Poster session 2: Epidemiology P2.01 Impact of secondary cardiovascular risk reduction persists at 10 years Matthew Young, Royal Infirmary, Edinburgh, United Kingdom Joanne McCardle, Royal Infirmary, Edinburgh, United Kingdom Aims: The mortality from diabetic foot ulceration is very high. Cohort studies put the ten year mortality at around 70% (Morbach). Two case controlled studies have demonstrated that enhanced cardiovascular risk reduction methods can reduce the mortality over a period of up to five years. To date no studies have looked beyond five years. Methods: Two cohorts of diabetes patients attending a single specialist foot clinic were followed for ten years after first foot ulcer. Cohort A: 202 (63% male) patients treated with intensive cardiovascular risk reduction therapies (statins, anti-platelets and ACE inhibitors) and Cohort B: 405 (62% male) historical control patients. Mortality was determined from national diabetes database records. Results: Cohort A had significantly lower mortality rates from year 1 (8% vs 16% p=0.005). However after 10 years this advantage was no longer statistically significant (65% vs 69% p=0.25). The annual mortality is detailed in Figure 1. Conclusions: Whilst applying secondary cardiovascular prevention to diabetes foot ulcer patients appears to delay mortality, the effect is reduced to non-significant levels as disease progression after 10 years appears to have a greater effect. References: Faglia et al. Diabetes Research Clinical Practice 2014;103, 292–297 Morbach et al. Diabetes Care.2012; 35: 2021–2027 Young et al. Diabetes Care 2008 31: 2143-2147. Mortality over time for both cohorts www.diabeticfoot.nl Page 1 of 10 P2.02 Cardiovascular prevention in patients with diabetic foot Lia Ferreira, Centro Hospitalar do Porto, Porto, Portugal Marta Almeida, Centro Hospitalar do Porto, Porto, Portugal Susana Garrido, Centro Hospitalar do Porto, Porto, Portugal Maria Teresa Pereira, Centro Hospitalar do Porto, Porto, Portugal Ana Rita Caldas, Centro Hospitalar do Porto, Porto, Portugal Raquel Almeida, Centro Hospitalar do Porto, Porto, Portugal Sara Pinto, Centro Hospitalar do Porto, Porto, Portugal José Muras, Centro Hospitalar do Porto, Porto, Portugal Isabel Gonçalves, Centro Hospitalar do Porto, Porto, Portugal Joana Martins, Centro Hospitalar do Porto, Porto, Portugal Helena Neto, Centro Hospitalar do Porto, Porto, Portugal Claúdia Amaral, Centro Hospitalar do Porto, Porto, Portugal André Carvalho, Centro Hospitalar do Porto, Porto, Portugal Claúdia Freitas, Centro Hospitalar do Porto, Porto, Portugal Rui Carvalho, Centro Hospitalar do Porto, Porto, Portugal Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among diabetic patients. To reduce cardiovascular risk, the American Diabetes Association recommend blood pressure control and treatment with statin and aspirin in those who have overt CVD as well as in those who have at least one cardiovascular risk factor or target organ damage. Objective:The purpose of this study was to evaluate strategies to reduce cardiovascular risk patients with diabetic foot. Methods: A retrospective observational study was performed. Patients observed for the first time in a multidisciplinary outpatient diabetic foot clinic between January and December 2012 were reviewed (n=613). Some data were collected: demographic data, type and duration of diabetes, HbA1c, micro and macrovascular complications, additional cardiovascular risk factors and treatment with statin, aspirin or antihypertensive medication. Results :Patients were mainly men (59.7%), with a mean age of 67.2 years old., 89.7% had type 2 diabetes, diagnosed 17±11 years before., The average of HbA1c was 8.0%. The majority had microvascular disease (52.7% retinopathy, 32.9% nephropathy and 75.7% peripheral neuropathy) or established macrovascular disease [22.9% coronary artery disease (CAD), 23.4% cerebrovascular disease (CeVD) and 57.4% had peripheral arterial disease (PAD)]. 83.5% had hypertension, 65.2% dyslipidemia and 12.1% were smokers. Regarding cardiovascular prevention 73.5%, 52% and 47% were treated with antihypertensive, statin and aspirin, respectively. These medications were significantly more frequent in patients with hypertension and dyslipidemia(p <0.05). The percentage of patients on aspirin was significantly higher in the presence of CAD and CeVD., The percentage of patients on statin was significantly higher among those with CAD(p <0.05). No differences were found regarding cardiovascular prevention strategies among patients with PAD. Conclusions: The level of intervention for reducing cardiovascular risk in this group of diabetic patients was insufficient. This may reflect an undervaluation of PAD in assessing cardiovascular risk. It is important to reinforce the need to adopt prevention strategies in these patients, which can reduce their morbidity and mortality. www.diabeticfoot.nl Page 2 of 10 P2.03 The prevalence of diabetic foot disease Claire O'Shea, Waikato District Health Board, Hamilton, New Zealand Aim: The aim of this research project is to establish the prevalence of high risk diabetic foot disease., Objectives: To determine the prevalence of early diabetic foot disease. To review the use of a foot screening tool by a non-podiatrist health professional. To obtain data that could help in planning for podiatry and foot care services in both primary and secondary care by reviewing the number of people identified with foot disease. Method: This project will involve those who consent to a foot screen being performed at the same appointment as their retinal eye screening appointment. This will capture data from, people with diabetes within a 6 month period from May to November 2014., People referred to the Diabetes Service mobile retinal photo screening service comprise of all known people with diabetes in the region other than those with established retinopathy who attend a specialist eye clinic., The health professional performing the foot screening will be trained by the primary researcher. A random sample of 5% will be independently reviewed by the primary researcher, to assess the consistency of the screening by the non-podiatrist. Demographic and descriptive data will be collected using excel and digital photography was used to take pictures of the feet., The Scottish Intercollegiate Guidelines Network diabetic foot risk and stratification and triage tool will be utilised to categorise the foot status by the lead researcher. The GP will be notified of the results of the foot screen so any necessary treatment plan can be actioned by the GP., Results: The preliminary results: total population was 3860 people, this project represents approximately 77% of people with diabetes within the region. 2192 consented to a foot screen., The risk categories results are low 69.4%, moderate 17.8%, high 12.6%, active 0.1%. Conclusion: This project will help in providing the needed data on diabetes foot disease for this population, align with what is occurring internationally and what has shown to be necessary by national documents produced over the past decade., This foot screening programme will work in partnership with primary and secondary care and will provide an objective and sound assessment, to allow comprehensive foot care for people with diabetes. www.diabeticfoot.nl Page 3 of 10 P2.04 The dialysis foot: Is there a difference in foot complications in African Hispanic and European Americans? Lawrence Lavery, UT Southwestern, Dallas, United States Javier LaFontaine, UT Southwestern, Dallas, United States David Lavery, Statistical Consultant, Denver, United States Suzanne van Asten, UT Southwestern, Dallas, United States Aim: In the US there is a large difference in the incidence of diabetes related amputations in African and Hispanic Americans compared to people of European descent. The aim of this study is to compare the prevalence of foot complications in a cohort of 327 dialysis patients with diabetes that were stratified according to race. Methods: We prospectively evaluated a cohort of dialysis patients with diabetes at 12 centers in Texas for peripheral neuropathy (PN), peripheral arterial disease (PAD), history of ulcers or amputations and active ulcers. PAD was defined as an ankle-brachial index <0.7, PN was defined as a vibration perception threshold >25 volts. Comparison of groups of data was performed using the chi square test. Results: There was no significant difference in the mentioned foot complications based on race or gender. 96.3% of subjects had at least one foot complication. 80% of patients with an amputation history had a leg or thigh level amputation. 26% reported symptoms of intermittent claudication. Conclusion: There is no difference in prevalence of diabetic foot complications in dialysis patients between races. Dialysis patients seem to have more diabetic foot complications than previously reported numbers in patients without kidney disease. N=327 No PN PN PAD PAD-PN Ulcer History Amputation History Active Ulcer Hispanic n=165 4.8% 2.4% 14.5% 39.4% 14.8% 18.2% 6.1% AfricanAmer n=56 3.6% 5.4% 14.3% 42.9% 10.7% 17.9% 5.4% White n=104 1.9% 8.7% 9.7% 37.5% 22.1% 12.5% 8.7% Total 3.7% 4.9% 12.5% 39.8% 16.2% 16.2% 6.7% Outcomes of diabetic foot complications across different races www.diabeticfoot.nl Page 4 of 10 P2.05 Anatomical classification of foot ulcers in "Entities of the DFS" Dirk Hochlenert, Centrum für Diabetologie, Endoskopie und Wundheilung, Köln, Germany Gerald Engels, Chirurgische Praxis am Bayenthalgürtel, Köln, Germany Stephan Morbach, Marienkrankenhaus Soest, Soest, Germany Aim: We developed a classification of diabetic foot ulcers based on the link between the localization and the causes. The term „entity“ describes a relatively homogenous clinical picture with defined localization and biomechanical disorder, probability of PAD and other causes as well as appropriate measures of offloading and prognostic information. Methods: Data and photos of 10.037 treatments with extra funding by special contracts with insurance companies were analyzed. Each photo was related to one of 50 defined areas of the foot. Risks and treatment results of were analyzed. Results: The 50 analyzed regions were summarized into 22 entities with comparable pathobiomechanical situations, offloading concepts and prognosis. Using interdisciplinary discussion appropriate methods of internal and external offloading could be allocated to distinct entities. Conclusions: Defining "entities" uses the association between localization and causes of the DFS to develop a systematization scheme. This enables the standardization of pressure redistribution. To shift load from risky areas to parts of the foot which are suitable for weight bearing is the best method of offloading, as it keeps the patient walking and respects the overall goal of maintaining mobility. This classification helps to spread the knowledge about how to obtain this weight redistribution by surgical procedures, devices or accomodative dressings. It enables a more accurate interdisciplinary discussion between surgeons, diabetologists and shoemakers about the preferable available techniques or the need of developing new approaches. The system also enables to estimate the prognosis more precisely. As a result, the “entities of the DFS” shall facilitate the further spreading, scientific discussion on offloading procedures and their further development. Hochlenert D, Engels G, Morbach S (2014) Das Diabetische Fußsyndrom - Über die Entität zur Therapie. Springer Verlag Berlin Heidelberg www.diabeticfoot.nl Page 5 of 10 P2.06 Risk factors for first ever recorded foot ulcer among patients with type 1 and type 2 diabetes Sine Hangaard, Steno Diabetes Center, Gentofte, Denmark Anne Rasmussen, Steno Diabetes Center, Gentofte, Denmark Thomas Almdal, Department of Medicine F, Gentofte University Hospital, Hellerup, Denmark Kirsten Engelhard Nielsen, Steno Diabetes Center, Gentofte, Denmark Annemette Anker Nielsen, Steno Diabetes Center, Gentofte, Denmark Volkert Siersma, The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark Per Holstein, Department of Dermatology and Copenhagen Wound Healing Center, Copenhagen, Denmark Aim: Diabetic foot ulcer (DFU) is a major complication of diabetes with an increasing burden for health care systems and impaired quality of life for patients. Knowledge of factors involved in the development of DFU may help in screening strategies to identify patients at high risk of DFU. The purpose of the present investigation was to identify risk factors for first recorded DFU over a period of 11 years. Methods: This cohort study included 4809 patients with type 1 diabetes (T1D) and 5959 patients with type 2 diabetes (T2D) treated at a large diabetes center in Denmark in the period 2001 to 2011. Patients with a prior or present DFU diagnosis were excluded from the study. Data on baseline characteristics and comorbidities were collected from electronic patient records. Influences of various risk factors of incident DFU were assessed as hazard ratios (HR) from Cox proportional hazard regression models on time from enrolment to DFU diagnosis or end-of-study (censoring). Results: The risk of developing DFU over a period of 11 years in patients with T2D was about 20%, twice that of patients with T1D. Among patients with T1D independent risk factors for the DFU incidence were high age (HR=1.4-2.5), micro albuminuria (HR=1.9), reduced vibration sense (HR=1.9-4.0), advanced retinopathy (HR=3.2–3.5), no palpable foot pulse (HR=2.3) and poor metabolic control (HR=2.2). 69.3% of all identified DFU’s were found in T1D patients with poor metabolic control at baseline. Among patients with T2D risk factors were male gender (HR=2.0), reduced vibration sense (HR=3.1-6.0) and advanced retinopathy (HR=2.7–4.4). 89.6% of all identified DFU’s were found in T2D patients with reduced vibration sense at baseline. Conclusions: The present study concludes that T2D patients are more likely to develop DFU than T1D patients. The identified risk factors for the development of DFU can be used to identify at-risk patients and when planning primary prevention programs to reduce the rate of foot ulceration and suggests that different approaches should be used in the two diabetes types. www.diabeticfoot.nl Page 6 of 10 P2.07 Differences in commonly measurable clinical and biomechanical parameters between ulcerated and non-ulcerated diabetic neuropathic patients Roozbeh Naemi, Staffordshire University, Stoke on Trent, United Kingdom Aoife Healy, Staffordshire University, Stoke on Trent, United Kingdom T Revathi, India Diabetes Research Foundation, Chennai, India Lakshmi Sundar, India Diabetes Research Foundation, Chennai, India Nachi Chockalingam, Staffordshire University, Stoke on Trent, United Kingdom Anju Pillai, India Diabetes Research Foundation, Chennai, India Ambady Ramachandran, India Diabetes Research Foundation, Chennai, India Aim: A variety of risk factors have been identified that contribute to ulceration in previous investigations (O’Brien, et al. 2014, Monteiro-Soares, et al. 2011). Some studies identified biomechanical parameters (i.e. limited joint mobility), and neuropathy score measures i.e. high vibration perception thresholds (VPTs) to be a risk factor for ulceration (Crawford et al, 2007), whilst other studies reported blood biochemical measures like increased Glycated haemoglobin (HbA1c) to increase ulceration risk (Boyko et al, 2006)., Therefore the aim of this study was to identify the parameters which can potentially identify patient, at risk of foot ulceration. Methods: 70 diabetic patients with neuropathy were recruited from and tested at a diabetes hospital in South India. Blood biochemical parameters, neuropathy scores, and biomechanical parameters including ankle and intersegmental foot range of motion and isometric strength, Romberg balance parameters and Foot Posture Index (FPI) were measured at the beginning of the study then patients were followed up for 18 months. At the end of follow-up, 4 patients had ulcerated. Independent t-test was utilised to identify significant differences (p<0.05) between ulcerated and ulcer free patients. Results and conclusion: The ulcerated group showed significantly higher: regional and average VPT scores for both the left (η2= 0.414) and the right foot (η2= 0.394), FPI for right (η2= 0.107) and left foot (η2= 0.123), load on the right forefoot during standing shod (η2= 0. 304 ) and right mid-foot range of motion (η2= 0. 080). The significantly lower Anterio-posterior centre of pressure excursion in shod closed eyes (η2= 0.183) and centre of pressure excursion area during shod open eyes (η2= 0.324) were observed in ulcerated patients. Patients with a higher neuropathy score, less centre of pressure variation during standing and more pronated feet seem to be more vulnerable to ulceration. References: Monteiro-Soares, M., et al. (2011). Diabetologia 54.5: 1190-1199. O’Brien, et al. (2014). Clinical Research on Foot and Ankle, 2(155), 2. Crawford, F., et al. (2007). Qjm 100.2: 65-86. Boyko, E.J., et al. (2006). Diabetes care 29.6: 1202-1207. Acknowledgements: DiabSmart, FP7-PEOPLE-2011-IAPP, EC Grant Agreement No 285985; www.diabeticfoot.nl Page 7 of 10 P2.09 Comparison of clinical characteristics and medical costs of patients with diabetic foot ulcer between 2004 and 2012 in China Yijuan Ban, Diabetes Center, 306th Hospital of PLA, Beijing, China, Xingwu Ran, West China Hospital Sichuan University, Chengdu, China Chuan Yang, Sun Yat-sen Memorial Hospital Sun Yat-sen University, Guangzhou, China, Penghua Wang, Tianjin Medical University Metabolic Diseases Hospital, Tianjin, China, Zhangrong Xu, Diabetes Center, 306th Hospital of PLA, Beijing, China Aim: To compare and analyze clinical characteristics, prognosis and medical cost in the patients with diabetic foot in 2004 and 2012 in China. Methods: Diabetic foot disease data from 14 teaching hospitals in 2004 and 15 teaching hospitals in 2012 in China were collected and analyzed. Results: 386 cases in 2004 and 682 cases in 2012 were recruited. No significant differences in age, educational level, duration of diabetes, glycosylated hemoglobin A1c, triglyceride, high density lipoprotein cholesterol, uric acid, prevalence of dyslipidemia, cerebrovascular and peripheral artery disease, peripheral neuropathy, the percentage of neuropathic or ischemic foot ulcer, and medical cost between the 2 groups. Duration of diabetic foot was shorter, more patients with smoking and/or drinking, lower fasting and post-meal glucose, total cholesteroland and low density lipoprotein cholesterol in 2012 than in 2004. The higher prevalence of hypertension, coronary heart disease, diabetic kidney disease, diabetic retinopathy, and more patients with infectious foot ulcer, more patients with severe foot disease whose foot ulcer classified as Wagner 3 and above or Texas D (76.6% vs 68.7%, 52.4% vs 29.5%,46.7% vs 34.3%;all P<0.05) in 2012. There were significantly lower major amputation rate, higher ulcer healing rate, shorter hospital stay(2.3% vs 5.9%,52.3% vs 18.2%,18(12-32) vs 21(15-32) d,all P<0.05 ), but higher total amputation rate (17.2% vs 10.2%,P<0.05) in 2012. Medical cost for these patients in 2012 and 2004 was 17183(9535~30599) vs 12364(7985~18725) Yuan, no significant difference after consumer price index corrected. Conclusions: The patients with diabetic foot disease in 2004 and 2012 were older, with more men, low educational level, long duration of diabetes, poor control of hyperglycemia, high medical cost and with more cardiovascular risk factors and diabetic complications. Compared with the patients in 2004, patients with diabetic foot in 2012 had more concomitant diseases and complications, with more severe foot ulcers and infections, higher total amputation rate, but lower major amputation rate, higher ulcer healing rate, and shorter hospital stay.Fund:The military clinical major projects of advanced technology (2010gxjs054) www.diabeticfoot.nl Page 8 of 10 P2.10 Long-term prognosis of diabetic patients with a first foot ulcer Susana Garrido, Centro Hospitalar do Porto, Porto, Portugal Jorge Dores, Centro Hospitalar do Porto, Porto, Portugal Cláudia Amaral, Centro Hospitalar do Porto, Porto, Portugal Cláudia Freitas, Centro Hospitalar do Porto, Porto, Portugal Helena Neto, Centro Hospitalar do Porto, Porto, Portugal Rosa Guimarães, Centro Hospitalar do Porto, Porto, Portugal Sara Pinto, Centro Hospitalar do Porto, Porto, Portugal Joana Martins, Centro Hospitalar do Porto, Porto, Portugal Isabel Gonçalves, Centro Hospitalar do Porto, Porto, Portugal José Muras, Centro Hospitalar do Porto, Porto, Portugal André Carvalho, Centro Hospitalar do Porto, Porto, Portugal Rui Carvalho, Centro Hospitalar do Porto, Porto, Portugal Background: Diabetic foot ulcer (DFU) is a major cause of morbidity and mortality in patients with diabetes. There is insufficient data on long-term outcomes in patients with a first DFU. Aims: To evaluate the 5-year outcomes of diabetic patients with a first DFU, concerning amputations and all-cause mortality, and to analyze the clinical and demographic variables related with mortality., Methods: Retrospective analysis of clinical data of patients with a DFU attending for the first time our Diabetic Foot Clinic during 2008. Patients with history of previous DFU were excluded, as were those with missing relevant data. Statistical analysis was performed using descriptive and inferential statistics as appropriate. Results: Of the 248 patients included in the study, 54 0% were male and 94 3% had type 2 diabetes. The median age at presentation was 70 years (IQR=16) and the median diabetes duration was 15 years (IQR=14). Ulcers were neuropathic in 37 0% of the patients and neuroischemic/ischemic in 63 0%. During the 5-year period, a total of 31 9% of the patients had at least one minor amputation and 23 7% a major amputation. The 5-year mortality rate was 45 3% for the entire group. Patients with neuroischemic/ischemic foot had a higher mortality rate (54 2% vs 28 9%, p<0 001). Patients who died were older at presentation (median age 75 years, IQR 12 vs 64 years, IQR=16; p<0 001) and had longer diabetes duration (median duration 15 years, IQR 20 vs 14 years, IQR=14; p=0 03). Other factors associated with a higher mortality were: ischemic heart disease (p=0 005), cerebrovascular disease (p<0 001), peripheral arterial disease (p<0 001) and hypertension (p=0 001). None of the other clinical and demographic variables tested were related with this outcome. Conclusion: DFU is associated with high amputation and mortality rates, especially among older patients with longer diabetes duration, history of macrovascular disease and hypertension. These patients must be carefully followed and managed by multidisciplinary teams. Acknowledgements: The authors thank A.Cruz, A.Serra, A.Silva, J.Correa, J.Vale, J.Cardoso, M.Laranjo, M.Gonçalves, M.Barreira, M.Fernandes, R.Rodrigues, R.Pereira, V.Tavares, medical students of ICBAS-UP, who contributed to the data collecting process www.diabeticfoot.nl Page 9 of 10 P2.11 Diabetes versus the rest: who has the greatest foot disease burden in our inpatient populations? Peter Lazzarini, Queensland University of Technology, Brisbane, Australia Vanessa Ng, Queensland Health, Brisbane, Australia Suzanne Kuys, Griffith University, Gold Coast, Australia Maarten Kamp, Queensland University of Technology, Brisbane, Australia Michael d'Emden, Queensland Health, Brisbane, Australia Courtney Thomas, Queensland Health, Mount Isa, Australia Jude Wills, Queensland Health, Rockhampton, Australia Ewan Kinnear, Queensland Health, Brisbane, Australia Scott Jen, Queensland Health, Ipswich, Australia Sheree Hurn, Queensland University of Technology, Brisbane, Australia Lloyd Reed, Queensland University of Technology, Brisbane, Australia Aim: Foot disease causes large numbers of hospitalisations, yet the exact prevalence is unclear., The aims of this paper were to investigate the point-prevalence of different foot complications in general inpatient populations, and, analyse differences in diabetes and nondiabetes sub-groups. Methods:, Eligible participants were all adults admitted overnight for any reason into five diverse hospitals on one day; excluding maternity, mental health and cognitively impaired. Participants underwent a physical foot examination by trained podiatrists to clinically diagnose foot complications using validated measures, including: wounds, infections, deformity, peripheral arterial disease (PAD) and peripheral neuropathy (PN)., Demographic, social determinant, medical history, foot disease history, self-care, footwear and reason for admission variables were also collected. Results: Overall, 733 (83%) of 883 eligible participants consented; mean±SD age 62±19 years, 480 (55.8%) male, 172 (23.5% (95% CI) (20.5-26.7)) had diabetes., Foot complications were a reason for admission in 11.2% (9.1-13.7) of participants., Diabetes inpatients had significantly higher prevalence of foot complications as a reason for admission than non-diabetes (19.8% vs 8.6%; p < 0.001)., Foot complication prevalence included: wounds 9.0% (5.1-8.7), infections 3.3% (2.2-4.9), deformity 22.4% (19.5-26.7), PAD 21.0% (18.2-24.1) and PN 22.0% (19.1-25.1)., Diabetes inpatients had significantly higher foot complication prevalence than non-diabetes (p < 0.01); wounds (15.7% vs 7.0%), infections (7.1% vs 2.2%), deformity (30.5% vs 19.9%), PAD (35.1% vs 16.7%) and PN (43.3% vs 15.4%)., In backwards stepwise multivariate analyses diabetes inpatients were independently associated (OR (95% CI) with PN (4.2 (2.8-6.3), PAD (2.1 (1.4-3.2)) and wounds (2.3 (1.3-3.9))., Conclusion: Findings indicate one in every ten inpatients, and one in five with diabetes, had been hospitalised with a foot complication as a reason., Diabetes was independently associated with inpatient foot complications and had significantly higher prevalence of all foot complications than non-diabetes inpatients., Further research is required to tackle this large inpatient foot complication burden, particular in diabetes inpatients. www.diabeticfoot.nl Page 10 of 10
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