Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
STRATIFICATION OF PATIENTS WITH DIABETES INTO RISK CATEGORIES FOR FOOT ULCERATION
East Afr Med j. 2009; 86(5)233- 239
Eric Mugambi
The Burden of Diabetes Diabetes is rather uncommon and very fatal…’Dr. Albert Cook, 1901, J trop med 190; 4:175-178
• 194,000,000 (5.1% adult population)
globally
• 3,000,000 deaths/year/globally
• 333,000,000 by 2025
• Kenya – 146,000 diabetics by 2025 (3rd
highest prevalence Africa)
Foot ulcers
• 30 Sec – estimated time a leg is lost to diabetes
• 70% - proportion of amputations related to diabetes
• 85% - proportion of diabetes related amputations preceded by ulcer
• Are you the 6th man?
• 4.9% (82/1788) - prevalence KNH
• 5% - prevalence in developed countries
• 11.4% - admissions attributable to foot ulcer KNH vs. USA/UK (20%)
• 17 weeks - mean ulcer duration
• 80% - ulcerating type
• 20% - gangrenous
• 25% - prevalence of microbial infections
• 0.1%- Charcot’s arthropathy
• 39% - hammer toe deformity
• 23% - diabetics with foot ulcer, with 1 preceding foot
exam
Local data
50% foot ulcers, KNH
20% ulcers KNH
Rare at KNH!5%
Diabetic foot – A Personal, Social and Economic Disaster
• Common cause of admission
• Prolonged in-hospital stay
• Life-long dependence on others
• Inability to work
• Misery
Bottom Line
• Primary prevention
• Cheap, available, validated easy to use tools
• Applicable within clinical setting
Justification
• Identification of modifiable risk factors aids
prevention
• Risk stratification helps in resource allocation
• Targeted allocation of resources reduces re-
ulceration by 60% and amputation by 85%
Methods
• Cross-sectional study
• Diabetic Outpatient Clinic, KNH (Sep 2006-Feb 2007)
• Systematic sampling, sample size = 218
• Ethics • More specifically assessed:
– Neuropathy - NDS
– Peripheral arterial disease - ABI
– Deformity
– Knowledge of foot care
– Monofilament – 5.07
242 met inclusion criteria
218 recruited
24 excluded: • 11 – active ulcers • 8 – diagnosis of DM not certain • 5 – declined participation
Risk factor assessment Physical examination
• NDS • ABPI • Monofilament RBS measurement
Risk categorization • No neuropathy • Neuropathy alone • Neuropathy + either PAD
or deformity • Previous
ulceration/amputation
Outline of study recruitment and methods
ABI
>1.30 - Non compressible
0.91-1.30 - Normal
0.41-0.90 - Mild-Moderate PAD
0.00-0.40 - Severe PAD
NDS
Ankle jerk (0-2)
Vibration (0-1)
Pin prick (0-1)
Temp (0-1)
Score
0-2 – No neuropathy
3-5 – Mild
6-8 – Mod
9-10 - Severe
Demographics
Characteristic Value
Male sex (%) 42
Age in years, mean (+SD) 58 (9)
Duration of DM in years, mean (+SD) 16 (4)
RBS, mmol/l, mean (+SD) 12 (4)
BMI kg/m2, mean (+SD) 26 (3)
OHA (%) 64
Insulin (%) 15
Previous ulcer (%) 16
Previous amputation (%) 8
Risk factors
• Prevalence Neuropathy – 42% (mild 21, mod 17 severe 4)
Peripheral arterial disease – 12%
Deformity – 46% (hallux valgus 14%)
• Monofilament Abnormal in 23% (Sensitivity 100% for severe
neuropathy; 72% for moderate neuropathy)
• Foot care education – 39%
• Foot examination – 12%
IWGDF
GROUP
PERCENTAGE
OF STUDY PATIENTS IN
EACH IWGDF group
ODDS RATIO* FOR
AMPUTATION ADAPTED FROM IWGDF
STUDY
0 NO NEUROPATHY
57 NA
1 NEUROPATHY ALONE
10 1.7
2 NEUROPATHY PLUS
EITHER PAD OR
DEFORMITY
16 12.1
3 PREVIOUS
ULCER/AMPUTATION
17 36.4
*Lawrence lavery et al, ARCH INT
MED/VOL 158 JAN 26, 1998
Risk Categories
Recommendation for follow up
• Group 0 – annual review
• Group 1 – semi-annual review
• Group 2 – quarterly review
• Group 3 – every 1 to 3 months
Conclusions
• One third (33%) of diabetic patients were at high risk for future foot ulceration:
– It is cost-effective to set up a separate foot clinic
– The opportunity cost is too high
• The 5.07 monofilament is a reliable easy to use tool in the detection of severe neuropathy, and can be easily adapted into our local setting
Thank you
Remember: In the time it has taken to deliver this
lecture, some 30 legs have been lost to diabetes!
Examine the feet of your diabetic patients!