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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1150-1156

Predictors of diabetic foot ulcer severity among patients attending Menoufia University Hospital, Egypt


Department of Family Medicine and Vascular Surgery, Faculty of Medicine, Menoufia University Hospital, Menoufia, Egypt

Date of Submission29-Apr-2022
Date of Decision04-Jun-2022
Date of Acceptance05-Jun-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Manal H Mohamed Al-Siad
Shebin El-Kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_147_22

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  Abstract 


Background
Diabetic foot ulcer (DFU) results in major medical, financial, and social burden for the patients, their families, and society.
Objective
To assess the severity of DFU and identify the predictors of ulcer severity among the studied patients.
Patients and methods
A cross-sectional study of 70 DFU patients was undertaken. They were evaluated through a structured self-administrated questionnaire composed of four parts (sociodemographic data, diabetes-related data, knowledge, and practice about foot care) followed by physical examination to assess DFU severity.
Results
According to Wagner's classification, grade 2 DFU was the most prevalent among the studied group (42.9%), Followed by Grade 3 (28.6%). A logistic regression analysis revealed that the following factors were significantly associated with high ulcer severity: elevated glycated hemoglobin [odds ratio (OR)=3.02, P = 0.002], treatment with insulin (OR = 4.94, P = 0.008), heavy smoking (OR = 49.00, P = 0.01), long duration of diabetes (OR = 3.02, P = 0.026), and unsatisfactory foot care practice (OR = 3.6, P = 0.02).
Conclusion
Heavy smoking, elevated glycated hemoglobin, and unsatisfactory foot care practice are preventable predictors of high ulcer severity. Therefore, multidisciplinary management programs that focus on smoking cessation and education about proper foot care and glycemic control is recommended to prevent exacerbation of DFU and decrease the incidence of lower-extremity amputations.

Keywords: diabetic foot ulcer, predictors, ulcer severity, Wagner's classification


How to cite this article:
Khalil NA, Shaheen HM, Alkhateep YM, Al-Siad MH, Barakat AM. Predictors of diabetic foot ulcer severity among patients attending Menoufia University Hospital, Egypt. Menoufia Med J 2022;35:1150-6

How to cite this URL:
Khalil NA, Shaheen HM, Alkhateep YM, Al-Siad MH, Barakat AM. Predictors of diabetic foot ulcer severity among patients attending Menoufia University Hospital, Egypt. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1150-6. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1150/359665




  Introduction Top


Diabetes mellitus (DM) is a group of metabolic disorders characterized by chronic hyperglycemia that leads to diabetic complications including peripheral neuropathy, peripheral vascular disease, increased risk of infection, and poor wound healing. The diabetic foot is defined as a group of syndromes in which neuropathy, ischemia, and infection lead to tissue breakdown resulting in morbidity and possible amputation[1].

Diabetes was estimated to affect 151 million people aged 20–79 years in 2000, and this figure had risen to 463 million in 2019. Egypt ranks eighth in the world in terms of diabetes prevalence, with an estimated 8.2 million patients. It is expected that by 2045, the number will have doubled. Egypt will have ascended to sixth place in the world by then[2].

Diabetic foot ulcer (DFU) is a prevalent complication of DM and accounts for significant morbidity, mortality, and healthcare expenditures. The incidence of developing an ulcer among diabetic patients may be as high as 25%. Once an ulcer has progressed, there is a high risk of below-knee amputation[3]. According to the International Diabetes Federation's 2015 prevalence data, foot ulcers were projected to occur annually in 9.1 million to 26.1 million diabetics worldwide. These numbers are alarming, as the clinical implications for the development of a DFU are not negligible[4].

The risk of developing DFUs is increased in the presence of comorbidities such as retinopathy, nephropathy, neuropathy, and peripheral vascular disease. In addition, DFUs are also affected by lifestyle factors such as smoking, alcohol intake, exercise, and habits of foot self-care practice[5]. Factors influencing distal neuropathy and vasculopathy are chronic hyperglycemia, ischemia of the endoneurial microvascular circulation, smoking, hypertension, and hyperlipidemia. So, the ulcer is triggered by a slight trauma in the presence of decreased immunity and bacterial invasion[6].

Meggitt-Wagner classification is the most often cited, simple, widely accepted, and reliable tool for evaluating diabetic foot lesions and effectively treating them. It includes six grades ranging from grade 0 to grade 5. Grade is determined based on depth of the skin lesion and the presence or absence of infection and gangrene[7]. Surgical interventions are required for patients with advanced grades (from grade 3 to grade 5) and showed increased amputation risk[8].

As few studies were conducted in Egypt to predict the need for amputation and high ulcer severity, this study was done to assess the severity of DFUs using Wagner's classification and predict the factors that contributed to the high ulcer severity among the studied group. So, identifying these factors is critical for developing strategies to prevent exacerbation of DFU and decrease the incidence of lower-extremity amputations.


  Patients and methods Top


This cross-sectional study was conducted at the vascular surgery clinic in Menoufia University Hospital from September 2020 to December 2021. All patients with DFU who attended the clinic during the period of data collection were enrolled in the study after obtaining their consent till the sample size was reached. However, diabetic patients who had traumatic ulcers, and cognitive and mental illnesses were excluded from the study.

The sample size was calculated based on the prevalence of type 2 diabetes in Egypt (15.6%)[9], power of the study (80%), the margin of error at 5% (standard value of 0.05), and confidence level of 95% (standard value of 1.96); a sample size of 61 patients was obtained and it was increased to 70 patients (round figure).

Eligible participants were interviewed through a structured self-administrated questionnaire followed by a clinical examination. The questionnaire is composed of four parts: (i) sociodemographic data including age, sex, marital status, residence, and 10 questions for assessing the socioeconomic standard based on the Fahmy et al.[10] socioeconomic scoring system. (ii) Diabetes-related data about smoking, duration of diabetes, family history of diabetes, diabetic medications, presence of other chronic diseases or diabetic complications, adherence to regular exercise (any type of exercises or at least 30 min physical activity for at least 5 days), adherence to dietary regimen recommended by the physician, and review of the value of last glycated hemoglobin (HbA1c) measurement. The smokers were classified into mild, moderate, or heavy smokers if they smoked less than 400, 400–800, more than 800 cigarettes/year, respectively. (iii) Questionnaire on Knowledge of Foot Care developed by Hasnain and Sheikh (15 questions) and assessed the knowledge about foot care. The items of the questionnaire were answered with 'yes,' 'no,' and 'I don't know.' The score ranged from 0 to 15, 0 for the 'wrong' and 'I don't know' answers and one for each 'correct' answer. Knowledge score was classified into satisfactory and unsatisfactory if correct answers were more than or equal to 50% and less than 50%, respectively[11]. (iv) Nottingham Assessment of Functional Foot Care questionnaire (NAFFC) (29 questions) was used for assessing the patients' practice of foot care. The responses to questions were recorded on a categorical scale (scored from 0 to 3) according to the frequency of occurrence of the behavior. The practice of foot care was classified into satisfactory and unsatisfactory if the patient score was more than or equal to 50% and less than 50%, respectively[12]. Both Knowledge and Assessment of Functional Foot Care questionnaires were translated into Arabic. Professors of internal medicine, family medicine, and community medicine tested the validity of the questionnaire and its ability to assess predictors for DFU. The content validity index of the designed questionnaire was calculated. It was 90% for the questionnaire used in the study. Reliability was calculated using Cronbach's alpha, which was 0.82 indicating good reliability.

The careful examination of the foot was done to determine the severity of DFU based on Wagner's classification to be categorized into grade 0 (indicates a high-risk foot with no ulceration), grade 1 (refers to superficial ulceration requiring antibiotics and strict glycemic control), grade 2 (ulcer with deep infection, without the involvement of the bone), grade 3 (ulcer with osteomyelitis), grade 4 (localized gangrene), and grade 5 (gangrene of the entire foot)[13]. The ulcer severity was classified into low-severity ulcers (including grade 1 and grade 2) and high-severity ulcers (including grade 3 and grade 4).

The research proposal was approved by the Ethics Committee of the Faculty of Medicine, Menoufia University. Written consent was taken from patients after explaining the purpose of the study and assuring confidentiality.

Statistical analysis

SPSS, version 22 (SPSS Inc., Chicago, Illinois, USA) was used to gather, tabulate, and statistically analyze the data. The mean and SD were used to present quantitative data. The χ2 test for parametric data and the Fisher exact test for nonparametric data were used to compare qualitative data presented in the form of numbers and percentages. An independent t test was used for comparing the means of two independent groups. Pearson's correlation was used for determining the correlation between parametric quantitative variables (between knowledge or practice and severity of ulcer). Logistic regression was performed to know the predictors of diabetic ulcer severity. Statistical significance was defined as a P value of less than 0.05.


  Results Top


This study showed that grade 2 DFU was the most prevalent among the studied patients (42.9%), Followed by Grade 3 (28.6%) and only 1.4% of them had grade 4 ulcers [Figure 1]a.
Figure 1: Distribution of the studied group (a) according to ulcer severity based on Wagner classification and (b) according to their knowledge about diabetic foot self-care.

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Regarding knowledge about foot care, the majority of patients (98%) knew that antidiabetic medications should be taken regularly to prevent complications and 97% of them knew that socks should be changed daily. On the other hand, about 9% of participants recognized how often they should check their feet and inside their shoes; 1.4% of patients were aware that talcum powder should be used to keep the areas between the toes dry; and only 4.3% of them were aware that lotion or moisturizing cream should be applied on the feet to prevent dryness of the skin [Figure 1]b.

There was no statistically significant difference between patients with low and high ulcer severity as regards patients' sociodemographic data (age, sex, work, marital status, residence, education, and socioeconomic standard) [Table 1].
Table 1: Relationship between diabetic foot ulcer severity and sociodemographic factors among the studied patients

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A statistically significant effect of increased duration of diabetes on the severity of foot ulcer was found. Also, medication type showed a significant relationship to DFU severity as 85.71% of patients on the oral hypoglycemic drug had low-severity ulcers.

The severity of DFU was also affected by the smoking index as the majority of heavy smokers (87.50%) had high-severity ulcers, while the majority of mild smokers (87.50%) had low-severity ulcers.

The mean HbA1c level was significantly higher among patients with high ulcer severity as the mean ± SD was 8.73 ± 0.85, but in low-severity ulcer patients it was 7.87 ± 0.91 [Table 2].
Table 2: Relationship between diabetic foot ulcer severity and diabetes-related factors among the studied patients

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There was a statistically significant difference between the patients' ulcer severity and foot self-care practice as 78% of patients with satisfactory practice had low-severity ulcers [Table 3].
Table 3: Relation between knowledge, practice of foot care, and diabetic foot ulcer severity among the studied patients

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There was negative correlation between ulcer severity and both foot self-care knowledge [Figure 2]a and practice [Figure 2]b with a correlation coefficient of − 0.35 and − 0.48, respectively.
Figure 2: Correlation analysis between ulcer severity and both foot self-care knowledge (a) and practice (b).

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A logistic regression analysis revealed that the following factors were associated with high ulcer severity: higher HbA1c [odds ratio (OR)=3.02, P = 0.002], treatment with insulin (OR = 4.94, P = 0.008), heavy smoking (OR = 49.00, P = 0.01), long duration of diabetes (OR = 3.02, P = 0.026), and unsatisfactory foot care practice (OR = 3.6, P = 0.02) [Table 4].
Table 4: Regression analysis to detect predictors of diabetic ulcer severity

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  Discussion Top


Wagner's grade 2 ulcer was the most common in this study (42.9%), while Wagner's grade 4 ulcer was the least common (1.4%). It was similar to a study conducted at Kermanshah Province's diabetes clinic, which revealed that 46.8% of ulcers were of grade 2 and 3.7% were of grade 4[14]. This was in contrast to the Hwang et al.[15] study which found that 10% of the patients had an ulcer of grade 2 and 28% grade 4.

Regarding knowledge about foot care, a vast majority of patients (98.6%) were aware that taking antidiabetic medications on a regular basis helps to avoid complications, and 97% of them were aware of the importance of changing socks daily. This may be due to that they were adherent to follow-up visits, where they received educational messages about these items. This was in line with the finding of studies conducted in Egypt by Kassab et al.[16] and Abu-Elenin et al.[17] as well as Sutariya and Kharadi[18] in India, which found that more than 90% of respondents were aware of the importance of taking diabetic medications on a regular basis to avoid diabetic complications.

Only 9% of participants in the current study recognized how often they should check their feet and inside their shoes, which is lower than another study conducted at Tanta University Hospital in Egypt by Abu-Elenin and colleagues (49.2 and 50.8%, respectively).

Only 1.4% of patients knew that talcum powder should be used to keep the spaces between the toes dry, and only 4.3% of patients knew that lotion or moisturising cream should be administered to the feet to avoid skin dryness. This was comparable to a study undertaken by Kassab et al.[16] in Egypt and Magbanua and Lim-Alba[19] in the Philippines, which found that more than half of the patients were unaware of how to properly use talcum powder and lotion on their feet.

The patients with high-severity ulcers had a higher median duration of diabetes. This was consistent with the findings of a study conducted in Indonesia by Syauta et al.[20], which discovered a significant correlation between DFU degrees and diabetes duration. This may be explained by that long diabetes duration is associated with the development of peripheral neuropathy and peripheral vascular disease. Peripheral neuropathy allows ulceration to develop after unrecognized trauma, whereas poor blood supply (ischemia) inhibits wound healing.

There was a significant relationship between severity of DFU and medication type, as 85.71% of patients on the oral hypoglycemic drug had low-severity ulcers, and half of the patients on both insulin and the oral hypoglycemic drug had high-severity ulcers. This could be attributed to the fact that initiation of insulin therapy is common through the later stages in the natural history of DM and correlates with the association of diabetic foot severity with a longer duration of DM. That was inconsistent with the study in China by Jiang et al.[21], which reported that insulin use appeared to be one of the primary factors accounting for the threefold reduced DFU risk in Asian patients.

The current study showed that there was a statistically significant relationship between DFU severity and smoking index as the majority of heavy smokers (87.50%) had high-severity ulcers. This result coincides with the findings of the Yekta et al.[22] study. The probable explanation is that smoking increases the incidence of vasculopathy that affects the severity of DFU. However, the study conducted in Kano by Habibu[23] showed that smoking had no significant association among participants with diabetic foot syndrome. Patients with low ulcer severity had lower mean HbA1c levels than patients with high ulcer severity. This was in accordance with the studies conducted in Nigeria by Habibu[23] and in Egypt by Al Kafrawy et al.[24], which showed that high HbA1c was a contributory factor for DFUs. Also several pieces of evidence showed that hyperglycemia-related advanced glycation end products play a major role in disturbing the normal wound-healing process. This was different from the study conducted in India by Vibha et al.[25], which showed that there was no statistically significant relationship between DFU severity and HbA1c.

As regards diabetic foot care practice, the majority of patients with satisfactory practice had low-severity ulcers. It was consistent with the findings of a study conducted in Ethiopia by Mariam et al.[26], which discovered that lack of foot self-care practice had a strong influence on DFU. This is may be attributed to the beneficial effect of regular feet washing, appropriate drying of feet after washing, daily inspection of the foot status on facilitating circulation, and early management of any abnormality that may occur on the foot. However, Saeedi P et al.[2] conducted a study in Ghana and discovered that foot care practices were not significant predictors of DFUs.

There was negative correlation between ulcer severity and both knowledge and practice of foot self-care. This was in line with a study conducted in Ethiopia, which discovered that DFUs were associated with lack of education and proper foot care practices among patients[26]. The Ghanaian study[2] found that diabetic foot care knowledge and practice were not significant predictors of DFUs. Furthermore, it differed from a study conducted in Port Said, Egypt by Serag[27], which found no link between patients' knowledge of diabetic foot care and their wound status, despite the fact that participants had a satisfactory level of knowledge, as they did not attend the clinic daily to change their dressing or use unsterile dressing during wound care at home.

The predictors of ulcer severity in the current study were smoking index, medication type, HbA1c mean value, duration of diabetes, and foot care practice.

El Din et al.[28] conducted an Egyptian study in diabetes outpatient clinics at a group of Governmental University Hospitals (Elmina, Assiut, Kena, Aswan, Alexandria, and Mansoura) and discovered that uncontrolled blood glucose levels, inappropriate foot care practice, and patients from Elmenia (one of Egypt's governorates) were potential risk factors for DFU.

According to a study conducted in Iran by Jalilian et al.[29], the influencing factors of DFU severity included smoking, lack of diabetes control, type of diabetes treatment, and older age. Another study conducted in Indonesia by Syauta and colleagues showed that there was a correlation between the degree of DFU according to Wagner's classification with smoking habits and diabetic duration[18].


  Conclusion Top


Heavy smoking, elevated HbA1c, and unsatisfactory foot care practice are preventable predictors of high ulcer severity. As a result, multidisciplinary management programs centered on smoking cessation, glycemic control, and proper foot care education will prevent DFU aggravation and reduce the rate of lower-extremity amputations significantly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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