RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA,
ANEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DESSERTATION
NAME OF THE CANDIDATE : Dr NITHIN HUMAYOON
ADDRESS : DEPARTMENT OF GENERAL SURGERY
Dr B R AMBEDKAR MEDICAL COLLEGE
BANGALORE – 560045.
NAME OF THE INSTITUTION : DR B R AMBEDKAR MEDICAL COLLEGE
BANGALORE.
COURSE OF STUDY & SUBJECT : MS GENERAL SURGERY.
DATE OF ADMISSION : 31st MAY 2013.
TITLE OF THE TOPIC : SURGICAL MANAGEMENT OF
DIABETIC FOOT AND FACTORS
INFLUENCING THE MANAGEMENT
OF DIABETIC FOOT
BRIEF RESUME OF THE INTENDED WORK:
7.1 NEED FOR STUDY:
Over the past few decades there has been an alarming rise in the prevalence of diabetis. According to the International Diabetes Foundation, there are more than 300 million people living with diabetes worldwide.1 The CPR (Crude prevalence rate) in the urban areas of India is thought to be 9 per cent.In rural areas, the prevalence is approximately 3 per cent of the total population.2.
Close to one-fifth of all adults with diabetes in the world live in the South-East Asia Region. Current estimates indicate that 8.3% of the adult population, or 71.4 million people, have diabetes in 2011, 61.3 million of whom are in India. The number of people with diabetes in the region will increase to 120.9 million by 2030, or 10.2% of the adult population.3
IGT (Impaired Glucose Tolerance) is also a mounting problem in India. The prevalence of IGT is thought to be around 8.7 per cent in urban areas and 7.9 per cent in rural areas, although this estimate may be too high. It is thought that around 35 per cent of IGT sufferers go on to develop type 2 diabetes, so India is genuinely facing a healthcare crisis.
Diabetes is also beginning to appear much earlier in life in India, meaning that chronic long-term complications are becoming more common. The implications for the Indian healthcare system are enormous.
One of the most important and disabling complications of diabetes mellitus (DM) is the diabetic foot ulcers (DFU). Development of DFU is traditionally believed to result from a combination of oxygen deficiency caused by peripheral vascular disease, peripheral neuropathy, minor foot traumas, foot deformities, and infection.4,5,6 DFU, with a lifetime development risk of 15% , incidence of 1–4%, and prevalence of 5.3% to 10.5% in all diabetic patients, accounts for more than half of the non-traumatic lower-extremity amputations in the world . Globally, one lower limb is lost every 30 seconds because of DFU 7. The range of mortality following diabetic foot amputation is 39–80% after 5 years, which is worse than the mortality rate for most malignancies.8 Approximately, 20% of hospital admissions among diabetic patients are in consequence of foot problems.9 Furthermore, DFU is among the most prevalent causes of hospitalization and morbidity and is responsible for more days of hospital stay than any other chronic complication of DM .
DFU lesions are significant health and socioeconomic problem as they exert adverse effects on patients’ quality of life and impose heavy economic burden on the patient and the state due to rising the need for rehabilitative and home care service. Given the DFU’s high prevalence, heavy burden, and severe impact on patients’ life quality, it is advisable that sufficient heed be paid to prevention of this particular complication of DM. Hence this study has been taken up to understand the clinical presentation, risk factors of diabetic foot and the various treatment modalities including surgical treatment and newer techniques for the management of diabetic foot and the factors influencing the management of diabetic foot.
7.2 REVIEW OF LITERATURE:
• A diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus.10 Presence of several characteristic diabetic foot pathologies is called diabetic foot syndrome.
• The most serious foot complications in diabetes are:11,12
Diabetic foot ulceration. -It occurs in 15% of all patients with diabetes and
precedes 84% of all diabetes-related lower leg amputations.13
Diabetic foot infections
Neuropathic osteoarthropathy of the foot
• Several factors predispose diabetic patients to developing a Diabetic foot, including neuropathy, vasculopathy and immunopathy. Peripheral neuropathy occurs early in the pathogenesis of diabetic foot complications and is considered the most prominent risk factor for diabetic foot ulcers 14.
• Diabetic patients with impaired protective sensation and altered pain response are vulnerable to trauma and extrinsic forces from ill-fitting shoewear. Motor neuropathy causes muscle weakness and intrinsic muscle imbalance leading to digital deformities such as hammered or clawed toes. This results in elevated plantar pressure due to metatarsophalangeal joint instability. Autonomic dysfunction leads to changes in microvascular blood flow and arteriolar-venous shunting, diminishing the effectiveness of perfusion and elevating skin temperatures. With the loss of sweat and oil gland function, the diabetic foot becomes dry and keratinized which cracks and fissures more easily, leading to a portal for infection. The most commonly utilized clinical method of objectively diagnosing sensory neuropathy in the foot and ankle setting involves the use of a Semmes-Weinstein 10-g monofilament to assess for protective sensation and a 128 Hz tuning fork for loss of vibratory sensation 15.
• Impaired host defenses secondary to hyperglycemia include defects in leukocyte function and morphologic changes to macrophages. Decreased chemotaxis of growth factors and cytokines, coupled with excess of metalloproteinases, impede normal wound healing by creating a prolonged inflammatory state. Fasting hyperglycemia and the presence of an open wound create a catabolic state. Negative nitrogen balance ensues secondary to insulin deprivation, caused by gluconeogenesis from protein breakdown. This metabolic dysfunction impairs the synthesis of proteins, fibroblasts and collagen, and further systemic deficiencies are propagated which lead to nutritional compromise. Research indicates impairment of the immune system with serum glucose levels ≥150 ml/dl16. Patients with diabetes tolerate infection poorly and infection adversely affects diabetic control. This repetitive cycle leads to uncontrolled hyperglycemia, further affecting the host's response to infection.
• In a large prospective study 17, significant independent risk factors for Diabetic foot included wounds that penetrated to bone, wounds with a duration >30 days, recurrent wounds, wounds with a traumatic etiology and the presence of PAD.
• The diagnosis of a Diabetic Foot Infection is made on the basis of clinical findings. According to the Infectious Disease Society of America (IDSA) guidelines, infection is present if there is obvious purulent drainage and/or the presence of two or more signs of inflammation (erythema, pain, tenderness, warmth, or induration) 18
• Objective physical examination should begin by acquiring vital signs, BMI and assessment of patient's general well-being. Hypothermia ( ................
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