Who are diabetic foot patients? A descriptive study on 873 patients

Tissue Engineering-Based Strategies for Diabetic Foot Ulcer Management

Significance: Diabetic foot ulcers (DFU) are a mounting problem with the increasingly frail population. Injuries that would otherwise heal are kept open by risk factors such as diabetes, obesity, and age-related conditions, which interferes with the natural wound healing processes. Recent Advances: This review summarizes recent advancements in the field of tissue engineering for the treatment of DFUs. FDA-approved approaches, including signaling-based therapies, stem cell therapies, and skin substitutes are summarized and cutting-edge experimental technologies that have the potential to manage chronic wounds, such as skin printing, skin organogenesis, skin self-assembly, and prevascularization, are discussed. Critical Issues: The standard of care for chronic wounds involves wound debridement, wound dressings, and resolving the underlying cause such as lowering the glycemic index and reducing wound pressure. Current DFU treatments are limited by low wound closure rates and poor regrown skin quality. New adjuvant therapies that facilitate wound closure in place of or in conjunction with standard care are critically needed. Future Directions: Tissue engineering strategies are limited by the plasticity of adult human cells. In addition to traditional techniques, genetic modification, although currently an emerging technology, has the potential to unlock human regeneration and can be incorporated in future therapeutics.

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.

Stem and Somatic Cell Monotherapy for the Treatment of Diabetic Foot Ulcers: Review of Clinical Studies and Mechanisms of Action

Diabetic foot ulcer (DFU) is one of the most severe complications of diabetes mellitus, often resulting in a limb amputation. A cell-based therapy is a highly promising approach for an effective DFU treatment. However, there is no consensus regarding the most effective cell type for DFU treatment. Various cell types contribute to chronic wound healing via different mechanisms. For example, application of keratinocytes can stimulate migration of native keratinocytes from the wound edge, while mesenchymal stem cells can correct limb ischemia. To assess the effectiveness of a certain cell type, it should be administered as a monotherapy without other substances and procedures that have additional therapeutic effects. In the present review, we described therapeutic effects of various cells and provided an overview of clinical studies in which stem and somatic cell-based therapy was administered as a monotherapy. Topical application of somatic cells contributes to DFU healing only, while injection of mesenchymal stem cells and mononuclear cells can break a pathophysiological chain leading from insufficient blood supply to DFU development. At the same time, the systemic use of mesenchymal stem cells carries greater risks. Undoubtedly, cell therapy is a potent tool for the treatment of DFU. However, it is vital to conduct further high-quality clinical research to determine the most effective cell type, dosage and way of administration for DFU treatment. Ischemia, neuropathy and neuro-ischemia are underlying factors of diabetic foot ulcer. Stem and somatic cells monotherapy can improve chronic wound healing via different mechanisms.

Predicting the Risk of Diabetic Foot Ulcers From Diabetics With Dysmetabolism: A Retrospective Clinical Trial

BACKGROUND

Diabetic foot ulcer (DFU) in patients with type 2 diabetes mellitus (T2D) often leads to amputation. Early intervention to prevent DFU is urgently necessary. So far, there have been no studies on predictive models associated with DFU risk factors. Our study aimed to quantify the predictive risk value of DFU, promote health education, and further develop behavioral interventions to reduce the incidence of DFU.

METHODS

Data from 973 consecutive patients with T2D was collected from two hospitals. Patients from the Guangxi Medical University First Affiliated Hospital formed the training cohort (n = 853), and those from the Wuming Hospital of Guangxi Medical University formed the validation cohort (n = 120). Independent variable grouping analysis and multivariate logistic regression analysis were used to determine the risk factors of DFUs. The prediction model was established according to the related risk factors. In addition, the accuracy of the model was evaluated by specificity, sensitivity, predictive value, and predictive likelihood ratio.

RESULTS

In total, 369 of the 853 patients (43.3%) and 60 of the 120 (50.0%) were diagnosed with DFUs in the two hospitals. The factors associated with DFU were old age, male gender, lower body mass index (BMI), longer duration of diabetes, history of foot disease, cardiac insufficiency, no use of oral hypoglycemic agent (OHA), high white blood cell count, high platelet count, low hemoglobin level, low lymphocyte absolute value, and high postprandial blood glucose. After incorporating these 12 factors, the nomogram drawn achieved good concordance indexes of 0.89 [95% confidence interval (CI): 0.87 to 0.91] in the training cohort and 0.84 (95% CI: 0.77 to 0.91) in the validation cohort in predicting DFUs and had well-fitted calibration curves. Patients who had a nomogram score of ≥180 were considered to have a low risk of DFU, whereas those having ≥180 were at high risk.

CONCLUSIONS

A nomogram was constructed by combining 12 identified risk factors of DFU. These 12 risk factors are easily available in hospitalized patients, so the prediction of DFU in hospitalized patients with T2D has potential clinical significance. The model provides a reliable prediction of the risk of DFU in patients with T2D.

Evaluation of Serum Vitamin D Levels in Diabetic Foot Infections: A Cross-Sectional Study in a Tertiary Care Center in South India

Background

The impact of diabetic foot infections is enormous in India. Studies on vitamin D levels in diabetes mellitus foot infections are scarce. The primary objective of the present study was to compare the serum vitamin D level between diabetics with foot infections and those without foot infections and the secondary objective was to assess the association between the vitamin D level and the severity of foot infections and outcomes.

Methods

The study included 176 type 2 diabetics who attended Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, between September 2012 and June 2014. The serum vitamin D level was measured for 88 diabetics with foot infections (Group 1) and 88 without foot infections (Group 2) using the ELISA 25OH vitamin D DIAsource kit (DIAsource ImmunoAssays S.A., Belgium) and compared. Both groups were followed up for 6 months for outcomes. The qualitative variables were analyzed using the χ2 test and the quantitative variables using the Student t test. The statistical analyses were performed using SPSS, version 17.0. A P value of less than 0.05 was considered significant.

Results

The mean serum vitamin D level was not significantly different between the two groups (P=0.306). Among the patients in Group 1 who either required amputations or died, 97.44% had subnormal vitamin D levels in contrast to 59.18% in those who were grafted or achieved wound healing (P=0.001). Among those who achieved wound healing within 6 months, 78.9% had normal vitamin D levels (P=0.0006).

Conclusion

The study found no significant difference in the serum level of vitamin D between diabetics with and without foot infections. However, vitamin D deficiency was associated with a poor outcome in diabetics with foot infections.

Effectiveness of a Collaborative Nursing Care Model for the Treatment of Patients with Diabetic Foot Disease by Transverse Tibial Bone Transport Technique: A Pilot Study

PURPOSE

Medical staff shortages remain a serious challenge, particularly to medical administrators. We aimed to analyze the effectiveness of a collaborative nursing care model in treatment of diabetic foot.

DESIGN

A quasi-experimental pilot study.

METHODS

Twenty-eight patients with diabetic foot treated by transverse tibial bone transport between January 2017 and March 2018 were randomized. The observational group received collaborative nursing care, while the control group received usual nursing care. Postoperative dorsal foot skin temperature, visual analog scale, self-rating anxiety scale (SAS) score, and other endpoints were assessed.

FINDINGS

Postoperative dorsal foot skin temperature was significantly higher in the observation group than in the control group. Visual analog scale and SAS scores were significantly lower in the observational group than in the control group.

CONCLUSIONS

The collaborative nursing care model enhanced collaboration between patient and health care providers, shortened hospital stay, and relieved postoperative pain and anxiety.

Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis

Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.

Effects of topical Vancomycin Dressing on Methicillin-Resistant Staphylococcus Aureus (MRSA) positive diabetic foot ulcers

Objective:

To compare the effects of simple saline dressings versus topical vancomycin dressings on Methicillin-resistant Staphylococcus Aureus positive chronic diabetic foot ulcers.

Methods:

It was quasi experimental study conducted in Combined Military Hospital Kohat and PNS-Shifa Hospital Karachi from 01 January 2017 to 31 December 2017. A total of 23 patients were included based on non-probability convenient sampling who had diabetes and presented with foot ulcers for more than two weeks showing positive growth of Methicillin-Resistant Staphylococcus Aureus. The patients were treated with simple saline soaked dressings and debridement at first for three weeks followed by three weeks of topical vancomycin dressings with debridement. Thus patients served as their own controls

Results:

The average change in surface area with saline dressing was +1.73 ±1.53cm² per week whereas with vancomycin soaked dressing it was --0.06±1.60 cm² per week (p <0.05). The average exudate also decreased from 1.78±1.23 to 0.99±0.72 (p<0.05) and same trend was observed in percentage of slough covering the ulcer from 45% ± 22.3% to 24.3% ±12.90% (p<0.05) with vancomycin dressing. Moreover, fifteen patients had negative culture for MRSA within 2 weeks.

Conclusion:

Vancomycin impregnated dressing in MRSA positive Diabetic foot may help achieve early healing as compared to simple conventional dressings with no systemic toxicity.

Propolis as an Adjuvant in the Healing of Human Diabetic Foot Wounds Receiving Care in the Diagnostic and Treatment Centre from the Regional Hospital of Talca

OBJECTIVE

Diabetic foot wounds are a relevant diabetes complication and a major health problem. It has been described that propolis has health benefits due to its anti-inflammatory, antioxidant, and support in the healing process. The current study assessed the effect of propolis as an adjuvant in the healing of human diabetic foot ulcers. This was evaluated in a randomized placebo-controlled study of subjects receiving care in the Diagnostic and Treatment Centre from the Regional Hospital of Talca, Chile.

RESEARCH DESIGN AND METHODS

Randomized subjects received ambulatory healing treatment for diabetes foot wounds with propolis spray (3%), which was applied to cover the entire wound surface each time it was dressed from week 0 until cicatrization or 8 weeks as a maximum. Two serum samples were taken (day 0 and end of the study) for cytokine and oxidative stress analyses. Also, macro- and microscopy were analyzed in the process of wound healing.

RESULTS

The study comprised 31 subjects with type 2 diabetes in treatment for diabetic foot wounds in the Diagnostic and Treatment Centre from the Regional Hospital of Talca. Propolis promotes a reduction of the wound's area by an average of 4 cm², related to an increase in the connective tissue deposit compared to the control. Also, propolis increased the glutathione (GSH) and GSH/glutathione disulfide (GSSG) ratio (p < 0.02), depleted tumor necrosis factor- (TNF-) α, and increased interleukin- (IL-) 10 levels. Topical propolis did not modify the biochemical parameters in the serum of the studied subjects.

CONCLUSIONS

The topical use of propolis turned out to be an interesting therapeutic strategy as an adjuvant in the care of diabetes foot wounds due to its ability to improve and promote healing based on its anti-inflammatory and antioxidant profile. This trial is registered with NCT03649243.

Prevalence and factors associated with chronic wounds in older adults in primary care

OBJECTIVE

To analyze the prevalence of pressure injuries, diabetic and vasculogenic ulcers and associated factors in older adults attended in primary care.

METHOD

A cross-sectional, analytical study with older adults attended in the Family Health Strategy in a Brazilian municipality. Data collection was performed from January to March 2016 using interviews and evaluations of injuries. The variables were submitted to the multivariate logistic regression model using the odds ratio, with their respective 95% confidence intervals and significance set at <0.05.

RESULTS

339 older adults participated in the study. The mean age was 71.1 years, 67.3% were female, 44% were illiterate, 85% had low family income, 91.7% had underlying diseases, 37.2% had dietary restrictions, and 76.1% did not practice physical activity. The prevalence of pressure injury was 5.0%, diabetic ulcer 3.2%, and vasculogenic ulcer 2.9%. Not working and not regularly practicing physical activity increased the chances of presenting these injuries by 1.5 and 2.3 times, respectively. Being actively mobility and not having dietary restrictions were protective factors for not developing chronic wounds.

CONCLUSION

The prevalence of injuries among older adults was high, and its occurrence is associated with socioeconomic and clinical characteristics.

Can we link foot ulcer with risk factors in diabetics? A study in a tertiary care hospital

OBJECTIVE

Although many studies worldwide explained the risk factors for developing Diabetic Foot Ulceration (DFU), little has been done to assess medical factors in DFU formation and link them in patients of Pakistan. This study aimed to link the DFU with different risk factors.

METHODS

This descriptive cross-sectional retrospective study was conducted in Diabetes Endocrine and Metabolic Centre / Post Graduate Medical Institute / Lahore General Hospital. Data of all patients presenting between July 2017 to June 2018 were analyzed for risk factors. Analysis was done on SPSS version 21.

RESULTS

Total of 3301 patient were seen during this period, out of which 2052 patient data was picked up as it was complete in respect to the information needed. Middle age, Male gender, Type 2 diabetes, and Hypertension, were insignificantly co-related. High waist circumference, Comorbidity like Neuropathy, Dyslipidemia, Greater body mass index, Poor compliance with Medication and type of medication used (combination of oral and injectable) were found statistically significant predictor for DFU. However retinopathy was not found to be a risk factor of DFU. This result was statistically significant.

CONCLUSION

Factors like obesity, waist circumference, combination of oral along with injectable therapies, neuropathy, dyslipidemia, retinopathy and poor compliance with medication were statistically significant and can be strongly linked with diabetic foot ulcer. Middle age, Male gender, Type 2 diabetes, and Hypertension were insignificantly co-related. However, further studies are needed in larger population to support these findings.

Depth and combined infection is important predictor of lower extremity amputations in hospitalized diabetic foot ulcer patients

BACKGROUND/AIMS

As the prevalence of diabetes mellitus and its complications increase rapidly, diabetic foot ulcers (DFUs), which are a major diabetic complication, are expected to increase. For prevention and effective treatment, it is important to understand the clinical course of DFUs. The aim of this study was to investigate the natural course and predictors of amputation in patients with DFUs who required hospitalization.

METHODS

A total of 209 patients with type 2 diabetes, aged 30 to 85 years, who visited emergency department or needed hospitalization due to DFUs were consecutively enrolled from May 2012 to January 2016, by retrospective medical record review. The main outcome was lower extremity amputation (LEA).

RESULTS

Among 192 patients who completed follow-up, 113 patients (58.9%) required LEAs. Compared to patients without amputation, baseline levels of white blood cell counts and C-reactive protein were higher in patients with amputation. In addition, bone and joint involvement was more frequently observed in patients with amputation. Multivariable regression analysis revealed that combined infection (odds ratio [OR], 11.39; 95% confidence interval [CI], 2.55 to 50.93; p = 0.001) and bone or joint involvement (OR, 3.74; 95% CI, 1.10 to 12.70; p = 0.035) were significantly associated with an increased risk of LEA.

CONCLUSION

The depth of the wound and combined infection of DFU, rather than the extent of the wound, were significant prognostic factors of LEAs in patients with type 2 diabetes.

Risk factors for diabetic foot ulcer recurrence: A prospective 2-year follow-up study in Egypt

OBJECTIVES

To determine the frequency of diabetic foot ulcer recurrence and its potential risk factors.

METHODS

This study included 93 patients with type 2 diabetes and followed for 2 years after primary healed foot ulceration. Demographic, diabetes related, comorbid and ulcer related variables were investigated as risk factors. Multiple logistic regression analysis was used to identify independent risk factors.

RESULTS

61.3% of patients had recurrent ulcers particularly in the forefoot (33.3%) and big toe (24.6%). Peripheral neuropathy, peripheral arterial disease or both were reported in 69%, 12% and 19% of feet with recurrent ulcers respectively. In multivariate analysis, the significant independent potential risk factors for recurrence of foot ulcers were smoking (P=0.040), poor glycemic control [HbA1c cutoff of 10%] (P=0.010), peripheral neuropathy with lost ankle reflex (P=0.0001), peripheral arterial disease (P=0.0001) and previous ulcer location (P=0.050).

CONCLUSION

The frequency rate of recurrent diabetic foot ulceration in patients with type 2 diabetes is high particularly in the first year despite regular follow-up and patient education.

Sociodemographic and clinical characteristics of patients with diabetic foot ulcer

Summary Introduction: Diabetic foot is one of the most serious complications of diabetes affecting about 15% of all diabetes patients, and it is the leading cause of nontraumatic lower limb amputations. This study presents a sociodemographic and clinical characterization of patients with diabetic foot ulcer indicated for amputation surgery. Methods: A cross-sectional study with 206 patients with type 2 diabetes and a diabetic foot ulcer indicated for amputation surgery. Patients were assessed on sociodemographic and clinical characteristics, pain intensity and pain interference, after answering the Brief Pain Inventory, and on pain descriptors according to the Douleur Neuropathique 4. Results: Most patients were male, with little formal education and a mean age of 66 years. They had been diagnosed with type 2 diabetes for 18 years on average, and with diabetic foot ulcer on average 4 years prior to the assessment. About 59% of patients experienced pain in the lower limb that significantly affect all areas of their functioning. Conclusion: The social demographic variables play an important role in diabetic foot ulceration. Given that the neuropathic ulcers are more easily preventable, systematic monitoring of patients with neuropathy is important. In patients with neuroischemic foot, strategies to cope or manage more efficiently the pain are paramount. Intervention should be multidisciplinary and take into account sociodemographic and clinical factors, as well as the presence, intensity and interference of pain in the patient's daily life activities and whether the patient has family or caregiver support.

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.

Diagnoses and clinical features associated with high risk for unplanned readmission in vascular surgery. A cohort study

Background

Readmission rate is an established health quality indicator. Preventable readmissions bear an unnecessary, high cost on the healthcare system. An analysis performed by the National Centre for Health Outcomes Development (NCHOD) has demonstrated an increasing trend in emergency readmissions in the UK. Vascular surgery has been reported to have high readmission rates second only to congestive heart failure. This study aims to identify diagnoses and other clinical risk factors for high unplanned readmission rates. This may be the first step to sparing both the health care system and patients of unnecessary readmissions.

Results

The overall 30 day readmission rate for Leeds Vascular Institute was 8.8%. The two diagnoses with the highest readmission rates were lower limb ischaemia and diabetic foot sepsis. The readmission rate for medical reasons was overwhelmingly higher than for surgical reasons (6.5% and 2.3% respectively). The most common medical diagnoses were renal disease and COPD. The majority of the patients readmitted under the care of vascular surgery required further surgical treatment.

Conclusion

Vascular units should focus on holistic and multidisciplinary treatment of lower limb ischaemia and diabetic foot sepsis, in order to prevent readmissions. Furthermore, the early involvement and input of physicians in the treatment of vascular patients with renal disease and COPD may be appropriate.

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Lower limb ischaemia and diabetic foot sepsis are the two diagnoses with the highest readmission rate.

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Vascular patients are more frequently readmitted for medical rather than surgical health problems.

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For vascular patients, the most common medical, readmission diagnoses are infection renal disease complications and COPD exacerbation.

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Most of the patients readmitted under vascular surgery necessitate further surgical treatment.

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Diabetes may be an independent risk factor for readmission.

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.

Management of hospitalized patients with diabetic foot infections

Diabetic foot infections (DFIs), which present with a variety of clinical manifestations, are commonly encountered by clinicians. They are associated with a high morbidity, a high amputation rate, a high mortality, and increased health care costs. An effective management of DFIs requires a multidisciplinary approach with a strong collaboration among all involved health care providers as well as patient involvement. Diagnosing DFIs appropriately requires consideration of the clinical symptoms and signs of infection in addition to supplementary laboratory testing such as inflammatory markers and imaging studies. The comprehensive patient assessment should include the predisposing risk factors for infection; the type, severity, and extent of the infection; and the assessment of neurologic and vascular status, comorbid conditions, and psychosocial factors. The comprehensive management of DFIs include not only effective antibiotic therapy but also surgical debridement, pressure offloading, wound care and moisture, maintaining good vascular perfusion, control of edema and pain, correction of metabolic abnormalities such as hyperglycemia, and addressing psychosocial and nutritional issues. Discharge planning that addresses full medical and social needs along with suitable follow-up, patient education and counseling, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient management of hospitalized patients with DFIs.

Diabetic hands: a study on strength and function

OBJECTIVE

To study hand strength and function in type 2 DM patients.

METHODS

We collected data on hand strength and function, disease duration, glycemic, creatinine and HbA1C levels, degree of pain and stiffness and physical examination in 100 DM patients comparing than with 100 hand osteoarthritis patients and 100 controls.

RESULTS

DM patients had hand strength and function better than osteoarthritis patients and worse than controls. De Quervain tendonitis associated with hand strength (p=0.005); hand function associated with carpal tunnel syndrome (p<0.0001), De Quervain tendinitis (p=0.006), HbA1C level (p=0.005), insulin use (p=0.030), disease duration (p=0.0006), pain (p<0.0001) and stiffness (p<0.0001) in univariated analysis. In multivariated analysis only disease duration and stiffness remain as significant.

CONCLUSION

Hand strength and function are impaired in DM patients. Loss of function associated with stiffness and disease duration; loss of strength associates with De Quervain tendinitis.

A social network analysis on clinical education of diabetic foot

INTRODUCTION

Identification of Educational Influentials (EIs) in clinical settings helps considerably to knowledge transfer among health and medical practice providers. The aim of this study was identifying EIs in diabetic foot ulcers (DFU) by medical students (clerks, interns and residents) and providing their relational pattern in this subject.

METHODS

Subjects were medical students at clerk, intern and resident levels in a local educational hospital. A standard questionnaire with four domains (knowledge, communication, participation and professional ethics) was used for identifying EIs. Students introduced those people with these characteristics who referred them for DFU. Respective communication networks were drawn as intra-group (such as resident-resident) and inter-group (such as intern-resident) networks and quantitative criteria of density, in-degree and out-degree centrality and reciprocity were measured.

RESULTS

The network density of clerks-residents (0.024) and interns-residents (0.038) were higher than clerks-attends (0.015) and interns-attends (0.05); indicating that there were more consulting interactions in former networks than the latter. Degree centrality in residents-related networks (clerks-residents = 2.3; interns-residents = 2.6) were higher than attends-related ones (clerks-attends = 1.1; interns-attends = 1.7), while they were not statistically significant. However, In-degree centralization, which indicating a degree of variance of the whole network of ingoing relationships, in attends-related networks was greater than resident-related networks.

CONCLUSION

Resident were consulted with almost as same as attends on DFU. It showed that residents were playing a remarkable role in knowledge transfer and they can be considered as EIs in this clinical setting. It seemed that the availability was the main reason for this key role.