Incidence Of Diabetic Foot Research Articles

Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers.

SBP variability may be a target for mitigating end-organ damage associated with vascular disease. We evaluated the relationship between increased SBP variability and risk of incident diabetic foot ulceration. Using a nested case-control design, we followed patients diagnosed with diabetes and treated within the US Department of Veterans Affairs Healthcare system for development of a diabetic foot ulcer (event) between 2006 and 2010. Each case was randomly matched to up to five controls based on age, sex, race/ethnicity, and calendar time. SBP variability was computed using at least three blood pressure measurements from the year preceding the event. The association between SBP variability and foot ulceration was examined using conditional logistic regression. Potential protective effects of calcium channel blockers, which blunt SBP variability, were also explored. The study sample included 51 111 cases and 129 247 controls. Compared with those in quartile 1 (lowest variability), patients in quartiles 2-4 had higher adjusted odds ratios for diabetic foot ulcer development: 1.11 (95% CI 1.07-1.16), 1.20 (95% CI 1.15-1.25), 1.29 (95% CI 1.24-1.34) (P for trend <0.001). Calcium channel blockers were associated with reduced risks of ulceration for those without peripheral vascular disease (OR = 0.87, 95% CI 0.84-0.90, P < 0.001) or neuropathy (OR = 0.85, 95% CI 0.82-0.89, P < 0.001) in adjusted subgroup analyses. This study describes a graded relationship between SBP variability and risk of diabetic foot ulceration, providing a potential new and modifiable target to reduce this common complication.

Hubungan Profil Lipid dengan Kejadian Ulkus Kaki Diabetik pada Pasien Diabetes Melitus Tipe 2 RSUP dr. Mohammad Hoesin Palembang

Diabetic foot ulcersare long-term complications of diabetes mellitus that may increase morbidity and mortality, also reduce the quality of life of the patients. One of the causes of diabetic foot ulcers is peripheral arterial disease due to dyslipidemia. This study was conducted to determine the relationships of lipid profile with diabetic foot ulcers in patients with type 2 diabetes mellitus. Analytical observational study with cross-sectional design was conducted in 69 diabetic patients. Data was retrieved secondarily by observing the medical records. Total cholesterol, triglycerides, LDL, HDL, and consumption of lipid-lowering drugs of the patients were all recorded. Documented variables were analyzed using Fisher Exact test if Chi-square test criterias were not fulfilled. There was a significant association between diabetic foot ulcers with total cholesterol (p=0,001) and HDL (p=0,015), while triglycerides (p=0,393) and LDL (p=0,176) did not have a significant association with diabetic foot ulcers.Multivariable logistic regression identified HDL (B=2,221, S.E.=1,131, Wald=3,855, p=0,050, exp(B)=9,220 IK95% 1,004–84,691)as the most influential lipid profile fraction to the incident diabetic foot ulcers. Total cholesterol and HDL had a significant association with diabetic foot ulcers. The most influential lipid profile fraction to the incident diabetic foot ulcers is HDL.

Trends in the epidemiology of diabetic foot and lower limb amputations in Russian Federation according to the Federal Diabetes Register (2013–2016)

BACKGROUND: The epidemiological study of diabetic foot (DF) is very important because of high risk lower limbs amputations in patients with diabetes mellitus (DM).&#x0D; AIMS: The aim of the study was to evaluate the DF prevalence in adult patients with type 1 (T1) and 2 (T2) diabetes in Russian Federation for period 201316years.&#x0D; METHODS: We have used the database of the Russian Federal Diabetes register, 81st regions included in the online register. Indicators were estimated per 10,000 adult DM patients (18years).&#x0D; RESULTS: In 2016, the prevalence of DF in RF was T1 4,7%, T2 1,9%, with marked interregional differences: 0,1519,9%, 0,0710,3%, respectively. The DF prevalence in RF decreased: T1 506,3473,6, T2 214,60194,8. The incidence of new DF cases/per year was stable in adults with T1: 20,820,4/; increased in T2 13.214.2. The mean age of DF diagnosis increased by 2years for both DM types. The average DM duration of DF determine increased T1 15.419.0years, T2 7.410.1years. Proportion of DF forms: neuropathic with trophic ulcer 41.6%, neuropathic form (Charcot's foot) 17.9%, the neuroischemic 28.3%, ischemic 12.2%, in T2: 41.6%, 7,4%, 32,4%, 18,5%, respectively. The amount of new cases of amputations/per year in dynamics: T1 10,512,4, T2 9,610,9, with marked interregional differences 0.132.9% in T1, 0.04-6.0% in T2. The mean DM duration before amputation increased in T1 18.421.3years, in T2 9.19.9. The average amputation age: T1 51.7years, T2 66.2years. There was marked decrease in proportion of major amputations: T1 43,637,0%, T2 52.245.5 by redistribution in one toe amputations T14,010.0%, in T22,89.1%.&#x0D; CONCLUSIONS: The dynamic of new DF cases in adult patients in Russian Federation is stable at T1, in T2 tends to increase. The interregional differences in frequency of DF and amputations may be due to differences in the quality of specialized care, the lack or shortage of diabetic foot cabinets, treatment of patients with DF in general surgical practice in a number of regions, which is recognized as a less effective strategy. A positive fact that proportion of high amputations declines, DF develops in later age and longer diabetes duration, that may reflect the increasing effectiveness of preventive lower limbs in diabetes.

Diabetes-related foot disorders among adult Ghanaians.

ABSTRACT Background: Diabetic foot remains a challenge in most low-middle-income countries (LMICs). A severe deficit in data exists on them in sub-Saharan Africa (SSA). Up-to-date data on the longitudinal trajectories and determinants can provide a benchmark for reducing diabetic foot complications in SSA. Objective: The primary objective of this study was to estimate trends in the incidence of diabetic foot and determine predictors in an adult Ghanaian diabetes cohort. Design: The study is a retrospective longitudinal study over a 12 year period. Methods: We applied Poisson regression analysis and Cox proportional hazard models to demographic and clinical information obtained from patients who enrolled in a diabetes specialist clinic in Ghana from 2005 to 2016 to identify longitudinal trends in incidence and predictors of diabetic foot. Results: The study comprised 7383 patients (63.8% female, mean follow-up duration: 8.6 years). The mean incidence of foot disorders was 8.39% (5.27% males and 3.12% females). An increase in the incidence of diabetic foot ranging from 3.25% in 2005 to 12.57% in 2016, p < 0.001, was determined. Diabetic foot, with adjusted hazard ratio (HR; 95% confidence interval (CI)), was predicted by disease duration, that is, for every 5-year increase in diabetes duration: 2.56 (1.41–3.06); male gender: 3.51 (1.41–3.06); increased body mass index (BMI), that is, for every 5 kg/m2: 3.20 (2.51–7.52); poor glycaemic control, that is, for every percentage increase in HbA1c: 1.11 (1.05–2.25), hypertension: 1.14 (1.12–3.21); nephropathy: 1.15 (1.12–3.21); and previous foot disorders: 3.24 (2.12–7.21). Conclusions: We have found a trend towards an increased incidence of diabetic foot in an outpatient tertiary diabetes setting in Ghana. Systemic and individual-level factors aimed at preventive foot screening as well as vascular risk factor control should be intensified in diabetic patients in Ghana and other LMICs. Abbreviations: BMI: Body Mass Index, BP: Blood Pressure, CI: Confidence Interval, HR: Hazard Ratio, HbA1c: Glycated Hemoglobin, PAD: Peripheral Arterial Disease, NCDs: Non Communicable Disease, SSA: Sub Saharan Africa.

Incidence of Diabetic Foot in Patients With Diabetes Mellitus in a Basic Health Unit

Introduction: Diabetic neuropathy is one of the complications that integrates the pathogenic diabetic foot triad. This neuropathy leads to a foot sensory loss, making the patient vulnerable to minor injuries that could precipitate lesions, subsequent infection and foot amputation. Therefore, the diagnosis needs to come from a complete and detailed physical examination. Objective: The present study aims to investigate the incidence of diabetic foot in diabetic patients who are users of the Basic Health Unit (BHS) in the city of Olinda, Pernambuco. Methodology: The sample of this descriptive exploratory of quantitative methods study was composed of 50 diabetic users of the Basic Health Unit. After signing a Free and Informed Consent Form, a questionnaire was applied regarding the perception of the diabetic on signs and symptoms which are observed in the diabetic foot, proceeding with a thorough evaluation of the feet using 10g of monofilament and performing the Pin Prick Test. Results and Discussion: In total, 70% of patients reported poor glycemic control, 63% reported neuropathic symptoms such as numbness and tingling in the feet and 57% of the evaluated patients have thickened nails and dried or scaly feet. Regarding the vascular evaluation 47% of the evaluated presented with a decreased pedal pulse and 7% presented with this same pulse absent, while 40% had decreased posterior tibial pulse and 7% did not present any pulse at palpation. Regarding the sensitivity assessment, 30% of diabetics presented abnormal results in one of the feet and 7% had no painful and tactile reflex through the sting sensation test. Conclusion: A preventive evaluation of the feet on diabetic patients resulted in important data that informs about the high prevalence of neuropathic findings, contributing to a greater knowledge for the UBS professional team about the presence of neuropathic foot in their diabetic users.

Effects of the whole nursing intervention on the control of the risk factors of diabetic foot

Objective To investigate the effects of the whole nursing intervention on the control of the risk factors of diabetic foot. Methods A total of 600 cases of type 2 diabetes patients with the risk factors of diabetic foot were randomly divided into observation group and control group, 300 respectively. For each group, there were three subgroups of low, medium and high risk of diabetic foot with 100 cases in each subgroup. Patients in two groups were given the whole nursing intervention and routine nursing intervention respectively. The foot skin conditions, ankle brachial index (ABI) and sensory threshold determination, weighted integral score of risk factors of diabetic foot and the incidence of diabetic foot before the intervention, 6 months post intervention, 12 months post intervention and 18 months post intervention were compared between two groups. Results Before the intervention, there were no statistically significant differences in the foot skin conditions, determination of ABI and sensory threshold, weighted integral score of risk factors of diabetic foot and the incidence of diabetic foot between two groups (P>0.05) . At 6 months post intervention, 12 months post intervention and 18 months post intervention, significant differences in the foot skin conditions were observed between two groups (P 0.05) . At 12 and 18 months post intervention, there were statistically significant differences in the ABI and sensory threshold value between two groups (P<0.05) . At 18 months post intervention, comparison of weighted integral scores of risk factors of diabetic foot between two groups showed that, in the observation group, the ratio of subgroup with low-risk increased, while the ratios of subgroups with medium and high-risk decreased; in the control group, the ratio of subgroup with low-risk decreased, while the ratios of subgroups with medium and high-risk increased. The differences were statistically significant (P<0.01) . There were 10 cases of diabetic foot in the observation group and 38 cases in the control group. The number of diabetic foots in the observation group was significantly lower than that in the control group, with a statistically significant difference (P<0.01) . Conclusions The effect of the whole nursing intervention on the control of the risk factors of diabetic foot is remarkable. Key words: Diabetic foot; Risk factor; Nursing intervention

The Association Between Geographic Density of Infectious Disease Physicians and Limb Preservation in Patients With Diabetic Foot Ulcers.

BackgroundAvoiding major (above-ankle) amputation in patients with diabetic foot ulcers is best accomplished by multidisciplinary care teams with access to infectious disease specialists. However, access to infectious disease physicians is partially influenced by geography. We assessed the effect of living in a hospital referral region with a high geographic density of infectious disease physicians on major amputation for patients with diabetic foot ulcers. We studied geographic density, rather than infectious disease consultation, to capture both the direct and indirect (eg, informal consultation) effects of access to these providers on major amputation.MethodsWe used a national retrospective cohort of 56440 Medicare enrollees with incident diabetic foot ulcers. Cox proportional hazard models were used to assess the relationship between infectious disease physician density and major amputation, while controlling for patient demographics, comorbidities, and ulcer severity.ResultsLiving in hospital referral regions with high geographic density of infectious disease physicians was associated with a reduced risk of major amputation after controlling for demographics, comorbidities, and ulcer severity (hazard ratio, .83; 95% confidence interval, .75–.91; P < .001). The relationship between the geographic density of infectious disease physicians and major amputation was not different based on ulcer severity and was maintained when adjusting for socioeconomic factors and modeling amputation-free survival.ConclusionsInfectious disease physicians may play an important role in limb salvage. Future studies should explore whether improved access to infectious disease physicians results in fewer major amputations.

Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes

AimDiabetic foot ulcers are associated with an increased risk of death. We evaluated whether ulcer severity at presentation predicts mortality. MethodsPatients from a national, retrospective, cohort of veterans with type 2 diabetes who developed incident diabetic foot ulcers between January 1, 2006 and September 1, 2010, were followed until death or the end of the study period, January 1, 2012. Ulcers were characterized as early stage, osteomyelitis, or gangrene at presentation. Cox proportional hazard regression identified independent predictors of death, controlling for comorbidities, laboratory parameters, and healthcare utilization. Results66,323 veterans were included in the cohort and followed for a mean of 27.7months: 1-, 2-, and 5-year survival rates were 80.80%, 69.01% and 28.64%, respectively. Compared to early stage ulcers, gangrene was associated with an increased risk of mortality (HR 1.70, 95% CI 1.57–1.83, p<0.001). The magnitude of this effect was greater than diagnosed vascular disease, i.e., coronary artery disease, peripheral arterial disease, or stroke. ConclusionInitial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke. Unrecognized or under-estimated vascular disease and/or sepsis secondary to gangrene should be explored as possible causal explanations.

Predictors of Mortality Following Incident Diabetic Foot Ulcers

Predictors of Mortality Following Incident Diabetic Foot Ulcers

Diabetic Foot Disease—Incidence and Risk Factors: A Clinical Study

ABSTRACTDiabetic foot disease is one of the most common, yet dreaded long-term complication of diabetes mellitus, especially in developing countries. It is the single-most common cause of nontraumatic lower limb amputations. Various studies worldwide have shown an incidence of diabetic foot to be 15 to 25%. Elderly males who are smokers and have habit of alcohol intake and have long duration of type 2 diabetes are at major risk for this problem. The other significant risk factors are: Poor glycemic control, neuropathy, angiopathy, nephropathy, and retinopathy. Management of diabetic foot disease involves a multidisciplinary approach. The present study was conducted with the aim to know about the prevalence of the incidence of diabetic foot disease in diabetic patients and to enumerate the different risk factors associated with it for the occurrence of diabetic foot disease in such patients at the time of presentation.Over a period of 1 year, a prospective study involving 1,016 diabetic patients as per World Health Organization (WHO) criteria were screened for diabetic foot disease. All cases were graded as per University of Texas classification. Incidence of diabetic foot disease was calculated and the risk factors were identified through proper history taking, clinical evaluation, and specialized tests as and when required.Some of the common risk factors identified in our study were: Elderly males from poor families having long-term type 2 diabetes and who were smokers and alcoholics. Many of these patients had other systemic complications of diabetes in the form of neuropathy, retinopathy, angiopathy, and nephropathy as well. A very important, yet easily modifiable risk factor was poor glycemic control. Our conclusion from the study is being that the diabetic foot disease is much common than anticipated in diabetes mellitus patients; it is on the rise and the resultant morbidity is very crippling to the affected individuals. Therefore it is very important to identify the risk factors and educate patients about them, especially the modifiable risk factors, so that its incidence and the morbidity can be brought down significantly.How to cite this articleSharma R, Kapila R, Sharma AK, Mann J. Diabetic Foot Disease—Incidence and Risk Factors: A Clinical Study. J Foot Ankle Surg (Asia-Pacific) 2016;3(1):41-46.

Diabetic Foot Among Elderly at Zagazig City: Risk Factors and Foot Care Practices

Background: Foot health problems are common in the elderly due to pathological changes in their feet. The aim of this study was to identify diabetic foot risk factors among the elderly at Zagazig City Subjects and methods; Analytic cross sectional study design was utilized. The study was conducted at Zagazig health insurance clinic for the elderly diabetic patients with purposive sample composed of (280) of the elderly diabetic patients. Tools, tool I, Interview questionnaire sheet composed of four parts (socio demographic characteristics, medical past p the foot inspection revealed that the majority of them had abnormal foot and statistically significant relations between patients practice and their level of education, job type and income. The foot inspection revealed that the patients had no infection, no ulcer and no low blood flow had a higher percentage of normal examination. Conclusion The study found several factors associated with higher incidence of diabetic foot among the elderly diabetic patients including: low educational level, longer duration of diabetes, smoker, lack of foot care and poor footwear. Recommendations: Educate diabetic patients, about diabetic foot care practice through educational program to reduce the risk of complications.

Clinico-bacteriological study of diabetic foot: an observational study

Background: Diabetic foot is the most important surgical manifestation of diabetes. With foot infection a major cause of morbidity bacterial infection play an important role in diabetic foot ulcers. Aim of this study was proposed to establish the bacterial profile and anti-microbial pattern of ulcer in an attempt to evaluate the role of infection in the foot lesions of diabetic patient. Associated factors like incidence, age, sex, predisposing factors, duration of diabetes, ulcer grade, hospital stay, modes of treatment, antibiotics sensitivity and other outcomes were also evaluated. Methods: This is a Prospective cohort study. The patients were admitted in surgical ward as provisional diagnosed cases of diabetic foot, were subjected to investigations including blood sugar (fasting, P.P, random), renal function test, x-ray of affected foot, fundus examination, grading of ulcer and various modes of treatment was given. Gross examination and culture from ulcers were done. Study was done in 104 patients over 1 year period. Results: One hundred four patients with diabetic foot were evaluated. Incidence of diabetic foot was 1.26%. Majority of cases were from rural areas (82.7%). Newly diagnosed cases of diabetes at admission (22.11%), majority of cases culture was positive (94.1% of 85). Staphylococcus was the predominant organism (61.17%), there were patients who were not on any mode of treatment (29.8%). Conclusions: Staphylococcus aureus a gram positive cocci was the most common micro-organism grown on culture from the ulcer (61.17%), next common micro-organism was Klebsiella (16.47%) gram negative bacilli. Piperacillin and metronidazole were most commonly used antibiotics. Diabetes was controlled by human actrapid (human regular insulin) in majority of the patients. Majority belonging to rural areas (82.7%). Most of the cases were relieved (77.88%). Only two cases fatality (1.92%) occurred during study period.

Diabetic Microangiopathy Is an Independent Predictor of Incident Diabetic Foot Ulcer.

Aim. To determine the diabetic foot ulcer incidence and examine its association with microangiopathy complications, including diabetic retinopathy (DR) and albuminuria (Alb), in type 2 diabetes patients. Methods. This was a retrospective cohort study of 1,305 patients with type 2 diabetes who were assigned to the following groups: Category 1, normoalbuminuria without DR (n = 712); Category 2, Alb without DR (n = 195); Category 3, normoalbuminuria with DR (n = 185); and Category 4, Alb with DR (n = 213). Cox proportional hazard models were used to compare the risks of developing diabetic foot ulcers across the categories. Results. During 14,249 person-years of follow-up, 50 subjects developed diabetic foot ulcers, with incidence rates of 1.6/1,000, 1.5/1,000, 3.4/1,000, and 12.5/1,000 person-years in Categories 1, 2, 3, and 4, respectively. After adjusting for the presence of diabetic neuropathy and macroangiopathy, the hazard ratios and 95% confidence intervals (CIs) for the risk of diabetic foot ulcer development were 0.66 (95% CI, 0.18–2.36), 1.72 (95% CI, 0.67–4.42), and 3.17 (95% CI, 1.52–6.61) in Categories 2, 3, and 4, respectively, compared with Category 1. Conclusion. The presence of DR and Alb significantly increases the risk of diabetic foot ulcer development.

Application of bundled nursing on diabetic foot accident prevention

Objective To discuss the effect of bundled nursing for diabetic foot accident prevention. Methods We chose 126 hospitalized diabetic patients from August 2011 to January 2012 as control group, and 121 patients from August 2013 to January 2014 as observation group. The former group guided with health education, and the latter group treated with bundled nursing for diabetic foot prevention. The incidence rate of diabetic foot, diabetes foot care knowledge and self-rating of foot self-care compared between two groups. Results There were no incidence of diabetic foot accident happened in the observation group while 22.22% of diabetic foot accident occurred in the control group. The knowledge scores of diabetic foot care and foot self-care acquired (35.39±3.09) and (86.93±3.99) in the observation group compared with (26.05±5.53) and (60.04±10.95) in the control group (t=52.87, 61.54, respectively; P<0.01). Conclusions Bundled care for diabetic foot accident prevention could effectively prevent the occurrence of diabetic foot accident, which ensure the safety of the care for hospitalized diabetic patients. Key words: Diabetes mellitus; Diabetic foot; Prevention; Bundled nursing

English

INTRODUCTION: The most frequent reason for hospitalization for patients with diabetes is foot complications, which accounts for up to 25% of all diabetic admissions. The clinical triad most commonly seen in diabetic foot ulcer is peripheral sensory neuropathy, trauma and deformity. Approximately 15% to 20 % of the population in US is hospitalized with complications at some-time during course of their disease. Diabetic foot infections are defines as any inframalleolar infection in a person with diabetes mellitus. Diabetic patients may develop many types of foot ulcers, any of which can get infected. Infection should be diagnosed clinically on the basis of cardinal manifestations. Selection of antibiotic regimen initially involves decision about route of therapy, spectrum of microorganisms to be covered, and the specific drugs to administer and later involves choosing the definitive regimen and the duration of treatment. OBJECTIVE: 1. Early detection of risk factors for ulceration by specific history and systematic examination of the foot. 2. To study the microbial agents of wound infection in the diabetic foot infections. 3. To classify the ulcers, which facilitates in logical approach to treatment and in predicting outcome? 4. To formulate the management by multidisciplinary approach. 5. To describe the surgical treatment and wound care of diabetic foot ulcers. MATERIALS AND METHODS: All the patients (Both out-patient basis and hospitalized patients) with diabetic foot ulcers of more than two weeks duration at Dr. B R Ambedkar Medical College and Hospital from November 2012 to February 2014 are counseled for investigation and treatment of diabetic foot ulcer and its complications. RESULTS AND CONCLUSION: 1. The incidence of diabetic foot was seen highest in 51 to 60 years. 2. Male to female ratio was 4:1. 3. By occupation, most patients were farmers (44%). 4. Diabetic foot most commonly seen in patients with duration of diabetes more than 5 years. 5. Most common mode of presentation is non-healing ulcer followed by foot abscess. 6. Duration of hospital stay was between 15 days to 45 days with average of around 30 days.

Diabetic Foot Classifications: Review of Literature

Diabetic foot is one of the most serious complications of diabetes. As the global burden of diabetes is increasing, the incidence of diabetic foot is equally on a rise. However, diabetic foot has been often ignored by people and also the treating physicians leading to a rise in major amputations. Various classifications have been proposed over decades describing the diabetic foot and the clinicians are hardly aware of them especially in developing and underdeveloped countries where this disease is rampantly increasing. One of the main reason for this unawareness is the fact that this disease is often less discussed in the standard teaching curriculum. The other probable reason is that physicians show more interest in learning other classification like that in oncology compared to disease like diabetic foot which actually deserves more importance. Further, even the trainee doctors and nurses show less inclination to know about diabetic foot classification as their teachers dont teach much about them. This unique review article serves to survey for the first time the various classifications proposed for the diabetic foot thereby helping the various treating physicians to update themselves in the diabetic foot.

Depression and Incident Diabetic Foot Ulcers: A Prospective Cohort Study

Objective To test whether depression is associated with an increased risk of incident diabetic foot ulcers. Methods The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes. Results Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44). Conclusion Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Incidence of Diabetic Foot and Associated Risk Factors in Type 2 Diabetic Patients: A Five-year Observational Study

Background: The frequency of lower extremity amputation due to diabetic foot has been increasing in type 2 diabetic patients. The aim of this study was to observe the incidence, clinical aspects and associated risk factors for diabetic foot. Methods: We evaluated the incidence of diabetic foot through a five-year observation of type 2 diabetic patients who presented to St. vincent's Hospital between Januar y and December 2003. To identify the risk factors for diabetic foot, we evaluated mean glycosylated hemoglobin A1c (HbA1c) every six months and assessed renal function based on the existence of proteinuria and estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) equation. Patients were also evaluated for retinopathy, peripheral neuropathy and autonomic neuropathy usi ng Ewing's method. Results: From an initial pool of 613 patients, the observational study o f 508 patients (82.9%) was completed. The mean age, duration of diabetes and HbA1c were 50.3 ± 10.6 yrs, 7.2 ± 6.5 yrs and 8.8 ± 2.1%, respectively. Diabetic foot occurred in 32 patients (6.3%). The incidence of diabetic foot increased when diabetic retinopathy (OR = 6.707, 2.314~19.439), peripheral neuropathy (OR = 2.949, 1.075~8.090), and autonomic neuropathy (OR = 3.967, 1.476~10.660) were present and when the MDRD GFR (OR = 5.089, 1.712~15.130) decreased. Mean HbA1c (OR = 12.013, 1.470~98.179) was found to be an independent risk factor for diabetic foot. Conclusion: The present study confirmed the importance of intensive glycemic control and the role of autonomic dysfunction in the development of diabetic foot. In addition, diabetic retinopathy and impaired renal function proved to be factors associated with the occurrence of diabetic foot. Therefore, intensive glycemic control, as well as periodic examination of renal function, are essential for the prevention of diabetic foot. (Korean Diabetes J 33:315-323, 2009)

Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.

To determine the frequency and constellations of anatomic, pathophysiologic, and environmental factors involved in the development of incident diabetic foot ulcers in patients with diabetes and no history of foot ulcers from Manchester, U.K., and Seattle, Washington, research settings. The Rothman model of causation was applied to the diabetic foot ulcer condition. The presence of structural deformities, peripheral neuropathy, ischemia, infection, edema, and callus formation was determined for diabetic individuals with incident foot ulcers in Manchester and Seattle. Demographic, health, diabetes, and ulcer data were ascertained for each patient. A multidisciplinary group of foot specialists blinded to patient identity independently reviewed detailed abstracts to determine component and sufficient causes present and contributing to the development of each patient's foot ulcer. A modified Delphi process assisted the group in reaching consensus on component causes for each patient. Estimates of the proportion of ulcers that could be ascribed to each component cause were computed. From among 92 study patients from Manchester and 56 from Seattle, 32 unique causal pathways were identified. A critical triad (neuropathy, minor foot trauma, foot deformity) was present in > 63% of patient's causal pathways to foot ulcers. The components edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Callus formation was associated with ulcer development in 30% of the pathways. Two unitary causes of ulcer were identified, with trauma and edema accounting for 6 and < 1% of ulcers, respectively. The majority of the lesions were on the plantar toes, forefoot, and midfoot. The most frequent component causes for lower-extremity ulcers were trauma, neuropathy, and deformity, which were present in a majority of patients. Clinicians are encouraged to use proven strategies to prevent and decrease the impact of modifiable conditions leading to foot ulcers in patients with diabetes.