RU2506894C1 - System of helping people with syndrome of diabetic foot - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: system is elaborated in order to treat people with syndrome of diabetic foot. For this purpose claimed is system of performing help to such people, which includes outpatient-polyclinic subsystem, ambulance subsystem, hospital subsystem, rehabilitation service subsystem, prevention service subsystem, formed on the basis of nosological forms of diabetes mellitus. System has possibility of any subsystem being switched to, depending on patient's state. Subsystems are connected to each other via two-way communication channels and are provided with diagnostics means, and/or treatment, and/or rehabilitation, and/or disease prevention. System also contains means for selection of optimal treatment scheme, means of formation, completion and processing of database, computed means, software, means for access to database. Database includes data about treatment schemes, results of examination of each patient, conclusion about current form of their disease with administered complex of procedures by medical staff, set of optimal treatment schemes and personal aid, with data about each subsystem resources.EFFECT: invention ensures elimination of further infection development, destruction of deep tissues of patient's organism associated with neurological disorders and reduction of main blood flow in arteries of lower extremities of different degree of severity, due to adequate, effective and timely response to patient's state on the basis of examination results and assessment of possibilities of involved medical institutions carried out in due time.5 cl, 2 tbl, 1 ex

Description

The invention relates to medicine, namely to the field of diagnosis and treatment of patients diagnosed with diabetes mellitus, and can be used to build the optimal scheme for assisting them in treatment.

There is a method and system for helping patients with diabetic foot syndrome to independently carry out a number of independent actions necessary for them in the treatment process (see RU 2244506, IPC АВВ 5/00, published on January 20, 2005). The method comprises collecting information on parameter values (blood glucose level, etc.) that are significant for independent procedures and associated with the physiological state of the patient, from portable devices (glucometer, etc.), building a patient’s metabolism model, into one or more patient databases , assessment of the predicted values of a specific parameter based on this model, processing of patient databases and providing the patient with alternative options for independent actions with the values of the specified parameters for each th of them. The assistance system comprises a computing system, a computer system, and a computer-readable medium with a program implementing the method.

The disadvantage of these methods and systems is the emphasis on the independent intake of certain drugs by patients and / or on their own certain medical procedures with the possibility of their alternative replacement, lack of information on generalizing the practice of diagnosis and treatment, on analyzing the capabilities of various medical and diagnostic institutions, able to carry out the necessary treatment in the medical field under consideration. The schemes and recommendations used are not accompanied by data on the resources of medical institutions, costly treatment data, which would allow us to assess the feasibility of implementing the optimal diagnostic and treatment regimen in a particular institution. As a result of this, situations often arise when a patient ends up in a diagnostic and treatment facility that cannot prescribe him an adequate examination and treatment based on his ability to have medical personnel of the required qualifications or available equipment with adequate capabilities, as well as the ability to make certain costs for this based on their funding capabilities, resources. The result of this use of the system is either insufficient or excessive, which does not correspond to the necessary purpose of the diagnostic / treatment methods, i.e. not optimal and ineffective use of inadequate diagnostic and treatment regimens. Often times are missed for the possibility of choosing the optimal organ-preserving treatment. An infection, ulcer and / or destruction of deep tissues associated with neurological disorders and a decrease in main blood flow in the arteries of the lower extremities of varying severity develops, pathological changes in the peripheral nervous system, arterial and microvasculature occur, which pose a direct threat to the development of ulcerative necrotic processes and foot gangrene , lower limbs in general. Thus, time and opportunities for the timely provision of effective care to patients are missed.

The objective of the invention is to develop a system to ensure an adequate, effective and timely response to the patient's condition based on the results of a sufficient examination and timely assessment of the capabilities of the involved medical institutions, based on the availability of medical personnel with the necessary qualifications, medical equipment and instruments, medicines and drugs, financial capabilities, etc. e. based on the capabilities of available resources.

The technical result consists in eliminating the further development of infection, further destruction of the deep tissues of the patient’s body associated with neurological disorders and a decrease in main blood flow in the arteries of the lower extremities of varying severity, eliminating pathological changes in the peripheral nervous system, arterial and microvasculature, which pose a direct threat to the development of ulcerative -Nekrotic processes and gangrene of the foot, lower limbs in general.

The problem is solved by a system of care for patients with diabetic foot syndrome, including an outpatient diagnostic subsystem formed on the basis of nosological forms of diabetes mellitus, a day care subsystem, an ambulance subsystem, a hospital subsystem with purulent-septic and vascular surgery departments, a rehabilitation service subsystem, and a prevention prevention service subsystem with the distribution of their functions, powers and responsibilities, with the possibility of connecting any subsystem, depending on the condition of the patient. Subsystems are interconnected by bilateral communication channels, means of prompt delivery of patients. The subsystems are equipped with diagnostic tools (paraclinical services - laboratories with equipment for determining the level of blood glucose, glazed hemoglobin, biochemical blood parameters, routine analyzes - general blood analysis, general urine analysis, determination of urine acetone, radiation diagnostics with duplex color scanning of limb vessels) , X-ray diagnostics, equipment for ultrasound of the abdominal cavity, ECG apparatus, equipment for determining the sensitivity of the lower extremities and the identification of ROPAT) - specialists (the presence in the state consultant neurologist, Podiatry, podiatrist, endocrinologist, internist, surgeon for purulent diseases, vascular surgeon)

- and / or by means of treatment (hospital for purulent-septic surgical pathology, department of vascular surgery, day hospital with consultants: neurologist, orthopedic traumatologist, endocrinologist, therapist),

- and / or rehabilitation means (physiotherapy, physiotherapy, massage room, orthopedic shoes and insoles manufacturing facilities),

- and / or means of disease prevention (outpatient diagnostic equipment with a computer database for clinical examination of patients, educational tools for patients at the diabetes school),

- means of choosing the optimal treatment regimen, depending on the severity of the disease and the similarity of the diagnostic results from the existing schemes in a central computer database,

- means of formation, replenishment and processing of the central database,

- computer tools, software products,

- means of access to the central database.

The central database includes data on possible replenished treatment regimens depending on the form of the disease, the results of the examination and treatment of each patient, a conclusion on the current form of his disease with an assigned set of measures by the medical staff, including the optimal personal treatment and care scheme, with data necessary equipment, tools and medical devices, medicines and preparations, consumables, depending on the stage and severity of the disease niya, labor costs according to the specified schemes. The database can be divided into sections according to the form and stage of the disease, for each patient. The communication of the subsystems with each other and with the central database is implemented through secure communication channels and video channels for conducting telemedicine sessions and visual distant consultations by specialists.

The system operates as follows.

Using previous experience and knowledge in the field of diagnosis and treatment of diabetes mellitus, the medical service of each subsystem: outpatient diagnostic, day hospital, ambulance, hospital, rehabilitation service, prevention service - on the scale of a territorial unit: region, region, region, city forms replenishes the database of treatment and diagnosis of each nosological form of the disease with the reflection of the optimal regimens for each form based on existing knowledge and experience. Databases pre-formed in this way are included in the central database of the Diabetic Foot Center, which is accessible to all subsystems through secure communication channels. The central database also includes information on the necessary resources of each subsystem, each medical institution to ensure the possibility of using one or another diagnostic scheme and / or treatment of the disease, correlating them with the capabilities of a particular subsystem (medical institution). The database is constantly updated and adjusted in accordance with new information on examination, treatment.

When a patient enters one or another subsystem of medical care, an initial examination is assigned to him, consistent with the general clinical picture of the patient’s condition, with the initial examination scheme reflected in the central database in its corresponding section. The initial examination scheme is preliminarily determined by the competent medical services and consists not only of the scheme itself, but is also accompanied by associated information related to the detailed description of the actions of all medical personnel of the subsystem, the use of equipment and tools, drugs and medicines, consumables, indicating the costs of their acquisition, maintenance and use. An initial examination and / or additional examination can be carried out by an outpatient diagnostic subsystem, in the direction (if necessary) of any subsystem. The provision of emergency (emergency) assistance can be carried out by a subsystem of any level, with minimal capabilities and resources; operational decisions are possible to continue treatment in accordance with the severity of the disease in a different subsystem, if necessary with urgent hospitalization.

After conducting the initial survey and obtaining its preliminary results, if necessary, a refinement survey is carried out with details and concretization of the necessary results, which requires an appeal to the central database, to its section, which reveals the capabilities of all subsystems with their resources. The results of a personal examination are entered into the section of the central database of the corresponding patient, replenishing it and enriching it with new data. According to the results of the examination, consultations and identification of patients at risk are conducted. Access of any subsystem to a common database is implemented with the participation of access tools using software products. In this case, optimal schemes are selected depending on the patient's condition, the presence of complications and concomitant pathology. According to the results of the refinement examinations by referring to the central database, the optimal treatment regimen is determined, accompanied by information with the required resources for its use. The optimal treatment regimen with the required resources is automatically correlated with the subsystem level of a medical institution using software products. Based on the information received, a decision is made to choose a subsystem of a medical institution that can provide appropriate adequate assistance, excluding the loss of time on the use of other treatment regimens that do not contribute to complete recovery.

If the severity of the disease and its stage are revealed, in particular, the areas of damage to the body in the form of complications of diabetes mellitus: angiopathy with micro- and / or macropathy of the vascular bed, neuropathy, ostearthropathy, retinopathy related to ophthalmic health problems, nephropathy, each of which require different approaches to the treatment and involvement of medical personnel from different fields of medicine, in particular, specialists in vascular surgeons and / or specialists in purulent-septic surgery, neurologists, endocrinolo s, podiatrists, ophthalmologists, nephrologists.

The creation of a unified medical and economic system for providing real and adequate care to patients based on information from a central database allows us to promptly prescribe timely treatment and avoid the severe, often irreversible, consequences of diabetes.

The following is an example from clinical practice.

Patient M., born in 1969, turned to the office of an outpatient reception of the Center “Diabetic Foot” in Kazan (hereinafter referred to as the Center “DS”) by self-treatment November 3, 2011. Complaints of pain in the right foot, swelling of the right foot and lower leg, pain in the right inguinal region, the presence of a soft tissue defect in the area of the plantar surface of the right foot, weakness, fever up to 37.5 ° C. From the anamnesis it was found that the patient has type 2 diabetes mellitus insulin-consuming for 8 years. Regarding an ulcer of the right foot, he was repeatedly treated on an outpatient basis. In the outpatient office, in accordance with the current primary accounting scheme reflected in the central database, examined by specialists: podologist surgeon, endocrinologist. Radiography of the right foot. Examined by a neurologist and orthopedic trauma surgeon. Tests taken: general blood test, general urine test, blood sugar level, biochemical blood test. According to the results of tests in the outpatient clinic, the diagnosis was made: diabetic foot syndrome, neuroischemic form (Wagner 4). Trophic ulcer of the right foot. Diabetic angiopathy KHAN2 st.Diabetic neuropathy. Osteomyelitis of the third metatarsal bone of the right foot. Right-sided inguinal reactive lymphadenitis. Type 2 diabetes mellitus, insulin-consuming, severe, subcompensated. Consulted by a general practitioner; diuretics are identified for the appointment, for a diagnosis of hypertension stage 2. Risk 4. LVH. CHF2.

Thus, within 4 hours on the basis of an outpatient reception cabinet, the patient received all the necessary consultations and routine research methods, according to the treatment standards for patients with diabetic foot syndrome, which are pre-installed and registered in the central database. The electronic file of the patient is entered into the database.

Based on the diagnosis, in accordance with the current scheme and in accordance with the capabilities of the individual subsystems of the general care system for patients with diabetic foot syndrome, established using the central database, the patient was hospitalized in the purulent-septic surgery department, the beds of which are located in the City Clinical Hospital No. 5 of Kazan where it was delivered urgently. An unplanned, urgent operation was performed: necrectomy, rehabilitation, drainage of a peptic ulcer. Immobilization of Total Contact Cast. Conservative therapy has been prescribed: neuroprotectors (derivatives of thioctic acid), anticoagulants (fraksiparin), angiprotectors (allrostadil), antibiotics (i / m and iv), NSAIDs, antihistamines. Long-acting insulin 16 units / morning / -18 units / evening /; short-acting insulin - 10 units. -10 units -10 units

The next day, November 4, 2011, taking into account vascular pathology and non-stopping edema of the right foot, within the framework of the surgical department of purulent-septic surgery, based on available resources, the patient underwent a color duplex scan of the vessels of the lower extremities:

Research Date: November 4, 2011 FULL NAME. patient: M., 41 years old.

COLOR DUPLEX VARIABLE RIGHT LOWER EXTREMITY.

Right lower limb

The diameter of the large saphenous vein (BPV) at the level of the safeno-femoral anastomosis is 7.6 mm, on the thigh 6.4 mm, the BPV is enlarged, compressed by a sensor, the blood flow is phase, with a Valsalva sample, moderate retrograde blood flow is recorded through the valve of the safeno-femoral anastomosis and through the valves of the main trunk of the BPV on the thigh. The main trunk of the BPV on the lower leg is also expanded, the walls are thickened to 10 mm. On the lower leg varicose dilated inflows of the BPV are visualized.

Small saphenous vein D. 6.6 mm, dilated, with signs of valvular failure. Deep veins: (total and superficial femoral, popliteal, posterior tibial veins) are not dilated, compressible by compression with a sensor, phase blood flow, Valsalva test negative.

The sural veins on the right are expanded D. to 6,6 mm, without signs of valve failure.

COLOR DUPLEX RIGHT LOWER LIMB ARTERY SCANNING

The intima-media complex in the common femoral artery (BOTH) on the right is not thickened 1.1-1.2 mm.

In the visualized areas, the arteries are passable, the lumen is free, the walls are not thickened. Speed indicators of blood flow, indices characterizing peripheral vascular resistance, are within normal limits. The main bloodstream is unchanged.

ETA walls are densified, thickened, stenosis 60%.

The walls of PT A are sealed, not thickened. __________ on right _______

Arteries LSK (cm / sec) Type of blood flow Common femoral artery 77 M Superficial femoral artery: 66 M Deep thigh artery 71 M Popliteal artery 66 m / m Postnatal artery 72 m / m Anterotibial artery 84 m / m

In the right inguinal region, multiple enlarged lymph nodes are visualized, with clear uneven contours, with preserved cortico-medullary differentiation, with a maximum size of up to 5.5 cm.

Conclusion: Echo-signs of phlebitis of the saphenous vein and varicose nodes of the saphenous vein on the lower leg. Echo-signs of thrombosis of the veins of the right foot. Dilation of the large saphenous vein on the lower leg and thigh. Echo-signs of moderate valvular failure of the safeno-femoral anastomosis and the main trunk of the BPV on the thigh. Dilation of the small saphenous vein, with signs of valvular urgency. Dilation of the sural veins, without signs of valve failure. Echo signs of diabetic macroangiopathy. Stenosis of the posterior tibial artery on the right by 60%. Echo signs of reactive lymphadenitis. Given the phenomena of venous thrombosis in the background of diabetic angiopathy, the patient was prescribed: urokinase 300 thousand units iv in physical. solution.

On the same day, November 4, 2011., After receiving data from the DS Center, in accordance with the accepted diagnostic scheme for a similar state of patients, the patient was consulted by an angiologist of the subsystem GAUZ RKB MH RT. To the diagnosis: Diabetic angiopathy of the lower extremities. Diabetic foot syndrome. HAN of the right lower limb Z. Postthrombophlebitis disease. Chronic venous insufficiency Zet (CEAP C6).

11.11.2011 the phenomena of venous thrombosis were stopped. The patient, in accordance with the selected treatment regimen and resource capabilities, was transferred to the Department of Vascular Surgery No. 1 of the “RCH” subsystem of the Ministry of Health of the Republic of Tajikistan, where after angiography he underwent balloon angioplasty at the level of the right lower leg and foot.

November 9, 2011 The patient was transferred back to the purulent-septic surgery department of the GKB subsystem No. 5 in Kazan to continue treatment based on the capabilities of the department. 12.11.2011 The operation was performed: exarticulation of 3 toes of the right foot with resection of the distal head of 3 metatarsal bones. Immobilization of Total Contact Cast.

11/28/2011 The patient was discharged from the hospital. It is observed on an outpatient basis in the Center "Diabetic foot" in Kazan.

Color duplex scan data after discharge (Ambulatory observation)

Research Date: 02/18/11 FULL NAME. patient: M., 42 years old.

COLOR DUPLEX VARIABLE RIGHT LOWER EXTREMITY. Right lower limb

The diameter of the great saphenous vein (BPV) at the level of the safeno-femoral anastomosis is 7 mm, on the thigh 9.0-6.0 mm, the lumen is passable, compressible by compression with the sensor, and an unstable low-speed retrograde blood flow is recorded during the Valsalva test. The main trunk of the BPV on the lower leg is also enlarged, the walls are not thickened, when performing proximal compression, reflux is recorded for 1 second. On the lower leg are the extended tributaries of the BPV. Small saphenous vein D. 6.0 mm, dilated, with signs of initial valve failure. Deep veins: (total and superficial femoral, popliteal, posterior vein veins) are passable, compressible by compression with a sensor, blood flow is smoothed, Valsalva test is negative. The sural veins on the right are expanded D. to 6,6 mm, without signs of valve failure.

COLOR DUPLEX RIGHT LOWER LIMB ARTERY SCANNING

The intima-media complex in the common femoral artery (BOTH) on the right is not thickened 1.1-1.2 mm. In the visualized areas, the arteries are passable, the lumen is free, the walls are not thickened. Speed indicators of blood flow, indices characterizing peripheral vascular resistance within normal limits. The main bloodstream is unchanged. ZTA walls are compacted, small hyperechoic inclusions are visualized - stenosis 30%. The walls of the PTA are compacted, small hyperechoic inclusions are visualized. In the arteries of the rear foot, blood flow is moderately reduced.

Arteries LSK (cm / sec) Type of blood flow Common femoral artery 83 M Superficial femoral artery: 75 M Deep thigh artery 48 M Popliteal artery 70 M Posterior biliary artery 97 M / ISM Anterotibial artery 87 M Rear foot 32 M / ISM

Conclusion:

Dilation of the large and small saphenous veins with signs of initial valve failure. The deep veins of the lower limb are passable.

Echo-signs of diabetic macroangiopathy with vasodilation of distal segments of the main arteries of the lower extremities. Stenosis of the posterior tibial artery on the right by 30%. Linear speed indicators in the arteries of the rear foot of the right foot are moderately reduced.

Compared with the initial data, the effect of the help system is obvious. The patient could lose a limb above the knee joint. After discharge - observation, periodic consultations by an endocrinologist, podologist, vascular surgeon and surgeon of purulent-septic pathology; outpatient treatment (tableted drugs), preventive treatment in the subsystem - day hospital. Direction to the rehabilitation subsystem to determine and manufacture the type of orthopedic shoes. If necessary, hospitalization and treatment with the connection of any subsystem, depending on the patient's condition.

Thus, in accordance with the diagnostic and treatment schemes reflected in the central database, based on the resource capabilities of a number of subsystems: an outpatient clinic, purulent-septic surgery department, City Clinical Hospital No. 5 of Kazan, GAUZ “RKB” of the Ministry of Health of the Republic of Tajikistan, operational examinations were carried out patient, surgical intervention, conservative treatment with minimal loss for the patient due to the timely provision of adequate medical care to him with the involvement of subsystems based on the resources available in them. Without this aid system, the patient would be doomed to large organ-bearing losses with inevitable disability and, without exception, death.

Claims (5)

1. The system of care for patients with diabetic foot syndrome includes the ambulatory-polyclinic subsystem, the ambulance subsystem, the hospital subsystem, the rehabilitation service subsystem, the prevention service subsystem with the distribution of their functions, and the subsystems connected by two-way communication channels formed on the basis of nosological forms of diabetes mellitus; equipped with diagnostic tools, and / or treatment, and / or rehabilitation, and / or disease prevention, with the ability to connect any subsystem depending and on the patient’s condition, as well as by means of choosing the optimal treatment regimen, means of forming, updating and processing the database, computer tools, software products, means of access to the database, the database includes data on treatment regimens, examination results of each patient, a conclusion about the current form of his illness with the prescribed set of measures for medical personnel, a set of optimal treatment regimens and personal assistance, with data on the resources of each subsystem. 2. The system according to claim 1, characterized in that the subsystems are connected by means of prompt delivery of patients. 3. The system according to claim 1, characterized in that the resources of the subsystems include equipment, tools and medical devices, medicines and preparations, consumables, financial capabilities. 4. The system according to claim 1, characterized in that the database is divided into data sections according to the form and stage of the disease, according to the data of each patient. 5. The system according to claim 1, characterized in that the communication of the subsystems with each other and with the database is implemented through closed communication channels and / or video channels.