Outcome Of Diabetic Foot Ulcers Research Articles

Association of serum C peptide level with the severity of diabetic foot ulcers and its healing rate

Objective To investigate the association of serum C peptide concentration with the severity and the outcome of diabetic foot ulcer(DFU). Methods The clinical data of 257 inpatients with DFU were collected, including fasting and postprandial 2h C peptide levels and C peptide area under curve(AUCCP). The patients were followed up on the outcomes of ulcers and death. The associations of serum C peptide concentration with the Wagner degree, infection severity, and healing rate were analyzed. Results The medians of fasting and 2h postprandial serum C peptide as well as AUCCP were 1.37(0.02~9.00)nmol/L, 3.22(0.02~29.61)nmol/L, and 511.65(3.60~2 691.30)nmol·min-1·L-1 respectively, which were lower than general levels. The time of follow-up in our study was 2.8(1.0~5.1)years. By the end of study, the wound of 75.88% patients was healed, 3.5% undergone major amputation, and 23.74% died. After adjusting for relative factors, there were no significant associations of serum fasting and postprandial C peptide levels and AUCCP with Wagner degree and infection severity(P>0.05). Cox regression analysis showed that the fasting plasma C peptide and hemoglobin were the independent protective factors for the healing of ulcers; old age, male, higher infection degree, and diabetes family history were their independent risk factors(all P<0.05). Conclusions The lower plasma fasting C peptide concentration in patients with DFU is not correlated with Wagner degree and infection severity, but closely related with healing rate. (Chin J Endocrinol Metab, 2017, 33: 17-22) Key words: Diabetic foot; Ulcers; Healing; C peptide

A retrospective study of management of diabetic foot ulcer in tertiary care hospital in North Karnataka

Background: Foot ulcers and amputations are a major cause of morbidity as well as emotional and physical disability for people with diabetes. A cumulative life time incidence of diabetic foot ulcer (DFU) is as high as fifteen percent making it a leading cause of non-traumatic amputations worldwide. The objective of the study was to assess the outcome of diabetic foot ulcer based on Meggitt-Wagner classification system.Methods: It was a retrospective review of 130 patients with diabetic foot ulcer managed at a tertiary care teaching hospital from January 2010-August 2016 in Bagalkot, North Karnataka, India.Results: In this study most of the patients were in the age group of 51-60 years, most of them being male 85%, 49.23% of patients with ulcers were over the plantar aspect of the foot and 40% of ulcers were Grade 2. 11.53% of patients required disarticulation of toes. 3.07% of patients required below knee amputation and 2.30% of patients require above knee amputations. 42.30% of the patients had peripheral neuropathy and 12.30% of the patients had associated peripheral arterial disease.Conclusions: Even though Meggitt-Wagner classification system is considered Gold Standard it has many disadvantages. The neuropathic changes, charcoats osteoarthropathy and associated vascular pathology has not taken into consideration, hence the outcome of the ulcer cannot be predicted.

Clinical profile and outcome of diabetic foot ulcer, a view from tertiary care hospital in Semarang, Indonesia.

ABSTRACT Background: This study attempted to determine the disease burden in terms of clinical profile and outcome of diabetic foot ulcer (DFU) admissions at a tertiary care hospital in a developing country. Methods: In this descriptive study, the data were collected from the medical record of diabetic patients with foot ulcer who were treated in Dr. Kariadi General Hospital during a 3-year period. The demographic characteristic, type of foot lesion, etiology, isolated microorganism, treatment, and outcome were reviewed. Results: Foot problems accounted for 16.2% of total diabetic admission (n = 1429). All patients had type 2 diabetes with no gender predominance. The mean age was 54.3 ± 8.6 years and diabetes control was very poor. Before admission, the ulcers had already developed for 4.7 ± 2.9 weeks; however, the majority of patients were unaware of the preceding causes. Ulcers were neuropathic in 42.2% of cases, neuroischemic in 29.9%, and pure ischemic at lesser percentage. More than 70% of ulcers were in Wagner grade ≥3 with infection event in nearly all patients. The most common isolates from culture were Gram-negative bacteria. A total of 98 (36.3%) lower extremity amputations (LEAs) at various level of the foot were carried out, including major LEA in 24 patients and multiple amputations in seven patients. Mortality rate due to DFU reached 10.7%. Conclusions: Diabetic foot problems constitute a source of morbidity, a reason for LEA surgery as well as being a cause of death among patients with diabetes mellitus.

Association of depression and its treatment on the outcome of diabetic foot ulcer

Aim: This study aimed to assess depression symptoms among patients with diabetic foot ulcer and to compare the outcome of diabetic foot ulcer between normal participants and participants with depressive symptoms. Methodology: This prospective, observational study was conducted at Baqai Institute of Diabetology and Endocrinology, after getting approval from ethics committee. Patients who were attending the foot clinic were invited to participate in the study. Diabetic foot ulcers were classified according to the University of Texas classification criteria. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Both groups were given standard diabetes and foot care treatment. In addition, antidepressant treatment was given to the participants with depressive symptoms for 3 months. After 3 months, PHQ-9 was again administered to the participants with depressive symptoms, and the outcome of foot ulcer was noted and compared to baseline data. Results: Of the total participants (n = 105), nearly half of them were found to have depressive symptoms (n = 53, 50.4%). At baseline, no significant difference was found in the distribution of hypertension, history of smoking and duration, grading and type of ulcers between normal participants and participants with depressive symptoms. Three months of antidepressant treatment brought significant improvement in the mean depression score (P ≤ 0.05). After 3 months, healing time of ulcers, rate of minor and major amputations, patients on treatment and patients who lost to follow-up were comparable between the groups. Conclusions: In this study, every second patient with diabetic foot ulcer was found to have depressive symptoms. Anti-depressive treatment alleviated depression and made foot ulcer outcome comparable to non-depressed patients.

Anemia in Patients With Diabetic Foot Ulcer: Prevalence, Clinical Characteristics, and Outcome.

The aim of this study was to describe the characteristics of diabetic foot ulcer (DFU) patients with anemia and assess the relationship between anemia and DFU outcome. A retrospective cohort study was conducted on patients with DFU who attended our hospital from May 2007 to September 2014. All of the variables in the DFU patients with and without anemia were compared. In this study, 353 subjects were included, anemia was present in 236 patients (66.9%). These patients were significantly male, more likely to be a smoker, had a lower level of serum albumin and worse kidney function, more likely to use at least 2 types of antibiotics and had a worse perfusion of the lower limb, a larger and deeper ulcer and a more severe infection. A multivariate analysis showed that male sex, lower serum albumin, and worse kidney function were independent predictors of anemia in DFU patients. Additionally, in multivariate models, anemia was one of the variables that was most significantly associated with adverse outcomes and with similar findings for secondary outcomes. Receiver operating characteristic analysis determined a hemoglobin cutoff of 12.3 g/dL (females) and 12.1 g/dL (males) to identify a high-risk population of DFU patients who would have adverse outcomes. So anemia is common in patients with DFU. Although typically mild or moderate, anemia has been associated with substantial morbidity and mortality in patients with DFU.

Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital in Haryana

Background: Diabetic foot ulcers are predisposing factor in 85% of lower limb amputations. This study was done to evaluate risk factors for the development of diabetes and associated foot problems in the rural area of Khanpur Kalan and adjoining villages of Haryana to educate the rural population for the promotion of healthy foot care and footwear habits. Objective: The aim of this study was to determine major risk factors and management outcome of diabetic foot ulcers to prevent amputation. Methods: This study was conducted in the Department of Plastic Surgery, Bhagat Phool Singh Government Medical College for Women, Khanpur Kalan, Sonepat, from December 2013 to November 2015 in 64 patients who reported in our outpatient department and emergency. Results: Sixty-four patients with type 2 diabetes mellitus were enrolled in the current study with different stages of diabetic foot presentations. They underwent different methods of surgical management: debridement, amputations, and skin grafting giving good and fast results. Eight patients underwent below-knee amputations, and six were subjected to forefoot amputation. Ten great toe amputations were performed. Two finger amputations were performed. Conclusion: Early diagnosis and management of diabetic foot ulcers can improve patient outcomes and reduce health-care costs.

Outcome of diabetic foot ulcer admissions at the medical wards of University of Nigeria Teaching Hospital Enugu, Nigeria

Diabetic foot ulcer (DFU) is associated with a high rate of morbidity, prolonged hospital stay, and serious complications including limb amputation. The objective of this study was to determine the outcome of DFU among medical inpatients in the University of Nigeria Teaching Hospital Enugu, Nigeria. Data from case records of diabetes-related admissions into the medical wards of the University of Nigeria Teaching Hospital Enugu (UNTH) between January 2009 and December 2012 were analyzed. Statistical analysis was done using SPSS v17. Out of 726 diabetes mellitus (DM)-related admissions (59.1 % males, 40.9 % females), DFU accounted for 119 (16.4 %), of which 65.5 % were males and 34.5 % were females. The mean duration of diabetes in DFU patients was 7.2 ± 5.8 years, while the median (interquartile range) duration of the ulcer before the presentation was 24 (14–60) days. The mean age of patients with DFU was 55.2 ± 13.2 years, while the duration of hospital stay ranged from 2 to 98 days, median (interquartile range (IQR)) of 16 (9.8–30.3) days. Out of the 119 DFU admissions, 88 (73.9 %) were discharged, 15 (12.6 %) died, while 16 (13.5 %) discharged themselves against medical advice (DAMA). Of those who were discharged, about 75 % were discharged with non-healed ulcers either for outpatient care or to surgical units. The most common Wagner grade of ulcer was grade 3 (41.5 %). Risk factors for ulceration were peripheral vascular disease in 47.1 % and peripheral neuropathy in 57.6 %. Mortality due to DFU accounted for 10.6 % of all diabetes mortality. Diabetic foot ulcer was a common reason for admission and characterized by late presentation and advanced ulcer stage. Diabetes foot ulcers admitted and managed in the medical wards were associated with poor outcome.

Diabetic foot in patients below 40 years of age

Data on diabetic foot ulcers (DFU) in young patients are scarce. We aimed to examine the risk factors, clinical presentation, wound characteristics, and outcome of DFU among young diabetic patients and to compare them with similar age diabetics without foot ulcer and those of older age diabetics with foot ulcers. A prospective cohort of 745 patients (834 ulcers) below 40 years of age, 7620 patients (9405 ulcers) ages 40 years and above, and 992 patients below 40 years diabetics without foot ulcers in a single multidisciplinary diabetes center were studied. Registered patients with foot ulcers in Jabir Abu Eliz Diabetes Centre (JADC) in Khartoum, Sudan from March 2001 to Dec 2011 were reviewed. Below 40 years of age constituted 8.9 % (n = 7450) of all patients with DFU. Male-to-female ratio was 1.7:1. IDDM type was prevalent in 60.9 %. Thirty-six per cent of below 40 years had peripheral neuropathy compared to 61.6 % of older group (p 7 % was significantly more in diabetics below 40 years with foot ulcers compared to those without foot ulcers (83.5 vs. 75.1 %) (p = 0.0002). In below 40 years of age, 80.1 % of ulcers healed compared to 70.6 % in older age group (p > 0.0002). Major lower extremity amputation was performed in 4.8 % in below 40 years patients compared to 7.3 % in older group (0.0105). Young diabetics with foot ulcers had significantly longer duration of the disease, more foot deformities, and callus formation and more severe neuropathy than young diabetics without ulcers but had a lesser duration of diabetes than elderly diabetics with foot ulcers. HbA1c in young diabetics with foot ulcers was significantly higher than young diabetics without ulcers, and their foot ulcers healed better and with less major lower extremity amputation than elderly patients.

Reliability and validity of the perfusion, extent, depth, infection and sensation (PEDIS) classification system and score in patients with diabetic foot ulcer.

AimsTo validate the perfusion, extent, depth, infection and sensation (PEDIS) classification system and to make the clinical practice easier, we created a score system and compared this system with two previously published common score systems.MethodsA retrospective cohort study was conducted on patients with diabetic foot ulcer (DFU) attending our hospital (n=364) from May 2007 to September 2013. Participants’ characteristics and all variables composing the PEDIS classification system were assessed.ResultsDuring a median follow-up of 25 months (range 6-82), ulcers healed in 217 of the 364 patients (59.6%), remained unhealed in 37 patients (10.2%), and were resolved by amputation in 62 patients (17.0%); 48 patients (13.2%) died. When measured using the PEDIS classification system, the outcome of DFU deteriorated with increasing severity of each subcategory. Additionally, longer ulcer history, worse perfusion of lower limb, a larger extent of the ulcer, a deeper wound, more severe infection, and loss of protective sensation were independent predictors of adverse outcome. More importantly, the new PEDIS score system showed good diagnostic accuracy, especially when compared with the SINBAD and Wagner score systems.ConclusionsThe PEDIS classification system, which encompasses relevant variables that contribute to the outcome of DFU and has excellent capacity for predicting the ulcer outcome, demonstrated acceptable accuracy. The PEDIS classification system might be useful in clinical practice and research both for the anticipation of health care costs and for comparing patient subgroups.

Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?

One of the most common and serious complications of diabetes mellitus is ulceration of the foot. Among persons with diabetes, 12%-25% will present to a healthcare institution for a foot disorder during their lifespan. Despite currently available medical and surgical treatments, these are still the most common diabetes-related cause of hospitalization and of lower extremity amputations. Thus, many adjunctive and complementary treatments have been developed in an attempt to improve outcomes. We herein review the available literature on the effectiveness of several treatments, including superficial and deep heaters, electro-therapy procedures, prophylactic methods, exercise and shoe modifications, on diabetic foot wounds. Overall, although physical therapy modalities seem to be useful in the treatment of diabetic foot wounds, further randomized clinical studies are required.

Negative pressure wound therapy in the treatment of diabetic foot ulcers: a systematic review of the literature.

Negative pressure wound therapy (NPWT) is an option for management of complex wounds such as diabetic foot ulcers; therefore, the nursing literature from 2000 to 2010 was reviewed for studies comparing clinical outcomes for diabetic foot ulcers treated with NPWT and those treated with standard moist wound therapy (SMWT). PubMed and OVID databases were explored using the following search terms: vacuum-assisted closure, NPWT, diabetic wounds, and standard most wound therapy. Research studies to judge efficacy were limited to the results from studies of experimental studies with randomized clinical trials on patients with diabetic foot wounds as the inclusion criteria. Four studies were identified that met the established criteria. Despite variations in patient population, methodology, and additional outcome variables studied, NPWT systems were shown to be more effective than SMWT with regard to proportion of healed wounds and rate of wound closure.

Assessing Outcome of Diabetic Foot Ulcers and Multidisciplinary Foot Clinic

Foot problem has been increasingly recognised as a major complication of diabetes, which is associated with a very high mortality and morbidity. Therefore Multi-Disciplinary Foot Clinics (MDFC) have been established all over the world to provide holistic care to these patients. There is a wide variation in the availability of a range of professional skills in the MDFC in different health economy. Therefore the care provided by these MDFC can vary from one place to other. It is very important to measure the outcome of these MDFC so that patients, regulatory authorities and funding bodies can compare them. Traditionally ulcer related outcomes such as the healing rate and the proportion of ulcers healed have been measured in many foot ulcer studies. Similarly the amputation rate is measured to determine the efficacy of diabetic foot management in an area of the health economy. However, these measures do not take into account other important factors such as the functional ability and the quality of life of patients. Therefore patient related outcomes such as the recurrence of ulcer, number of working days lost, the mobility of patient following treatment, survival following first episode of ulceration etc also needs to be measured, which are very important from the patient's perspective. This review looks into various patient related outcomes that can and should be measured to assess the quality of care provided by the MDFC.

Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital (在公立、私立以及退伍军人管理局医院中的糖尿病足溃疡的最初表现与治疗结果的差异)

Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes. A retrospective chart review of diabetic patients with a new diagnosis of a foot ulcer at geographically adjacent, but independent public, private, and Veterans Administration (VA) hospitals was conducted. Healing and lower extremity amputation outcomes were assessed. Across the three hospitals, 234 patients met the inclusion criteria. Patients at the VA hospital were older (mean 72.5 years; P < 0.001) and had gangrenous ulcers (mean 14.1%; P < 0.001) compared with patients in the private and public hospitals. Public hospital patients were mostly Hispanic (mean 54%; P < 0.001) with a shorter duration of diabetes (mean 12.8 years; P = 0.02), but were more poorly controlled than VA and private hospital patients (P ≤ 0.001). Prior amputation (odds ratio [OR] 1.97; P = 0.016) and non-Caucasian race (OR 2.42; P = 0.004) increased the risk of amputation on multivariate analysis. Osteomyelitis (P = 0.0371) and gangrene (P < 0.001) are independent risk factors for amputation. Across all three hospitals, 42.3% of patients were treated by amputation (6.8% private, 12% public and 23.5% VA; P < 0.001). In a single triumvirate health care system where the patient population is stratified primarily by insurance, VA patients have significantly higher amputation rates compared with patients at adjacent private and public hospitals. The VA patients are largely racial minorities with advanced DFU progression to gangrenous ulcers.

Improving major amputation rates in the multicomplex diabetic foot patient: focus on the severity of peripheral arterial disease

Peripheral arterial disease (PAD), as well as diabetic neuropathy, is a risk factor for the development of diabetic foot ulcers. The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic foot by stratifying these subjects according to the severity of PAD. In a prospective study, patients with new diabetic foot ulcers have been treated and investigated by structured healthcare. Subjects were recruited between 1 January 2000 and 31 December 2007. All study participants underwent a 2-year follow-up observation period. The patients underwent a standardized examination and classification of their foot ulcers according to a modification of the University of Texas Wound Classification System. The severity of PAD was estimated by measurement of the ankle brachial index (ABI) and the continuous wave Doppler flow curve into undisturbed perfusion (0.9 < ABI < 1.3), compensated perfusion (0.5 < ABI < 0.9), decompensated perfusion (ABI < 0.5) and medial arterial calcification. A total of 678 patients with diabetic foot were consecutively included into the study (69% male, mean age 66.3 ± 11.0 years, mean diabetes duration 15.8 ± 10.2 years). Major amputations (above the ankle) were performed in 4.7% of the patients. 22.1% of these subjects had decompensated PAD. These subjects had delayed ulcer healing, higher risk for major amputation [odds ratio (OR) 7.7, 95% confidence interval (CI) 2.8-21.2, p < 0.001] and mortality (OR 4.9, 95 % CI 1.1-22.1, p < 0.05). This prospective study shows that the severity of PAD significantly influences the outcome of diabetic foot ulcers regarding to wound healing, major amputation and mortality.

Risk factors, ulcer grade and management outcome of diabetic foot ulcers in a Tropical Tertiary Care Hospital

Background:The objective was to determine the risk factors, ulcer grade, and management outcome of patients with diabetic foot ulcers (DFU) managed in a tropical tertiary hospital.Materials and Methods:This is a prospective observational study of all consecutive diabetes mellitus (DM) patients with DFU admitted in the University of Benin Teaching Hospital, Benin City, Nigeria over a 26-month period. Data documented included age, gender, type of DM, duration of DM, risk factors of DFU, duration of DFU, Wagner's ulcer grade, and the blood glucose at presentation and management outcome.Results:Thirty-four (55.7%) of the 61 study subjects were females. Their mean age was 56.29±12.71 years. 85.2% had type 2 DM. 13.1% of the patients were newly diagnosed diabetic at presentation. The mean duration of DM was 7.8±6.98 years. The mean duration of DFU was 46.09±47.82 days and the casual blood glucose level at presentation was 18.41±9.31mmol/l. Risk factors of DFU included spontaneous blisters (52.46%), peripheral vascular disease (44.3%), peripheral neuropathy (42.6%), and visual impairment (21.3%). The common ulcer grades were IV (44.3%) and III (36.1%).The amputation rate was 52.2% while the mortality rate was 14.3%.The baseline ulcer grade was significantly associated with the risk of lower extremity amputation, and the odds ratio was 2.36 (95% 1.06-5.21).Conclusions:Spontaneous blisters, peripheral vascular disease, peripheral neuropathy,and visual impairment are common risk factors of DFUs. Many of our patients with DFUs presented with grade IV and V ulcers with the resultant high rate of lower extremity amputations (LEAs). Early presentation and treatment of DFUs will reduce LEAs.

A retrospective study of diabetic foot ulcers treated with hyperbaric oxygen therapy.

A retrospective review of patient medical records was conducted to assess what factors influence the outcomes of diabetic foot ulcers treated with hyperbaric oxygen (HBO) therapy. Patients referred to the Diving Diseases Research Centre for HBO therapy for the treatment of diabetic foot ulcers during a 2-year period were included in this study. Data collected from 30 sets of patient records were entered into SPSS and statistical analysis was undertaken to investigate whether any underlying pathologies or confounding factors appeared to influence patient outcome. A 73.3% of patients achieved a successful outcome of partial healing, major amputation no longer required, amputation level lower than anticipated prior to HBO or healing at the end of HBO therapy and 70% remained successful 3 months later. A 13.3% of patients were lost to follow-up at 3 months and one patient (3.3%) had a major amputation. Steroid therapy, peripheral vascular disease, previous minor amputation, type of diabetes, previous HBO therapy, larvae therapy, the use of interactive dressings and haemoglobin A1c levels were all observed to have had a significant relationship with patient outcome (P < 0.05). These results were compared with data from other published research conducted in this area on similar patient groups. A larger scale study focussing on the factors found to be significant in this study is recommended. An improvement of patient documentation would allow patient outcomes to be more consistently monitored in the future.

The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital

AimWound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70–80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU). Materials and methodsData from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula. ResultsThe study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions. ConclusionsThe results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.

Presentation and Outcome of Diabetic Foot Ulcers in Saudi Arabian Patients

The purpose of this study was to evaluate associated risk factors, clinical presentation, and outcome of diabetic foot ulcers (DFUs) in a Saudi Arabian hospital. This is a prospective study of diabetic patients with foot ulcers at Saudi Aramco Medical Services Organization. The participants were referred to a wound care specialist. The study was conducted from December 2003 to December 2004 and included a total of 62 patients (30 men and 32 women). The mean age (SD) was 64.8 years (+ 12 years), with a range from 39 to 82 years. During the study period, 19% (12 of 62) of patients had amputations represented by 2 above-knee amputations, 3 below-knee amputations, and 7 limb-sparing surgeries. All patients with DFUs who underwent surgical amputation had a Wagner Classification of grade 4 (n = 9; 75%) or grade 5 (n = 3; 25%). Three patients (25%) had prior surgical limb-sparing amputations, and 11 (91%) patients were on insulin therapy. The associated risk factors with amputation were hypertension, peripheral vascular disease, absence of pedal pulses, and ischemic heart disease (P < .05). DFUs continue to be an important cause of morbidity and resulted in an amputation rate of 19%.

Comparison of three systems of classification in predicting the outcome of diabetic foot ulcers in a Brazilian population

The aim was to compare three ulcer classification systems as predictors of the outcome of diabetic foot ulcers: the Wagner, the University of Texas (UT) and the size (area, depth), sepsis, arteriopathy, denervation system (S(AD)SAD) systems in a specialist clinic in Brazil. Ulcer area, depth, appearance, infection and associated ischaemia and neuropathy were recorded in a consecutive series of 94 subjects. A novel score, the S(AD)SAD score, was derived from the sum of individual items of the S(AD)SAD system, and was evaluated. Follow-up was for at least 6 months. The primary outcome measure was the incidence of healing. Mean age was 57.6 years; 57 (60.6%) were male. Forty-eight ulcers (51.1%) healed without surgery; 11 (12.2%) subjects underwent minor amputation. Significant differences in terms of healing were observed for depth (P=0.002), infection (P=0.006) and denervation (P=0.002) using the S(AD)SAD system, for UT grade (P=0.002) and stage (P=0.032) and for Wagner grades (P=0.002). Ulcers with an S(AD)SAD score of <or=9 (total possible 15) were 7.6 times more likely to heal than scores >or=10 (P<0.001). All three systems predicted ulcer outcome. The S(AD)SAD score of ulcer severity could represent a useful addition to routine clinical practice. The association between outcome and ulcer depth confirms earlier reports. The association with infection was stronger than that reported from the centres in Europe or North America. The very strong association with neuropathy has only previously been observed in Tanzania. Studies designed to compare the outcome in different countries should adopt systems of classification, which are valid for the populations studied.

Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital.

To determine major risk factors and management outcome of diabetic foot ulcers in order to prevent amputation. Cross-sectional descriptive study. Study was conducted at the Department of Medicine, Civil Hospital Karachi, from January 2005 to December 2006. One-hundred and sixteen consecutive diabetic patients, with foot ulcers of Wagner's grade 1 to 4 were assessed at baseline for demographic information, detailed history, neuropathy, peripheral pulses and frequency of diabetic complication. Glycemic control was determined on the basis of HbA1c levels. Appropriate medical and surgical treatments were carried out and patients were followed-up until healing or for 6 months as end point of study. Outcome was recorded as healed, incomplete healing and amputated. A majority of subjects had type 2 diabetes (95.7%) with male predominance (66%). The mean age was 54.29 +/- 7.71 years. Most of the patients were overweight, hyperglycemic and had diabetes > 10 years duration. Neuropathic ulcers were found in 91 (78.4%) patients, while rest of the 25 (22.6 %) had neuroischemic ulcers. Wound cultures revealed polymicrobial organisms. Foot ulcers of 89 (77.7%) patients healed without amputation and 17 (14.7%) patients had minor or major amputations. Long-duration of diabetes, poor glycemic control and type of foot ulcers had effect on prognosis (p<0.05). Effective glycemic control, optimal wound care, aggressive medical management and timely surgical intervention may decrease disabling morbidity with better outcome of diabetic foot ulcer.