Diabetes and foot ulcer

Dr. Turin Chowdhury

Diabetes mellitus is a disease where people have too much glucose (a kind of sugar) in the blood. Glucose level in the blood is controlled by several hormones. Hormones are chemicals in your body that send messages from cells to other cells. Insulin is a hormone made by the pancreas. When you eat, the pancreas makes insulin to send a message to other cells in the body. This insulin tells the cells to take up glucose from the blood. This glucose is used by cells for energy. Extra glucose that is not needed right away is stored in some cells as glycogen. When you are not eating, cells break down glycogen to have glucose to use as energy.
   Whatever food we consume that is transformed into glucose in our body. This glucose is than transported to our body cells by blood to be used as energy source. In this phase we need a hormone named Insulin which assists the glucose in the blood to enter in the cells. When blood glucose levels rise, cells named beta cells in pancreas release insulin. Pancreas is an organ located behind our stomach. With reduced amount of insulin or no insulin the body cells are deprived from the very essential glucose, even if plenty of glucose is available in the blood. If in any way there is deficiency of insulin in our body or the available insulin can not work properly then our body faces problem in glucose utilization. This condition is called as Diabetes Mellitus, commonly called diabetes.
   
   Effect of diabetes on foot
   Diabetes causes the blood sugar levels to be higher than normal. Over time, high blood sugar levels can damage the blood vessels and nerves in our body. The damage in the blood vessels is more prominent in the peripheral blood vessels, such as blood vessels of our foot. Damage to the blood vessels in the feet will deprive that part of good supply of blood. On the other hand damage to the nerves reduce the feeling in the part effected. This is called diabetic neuropathy. This, in turn, may make us less able to sense injury or pressure on our foot. One may not notice foot injury until severe infection develops, because he or she will not feel any pain due to the injury, thus will be unaware of it. If little injuries aren't taken care of, they can get worse and turn into ulcers. If these ulcers become infected, the person may have to go to the hospital or, in very serious cases, have a foot amputated.
   
   Diabetic foot ulcers
   Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation such as friction or pressure, and any kind of trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of feeling in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain and one may not even be aware of the problem. Diabetic related vascular disease can complicate a foot ulcer, reducing the body's ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body's ability to fight off a potential infection and also retard healing.
   
   Healing factors
   Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and wound treatment. Healing may occur within weeks or require several months. If the wound location s in such a place of the foot that there is continuous pressure on the wound, then the wound will need special care to heal, like resting the foot. If the blood circulation towards the region of the wound is hampered, it will affect healing process. Additional to that bad wound care or bad wound hygiene will effect the wound healing. The blood level of the glucose is one more important factor for wound healing. A bad glucose control will affect the wound healing negatively.
   
   Complication
   An apparent harmless foot ulcer can end up being a life threatening issue for a diabetic patient. Foot ulcers in patients with diabetes have higher risk of infection and leading to amputation, reducing function and quality of life dramatically, and increase disease burden and health care costs. In instances the complications may become fatal, leading to death.
   
   Risk factors
   If one has diabetes then the person is at higher risk for developing foot problems. The risk factors associated with this are:
   * Have had long term diabetes, such as diabetes more than 10-12 years
   * Being aged person of more than 45-50 years,
   * Being male in gender,
   * Have poor glucose control for the diabetic problem,
   * Have eye, kidney, or heart problems of diabetic related complications.
   Identifying the problem
   Identifying the problem in its very early stage is very important in regard to foot care for each person with diabetes. For that purpose a diabetic person must check his or her foot everyday, and this is especially important if that person is long time diabetic. One has to look for -
   * Loss of feeling in the feet.
   * Changes in the shape of the feet.
   * Foot ulcers or sores that do not heal.
   
   Avoiding the problem
   The much used statement - "Prevention is better than cure" - is very much true for diabetic foot ulcers. These ulcers are very problematical to deal with, thus prevention effort will save lots of money and discomfort. Major diabetic foot problems can be prevented with just a little effort of few minutes of daily foot care. The following steps can help in the effort.
   * Should keep control of the blood sugar level as close to normal as possible.
   * Should wash feet every day with lukewarm water and mild soap.
   * After washing feet or having bathed, should dry feet well.
   * Better use soft towels and gently clean feet; do not rub hard.
   * It is good to apply any cream or lotion, especially on the heels to keep the skin of feet smooth.
   * If the skin is cracked then discuss with a doctor about treating it.
   * Make a habit of checking feet thoroughly every day. Consult doctor at the very beginning if you find signs of redness, swelling, pain that does not leave, or numbness or tingling in any part of foot.
   * Treat calluses, corns or bunions with consulting doctor first.
   * Be careful not to have even minor cuts during cutting the toe nails. Some more cut toenails straight across to avoid ingrown toenails.
   * Do not let your feet get too hot or too cold.
   * Do not go outside or uneven surfaces barefoot.
   * Never wear shoes without socks.
   * Avoid wearing sandals or other open-toed shoes.
   * Avoid high-heeled shoes, shoes with pointed toes, uncomfortable tight shoes that might compress the toes and cause cuts or blisters.
   * Never wear too tight socks, nylon socks, socks with elastic band with inside seams. Wear well-padded cotton socks or stockings.
   * Loosen the new shoes slowly by wearing them for short period a day for several days.
   * Change socks and shoes every day. Have at least 2 pairs of shoes so you can switch pairs every other day.
   * Look inside your shoes every day for things like gravel or torn linings. These things could rub against your feet and cause blisters or sores.
   Visiting the doctor Diabetic patients' feet, especially for the ones with long time diabetes should be periodically checked by the physician or health care nurse during the routine check up. On the other hand a diabetic patient having any problems, such as loss of feeling, sores or ingrown toenails, must inform the physician immediately. Podiatric physician Podiatric physician/surgeon is trained health care professionals trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training includes all the problems related systems and structures of the foot and lower leg. They covers the conditions including problems of foot and legs in aspect of neurological, circulatory, skin, bones, joints, ligaments, tendons, muscles, and nerves.

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Dastardly durians

Rayyan Kamal

Durians are banned from the Singapore subway. Surrounded by a red circle and cut in half by a red line on signs that are easily visible at every station, this prickly, renegade fruit looks like a bomb in these pictures. In real life, it has a more striking resemblance to the jackfruit. Its crime? It stinks, I am told. The relevant authorities no doubt believe that the smuggling of this despicably malodorous monstrosity into the subway could result in unparalleled pandemonium, not to mention traumatized noses.
   Less surprisingly, eating, drinking and smoking are also strictly prohibited. Last week I received a stern rebuke from a plainclothes policeman (they are never in uniform) for taking a swig from my water bottle.
   My American flat mates are not impressed by Singapore. It has no culture. It's too artificial. It's a police state. It has the highest number of state-sanctioned executions of any country in the world. The locals are like robots - all they care about is wasting their money at one of the island's thousand malls. They never question their government, not like that would change anything. The government is clinically swift to crush any opposition. Singapore is plain boring, they say.
   The fact that, since 1991, Singapore has hanged 400 prisoners, most of whom were convicted for drug trafficking or murders, is disturbing. The island-state probably has the world's harshest penalties for drug trafficking and possession. If you are caught with 500 or more grams of cannabis on your person, you will be hanged. No exceptions, or none that I've heard of. Singapore is also one of the few first-world countries that employs corporal punishment on criminals. "Strokes of the cane" are dished out to perpetrators of crimes like stealing.
   Though I wouldn't argue that the nation's justice system is exceedingly harsh, I also think that it has many merits that should not be ignored. This small, unnoticeable island has attained a level of prosperity that its fellow Asian nations can only dream of. Bangladesh certainly has culture, but who needs culture when you are barely making enough to get by? I wonder how many Bangladeshis would refuse to exchange culture for money. And what's worse? A relatively high incidence of state-sanctioned executions that is complemented by a very low number of murders or a laudably small number of state-sanctioned executions that is accompanied by an alarmingly high frequency of unnatural deaths? But now I'm oversimplifying matters.
   It should be mentioned that experiencing "culture" in Asia is often associated with mimicking the less affluent. Culture is eating diarrhea-giving food at hawker stands, riding on tuk-tuks (Cambodia's version of baby-taxis) and staying at cheaper hotels because the expensive ones are too artificial, too sterile. Is Asian "culture" synonymous with poverty as prosperity is associated with the West? It probably will be until wealthy Asians become inventive and popularize their own expressions of affluence.
   I don't find Singapore boring. But then again, I am slow to tire of shopping malls, beaches, and nightclubs. And I have yet to sample those tantalizing durians.
   Rayyan Kamal is a sophomore at Yale University.

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Chowdhury Irad Ahmed Siddiky, Ph.D.

A state is many things: a history, a group of people, a set of laws. When a society does not prevent actions whose allowance yields a net loss to each of its members, the society has taken liberty to a point where it becomes counter-productive. Thus it becomes a prejudiced and reactionary society, as opposed to a liberal one. The validity of laws in any society depends on the continuation of the legal order under which those laws were made. Once that legal order is destroyed, the laws cease to have validity.
   
   Troubled state
   If the destruction of the legal order is caused by political disorder, criminal action, unqualified military rule with criminal motive and anarchy, then it can be said that the state has failed to fulfil the basic needs of a substantial element of its population and can therefore be called a "troubled state." A state in trouble often casts fundamental doubt on the legitimacy of the regime in power. The disintegration of law and order also exposes the latent incapacity and failure of the government to deal with those problems. The presence of a well-functioning government does not mean that a sovereign state will have the capacity to establish an assured peaceful law and order situation over time. Still, the government is spared the indignity of the jurisprudential insult of being asked whether law exists, unless the sort of chaos prevails that leads outsiders to label the reality as an instance of a marginal state or a failed state, or a terrorist state, as we are compelled to believe by recent course of political events in Bangladesh.
   
   Internal instability
   A major reason of worry about "failed states," "marginal states" and "troubled states" is due to the suffering caused internally by a lack of security as well as the instability generated externally, either in the region, or in the world as a whole. A state, which is unstable internally, incites its more expansionary neighbours into action, as internal instability usually implies military weakness. However, it might also cause concern to its neighbour, being a source of refugees and a collapsing economy, which might have an effect on its neighbour's economy.
   The economic aspect is closely related to the political aspect. A system of economic distribution in a stable state relies on a reasonably stable legal system whose efficacy requires an effective government.
   
   Elite and poverty
   Working and owning things in particular require a functioning legal framework. This, of course, gives great power to the people in charge of the decision making process for what the legal framework is. They can ensure that they get the lion's share of what is available in the society. Thus, societies in which the elites are difficult to challenge reinforce these elites by allocation of resources to those elites.
   In the case of open and broadly democratic societies this is more restricted in that elites can be challenged. Their activities are more transparent and they have less of a monopoly grip on the levers of the state.
   Ironically, states with a weak and authoritarian political leadership in a dynastic political order skirted by procedural democracy of a rubber-stamp parliament can both shift resources towards the elites and leave the rest of the population in poverty. Cases from Bangladesh and Nigeria correspond to this model. In a poor country the prospect of diverting wealth to the elite is particularly appealing. Consequently, there is a struggle to become a member of the elite, bringing governmental instability to many poor countries.
   
   Scam, profit, crime
   Also, in a poor country with inadequate or corrupt police, scam and bribery are attractive. It is much more profitable to form an armed band and rob other people than to go to all the trouble of making and selling things. The weakness of this argument when generalised to a whole state is obvious. Nothing gets produced and the decline continues further. There is a stage in the whole process where the economy simply collapses. Well before that stage, the economy can be severely impeded by the profitability of crime as in the case of Bangladesh.
   A state is supposed to provide its citizens with physical security, against attack either internally or by foreigners. The internal attacks can come from political groups or groups of organized crime. Essentially, there are two forms of internal stability. Consensual stability exists when stability is brought about by normal policing and threats to security come from criminal activities. This was the situation in Bangladesh in most peaceful times.
   When criminal activities are at a high level - just like the period immediately preceding the current covert martial law in Bangladesh, consensual stability is not provided even though the political system might be comparatively stable. In this scenario, what is provided is called Coercive Stability.
   
   Coercive stability
   Coercive stability exists when states provide physical security in the sense of comparative order internally, but at the cost of severe repression, which can legitimately be regarded as violence, and certainly impeding the liberty if not the security of the necessarily tranquil inhabitants. The entire law and order enforcement campaign of the current Caretaker Government (CG) with covert support of the Bangladesh Armed Forces is nothing more than a legitimate exercise by the "troubled state" of Bangladesh to deliver that much needed coercive stability in the interest of its people.
   The past regimes of Bangladesh characterised by political dynasties and elected dictatorships have taken Bangladesh on the highway to becoming a failed state. Under such circumstances the covert intervention of the army with covert support and intervention of the international community is a blessing in disguise for Bangladesh.

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ROAMING RACONTEUR

Usurpers of democracy

Saad Quasem

15,000 miles away from my homeland; I close my eyes and think of my homeland. I see the mighty rivers and golden fields of Bangladesh flanking the country. I see the monsoon rain fertilising the fields for a blissful harvest. I am well aware that the physical beauty of the country would remain intact.
   I open my eyes and return to the reality. A large influential group of people have managed to ransack the nation fully. Just about everyday there are new revelations that play havoc with our minds. I try to refrain from discussing politics; but it is no longer politics when the implications involve every aspect of the society and our morals, values, ethics and the whole concept of being Bangladeshi are at stake. The sacrifices made at the cost of 30 million lives and untold miseries suffered during the nine month long war of liberation to secure independence have all been lost in vain. With such a staggering loss, one loses dignity, honour, hope and pride.
   As a Bangladeshi I feel the pride each and every Bangladeshi must have felt at the dawn of Independence. I probably felt the exactly opposite, the day the state of emergency was declared on the 11th of January this year. The declaration of emergency was not only the consequences of poor governance of the months before but also the past decades as well. It was a much needed ordeal. Indeed, under the emergency rule, the government is trying to take back Bangladesh to normalcy.
   The current Caretaker Government's crackdown on corruption and the initiatives to clean up politics in the society have revealed unbelievable depths and dimensions of corruption, misuse and abuse of state power for personal gains. How can we accept that the State Minister for Home Affairs was bribed Tk 20 crore for twisting a murder case and allowing the murderer to escape? What kind of a leader allows her sons to exponentially monopolise almost every sector of business? Is it acceptable that the leader of the opposition plans to burn down buses carrying innocent civilians and spark riots in garment factories, just so that the government is destabilised? Really, in which democracy had leading ministers literally granted asylum to the leading terrorists. In prison, the top leaders are affirming these allegations and it makes me feel disgusting just about every political leader.
   The current crackdown was as essential for Bangladesh as water is to any human being. I have more trust in the non-elected government than the one I helped to elect.
   Bangladesh was created on the premise of democracy and the leaders who have helped to ruin the essences of it should be provided with the same status as those we call Razakars. If anything, these symbols of corruption, extortion and violence have caused the country unmitigated harm. Yet, the high profile politicians have shown no sign of repentance or shame for what they have done.
   The country's seasoned politicians have now been put in jail and are being accused of corruption, cronyism, perjury and above all, immorality. What an irony? The Emergency has proved to be a blessing in disguise. While it is overdue, yet it certainly is a disgrace to welcome an emergency as opposed to a constitutional democracy. What a shame!
   I intend to thank the caretaker government for instigating the reforms in society we much needed.

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