The Journal of Diabetic Foot Complications

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Prevalence of Diabetic Foot Ulcer and Associated Risk Factors in Diabetic Patients From North India. Authors:

Shailesh K. Shahi M.Sc.1, *Ashok Kumar M.Sc., Ph.D 1; Sushil Kumar M.Sc., Ph.D.2; Surya K Singh MBBS, MD,DM3, Sanjeev K. Gupta MBBS, MS,DNB, FRCS4 , T.B Singh M.Sc., Ph.D.5

The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 3, No. 4, Pages 83-91 © All rights reserved.

Abstract: Objectives: This study aimed to prospectively determine risk factors for foot ulceration in diabetic cases of North India. Research Design and Method: This was an observational study where 678 diabetic patients were examined, of which 97 reported diabetic foot ulcers (DFUs). Patients were interviewed using a pre-tested structured questionnaire to document clinical history. Statistical analysis was performed using SPSS 16.0 software. Results: Prevalence of DFUs among diabetic patients was 14.30% (95% CI=11.67-16.94). Of 581 patients suffering from diabetes alone, 42.16% (95% CI 68.17-77.67) belonged to rural areas whereas among the cases with DFUs (n 97), 70.10% belonged to rural areas. In a multivariate logistic regression model, important risk factors for DFUs included age >50 years (OR- 6.97, P = 0.00), duration of diabetes 4 to 8 years (OR = 2.47, P = 0.00) and > 8 years (OR=3.03, P = 0.00), rural location (OR = 0.44, P = 0.00), oral hypoglycemic treatment (OR = 2.90, P = 0.00), insulin treatment (OR = 9.58, P = 0.00), and tobacco use (OR= 0.57, P = 0.00). Conclusion: A high prevalence of foot ulcers was confirmed among North Indian rural diabetic patients. Age, duration of diabetes, tobacco use, oral hypoglycemic treatment/insulin use and rural location were identified as important risk factors. Key words: Diabetes, Diabetic foot ulcer, Risk factors, Amputation, North India. Corresponding author:

Affiliations:

Prof. Ashok Kumar School of Biotechnology Banaras Hindu University Varanasi-221 005, India Tel. No.: 091-542-2368331/6701593 Fax No.: 091-542-2368693/2368174 Email: [email protected]

1. School of Biotechnology, Banaras Hindu University, Varanasi, India. 2. School of Pharmacy, University of Colorado, Denver, Colorado, USA . 3. Department of Endocrinology and Metabolism, 4. Department of General Surgery,. 5. Division of Biostatistics, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.

I

ntroduction

India with approximately 42 million cases is ranked first in the list of the ten nations most affected with diabetes1, 2. Among diabetes mellitus related complications, foot ulceration is the most common, affecting approximately 15% of diabetic patients during their lifetime2. This can be attributed to several social and cultural practices such as barefoot walking, inadequate facilities for diabetes care and education, and poor socioeconomic conditions3. Limb amputa-

tion has a major impact on the individual, not only in distorting body image, but also with regard to loss of productivity, increasing dependency, and costs of treating foot ulcers if patients require inpatient care4. Sporadic qualitative research suggests that diabetic foot ulceration has a profound social impact with patients reporting stigma, social isolation, loss of social role, and unemployment5.

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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91

Foot ulceration is preventable, and relatively simple interventions can reduce amputations by up to 80%. Good control of hemoglobin, blood pressure, and lipid levels are well established as being crucial elements in the reduction of risk for complications of diabetes6,7. Regular evaluation and early treatment are the most effective mechanisms to prevent the devastating diabetic foot complications. Unfortunately, the majority of patients admitted to the hospital for diabetic foot complications receive a less than adequate lower extremity evaluation8. Though there is an obvious increase in diabetic foot care awareness, there are tremendous gaps in routine foot evaluations. To achieve

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such aims, early detection of the foot at risk should be afforded a high clinical priority. Our interest in identifying the prevalence of risk factors aroused mainly due to the fact that the number of cases attending to university hospital with diabetic foot ulcers (DFUs) has increased tremendously during the last 3 to 4 years. Furthermore, little, if any, study has been made to assess the involvement of risk factors in diabetic foot infection among the patients of North India. To our knowledge, this is probably the first report wherein a hospital-based survey from North India was conducted to evaluate the role of risk factors involved in DFUs.

ubjects and methods

This study was conducted in collaboration with the School of Biotechnology and the Department of Endocrinology and Metabolism, and the Department of General Surgery at Sir Sunderlal Hospital, Institute of Medical Sciences. The study was conducted after seeking prior approval of the ethical committee of the institute (Ref. No. Dean/2006-07/1091 dated April 21, 2007). Prior written consent was taken from every recruited patient. In total, 678 diabetic patients attending to the hospital were examined and 97 were diagnosed and treated for diabetic foot lesions between January 2009 and December 2010. Diabetes was diagnosed following the criteria of the World Health Organization of a fasting venous plasma glucose >7.0 mmol/l or a 2 hr post-prandial venous plasma glucose level of >11.1 mmol/l using the glucose oxidase method9. Patients were interviewed using a pre-tested structured questionnaire to document clinical history namely family/social history, age, sex, routine habits (smoking, tobacco chewing and alcohol intake), duration of diabetes and diabetic foot, treatment, and causes of foot ulcer. Patients were critically asked to provide details related to the duration of the diabetic foot ulcer and possible causative factors if they were able to sense the presence of the foot ulcer before it’s actual appearance. Physical examination was performed to identify

associated medical complications such as edema, cellulitis, Wagner grading, hypertension, nephropathy, retinopathy and sensory neuropathy in DFU patients. Both feet were examined in search of signs of vasculopathy (edema, discoloration, decreased hair growth), and foot lesions. Foot lesions were classified using the Wagner grading system10. Diabetic foot infection was assessed for non-limb-threatening infections and limb-threatening infections. Clinically, nonlimb-threatening infections are usually seen with ulceration, which is typically superficial. Limbthreatening infections have cellulitis that extends greater than 2 cm. Sensory neuropathy was determined by Semmes-Weinstein 10 g monofilament test over four plantar sites for both feet as recommended by the lower extremity amputation prevention program11. Nephropathy was considered positive when the serum creatinine was 1.5 mg/dl or more, or persistent proteinuria of 0.5 g or more daily. Retinopathy was considered positive when simple or proliferative retinopathy was observed at fundus examination. Cardiac status was determined by coding of a standard 12-lead ECG using the cardiac ischemic injury score12. For the univariate analysis the chi-square test and student t-test were used. Multivariate binary logistic regression analysis was done considering that the diabetic foot ulcers are 84

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91

affected by all the potential risk factors. All the significant predictors of DFUs of the univariate analysis were included in the multivariate regression model. The 95% confidence interval (CI) was calculated wherever found appropriate.

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P-values less than 0.05 were considered significant at two tailed tests. Statistical analysis was performed using SPSS 16.0 software Windows version (Inc., Chicago, USA).

esults

Routine examination of 678 diabetic (type 2 diabetes 87%) patients revealed the prevalence of diabetic foot ulcers in 97 (14.30%) subjects (95% CI=11.67-16.94). Among patients

with diabetes only (n 581) 65.74% were male and 34.25% belonged to the female group. Of the 97 DFU cases, 71.13% were male and 28.86 % female (Table 1). With diabetic foot (n 97) 55.26 ± 12.10

Student t / Chi squire test

P value

Age (years)

Without diabetic foot (n 581) 47.76 ± 8.32

t=7.63

0.000

Duration of diabetes (years)

7.59 ± 4.86

11.5 ± 5.74

t=7.13

0.000

Duration of foot ulcer (weeks)

-

11.88 ± 25.40

-

-

Male (n)

382 (65.74)

69 (71.13)

Female (n)

199 (34.25)

28 (28.86)

1.8

0.300

Rural (n)

245 (42.16)

68 (70.10)

Urban (n)

336 (57.83)

29 (29.90)

26.1

0.000

Smoking habit (yes/no)

86 (14.80)

21 (21.64)

2.93

0.067

Tobacco chewing (yes/no)

63 (10.84)

32 (32.98)

33.84

0.000

Alcohol intake (yes/no)

91 (15.66)

12 (12.37)

0.7

0.403

Smoking +Tobacco chewing (yes/no)

18 (3.09)

5 (5.15)

1.07

0.300

Smoking + Alcohol intake (yes/no)

69 (11.87)

7 (7.21)

1.81

0.180

Tobacco chewing + Smoking + Alcohol intake (yes/no)

12 (2.06)

3 (3.09)

0.41

0.524

Oral anti diabetics (yes/no)

285 (49.05)

13 (13.40)

42.89

0.000

Insulin treatment (yes/no)

23 (3.95)

84 (86.59)

427.1

0.000

Diet treatment only (yes/no)

273 (46.98)

-

Recurrent ulcer (n)

-

16 (16.49)

-

-

Major amputation (above ankle, n)

-

1 (1.03)

-

-

Digital amputation (n)

-

13 (13.40)

-

-

Syme’s amputation (n)

-

1 (1.03)

-

-

Ulcer of the patients healed (n)

-

91 (93.81)

-

-

Patients left hospital against medical advice(n)

-

6 (6.18 )

-

-

Parameters

-

Table 1: Descriptive profiles of patients with diabetic status. advice(n) | Value in parenthesis indicates percentage.

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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91

Diabetic patients with DFUs were older (mean age, 55.26 ± 12.10 years) than patients without DFUs (mean age, 47.76 ± 8.32 years, p = 0.00). The mean duration of diabetes was higher in DFU cases (11.5 ± 5.74 years) than patients having no sign of DFUs (7.59 ± 4.86 years, p = 0.00). Out of 581 patients having diabetes alone, 42.16% belonged to rural areas and 57.83% were from urban areas. On the other hand, in the DFUs group 70.10 % cases belonged to rural areas and 29.90 % were from urban areas. The risk of DFUs was higher in patients of rural areas than in urban diabetic patients (p = 0.00). Those using oral hypoglycemic/insulin were at a higher risk of developing DFUs. The use of a hypoglycemic agent was significantly associated with DFUs (p = 0.00). Data of daily habits in terms of smoking, tobacco chewing and alcohol intake showed relatively higher percentage of subjects suffering from DFUs as compared to those having normal habits (Table 1). Among the data of daily habits, risk of DFUs was significantly associated with tobacco chewing diabetic patients (p = 0.00). (Table 1). In a multivariate regression analysis using logistic regression with age and duration of diabetes as a quantitative variable and rural location, tobacco use, oral hypoglycemic/insulin treatment as categorical variables, a significant positive association of the age, duration of diabetes, tobacco chewing habit, insulin use and rural location was found (Table 2). A multiple logistic regression analysis of the risk factors for the DFUs was performed using all the significant risk factors at the univariate level. This analysis showed that all the variables mentioned in Table 2 were independent risk factors of DFUs (p < 0.05 for all). Odds ratio for each risk factor is presented in Table 2. A stepwise logistic regression model was used to determine the most significant independent risk factors of DFUs. Results are shown in Table 3. The percentage value of sensitivity 95.7 and specificity 93.8 respectively for risk of foot ulcers clearly indicated the overall involvement of risk factors for DFUs.

Manifestation of limb lesions Critical examination of limbs showed that the majority of patients suffered with mixed lesions (abscess, cellulitis and gangrene). The incidence

Open access publishing P value OR

Significant parameter

95% CI

1

Age < 50 years (ref.)

-

Age ≥ 50 years

0.00

Duration of diabetes 0-4 years (ref.)

-

Duration of diabetes 4-8 years

0.00

2.47

Duration of diabetes ≥ 8 years

0.00

3.03

Location (Urban/Rural)

0.00

0.44

0.19-1.02

Tobacco

0.00

0.57

0.20-1.55

Nil (ref.)

-

Oral hypoglycemic

0.00

2.90

Insulin

0.00

9.58

6.97 1

1

Table 2: Multivariate logistic regression analysis for the risk factors associated with diabetic foot ulcer.

Factors

Sensitivity Specificity

Overall accuracy

Insulin

96.0

86.6

94.7

Insulin + duration of diabetes

94.8

95.9

95.0

Insulin + duration of diabetes + age

95.0

95.9

95.1

Insulin + duration of diabetes + age + location

95.7

93.8

94.4

Table 3: logistic regression analysis for DFUs.

of ulcer was highest (100%), followed by cellulitis (97.93%) and gangrene (14.43%). Further assessment revealed that 56.70% of patients had limb-threatening ulcers while 43.29% had nonlimb-threatening ulcers. Localization of the ulcers The location of ulcers was maximum in the right lower limb (below ankle, n-51) followed by the left lower limb (below ankle, n-37), and right limb above the ankle (n-8). The lowest frequency was noticed in the left limb above the ankle (n-7). Of all patients, 6 had ulcers involving more than one limb (both limbs/ below or above ankle) bringing the total number of ulcers to 103 in 97 patients.

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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91

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History of limb ulcer/gangrene

Duration and grade of ulcers

Our survey of 97 DFUs patients revealed that 16 (16.49%) had suffered from foot ulcer previously. Among these, 10 (10.30%) had ulcers in the right lower limb (below ankle), 5 (5.15%) in the left lower limb (below ankle), and one (1.03%) in the left upper limb (above ankle). Furthermore, two (2.06%) had undergone amputations, and 11 (11.34%) suffered from the complications of gangrene.

Data of Table 4 show the duration of ulcers, the value was obtained from all the patients at the time of recruitment and their first visit to S.S. hospital. It is evident that the mean duration of ulcers was 11.88 ± 25.40 weeks. Critical examination of ulcers for grading revealed that the percentage of grade III lesion was highest (31.06%) followed by grades II and IV (Table 5). Interestingly, data based on daily habit of subjects revealed that the percentage of grades III and IV ulcers was significantly higher in those patients who were habitual of chewing tobacco, smoking and/or alcohol intake. Of all the patients, the percentage of III and IV grades of ulcers was highest in those who were habitual of smoking and chewing tobacco daily (Table 5). As such, the percentage of grade III ulcer (66.66%) alone was highest in those patients who were habitual of smoking, chewing tobacco and drinking alcohol every day.

Factors involved in the appearance of limb ulcers

Case history of DFU patients revealed that the ulcers evolved spontaneously with no identifiable role of any aetiological factors in 45 (46.4%) cases (Table 4). In the remaining patients, the ulcers resulted from minor trauma, ill fitting shoes, nail puncture etc (Table 4). Expected events

Patients (n=97)

Unknown

45

46.39

Minor trauma

19

19.58

Bulla formation

13

13.40

Ill-fitting shoes

10

10.30

Nail puncture

6

6.18

Burns

2

2.06

Heel crack

2

2.06

Nil (ref.)

-

1

Oral hypoglycemic

0.00

2.90

Insulin

0.00

9.58

Duration of ulcer

Patients (n=97)

1–5

33

34.02

6 – 10

43

44.32

11 -15

4

4.12

16 -20

6

6.18

>20

11

11.34

%

Associated co-morbidities/complications

Sensory neuropathy was the prominent risk factor for DFUs as 73 (75.25%) patients reported it. The prevalence of other co-morbidities namely retinopathy, hypertension and nephropathy was also notable, the values being 43 (44.32%), 29 (29.89%) and 14 (14.43%) respectively in different patients. The incidence of peripheral vascular disease as assessed by Color Doppler and Ankle brachial pressure index (ABPI) measurement was observed in 33 patients (34.02%) of which 8 (8.24%) had gangrene of the foot. Patient Management and Outcomes

%

Table 4: Factors involved in the appearance and duration of diabetic ulcers before presentation.

Insulin and oral hypoglycemic agents were used for diabetic control in all the 97 patients having DFUs. In general, patients were given oral or parenteral antibiotics, topical antimicrobial agents, hypertonic saline soaks, and wound debridement. 42 patients preferred conservative mode of treatment and were discharged for home. However, they were advised to visit the diabetic foot clinic once in a month for follow up. 87 Complete healing of ulcers in all these

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91 Habit

No of Patients

Normal (control) Smokingb

Grade of ulcersa

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II 8 (47.05)

III 3 (17.64)

IV

V

17 (17.52)*

I 5 (29.41)

1 (5.88)

0

21(21.64)

3 (14.28)

5 (23.80)

7 (33.33)

6 (28.57)

0

Tobacco chewingc

32 (32.98)

4 (12.50)

9 (28.12)

12 (37.50)

13 (40.62)

0

Alcohol intake

12 (12.37)

2 (16.66)

3 (25.00)

4 (33.33)

2 (16.66)

1 (8.33)

Smoking+ tobacco

5 (5.15)

0

1 (20.00)

2 (40.00)

2 (40.00)

0

Smoking+ alcohol

7 (7.21)

1 (14.28)

2 (28.57)

2 (28.57)

2 (28.57)

0

Smoking+ tobacco + alcohol

3 (3.09)

0

0

2 (66.66)

1 (33.33)

0

15(14.56)

28(27.18)

d

Total

97

32 (31.06)

27 (26.21)

1(0.97)

Table 5: Factors involved in the appearance and duration of diabetic ulcers before presentation

a. 6 patients had ulcers at more than one locations (both limbs/ upper and/ or lower portions), thereby the total number of ulcers being103. b. Include those patients who smoked < 10 cigarettes/day. c. Patients chewing dried raw tobacco leaf or processed tobacco powder or tobacco mixed in Pan parag and/or betel leaf. d. Include those patients who regularly drink approx. 200 ml ethanol per week. *Value in parenthesis indicates %.

cases was noted in 6-15 weeks. Six (6.18%) patients left hospital against medical advice for various reasons. Patients with diabetes alone were treated by traditional means mostly by oral anti-diabetic agents but those having very high level of bloodglucose were subjected to take insulin therapy. Fifty-five patients suffering from grades III to V DFUs were admitted and administered parenteral antibiotics following investigations of microbiological profile and culture sensitivity of the pathogenic organisms (obtained by deep wound biopsies). For the management of diabetic foot infection, debridement, drainage, and washing and dressing of wounds were regularly done. Antibiotics used included cefoperazone, linezolid, clindamycin, metronidazole, aminoglycosides, meropenem, and amoxicillin-clavulanic acid. The average time

D

required for healing of ulcers was 28 weeks (range 12-62 weeks). However, fifteen (15.47 %) patients underwent amputation during the course of this study. One underwent major amputation (amputation above the ankle), the remaining underwent minor amputations (below the ankle), mainly of the ray (n-5), toes (n-8) and 1 Syme amputation. (Table 1). The average duration of hospital stay for patients admitted for amputation was 12 weeks (range 6 to 20 weeks). The ulcers healed satisfactorily in 93.81% patients but required outpatient wound care. Patients were advised on foot care including appropriate selection of foot wear and the importance of regular checkups by their primary care physician. The importance of good glycemic control was repeatedly emphasized. All the patients were encouraged to visit hospital (diabetic foot clinic) for regular follow-up.

iscussion

This study shows that a large number of diabetic patients (14.30%) admitted to SS Hospital, Banaras Hindu University, Varanasi, have DFUs. Previous studies have reported the prevalence of DFUs in the range of 5.3-10.5% among diabetic patients13,14. However, a higher percentage (above 14%) of DFUs has been reported from a hospital-based survey conducted in Nigeria15. Our findings are similar to the study conducted in Nigeria. This might be due to similarities in the level of healthcare management and socio-economic status of the subjects

of both the country. The occurrence of DFUs mostly in males and middle aged subjects has been reported by several researchers14,15. In the present study, we found 71.13% of males and 28.86% of females with a mean age of 55.25 years having DFUs and thus support the findings of previous workers. The increase in DFUs among diabetic patients is worrying for individual families as males are the backbone and the sole earning members of the family, particularly in India.

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Recent studies conducted in rural areas of Kerala, Maharashtra and Andhra Pradesh have suggested that the prevalence of diabetes has increased from around 1.9% to 3–12%, and even 13.2% in one study1,16,17. Our study aimed to reveal the prevalence of DFUs in diabetic patients and the results obtained showed that diabetic patients hailing from rural areas are more prone to foot ulcers (70.10 %) than those living in urban areas (29.90 %). This may be due to the fact that individuals in rural areas of India often sleep in huts, farm houses, or outdoors on the farm. These people are commonly subject to rodent bites, especially to the feet of patients with diabetes which can lead to chronic ulcers. Another common factor in farmers is barefoot walking, which can result in damage to the feet by sticks and thorns. Additionally, many rural people, especially monks and devotees, walk barefoot on roads as part of a religious ritual. The resultant burns, especially on the feet of patients with diabetes, can lead to chronic ulcers13. A close observation of localization of lesions revealed that calluses developed at zones of high pressure, and this is consistent with earlier reports18. Several reports suggest that patients with diabetes and peripheral neuropathy are at a higher risk of plantar ulcers due to excessive localized pressures. In fact higher peak pressure has been related to a higher risk of ulceration in the forefoot in retrospective studies18,19. However, it has also been reported that foot structure and certain deformities affect plantar pressure. We could not study foot deformities, but localization of ulcers was noted at places other than the places of localized pressure. We found that 51.67% of ulcers affected the right lower limb and 37 % in left lower limb. To a certain extent, our findings differ from the study of Unachukwu et al15 wherein 43.33% and 53.33% of ulcers were noted in the right and left lower limb, respectively. This discrepancy could be due to the differences in the number of subjects enrolled in the present study.

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Findings pertaining to grade of ulcers in patients with habits of smoking, chewing tobacco and alcohol intake seem very interesting. The percentage of grade III and IV ulcers was higher in subjects habitual of either smoking, chewing tobacco or alcohol consumption as compared to those with normal habits. It is hard to explain the incidence of a very high percentage of grade III and IV ulcers in these patients in view of the report that smoking or intake of alcohol does not appear to be risk factor for DFU14. It is possible that smoking, chewing tobacco or alcohol consumption by patients some how affect the control of glucose level which in turn causes long duration of hypoglycemic status. Most probably, uncontrolled glucose level delays wound healing and results in severity of ulcers and appearance of grade III and IV ulcers. It would be worthwhile to estimate blood sugar level in diabetic patients with or without DFUs but addicted with smoking, tobacco chewing and/or alcohol intake. Involvement of several risk factors in the formation of DFUs has been reported by various researchers13,14,20. More commonly, long duration and poor metabolic control of diabetes are thought to increase the risk of chronic complications21. Our findings demonstrate that older age, fairly long average duration of diabetes (11.50 years), patients of rural areas, tobacco chewing and hypoglycemic treatment are independently associated risk factors for the development of foot ulcers. Additionally, certain patients probably had diabetes and DFUs for longer durations but ignored treatment or were not properly treated. They visited the hospital for the first time. A similar trend has been reported from Nigeria25. There are reports which suggest that neuropathy and ischemia are the major risk factors for DFUs. Other risk factors namely age, sex (male), foot deformities, nephropathy, retinopathy, co-morbidities such as heart diseases and hypertension, previous amputation of one limb and HbA1c are also regarded as contributory factors for DFUs14,21. We observed positive associations for age, duration of diabetes,

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tobacco chewing, insulin use and rural location with diabetic foot complications. Additionally, the role of sensory neuropathy as a risk factor for diabetic foot complications seems important. More than 75% of subjects in the present study had sensory neuropathy; this is indeed worrying because such patients could endure minor trauma without being aware of the injury until it worsens. This puts their feet at increased risk for mechanical and thermal trauma. It has been suggested that with an improved health education program offering advice on protection in the home and at work, good hygiene, and physical examination (using mirrors to examine feet may help), patients and physicians may help to alleviate this complication. Findings of the present study also point to the role of nephropathy as an independent risk factor in diabetic foot patients, as is consistent with other reports22, 23. An increased risk of DFUs with diabetic nephropathy was detected by the American Diabetes Association consensus group. This group also showed an increased risk of nonvascular DFUs including 40% of the patients with chronic renal failure24. Previous ulceration and amputation have been recognized as risk factors for subsequent diabetic limb ulceration. It is presumed that patients with history of ulceration possess all the risk factors necessary to produce another ulceration. It has been reported that between 20-58% of patients develop another ulcer within a year after healing a wound26. Findings of the present study partly support the report of earlier workers where role of previous ulceration and amputa-

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tion have been recognized as risk factors for the development of new ulcers26. Improved blood-glucose control is the key to primary prevention of diabetes related complications such as DFUs26,27. Together with this, regular monitoring of blood-glucose level is also essential for management of DFUs. In this study, strict instructions as well as hospitalization proved useful in managing glucose levels in all the patients either by oral anti-diabetic agents or insulin. Emphasis was also given to prevent foot infection. This was managed by means of frequent debridement, drainage, and washing and dressing, along with antibiotic therapy. In a previous study, we reported that prior evaluation of bacterial flora and their antibiotic sensitivity is crucial in selection of potent antibiotics for management of DFUs28. With prior assessment of bacterial flora and antibiotic sensitivity testing, it was possible to manage wound healing in 91 subjects. However, 15 (15.46%) subjects had to undergo amputation and they did not show further complications. It is pertinent to mention that all these subjects had very deep wounds and had a history of long duration of uncontrolled blood-glucose levels. Altogether our findings clearly show that the management of DFUs could be achieved through control of bloodglucose levels, as well as prevention of infection and assessment of microbial flora before administration of antibiotics. Patients’ education is of utmost importance for the management of diabetes and its related complications.

onclusion

Our study confirmed the high prevalence of foot ulcers amongst diabetics in the rural population of North India. Foot ulcers were often associated with abscess, cellulitis and gangrene, thus requiring hospitalization. The study also identified some important risk factors for DFUs including older age, long duration of diabetes, tobacco chewing, insulin administration and rural location of patients. Sensory neuropathy and previous ulceration were also found to

be important risk factors for diabetic foot complications. It is felt that knowledge of the risk factors is of paramount importance for early and better management of DFUs. There is a need to educate and create awareness about diabetes and its complications, especially amongst rural populations. Findings of this study are relevant to the national policy makers for planning better means to fight the epidemic of diabetes and 90 DFUs.

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91

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cknowledgements

S K Shahi is grateful to ICMR, New Delhi (India), for the award of Senior Research Fellowship (80/622/2009-ECD-1). SK is grateful to

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University Grants Commission, New Delhi, India, for the award of Junior Research Fellowship.

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