Fatores de risco para a ocorrência das úlceras plantares decorrente da hanseníase / Factors for plantar ulcers caused by leprosy

A hanseníase é doença infectocontagiosa de evolução lenta, causada pelo Mycobacterium leprae. A afinidade do bacilo da hanseníase por células do sistema nervoso periférico acomete, principalmente, os nervos superficiais da pele e dos nervos periféricos, causando neuropatia autonômica, sensitiva e motora que acarreta a diminuição ou ausência da sensibilidade e fraqueza muscular nos olhos, mãos e pés. Se não forem tratadas a tempo, podem provocar o surgimento de incapacidades físicas. Uma das incapacidades físicas mais comuns, vistas na prática clínica, são as úlceras na região plantar, que ocorre devido o comprometimento do nervo tibial, ocasionando déficits motores, sensitivos e autonômicos no trajeto do mesmo. O objetivo do estudo foi identificar os fatores de risco para a ocorrência das úlceras plantares em pacientes diagnosticados com hanseníase no Hospital Eduardo de Menezes da Fundação Hospitalar do Estado de Minas Gerais no período de 2005 a 2016. Trata-se de um estudo epidemiológico, do tipo observacional, transversal e analítico. A população foi composta pelos casos de hanseníase notificados no Hospital Eduardo de Menezes, no período de 2005 a 2016. Para a análise univariada foram utilizados os testes Qui-quadrado de Pearson ou teste exato de Fisher e teste de Mann-Whitney, com significância estatística de 5% (p < 0,05). Na análise multivariada por meio da árvore de decisão utilizando o algoritmo CHAID. Os resultados mostraram que forma clinica, grau de incapacidade física na alta, nervo acometido e o não uso de palmilhas ou calçado adaptado antes de surgir à úlcera se mostraram fatores de risco para a ocorrência de úlcera plantar. Foi identificado que entre os pacientes com grau de incapacidade 0 na alta, não existem casos de úlcera. Já entre aqueles com grau 1, e a forma clínica é DD ou DV a probabilidade de úlcera aumenta para 8,7%. Os pacientes com grau de incapacidade 2 na alta, nervo acometido tibial ou nervos fibular e tibial, mas que usavam palmilha ou calçado especial tem probabilidade de úlcera de 65,9%. Se o paciente não usava palmilhas ou calçados especiais antes de surgir à úlcera a probabilidade de ocorrência da úlcera aumenta para 95,7%. O presente estudo evidenciou a necessidade do diagnóstico precoce da hanseníase, como também da eficiente associação das intervenções medicamentosas e não medicamentosas por meio das técnicas de prevenção de incapacidade e uso de palmilhas acomodativas e/ou calçados especiais.(AU)

Leprosy is an infecto-contagious disease caused by Mycobacterium leprae. Leprosy bacillus' affinity for neural system cells affects mainly superficial skin nerves and periferal nerve roots, resulting in autonomic, sensitive and motor neuropathy, that leads to reduction or absency of sensitivity, and muscular weaknessin the eyes, hands and feet. If not timely treated, these can result in physical disabilities. Amid the most frequent physical disabilities seen in clinical practice are plantar ulcers, wich are caused by tibial nerve impairement, leading to motor, sensitive and autonomic deficits along tibial nerve trajectory. The objective os the present article was to identify risk factors for plantar ulcers in patients who were diagnosed for leprosy at Eduardo Menezes Hospital, Minas Gerais State Hospital Foundation, from 2005 to 2016. This is an epidemiological, observational, transversal, analytical study.The studied population was made of notified cases of leprosy, diagnosed at Eduardo de Menezes Hospital from 2005 to 2016. Pearson's qui-square, Fisher's exact test and Mann-Whitney's test, with 5% statistical significancy (p < 0,05), where used for univariate analysis. For multivariate analysis, CHAID algorythm decision tree was used. Results showed that clinical type, physical disability grade at the time of discharge, impaired nerve and absence of use of insoles or adapted shoes before the appearance of ulcers where risk factors for plantar ulcers ocurrence. For patients with 0 disability grade at discharge there where no cases of plantar ulcers. For those with grade 1 disability, clinical type was a relevant risk fator. For patients with grade 1 disability and type V or DT clinical types, probability was also zero. On the other hand, for DD and DV clinical types, probabilities rise up to 8,7%. Patients with grade 2 at discharge with or without fibular or other nerve impairement also have no probability of plantar ulcers ocurrence. AMong patients with grade 2 disability, tibial nerve impairment or both tibial and fibular nerve impairment, but who made use of insoles ou adapted shoes had a 65,9% probability of developing ulcers. In patients who do not use insoles ou special shoes before ulcer formation,probability of developing ulcers rises up to 95,7%. Present study has highlighted the need of early diagnosis of leprosy, and also the need of the use of efficient association of drug and non-drug techniques of disability prevention and use of insoles and/or special shoes.(AU)

Risco à ulceração nos pés de diabéticos: estudo transversal / Ulceration risk in diabetic feet: a cross-sectional study / Riesgo de ulceración en los pies de diabéticos: estudio transversal

OBJETIVO: Identificar a prevalência do risco à ulceração nos pés de pessoas com diabetes mellitus (DM) residentes em área rural. MÉTODO: Estudo transversal, realizado com 293 pessoas com diabetes mellitus tipo 2 e idade superior a 40 anos, considerando as características socioeconômicas, demográficas, dados clínicos e estilo de vida. A coleta de dados foi realizada mediante entrevista, análise de prontuário e exame clínico dos pés. RESULTADO: O risco à ulceração foi encontrado em 37,2% no pé direito e 35,8% no pé esquerdo, predominando o grau de risco 2. A idade avançada, o baixo nível educacional, o uso de insulina e as outras complicações crônicas do DM foram fatores associados à maior prevalência de risco a ulceração nos pés. CONCLUSÃO: Evidenciou-se a necessidade de implementação de ações que considerem as especificidades das populações rurais, principalmente no que se refere à mudança no estilo de vida para o controle do DM.

AIM: To identify the prevalence of ulceration risk in the feet of people with diabetes mellitus (DM) living in rural areas. METHODS: This is a cross-sectional study, conducted with 293 people suffering from type 2 diabetes mellitus and older than 40 years, considering their socio-economic, demographic and clinical characteristics and lifestyle. Data collection was carried out through interviews, medical record analysis and clinical examination of the feet. RESULT: There was a risk of ulceration on the right foot in 37.2% of the cases and 35.8% in the left foot, and degree 2 risk was predominant. Complications such as greater age, low levels of education, the use of insulin and other chronic issues related to DM were factors associated with a higher prevalence of ulceration risk with regard to the feet. CONCLUSION: The need to implement action that considers the specifics of rural populations was evident, especially with regard to changes in lifestyle in order to control the DM.

OBJETIVO: Identificar la prevalencia del riesgo de ulceración en los pies de personas con diabetes mellitus (DM) residentes en área rural. MÉTODO: Estudio transversal, realizado con 293 personas con diabetes mellitus tipo 2 y edad superior a 40 años, considerando las características socioeconómicas, demográficas, datos clínicos y estilo de vida. La colecta de datos fue realizada mediante entrevista, análisis de historia clínica y examen clínico de los pies. RESULTADO: El riesgo de ulceración fue encontrado en 37,2% en el pie derecho y 35,8% en el pie izquierdo, predominando el grado de riesgo 2. La edad avanzada, el bajo nivel educacional, el uso de insulina y las otras complicaciones crónicas de la DM fueron factores asociados a la mayor prevalencia de riesgo a ulceración en los pies. CONCLUSIÓN: Se evidenció la necesidad de implementación de acciones que consideren las especificidades de las poblaciones rurales, principalmente en lo que se refiere al cambio en el estilo de vida para el control de la DM.

Foot ulcers among diabetic patients visiting surgery department in a university teaching hospital in Ajman, UAE

Diabetes is a very common lifestyle-related metabolic disease in UAE. UAE has the second highest prevalence of diabetes worldwide. Foot problems are one of the commonest reasons for hospital admission among diabetics. The major risk factors for foot disease are peripheral neuropathy, peripheral vascular disease, poor vision and foot deformities. Development of foot ulceration is preventable. To assess the frequency of foot ulcers among diabetic patients visiting the surgery department in a university teaching hospital in Ajman, UAE especially in relation to gender, nationality and age. This hospital-based retrospective record analysis was conducted for patients with diabetes mellitus visiting department of surgery for a period of 8 years from 2002 to 2010. Among the diabetic patients recruited for this study, 75% were males and 25% were females. Among these diabetic patients, 76.3% of male patients were diagnosed with foot ulcers as opposed to 23.8% of female patients. It was witnessed that majority of diabetic patients were from Asia [53.1%] and Middle East [33.8%] whereas African [12.3%] and European [0.8%] patients made up a minority. Diabetic foot ulcers were reported more in Asian patients [57%] compared to patients from Middle East [29.1%]. The age of majority of the diabetic patients in this study was the range of 30 to 70 years and diabetic foot ulcers were most prevalent in the age group 50 to 59 years [42.5%] and least prevalent in the age group 20 to 29 years [5%]. Asian middle-aged male diabetics are most likely to have foot complications. It is important to educate all diabetic patients about the importance of self-examination of both feet, and physicians should routinely examine the feet of all diabetic patients, which would go a long way in preventing development of foot ulcers

A comparative study between total contact casting and conventional dressings in the non-surgical management of diabetic plantar foot ulcers.

Of all non-traumatic amputations 50% occur in Diabetics, mostly as a final outcome of foot ulcers. A major biomechanical factor in the causation of foot ulcers in persons with diabetes mellitus is elevated peak plantar pressure. Offloading the ulcer area in the form of equalisation of pressure across the plantar surface can accelerate healing of the ulcer. Total contact casting is one such method of offloading, and this study attempts to investigate the advantages of the above method as compared to conventional dressings in the physiatric management of the depth--ischaemia grades 1A, 1B, 2A, 2B neuropathic plantar ulcers in a diabetic patient. The outcome measure was the time taken for complete resolution of the ulcers. Of the 29 patients in Category A treated with total contact casting involving a total of 39 foot ulcers, 36 healed, which was statistically significant (p < 0.05) as compared to 25 out of the 33 ulcers healing in Category B consisting of 26 patients treated by conventional dressings alone. Total contact casting is an effective, rapid, economical, ambulatory and outpatient--based method for the treatment of diabetic foot ulcers.

A survey study on diabetes management and complication status in primary care setting in Thailand.

OBJECTIVE: Healthcare service in Thailand is stratified into three levels with different facilities of care. This cross-sectional survey study described diabetes management, diabetes control, and late complication status among patients managed in urban primary health care clinics. MATERIAL AND METHOD: Thirty-seven primary health care units were randomly selected. Each unit enrolled up to 30 patients having been managed in the unit for at least one year. The patients were interviewed, and the medical records such as demographic data, management practice, glycemic control, and complications were retrospectively reviewed for a period of one year. All data were entered in the case record forms, transferred into a database by electronic scanning, and analyzed by SAS version 6.12. One thousand and seventy-eight patients, including 300 males and 778 females, were recruited in the present study. RESULT: Their mean +/- SD of age, onset age, and diabetes duration were 58.2 +/- 11.3, 52.2 +/- 11.4 and 6.2 +/- 4.0 years, respectively. Six percent of the patients were type 1, and 94% were type 2 diabetes. Two-thirds of the patients engaged in diabetes education > or = 5 days during the previous year. Monitoring of glycemic control was largely by measurement of fasting plasma glucose (FPG) in the unit. Determination of hemoglobin A1c (HbA1c), total cholesterol, triglyceride, HDL-cholesterol, serum creatinine, urinary protein, and microalbuminuria were observed in 0.7, 17.4, 11.7, 6.9, 38.2, 33.0, and 0.9% of the patients, respectively. Mean +/- SD of FPG was 8.3 +/- 2.7 mmol/l, and HbA1c was 8.6 +/- 1.9%. The percentage of patients with FPG < 6.7 mmol/l and HbA1c < 7% were 28.7 and 19.6%, respectively. An annual eye and foot examination was performed in 21.5% and 45% of the patients, respectively. The prevalence of late complications included retinopathy (13.6%), proteinuria (17.0%), end stage renal failure (0.1%), peripheral neuropathy (34%), acute foot ulcer/gangrene (1.2%), healed foot ulcer (6.9%), stroke (1.9%), and myocardial infarction (0.7%). CONCLUSION: The present study results demonstrated that necessary, routine assessments were not regularly practiced by caregivers in primary care units. In addition, peripheral neuropathy was the most common observed complication and this might explain the high rate of foot ulcers in this cohort.

Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study

Although epidemiological studies have persistently shown a high prevalence of diabetes in Arabs, the control of diabetes is still poor and complications of diabetes are common. We examined the prevalence of diabetic peripheral neuropathy [DN], neuropathic foot ulceration [FU] and peripheral vascular disease [PVD], and potential risk factors for these complications among patients attending primary care diabetes clinics in Bahrain. We studied 1477 diabetic patients [Type 2 diabetes 93%]; to, including 635 men and 842 women, with ages ranging from 18-75 years in a cross-sectional study. The main predictor variables were demographic and clinical data, including assessment of foot and blood parameters. Mean age of the patients and duration of diabetes were 57.3 +/- 6.32 and 9.5 +/- 8.4 years, respectively. DN was present in 36.6% of the population, FU in 5.9%, and PVD in 11.8%. Diabetic patients with neuropathy were older than patients without neuropathy [P=0.001] and had had diabetes longer [P=0.002]. Diabetic patients with foot ulcers had more severe neuropathy and higher vibration perception thresholds values than patients without foot ulcers [P<0.05]. Older age, poor glycemic control, longer duration of diabetes, elevated cholesterol levels, current smoking, obesity defined by body mass index, large waist circumference, elevated triglycerides levels and hypertension but not gender, were significant risk factors for DN in both the univariate and the multivariate analyses [P< 0.05]. DN and PVD also remained significant risk factors for foot ulceration in the multiple logistic regression analysis. Rates of DN and PVD are high among diabetic patients in Bahrain. Implementation of strategies for prevention, early detection, and appropriate treatment at the primary health care level are urgently needed

Management of simple plantar ulcers by home based self-care.

Seeking a solution to bring down the prevalence of simple plantar ulcers in the field, Damien Foundation India Trust (DFIT), Chennai, developed a curriculum to teach the field staff of all its projects. The purpose was to make patients self-reliant in the care of their plantar ulcers in their homes. The strategy used was to make patients take care of their ulcers using tools found in their homes and surroundings and become responsible for the care of their limbs. This strategy was implemented in eight projects of DFIT and the programme was followed regularly for one year. Regular monitoring and evaluation showed that under this strategy the prevalence of plantar ulcers was reduced by about 50%.