Poster session 20: Developing countries
P20.01
Do diabetic foot problems really care in India-A podiatrist view
Mallikarjun Rao, Dia Foot Care, Bangalore, India
Aim: To analyze the current status of Diabetic foot scenario in India.
Method: A total of 100 patients were included in this study. The first patients who visited to
us in the month of March from 2010 to 2014 were randomly selected for our study.
Results: 69% of patients seen by a podiatrist in his setup had detected foot problems.
24.6% of the Diabetic foot patients had chronic non-healing ulcers. 49.3 % of foot patients
after detailed counseling accepted diabetic footwear whereas the remaining 50.7% refused
diabetic footwear and continued their regular footwear oblique bear foot walking. 18.8% of
the patients already had some form of amputation before consulted the podiatrist. A total of
only 52% of the patients had serial follow up with the podiatrist and they actually cared of
their feet.
Conclusion: Today in an era of improved health care globally, if one sees’ from above data
there is not much improvement of Diabetic foot care from patient point of view. It seems that
they are still underestimating the gravity of diabetic foot problems and the risk of major
amputations.
Key words: Diabetic foot, India, Care.
References:
• The Foot in Diabetis by Andrew J. M. Boulton, Peter R. Cavangh and Gary Rayman.Fourth
Edition 2006, John Wiley & Sons Limited.
• Managing the Diabetic Foot by Michael E. Edmonds and Alethea VM Foster.2000,
Janssen-Cilag, Blackwel Science.
• 101 Tips on Foot Care for people with Diabetes. Second Edition 2006 by American
Diabetes association.
• Handbook of Diabetic Foot Care. by Bal A., Das A.K., Pandsey Sharad, Suresh K.R., Vijay
viswanathan, Kelkar Sanjeev. 2005 By Diabetic Foot Society, India.
www.diabeticfoot.nl
Page 1 of 10
P20.02
A community-based project on increasing diabetes foot-care awareness in a
developing country in the pacific: A podiatrist’s observations
Malindu Fernando, James Cook University, Townsville, Australia
Aim: The Pacific region has one of the highest prevalence of diabetes in the world per
capita. In some countries over 40% of the adult population have diabetes. This presentation
aims to highlight the current burden of diabetic foot disease observed in the islands of
Kiribati. It will also highlight how a community led-intervention involving a podiatrist can have
a positive impact on peoples’ health and understanding of diabetes and foot complications.
Methods: A qualitative approach will be used to demonstrate a podiatrist’s experience of
travelling to Kiribati with a dietitian and his encounters in observing and consulting with
diabetes patients in Kiribati. The experience of working alongside the Ministry of Health noncommunicable disease team to carry out a community-based awareness and education
program regarding diabetes management and foot care will also be discussed.
Results: Amputation rates due to diabetes in the pacific are rapidly increasing most likely
due to limited resources, a lack of specialists and limited understanding regarding diabetic
foot disease. Small community based projects, in addition to acute and preventative-care, is
crucial to increasing public awareness regarding how diabetes affects the lower limb and to
highlight the importance of foot care in preventing foot ulcers and amputations. The
importance of community-lead interventions in relation to promoting healthy eating, exercise
and medical check-ups are paramount to combat the currently high burden of lower limb
disease which is predicted to increase over the next decade.,
Conclusion:, Empowering communities in the pacific with knowledge regarding diabetic foot
disease and the importance of foot care has potential to reduce the burden of diabetic foot
disease.
Acknowledgements: This project was self-funded.
www.diabeticfoot.nl
Page 2 of 10
P20.03
A retrospective analysis of risk factors for diabetic foot amputation in Dr. Kariadi
Hospital, Semarang
Ridho Naibaho, Medical Faculty of Dipenogoro University, Dr. Kariadi Hospital, Semarang,
Indonesia
Tania Minuljo, Medical Faculty of Dipenogoro University, Dr. Kariadi Hospital, Semarang,
Indonesia, Semarang, Indonesia
Tjokorda Gde Dalem Pemayun, Medical Faculty of Dipenogoro University, Dr. Kariadi
Hospital , Semarang, Indonesia
Background: Diabetic foot (DF) ulcer is the main cause of nontraumatic lower limb
amputation. Early recognition and management of risk factors for foot complications may
prevent amputations and better overall management.
Materials and Methods: We reviewed retrospectively the medical charts of 41 patients with
complicated DF whose admitted to dr. Kariadi Hospital during the period of January 2013 to
December 2013. Information about clinical and laboratory data, diabetes complications, and
history of comorbidities were collected to determine the risk factors of amputation in these
patients. We divided these patients into two groups, those with or without amputation and
carried out a comparative analysis of the variables in both groups.
Results: Fourty one patients were included in the analysis, 17 males and 24 females with a
female/male ratio of 1.4 to 1. The duration of being affected by diabetes mellitus lies
between 1 month and 20 years (mean: 6.01 ± 5.35 years). They were aged ranged from 37
to 82 years (mean: 54.23 ± 10.03 years). Of those, 16 patients (39%) were underwent an
amputation. Major amputation was performed in 3 patients (7.3%) and minor amputation in
13 patients (31.7%). Relative Risk (RR) for amputation in hypertensive respondents was
1.54 [95% CI: 0.40 – 5.87; p=0.52], admission plasma glucose ≥ 300 mg/dL was 1.18 [95%
CI: 0.33 – 4.19; p=0.79] and HbA1c ≥ 10% was 2.77 [95% CI: 0.69 – 10.9; p=0.14].
Meanwhile, serum albumin concentration ≤ 2.5 gr/dL brings as much as 1.72 RR [95% CI:
0.46 – 6.46; p=0.41], fasting triglycerides ≥ 200 mg/dL was 1.64 [95% CI: 0.20 – 13.01;
p=0.63], ulcer duration ≥ 2 weeks was 1.63 [95% CI: 0.46 – 5.75; p=0.44] and neuropathy
was 1.53 [95% CI: 0.42 – 5.53; p=0.51]. High Wagner’s grade (Grade 4 and 5) was the
only significant independent risk factors for amputation with RR of 2.41 [95% CI: 1.57 – 3.72;
p<0.001).
Conclusion: The risk factors for amputation were higher Wagner's grade of diabetic foot
ulcer. Others factors such as the presence of hypertension, admission plasma blood glucose
≥ 300 mg/dL, HbA1c ≥ 10%, plasma albumin ≤ 2.5 gr/dL, plasma triglycerides ≥ 200 mg/dL,
ulcer duration ≥ 2 weeks, and neuropathy showed an increased of RR for an incident of limb
amputation, though not statistically significant.
www.diabeticfoot.nl
Page 3 of 10
P20.04
Profile of patients with diabetic foot ulcer: Hospital based study
Tania Tedjo, Diponegoro University, Semarang, Indonesia
Tjokorda Gde Dalem Pemayun, Diponegoro University, Semarang, Indonesia
Ridho Monotoc Naibaho, Diponegoro University, Semarang, Indonesia
Background: Diabetic foot ulcer seen in 15-20% of diabetic patients. Lower extremity
amputation is an increasing problem among patients with diabetic foot ulcer especially in
developing countries.
Aim: The aim of this study is to figure out the clinical profile, treatment, and health coverage
of patients with diabetic foot ulcers in our hospital.
Material and methods: This is a retrospective study reviewing medical records from
diabetic foot ulcer patients admitted to Dr. Kariadi General Hospital, Central Java Province,
Indonesia. Fourty one out of 142 patients were eligible for further analysis. Study period was
between January and December 2013.
Results: Diabetic foot ulcers account for 4 7% of all hospitalization associated with diabetes.
Male to female ratio 1:1 4; mean of age 54 3±10 0 years; mean disease duration of diabetes
6 01±5 3 years. Mean of A1c level and RBG on admission were 11 4±2 6% and 333 3±148
mg% respectively. Mean creatinin level 1 6±1 4 mg%. Smoking habitude 19 5% and history
of previous amputation 26 8%. Ulcer severity (Wagner’s Grading system): grade 1(2 4%),
grade 2(26 8%), grade 3(26 8%), grade 4(36 6%) and grade 5(7 4%). Precipitating event for
ulcer: unknown 43 9%, minor trauma 22%, and etc 34 1%. Mean duration of ulcer before
admission 27 7±31 6 days.Long-term diabetic complications including retinopathy 53 6%,
nephropathy 56 1%, polyneuropathy 26 8%, hypertension 36 5%, low HDL level 75 6%, and
hypertriglyceridemia 9 7%. Co-morbidities including anemia 92 6%, hypoalbuminemia
90.2%, and bacterial pneumonia 12 2%. Microbiologic culture were predominantly P.
mirabilis and K. pneumonia. Half of subjects were fully subsidized by the government health
insurance. Mean LOS 18 8±11 1 days. Overall, 39% were amputated in various degree.
Conclusion: Most of our patients were in their fifth decades. Eventhough disease duration in
most subject were under 5 years, overall rate of glycaemic control was sub-optimal and they
already had chronic complication. Patients mostly came with late and advanced ulcer
condition. Precipitating factors for ulcer were mostly unknown. More than one third ended in
amputation. Half of subjects were fully funded.
This research was funded by the authors.
www.diabeticfoot.nl
Page 4 of 10
P20.05
Tropical Diabetic Hand Syndrome (TDHS): Risk factors in an adult diabetes population
Zulfiqarali Abbas, MUHAS / AMC, Dar es Salaam, Tanzania
Janet Lutale, MUHAS, Dar es Salaam, Tanzania
Aims:, To determine characteristics and risk factors of the tropical diabetic hand syndrome
(TDHS), a condition associated with significant morbidity and mortality in Africa.
Methods:, This was a prospective study of Tanzanian diabetes population presenting with
the TDHS during February 1998 to November 2014. A case patient was defined as any
patient with diabetes presenting with hand cellulitis, ulceration, or gangrene.
Results: A total of 736 patients had illnesses that met the case definition; 406 (55%) were
male, 628 (86%) had type 2 diabetes, and all had first episodes of diabetes. Median age of
patients was 54 years (range: 15--89 years), median interval since diagnosis of diabetes was
5 years (range: 2 weeks--19 years), and median body mass index was 25.2 kg/m2 (range:
15--44 kg/m2). Patients' median blood glucose level at initial presentation was 12mmols/l
(range: 3.1—33.3mmols/l). Peripheral neuropathy was present in 20 (3%) patients; two
patients had evidence of peripheral vascular disease, which was ascertained through
Doppler studies.
The initial precipitating causes of TDHS varied from unknown cause in 112 (15%); cutting
nails 88 (12%) patients, abscess 78(11%), blisters 137 (19%) and burns 44 (6%). Hand
trauma in 78 (11%); itching occurred in 42 (6%); boils as a cause in 22 (3%) and pricks in 81
(12%) patients.
All 736 patients had hand ulcerations; 637 (84%) were purulent with soft tissue infection,
28 (4%) had a deep ulcer which involved the bone, and 69(9%) had localized or widespread
gangrene of the arm. The median time between onset of symptoms and initial clinical
evaluation by a physician was 14 days (range: 2--252 days). Over all 40 (6%) patients died.
Overall, 393 (53%) patients underwent surgery; 71 (10%) had gangrene of the hand and
required amputation of fingers, hand, or arm because of very rapid progression to gangrene.
The remaining 322 (43%) patients who had surgery underwent incision and drainage and
debridement.
Conclusion: The major risk factors for the tropical diabetic hand syndrome are intrinsically
related to the underlying disease. Thus, prevention of hand infections may require
aggressive glucose control and education on hand care and the importance of seeing a
doctor promptly at the onset of symptoms.
www.diabeticfoot.nl
Page 5 of 10
P20.06
Onycomycosis in diabetes patients in fako division: causative agents associated
factors and antifungal sensitivity patterns
Mouliom Rene, Regional Hospital Limbe, Limbe, Cameroon
Introduction: Onychomycosis is an infection of the nail unit by a fungus, it is the commonest
nail disease worldwide. It is a common infection among Diabetes patients.
Objectives:
-To determine the prevalence of onychomycosis in diabetes patients
in Fako division
-Describe demographic, socioeconomic and clinical factors associated
-Isolate causative fungi and to assess the antifungal pattern of isolates
Methodology:
--Cross-sectional descriptive and analytic hospital-based study
--diabetic patients age 21 and more
--The study was conducted in diabetic clinics of the Buea and Limbe Regional Hospitals
South West Region, Cameroon
--Toenail, finger nail and skin scrapings as well as nail clippings was collected and,
observed under the microscope with 10% potassium hydroxide and glycerol, cultured on
selective and differential media to isolate causative fungi.
Result: A total of 152 cases could be analyse The mean age of study participants was
56.6yrs (SD= 12.2)., Females constituted 177(77%) of the study participants while 35(23%)
were males
Type II diabetics constituted149 (98%) 0f study participants while Type I diabetics
constituted 3(2%) of the study population
The prevalence of clinical onychomycosis with respect to the diagnostic tests was as follows:
microscopy only (25%), culture only (34%) and both microscopy and culture (41%).
Trichophyton rubrum was the most common causative agent isolated (62%) followed by
Trichophyton metagraphyte(22%) and lastly Trichophyton tonsurans(16%).
Conclusion: One out of every two diabetes patient in Fako, have onychomycosis and this is
detrimental to their health as it could lead tofoot infection and, amputations.
. Trichophyton rubrum is the most common dermatophyte in diabeteic patients in Fako
- isolates were sensitive to miconazole, ketoconazole and amphotericin B
www.diabeticfoot.nl
Page 6 of 10
P20.07
Diabetic foot infection a major challenge in a low resource society; a study from
Pakistan
Zahid Miyan, Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan
Abdul Basit, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University,
Karachi, Pakistan
Muhammad Saif Ulhaque, Baqai Institute of Diabetology and Endocrinology, Baqai Medical
University, Karachi, Pakistan
Rubina Sabir, Baqai Institute of Diabetology and Endocrinology, Baqai Medical University,
Karachi, Pakistan
Background: Foot infections are common in patients with diabetes and are associated with
high morbidity rate and developing a risk of lower extremity amputation. The aim of the study
was to determine the presentation and outcome of diabetic foot infections in a resource
constraint society.
Methodology: This study was conducted from January 2013 to April 2014. Patients
presented in diabetic foot word at Baqai Institute of Diabetology and Endocrinology, (BIDE),
a tertiary care diabetes center of Karachi - Pakistan, were recruited after obtaining signed
informed consent. Ethical approval was obtained from Institutional Review Board (IRB) of the
institution. Patients with foot problems were classified according to the University of Texas
classification. In patients with foot infections culture specimens of tissue, pus and/or bone
were taken. Bacterial isolates were identified and their antimicrobial susceptibility pattern
was determined. The details of demography, anthropometry, and medical history were
collected on structured software [Health Management System, (HMS)] through one to one
interviews conducted by doctors and blood samples were collected by the paramedical staff.
Results: Data is in analysis phase the final results will be presented at the time of
conference. According to the preliminary results, Out of 232 subject 207 (89.6%) were found
as neuropathic ulcers. Pseudomonas aeruginosa was detected in 43 (18.53%) specimens,
Escherichia coli was isolated in 54 (23.27%), Proteus species in 74 (31.89%), Klebsiella
pneumonia in 51 (21.98%) and Methicillin-resistant Staphylococcus aureus (MRSA) was
detected in 62 (26.72%) specimens. Multi-drug resistant (MDR) organisms were isolated in
more than 50% specimens.
Conclusions: High prevalence of multi-drug resistant (MDR) organisms was observed in the
present study. Patients with diabetic foot infections were found to have significantly high
amputations. Emergence of antimicrobial resistance has become a major challenge in
diabetic foot infections in a resource constraint society such as Pakistan.
www.diabeticfoot.nl
Page 7 of 10
P20.08
Cost of treatment of ischemic diabetic foot: comparison between open and
endovascular revascularization
Daniel Mendes, Hospital Felício Rocho, Belo Horizonte, Brazil
Stenyo Fernandes, Hospital Felício Rocho, Belo Horizonte, Brazil
Júlio Maciel, Hospital Felício Rocho, Belo Horizonte, Brazil
Caetano Lopes, Hospital Felício Rocho, Belo Horizonte, Brazil
Rodrigo Lopes, Hospital Felício Rocho, Belo Horizonte, Brazil
Leonardo Bez, Hospital Felício Rocho, Belo Horizonte, Brazil
Gustavo Kleinsorge, Hospital Felício Rocho, Belo Horizonte, Brazil
André Mourão, Hospital Felício Rocho, Belo Horizonte, Brazil
Introduction: Ischemic ulcers in diabetics are responsible for much of amputations and they
have a high cost of treatment. There are several publications on the financial impact of
diabetic foot complications in developed countries, however there is no data about the cost
of ischemic diabetic foot in our local society. Most ischemic patients are currently treated by
endovascular approach, wich has been another issue of debate in our society because of
high cost of these procedures.
Aim of the study: The objective is to compare the cost of the ischemic diabetic foot
treatment between groups submitted to endovascular treatment (ENDO group) and open
revascularization (BYPASS group).
Methods: Retrospective analysis of patients treated at the Diabetic Foot Center of the
hospital between january-2013 and july-2014. Inclusion criteria: patients with diabetic foot
ulcers with indication to revascularization, classified in Rutherford 5 or 6.
Results: We treated 46 patients, 23 men, mean age of 71 7 years-old. A total of 56 vascular
interventions were made, 40 lower limb angioplasties (ENDO) and 16 open surgeries
(BYPASS). The average cost of the intervention in the ENDO group was € 6.548 47 and €
5.355 44 in BYPASS group (p=0 23). The median time to complete healing of the foot was
143 2 days in the ENDO group and 121 1 days in BYPASS group. The total cost of
treatment was € 7.591 98 for the ENDO group and € 5.614 42 for the BYPASS (p=0 02).
ENDO group patients required 15% of re-interventions and a higher number of visits to the
diabetic foot center for clinical control. The overal limb salvage rate was 88% for both
groups.
Conclusions: It is more expensive to treat patients by endovascular way, although this is
the most common approach. Older and sicker patients are treated preferably by
percutaneous procedures, with greater use of hospital resources. The type of
revascularization and the use of hospital resources impacted in total costs. The
management of patients in a center specialized in diabetic foot care makes possible the
analysis of expenses.
Funding. The authors funded this study. There are no conflicts of interest.
www.diabeticfoot.nl
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P20.09
Glycemic control on foot ulcer healing of cambodian diabetic patients
Sith Dara Sea, International University, Phnom Penh, Cambodia
Khun Touch, Preah Kossamak Hospital & Cambodian Diabetes Association, Phnom Penh,
Phnom Penh, Cambodia
Objective: To find out the effects of glycemic control, based on HbA1c on foot ulcer healing
of Cambodian diabetic patients.
Methods: 50 diabetic patients with age range 35-70 years old (41 females and 9 males) are
included in this study. They all suffered peripheral neuropathies, but their peripheral vascular
diseases were in mild stage with normal blood flows, and no stenosis occurred in blood
vessels.
Results: Among 50 patients, 41 female patients were confirmed to have HbA1c less than
7% which resulted in complete and rapid foot ulcer healing within 2 weeks; whereas, 5 male
patients had HbA1c between 7 to 9 %. As a result, their foot ulcer was healed more slowly in
4 weeks. Furthermore, 4 male patients were claimed to have HbA1c more than 9 %; hence,
their foot ulcer was not healed even with more than 4 weeks of treatment in the same
conditions as the two previous cases. It was really difficult to control HbA1c of male patients
due to the fact that they tended to drink and smoke more than female patients.,
Conclusion: HbA1c affects foot ulcer healing process of diabetic patients. The higher the
HbA1c degree, the less is the chance for the foot ulcer to heal. Therefore, the ideal glycemic
control for these patients is to keep their HbA1c lower than 7%.
Source of funding: Diabetology Department, Preah Kossamak Hospital, Phnom Penh,
Cambodia.
www.diabeticfoot.nl
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P20.10
The efficacy and cost effectiveness of an interface- interdesciplinary wound care
approach, at primary care level
Hashim Mohamed, Weill Cornell Medical College-Qatar, Doha, Qatar
Aim: To test the feasibility and efficacy of an interface- interdisciplinary wound care,
approach at primary care level in developing countries
Methods:, Over the last two decades diabetes has reached epidemic proportions in the
Persian Gulf region .The cost of managing acute and chronic wounds is, posing a huge
burden on the health system in developing countries due to scarce resources. As a result we
have created an interface- interdisciplinary team led by a family, physician with special
interest in wound care, wound nurse and, a radiologist at Um Gwailinah health Centre,
Doha, Qatar. The family physician provided, ( metabolic control, psychological support,
health education and wound care)which was, cost effective. This, interdisciplinary team
acted as an interface between primary and secondary care., We have, successfully, treated
hundreds of, both acute and chronic ulcers, of various etiologies including diabetic foot
ulceration over a four year period resulting in reduction in referral to secondary care,
reduction in the cost of wound dressing especially with the introduction of an adjunct therapy
(natural Honey ), and increased satisfaction of both patients and health personnel alike.
Results: The creation of an interface- interdisciplinary team at primary care level have led to
a 65% reduction in referral to secondary care, 75% reduction in the wound dressing, budget
and increased satisfaction of both health professionals and patients alike .
Conclusion : the concept of interface- interdisciplinary team approach for wound care, at
primary care level, is feasible efficacious, and cost effective.
www.diabeticfoot.nl
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