1. Alavi, Afsaneh MD

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Iran is a Middle Eastern country whose borders include the Caspian Sea, Azerbaijan, and Turkmenistan in the north; Turkey and Iraq in the west; Pakistan and Afghanistan in the east; and the Persian Gulf and the Gulf of Oman in the south. It has a population of nearly 70 million, and Islam is its primary religion.


I was born in the southeastern Iranian province of Kerman, and I trained as a dermatologist. My training, however, was not adequate to manage the many wound problems I was seeing among my patients. This lack of expertise in wound management was not the only barrier to adequate care. Iran has a long way to go to change customs, create interprofessional care teams, and translate the evidence base in wound care into practice.


Diabetic foot ulcers and pressure ulcers are the 2 major wound types I have encountered while practicing in Iran. In this article, I will define the problems and examine the progress that has been made in upgrading practice in the country.


Defining the Diabetes Problem

More than 2 million Iranians have diabetes mellitus, making this disease one of the country's main health care concerns. Unfortunately, the care of persons with diabetes is fragmented; with only a handful of podiatrists in the country, there are few practitioners available to manage foot care issues. In accordance with Islamic tradition, many individuals walk barefoot in the home and in the mosque. Naturally, this practice increases the risk for foot injuries in persons with diabetes.


It is difficult to find data on foot amputation rates in persons with diabetes in Iran; the only published patient information is from hospital inpatients. In these individuals, amputations occurred in more than 30% of those admitted with a foot ulcer and diabetes. Studies have shown that approximately 50% of persons with diabetes in Iran were not aware of their disease.1-3


To better understand the risk of amputation, my colleagues and I designed a study to examine the characteristics of patients with diabetic foot ulcers attending an outpatient diabetic clinic in Kerman. This prospective, descriptive study included 247 patients with diabetes. The objective was to define clinical features of foot problems in patients with diabetes, such as callus formation and other foot abnormalities. The mean age of patients with diabetes in the study was 52 +/- 12 years; this was a relatively young population with a recent onset of diabetes.


The prevalence of callus in the enrolled patients was 12%, and heel cracks were noted in half of the patients, a surprisingly high proportion. A significant relationship was found between callus and the presence of hammertoe, ulceration, and the absence of tibialis posterior pulse (odds ratio of 4, 3, and 5, respectively). The prevalence of foot ulcer was 4%.

Figure. Afsaneh Alav... - Click to enlarge in new windowFigure. Afsaneh Alavi, MD, at the Abasi Hotel in Isfahan, Iran. Photo/courtesy R. Gary Sibbald.

Defining the Pressure Ulcer Problem

The other wound care issue I have encountered in Iran is pressure ulcers, especially among young Iranians with spinal cord injuries. The mean age of this patient population is 37 +/- 6 years. Approximately 5000 Iranians have spinal cord injuries, about 2000 who were injured in the Iran-Iraq war and about 3000 who were disabled by other causes.4


A study of 156 persons with peripheral nerve injury demonstrated a high risk of pressure ulcers, especially among those with injuries that involved the sciatic nerve (24.8%).5 The mean age of persons with nerve injuries in this study was 29 T 12 years. This young population exemplifies the importance of screening high-risk patients as a means of preventing pressure ulcers to relieve personal suffering and reduce costs to the health care system in Iran.


Overcoming Barriers to Care

Many patients with diabetic foot ulcers and pressure ulcers are unnecessarily leading disabled lives because of barriers caused by economic, social, cultural, and medical conditions in Iran. Fundamental changes are needed to increase their quality of life.


Because I had such a strong desire to help these patients and to change practices in my country, I knew I had to upgrade my knowledge in wound management. My first step was to enroll in the international interdisciplinary wound care course at the University of Toronto, Toronto, Ontario, Canada, in 2004. I completed the course in 2005, and I am now involved in a 2-year fellowship in wound healing at the University of Toronto. I also connected my supervisor in Toronto, Dr R. Gary Sibbald, with the chancellor of the medical school at the University of Tehran in Iran, an endocrinologist who is developing a new diabetic research and patient care center at the university. Six of my colleagues from Iran have now enrolled in the interdisciplinary course at the University of Toronto.


Our goal is to overcome entrenched barriers to care, but it has not been easy. Collaborative efforts between policymakers and health care professionals are needed to help remedy the situation. We need to close the educational gaps to provide best-practice toolkits and programs for the country's health care professionals and patients. It is critical to provide interprofessional programs in everyday practice and to train health care professionals to work collaboratively, sharing knowledge and expertise to improve patient outcomes. The educational process in wound care, as well as subject expertise and cultural experiences, is very important.


We are beginning to make some progress. The Canadian Association of Wound Care's quick reference guide to diabetic foot care (which includes best practices built on the Registered Nurses Association of Ontario's interprofessional guideline) has been translated into the local Farsi language. This will allow the application of best practices for persons with diabetes in Iran. It is important to remember when translating best practices for other cultures that the recommendations must include a realistic use of the region's available resources and budget.


Commitment to Improving Care

I am committed to the goal of helping to decrease the suffering of Iranian patients with chronic wounds. This process must include an understanding and a correction of pathogenic factors (ie, treat the cause), cultural issues, economic problems, and lifestyle issues combined with adherence to standards of care (patient-centered concerns) as a foundation for improving future patient care. In the coming years, I plan to do my part by dedicating my time to:


* educating health care professionals on the importance of screening, prevention, and optimal patient care


* empowering patients with knowledge, considering the differences in culture, lifestyle, and health care systems


* encouraging the development of interprofessional teams and collaborative work


* facilitating the global development of communities of practice so that health care professionals can continue lifelong learning and share their wound experiences and challenges.





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3. Alberti KG, Zimmet PZ. Definition, diagnosis and classifications of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15:539-53. [Context Link]


4. Hollisaz MT, Khedmat H, Yari F. A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers. BMC Dermatol 2004;4:18. [Context Link]


5. Ahrari MN, Zangiabadi N, Asadi A, Sarafi Nejad A. Prevalence and distribution of peripheral nerve injuries in victims of Bam earthquake. Electromyogr Clin Neurophysiol 2006; 46:59-62. [Context Link]