Determinants of the Risk for Diabetic Foot Ulceration in Sohag University Hospital

Background: One of the most common complications of diabetes in the lower extremity is the diabetic foot ulceration (DFU). Objective: To identify the determinants of the risk for diabetic foot ulceration (DFU) in terms of peripheral neuropathy (PN) or peripheral vascular disease (PVD) among a sample of diabetic foot patients. Methods: A cross sectional study included 100 diabetic foot patients attending Sohag University Hospital for follow up during the period from January 2009 to January 2010. They were subjected to complete medical history taking and thorough clinical examination. Diabetic Neuropathy Symptoms (DNS) along with the Diabetic Neuropathy Examination (DNE) scores were used together to define and assess PN. PVD diagnosis was based on identification of claudication pain symptoms; absent or weak foot pulses on palpation of the dorsalis pedis and/or the tibialis posterior arteries; coldness of skin; and finally confirmed by arterial doppler of lower limbs. Results: The mean age of the patients was 57.92 ± 9.2 years; 65% were males and 79% lived in rural areas. The majority (79%) had type 2 DM with mean disease-duration of 13.4 ± 6.9 years. Fifty percent of the study patients were smokers and ex-smokers, 33% were hypertensive and 24% had previous history of foot ulceration or amputation. Male gender, old age, low socioeconomic status, smoking, hypertension, type 2 DM, long duration of DM, uncontrolled DM, and previous history of foot ulceration, amputation or other diabetic complications were all significant determinants of PN and PVD; two major risk factors of DFU.


INTRODUCTION
Knowledge of diabetes dates back to centuries before Christ. (1)Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus (DM).Infection and/or gangrene of the foot are relatively common in diabetic patients due to arterial insufficiency, diabetic neuropathy and delayed wound healing.Diabetic foot is responsible for up to 50% of diabetes related hospital admissions. (2)abetic foot ulcer (DFU) is one of the common but often neglected complications of diabetes.There is no doubt that people with Bull High Inst Public Health Vol.40 No. 4 [2010]   DFU have considerable mortality and morbidity.The risk of death for those with foot ulcers is 12.1 per 100 persons per year-years of follow-up compared to 5.1 in those without foot ulcers. (3)Similarly, the risk for amputation in patients with diabetes is 15 times greater than that for the non-diabetic population and the majority of amputations are preceded by DFU.In addition to increased morbidity and mortality, patients with DFU have a poorer quality of life in comparison to those without ulcers. (4)cent studies have revealed that interacting complex mechanisms are involved in the pathogenesis of DFU.
There is defective normal healing processes of the tissues. (5)Many chemo-cytokines are involved, including matrix metalloproteinases, serine proteinases, integrins, chemokines, replicative cell senescence, growth factors and adult stem cells. (6)Diabetic patients with tissue injury initially display impairment in the immune system response with reduced chemotactic effects to recruit inflammatory cells into the damaged tissues, thus, slowing down healing and increasing the risk of bacterial infection. (7)llowing this initial period, the process switches to an exacerbation of inflammation and proteolysis. (8)The result of prolonged exposure to hyperglycemia also generates glycation of proteins and disturbances of cell responses, thus, further hindering the process of fibrosis and tissue repair. (9)Infection is usually the consequence rather than the cause of diabetic foot ulcers.Infected chronic ulcers may be classified as mild to moderate or severe, when osteomyelitis is involved. (10)e of the most common complications of diabetes in the lower extremity is the DFU.It is estimated that 15% of patients with diabetes will develop a lower extremity ulcer during the course of their disease. (11)While most ulcers can be successfully treated in the office or outpatient setting, infected and/or ischemic foot ulcers are a major cause for diabetes related hospitalization. (12) the United States, the total costs for both direct and indirect health care for persons with diabetes in 1997 has been estimated to be $98 billion.Costs for ulcer care have been estimated to lie within the range of $4,595 per ulcer episode to nearly $28,000 for the 2 years after diagnosis. (13)The estimated overall total costs in the United States for diabetic foot disease can approach or exceed $6 billion annually. (14)ypt is currently among the top 10 countries with the highest prevalence of diabetes and will remain so as 7.6 million Egyptians will have the disease by 2025.(15) In general, few studies have reported the prevalence of diabetic foot ulceration (DFU) as part of diabetes-related complications and, to our knowledge; there have been very few surveys on DFU risk factors in Egypt.
Mild foot ulcers precede most of the nontraumatic amputations in people with diabetes.

According to the International Diabetes
Federation and the International Working Group on the Diabetic Foot, (14) it is possible to reduce amputation rates by between 49% and 85% through a care strategy that combines: prevention; the multi-disciplinary treatment of foot ulcers; appropriate organization; close monitoring; and the education of people with diabetes and healthcare professionals. (16)us, it is essential that foot care services, which are very scarce in Egypt, be urgently initiated to cope with the rapidly increasing prevalence of diabetes and its complications among Egyptians.subjected to the following tools and techniques: 1. Structured interview questionnaire to collect the following data: • Name, age, sex, occupation, marital status, residence, and history of smoking.
• Type of diabetes, duration of diabetes, therapeutic history and diabetic control.
• Presence of vascular symptoms such as cramps and/or claudication and neuropathic symptoms such as tingling, numbness, and burning sensation with a 'stocking and glove' distribution.
• to define and assess neuropathy. (16)The DNS Nearly one quarter of the studied diabetic foot patients (24%) had PVD.
Table 6 shows the association between PVD and some socio-demographic and medical variables.It indicates that PVD can be predicted by several factors.Among these factors were: male gender (79.2%, p=0.007), hypertension (37.5%, p =0.001), old age of 55 years or more (75%, p =0.02).Smoking was also an important predicting factor for PVD, 62.5% of cases were smokers or being an exsmoker (p=0.04).Also the presence of other diabetic complications such as diabetic nephropathy, diabetic retinopathy, and hypertension were important risk factors for PVD in patients with diabetic foot (p=0.03).
Long duration of DM was highly significantly associated with PVD (p=0.001),75% of cases had duration of diabetes more than 10 years.
Only 3% of cases of the studied sample received prior foot care knowledge, all of them were employees and living at urban areas.entifying diabetic patients at risk for DFU is very important in preventing this common and serious complication of diabetes and to decrease its effect on diabetic patients and the community in general. (17)is study has been conducted to identify sample showed that 55%, 24% and 1% had diabetic PN, PVD and previous history of foot ulcer respectively.These results when compared to data from near-by countries show that, the situation in Egypt seems to be alarming.In one study in the Gulf area, the prevalence of neuropathy, PVD and foot ulcer was found to be 36.6%,11.8% and 5.9% respectively. (17)The lower prevalence of ulcers in our study could be explained by the late presentation of the cases and the lack of welldeveloped foot care programs.
In general few studies were done to assess the risk factors of diabetic foot in Egypt and the world.This is the first study conducted in our university to assess and evaluate sociodemographic and medical factors that determine the risk for DFU in terms of PN and PVD.
The present study revealed that about 65% of the study population males.Male gender predominance was consistent with many earlier studies as that of Emad et al, (2009) (18) who found that most of the studied patients in his study that was done to assess risk factors of diabetic foot in Suez Canal University were males (67%).
Also Fatma et al, (2007) (17)   this raises a major alarm urging a better care for diabetic foot in our community. (19)ople at greatest risk of diabetic foot complications can easily be identified by careful clinical examination of the feet so, education and frequent follow-up is indicated for these patients. (20)Diabetic foot ulcers is a leading cause of amputations, affect 15% of people with diabetes. (21)Thanks to foot-care programs, the incidence of diabetic foot amputation is decreasing in developed countries and was found to be 2.4 per 1000 diabetes-patients in Norway. (21)nclusively, male gender, old age, low Awareness of the determinants of the risk for DFU is an inevitable step on the way to achieve a competent Foot-care system for diabetic patients in our community that would decrease morbidity and mortality, as well as, the economic burden in Egypt.

1 .
Clinical examination of the foot to identify PN, PVD or other risk factors of diabetic foot ulceration such as callus and oedema. (16)Both feet were examined for signs of vasculopathy and neuropathy including skin status (color, thickness, dryness, cracking, atrophic changes, and decreased hair growth).PN was assessed by vibratory, monofilament, muscle strength and tendon reflex testing.Pressure, pain, vibration and joint position sensitivities were evaluated bilaterally.For pressure perception, the 10 g Semmes-Weinstein monofilaments was used on 4 sites of the foot.These sites were without callus, notably the pulps of the hallux and metatarsal heads of first, third and fifth toes.The site was considered sensate if the patient responded, "yes" upon contact with the monofilament and insensate if there was no response.For vibration perception, a 128 Hz tuning fork was applied at 3 sites on the foot; the pulp of the hallux, the lateral and the medial malleoli.The patient was asked to describe what he felt.If he/she described a feeling of vibrations, the site concerned was considered normal.If he/she described anything other than vibrations, the site concerned was considered abnormal.In addition, pin-prick perception on the dorsal surface of the great toe and the index finger were evaluated.Neuropathy was further assessed by examining the tendon reflexes bilaterally and testing for muscle strength by examining for extension of the knee and dorsiflexion of the foot.Diabetic Neuropathy Symptoms (DNS) along with the Diabetic Neuropathy Examination (DNE) scores were used together two major risk factors of DFU namely; PN and PVD and their determinants.The studied Bull High Inst Public Health Vol.40 No.4 [2010]

2 .
Most cases of type 1 DM developed diabetic foot complication after duration of DM more than 15years (81%) and no cases developed diabetic foot complication before 5 years.About thirty nine percent of type 2 DM patients in our study developed foot complication after 10-15 years from the disease onset while 27.8% of cases developed diabetic foot complication after duration of DM more than 15 years and 10.1% developed foot complication before 5 years duration.As regards foot amputation, 23% of our study patients had this hard experience, when compared to other international data, socioeconomic status, type 2 DM, smoking, hypertension, increased duration of DM, previous history of foot ulceration, amputation or other diabetic complications, uncontrolled DM, were main determinants of the risk for DFU as evidenced by two major risk factors namely diabetic neuropathy and PVD.

Table 2 . Relation between duration and type of diabetes among the studied sample Type of diabetes Duration of diabetes (years)
a Chi square test