Josivan Gomes de Lima, Lúcia Helena Coelho Nóbrega, Maria Lúcia Coelho Nóbrega
Hospital Universitário Onofre Lopes, Natal, Brazil (J Gomes de Lima MD, L H Coelho Nóbrega MD, M L Coelho Nóbrega MD).
In Brazil, diabetes is now thought to affect more than 7% of the adult population, and many of these patients find it difficult to maintain good glycaemic control. About 60% of people in Brazil do not have private health insurance and receive treatment at public hospitals, where the only insulin available is isophane, and the only tablets are metformin and glyburide. Even these treatments may not always be available. Without good control, chronic complications are more likely. In one respect, however, the situation is improving in Brazil because more specialist foot clinics have opened – largely through the efforts of Dr Hermelinda Pedrosa. Yet despite these new clinics, the situation is still far from ideal and the rate of amputation is very high. The high rate of amputations is partly because of limitations within the public health services, with the inability of doctors to provide comprehensive and long-term surveillance of patients who are at risk, failure to prescribe appropriate antibiotics, lack of resources to allow a proper trial of conservative management; and limited access to vascular reconstruction. Because there is little formal foot-care education, many patients are unaware of the risk and tend to present late. For those with health insurance and, usually, better socioeconomic circumstances, the situation is not so desperate and the incidence of avoidable amputation is much lower.
Figure 1 shows the foot of 60-year-old female private patient with type 2 diabetes and who developed an ulcer after minor trauma to the big toe. The big toe was secondarily infected, with erythema, swelling, and areas of necrosis and slough. The ulcer responded well to three months’ treatment with systemic antibiotics and regular dressings. Choice of footwear is not optimum and the foot remains at risk of further episodes (figure 2).