Incidence of Diabetic Foot Ulcer and Its Predictors Among Diabetes Mellitus Patients at Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia: A Retrospective Follow-Up Study

Time to development of macrovascular complications and its predictors among type 2 diabetes mellitus patients at Jimma University Medical Center

BACKGROUND

Type 2 diabetes mellitus is a serious metabolic disease that is often associated with vascular complications. The increasing prevalence of type 2 diabetes mellitus poses significant public health challenges, particularly in Low and Middle-Income Countries where healthcare resources are often limited. In Africa, the burden of T2DM is rising rapidly, leading to a consequential increase in macrovascular complications such as cardiovascular disease and stroke. These complications not only affect the quality of life but also significantly contribute to morbidity and mortality among affected individuals. The main objective of this study was to assess the time to development of macrovascular complications and identify its predictors among type 2 diabetes mellitus patients in Jimma University medical center from 2018-2022.

METHODS

Institutional-based retrospective follow-up study was conducted in Jimma University Medical Center among newly diagnosed type 2 diabetes mellitus patient from 2018, to 2022. A systematic sampling technique was used to recruit 452 records of type 2 diabetes mellitus patients. The Kaplan-Meier curve and the log-rank tests were used to determine the time to macro-vascular complications, and evaluate the significant difference in survival probability among predictors respectively. The overall goodness of the Cox proportional hazard model was checked by Cox-Snell residuals. Bivariable and multivariable cox-proportional hazard regression were used to identify the association between the variables and survival time.

RESULTS

The median survival time to development of macro vascular complications was 24 months. Urban residence [(Adjusted hazard ratio = 2.02; 95% CI: (1.33, 3.05)], having hypertension at start of diabetic treatment [(AHR = 1.52; 95% CI: (1.06, 2.13)], baseline age ≥ 60 years [(AHR = 4.42; 95% CI: (1.72, 11.29)], having dyslipidemia at baseline [(AHR = 1.82; 95% CI: (1.13, 2.93)], High density lipoprotein cholesterol levels < 40 mg/dl [(AHR = 2.11; (1.16, 3.81)], triglycerides > 150 mg/dl [(AHR = 1.48; 95% CI:( 1.02, 2.13)], Hemoglobin A1C level > 7% [(AHR = 1.49; 95% CI: (1.04, 2.14)], and Oral hypoglycemic agents + insulin [(AHR = 2.73; 95% CI: (1.81, 4.09)] were the significant predictors of the time to development of macro vascular complications.

CONCLUSION

Findings in this study indicated that the median time to development of macro vascular complications among type 2 diabetes mellitus patients was 24 months. Baseline age category in years, residence, presence of hypertension, presence of dyslipidemia, High density lipoprotein-cholesterol level < 40 mg/dl, triglyceride > 150 mg/dl, HgbA1C > 7% at baseline, and medication regimens were identified as independent significant predictors of the time to development of macro vascular complications among type 2 diabetes mellitus patients. The findings call attention to the role of treatment regimens, particularly the use of combination therapies involving oral hypoglycemic agents and insulin, which were associated with increased hazards for complications. High incidence of macrovascular complications within a short follow-up period underscores the need for proactive, individualized care strategies in T2DM management. By focusing on early identification of at-risk patients and tailoring treatment plans accordingly, healthcare providers can potentially improve outcomes and reduce the burden of macro vascular complications in this population.

The Burden of Diabetic Foot Ulcers in Urban India: A Community Healthcare Setup-Based Study

Introduction

Foot ulcer is the most common cause of hospitalisation among people with diabetes (PWD). The objective of the study is to determine the incidence of diabetic foot ulcers (DFUs) in the urban community in India and its relationship with glycemic level and demographic parameters like age and sex among diabetic patients.

Methods

A retrospective observational study was performed from January 2016 to December 2018 at an urban community set up in Mumbai. The study was conducted in a healthcare setting, providing lifelong contributory healthcare to beneficiaries of an employees' universal healthcare scheme. PWD from the community was identified using prescriptions of anti-diabetic medications. We identified patients with DFUs from electronic medical records from the hospital information system (HIS). The yearly incidence rate of DFU among PWD was estimated for the study period. The association between glycemic control and the demographic profile of patients with DFU was studied using binary logistic regression.

Results

The study documents the average incidence of 66 DFU patients among 10,000 PWD per year in the community. Logistic regression analysis showed higher odds for the elderly age group (OR 2.863) compared to lower age for developing DFU. Similarly, poor control (HbA1c >7%) over glycemic level has a higher chance (OR 1.713) of DFU than that of optimum glycemic control (HbA1c ≤7%). Among the DFU, 15.29% of patients required amputation during the study period.

Conclusion

The study documents the community-level incidence of DFUs among patients with diabetes. High glycemic levels and elderly age groups (≥60) are the associated risk factors for DFU.

Evaluating and mapping the evidence that screening for diabetic foot disease meets the criteria for population-wide screening: a scoping review

Objective

To evaluate and map the evidence around diabetes-related foot screening using the World Health Organisation screening principles, which set the gold standard for determining the appropriateness of introducing population-wide screening programmes internationally.

Design

A scoping review methodology in line with Arksey and O'Malley and the Joanna Briggs Institute.

Data sources

Medline (EBSCO), Scopus, ScienceDirect and EMBASE between 24 May 2022 and 12 July 2022. Reference lists of the selected studies, and 'Google' and 'Google Scholar' were also searched.

Eligibility criteria

Inclusion criteria were informed by the principles of screening. Articles, published in English since 2000, reporting on the impact of the diabetes-related foot ulcers, effectiveness of treatment available for those identified as being at risk, reliability of screening tests for screening for the at-risk foot and the effectiveness, cost-effectiveness, safety and ethics of diabetes-related foot screening programmes were included.

Data extraction and synthesis

Data were extracted by one reviewer, with data extraction headings relating to the principles of screening. A narrative synthesis approach was used to report the information from included studies.

Results

46 articles were deemed eligible for inclusion. Diabetes-related foot ulcers are an important health condition associated with increased risk of mortality and poorer quality of life. However, there is insufficient evidence on the effectiveness of treatments to prevent disease development. Moreover, while consensus exists on what screening tools should be used to screen for risk factors, there is no agreement on threshold values. Finally, there is no available information on the potential budgetary, organisational or societal implications of a whole-population diabetes-related foot screening programme.

Conclusion

Existing evidence does not support the introduction of an organised population-wide screening programme in the context of World Health Organisation screening principles. Further research on treatment and management strategies for the at-risk foot and of whole-population screening programmes is required.

Two-year incidence and risk factors of diabetic foot ulcer: second phase report of Ahvaz diabetic foot cohort (ADFC) study

AIM/INTRODUCTION

This study was designed as the second phase of a prospective cohort study to evaluate the incidence and risk factors of diabetic foot ulcers (DFU).

MATERIALS AND METHODS

The study was conducted in a university hospital in Iran. Each participant was checked and followed up for two years in terms of developing newfound DFU as ultimate outcome. We investigated the variables using univariate analysis and then by backward elimination multiple logistic regression.

RESULTS

We followed up 901 eligible patients with diabetes for two years. The mean age of the participants was 53.24 ± 11.46 years, and 58.53% of them were female. The two-year cumulative incidence of diabetic foot ulcer was 8% (95% CI 0.071, 0.089) [Incidence rate: 49.9 /1000 person-years]. However, the second-year incidence which was coincident with the COVID-19 pandemic was higher than the first-year incidence (4.18% and 1.8%, respectively). Based on our analysis, the following variables were the main risk factors for DFU incidence: former history of DFU or amputation [OR = 76.5, 95% CI(33.45,174.97), P value < 0.001], ill-fitting foot-wear [OR = 10.38, 95% CI(4.47,24.12), P value < 0.001], smoking [OR = 3.87,95%CI(1.28, 11.71),P value = 0.016], lack of preventive foot care [OR = 2.91%CI(1.02,8.29),P value = 0.045], and insufficient physical activity[OR = 2.25,95% CI(0.95,5.35),P value = 0.066].

CONCLUSION

Overall, the two-year cumulative incidence of diabetic foot ulcer was 8% [Incidence rate: 49.9 /1000 person-years]; however, the second-year incidence was higher than the first-year incidence which was coincident with the COVID-19 pandemic (4.18% and 1.8%, respectively). Independent risk factors of DFU occurrence were prior history of DFU or amputation, ill-fitting footwear, smoking, lack of preventive foot care, and insufficient physical activity.

Incidence of the first diabetic foot ulcer: A systematic review and meta-analysis

AIM

Investigate the incidence of the first diabetic foot ulcer.

METHOD

This is a systematic review with meta-analysis of cohort studies following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. A systematic search of Medline databases via PubMed, Embase, Lilacs, Scopus databases, and Web of Science was performed until July 2021. In addition to investigating the incidence of the first diabetic foot ulcer, the influence of the variables of the Human Development Index (HDI), glycated hemoglobin, and follow-up time of the participants on the incidence of the first diabetic foot ulcer (DFU) was analyzed through meta-regression. For the meta-analysis of cumulative incidence and possible variable associations, RevMan software was used in the Metaprop data package with 95% confidence interval (CI).

RESULTS

A total of 9,772 articles were identified out of which 87 were selected and 12 studies ultimately included in the systematic review and meta-analysis. The meta-analysis of cumulative incidence was 5.65% (95% CI: 4.20; 7.57). By meta-regression, a significant inverse association was identified between DFU incidence and HDI (estimate - 2.38; 95% CI - 4.10--0.67; p = 0.01).

CONCLUSION

The study presents the cumulative incidence for the first DFU, an inexistent datum in the national and international literature, and the HDI was inversely associated with the incidence of DFU.

Value of cystatin C in predicting recurrence in patients with severe diabetic foot and diabetic foot ulcer

Objective: Our objective is to investigate the risk factors and predictive ability of severe diabetic foot (DF) and diabetic foot ulcers (DFUs). Patients & methods: The efficacy of cystatin C in predicting the recurrence of DF and DFU was evaluated using a receiver operating characteristic curve. Results: The findings indicate that, in contrast to non-severe patients, severe cases exhibit elevated levels of cystatin C (p < 0.05). Additionally, a statistically significant increase in cystatin C levels was observed in the subgroup of patients with recurrent DFU (p < 0.01). Conclusion: Cystatin C emerged as a significant risk factor for severe DF and recurrent DFU, with the potential for predicting their occurrence.

Role of M1 macrophages in diabetic foot ulcers and related immune regulatory mechanisms

Objectives: Diabetes foot ulcers (DFUs) are characterized by immune infiltration of M1 macrophages observed in foot skin, in which immune-associated genes (IRGs) play a prominent role. The precise expression of IRGs as well as any possible regulatory mechanisms that could be present in DFUs is yet unknown. Methods: The sequencing data of single-cell RNA (scRNA) in the foot skin of patients with DFUs were analyzed, screening out the cluster marker genes of foot skin obtained from the ImmPort database. IRG activity was assessed with the AUCell software package. The IRGs of DFUs were explored by analyzing the batch sequencing dataset of DFU skin tissue. HumanTFDB was adopted to identify relevant regulatory transcription factors (TFs). The STRING dataset was used to build the main TF protein-protein interaction networks. WB and immunofluorescence methods were used to verify M1 macrophage-related immune regulators. Results: There were 16 clusters found: SMC1, fibro, t-lympho, he fibro, vasendo, baselkera, diffkera, SMC2, M1 macro, M2 macro, sweet/seba, B-Lympho, Melanio, lymphendo, plasma, and Schwann. M1 and M2 macrophages both had considerably higher AUC ratings than patients with DFUs compared to other sub-populations of cells. The proportion of M1 macrophages was the highest in the non-healing group. According to scRNA analysis and batch sequencing data by GO and KEGG, DEGs were enriched in immune response. Some 106 M1 macro-IRGs were finally identified and 25 transcription factors were revealed as associated with IRG expression. The PPI network indicated NFE2L2, REL, ETV6, MAF, and NF1B as central transcription factors. Conclusion: Based on the bio-informatics analysis of scRNA and high-throughput sequencing data, we concluded that M1 macrophages may serve as the influencing factor of DFUs' non-union. In addition, NFE2L2 could be involved in the regulation of IRG expression within M1 macrophages.

Re-understanding and focusing on normoalbuminuric diabetic kidney disease

Diabetes mellitus (DM) has grown up to be an important issue of global public health because of its high incidence rate. About 25% of DM patients can develop diabetic foot/ulcers (DF/DFU). Diabetic kidney disease (DKD) is the main cause of end-stage kidney disease (ESKD). DF/DFU and DKD are serious complications of DM. Therefore, early diagnosis and timely prevention and treatment of DF/DFU and DKD are essential for the progress of DM. The clinical diagnosis and staging of DKD are mostly based on the urinary albumin excretion rate (UAER) and EGFR. However, clinically, DKD patients show normoalbuminuric diabetic kidney disease (NADKD) instead of clinical proteinuria. The old NADKD concept is no longer suitable and should be updated accordingly with the redefinition of normal proteinuria by NKF/FDA. Based on the relevant guidelines of DM and CKD and combined with the current situation of clinical research, the review described NADKD from the aspects of epidemiology, pathological mechanism, clinical characteristics, biomarkers, disease diagnosis, and the relationship with DF/DFU to arouse the new understanding of NADKD in the medical profession and pay attention to it.

Risk assessment of amputation in patients with diabetic foot

The prevalence of diabetes has increased dramatically over the past decade, especially in developing countries, reaching pandemic proportions. Although has been the most important factor influencing the prevalence of type 2 diabetes, the prevalence of type 2 diabetes is on the increase among younger adults. The subsequent rate of increase with age is variable, which is more evident in societies where the general prevalence of the disease is higher. Based on clinical and statistical data obtained from the patients who were admitted to The First and Second Surgery Wards in the Sibiu County Emergency University Clinical Hospital (Sibiu, Romania) and the Proctoven Clinic (Sibiu, Romania) between January 2018 and December 2020, the present study attempted to devise a risk score that can be applied for the benefit of patients. The ultimate aim was that this risk score may be eventually applied by diabetologists and surgeons to assess the risk of amputation in patients with diabetic foot lesions. An important part in the therapeutic management of diabetic foot injuries is the assessment of risk factors. Using this risk score system devised, the risk factors that were found to exert influence in aggravating diabetic foot injuries are smoking, obesity, dyslipidaemia, unbalanced diabetes mellitus (glycated haemoglobin ≥7.5%), duration of diabetes >5 years, hepatic steatosis and the co-existence of various heart diseases. To conclude, all these risk factors aforementioned can decrease the effectiveness of treatment and can have a significant impact on the quality of life, if they are not well known.

Incidence and predictor of diabetic foot ulcer and its association with change in fasting blood sugar among diabetes mellitus patients at referral hospitals in Northwest Ethiopia, 2021

Background

Diabetes mellitus is one of the global public health problems and fasting blood sugar is an important indicator of diabetes management. Uncontrolled diabetes can lead to diabetic foot ulcers, which is a common and disabling complication. The association between fasting blood glucose level and the incidence of diabetic foot ulcers is rarely considered, and knowing its predictors is good for clinical decision-making. Therefore, the aim of this study was to determine the incidence and predictors of diabetic foot ulcers and its association with changes in fasting blood sugar among diabetes mellitus patients at referral hospitals in Northwest Ethiopia.

Methods

A multicenter retrospective follow-up study was conducted at a referral hospital in Northwest Ethiopia. A total of 539 newly diagnosed DM patients who had follow-up from 2010 to 2020 were selected using a computer-generated simple random sampling technique. Data was entered using Epi-Data 4.6 and analyzed in R software version 4.1. A Cox proportional hazard with a linear mixed effect model was jointly modeled and 95% Cl was used to select significant variables. AIC and BIC were used for model comparison.

Result

A total of 539 diabetes patients were followed for a total of 28727.53 person-month observations. Overall, 65 (12.1%) patients developed diabetic foot ulcers with incidence rate of 2.26/1000-person month observation with a 95% CI of [1.77, 2.88]. Being rural (AHR = 2.30, 95%CI: [1.23, 4.29]), being a DM patient with Diabetic Neuropathy (AHR = 2.61, 95%CI: [1.12, 6.06]), and having peripheral arterial disease(PAD) (AHR = 2.96, 95%CI: [1.37, 6.40]) were significant predictors of DFU. The time-dependent lagged value of fasting blood sugar change was significantly associated to the incident of DFU (α = 1.85, AHR = 6.35, 95%CI [2.40, 16.79]).

Conclusion and recommendation

In this study, the incidence of DFU was higher than in previous studies and was influenced by multiple factors like rural residence, having neuropathy, and PAD were significant predictors of the incidence of DFU. In addition, longitudinal changes in fasting blood sugar were associated with an increased risk of DFU. Health professionals and DM patients should give greater attention to the identified risk factors for DFU were recommended.

Prevalences of diabetic foot ulcer and foot self-care practice, and associated factors in adult patients with diabetes in south-east Ethiopia

OBJECTIVE

We aimed to assess the prevalences of foot ulcer and foot self-care practices, and identify associated factors in adult patients with diabetes attending a referral hospital in south-east Ethiopia.

METHODS

We performed a cross-sectional study of 267 diabetic patients. Multivariable binary logistic regression was used to identify factors associated with diabetic foot ulcer and foot self-care practice.

RESULTS

The prevalence of diabetic foot ulcer was 11.2% (95% confidence interval [CI] 7.42-15.05). One hundred and forty-four (53.9%; 47.9, 59.9) patients demonstrated good foot self-care. Living rurally (adjusted odds ratio 2.27; 95% CI: 1.86-6.97), lack of regular exercise (3.91; 1.51-10.10), peripheral neuropathy (2.77; 1.05-7.33) and foot calluses (5.69; 1.74-18.59) were associated with diabetic foot ulcer. Urban inhabitants (2.01; 1.09-3.69), patients with diabetes for >10 years (2.92; 1.48-5.77), women (2.95; 1.66-5.22), and patients with a glucometer at home (2.05; 1.09-3.85) were more likely to have good foot self-care practice.

CONCLUSION

The prevalence of diabetic foot ulcer was 11.2%. This prevalence is lower than those identified in other Ethiopian studies. However, patient awareness regarding foot self-care practice and risk reduction should be improved.

Foot self-care behaviour in type 2 diabetes adults with and without comorbid heart failure

AIMS

To compare the correlates of foot self-care behaviours among type 2 diabetes mellitus (T2D) adults with and without comorbid heart failure (HF).

DESIGN

Cross-sectional, correlational, comparative design.

METHODS

A 210 T2D adults (105 with HF and 105 without HF) participated from August-December 2020. Foot self-care behaviour was measured using the foot care subscale of the Summary of Diabetes Self-Care Activities (SDSCA) instrument. A stepwise logistic regression analysis was used to explore variables predicting foot self-care behaviour.

RESULTS

The participants' mean age was 58.7 ± 10.9 years. Poor foot self-care behaviour was reported in T2D adults both with (53.3%) and without (54.3%) HF. Participants with HF-comorbidity were statistically significantly older and had higher total daily medication intake. Household income and the total number of daily medications statistically significantly predicted foot self-care behaviour in HF-comorbid T2D adults. Marital status, social support and body mass index predicted foot self-care behaviour in the non-HF group.

A male’s foot is being shot by an ulcer, not a gunshot! The magnitude and associated factors of diabetic foot ulcer among diabetes mellitus patients on chronic care follow-up of southwestern Ethiopian hospital: A cross-sectional study

Background

Diabetic foot ulcer (DFU) is one of the main complications of diabetes mellitus associated with major morbidity and mortality. DFU is the major cause of infection and lower extremity amputations in diabetic patients. Despite this, there was a scanty finding on associated factors of foot ulcer among diabetes mellitus.

Methods

Facility-based cross-sectional study was conducted among diabetes mellitus patients at BGH from August 1, 2021 - 30, 2021. The validated tool of the Nottingham Assessment of Functional Footcare (NAFF) was used to assess the diabetic foot self-care practice. Multivariate logistic regression was used to analyze the associations between the dependent variables and independent variables. Data were analyzed using a statistical package for social science (SPSS version 23).

Results

A total of 162 respondents with a response rate of 100% have participated in the study. Of the respondents, 88 (54.3%) were females and the mean and SD of the age were 35.8 and 12.70. The prevalence of diabetic foot ulcers in our study area was 24(14.81%). The results of the multivariable logistic regression analysis revealed that being a male (AOR = 2.143; 95% CI: 0.691–6.65), poor diabetic foot care practice (AOR = 3.761; 95CI: 1.188–11.90), and having a co-morbidity (AOR = 2.507; 95CI: 3.270–5.95)were more likely to experience a diabetic foot ulcer than their counterparts.

Conclusion

The prevalence of diabetic foot ulcers among diabetic patients in BGH was found to be high. The presence of comorbidity, being a male, and foot care practice were factors that predict the occurrences of diabetic foot ulcers. Therefore, the ongoing medical education on the foot care practices should be given to diabetes mellitus patients.

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Diabetic foot ulcer is one of the main complications in diabetes mellitus.

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Diabetic foot is defined as the presence of infection, ulceration and/or destruction of deep tissues.

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Diabetic foot ulcer is a major cause of infection and lower extremity amputations in diabetic patients.

Screening for identification of patients at high risk for diabetes-related foot ulcers: a cross-sectional study

OBJECTIVE

Diabetes affected 463 million people globally in 2019, and this number is anticipated to reach 700 million by 2045. Diabetes results in lower limb amputation every 30 seconds. Egypt has a high prevalence of diabetic foot disease among patients with type 2 diabetes mellitus (T2DM). We aimed to identify high-risk patients for diabetic foot ulcers (DFUs) in Egypt.

METHODS

We designed a cross-sectional study among adult patients with diabetes at Asyut University Hospital. Inlow's 60-second diabetic foot screening tool was used to assess the risk of DFU. Neuropathy was assessed using the 10g monofilament test, and laboratory testing was performed to assess glycosylated hemoglobin (HbA1c) and diabetes control levels.

RESULTS

Participants were aged 46.11 ± 9.18 years; 56% had T2DM and HbA1c levels >7%. In total, 47.9% of participants were at risk for DFUs. This risk was higher in patients who were older, male, widowed, working, illiterate, living in rural areas, and patients with diabetes duration >10 years, body mass index >32 kg/m2, uncontrolled blood glucose levels, on an insulin regimen, and smokers.

CONCLUSIONS

Increasing health care providers' awareness and ability to identify high-risk patients is critical to prevent DFUs and reduce the risk of amputation.

Prevalence of diabetic foot amongst adults with diabetes mellitus in northern Sudan: A cross-sectional study

OBJECTIVE

The aim of this study was to determine the prevalence and associated factors for diabetic foot (DF) amongst patients with diabetes Mellites (DM) in Nahr an Nil State (River Nile State), Sudan.

METHODS

We conducted a cross-sectional study between May and August 2018. DM patients were examined for DF, and clinical data were collected through a questionnaire.

RESULTS

A total of 2048 DM patients were enrolled in the study. Their median (interquartile range) age was 58 (15) years. Over half (54.2%) of the patients were female. The median (interquartile range) of the duration of diabetes was 5 (6) years. In this sample, 70.1% of the patients had type 2 DM and 47.6% had hypertension as well. Of all enrolled patients, 21.2% had normal weight, 1.2% were underweight, 37.2% were overweight and 40.4% were obese. Two hundred and sixty (12.7%) patients had DF. Multivariate regression analyses showed that age [adjusted odds ratio (AOR) = 1.21; 95% confidence interval (CI): 1.18-1.24] and duration of DM (AOR = 1.09; 95% CI: 1.05-1.14) were positively associated with DF. Moreover, type 2 DM (AOR = 1.77; 95% CI: 1.17-2.68), family history of DM (AOR = 1.5; 95% CI: 1.07-2.09), hypertension (AOR = 2.93; 95% CI: 2.07-4.16) and obesity (AOR = 2.86; 95% CI: 1.70-4.81) were associated with DF. There was no significant association between DF and gender or overweight status.

CONCLUSION

This study found a high prevalence of DF. Older age, type 2 DM, duration of DM, family history of DM and hypertension are associated with DF.

Development and validation of an incidence risk prediction model for early foot ulcer in diabetes based on a high evidence systematic review and meta-analysis

OBJECTIVES

To develop and validate a model for predicting the risk of early diabetic foot ulcer (DFU) based on systematic review and meta-analysis.

METHODS

Data were analyzed from the risk factors of DFU with their corresponding risk ratio (RR) by meta-analysis. The DFU prediction model included statistically significant risk factors from the meta-analysis, all of which were scored by its weightings, and the prediction model was externally validated using a validation cohort from China. The occurrence of early DFU was defined as patients with type 2 diabetes who were free of DFU at baseline and diagnosed with DFU at follow-up. Evaluation of model performance was based on the area under the discrimination receiver operating characteristic curve (ROC), with optimal cutoff point determined by calculation of sensitivity and specificity. Kaplan-Meier curve were performed tocompare the cumulative risk of different groups.

RESULTS

Our meta-analysis confirmed a cumulative incidence of approximately 6.0% in 46,521 patients with diabetes. The final risk prediction model included Sex, BMI, HbA1c, Smoker, DN, DR, DPN, Intermittent Claudication, Foot care, and their RRs were 1.87, 1.08, 1.21, 1.77, 2.97, 2.98, 2.76, 3.77, 0.38, respectively. The total score of all risk factors was 80 points according to their weightings. The prediction model showed good discrimination with AUC = 0.798 (95 %CI 0.738-0.858). At the optimal cut-off value of 46.5 points, the sensitivity, specificity and Youden index were 0.769, 0.798 and 0.567, respectively. The final model stratified the validation cohort into low, low-intermediate, high-intermediate and high-risk groups; Compared with low-risk group, the RR with 95 %CI of developing DFU in high-intermediate and high-risk group were 17.23 (5.12-58.02), p < 0.01 and 46.11 (5.16-91.74), p < 0.01, respectively.

CONCLUSION

We have developed a simple tool to facilitates early identification of patients with diabetes at high risk of developing DFU based on scores. This simple tool may improve clinical decision-making and potentially guide early intervention.

Predictors of Foot Ulcers Among Diabetic Patients at a Tertiary Care Center, Egypt

BACKGROUND AND PURPOSE

Diabetic foot ulcers (DFUs) markedly contribute to morbidity and mortality of diabetic patients. Hence, this study was conducted to investigate the predictors of foot ulcers among Egyptian diabetic patients.

METHODS

A case-control study was conducted among 488 diabetic patients attending the inpatient departments and outpatient clinics at the National Diabetes Institute in Egypt. A pretested data collection sheet was designed to collect and record the following: socio-demographic data, diabetic history and lifestyle characteristics, recorded comorbidities, and the results of foot examination.

RESULTS

Significant positive predictors of DFUs on multivariate logistic regression analysis included presence of three or more comorbidities; two or more diabetic complications; callus; and flatfoot. Significant protective (negative) predictors were management of diabetes by diet, oral hypoglycemic drugs (OHGs), and insulin; and intact vibration sense.

CONCLUSION

Significant positive predictors of DFUs on multivariate analysis were presence of three or more comorbidities, two or more diabetic complications, callus and flatfoot, while protective predictors were management of diabetes by diet, OHGs, and insulin; and intact vibration sense. Hence, close monitoring should be provided to diabetic patients with comorbidities and complications to reduce the risk of DFUs.

Risk factors of diabetic foot ulcer in patients with type 2 diabetes: a retrospective cohort study

The aim of this study is to investigate the risk factors of diabetic foot ulcer (DFU) in patients with Type 2 diabetes. Baseline characteristics of DFU-free patients with Type 2 diabetes were retrospectively collected and DFU was identified during the follow-up. Incidence of DFU was calculated and cumulative incidence was estimated by Kaplan-Meier method. Cox regression model was used to explore factors associated with DFU. A total of 980 patients were included with a median follow-up time of 28.7 months. 259 (26.4%) patients developed DFU with an incidence rate of 11.3 per 100 person-years. The cumulative incidences of DFU at 1 year and 2 years during the follow-up were 5.4% (95% CI 3.9-6.9%) and 14.1% (95% CI 11.7-16.5%), respectively. Cox regression analysis indicated that factors associated with developing DFU included age (hazard ratio (HR)=1.06, 95% CI 1.05-1.07, per 1-year increase), body mass index (HR=1.05, 95% CI 1.02-1.07), higher level of education (HR=0.77, 95% CI 0.60-0.98), hypertension (HR=1.90, 95% CI 1.47-2.45), hyperlipidemia (HR=2.63, 95% CI 2.02-3.43), coronary heart disease (HR=2.88, 95% CI 2.22-3.75), heart failure (HR=2.47, 95% CI 1.91-3.20), stroke (HR=2.44, 95% CI 1.86-3.19), diabetic retinopathy (HR=1.86, 95% CI 1.40-2.48), diabetic kidney disease (HR=1.89, 95% CI 1.41-2.53), diabetic neuropathy (HR=1.73, 95% CI 1.31-2.30), poor glycemic control (HR=1.13, 95% CI 1.07-1.19, per 1% glycosylated hemoglobin increase), and course of diabetes (HR=1.01, 95% CI 1.00-1.01, per 1-month increase). The results showed a relatively high incidence of DFU, and revealed several baseline characteristics identified as risk factors of developing DFU.

Correlation Between Extracutaneous Microvascular Complications and Diabetic Foot Ulcers in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes is a metabolic disease that is taking an epidemic proportion around the world. The occurrence of microvascular complications and diabetic foot ulcer is associated with an increased mortality and morbidity incidence, which is the most serious complication of this disease, which significantly reduce the quality of patient life.

OBJECTIVE

The aim of the study was to determine the correlation of extracutaneous microvascular complications with diabetic foot ulcer in patients with type 2 diabetes.

METHOD

The study was prospective, and included 160 patients with type 2 diabetes. It was conducted at the University Clinical Center of the Republic of Srpska in the period from January 2016 until December 2019. The respondents were adults, of both sexes, suffering from type 2 diabetes, in whom complications of this disease are present. Glycemic control was established based on a target HbA1c value of 7%.

RESULTS

Of the 160 patients in the study, 53.8% were men and 46.2% were women. The average age of the patients was 70.11%±10.05 years. Extracutaneous microvascular complications were present in 85 patients (53.1%); of which 30.2% had well-regulated glycemia (HbA1c≤7.0%), while 61.5% (p<0.001) had unregulated glycemia (HbA1c≥7.0). Polyneuropathy was present in 23.3% of patients with HbA1c≤7.0%, while 41.0% of patients had HbA1c≥7.0% (p<0.043). Nephropathy with HbA1c≤7.0% was present in 36.8% of cases compared to patients with HbA1c≥7.0 in whom the prevalence was 36.8% (p<0.004). Out of total, 25.6% had retinopathy with HbA1c≤7.0%, while in 41.9% of patients with HbA1c≥7.0% (p <0.067). Diabetic ulcer foot was present in 13 patients with HbA1c≥7 (11.1%) compared to patients with HbA1c≤7.0% where there was no occurrence of this complication 0.0% (p<0.021). At the same time, 5.6% of patients had a diabetic foot ulcer with polyneuropathy (p=0.010), 4.4% had neuropathy (p=0.058) and 5.6% had retinopathy (p=0.014).

CONCLUSION

The high incidence of extracutaneous microvascular complications and diabetic foot ulcer in patients with type 2 diabetes requires a multidisciplinary approach of medical professionals that includes prevention of risk factors and good regulation of glycemia.