for care givers to understand that they must examine and test the sensation of that patient, and that a patient’s ability to protect him/her self from injury," he stressed.

It is against this backdrop, therefore, that the Foundation deemed it "essential" to ensure the island’s eight polyclinics and the Diabetes Clinic at the QEH had a mechanism in place for testing sensations in the feet.?? The monofilament – a tool conventionally used worldwide for testing sensation – was introduced for the first time in Barbados through the benevolence of the Foundation and its Step by Step programme. The aim was to enhance the Ministry’s efforts in controlling the complications of diabetes, and, in particular, amputations.

As the 4,400 monofilaments were handed over by COO, Simone McConnie, Ministry officials were given the assurance that as insignificant as they looked, monofilaments were important tools in the "whole screening programme for diabetes".?? She explained that recognising ???loss of sensation’ was a very difficult thing for a person to comprehend or accept, given that usually individuals do respond to pain.???? She further pointed out that loss of sensation could result in a person wearing inappropriate footwear that might be too tight, too small or contain foreign bodies such as tacks and pins that can lead to foot problems.

It was also underscored that while loss of sensation was one aspect of this disease, reduced blood flow may also be present. Individuals with good sensation may exhibit symptoms of poor blood flow which can be detected as intermittent

claudication (cramps in the calves) in the early stages of poor circulation.?? However, reduced sensations to the foot may result in a missed warning sign, as persons "will not complain of foot pain".

Ms McConnie, who is also a podiatrist, recounted experiences of people with no knowledge of tacks and other objects in their feet or shoes, and noted that "…these are elements where once there is an abrasion to the skin would mean that bacteria can get in, and, with a diabetic, it means invariably that overnight you could end up in the hospital, and the next day you may be looking at an amputation of your foot or part of it."

The point was also made that once neuropathy was known, doctors could look out for signs of other complications. "There are studies out there that state that once you have one complication you have got them all, but you just have them at different degrees," she maintained.

Benefits that monofilaments will bring to the health care sector are expected to be numerous for clients. One of the key aspects in limb salvage and saving feet is recognising there is a problem at an early stage. Presentation of loss of sensation for a diabetic means that he/she needs to be seen by the doctor more regularly; needs to be sought out and educated, and reminded how important it is to have his/her feet checked and how to examine them daily.

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Minister of Health, Donville Inniss, has his foot tested by podiatrist Simone McConnie. (C. Pitt/BGIS)??

The thin flickering strip on this high standard implement, called the monofilament, is known to deliver some 10 grams of pressure to the foot, in its search for sensation.?? The specific pressure points which it tests for lack of or presence of sensation include underneath the big toe, underneath the ball of the foot, on the heel, and the tip of the toes.?? Eventually, the tool could be given to patients at the end of therapy to allow for self-testing at home, and, as noted by the representatives of the Diabetes Foundation, "It is very cost effective and cost efficient because we can also encourage our diabetics to help themselves."??

Worth just over $10, 000, the set of monofilaments are expected to be used in at least 12 centres, with each centre receiving approximately 360, as a starter. Overtime, their usage will be managed and monitored by the Foundation with the aim of supplying even more.

The monofilaments were sourced via the Step-by-Step programme that was launched here in 2008, by the Diabetes Foundation of Barbados.?? Step-by Step has its origins in Tanzania and India, where the dearth of real professionals led to the training of lay persons in simple basic tools of screening to detect early complications in the diabetic foot.???? It is an educational programme, that seeks to train health care professionals (doctors and nurses), as well as care givers who go into the community, visiting patients at home or on worksites, and proffering advice on how best to deal with their feet.?? Step-by-Step is sponsored by the International Diabetes Federation and the World Diabetes Foundation. Locally, it is supported by the Ministry of Health; the Rotary Club of Barbados South and ESSO.

With the introduction of monofilaments, it is highly anticipated that better preservation of limb on the island will lead to the attainment of a key goal of the Health Ministry and Diabetes Foundation – that of reducing the number of amputees annually to a significant fraction of what is now – from 200 and over, to less than 100 within a three to four-year period.

jgill@barbados.gov.bb

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