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Predictors of the outcome of diabetic foot ulcer at Assiut university hospital
 

Predictors of the outcome of diabetic foot ulcer at Assiut university hospital

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Diabetic foot ulcers are a common and much feared complication of diabetes, with recent studies suggesting that the lifetime risk of developing foot ulcer in diabetic patients may be as high as 25% ...

Diabetic foot ulcers are a common and much feared complication of diabetes, with recent studies suggesting that the lifetime risk of developing foot ulcer in diabetic patients may be as high as 25% (Singh et al.,2005).
Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration.
A list of the principal risk factors that might result in foot ulcer development are demonstrated ( Abbott et al ., 2002.)

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    Predictors of the outcome of diabetic foot ulcer at Assiut university hospital Predictors of the outcome of diabetic foot ulcer at Assiut university hospital Presentation Transcript

    • Predictors of the outcome ofdiabetic foot ulcer at Assiut university hospital By Walaa Anwar Muhammad Khalifa M.B.B.CH M.ScFaculty of medicine M.ScFaculty Assiut University Under supervision of Prof. Dr. Lobna Farag Eltoony Professor of internal medicine&head of endocrinology unit Faculty of medicine Assiut University Dr. Mona Muhammad Soliman Lecturer of internal medicine Faculty of medicine Assiut University
    • Introduction Diabetic foot ulcers are a common and much feared complication of diabetes, with recent studies suggesting that the lifetime risk of developing foot ulcer in diabetic patients may be as high as 25% (Singh et al.,2005). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration. A list of the principal risk factors that might result in foot ulcer development are demonstrated ( Abbott et al ., 2002.)
    • Risk factors of foot ulcer1- Previous amputation.2- Past history of foot ulceration.3- Peripheral neuropathy.4- Peripheral vascular disease.5- Foot deformity.6- Visual impairment.7- Diabetic nephropathy.8- Poor glycemic control.9- Cigarette smoking
    •  The most common triad of causes that interact and result in foot ulceration has been identified as neuropathy, deformity and trauma ( Boulton et al., 2004)
    • • The risk of amputation is 15 to 40 times greater in a person with diabetes than in one who doesnt have the disease( Nabuurs et al..2005).
    •  The population of diabetic patients who present with foot ulceration areheterogenous,there are characteristics that may vary among patients, such as the presence of peripheral arterial diseaseinfection,andco-morbidities. Peripheral arterial disease is considered an important predictor of outcome (Prompers et al., 2007).
    •  Therefore. Outcome data on these patients with diabetic foot ulcer are needed such a requirement is underlined by the fact that although diabetic foot ulcers are usually reported and analyzed as one clinical entity marked differences in patient, foot and ulcer characteristics can exist between patients. These observations raise the question of wether predictors of outcome in patients may differ (Prompers et al., 2007).
    • The aim of the study To assess the potential baseline clinical and laboratory characteristics that best predict poor outcome (non healing of the foot ulcer). The main outcome of the study is complete healing of the foot within the maximum follow up period of 1 year. Healing was defined as healing (intact skin) of the whole foot at two consecutive visits.
    • Patients & study design It is a prospective study in which 100 patients with diabetic foot ulcer will be followed and managed for 1 year. About 50 patients are still under research. Patients included were those presenting for the first time with a new foot ulcer within period of 12 months.
    • Excluded patients1- Patients who had been treated for an ulcer on the ipsilateral foot during the previous 12 months.2- Patients with sever end organ failure.3- Patients with gangrenous foot. eg, gas gangrene.
    • Method Data collected prospectively of patients referred to a foot care clinic recorded Data include. Demographics,detailed history and complete physical examination Data on co- morbidities including ( retinopathy nephropathy, hypertension and ischemic heart disease) .
    •  Data on foot examination include. (foot inspection, Pedal pulse, ABI measurement and joint examination). Data on ulcer characteristics. ulcers were classified according to1-PEDIS system. ( perfusion, extent, depth, infection and sensation ) .
    • -2Meggitt- wagner classification of foot ulcersGrade0:Pre- or post- ulcerative lesion completely epithelializedGrade1:Superficial, full thickness ulcer limited to the dermis, not extending to the subcutisGrade 2:Ulcer of the skin extending through the subcutis with exposed tendon or bone and without osteomyelitis or abscessGrade 3:Deep ulcers with osteomyelitis or abscess formationGrade 4:Localized gangrene of the toes or the forefootGrade 5:Foot with extensive gangrene
    • 3- The university of Texas classification 1998 Grade Stage 0 1 2 3 Pre- or post- Superficial Wound Wound A ulcerative wound not penetrating penetrating lesion involving to tendon or to bone or completely tendon, capsule joint epithelailizd capsule or bone With With With With B infection infection infection infection With With With With C ischemia ischemia ischemia ischemia With With With With D infection infection infection infection and and and and ischemia ischemia ischemia ischemia
    •  Laboratory data include Complete blood picture, liver function, urea and creatinine ,24 hrs proteins in urine, creatinine clearance, lipogram and (Hb A1c).
    • Management of diabetic foot ulcerAll Patients were treated According to protocols based on the international consensus on the diabetic foot which include offloading ,diagnosis and treatment of infection, assessment of vascular status and regular wound debridement .
    • Results of 50 patients:In 50 patients: 34 (68%) females ,the mean age 50.76 ± 13.35.
    • Diagram (2) :shows results of patient s om pt m sy c hi at op ur ne p y ra characteristics e th lin su in n tio ta pu am of y or st hi st pa s er ok sm n- no 0 50 40 30 20 10 no. of cases
    • Diagram(3):shows results of foot inspection
    • Table(1)Baseline characteristics of patients with healed and unhealed ulcers Healed Unhealed Total Variable P-value (n= 31) (n= 19) (n= 50) Age: 47.39 ± 11.42 56.26 ± 16.76 50.76 ± 13.35 0.021 Sex: Males n% 6(37.5%) 10(62.5%) 16 0.014 Females n% 25(73.6%) 9(26.4%) 34 Smoking (n%) 2(20.0%) 8(80.0%) 10 0.007 BMI 31.64 ± 3.88 29.21 ± 5.60 30.72 ± 4.71 NS Diabetes duration: < 10 years 22(84.6%) 4(15.4%) 26 0.001 ≥ 10years 9(37.5%) 15(62.5%) 24 Insulin use (n%) 25(61.0%) 16(39.0%) 41 NS Retinopathy (n%) 10(50%) 10(50%) 20 NS Hypertension 10(47.6%) 11(53.4%) 21 NS Ischemic heart disease 6(42.9%) 8(57.1%) 14 NS Nephropathy 6(35.3%) 11(64.7%) 17 0.005
    • Table(2)Baseline characteristics of ulcer examination andrelation to healing Variable Healed( n=31) Unhealed n=19 Total P-value Sever neuropathy(n % 4(30.7%) 9(69.3%) 13 0.018 ABI 0.93±0.05 0.75±0.09 0.86±0.8 0.000 Colour change (n%) 1(10%) 9(90.0%) 10 0.001 Superficial infection 8(53.3%) 7(46.7%) 15 NS Deep infection 2(20%) 8(80%) 10 0.007 Ulcer site: For foot 10(32.2%) 3(15.8%) 13 NS Mid foot 4(12.9%) 4(21%) 8 NS Hind foot 6(19.3%) 7(36.8%) 13 NS Toes 8(25.8%) 4(21%) 12 NS Dorsum 3(9.6%) 1(5.2%) 4 NS Ulcer extent 1-5cm 23(76.7%) 7(23.3%) 30 0.009 >5cm 8(40.0%) 12(60.0%) 20 Ulcer duration <1 week 15(88.3%) 2(11.7%) 17 0.001 1 week-3months 13(68.4%) 6(31.6%) 19 >3 months 3(21.4%) 11(78.6%) 14
    • Base line characteristics of ulcer examination and relation to healing(cont.) Variable Healed Unhealed Total p. value Ulcer depth (n%) Grade.1 16(88.9%) 2(11.1%) 18 0.005 Grade.2 13(54.2%) 11(45.8%) 24 Grade.3 2(25.0%) 6(75.0%) 8 Texas class. (n%) 1A+2A 21(84%) 4(16%) 25 0.001 2D+3D 1(10.0%) 9(90.0%) 10 0.001 Wagner class. (n%): Grade 1 16(88.9%) 2(11.1%) 18 0.001 Grade 2 13(59.1%) 9(40.9%) 22 Grade 3 2(20%) 8(80%) 10
    • Table (3) aboratory data and relation to healing Variable UnHealed n=19 Healed n=31 P-valueUrea mmol/L 8.09 ± 2.63 6.68 ± 1.94 NSS.Creatinine umol/L 206.63 ± 165.50 93.36 ± 36.60 0.001Cr.Clearance ml/min 56.25 ± 32.07 92.53 ± 27.18 0.00024 hr protein in urine mg/l 442.42 ± 226.22 229.71 ± 149.42 0.000WBCS k/ul 11.39 ± 3.90 7.33 ± 2.04 0.000Hgb gm/dl 10.11 ± 1.73 11.62 ± 1.08 0.004Platelets k/ul 247.00 ± 28.93 235.10 ± 27.07 NSHb A1c H% 12.88 ± 2.03 8.06 ± 0.99 0.008Serum albumin g/l 26.28 ± 5.87 30.69 ± 4.37 0.004Bilirubin umol/l 11.31 ± 3.05 10.97 ± 2.61 NSALT Iu/l 20.31 ± 4.81 15.72 ± 6.20 NSAST Iu/l 18.03 ± 6.46 16.65 ± 5.95 NSS. Cholest mg/dl 228.47 ± 67.16 189.39 ± 45.35 0.010TG mg/dl 162.56 ± 40.69 139.42 ± 87.64 0.000HDLmg/dl 37.49 ± 8.07 43.15 ± 8.60 0.000LDLmg/dl 113.42 ± 29.78 95.92 ± 16.14 0.048
    • Table (4)Multivariate regression analysis of predictor.variables towards unhealing Outcome: unhealing Predictor variable Sig. OR 95.0%C.I.Duration of diabetes: > 10 yrs 0.008* 2.16 1.02-2.61Male sex 0.024* 1.11 1.03-2.86Sever p.neuropathy 0.012* 1.13 0.89-1.46Texas grade 2D, 3D 0.004* 1.24 1.15-3.24Wagner grade-3 0.005* 1.18 1.09-2.98>3 months Ulcer duration 0.013* 1.12 1.33-2.85ABI< 0.8 0.006* 1.16 1.05-2.68
    • (Case (1
    • (Case (2
    • (Case (3
    • Case 4
    • Case 5
    • Case 6
    • Unhealed cases
    • Conclusion In conclusion, the major findings from this study are, male sex, duration of diabetes ≥10years, sever pripheral neuropathy, ulcer duration>3month,Wagner grade3,Texas grade2D,3D and limb ischemia as ABI<0.8 independently predict poor outcome (unhealing) of diabetic foot ulcer .
    • References1-Abbot CA , Carrington AL Ashe H , Baths , every l.c Giriffiths J , HannAW,HussainA , JacksonN , Johnson KE . Ryder CH , Tor kingtonR , van Ross ER ,WALLEY AM , WIDDOWS P , Williamsons , Boulton AJ :The north – west diabetes foot care study : inciderce of , and risk factors for newdiabetic foot ulceration in acommunity . based patient cohort . Diabet Med 2002 ,19:377-389 .2-Boulton AJ , kirsner RS , vileikytel : clinical practice: neuropathic diabetic footulcers . NE ngl J Med 2004 , 351:48-55 3-33-Nabuvrs- Franssen M H, Huijberts MS, Nieuwenhuijzn kruseman A C ,Willems J, schaper N C , health- related quality of life of diabetic foot ulcer patientsand their caregivers . Diabefologia 2005 48 : 1906-19104-prompersl , Huijberts M, Apelqvist J : optimal organization of heath careindiabetic foot diseaseintroduction to the eurodiale study . intj low extreme wounds 2007 6:11-176- Singh N , Armstrong DG , lipsky BA : preventing foot ulcers in patients withdiabetes JAMA 2005 293 : 217-228