First of all we render all our gratitude and respect to THE ALMIGHTY for his abundant and flowless blessings to complete the work successfully. Secondly we would like to thank our parents and friends who helped us a lot in finalizing this project within the limited time frame. Finally we would like to express our special thanks to our guide (Dr.Shushmaa Muchukota,other co-guides and our prinicipal) who gave us the golden opportunity to do this wonderful project on the topic “ASSESSMENT OF THE QUALITY OF LIFE OF DIABETICFOOTPATIENTS IN COMPARISON WITH NON DIABETICFOOTPATIENTS AND ROLE OF CLINICAL PHARMACIST IN PATIENT COUNSELLING – A CROSS SECTIONAL STUDY” which also helped us in doing a lot of Research and we came to know about so many new things we are really thankful to them.
complication, and hence a reflection of the patient’s general condition and the degree of wound inflammation . On the other hand, unlike our findings showing no significant relationship between HbA1c and limb salvage surgery outcomes, previous studies have reported that HbA1c is a risk factor for diabeticfoot complications [17-19]. Chronic renal failure is also an important risk factor for proximal osteotomy. In our study, 11 of 22 patients with chronic renal failure experienced limb salvage surgery failure. In previous reports, among chronic renal failure patients on dialysis who underwent limb salvage surgery, about 50% experienced failure and went to amputation. It has been reported that the risk of lower limb amputation is greater in diabeticfootpatients with kidney disease [15,20]. However, in this study, creatinine was not a sig- nificant risk factor. Why creatinine was not found to be a risk factor for salvage failure in our study, although it has been identified as a risk factor for major limb amputa- tion in previous studies, cannot be explained satisfactorily. The authors supposed that the reason was that creatinine levels could be controlled directly depending on the treat- ment for renal failure, such as dialysis [15,21].
Protocols which consider the foot as a single rigid segment or does not consider the motion of the midfoot relatives to the adjacent subsegments cannot fully describe the dia- betic foot disease consequences [13-20,20-22]. Therefore direct skin marker placement on selected anatomical landmarks (ALs), was chosen, together with a 3D four seg- ments foot kinematics protocol. A static acquisition was used to define the anatomical Bone Embedded Frames (anatomical BEFs). Diabeticpatients frequently have rigidity of toes or presence of ulcers which make protocols requiring marker placement on hallux impossible [13,18,19,21,22]. Moreover, the most recent studies [19,21,22] do not report all three rotational degrees of freedom of the three relevant foot sub-segments. Foot bio- mechanics alteration in the neuropathic patients  affects also their posture [6,23], this entails that a foot motion analysis protocol must be incorporated in a full body gait analysis protocol [15-17,20,24-26]. Finally, no study has reported on the clinical impact of foot kine- matic analysis in diabeticpatients [13,14,18,19,21,22]. The objective of this study was to devise a reproducible and clinically meaningful protocol  specific for the treatment of diabeticpatients, which starting from the kinematics could help in preventing diabeticfoot from ulcer or callus formation.
Another limitation to consider is that recordings were made in a setting of short-medium dimensions. Therefore, the absence of statistically significant dif- ferences in gait speed and cadence can be explained because patients walked for distances probably not enough to make out substantial differences in spatio- temporal parameters. It is also important to specify that Gait Analysis was performed at a self-selected speed without any external standardization of walking speed (e.g. using treadmill) in order to investigate ac- tual daily functions of subjects. As regards the long distances, three studies reported that patients with DNP walked slower than healthy controls [21, 28, 36]. However, two studies reported that subjects with DNP walked faster compared to the healthy control group and to diabetic controls [37, 38]. In general, anyway, it is plausible to affirm that with the advance of the disease the walking speed is reduced, also be- cause it is thought that slower speed in neuropathic patients is useful to maintain dynamic stability during overground walking.
One of the complications carried by diabetes clinical pictures is the so-called diabeticfoot, regardless of age, genre, ethnic group, and socio-economic level; limb amputation is usually an inevitable means to an end. The present re- search work had the purpose to determine microorganism responsible of ulcer infection in diabeticfoot on its more frequent occurrence. Diabeticfoot is a public health issue for its high incidence and its high sanitary costs. The pre- sent work consisted on a descriptive-retrospective research to seventy patients who were attended in a privately-owned hospital in Machala-Ecuador. Type III (according to Wagner scale) was determined as most frequent value. Microor- ganisms with a higher incidence degree were found to be gram-negative bacteria Escherichia Coli 27 (69.28%) and gram-positive bacteria Staphylococcus aereus 25 (80%).
Data were collected by three instruments: demographic characteristics questionnaire, Multidimensional Health Locus of Control scale and foot self-care questionnaire. De- mographic questionnaire consisted of 11 questions about age, sex, type of diabetes, duration of diabetes, level of education, marital status, occupation, and income lev- el. Health locus of control questionnaire was designed in 1970 by Wallston and Wallston (10). This scale consists of 18 statements that each subscale allocates 6 items to itself. Answer of each statement is a 6-point Likert scale from strongly agree to strongly disagree (17,18). The validity reported for the three subscales of internal, powerful others, and luck is 0.59, 0.55, and 0.67, respectively. Also, related kuder- Richardson coefficient is reported as 0.50, 0.62, and 0.77, respectively. In Iran, this scale was translated and validated by Mor- owatisharifabad and colleagues in 2009 for diabetic patient and in 2007 by Moshki and colleagues with acceptable validity (13,17). In this study, to determine the reliability of this tool, internal consistency (Cronbach’s alpha) was used, and for the internal health locus of control, powerful others and chance 0.75, 0.79, and 0.72 were obtained, respectively. To assess self-care behaviors, we used self-care behavior questionnaire, which is designed in 2012 by Eshgh based on the Orem's self-care model with reported correlation coefficients of 0.92 and correla- tion of 0.97 in the test-re-test (19). The
Purpose: To evaluate Charcot neuroarthropathy in diabeticfootpatients at tertiary hospital. Me- thods and Material: It is a retrospective study from 2005 to 2015 of Charcot footpatients in di- abetic patients admitted in King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Sixty-four patients were admitted as diabeticfoot disease and were studied by reviewing patients records of demography, pain, discharge, duration of disease, duration and types of diabetes IDDM [Insulin Dependant Diabetes Mellitus] NIDDM [Non Insulin Dependent Diabetes Mellitus], history of trau- ma, peripheral vascular disease, obesity, hypertension, co-morbid conditions, previous surgery, involvement of fore foot/midfoot/hindfoot, deformity, ulcer and treatment like casts, offloading devices, pharmacological like biphosphonates, debridement, osteotomy, arthrodesis, exostectomy, and amputation. Results: Majority of patients were males (81.2%). Mean age was 61.75 years. Pain was reported in 25% of patients, numbness in 12.5%, foot deformity in 23.4%, pus discharge in 73.4%, difficulty in walking in 12.5%, and 10.9% had history of trauma. Majority of patients were NIDDM 68.8%, IDDM 31.3%, (62.5% had DM more than 10 years and 36.9% had DM less than 10 years), controlled DM in 21.9% and uncontrolled DM in 73.4%, nephropathy in 46.3%, neuropathy in 59.4%, retinopathy in 40.6%, cardiomyopathy in 48.4% and vasculopathy in 56.3%. Charcot arthropathy was in 28.1% of cases and forefoot was involved in 65.5%, midfoot in 4.7% and hind- foot/ankle in 21.9%. It was forefoot which was mainly involved in Charcot joint disease. It was demonstrated by X-rays which showed subluxation in 40.6%, dislocation in 54.7%, disorganized foot joints in 42.2%, bone resorption in 23.4%, osteomyelitis in 14.1%, fractures in 50%, joint
Foot ulcers are one of the major complications of diabetes; they have a poor tendency to heal, which may result in long stay in hospital for treatment. The foot in diabetic patient is the cross road of several of several pathological processes, in which almost all components of lower extremity are involved- skin, subcutaneous tissue, muscles, bones, joints, blood vessels and nerves. An understanding of the development of the complications and application of preventive and management strategies will reduce the complications of diabeticfoot. Patients who are diabetic should take proper care of their feet so that they will not suffer from the consequences. They should take proper medical care at the earliest once any trauma occurs, so that the chain of events could be halted.
This study shows that there are few most common risk factors associated with Diabeticfoot disease, and all of these risk factors can be controlled by maintaining blood glucose level both fasting and random within normal reference range as by doing this we can reduce the risk of Diabetes complications, ultimately we can cut down the frequency of Diabeticfoot disease. Also this study shows that our subjects although have much knowledge and also practices few aspects but in general they are lacking in other aspects so by increasing awareness about diabetes and diabeticfoot care we can cut down the rate of diabeticfoot disease, a
of Internal Medicine and endocrinology of the Hospital of Mali. It was focused on all hospitalized diabeticpatients. Results: Thirty-two (32) patients had a foot at risk among 76 diabeticpatients during the study period representing 42.10%. The sex ratio was 0.52. Type 2 diabetes accounted for 82%. A glycemic imbal- ance (HBA1C > 7%) was observed in 88.15%. Eighteen percent (18%) of patients had a history of ulceration or amputation; 33% were walking barefoot; 78.9% had tingles in the foot; 31.6% had intermittent claudication; 64.5% had foot cleanliness; 8% claw toes; 42% had abolition or reduction of superficial ten- derness to monofilament and 21% had mixed foot (neuropathy + arteriopa- thy). In our study, 58.9% of patients had no risk of podiatry. Conclusion: Screening of foot at risk is essential in the management of diabetes because it determines the podiatric risk enabling to minimize future functional disabilities.
This system has been proposed to provide a low cost, short- time remedy for the patients have diabetic disorder. It is designed to control the high pressure areas of his feet by provide vibrations of different frequency as required by the user, along the muscles of his feet. This device can be used from anywhere and anytime. The future enhancements can be made by minimizing the size of the components utilized inside the shoe to make it seem more comfortable to the user who wears it. The footwear unit can also be connected to the mobile phone.
The cause of persistent cellulitis and non- healing infection is usually underlying deep infection or osteomyelitis. Other patients may present with gangrene, open joint or exposed bone, or abscess. In these patients, surgical debridement is required in addition to antibiotic therapy. Small open wounds can be treated with simple debridement, but often there is deep tissue involvement that is not visible on the surface. To remove all non-viable tissue and wide drainage, amputation may be required. If there is extensive infection of the foot with gas, calf pain or systemic sepsis, the patient may require amputation as an initial therapy. After surgical debridement, patients are treated with aggressive wound care using dressing changes and continued broad- spectrum antibiotic therapy until intra-operative
Energy harvesting and other applications of piezoelectrics has widely studied and used . Effective circuits, different concepts [8, 9], integration of sensor with electronics have been investigated for better applications [10, 11, 12].Few companies developed only platform to avoid the numbness and foot ulcers. But, no feedback was be taken in the existed models. Ignored and untreated, minor sores on the skin of the foot can turn into severe problems with potentially devastating consequences, namely, numbness which turn into foot ulcers in later stages so protective way and independent risk study was proposed as a simple monitoring system to predict the foot ulcers in patients. Related to this concept recent developments on security was done by researchers. Pressure points data can be easily noticed and record the data. Simple GUI based android electronic tool can warn the patient periodically.
A total of 164 patients with foot problems were eligible for this study from 203 patients initially assessed during the study period. However, only 140 patients with foot complications agreed to be in the study and were recruited (85.4% response rate). One hundred and thirty-four patients without foot problems were selected as the control group. The demographic characteristics of the 274 patients are presented in Table I and the clinical characteristics are presented in Table II. Both groups were statistically comparable in the demographic characteristics except for household income. For clinical characteristics, differences were seen in the diabetes duration and the types of diabetes treatment taken between respondents in the two groups. More than half of patients with foot problems have had diabetes longer than ten years compared to only about one third in the comparison group. Insulin therapy either on its own or in combination with oral hypoglycaemic agents was more frequently prescribed for patients with foot problems (47.2%) when compared to those without foot problems (17.2%) translating to a ratio of 2.7:1.
Neurogenic arthropathy is another condition that can adversely affect the feet of a person with diabetes as a result of nerve damage. This condition is also known as Charcot joints (Jean-Martin Charcot was a French neurologist). It weakens the bones of the foot in people with severe nerve damage. With bone weakness, micro fractures may occur, and in severe cases, joint damage may even occur. As a result of nerve damage, sensation in the feet disappears. Then the patient does not feel pain, injury or temperature changes. This means that it is likely that the patient will move normally, causing an open fracture and making the situation worse. The foot may be deformed or deformed. Distortions also increase the risk of foot ulcers. If the foot feels overheated or begins to swell after a small impact or injury, this may indicate the first signs of Charcot's joints. There may (but does not have to) be pain, redness and / or swelling appear, and when touching a sick foot, it will seem warmer than a healthy foot [4, 7, 10].
Among the complications of diabetes, lower limb am- putation is considered to be potentially preventable.  Most lower limb amputations in patients with diabetes are preceded by a foot ulcer, whose risk factors apart from PVD and PN, are barefoot walking, inappropriate footwear, poor foot hygiene and delay in seeking medical attention . These non-traditional risk factors can be modified if identified early, and if patients have adequate knowledge of foot care and put that knowledge into practice.  In recent years, the level of interest and knowledge about DFU has grown considerably, as wit- nessed by the development of an international consen- sus, clinical guidelines to be used in both prevention and treatment of diabeticfoot, and improvements in evidence-based clinical practice. All patients, if given proper guidance and education regarding foot care, should be able to make significant improvements in their foot care. Evidence that foot care education alone pre- vents DFU and amputation has been inconsistency due to lack of high quality randomized trials. However, this lack of evidence is not evidence of no effect [8, 9]. Current guidelines for standardized care of diabetic pa- tients recommend annual screening for high risk feet. Those identified as high risk should receive enhanced and focused foot care education .
Table 4 presents the effect of physician advice and patients knowledge of foot-care practices. About 70% of patients had good knowledge scores: equal to or more than the median score. Table S1 shows patients’ knowledge of individual items related to diabeticfoot care. The results inferred that foot-care practice was high among the group of patients who got advice from their physicians. Their foot-care practice was significantly high for “carefully dry between toes after wash- ing feet” (P= 0.0001) and “moisturizing feet daily” (P= 0.013) compared to the no-advice group. Similarly, patients’ with good foot-care knowledge showed a positive effect on foot- care practices compared to the poor-knowledge group.
Normally intracellular glucose is predominantly phosphorylated to Glucose 6 phosphate by the enzyme Hexokinase to be metabolized later on by glycolysis and HMP shunt and only some amount is converted to sorbitol by the Polyol pathway. Enzyme Aldose reductase is the rate limiting step in this alternate pathway and it has a low affinity for glucose. Under conditions of hyperglycemia there is increased flux of glucose through this pathway that is about 30% and is metabolized in this way. In a hyperglycemic environment, however, increased intracellular glucose results in increased enzymatic conversion to the polyalcohol sorbitol, with concomitant decreases in NADPH. The mechanism by which glucose flux through the polyol pathway is detrimental and not clearly defined. It has been proposed that oxidation of sorbitol by NAD+ increases the cytosolic ratio of NADH/NAD+, there by inhibiting activity of enzyme glyceraldehydes-3-phosphate dehydrogenase and increasing concentratons of triose phosphate. Elevated triosephosphate concentratons could increase formation of both methylglyoxal, a precursor of AGE and diacylglycerol, thus activating PKC . It has also been found that reduction of glucose to sorbitol by NADPH consumes the cofactor NADPH which is required for regenerating reduced glutathione (GSH). This can lead to oxidative stress as glutathione is an important cellular antioxidant. Some other proposed mechanisms are sorbitol induced osmotic stress and decreased Na+,K+-ATPase activity. But the sorbitol concentration in diabetic vessels and nerves are too low to be considered significant 83] (Figure 2). The third important mechanism is the activation of family of Protein Kinase C enzymes which are cell signaling enzymes. These enzymes are involved in diverse cellular functions ranging from cell growth and differentiation, apoptosis, protein trafficking, cytoskeletal rearrangement, and cell polarity. PKC isofoms are activated by second messenger Diacyl glycerol. In states of hyperglycemia, there is increased concentration of DAG as a result of its denovo synthesis from glyceraldehyde-3-phosphate. Activation of PKC has been associated with suppression of nitric oxide (NO) production via inhibition of insulin stimulated expression of endothelial
automatically treated with antibiotics since although as open chronic wounds there may be many commensal or- ganisms, about half are not infected [3-5]. Several foot- ulcer classification methods have been proposed in order to organize the proposed appropriate treatment plan but none have been universally accepted. The Wagner- Meggitt clas- sification is based mainly on wound depth and consists of 6 wound grades (Table 1) . The University of Texas system grades the ulcers by depth, then stages them by the pres- ence or absence of infection and ischaemia [6,7]. As there is the need for rapid and more appropriate therapy to facili- tate healing, the international working group on the dia- betic foot proposed the PEDIS classification which grades the wound on a 5- feature basis: perfusion (arterial supply), extent (area), depth, infection and sensation . They also classified diabeticfoot infections into four grades: Grade 1 (no infection; Grade 2 (mild) in subcutaneous tissue only; Grade 3 (moderate) with extensive erythema and infection of deeper tissue and Grade 4 (severe) with systemic inflam- matory response indicating severe infection (Table 2) [1-4,7]. Most diabeticfoot infections require some surgical intervention, ranging from minor (debridement) to major interventions including amputation. The main emphasis of the current international guidelines on the management of the diabeticfoot is prevention, early recognition and
It was conducted at the DiabeticFoot Outpatient Clinic of a public tertiary teaching hospital located in the city of Curitiba, which serves patients from all regions of the state of Paraná. Two nurses specialized in the treatment of DiabeticFoot work at this outpatient clinic. They carry out nursing consultations and provide guidance to patients, their families or carers as to caring at home for lesions, general care of the feet and lesion prevention, in addition to care intended to promote health. Patients are referred to this clinic when they have feet ulcers or other serious problems with their feet. Once the initial problem that gave rise to the referral to the clinic has been resolved, all patients join the clinic’s monitoring programme in order to prevent lesions and amputations. The interval between these consultations is based on risk stratification (International Working Group on the DiabeticFoot [IWGDF], 2011; Boulton et al., 2008). In the event of relapses or new ulcers, patients are advised to seek care as soon as they notice the problem, in order to start treatment immediately with the aim of reducing complications and amputations. The data were collected between October 2016 and March 2017. The study population was comprised of 60 adult patients of both sexes, out of a total of 125 patients who were being monitored by the DiabeticFoot outpatient clinic during the study period. They were divided into a group of 30 patients with lower limb ulceration and another group of 30 patients who did not have ulceration. Patients were selected using non-probability convenience sampling. The inclusion criteria were: patients with confirmed diagnosis of type 1 Diabetes Mellitus (DM1) or type 2 Diabetes Mellitus (DM2), aged over 18 years, of any colour/race/ethnicity/sex, monitored by the DiabeticFoot outpatient clinic, with and without lower limb ulceration, with physical and mental ability to answer the questionnaires.