Prevalence of risk factors for diabetic foot complications

Epidemiology of Diabetes Foot Amputation and its Risk Factors in the Middle East Region: A Systematic Review and Meta-Analysis

This study aimed to review epidemiology of diabetic foot (DF) amputation and provide a pooled estimation of DF amputation rate in the region. A comprehensive search was performed in Web of Science, PubMed, Scopus and EMBASE databases using appropriate search term. Obtained records were entered endnote software and after removing duplicats were screened by title, abstract and full text. Data was extracted from the remained documents. Random effect meta-analysis was used to pool the estimated prevalence rate due to sever heterogeneity between studies. Finally 17 articles in diabetes, 20 in patients with DFU (diabetic foot ulcer) and two in both remained after screening and included in meta-analysis. Overall pooled amputation rate in diabetes was 2% (95% CI: 1%-3%) which was not significantly different between countries. The pooled prevalence of amputation rate in DFU patients was 33% (24%-43%) and the pooled prevalence in Saudi Arabia was significantly higher than in other countries. The estimated rate of foot amputation in diabetes patients and those with DFUs in the Middle East region is approximately high, which may indicate low quality of preventive foot care, low socioeconomics and low patients awareness or education in countries with high amputation rate.

Prevalence, risk level and risk factors of diabetic foot ulcer among adult individuals with diabetes in the Southeastern Anatolia Region of Turkiye

OBJECTIVE

The aim of the study was to determine the prevalence, risk, and predisposing factors of diabetic foot ulcers in adults with diabetes.

METHODS

This study is multi-centered descriptive cross-sectional research. Data were collected between June 2022 and November 2022 in seven cities, including five teaching and research hospitals and two public hospitals. The study included 357 people with diabetes. The sample was selected using stratified and systematic sampling. General demographic characteristics, medical history, laboratory and foot examination results, history of foot ulcer and/or amputation, skin and nail problems, peripheral sensory loss (10 g-Semmes-Weinstein monofilament) and vascular assessment were obtained. Logistic regression analysis was used to screen for factors affecting the diabetic foot.

RESULTS

The prevalence of diabetic foot ulcers was 17.1 % (%13.2-%21.5; %95 CI). Among 296 individuals with diabetes without foot ulcers, 86.5 % (256) had risk level 0, 7.3 % (26) had risk level 1, 3.4 % (10) had risk level 2, and 1.4 % (4) had risk level 3. In regression analysis, the variables of peripheral arterial disease (Exp β: 3.781 - P = .027), history of ulcer (Exp β = 26,180 - P < .001), edema (Exp β: 9.784 - P < .001), fungus between the toes (Exp β = 5.284 - p = .009) were associated with a significantly increased risk of developing diabetic foot.

CONCLUSION

The prevalence of diabetic foot ulcers was found to be approximately two out of every 10 patients with diabetes, and peripheral arterial disease, history of ulcers, edema, and presence of fungus between the toes were found to be among the risks predicting diabetic foot. All diabetic individuals should be diagnosed in terms of diabetic foot risk factors, and follow-up and treatment should be planned considering the basic building blocks of diabetic foot prevention according to the determined risk group.

Level of and factors associated with foot self-care among people with diabetes in Idlib Province of Northwest Syria: A cross-sectional study

Background and aims

Diabetic foot and lower limb problems are among the most neglected complications during the Syrian armed conflict due to the absence of a functioning health infrastructure, including early detection and timely management of limb-threatening wounds. This study aimed to determine self-reported diabetes-related foot disease (DRFD), adherence to recommended foot self-care (FSC) practices, and associated factors among people with diabetes in war-torn Northwest Syria (NWS).

Methods

This was a cross-sectional study conducted at six primary care clinics in Idlib, NWS, between March 27 and April 17, 2022, utilizing the validated interviewer-administered Diabetes Foot Disease and Foot Care Questionnaire. Data on demographic characteristics, DRFD, and FSC practices were collected. FSC score was determined by adding the points from all 12 FSC items, with a maximum score of 48, and were categorized into very poor (≤12), poor (13-24), moderate (25-36), and good (37-48). A convenience sample of 331 consecutive Syrians, aged ≥18 years, with diabetes, were invited. Multiple linear regression was used to identify variables associated with FSC practices.

Results

A total of 328 patients completed the questionnaire (response rate: 99.1%). The overall FSC score was average (mean total score 27.24, SD 7.03). Over one-third (37.8%) had a very poor/poor score, 50.3% had an average score, and 11.9% had a good score. Household income/month of ≥51 USD (β = 2.6, 95% confidence interval [95% CI]:1.06-4.1, p = 0.001) and diabetes duration of ≥10 years (β = 1.8, 95% Cl: 0.2-3.4, p = 0.027) significantly predicted better FSC practice.

Conclusion

A significant proportion of participants had inadequate adoption FSC behaviors. Higher socioeconomic status was associated with better FSC practices. Future research should evaluate diabetic foot education and professional foot care in this population.

Severity of Neuropathy-Related Disability and Associated Factors of Diabetic Peripheral Neuropathy in a Tertiary Healthcare Center: A Comparative Cross-Sectional Study

BACKGROUND AND OBJECTIVES

The widespread presence of diabetic peripheral neuropathy (DN) and its related variables among diagnosed diabetes mellitus (DM) patients in Kerala lacks sufficient evidence. The objective of this study was to evaluate the frequency of DN and its related risk variables among those with DM who were receiving care at a tertiary health institution in Kerala.

MATERIALS AND METHODS

This study was conducted in a tertiary health center in Kerala using a cross-sectional design. The diagnosis of diabetes was established by assessing the glycated hemoglobin A1c (HbA1c) level and the fasting blood glucose (FBG) level. A validated survey questionnaire was employed to gather demographic data as well as the medical history of DM and associated ailments. A thorough physical examination, BMI, and blood pressure were recorded. Dermatological, musculoskeletal, neurological, and vascular assessments were conducted. The subjects were assessed for neuropathy using a neuropathy disability score (NDS). Consequently, those who met the criteria for DM were classified into two groups: those with neuropathy and those without neuropathy. All research participants underwent laboratory examinations such as blood lipid profiles, HbA1c, and vitamin B12 complex concentrations.

RESULTS

The study included 200 DM patients; 120 men and 80 women. Study participants were 40-70 years old, with a median age of 53. The prevalence of DN significantly increased with age (p<0.001). The longer a patient had DM, the higher the prevalence of DN, and this variance in percentage was statistically significant (p<0.009) with an OR (odds ratio) of 9.246. A statistically significant 81 (40.5%) of participants graduated, compared to 119 (59.5%) with only higher secondary education or less (OR = 2.042; p = 0.014). Approximately 107 (53.5%) of individuals earned an income under two lakhs, and this disparity was deemed statistically significant (p = 0.003) with an OR of 2.357. In the group of individuals being studied, 53 (26.5%) of them experienced a decrease in pressure sensation, 47 (23.5%) had a decrease or absence of vibration perception, 48 (24%) had an absence or decreased pinprick response, and 46 (23%) had an absent ankle reflex. The study found that the most commonly reported symptoms were tingling (n = 44; 22%), numbness (n = 42; 21%), burning (n = 37; 18.5%), pricking (n = 29; 14.5%), and pain (n = 27; 13.5%). A strong association was found between DN and glycemic status, namely, FBG levels exceeding 140 mg/dL (OR = 4.511, p < 0.001) and HbA1c levels exceeding 6.5% (OR = 3.87, p < 0.001). The prevalence of abnormal vitamin B12 levels in individuals with DN was 63% (p = 0.19), indicating that the finding was not statistically significant. Within the group of individuals with DN being studied, 22% exhibited mild neuropathy, 34% displayed moderate neuropathy, and 44% had severe neuropathy. The DN individuals had significantly reduced ankle dorsiflexion in cases of severe NDS scores compared to those with mild to moderate NDS scores (p = 0.009). During the binary logistic regression analysis, it was shown that the duration of DM (OR = 1.73; p = 0.038) and FBG levels (OR = 2.87; p = 0.018) were determined as predictors for DN.

CONCLUSION

The findings of this study reveal that the duration of diabetes, age, literacy level, income, HbA1c, and FBG were substantially related to a higher likelihood of DN among diabetic patients.

Epidemiologic and clinical characteristics of diabetic foot ulcer among patients with diabetes in Afghanistan: An IDF supported initiative

AIM

The aim is to illustrate epidemiological and clinical characteristics of diabetic patients with foot ulcer (DFU) in Kabul diabetic medical center (KDMC), Afghanistan.

METHOD

It is a descriptive study explaining the characteristics of diabetic patients with DFU admitted to KDMC, between 1/9/2019 to 31/8/2020 which is a center for management of diabetic patients including DFU. The university of Texas diabetic classification for DFU was used.

RESULTS

Totally 3159 patients admitted to KMDC of whom 47.4% were females and 96.7% type 2 diabetes. The proportion of DFU was 9.2%. The patients' mean age was 55.4 ± 10.6 years and 78% were coming from Kabul. Prevalence of smoking and snuff use were 8.6% and 5.6% respectively. Majority of females 93% were housewives. The duration of diabetes was 5-19 years. Almost two-third were under glycaemia and HbA1c control and 9.2% had history of amputation. The common symptoms were burning, aching, numbness and tingling. The most common cause of DFU was both neuropathy and arteriopathy. After treatment 16% were referred for orthopedic procedures.

CONCLUSIONS

DFU affects almost one-tenth of diabetics while a significant number of patients attend at late stage requiring orthopedic treatment. Monitoring of diabetic patients to prevent DFU is important is recommended.

Topical Turmeric Ointment in the Treatment of Diabetic Foot Ulcers: A Randomized, Placebo-Controlled Study

Diabetic foot is a serious complication of diabetes which has significant medical and socioeconomic impacts. Turmeric is a popular Indian spice that has been used for centuries in herbal medicines for the treatment of a variety of ailments such as rheumatism, diabetic ulcers, anorexia, cough and sinusitis. Curcumin is the main ingredient presents in turmeric and responsible for its yellow color. We report here a randomized, placebo-controlled investigation into the effectiveness of topical turmeric ointment in the treatment of diabetic foot ulcers. Seventy-six patients enrolled in the study. They were randomly divided into two groups, one of which received topical turmeric ointment and the other received placebo. Preparations were applied twice daily after irrigation of the wound by normal saline and dressed. Image analysis software was used to evaluate photographs of the ulcers and quantify the difference between treatment and placebo groups. Topical turmeric ointment demonstrated statistically significant reduction (p < .001) in the size of diabetic ulcers at five weeks compared to placebo, independently of fasting blood sugar and HbA1C levels. Turmeric ointment may be an effective treatment for diabetic foot ulcers.

Surgical Outcomes of Regional Versus General Anesthesia in 203 Patients with Upper- and Lower-Extremity Amputation: A Retrospective Study from a Single Center in Turkey

BACKGROUND This retrospective study from a single center in Turkey aimed to compare the surgical results of regional anesthesia and general anesthesia in 203 patients with upper- and lower-extremity amputations. MATERIAL AND METHODS The study population consisted of patients who underwent extremity amputation between 2017 and 2021. Patients' demographic data, comorbidities, American Society of Anesthesiology (ASA) scores, amputated extremities, causes and extents of amputations, length of hospital stay, associated mortality/morbidity, and postoperative 90-day mortality data were comparatively analyzed between the groups created according to the anesthesia methods used in amputations. RESULTS The study consisted of 203 patients, of whom 80.8% were male. The most commonly used anesthesia method was peripheral nerve blocks (32.5%), followed by spinal anesthesia (31.5%), general anesthesia (31.0%), epidural anesthesia (2.0%), combined spinal-epidural anesthesia (1.5%), and sedo-analgesia (1.5%). Of the amputations performed, 37.0% were upper-extremity and 63.0% were lower-extremity. Peripheral nerve blocks were used most frequently in upper-extremity amputations (71.5%), and spinal anesthesia was used most frequently in lower-extremity amputations (48.9%). The mean length of hospital stay of the patients who underwent surgery under regional anesthesia methods was shorter than that of those who underwent general anesthesia (8.7±7.4 days vs 15.0±20.6 days). The mortality rate was 0.5% in the first 24 h, 0.5% in the next 48 h, and 4.9% in total. CONCLUSIONS The study findings demonstrated that performing extremity amputations under regional anesthesia techniques, particularly peripheral nerve blocks, reduces mortality/morbidity, the need for postoperative intensive care, mean length of stay in hospital, and hospital costs.

Evaluation of Risk Factors for Diabetic Peripheral Neuropathy Among Saudi Type 2 Diabetic Patients with Longer Duration of Diabetes

BACKGROUND

Neuropathy is the most common microvascular complications among diabetic patients. Diabetic peripheral neuropathy (DPN) is the predominant variety which may associate with increased in mortality and morbidity among type 2 diabetes mellitus (T2DM).

OBJECTIVE

To assess the prevalence of diabetic peripheral neuropathy and its correlation with risk factors among T2DM.

METHODS

This was a cross-sectional retrospective study, data was collected from a previous cohort study conducted at the University Diabetes Center, King Saud University Medical City (KSUMC), King Saud University, Riyadh, Saudi Arabia. The data of T2DM patients were collected from case report form, included demographic data, history of chronic diabetes neuropathy, and laboratory reports. Statistical analysis includes Student`s t test, chi square test, and Pearson correlation and logistic regression were performed.

RESULTS

A total of 430 patients with T2DM data was collected and analyzed, and of them 54% were females, with the mean age of 55.88 years. The prevalence of diabetic neuropathy among study participants were 40.2%, and 73.3% of them having the subtype polyneuropathy. The mean BMI; p = 0.006, FBS; p < 0.001, HbA1c; p < 0.001, cholesterol p = 0.001, LDL; p < 0.001, and triglyceride; p < 0.001 levels were a significantly higher among participants with diabetic neuropathy than without neuropathy. The male gender (Risk Ratio: 1.294, 95% CI:1.090, 1.536) p = 0.003, fasting blood glucose (Risk Ratio: 1.157, 95% CI:1.051, 1.273) p = 0.003 Cholesterol (Risk Ratio: 1.588, 95% CI:1.174, 2.147) p = 0.003, triglyceride (Risk Ratio: 1.290, 95% CI:1.086, 1.538), p = 0.004, and LDL (Risk Ratio: 1.299, 95% CI:1.073, 1.574), p = 0.007) were found to be significant risk factors for DPN.

CONCLUSION

DPN is highly prevalent among T2DM patients in Saudi Arabia. Poor glycemic control and hyperlipidemia were associated with significantly higher risk for DPN patients among T2DM.

Diabetes mellitus foot ulcer and associated factors among Type 2 diabetes patients in a Tertiary Institution in Southwest Nigeria

Aim

This study aims to assess the proportion of diabetic foot ulcer (DMFU) and associated factors among patients with type 2 diabetes in a tertiary hospital in Southwest Nigeria.

Methods

A pretested semi-structured interviewer-administered questionnaire adapted from the STEPwise Approach to Surveillance of Noncommunicable Disease Risk Factors of WHO.14 was used for data collection from a sample of 181 patients with type 2 diabetes mellitus. Sociodemographic, behavioral, clinical, and laboratory variables were collated from the participants. Chi-square test and logistic regression were used to identify the predictors of DMFU.

Results

A total of 166 patients had their questionnaires completed. The mean age (standard deviation) of the respondents was 62.6 (14.3) years. The proportion of DMFU was 18.7%. More than two-third (71.1%) of our respondents had clinical symptoms suggestive of peripheral neuropathy while 34.3% of the patients seen in the study had evidence of peripheral vascular disease on duplex Doppler ultrasound. Male patients were about five times more likely to have DMFU than female patients (adjusted odds ratio [AOR] =5.27; 95% confidence interval [CI] = 1.001-27.841). Those with duration of diabetes ≥10 years were more likely to have DMFU than those with disease duration <10 years (AOR = 15.47; 95% CI = 1.201-199.314). Patients with fasting blood glucose (FBG) of ≥ 7.2 mmol/L were about four times more likely to have DMFU than those with FBG of <7.2 mmol/L (AOR = 4.19; 95% CI = 1.618-18.463).

Conclusions

The proportion of DMFU was 18.7%, and the predictors identified included sex, duration of disease, and FBG level.

"Loss of a limb is not loss of a life". Knowledge and attitude on diabetic foot ulcer care and associated factors among diabetic mellitus patients on chronic care follow-up of southwestern Ethiopian hospitals: A multicenter cross-sectional study

BACKGROUND

Diabetic foot ulcer (DFU) is a full-thickness wound penetrating through the dermis located below the ankle in a diabetes patient. The incidence of diabetic foot ulcers has increased due to the worldwide prevalence of diabetic mellitus (DM) and the poor knowledge and attitude of diabetic foot self-care. Therefore, the study was aimed to assess the knowledge and attitude on diabetic foot ulcers and associated factors among diabetic mellitus patients of southwestern Ethiopian hospitals.

METHODS

A multicenter cross-sectional study design was used. All diabetic patients fulfilling the inclusion criteria and treated as outpatient in the study period from August 9, 2021 to September 5, 2021 G was interviewed through a semi-structured questionnaire at Bedele General Hospital and Mettu Karl Comprehensive Specialized Hospital. Data was analyzed using a statistical package for social science (SPSS 23 version).

RESULT

Out of 387 diabetic patients, 234(60.5) were male and 266(68.7%) were married. The mean age of the participants was 41.73(SD ± 15.637) years and the majority 87(22.5) of the patients age were greater than 55 years. A total of 11(28.7%) patients had a diabetes mellitus duration between 5 and 10 years and more than half 213(55%) of the patients had a co-morbidity. Regarding the diabetic foot care, a total of 180(46.5%) and 257(66.4%) of the patients had good knowledge and attitude, respectively. Educational level(AOR = 2.705(1.380-5.299), P = 0.004) and age[AOR = 1.254(0.768-2.048), P = 0.017] were the predictors of knowledge. Monthly income (AOR = 2.879(1.043-7.944), P = 0.041), educational level (AOR = 2.415(1.121-5.20), P = 0.024), previous information (AOR = 4.022(2.311-7.000), P < 0.001) and previous history of foot ulcers (AOR = 1.976(1.126-3.466), P = 0.018) were factors associated with the attitude of diabetic foot ulcer.

CONCLUSION

More than half of the study participants had poor knowledge while the majority of them had a good attitude. Educational level and age were significantly associated with knowledge. Monthly income, educational level, previous information, and previous history of foot ulcers were predictors of attitude towards diabetic foot care. Therefore, the health care providers should provide diabetic foot care education to reduce further complications of foot ulcers. Besides this, special attention should be given to patients who developed diabetic foot ulcers and have low socio-economic status.

Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review

Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.

Lipoprotein Ratios: A Potential Biomarker for Clinical Diagnosis of Atherosclerosis in Type 1 Diabetic Patients With Foot Ulceration

Background Lipoprotein ratios are indicators of atherosclerosis and related diseases such as cardiovascular diseases (CVDs). Early and accurate diagnosis of atherosclerotic disease in patients with diabetic foot ulceration (DFU) is required urgently and remains fundamental to assess the risk of CVDs. This study aimed to determine whether lipoprotein ratios can predict atherosclerosis in type 1 diabetic patients with DFU. Methodology This was a cross-sectional study including 255 patients with confirmed type 1 diabetes with a male-to-female ratio of 1.19. Patients admitted to the hospital due to diabetes-related complications were divided into the following groups: patients without DFU (n = 153) and patients with DFU (n = 102). Clinical, biological, and pathophysiological features of patients were compared. Results Our study reported a distinct predominance of males (54.50%), with a mean age of 28.64 ± 10.92 years and duration of diabetes of 10.40 ± 9.25 years. The prevalence of DFU was 40.0%. The receiver operator characteristic curve was applied to define the best cut-off lipid ratios to detect atherosclerosis. Total cholesterol (TC)/high-density lipoprotein (HDL) ratio was a valid marker for atherosclerosis with a sensitivity of 86.3%, specificity of 71.4%, and diagnostic accuracy of 0.836%. The findings showed that the fourth quartiles (odds ratio [OR] = 83.02 [22.18-310.75]; p = <10^-3) of TC/HDL ratio was significantly higher in patients with DFU. Similarly, the last quartiles (fourth) of low-density lipoprotein (LDL)/HDL and triglyceride (TG)/HDL ratio were higher in DFU group (OR = 33.71 [12.04-94.38], p = <10^-3; OR = 9.60 [4.27-21.58], p = <10^-3; respectively). In the DFU group, conventional lipid profiles and lipid ratios were markedly higher in males compared to females patients (TG = 1.31 ± 0.69 g/L vs. 1.04 ± 0.84 g/L, p = 0.04; respectively; TC/HDL = 4.79 ± 1.04 vs. 4.22 ± 0.98, p = 0.03; respectively; LDL/HDL = 2.91 ± 1.13 vs. 2.17 ± 1.28, p = 0.01; respectively; TG/HDL = 3.65 ± 2.53 vs. 2.67 ± 1.94, p = 0.008; respectively). Conclusions Elevated atherogenic indices were significantly associated with the atherosclerotic load in patients with DFU, supporting the use of lipid ratios as a biomarker for the diagnosis of atherosclerosis disease in clinical practice in the future.

Development and Pilot Testing of a Diabetes Foot Care and Complications Questionnaire for Adults with Diabetes in Oman: The Diabetic Foot Disease and Foot Care Questionnaire

Objectives

Diabetic foot disease causes substantial morbidity and mortality, but it can be prevented. Our study examined the frequency of diabetes-related foot problems and foot self-care practices, as reported by consecutive patients attending primary and secondary diabetes services in Muscat, Oman.

Methods

A cross-sectional survey utilizing a newly developed and pre-tested questionnaire was conducted at eight primary health care centers and one polyclinic (secondary care) in A'Seeb, Muscat. A convenience sample of 353 consecutive Omanis, aged 20 years and above, diagnosed with diabetes were invited to participate in this study. We collected data on clinico-demographic characteristics, patient-reported foot complications, and foot self-care practices.

Results

Of the 350 patients who agreed to participate (mean diabetes duration 7.9±7.4 years, response rate: 99.2%), 62.3% were female, 57.4% were unemployed, more than half were illiterate (52.9%), and around three-quarters (71.4%) were unsure of the type of diabetes they had. More than half (55.1%) reported having at least one or more sensory peripheral neuropathy symptoms, almost half (49.1%) reported one or more peripheral vascular disease symptoms in the previous month, and 12.5% a history of foot ulceration. Reported foot self-care practices were overall suboptimal; 54.7% did not examine the bottom of their feet each day.

Conclusions

Although self-reported diabetes-related foot complications were common in this population, foot self-care practices were inadequate. These findings suggest a need for the provision of regular foot care education to patients with diabetes. Future research should explore barriers to recommended foot self-care practices.

Risk factors affecting amputation in diabetic foot

Background

A diabetic foot is the most common cause of non-traumatic lower extremity amputations (LEA). The study seeks to assess the risk factors of amputation in patients with diabetic foot ulcers (DFU).

Methods

The study was conducted on 351 patients with DFUs from January 2010 to December 2018. Their demographic characteristics, disease history, laboratory data, ankle-brachial index, Wagner classification, osteomyelitis, sarcopenia index, and ulcer sizes were considered as variables to predict outcome. A chi-square test and multivariate logistic regression analysis were performed to test the relationship of the data gathered. Additionally, the subjects were divided into two groups based on their amputation surgery.

Results

Out of the 351 subjects, 170 required LEA. The mean age of the subjects was 61 years and the mean duration of diabetes was 15 years; there was no significant difference between the two groups in terms of these averages. Osteomyelitis (hazard ratio [HR], 6.164; 95% confidence interval [CI], 3.561−10.671), lesion on percutaneous transluminal angioplasty (HR, 2.494; 95% CI, 1.087−5.721), estimated glomerular filtration rate (eGFR; HR, 0.99; 95% CI, 0.981−0.999), ulcer size (HR, 1.247; 95% CI, 1.107−1.405), and forefoot ulcer location (HR, 2.475; 95% CI, 0.224−0.73) were associated with risk of amputation.

Conclusion

Osteomyelitis, peripheral artery disease, chronic kidney disease, ulcer size, and forefoot ulcer location were risk factors for amputation in diabetic foot patients. Further investigation would contribute to the establishment of a diabetic foot risk stratification system for Koreans, allowing for optimal individualized treatment.

Determinants of Diabetic Complication Among Adult Diabetic Patients in Debre Markos Referral Hospital, Northwest Ethiopia, 2018: Unmatched Case Control Study

BACKGROUND

Diabetes mellitus is a group of common metabolic disorders that share the phenotype of hyperglycemia, and are caused by a complex interaction of genetics and environmental factors. Diabetes mellitus produces change in the blood vessels and therefore affects almost every part of the body.

METHODS

A hospital-based unmatched case control study was conducted from February 2018 to April 2018 at Debre Markos Referral Hospital. Data were collected from 204 individuals, 136 controls and 68 cases using an interviewer-administered questionnaire and patient chart. Data were entered into EPI-data 3.1 software and exported to SPSS version 21 for analysis. Descriptive analysis including mean, median and proportions was carried out. In bivariate analysis, variables below 0.25 significance level were selected for multivariable analysis. For multivariable analysis, a backward model was selected and 95% confidence interval variables with P-values below 0.05 in multivariable analysis were declared as significant variables.

RESULTS

Of the total respondents, 68 were cases and 136 were controls, with an overall response rate of 98.55%. Of these respondents, 57.4% and 57.8% were males and type 1 diabetic patients, respectively. This study found that ages of 38-47 (AOR= 5.60 (1.62-19.38)) and >47 (AOR=4.81 (1.32-17.5)), income of 1000-1499 (AOR=3.10 (1.05-9.08)), self-reported drug adherence (AOR=5.146 (1.651-16.04)), FBS of 70-130 mg/dL 0.095 (0.022-0.414) and ≥131 mg/dL (0.05 (0.011-0.223)) and type 1 diabetic mellitus (AOR=4.73 (1.765-12.72)) were significantly associated with diabetes mellitus complications.

CONCLUSION AND RECOMMENDATIONS

The study identified important determinants of diabetic complications. Poor glycemic control, poor adherence, and income were found to be modifiable determinants; on the other hand, age and type of diabetic mellitus are non-modifiable determinants of diabetic complications. Clinicians should implement a comprehensive care plan that will address patients' adherence and glycemic control problems.

Treatment destinations and visit frequencies for patients seeking medical treatment overseas from the United Arab Emirates: results from Dubai Health Authority reporting during 2009-2016

BACKGROUND

Each year, the Dubai Health Authority (DHA) spends millions of dollars to cover the costs of United Arab Emirates (UAE) nationals seeking healthcare overseas. Patients may travel overseas to seek an array of treatments. It is important to analyze the number of trips and treatment destinations for patients travelling overseas to provide baseline information for the DHA to improve polices and strategies related to overseas treatment for UAE nationals.

METHODS

Administrative data were obtained from the DHA for UAE nationals who sought medical treatment overseas during 2009-2016. We examined the number of trips and treatment destinations by medical specialty, age, gender, years of travel and travel seasons. Multinomial logistic and negative binomial regression models were used to assess the relationships of the treatment destinations and number of trips, respectively, with the key variables of interest.

RESULTS

The study included data from 6557 UAE nationals. The top three treatment destinations were Germany (46%), the UK (19%) and Thailand (14%). The most common medical specialties were orthopedic surgery (13%), oncology (13%) and neurosurgery (10%). Oncology had the highest expected number of trips adjusted for a number of covariates (IRR 1.34, 95% CI: 1.24-1.44). Regarding destination variation, patients had a lower relative risk ratio of seeking healthcare in Germany in the winter (RRR 0.68, 95% CI: 0.57-0.80). Endocrinology was the most common medical specialty sought in the UK (RRR 3.36, 95% CI: 2.01-5.60).

CONCLUSIONS

This is the first study to systematically examine the current practice of medical treatment overseas among UAE nationals. The results demonstrate that treatment destinations, medical specialties for which treatment was sought, age, gender and travel season are significant factors in understanding overseas travel for medical care. The study can guide the DHA in collecting more data for further research that may lead to policy-relevant information about sending patients to the best-quality treatment choices at an optimal cost.

Prevalence of Foot Complications in People With Type 2 Diabetes Mellitus: A Community-Based Survey in Rural Udupi

The objective of the study was to determine the prevalence of foot complications among people with type 2 diabetes mellitus in the rural part of Udupi district, Karnataka, India. A cross-sectional observational study design was conducted in the rural area of Udupi district. In the study, accredited social health activists were trained to screen people with type 2 diabetes mellitus for diabetic foot complications at a community level. Adults over 35 years of age were screened for the presence of type 2 diabetes mellitus by accredited social health activists who reside in the rural part of Udupi district. Participants with type 2 diabetes mellitus were included in the study. Blood glucose level was measured using a glucometer. Foot examination was done by visual inspection, monofilament, tuning fork, and pedal pulse. In the present study, 2110 among the total participants were found to have type 2 diabetes mellitus. The prevalence of musculoskeletal foot complications was 1218 (58%), vascular problem 466 (22.2%), sensory neuropathy 634 (30.2%), autonomic neuropathy 1729 (81.9%), ulcer 134 (6.38%), and infection 561 (26.7%) among people with type 2 diabetes mellitus. In the current study, we found 84.7% of people residing in rural Udupi had type 2 diabetes mellitus. Hence, there is a strong need to create awareness about diabetic foot care in these people.

Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan

BACKGROUND

Diabetic foot ulceration is a serious limb-threatening complication of diabetes. It is the common cause of hospital admissions and amputations. The objective of the study was to determine the prevalence of diabetic foot ulcers (DFU) and its association with age, gender, duration of diabetes, peripheral neuropathy (PN), peripheral arterial disease (PAD) and HbA1c.

METHODS

A total of 1940 people (≥ 30 years of age) with type 2 diabetes coming to the Sakina Institute of Diabetes and Endocrine Research (specialist diabetes clinic) at Shalamar Hospital, Lahore, Pakistan, were recruited over a period of 1 year from January 2016 to January 2017. The foot ulcers were identified according to the University of Texas classification. PN was assessed by biothesiometer and PAD by ankle-brachial index (< 0.9). Body weight, height, body mass index (BMI), HbA1c and duration of diabetes were recorded.

RESULTS

The prevalence of DFU was 7.02%, of which 4.5% of the ulcers were on the planter and 2.6% on the dorsal surface of the foot; 8.5% of the persons had bilateral foot ulcers and 0.4% subjects had Charcot deformity. There was significant association of foot ulcers with age, duration of diabetes, HbA1c, PN and PAD, whereas no association was observed with gender and BMI. PN and PAD were observed in 26.3 and 6.68% of people with diabetes respectively. Neuropathic ulcers and neuro-ischemic ulcers were identified in 74 and 19% of the study population. Logistic regression analysis revealed significant odds ratio for peripheral neuropathy 23.9 (95% confidence interval (5.41-105.6).

CONCLUSIONS

Peripheral neuropathy is the commonest cause of foot ulcers. An optimum control of blood glucose to prevent neuropathy and regular feet examination of every person with diabetes may go a long way in preventing foot ulceration.

Aesthetic Surgical Procedures in Men: Major Complications and Associated Risk Factors

BACKGROUND

The number of men undergoing cosmetic surgery is increasing in North America.

OBJECTIVES

To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures.

RESULTS

Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56).

CONCLUSIONS

Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures.

LEVEL OF EVIDENCE 2

Descriptive study on the knowledge, attitudes and practices regarding the diabetic foot

OBJECTIVES

The aim of this study is to assess the knowledge, attitudes, practices and risk factors influencing diabetic foot ulcers among diabetes patients attending a diabetic clinic in a Saudi hospital.

METHODS

In this cross-sectional study, a random sample of 229 participants was selected from the diabetic clinic of the outpatient department of King Fahd Hospital of the University of Dammam during January to March 2015. A pre-tested structured questionnaire was administered to the diabetes patients to obtain information regarding the outcome variables.

RESULTS

The results showed that diabetic foot ulcers were observed among 26% of diabetic patients. Concerning knowledge of the diabetic foot, the majority of participants had good education and favourable attitudes towards diabetic foot care. Interestingly, the results demonstrated that despite these characteristics, a high percentage of the participants ignored very important information and instructions before buying new shoes.

CONCLUSION

All diabetic patients with diabetes mellitus should be educated regarding diabetic foot complications and the characteristic specifications of diabetic shoes. However, levels of knowledge, attitudes and practices should be improved. This improvement could be achieved by an awareness programme for the early detection and care of diabetic foot problems in KSA.

Outcomes Achieved With Use of a Prefabricated Roll-On Total Contact Cast

BACKGROUND

The total contact cast (TCC) is considered the gold standard for offloading of plantar diabetic foot ulcerations, yet its use remains suboptimal for a variety of reasons. Prefabricated TCC systems have been developed to help enhance TCC use. The primary objective of this study was to determine if healing rates obtained with use of a prefabricated roll-on TCC were similar to those reported with conventional TCC use. Secondary outcomes measured were the incidence of iatrogenic ulceration, amputation, and recurrent ulceration, and patient tolerance of the device.

METHODS

A retrospective chart review was performed on all patients in whom TCC was used for treatment of an ulceration at our institution from April 2013 to December 2016. Seventy patients (132 ulcerations) were identified.

RESULTS

An 85.6% healing rate was achieved. Five subjects (7.1%) sustained 11 iatrogenic ulcerations. All resolved with local treatment and continued casting. Thirteen subjects (18.6%) underwent amputation. No amputation occurred because of TCC application technique or use. Fifteen ulcerations (12 subjects, 17.1%) recurred. Greater than 70% resolved with re-initiation of TCC use. Forty-three subjects (61.4%) tolerated use of the prefabricated roll-on TCC.

CONCLUSION

Similar healing rates and reduced rates of iatrogenic ulceration, amputation, and recurrent ulceration were attained with use of a prefabricated roll-on TCC. These results, good patient tolerance, and the reduced administrative and clinical time related to supply acquisition, training, and proper application supports use of this device as a viable alternative to a conventional TCC for treatment of plantar neuropathic foot ulcerations.

LEVEL OF EVIDENCE

Level IV, case series.

Prevalence of Diabetic Foot Ulcer and Associated Factors among Adult Diabetic Patients Who Attend the Diabetic Follow-Up Clinic at the University of Gondar Referral Hospital, North West Ethiopia, 2016: Institutional-Based Cross-Sectional Study

Diabetes mellitus is a metabolic disorder which is characterized by multiple long-term complications that affect almost every system in the body. Foot ulcers are one of the main complications of diabetes mellitus. However, there is limited evidence on the occurrence of foot ulcer and influencing factors in Ethiopia. An institutional-based cross-sectional study was conducted in Gondar University Hospital, Ethiopia, to investigate foot ulcer occurrence in diabetic patients. Systematic random sampling was used to select 279 study participants. Bivariate and multivariable logistic regression model was fitted to identify factors associated with diabetic foot ulcer. Odds ratio with 95% confidence interval was computed to determine the level of significance. Diabetic foot ulcer was found to be 13.6%. Rural residence [AOR = 2.57; 95% CI: 1.42, 5.93], type II diabetes mellitus [AOR = 2.58; 95% CI: 1.22, 6.45], overweight [AOR = 2.12; 95% CI: 1.15, 3.10], obesity [AOR = 2.65; 95% CI: 1.25, 5.83], poor foot self-care practice [AOR = 2.52; 95% CI: 1.21, 6.53], and neuropathy [AOR = 21.76; 95% CI: 8.43, 57.47] were factors associated with diabetic foot ulcer. Diabetic foot ulcer was found to be high. Provision of special emphasis for rural residence, decreasing excessive weight gain, managing neuropathy, and promoting foot self-care practice would decrease diabetic foot ulcer.

Risk factors for occurrence and recurrence of diabetic foot ulcers among Iraqi diabetic patients

There are a few studies that discuss the medical causes for diabetic foot (DF) ulcerations in Iraq, one of them in Wasit province. The aim of our study was to analyze the medical, therapeutic, and patient risk factors for developing DF ulcerations among diabetic patients in Baghdad, Iraq.

Clinical profile and surgical management of diabetic foot in Benghazi, Libya

BACKGROUND

The aim of this study was to outline the patterns and management of diabetic foot ulcer (DFU) and compare our experience with other published data.

PATIENTS AND METHODS

All consecutive patients admitted to Al-Jala Hospital with diabetic foot from June, 2008 to May, 2013 were reviewed retrospectively.

RESULTS

A total of 542 patients were studied, Wagner's grade III ulcers were the most prevalent (31%), followed by grade II (25%). About 10% of patients underwent major amputations and 24.2% underwent minor amputations. The amputation rate was 34%, and the mortality rate was 2%.

CONCLUSION

Diabetic foot infections cause significant morbidity and mortality among patients with diabetes in Benghazi. There is a need to establish a diabetic foot clinic in Benghazi with a multidisciplinary team to reduce the rates of hospital admission and amputation, as well as hospital stay duration.

DiabCare survey of diabetes management and complications in the Gulf countries

AIM

To describe the status of diabetes control and complications, and the quality of diabetes management in Saudi Arabia, Kuwait, and the United Arab Emirates, and to obtain an insight into the relationship between these factors.

METHODS

Patients with diabetes for>12 months were enrolled from specialist clinics and general hospitals. All available data from the patients' medical files including patient demographics; glycemic, lipid, and blood pressure status; diabetes-related complications; and diabetes management were recorded in data collection forms and analyzed.

RESULTS

Overall, 1290 patients with diabetes were enrolled with a mean (±standard deviation) age of 49.4 ± 12.3 years and duration of diabetes of 8.7 ± 5.9 years. Glycemic control was poor: Mean glycated hemoglobin A1c of 8.3 ± 2.0%, fasting and postprandial plasma glucose levels of 155.9 ± 57.1 mg/dL (8.7 ± 3.2 mmol/L), and 218.2 ± 87.4 mg/dL (12.1 ± 4.9 mmol/L), respectively. Diabetes-related complications such as neuropathy (34.9% of patients), background retinopathy (29.9%), and cataract (14.1%) were common. Cardiovascular complications were reported in <10% of patients, and microalbuminuria was detected in 34.4% of patients. Oral antidiabetic drug (OAD) monotherapy (43.3%) was the most common treatment, followed by insulin + OADs (39.3%) and insulin monotherapy (17.6%).

CONCLUSION

The status of diabetes care was found to be suboptimal. Further improvements in diabetes management are necessary to prevent or delay the development of diabetes-related complications.

Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection

The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.

Illiteracy and diabetic foot complications

BACKGROUND

Diabetes is especially common in the United Arab Emirates. Its complications in patients residing in the region have yet to be fully explored. This study reports on foot problems in our diabetic patients, with emphasis on the impact of illiteracy on foot care and complications due to diabetes.

METHODS

Adults were randomly recruited from the Diabetes Center at Tawam-John Hopkins affiliated hospital. A questionnaire addressing foot care and problems was completed for all patients. In addition, an examination was performed by a trained nurse, an endocrinologist, and a podiatrist.

RESULTS

Four hundred twenty-two adults with type 2 (93%) or type 1 (7%) diabetes were enrolled; 67% were females. Patients' mean age was 52 ± 13 years and duration of diabetes ≥ 1 year. Illiterate patients were 51% and were less likely to practice foot care (p=0.002), recognize foot risk factors (p=0.004), use proper footwear (p=0.010), and being physically active (p<0.001). In addition, they were more likely to have diabetic complications, such as neuropathy (p=0.027), eye disease (p=0.032), hypertension (p<0.001), obesity (p=0.003), increased body fat percentage (p<0.001), reduced capillary refill time (p=0.002), reduced monofilament (p=0.003), and reduced vibration (p<0.001). Logistic regression analysis revealed literates [OR=2.4, CI=1.1-5.4, p=0.031], female gender [OR=2.7, CI=1.1-6.2, p=0.023], and history of foot ulcer [OR=6.0, CI=2.1-17.2, p=0.001] were predictors of practicing foot care.

CONCLUSION

Illiteracy invoked significant challenges to diabetic attentiveness and imposed increased foot complications. Physicians should realize that illiterate patients are vulnerable and require effective strategies to improve their education about the disease and reduce their diabetic complications.

Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice

INTRODUCTION

Diabetes mellitus is a global health problem with rising prevalence worldwide. Diabetes mellitus is a multisystem disease affects many systems and tissues. Foot problems are not uncommon with diabetes and foot ulceration is one of theses problems. Risk factors for foot ulcerations may differ from community to community based on many factors.

OBJECTIVES

To determine the risk factors for diabetic foot ulceration among Saudi diabetic patients with type 2 diabetes attending primary care center.

METHODOLOGY

Cross sectional study was designed. Four hundred subjects were selected randomly. Inclusion criteria were settled. Three hundred and fifty subjects (350) were participated. Especial assessment form was designed. Data was collected and analyzed using SPPS ver 14.

RESULTS

Three hundred and fifty subjects were participated (57% male and 43% female). The prevalence of peripheral vascular disease was 15%, hulux vulgus 22.5%, inappropriate foot wear 41%, peripheral neuropathy 47.5%. Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration.

CONCLUSION

Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration.

Prevalence of diabetic foot disorders and related risk factors among Egyptian subjects with diabetes

INTRODUCTION

Multiple pathologies including diabetic neuropathy, peripheral vascular disease (PVD) and infection contribute to lower extremities amputation in diabetes.

AIM

We examined the prevalence of diabetic foot problems and related risk factors in Egypt.

SUBJECTS AND METHODS

Between July 2008 and December 2009, 1000 male and 1000 female consecutive adult patients with diabetes (≥ 18-year-old) attending the Alexandria University Diabetic Foot Screening Clinic were surveyed for history/presence of foot ulcers and/or amputations, skin/nail changes, joint mobility, sensory neuropathy (10 g-Semmes-Weinstein Monofilament) and peripheral vascular disease (PVD) using Ankle Brachial Index (ABI).

RESULTS

The majority of patients had type 2 diabetes (96.75%) with a mean age of 57.30 ± 10.47 years and a mean disease duration of 11.76 ± 8.26 years. The mean body mass index was 32.84 ± 6.31 kg/m(2) with 29.55% being current or ex-smokers. In these subjects, 4.4% had a past history of non-traumatic amputation (male:female: 6.2% vs. 2.6%, p < 0.001); 6.1% had past history (10.3% vs. 7%, p = 0.009) and 8.7% had active foot ulceration (8.1% vs. 4.1% p < 0.001) with a male preponderance. The prevalence of sensory neuropathy was 29.3% (M:F: 30.7%: 27.9%) and peripheral vascular disease (PVD) was 11% (M:F 11.8%:10.2%). Diabetic foot complications were associated with disease duration (p < 0.001), history of coronary artery disease (p = 0.001), stroke (p = 0.009), PVD (p < 0.001), laser photocoagulation (p < 0.001), sensory neuropathy (p < 0.001) and renal replacement therapy (p < 0.001). On multivariate analysis, diabetes duration, foot fissures, Charcot's foot, limited joint mobility, PVD and sensory neuropathy remained independently associated with diabetic foot disorders.

CONCLUSION

In Egypt, a mosaic of risk factors contributes to the high prevalence of diabetic foot disease in type 2 diabetes. These findings call for regular assessment of vascular, neuropathic and skin status to prevent these serious foot complications.

Noncontrast MRA of pedal arteries in type II diabetes: effect of disease load on vessel visibility

RATIONALE AND OBJECTIVES

Noncontrast magnetic resonance angiography (NC-MRA) of pedal artery remains challenging because of the global and regional disease load, tissue integrity, and altered microcirculation. This study aims to investigate the feasibility of the NC-MRA of pedal arteries with flow-sensitive dephasing-prepared steady-state free precession (FSD-SSFP) and to explore the effect of disease load of type II diabetes on the vessel depiction.

MATERIALS AND METHODS

FSD-SSFP was performed on a 1.5-T magnetic resonance system before the contrast-enhanced MRA (CE-MRA) as a reference standard in 39 consecutive diabetic subjects (29 men and 16 women, aged 57.9 ± 11.4 years). Two experienced radiologists evaluated the overall artery visibility (VA) and the contamination from soft tissue (SC) and veins (VC) with a four-point scale. Chronic complications and measures including random blood glucose (RBG), lipid panel, body mass index, risk of diabetic foot ulcers (RDF), and glycated hemoglobin (HbA1c) by the imaging were recorded as disease load indicators. Spearman rank correlation and ordinal regression were performed to investigate the effect of disease load on the depiction of pedal arteries.

RESULTS

The measurement of RBG and RDF were significantly correlated with the VC in CE-MRA and with the overall visibility of pedal arteries in NC-MRA (P < .025 and P < .001, respectively). Blood pressure was the only parameter that was significantly associated with SC in NC-MRA with FSD-SSFP (P < .025). For CE-MRA the effect of RDF on the overall VA manifested a significant linear trend (P < .001), and the level of RBG was substantially associated with the VC (P < .025) without significantly impacting VA and SC. Hypertension only correlated with SC in NC-MRA. VA was found independent of the presence of diabetic nephropathy, coronary artery disease, abnormal lipid panel, HbA1c (75.0%), or optimized m1 value that ranged from 70 to 160 mT⋅ms(2)/m (mean, 125 ± 18 mT⋅ms(2)/m) in this study.

CONCLUSIONS

FSD-SSFP proved to be a useful modality of NC-MRA for pedal artery imaging in diabetic patients. The vessel depiction is subject to the local and systemic disease load of type II diabetes. Technical optimization of the flow-sensitive dephasing gradient moment and properly choosing candidate would help augment the potential of this technique in patient care of peripheral artery disease.

Balance and ankle muscle strength predict spatiotemporal gait parameters in individuals with diabetic peripheral neuropathy

AIMS

The aims of this study were to evaluate aspects of balance, ankle muscle strength and spatiotemporal gait parameters in individuals with diabetic peripheral neuropathy (DPN) and verify whether deficits in spatiotemporal gait parameters were associated with ankle muscle strength and balance performance.

MATERIALS AND METHODS

Thirty individuals with DPN and 30 control individuals have participated. Spatiotemporal gait parameters were evaluated by measuring the time to walk a set distance during self-selected and maximal walking speeds. Functional mobility and balance performance were assessed using the Functional Reach and the Time Up and Go tests. Ankle isometric muscle strength was assessed with a handheld digital dynamometer. Analyses of variance were employed to verify possible differences between groups and conditions. Multiple linear regression analysis was employed to uncover possible predictors of gait deficits.

RESULTS

Gait spatiotemporal, functional mobility, balance performance and ankle muscle strength were affected in individuals with DPN. The Time Up and Go test performance and ankle muscle isometric strength were associated to spatiotemporal gait changes, especially during maximal walking speed condition.

CONCLUSION

Functional mobility and balance performance are damaged in DPN and balance performance and ankle muscle strength can be used to predict spatiotemporal gait parameters in individuals with DPN.

Prevalence of risk factors for diabetic foot complications in a Chinese tertiary hospital

AIMS

To determine the prevalency of risk factors for diabetic foot complications in diabetic patients free of active ulceration in a hospital setting and to investigate the knowledge of foot care of the patients.

METHODS

A retrospective study was conducted on a cohort of 296 patients with diabetes hospitalized in a tertiary hospital. A convenience sampling was adopted to recruit subjects during 2012/2013. All completed an interviewer-administered questionnaire and underwent medical assessment including foot examination and assessment of presence of peripheral sensory neuropathy (PSN) and peripheral arterial disease (PVD). The patients were assigned to a foot risk category which was developed by the International Working Group on the Diabetic Foot (IWGDF).

RESULTS

296 inpatients were evaluated. Foot deformity was noticed in 124 patients (42%), hallux valgus was the most prevalent abnormality, found in 65% of patients. Prevalency of neuropathy hypertension, nephropathy and retinopathy were 66.2%, 57.1%, 48.3% and 44.9% respectively. 37 (12.5%) patients had a history of ulceration (n = 33) and/or toe amputation (n = 4). According to the classification system of the IWGDF, 35.1% of patients were considered as having low-risk by the modified IWGDF classification (group 0), and 49% of the study population were at high risk for pedal ulceration (group 2 and 3). There was a clear trend between the increasing severity of the staging and HbA1c, duration of diabetes, prevalence of hypertension, nephropathy and retinopathy and absent of physical activity. The mean knowledge score of foot care was 21.21±3.84.

CONCLUSION

The risk factors for foot ulceration and lack of fool care knowledge was rather common in a hospital-based diabetic population, emphasizing the importance of implementing simple and affordable screening tools and methods to identify high-risk patients and providing foot care education for them.

Diabetic foot risk factors in type 2 diabetes patients: a cross-sectional case control study

Background

Diabetic foot is a serious condition in patients with a long lasting diabetes mellitus. Diabetic foot treated improperly may lead not only to delayed ulceration healing, generalized inflammation, unnecessary surgical intervention, but also to the lower limb amputation. The aim of this study was to compare diabetic foot risk factors in population with type 2 diabetes and risk factors for diabetes in healthy subjects.

Methods

The study included 900 subjects: 145 with diabetic foot, 293 with type 2 diabetes without diabetic foot and 462 healthy controls matched in terms of mean age, gender structure and cardiovascular diseases absence. Study was conducted in Gastroenterology and Metabolic Diseases Department, Medical University of Warsaw, Poland. In statistical analysis a logistic regression model, U Mann-Whitney’s and t-Student test were used.

Results

The binomial logit models analysis showed that the risk of diabetic foot in patients with type 2 diabetes was decreased by patient’s age (odds ratio [OR] = 0.94; 95% confidence interval [CI]: 0.92-0.96; p = 0.00001) and hyperlipidaemia (OR = 0.54; 95% CI: 0.36-0.81; p = 0.01). In contrast, male gender (OR = 2.83; 95% CI: 1.86-4.28; p = 0.00001) diabetes duration (OR = 1.04; 95% CI: 1.03-1.06; p = 0.0003), weight (OR = 1.04; 95% CI: 1.03-1.06; p = 0.00001), height (OR = 1.08; 95% CI: 1.05-1.11; p = 0.00001) and waist circumference (OR = 1.028; 95% CI: 1.007-1.050; p = 0.006) increase the risk of diabetic foot. The onset of type 2 diabetes in healthy subjects was increased by weight (OR = 1.035; 95% CI: 1.024-1.046; p = 0.00001), WC (OR = 1.075; 95% CI: 1.055-1.096; p = 00001), hip circumference (OR = 1.03; 95% CI: 1.01-1.05; p = 0.005), overweight defined with body mass index (BMI) above 24,9 kg/m² (OR = 2.49; 95% CI: 1.77-3.51; p = 0.00001) and hyperlipidaemia (OR = 3.53; 95% CI: 2.57-4.84; p = 0.00001).

Conclusions

Risk factors for Type 2 diabetes and diabetic foot are only partially common. Study proved that patients who are prone to developing diabetic foot experience different risk factors than patients who are at risk of diabetes. Identification of relationship between diabetic foot and diabetes risk factors in appropriate groups may help clinicians to focus on certain factors in diabetic foot prevention.

Socio-demographic Determinants of Compliance among Type 2 Diabetic Patients in Abha, Saudi Arabia

BACKGROUND AND OBJECTIVES

Saudi Arabia has one of the highest prevalence of diabetes. This study was conducted with the following objectives: (1) To study the socio-demographic profile of diabetic patients in Abha. (2) To find the socio-demographic determinants of compliance among diabetic patients in Abha.

MATERIAL AND METHODS

A self administered questionnaire which had detailed the socio-demographic features and various aspects of compliance was used on a random sample of registered diabetics at two primary health care centres of Abha.

RESULTS

Most of the patients (70.4 percent) were between 40-60 years age. Most of the patients were men (about 60 percent) and Saudis. Majority of patients did not have a university education. Young patients (age<40) were more compliant with all aspects of management, except medication (23.8 percent). Women were significantly more compliant with exercise (49.7 percent), while men were significantly more compliant with follow up (81.1 percent). Saudi patients were significantly compliant with medication (79.2 percent), while non Saudis were compliant with exercise (62.9 percent). All single patients were diet compliant. Smokers were significantly less compliant with exercise. Patients with normal BMI were significantly more compliant with diet and exercise.

CONCLUSION

Patients were found to be generally less compliant towards the regimen. Socio-demographic factors which were significantly associated with non compliance were age, gender, nationality, educational status, marital status, smoking status and BMI.

[A comparative study of social representations of diabetes mellitus and diabetic foot]

The study aimed to investigate social representations of the terms "diabetes" and "diabetic foot" in different populations. Participants were divided into groups: diabetics (GD); non- diabetics (GN); and non-diabetic healthcare professionals (GP). Personal data were collected, and subjects answered two questions that were expected to evoke five words that came to mind when they thought of "diabetes" and then "diabetic foot". The evoked material was analyzed with the software Ensemble de Programmes Permettant l'Analyse dês Èvocations. A total of 161 subjects participated, including GD (n = 72) with a mean age of 56.12 ± 5.49 years; GN (n = 38) with a mean age of 54.29 ± 7.91 years; and GP (n = 51) with 34.95 ± 7.52 years. The term "diabetes" evoked 297 words in GD, 172 in GN, and 235 words in GP. The term "diabetic foot" evoked 180 words in GD, 90 in GN, and 236 in GP. The groups proved to be anxious for more information, thus confirming the need for awareness-raising and educational programs on diabetes, covering comprehensive issues concerning the disease.

Predictors of diabetic foot and leg ulcers in a developing country with a rapid increase in the prevalence of diabetes mellitus

Objective

To identify the socio demographic, life style and foot examination related predictors of diabetic foot and leg ulcers with a view to develop a screening tool appropriate for the use in an outpatient setting.

Research design and methods

This cross sectional study included type 2 diabetes mellitus (DM) patients; 88 subjects with leg and foot ulcers and 80 non ulcer controls. Socio demographic data and life style factors were documented. Foot was examined for skin changes and structural abnormalities. Distal peripheral neuropathy was assessed by pressure sense, vibration sense and joint position sense. Multivariate analysis by logistic regression was used to determine the significant predictors in screening for foot ulcers.

Results

Education of grade 6 and below (OR - 1.41, 95% CI; 1.03 - 4.68), low income (OR - 23.3, 95% CI; 1.5 - 34.0), impaired vibration sense (OR - 24.79, 95% CI; 9.3 - 66.2), abnormal monofilament test on first (OR - 1.69, 95% CI; 1.36 - 16.6), third (OR - 3.4, 95% CI; 1.1 - 10.6) and fifth (OR - 1.8, 95% CI; 1.61- 12.6) toes are found to be predictors of increased risk whereas incidental diagnosis of DM (OR - 0.03, 95% CI; 0.003 - 0.28), wearing covered shoes (OR - 0.003, 95% CI; 0.00 - 0.28), presence of normal skin color (OR - 0.01, 95% CI; 0.001 - 0.14) and normal monofilament test on first metatarsal head (OR - 0.10, 95% CI; 0.00 - 0.67) are protective factors for ulcers.

Conclusions

Ten independent risk and protective factors identified in this study are proposed as a simple screening tool to predict the risk of developing leg and foot ulcers in patients with DM.

Diabetes in the Middle East and North Africa

AIMS

Even though the Middle East and North Africa (MENA) region had the highest comparative prevalence of diabetes in 2012, little is known about the nuances of diabetes risk and capacity to address the burdens. To provide a comprehensive overview, we reviewed the literature on diabetes in the MENA region.

METHODS

We conducted a systematic search in PubMed between January 1990 and January 2012 for studies on diabetes in the MENA region without language restriction.

RESULTS

There was a paucity of country-specific epidemiology data in the region. Diabetes prevalence varied widely across studies, from 2.5% in 1982 to 31.6% in 2011. Older age and higher body mass index were the most strongly associated risk factors for diabetes. Among people with diabetes, over half did not meet recommended care targets. In addition, macrovascular and microvascular complications were observed in 9-12% and 15-54% of diabetes population, respectively.

CONCLUSIONS

This review suggests a need for more representative surveillance data in this noteworthy focal point of the global diabetes epidemic. Such actions will not only help to understand the actual burden of diabetes but also motivate actions on design and implementation of diabetes prevention and control programs.

Factors associated with consumption of diabetic diet among type 2 diabetic subjects from Ahmedabad, Western India

This cross-sectional study assessed the current situation of and factors associated with consumption of diabetic diet among 399 type 2 diabetes mellitus (T2DM) subjects from Ahmedabad, Western India. The study was performed with diagnosed (at least one year old) diabetic subjects who attended the Department of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya Hospital), Ahmedabad during July 2010-November 2010. The subjects completed an interviewer-administered questionnaire. The questionnaire included variables, such as sociodemographic factors, family history of diabetes, behavioural profile, risk profile (glycaemic status, hypertension, and obesity), and diet-related history (consumption of diabetic diet, consumption of low fat/skimmed milk, method of cooking, and sources for diet advice). Blood pressure, body mass index, glycosylated haemoglobin (HbA1c) level, and fasting lipid profile were measured. All analyses including multivariate logistic regression were conducted using SPSS, version 11.5. In total, 399 T2DM subjects (65% male, 35% female) with mean age of 53.16 +/- 7.95 years were studied. Although 73% of T2DM subjects were consuming diabetic diet, the good glycaemic control (HbA1c level < 7%) was achieved only in 35% of the subjects. The majority (75%) of the subjects had a positive family history of diabetes, and 52% were obese. In 77%, the main source of dietary advice was doctor. In 36%, the main methods of cooking were: boiling and roasting. The final multivariate model showed that visit to dietician, level of education, intake of low fat, and family history of diabetes were independent predictors for diabetic diet consumption among T2DM subjects. However, longitudinal and cohort studies are required to establish the association between consumption of diabetic diet and glycaemic control.

Medical thermography: a diagnostic approach for type 2 diabetes based on non-contact infrared thermal imaging

To test the potential of Infrared (IR) thermography in diagnosing as well as predicting type 2 diabetes and its complications compared with biochemical assay of HbA(1c) as standard. As per American Diabetes Association criteria, threshold for diagnosis of diabetes was set as HbA(1c) ≥ 6.5 % (7.7 mmol L⁻¹). The total subjects (n = 62) were studied out of which control (n = 32) and diabetic subjects (n = 30). IR camera was used to capture the thermal images of the skin for diagnosis of the disease; receiver operating characteristic (ROC) curve was used to set temperature (°C) as threshold for statistically significant body regions under t test. In diabetic group, HbA(1c) showed negative correlation with carotid region (r = -0.471, p < 0.01) and the mean skin temperature was lower than the normal group at body regions namely knee (p = 0.002), tibia (p = 0.003), forehead (p = 0.014), and palm (p = 0.019). The palm region showed highest area under the curve of 0.711 (95% CI: 0.581-0.842) and the threshold was set as ≤33.85 °C, thereby sensitivity (90%) and specificity (56%) was obtained in determining the undiagnosed diabetes with positive predictive value of 65%, negative predictive value of 85% and accuracy of 73%. As HbA(1c) increases, skin temperature decreases. Skin temperature enables early detection of diabetes as compared to HbA(1c). The decrease in skin temperature may be due to the decrease in the basal metabolic rate, poor blood perfusion and high insulin resistance. Thermography can be used as a diagnostic as well as prognostic tool for the diabetes.

Risk factors for lower extremity amputation among patients with diabetes in Singapore

BACKGROUND

Among other risk factors, renal disease and ethnicity have been associated with diabetic lower extremity amputation (LEA) in Western populations. However, little is known about risk factors for LEA among Asian patients.

OBJECTIVE

The objective was to assess the proportion of hospitalized patients with diabetes who have a LEA among all hospital patients with diabetes mellitus (DM) and to investigate risk factors for diabetic LEA (especially renal disease and ethnicity) using hospital discharge database.

METHOD

A retrospective study of hospital discharge database (2004-2009) was performed to identify patients with DM, LEA and renal disease using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Australian Modification codes.

RESULTS

Of 44 917 hospitalized patients with DM during the 6 years, 7312 (16.3%) patients had renal disease, and 1457 (3.2%) patients had LEA. DM patients with renal disease had significant higher rates of LEA (7.1%) compared to DM patients without renal disease (2.5%, P < .001). The differences were present for foot (2.7% vs. 1.2%), ankle or leg (2.8% vs. 0.9%), and knee or above amputation (1.6% vs. 0.4%, all P<.001). Malays had the highest rate of diabetic LEA (5.1%), followed by Indians (3.0%), Chinese (3.0%), and others (2.3%, P < .001). In logistic regression analyses, renal disease and ethnicity were significant predictors of diabetic LEA (renal disease: odds ratio 3.2, 95% confidence interval 2.8-3.6; ethnicity: odds ratio, 1.6, Malays vs. Chinese, P < .001; 1.0, Indians vs. Chinese, P = .784) after adjustment for age, gender, and year of discharge.

CONCLUSION

DM patients with renal disease and Malay ethnicity had higher rates of LEA in this Asian patient population. Malay patients with DM and diabetic patients with renal disease should be considered as high-risk groups for LEA and therefore screened and monitored systematically.

Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region

The prevalence of painful diabetic peripheral neuropathy (DPN) was evaluated in type 1 or type 2 diabetes mellitus patients (n = 4097) attending outpatient clinics across the Middle East. Overall, 53.7% of 3989 patients with DN4 data met the criteria for painful DPN (Douleur Neuropathique-4 [DN4] scores ≥ 4). Significant predictors of painful DPN included long history (≥ 10 years) of diabetes (odds ratio [OR] 2.43), age ≥ 65 years (OR 2.13), age 50 - 64 years (OR 1.75), presence of type 1 versus type 2 diabetes (OR 1.59), body mass index > 30 kg/m(2) (OR 1.35) and female gender (OR 1.27). Living in one of the Gulf States was associated with the lowest odds of having painful DPN (OR 0.44). The odds of painful DPN were highest among patients with peripheral vascular disease (OR 4.98), diabetic retinopathy (OR 3.90) and diabetic nephropathy (OR 3.23). Because of the high prevalence and associated suffering, disability and economic burden of painful DPN, it is important that diabetic patients are periodically screened, using a simple instrument such as the DN4, and receive appropriate treatment if symptoms develop.

A hospital-based observational study of type 2 diabetic subjects from Gujarat, India

The aim of this observational study was to describe the profile of subjects with type 2 diabetes mellitus from Gujarat, India. The study was performed with newly-diagnosed 622 type 2 diabetic subjects who attended the Department of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya), Ahmedabad, during August 2006-January 2009. The subjects completed an interviewer-administered questionnaire. The questionnaire included variables, such as sociodemographic factors, presenting symptoms, risk profile (hypertension, obesity, dyslipidaemia, and glycaemic status), family history of diabetes, physical activity, and behavioural profile. Blood pressure, body mass index (BMI), glycosylated haemoglobin levels, and fasting lipid profile were measured. Descriptive and bivariate analyses were carried out using the SPSS software (version 11.5). In total; 622 type 2 diabetes mellitus (T2DM) cases with mean age of 47.7 +/- 10.9 years were studied. Of the 622 subjects, 384 (62%) were male. The majority (68%) of the T2DM subjects were obese, and 67% had a positive family history of diabetes. Renal dysfunctions and vision impairment were, respectively, found in 10% (n=62) and 9% (n=57) of the 622 T2DM subjects. The mean HbAlc level was 9.02 +/- 1.67%, and good glycaemic control (HbAlc level <7%) was achieved only in 7.4% of the T2DM subjects. Results of chi-square analysis showed that higher BMI (> or =25 kg/m2) was significantly associated with hypertension among the T2DM subjects (p < 0.01). There were significant differences (p < 0.05) between male and female subjects with respect to mean age, BMI, waist- and hip-circumference, and mean low-density lipoprotein (LDL) level. The results revealed that many factors, such as obesity, family history of diabetes, dyslipidaemia, uncontrolled glycaemic status, sedentary lifestyles, and hypertension were prevalent among the T2DM subjects. The characterization of this risk profile will contribute to designing more effective and specific strategies for screening and controlling T2DM in Gujarat, India.