Treatment of diabetic foot lesions in hospital: results of 2 successive five-year periods, 1989-1993 and 1994-1998.

OBJECTIVES: To assess the impact of an educational training program we initiated in 1994 for GPs about diabetic foot ulcer (DFU) management, we compared the rate and level of lower limb amputation (LLA) in diabetic patients performed in our unit between two consecutive five-year periods, 1989-1993 and 1994-1998. PATIENTS AND METHODS: During the first period, 132 patients with 163 lesions (9.2% of the total admissions for diabetes) were compared with 176 with 183 lesions (10.5%) during the second period. Patients' mean age was the same in both periods: 59.6 +/- 11.7 in 1989-1993 and 58.3 +/- 13.1 in 1994-1998 [Not statistically significant, NS]. RESULTS: Patients age, sex ratio, type of diabetes and severity of the lesion (as assessed according to Wagner classification) were essentially the same during the two periods. Most of the foot lesions ( approximately 90%) were purely neuropathic or neuro-ischaemic, with no change in repartition between the two periods. Primary healing was 59.1% in the 1st period and 56.8% in the second. No change in minor and major amputation rate was observed between the 1st period (14.4 and 15.9%, respectively) and the second (11.4 and 16.5%, respectively). The in-hospital mortality rate was unchanged (9.1 vs 8.5%, NS), while the percentage of patients who left hospital against medical advice and dropped out of follow up increased from 1.5 to 6.8% (p<0.04). Mean length of hospitalisation was identical, about 43 days. CONCLUSIONS: In spite of implementing educational program for GPs, no improvement in the DFU management was noted as emphasised by absence of any significant change in amputation rate before (1st period) and after initiating the program (2nd period). These disappointing results can be explained by several factors: weakness of our educational program, lack of motivation from GPs, absence of a structured multidisciplinary prevention approach. The main problem, common to developing countries, remains the insufficiency of financial resources. Moreover, civil disturbances can make the problem more difficult to manage, as in Algeria since 1991.

Infections of the upper extremity in hospitalized diabetic patients: A prospective study.

OBJECTIVES: To study the clinical characteristics of a group of patients with diabetes and established upper extremity infections and to determine the causative factors of hand infections. METHODS: Prospective study of diabetic patients referred in to our service with infections of the upper extremity from January 1992 to December 2001. RESULTS: Twenty-six diabetic patients with an infection of the upper extremity were studied (17 F, 9 M). The admission rate equalled 0.7%. Twenty-one patients (80.8%) presented a Type 2 diabetes and 5 a Type 1 diabetes (19.2%). The diagnosis age of diabetes was 44.6 +/- 13.8 Years (range: 16-62). The average age at the occurrence of the lesion was 52.5 +/- 15.1 Years (range: 21-73). The average duration of diabetes was 8.3 +/- 5.9 Years (range: 0-22). Diabetes was, in all the cases, poorly controlled because of an inadequate hypoglycaemic treatment and/or bad compliance. The patients had a high prevalence of peripheral neuropathy (n=17; 65.4%). The delays in presentation to the doctor and those related to hospitalization were respectively 9.1 +/- 10.0 days (n=23) and 16.8 +/- 12.1 days. The hospitalization length reached 33.6 +/- 22.6 days (range: 7-93). The final results, 6 Months after hospitalization, were as follows: the death rate reached 19.2% (n=5); 23.1% of the patients (n=6) had a minor amputation; for 53.8% of the patients (n=14), the lesions healed without any amputation. One patient left hospital against medical advice. Eleven out of 20 patients (55%), amputated or not, were left with deformities and a subjective dysfunction of the affected limb. CONCLUSION: Infections of the upper extremity in diabetic patients constitute an uncommon but serious complication. They seem to be more frequent in housewives. They result in a high morbIdity. Prevention of these infections should be based on patients' education (compliance with diabetes treatment, hand care, prompt visit to the doctor) and General Practitioners' training for an adequate treatment and/or a rapId patient referral to hospital.

Management of diabetic foot lesions in hospital: costs and benefits.

OBJECTIVE: The aim of this study was to evaluate the direct and indirect costs associated with diabetic-related foot lesions in patients hospitalized in a department of Endocrinology and Diabetology (36 beds). MATERIAL AND METHODS: Direct costs included costs associated with hospital stay, laboratory testing, medical and surgical treatment. Lesions were classified in 3 groups (I, II, III) according to their importance (Wagner classification). RESULTS: Among 1,779 admissions for diabetes, 163 (i.e., 9.16%) were related to a foot lesion. The stay in hospital for these lesions reached 7,247 days over a 5-year period, with an average stay duration of 45 days per lesion. Mean length of hospital stay varied according to the importance of the lesion: 26.87 days, 48.25 days, 57.12 days for group I, II and III, respectively. The total cost amounted to 914,534.39 US dollars and the mean cost 5,610.64 US dollars. Mean cost was 3,326.76, 5,712.24, 7,399.74 US dollars for group I, II and III, respectively. Nearly 80% of the financial costs were due to hospital stay. Primary healing occurred in 59.09% of the patients (n=78); 17.4% (n=23) of the patients required major amputation, 14.4% (n=19) minor amputation. Death rate reached 9.1% (n=12). CONCLUSION: An increase in length of stay and costs with importance of the lesion was identified. The strategy of care of the diabetic lesions should be based upon the prevention of ulcer formation: it seems actually the best mean (the least expensive) in a developing country where financial resources are very limited. This prevention should be made through regular patient education, appropriately fitted shoes, and regular careful examination by a General Practitioner or a Diabetologist.

Diabetic foot lesions: etiologic and prognostic factors.

The clinical characteristics of 132 diabetic patients referred for treatment of foot lesions were surveyed. One hundred and sixty three lesions (n=163) concerned 88 men and 44 women during a five-year period (from January 1989 to December 1993). Hospitalisation rate equalled 9.16%, i.e. 11.17% for men and 6.82% for women (p <0.001); the men/women ratio was 1.64. Eighty nine per cent (89%) of patients presented type 2 diabetes and 11% of patients type 1 diabetes. Mean age at the first foot lesion was 59.64 +/- 11.74 years. The mean duration of diabetes was 10.95 +/- 6.80 years. The patients had a high prevalence of diabetic complications, particularly peripheral neuropathy (84.85%) and obvious peripheral arteriopathy (78.78%). Infection was almost constant. There was no significant difference between men and women as far as the prevalence of complications was concerned. Smoking habits were noticed only in men. Inadequate footwear was considered as the major exogenous risk factor leading to a foot lesion. The definitive results 6 months after hospitalisation were as follows: the death rate was 9.09% (n=2; 11 men and 1 women, NS); 15.90% of patients (n=12) underwent a major amputation (4 at the level of the thigh, 17 at the level of the leg), 14.39% of patients (n=19) underwent a minor amputation; in 59.09% of patients (n=78) there was no amputation. Two patients (1.51%) underwent two consecutive amputations, left hospital against medical advice during their second hospitalisation, and then were lost sight. The prevalence of foot lesions was more important in men. Moreover, seriousness of the lesions and consequently the rate of amputations were important in men; this was probably due to smoking habits. The factors that influence the outcome seem to be: male gender, delay of management, quality of medical treatment, surgical attitude, inadequate level of amputation and finally lack of structured prevention. Prevention then should be based on the patient's education, general practitioners' training and a better and more efficient cooperation between surgeons and diabetologists.