prevalence of risk factors for diabetic foot ulcer and risk stratification in type 2 diabetes dr....
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PREVALENCE OF RISK PREVALENCE OF RISK FACTORS FOR DIABETIC FACTORS FOR DIABETIC FOOT ULCER AND RISK FOOT ULCER AND RISK
STRATIFICATION IN TYPE 2 STRATIFICATION IN TYPE 2 DIABETESDIABETES
DR. NEETA DESHPANDEDR. NEETA DESHPANDEASSOCIATE PROF.,JN MEDICAL ASSOCIATE PROF.,JN MEDICAL COLLEGE AND KLE HOSPITAL, COLLEGE AND KLE HOSPITAL,
BELGAUMBELGAUM
INTRODUCTIONINTRODUCTION
40-70% of LL amputations related to 40-70% of LL amputations related to DMDM
Substantial emotional, physical and Substantial emotional, physical and financial lossesfinancial losses
Illiteracy, lack of knowledgeIlliteracy, lack of knowledge
Largely preventable through early Largely preventable through early detection of “high-risk” feet, detection of “high-risk” feet, preventive footwear and counselingpreventive footwear and counseling
AIMS AND OBJECTIVESAIMS AND OBJECTIVES
To know prevalence of risk factors for To know prevalence of risk factors for diabetic foot ulceration and diabetic foot ulceration and stratification into risk categoriesstratification into risk categories
To correlate risk categories to age, To correlate risk categories to age, duration of DM, glycemic control and duration of DM, glycemic control and SESSES
INCLUSION CRITERIAINCLUSION CRITERIA
All known cases of type 2 DM of more All known cases of type 2 DM of more than 1 year durationthan 1 year duration
EXCLUSION CRITERIAEXCLUSION CRITERIA
Patients with current foot ulcerPatients with current foot ulcer
Patients of DM admitted for other Patients of DM admitted for other neurological causesneurological causes
METHODOLOGYMETHODOLOGY215 type 2 diabetics who were willing 215 type 2 diabetics who were willing to participate in the study were to participate in the study were questioned in detail – age, duration questioned in detail – age, duration of diabetes, footwear practices, level of diabetes, footwear practices, level of education, symptoms of of education, symptoms of neuropathy, vasculopathy, previous neuropathy, vasculopathy, previous foot ulcer/amputationfoot ulcer/amputationThorough foot examination was doneThorough foot examination was doneBlood sample was collected for Blood sample was collected for HbA1cHbA1c
Definitions of recorded dataDefinitions of recorded data
HISTORY OF FOOT ULCER – Healed HISTORY OF FOOT ULCER – Healed foot ulcer of more than 3 months foot ulcer of more than 3 months durationduration
HISTORY OF LL AMP – Non-traumatic HISTORY OF LL AMP – Non-traumatic amp at any level in the LLamp at any level in the LL
PAD – Intermittent claudication or h/o PAD – Intermittent claudication or h/o reconstructive vascular surgery reconstructive vascular surgery and/or absence of foot pulsesand/or absence of foot pulses
Definitions of recorded data - contdDefinitions of recorded data - contd
SENSORY NEUROPATHY - SENSORY NEUROPATHY - > > 1 “no 1 “no response” to 10 g MF applied to 10 response” to 10 g MF applied to 10 sites (9 plantar and 1 dorsal) and/or sites (9 plantar and 1 dorsal) and/or NDSNDS
FOOT DEFORMITY – hallux valgus, FOOT DEFORMITY – hallux valgus, overlapping toes, fixed clawed toes, overlapping toes, fixed clawed toes, pes cavus/planus, Charcot foot, pes cavus/planus, Charcot foot, prominent metatarsal headsprominent metatarsal heads
NEUROPATHY DISABILITY NEUROPATHY DISABILITY SCORE – RIGHT AND LEFTSCORE – RIGHT AND LEFT
VibrationVibration sense sense (dorsum of big toe) : (dorsum of big toe) : Present=0, Present=0, reduced/absent=1reduced/absent=1Pin prickPin prick : : Present=0, Present=0, reduced/absent=1reduced/absent=1Ankle jerkAnkle jerk : : present=0, present present=0, present on reinforcement=1,on reinforcement=1,
absent=2absent=2
TOTAL SCORE:TOTAL SCORE:
3-4 Mild neuropathy3-4 Mild neuropathy
5-7 Moderate5-7 Moderate
8-10 Severe8-10 Severe
CLASSIFICATION OF INTERNATIONAL CLASSIFICATION OF INTERNATIONAL WORKING GROUP ON DIABETIC FOOTWORKING GROUP ON DIABETIC FOOT
RISK CATEGORYRISK CATEGORY
00
11
22
33
DESCRIPTIONDESCRIPTIONNo sensory neuropathyNo sensory neuropathy
Sensory neuropathy Sensory neuropathy onlyonly
SN+PVD &/or SN+PVD &/or deformitydeformity
Previous Previous ulcer/amputationulcer/amputation
Statistical MethodsStatistical Methods
.Chi – square test and unpaired ‘t’ test.Chi – square test and unpaired ‘t’ test
Age and Sex distributionAge and Sex distribution
AGEAGE MALEMALE FEMALEFEMALE TOTALTOTAL
45-5545-55 7070 3838 108108
56-6556-65 4242 3737 7979
66-7566-75 1818 44 2222
76-8576-85 44 22 0606
134134 8181 215215
Duration of diabetesDuration of diabetes
61
77
58
127
0
10
20
30
40
50
60
70
80
No.
of
Cases
< 5 6 to 10 11 to 15 16 to 20 > 20
Duration of Diabetes
Prevalence of risk factorsPrevalence of risk factorsCASESCASES PERCENTAGEPERCENTAGE
NeuropathyNeuropathy 8383 38.638.6
VasculopathyVasculopathy 2222 10.2310.23
Foot Foot deformitydeformity
1212 5.585.58
Prev Prev ulcer/ampulcer/amp
1010 4.654.65
Prevalence of risk factorsPrevalence of risk factors
83
22
12 10
0
10
20
30
40
50
60
70
80
90
No.
of
Cases
Neuropathy Vasculopathy Foot deformities Previous ulcer oramputation
Graph showing Prevalence of Neuropathy, Vasculopathy, Foot deformities and previous ulcer or amputation in the study population
Neuropathy Disability ScoreNeuropathy Disability ScoreNo. Of CasesNo. Of Cases PercentagePercentage
Mild (NDS 3-Mild (NDS 3-4)4)
4545 54.2254.22
Mod (NDS 5-Mod (NDS 5-7)7)
1616 19.2819.28
Severe (NDS Severe (NDS 8-10)8-10)
2222 26.5026.50
Mean duration of diabetesMean duration of diabetesMean (Years)Mean (Years) SDSD
Group 0Group 0 54.854.8 2.72.7
Group 1Group 1 1212 2.612.61
Group 2Group 2 17.517.5 1.451.45
Group 3Group 3 2121 3.623.62
Mean duration of diabetesMean duration of diabetes
5.8
12
17.5
21
0
5
10
15
20
25
Mean d
ura
tion o
f dia
bete
s (
Yrs
)
Group 0 Group 1 Group 2 Group 3
Graph showing mean duration of diabetes in each group distribution
Mean AgeMean Age
52.959.28
68.9276
0
10
20
30
40
50
60
70
80
Mean A
ge o
f th
e P
atients
(Yrs
)
Group 0 Group 1 Group 2 Group 3
Graph showing mean age of the patients in each group distribution
Glycemic controlGlycemic control
HbA1cHbA1c GoodGood
(<8%)(<8%)FairFair
(8.1-10%)(8.1-10%)PoorPoor
(>10%)(>10%)
Group 0Group 0 6464 2020 1616
Group 1Group 1 4343 4949 88
Group 2Group 2 2525 3333 4242
Group 3Group 3 1010 4040 5050
Glycemic controlGlycemic control
64
2016
4349
8
25
33
42
10
40
50
0
10
20
30
40
50
60
70
Group 0 Group 1 Group 2 Group 3
Graph showing Percentage of patients of different glycemic control in each group distribution
Good Fair Poor
Barefoot walkingBarefoot walking
42
5870
30
83
17
100
00
20
40
60
80
100
Perc
enta
ge
Group 0 Group 1 Group 2 Group 3
Graph showing Percentage of Bare foot walkers in each group distribution
Present Absent
Level of educationLevel of education
44 45 4349
3219
75
178
100
0 00
20
40
60
80
100
Perc
enta
ge
Group 0 Group 1 Group 2 Group 3
Graph showing level of Education in group
Iliterate Schooling College
ConclusionsConclusionsOverall prevalence of neuropathy is higher Overall prevalence of neuropathy is higher than vasculopathy (38.6% Vs 10.2%)than vasculopathy (38.6% Vs 10.2%)
Age (p<0.01), duration of diabetes Age (p<0.01), duration of diabetes (p<0.001) and glycemic control (p<0.001) and glycemic control (p<0.01)are significantly correlated to (p<0.01)are significantly correlated to high-risk feethigh-risk feet
Barefoot walking (p<0.001) and level of Barefoot walking (p<0.001) and level of education (p<0.0002) are important risk education (p<0.0002) are important risk factors factors