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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:
ntroduction
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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
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 its actual appearance.
Physical examination was performed to identify
The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
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
Student t /
Chi squire test
P value
Age (years)
t=7.63
0.000
7.59 4.86
11.5 5.74
t=7.13
0.000
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
86 (14.80)
21 (21.64)
2.93
0.067
63 (10.84)
32 (32.98)
33.84
0.000
91 (15.66)
12 (12.37)
0.7
0.403
18 (3.09)
5 (5.15)
1.07
0.300
69 (11.87)
7 (7.21)
1.81
0.180
12 (2.06)
3 (3.09)
0.41
0.524
285 (49.05)
13 (13.40)
42.89
0.000
23 (3.95)
84 (86.59)
427.1
0.000
273 (46.98)
16 (16.49)
1 (1.03)
13 (13.40)
1 (1.03)
91 (93.81)
6 (6.18 )
Parameters
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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
Significant parameter
95% CI
Age 50 years
0.00
0.00
2.47
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
Factors
Sensitivity Specificity
Overall
accuracy
Insulin
96.0
86.6
94.7
94.8
95.9
95.0
95.0
95.9
95.1
95.7
93.8
94.4
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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
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
6.18
Burns
2.06
Heel crack
2.06
Nil (ref.)
Oral hypoglycemic
0.00
2.90
Insulin
0.00
9.58
Duration of ulcer
Patients
(n=97)
15
33
34.02
6 10
43
44.32
11 -15
4.12
16 -20
6.18
>20
11
11.34
Associated co-morbidities/complications
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
II
8 (47.05)
III
3 (17.64)
IV
17 (17.52)*
I
5 (29.41)
1 (5.88)
21(21.64)
3 (14.28)
5 (23.80)
7 (33.33)
6 (28.57)
Tobacco chewingc
32 (32.98)
4 (12.50)
9 (28.12)
12 (37.50)
13 (40.62)
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)
1 (20.00)
2 (40.00)
2 (40.00)
Smoking+ alcohol
7 (7.21)
1 (14.28)
2 (28.57)
2 (28.57)
2 (28.57)
3 (3.09)
2 (66.66)
1 (33.33)
15(14.56)
28(27.18)
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
iscussion
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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
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The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
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
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DFUs.
The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 3, No. 4, Pages 83-91
cknowledgements
eferences
20) Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR,
Smith DG. A prospective study of risk factors for diabetic foot ulcer.
The Seattle diabetic foot study. Diabetes Care 1999; 22:1036-1042.
21) Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel
CS, Lipsky BA. Risk factors for foot infections in individuals with
diabetes. Diabetes Care 2006; 29: 1288-1293.
23) Carlson T, Reed JF. A case-control study of the risk factor for toe
amputation in a diabetic population. Int J Low Extrem Wounds 2003;
2:19-21.
10) Wagner FW. The dysvascular foot: a system for diagnosis and
treatment. Foot Ankle 1981; 2: 64-122.
11) Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic
wound classification system. The contribution of depth, infection, and
ischaemia to risk of amputation. Diabetes Care 1998; 21:855-859.
12) Rautaharju PM, Warren JW, Jain U, Wolf HK, Nielsen CL.
Cardiac infarction injury score: an electrocardiographic coding
scheme for ischaemic heart disease. Circulation 1981; 64:249-256.
13) Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003;
361: 1545-1551.
14) Merza Z, Tesfaye S. The risk factors for diabetic foot ulceration.
The Foot 2003;13: 125-129.
15) Unachukwu C, Babatunde S, Ihekwaba EI. Diabetes, hand
and/or foot ulcers: A cross-sectional hospital-based study in Port
Harcourt, Nigeria. Diabetes Res Clin Pract 2007; 75: 148-152.
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