poster 2416

1 8 t h I N T E R N A T I O N A L D I A B E T E S F E D E R A T I O N C O N G R E S S August 24-29, 2003, PARIS - France

Poster Display Diabetic Foot

2414 Risk factors for foot ulceration in Nigerian diabetic patients A. E. Ohwovoriole, A. O. Ogbera; Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria. Background and Aims: Diabetes mellitus foot syndrome (DMFS) is an important cause of morbidity and mortality in Nigerian diabetics. Identification of risk factors is of paramount significance in the prevention of this-all important complication of diabetes mellitus. As such this study set out to determine the risk factors of DMFS of which the results are hoped to be of practical usefulness to care-givers, policy makers and as well as to people living with diabetes mellitus. Materials and Methods: This was a case control study in which 47 diabetic patients with past or present history of diabetic foot ulceration were studied. Equal numbers of controls who were diabetic patients with no past/present history of DMFS were studied. Relevant history, general physical examination, neurological, vascular, ocular, metabolic and other assessment were carried out in these two groups of patients. Data were analyzed using the statistical package for social sciences (SPSS). The test statistics used included Student's t test, Chi squared test and logistic regression for the determination of odds ratio. Results: The risk factors that were strongly associated with foot ulceration included peripheral vascular disease, male sex, nephropathy, retinopathy, foot deformities, history of previous ulceration and amputation, the presence of cataract, poor glycaemic control, neuropathy, and Tinea pedis. Weakly associated risk factors for foot ulceration were walking unshod, being of a low socio-economic status and smoking. Conclusion: The risk factors for diabetic foot ulceration as seen in this study are potentially reversible. As part of a comprehensive foot care program, education and acqusition of skills on foot care should be directed at the patients, family members of the patients as well as the health care providers.



2415 Major cases of diabetic foot ulceration and amputation among the patients in Uzbekistan. T. T. Kamalov1, Z. K. Dosova1, A. A. Rakhimdjanov1, S. K. Kuziev1, Z. M. Shamansurova2; 1Diabetic Foot, Institute of Endocrinology, Tashkent, Uzbekistan, 2Diabetology, Institute of Endocrinology, Tashkent, Uzbekistan. Background and Aims: Diabetic foot is a major social problem, which involve increasing of expenses for care. Cases of foot damage may be different according to life style and habitation. Identification of the major cases of foot ulceration and amputation are important in future preventing actions among the patients in the region. Materials and Methods: 181 patients data which were cured at the Diabetic Foot Department at the Institute of Endocrinology in Uzbekistan with chirurgic problem were analysis. Results: Duration of disease were 11.3 years in type 1 DM and 6.7 at the type 2 DM. With type 1 DM were 15% and other 85% patients were with type 2 DM, 47.5% female and 52.5% male among them. 77% of all foot problem were undergo to amputation. Surprisingly that 50% of ulcers were localized on right and 50% on the left leg, 25% of patients had amputations in past. Diabetic nephropathy presented in 93% patients but Uremia was detected in 2% of all cases. Diabetic rethinopathy was detected in all 100% patients, where prolipherative DR consist in 13.6%. At the Foot Department 93% of patients were treated with insulin, 4.5% in combination insulin with antidiabetic drugs. 4.5% only with drug and 1% with diet. In 36% patients had reccurence ulceration and amputation in future. Frequency cause of diabetic foot was burning of feet after heating by water heater (50%), in second foot ulcer come after cessation or decreasing of dosage of insulin injection (19%), in third - after footwear problem (15%). Diabetic self-control in single causes consist only blood glucose control by glucometr without control of diet, calory intake, weight control, microalbuminuria and blood pressure not been checked before in 79%. Conclusion: The major causes of the diabetic foot ulceration are burning after water heater, which equally may find in both left and right leg and not depended from sex, but depended from disease duration, presence of other diabetic complications, history of amputation. Education may be one of the effective way of the preventing foot ulceration and must be intensive in early beginning of the disease.



2416 Direct costs related to diabetic patients' hospitalizations. Relative impact of foot lesions. A. Benotmane, T. Benkhelifa, M. E. Amani, K. Faraoun, S. Fédala, F. Mohammedi; Endocrinologie-Diabétologie, Centre Hospitalo-Universitaire, Oran, Algeria. Objectives: To determine the direct costs for patients with diabetes hospitalized in a department of Endocrinology-Diabetologia and the costs due to foot lesions compared to the costs related to other causes of hospitalization. Patients and methods: This retrospective study, set in Oran, Algeria, took into account all adult patients with type 1 and type 2 diabetes, admitted in 1995. Costs related to hospital stay, inpatient care, laboratories studies and surgical treatment were calculated in Algerian dinars, then converted in US dollars. Comparisons were assessed using Epi-Info, version 6. Differences in qualitative measures were tested for significance by the chi-square test, and in quantitative measures by the Student�s t-test. Statistical significance was defined as p value < 0.05. Results: There were 308 admisssions for 70 patients with type 1 diabetes and 234 patients with type 2 diabetes. Women represented 61.40% of the cases. The mean age of the patients was 51.22 ± 17.22 years. The mean duration of the disease was 9.81 ± 7.41 years. Admissions were classified into 5 categories: new cases of diabetes (n=30, 9.74%), ophthalmic complications (n=31, 10.06%), infections unrelated to a foot ulcer (n= 127, 41.23%), foot lesions (n=39, 12.66%), other admissions (n=81, 26.30%). Patients with myocardial infarction or stroke were not hospitalized in our department. The mean length of stay was 15.86 ± 21.47 days; it was longer for patients with a foot lesion compared to others (54.74 ± 38.88 days versus 10.33 ± 7.86 days, p <10-9). The total annual duration of hospitalization amounted to 4886 days. Diabetic patients with a foot lesion accounted for 43.70% (i.e. 2135 days) of the total number of bed days, whereas the admission for a foot lesion represented only 12.66% of all admissions. The total annual direct costs were evaluated at 628 878 US dollars. The annual per episode cost was about 2042 US dollars. It was estimated at 7246 ± 5009 US dollars for the patients with a foot lesion, which was 5.63 times higher than the annual per episode cost for the other patients (1287 ± 918 US dollars), p <10-9. The largest part of this cost was the hospital bed which was about 75% of the total costs. Mean costs were higher for patients with type 2 diabetes. Conclusion: Diabetic foot lesions constitute an expensive complication. The better means to decrease the costs related to this complication is based upon prevention. In order to improve the outcome and the costs of management, and to diminish the burden of the diabetological department, care of foot lesions should be assumed in specialized multidisciplinary foot clinics.



2417 Diabetic foot disease - unnoticed problem in India. A. Majumder; Medical Department, Indian Airlines Limited, Calcutta, India. Background and Aims: Diabetes is the leading cause of non-traumatic amputation of the lower limb all over the world.India harbours more than 40 million diabetic subjects. Prevalence of diadetic foot disease in India is unknown. Prevalence and aetiology of diabetic foot disease are studied in a small group of patients attending the medical clinic. Materials and Methods: 122 enrolled diabetic subjects ( 3 cases of Type 1, 103 cases of Type 2 and 16 cases of Fibrocalculous Pancreatic Diabetes ) with a mean 7.8 years duration of diabetes are evaluated. Evaluation is based on history and clinical findings. No modern technology or gaget were used. Results: Out of 122 subjects, 60 ( 49 % ) have clinically detectable peripheral neuropathy, 8 ( 6.5 % ) have clinically detectable peripheral vascular disease and 12 ( 10 % ) have diabetic foot disease, ranging from excoriation of skin to frank gangrene. Following changes in the foot have been noticed in these 12 patients in variable combinations : (1) shiny skin with loss of hair and thickened toe nails, (2) fungal infection and ingrowing toe nails, (3) claw toes, hammer toes and bunions, (4) ulcers on the dorsal and planter surfaces, (5) gangrene in digits. In the background of peripheral neuropathy and / or peripheral vascular disease some common insults are responsible for diabetic foot disease : (1) minor trauma, (2) illfitting shoes and (3) self surgery for corn. Few causative factors responsible for diabetic foot disease unique in India are found : (1) barefoot working in paddy field, (2) using chappals made from unacceptable hard materials like plastic or tyres of car, (3) long bare foot walking for religious reason, (4) nibbling of anaesthetic foot by rodents (who sleeps on floor), (5) high incidence of lean type 2 diabetes (41 cases out of 103 type 2 diabetes) with higher incidence of (70%) of peripheral neuropathy leading into higher incidence of diabetic foot disease (9 cases, 21%). Probably general physicians have failed to address this problem as these 122 subjects never received any advice regarding foot care from their treating general physicians. Conclusion: Prevalence of diabetic foot disease in India is high, compounded by certain socio-economic and unique traditional features prevalent in this country. Its significance is not yet perceived by the general physicians. Increase in awareness among patients as well as among treating physicians are essential.



2418 Risk factors for diabetic foot ulcer: a case- control study in Indian perspective. K. Biswas1, A. C. Ammini1, S. N. Dwivedi2, P. Shah3; 1Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India, 2Biostatistics, All India Institute of Medical Sciences, New Delhi, India, 3Medicine, Creighton University, Omaha, NY, United States. Background and Aims: Foot ulcer is one of the common complication of diabetes, often leading to amputation of lower limb if neglected. Various factors independently or in combination predispose to the ulcer. Early identification of these factors and intervention accordingly help in saving the foot. This study is undertaken to identify the risk factors for development of foot ulcer in diabetic subjects compared to age and sex- matched diabetic controls. Material and Methods: Thirty cases with grade 2 or more (Wagner�s score) foot ulcer requiring surgical intervention and 30 age (+/-5)- and sex- matched diabetic controls without foot ulcer were interrogated following a preset questionnaire about duration of diabetes, drugs for control, peripheral and autonomic neuropathy, peripheral vascular disease, nephropathy, retinopathy, coronary artery disease, cerebrovacular accident, previous foot ulcer and foot care practised. Detailed general and systemic examination for complications along with examination of foot done. Relevant biochemical tests were undertaken. A scoring system was used for analysis of data practice of foot care, signs of peripheral neuropathy and peripheral vascular disease. Relevant biochemical tests were done. McNemar�s Chi-square test with correction and paired t- test were used for analysis of data. Results: Physical injury (including shoe-related) and chemical injury were found to be the most common pivotal event (66.7%) for foot ulceration. By univariate analysis, significant association was found with duration of diabetes, symptoms of peripheral neuropathy peripheral vascular disease, lack of foot-care with the cases(p<0.001). History of previous foot problem and evidence of autonomic neuropathy were also found to be significantly associated (p<0.01 and p<0.05 respectively).On physical examination, preexisting foot deformity, shin spots, condition of the skin and nails in the lower limbs, restriction of joint movement, signs of peripheral arterial insufficiency in the lower limbs, orthostatic hypotension, signs of peripheral neuropathy and vibration score in the lower limb, and retinopathy were found to be significant risk factor for development of foot ulcer in diabetic patients (p<0.001). Fasting blood glucose, glycosylated hemoglobin, clinically significant proteinuria (>500mg/day) were found to be significantly associated with foot ulcer. No significant association was found with macrovascular events, tobacco use, barefoot walking, hypertension and ankle-brachial index, triglyceride and cholesterol. Conclusion: The factors which form the mainstay for prevention of ulceration of foot in diabetic subjects are regular adequate foot care, proper control of diabetes and thus prevention of complications of diabetes.



2419 Clinical and investigative profile of patients with diabetic foot from north India. D. Dhanwal1, P. Kumar2, R. Nehru3; 1Medicine (Division of Endocrinology), Maulana Azad Medical College, New Delhi, India, 2Medicine, Maulana Azad Medical College, New Delhi, India, 3Neurology, Maulana Azad Medical College, New Delhi, India. Background and Aims: Diabetic foot is a common problem in North India. Epidemiology and risk factors are different as compared to that seen in West. There are very few studies on risk factor assessment in diabetic foot ulcer from North India, therefore present study was undertaken to study clinical profile and risk factor assessment in diabetic foot. Materials and Methods: Twenty consecutive patients with diabetic foot ulcer were included. All patients were subjected to detailed clinical assessment, biochemical profile , Doppler study for peripheral vascular disease and nerve conduction studies. Results: Mean age was 51.5±9.0 years, male:female 9:1, mean duration of diabetes mellitus was 5.9±4.2 years. Fifteen patients (75%) were from lower socioeconomic group and all patients had poor metabolic control with a mean HbA1C of 9.8%. Foot ulcer (Wagener's) grading was: 75% grade 2; 10% grade 3 and 15% grade 4. Bacteriological culture was positive in 75% cases ( most common organism being E.coli, sensitive to ciprofloxacin). Nerve conduction abnormalities were detected in 75% cases (subclinical peripheral neuropathy in 45%). Forty percent of ulcers healed conservatively, 15% underwent amputation and 45% ulcers showed partial healing after six months therapy. Other risk factors were: hypertention (35%), cardiovascular disease (20%), smoking (65%), bare foot walking(30%), poor self foot care (100%) and foot deformities in 30% cases. Conclusions: Diabetic foot ulcer in North Indian patients is multifactorial, bacterial infection being common. Major risk factors are poor socioeconomic status, bare foot walking, poor self foot care, poor metabolic control and presence of subclical peripheral neuropathy.



2420 Evaluation of risk factors for developing foot problems in Indian diabetics. H. B. Chandalia, A. Prabhu, S. Shaikh, V. Kapoor; Diabetes Endocrine Nutrition Management and Research Centre, Mumbai, India. Background and Aims: To evaluate risk factors for developing foot problems in Indian diabetics. Material and Method: We assessed 300 diabetic and 100 age, sex matched controls by inspection of feet for the presence of any external deformities or infection, assessment of sensory function (vibration perception threshold, VPT) and vascular status (foot pulses and ankle-brachial ratio, A/B ratio). A structured questionnaire evaluated their education level, history of tobacco abuse, type of footwear used and knowledge about foot care. Results: Average VPT in the diabetic and the control group was 15.62 ± 10.39 and 8.36 ± 3.61 V respectively (p < 0.01). Average A/B ratio in the diabetic and control group was 1.14 ± 0.18 and 1.15 ± 0.12 respectively (p < 0.01). Questionnaire score in the diabetic and control group was 57 % and 40.3 % respectively. In the diabetes category, 131 diabetic patients had not received previous foot care education. 14 patients gave history of foot ulceration in the past and were labeled as the complicated group. Comparison of complicated vs uncomplicated group respectively showed: duration of diabetes 10.85 ± 6.53 vs 9.83 ± 7.99 yrs, VPT 19.57 ± 11.26 vs 15.20 ± 10.21 V (p < 0.01), A/B ratio 1.05 ± 0.19 vs 1.14 ± 0.18 (p < 0.05), questionnaire score 40.8 % vs 57 %, high risk footwear 21.5 % vs 7.83 % . Conclusion: Besides the accepted risk factors of significantly impaired VPT and A/B ratio, Indian diabetics have poor knowledge of foot care and use high risk footwear.



2421 Biophysical characteristics of diabetic patients with foot ulcer in a Bangladeshi population. M. A. Islam1, Y. Talukder2, M. A. Sayeed3, B. Rokeya3; 1General Hospital, Sirajganj, Bangladesh, 2BNSB Eye Hospital, Sirajganj, Bangladesh, 3BIRDEM, Dhaka, Bangladesh. Background and Aims: Many epidemiological studies reported an increase in amputation rates even in the USA, England and Scotland despite increased foot care education, research and prevention. This increasing trend has been attributed mainly to diabetes to failure of early detection of the risk group. This study is aimed to find out the prevalence of diabetic foot characteristics of diabetic patients that developed foot ulcer. Materials and Methods: This study was carried out in a district hospital, a secondary health care center, which covers 270,7011 population. The outpatient department registered 1561 diabetic subjects in 23 months. Of these diabetic subjects, 50 (M/F = 30/20) presented with foot ulcer. We investigated the latter subjects for geographic location, family income, height, weight, mid-arm circumference (MAC), monofilament test, electrocardiogram (ECG),ophthalmoscopy, fasting blood glucose (FBG), fructosamine, lipids and micro-albumin creatinine ratio (ACR). Body mass index (BMI) was calculated as wt in kg/ ht m sq. Results: The prevalence of foot ulcer among the diabetic population was 3.2%. Among them, only 4% were from higher social class, whereas, 96% were either from lower middle or poor class. The urban subjects were only 26% and the rest 74% were either from rural or suburban communities. The mean (SD) of age was 52 (12)y, BMI 20.3 (4.4) and MAC 23.4 (3.0)cm. Their FBG and fructosamine levels were 13.2 (6.0) mmol/l and 354 (113) micromol/l, respectively. A 10-g monofilament test could detect abnormal or absent sensation in 68% of the cases. Most importantly, the sensory impairment was found significantly associated with coronary heart disease (p<0.03) and retinopathy (p<0.05). Conclusion: The study revealed that the prevalence of foot ulcer among diabetic population in Bangladesh is not negligible. The prevalence was much higher in the low social class and in rural population. The monofilament test was found to be an important simple test for detecting early stage of impaired sensation related to foot ulcer.



2422 Diabetic foot - a scenario from north eastern India. S. D. C. DuttaChoudhury1, D. C. Choudhury2, P. Baruah3; 1Department of Endocrinology, Guwahati Medical College Hospital, Guwahati (ASSAM), India, 2Department of Opthalmology, N.L. Medicare & Research Center, Guwahati (ASSAM), India, 3Department of Surgery, Guwahati Medical College Hospital, Guwahati (ASSAM), India. Background and Aims: Diabetic foot is one of the most common problems of the diabetics. This requires prolonged hospitalisation and high expenditure for treatment, thereby leading to socio-economic burden. The main objective is to find out the incidence of foot problems in diabetics. Materials and Methods: N.L.B. Diabetic and Endocrine Center, which is located in the North Eastern India, registered 4914 diabetic patients over a period of 4 years (1996 - 2000). Of these, 925 patients were hospitalised for different complications. This included 95 patients (10.3 %) in the age group of 31 years to 76 years, who had foot problems, the ratio being 63 male patients to 32 female patients. Duration of diabetes varied from 2 months to 16 years. Results: The most common location of foot ulcers were planter surfaces of foot. According to Wagner's classification, grade-4 leision having gangrene of the toes were present in 25 cases, 6 had grade-3 ulcer with Osteomyelitis, 50 had grade-2 ulcer with cellulitis and 14 had grade-1 ulcer. Causative factors in most of the cases were ignorance and negligence of foot care. History of injury were present in 11 cases. Accompanying Neuropathy was a frequent observation (78%) and there was less prevalance of peripheral vascular disease. Bacteria isolated were gram positive aerobes in 27 cases, gram negative aerobes in 50 cases and anaerobes in 18 cases. 23 patients required amputation of toes, 4 patients required above knee amputations and 6 required amputation at the level of ankle. Conservative treatments with wound debridement, incision drainage, sloughectomy and dressings were done in the rest of the cases. Average hospital stay varied from 3 weeks to 4 months. Conclusion: Therefore, diabetic education and foot care is very essential for every diabetic patient.



2423 Clinical assessment and risk factors for delay in complete resolution of diabetic foot ulcer in Type 2 diabetic patients. S. Salazar, R. Cartin, C. Arguedas; Internal Medicine, Hospital Mexico, San Jose, Costa Rica. Background and Aims: To assess and describe the clinical facts around patients with diabetic foot ulcer and to determine the risk factors that delay the complete resolution of the ulcer. Research Design and Methods: During 2 years, patients with diabetic foot ulcer were followed by the diabetic foot clinic at Hospital México . General descriptive data were collected as age, gender, diabetes duration and treatment. Metabolic control was measured using HbA1c levels. Other diabetic complications were assessed : retinopathy, proteinuria and creatinine, and sensitive neuropathy using the 5.07 monofilament. Other clinical important data were noted : Foot X-ray description, cause of lesion, concomitant soft tissue infection and use of antibiotics. Ulcer characteristics were described: depth, area, previous ulcer,hospitalization due to the ulcer, predominance, time of appearance and time of total cure. Means and standard deviations were calculated for continuous variables and percentages for categorical variables. Stepwise Cox regression analysis was used to find independent factors for no complete resolution of ulcer at 6 months of management in the clinic. p value of less than 0.05 was considered statistically significant . SPSS software for windows version 8.0 was used for the data management. The local committee for bioethics approved the study. Results: 32 patients agreed to participate in the study. Mean age 61 ±11 years. 54% were women. Diabetes duration mean was 19 ±4 years. 84,8% of patients were on insulin treatment. 40 % of patients had history of previous foot ulcer. Mean time duration of ulcer appearance before attending to the clinic was 7,58 ± 2,1 months. Regarding ulcer characteristics: hyperkerathosis was the most common cause of the ulcer ( 48,5%), followed by blunt trauma (21%), mean area was 3,5 ± 0,9 cm2 and depth 0,42±002 cm. Concomitant soft tissue infection was present in 75% of patients. Right lower limb ulcer was predominant in 53% of subjects. The mean duration for ulcers to be healed was 7,23±2.3 months. Only 10 patients required hospitalization for a mean of 8,53±4,2 days. Antibiotics were used in 72%of patients. Metabolic control showed a mean HbA1c of 11,66 ±3,7 %. Retinopathy was present in 88% of patients, and sensitive neuropathy in 75% of diabetics. Foot X-Ray was ordered in 43% of patients, being the presence of chronic osteomyelitis the most common description ( 18%). Mean proteinuria and creatinine were 325±58mg in 24 hour and 1,1 ±0,45 mg respectively. The following factors were independently related to no complete resolution of ulcer at six months: proteinuria ( RR 95% CI) 2,8 ( 1,4-3,2), Ulcer depth ( RR 95% CI) 1,8 (1,2-2,6) and duration of ulcer prior to clinic attendance ( RR 95% CI) 3,3 ( 1,9-5,1). Conclusions: Proteinuria level, ulcer depth and duration of the ulcer are the main risk factors for the no resolution of foot ulcers at 6 months in Type 2 diabetic patients in Costa Rica. Most of the patients with diabetic foot ulcers have a poor metabolic control and concomitant microangiopathic complications.



2424 The epidemiology of diabetic foot ulcer in Cameroon: a hospital based study. A. P. Kengne1, L. Simo1, S. P. Choukem1, M. Y. Dehayem1, L. Fezeu2, F. Assah2, J. C. Mbanya1; 1Department of Internal medicine and specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon, 2Diabetes and Endocrine Unit, Hôpital Central de Yaoundé, Yaounde, Cameroon. Background and Aims: The prevalence of diabetes in African communities is increasing with ageing of the population and lifestyle changes associated with rapid urbanisation. Long-term complications here occur with high frequency early in the course of diabetes. Foot ulcer occur as a result of vascular complications, neurological and infectious complications, and will affect up to 10% of the diabetic population. This study was undertaken to determine the prevalence, clinical features, associated micro-organism and their sensitivity, and clinical outcome of foot ulcers in diabetic patients admitted to the Diabetes and Endocrine unit of Yaounde Central Hospital, Cameroon. Material and Methods: A retrospective cohort study of hospitalized, adult diabetes patients with foot ulcers was conducted from November 1999 to October 2002. Clinical and epidemiological data were recorded, followed by a record of microbiological investigations where available. The duration of hospitalisation and clinical outcome was also documented. Results: Of 503 diabetes patients admitted during the study period, 54 (10.7%) had foot ulcers. Male subject represented 66.7% of this population. One patient had type 1 diabetes. The mean age of the study population was mean: 59,7 ± 11.1 years. The known duration of diabetes varied between 0 and 36 years (mean: 9.29 ± 8.41), with foot ulcer being the presenting sign in 6 patients.. This duration was significantly elevated in female (p=0,03). Nine patients (16.7%) were selected for surgery (minor and major amputations); the rest were managed conservatively. The duration of hospitalisation ranged from 1 to 138 days (mean 33.09 ± 29.06 days). The related bed occupancy was 30%. Microbiological analysis available for 21 patients show a high frequency of association of micro-organism in the same patient. Proteus mirabilis was present in 50% of sample and, half the time, it was associated with Staphylococcus aureus. All the micro-organism isolated shown high sensitivity to second generation quinolone and regularly to aminoside. Nine (16.7%) patients died, 7 (13,0%) were discharged upon request while the remaining were discharged regularly. Conclusions: This study strongly suggests that diabetic foot is among the leading causes of hospital admission in our setting; and the main cause of prolonged hospital stay and bed occupancy. The mortality rate among this patient is high and the combination of second generation quinolone and aminoside can be proposed as probabilistic antibiotic approach to foot infection in a resource limited area. There is an urgent need for preventive measures to reduce the burden of diabetic foot ulcer in this population. To be much more effective this strategy need to be applied as a part of global approach to diabetes mellitus management in the country at large.



2425 Foot fungal infections in diabetic Tunisian patients: prevalence and risk factors. C. Ben Slama1, R. Bouguerra1, O. Essaies1, L. Ben Salem1, N. Ezzine Sebai2, M. R. Kamoun2; 1Service d'Endocrinologie et Métabolisme, Institut National de Nutrition, Tunis, Tunisia, 2Service de Dermatologie, Hôpital Charles Nicolle, Tunis, Tunisia. Background and Aims: Foot fungal infection increases the risk of secondary infection in diabetic patients. The prevalence of onychomycosis is higher among diabetic patients than in non diabetic population and is estimated to be 32 and 35% respectively in USA and Canada. Aims of this study are to determine the prevalence of fungal lesions on foot of diabetic Tunisian patients and to identify risk factors. Materials and Methods: Feet of three hundred diabetic patients (140 males and 160 females) were examined by a dermatologist to search lesions of skin and of toenail. 130 of them were type 1 and 170 type 2 diabetic patients. Mean age was 44.1 ± 17 years and mean BMI 25.3 ± 5 kg/m². Microscopic mycological examination and fungal culture were performed in cases where clinical signs of fungal infection were present. Results: Clinical signs of presumed fungal infections were found in feet of 38.4% of patients, accounting for approximatively 62% of all fungal skin infections in these patients. Mycological evidence of onychomycosis was present in 26.6% of patients (80/300) , mostly due to dermatophytes. Interdigital mycosis infection was present in 40.3% of patients (121/300), caused by dermatophytes in 56% and by candida albicans in 10% of cases. Development of fungal foot infection was significantly correlated with older age (p < 0.01), male gender (p < 0.01), obesity (p < 0.001) and type 2 diabetes (p < 0.01). The degree of glycemic control at time of investigation was not a significant predictor for the development of fungal infection. Conclusion: Toenail onychomycosis was present in one third of subjects with diabetes. Predisposing factors included age, male gender and increasing body mass index.



2426 Clinical and metabolic study of the diabetic foot in the Hospital Arzobispo Loayza of June 2000 to May 2002 in Lima, Peru. L. A. Neyra, M. Borchane, J. Cueva, O. Castillo, J. Solis, G. Rodriguez, P. Cornejo, F. García, H. Manrique, J. Calderón; Endocrinology, Arzobispo Loayza Hospital, Lima, Peru. Background and Aims: The purpose of this study is to evaluate the clinical characteristics as well as the metabolic control and the chronic complications in patients with diabetes taking part in the Diabetic Foot Program. Materials and Methods: This is a transversal study in which we have evaluated 1074 patients with Diabetes mellitus. We evaluated and determinated clinical and metabolic characteristics of the patients when they entered the Diabetic Foot Program at Arzobispo Loayza Hospital from June 2000 to May 2002. Results: 74,3% of the subjects were female patients. The average age of the group was 59,09 (SD+11,4) years. 95,42% of the cases presented type 2 diabetes. The average time during which they had suffered the illness was of 6,59 years. The Body mass index (BMI) average of the group was 28,71 Kg/m2. As treatment for diabetes: 19,65% only took a diet, 74,89% combined a diet with oral antidiabetics, 4,58% combined a diet with Insulin and 0,87% combined diet with oral antidiabetics and Insulin. As a part of the metabolic control of the patients we performed glycemia test in fast in 451 cases which showed a glycemia average in fast of 146,99mg/dl. We also performed 71 Post prandial glycemia tests which showed an average of 162,42mg/dl. Besides we performed 227 HbA1c tests showing an average of 9,86%. From 359 total cholesterol tests we obtained an average of 215,98mg/dl, from 339 triglycerides tests we obtained an average of 184,35mg/dl, in 231 cases we performed HDL-c tests which showed an average of 43,24mg/dl and in 206 cases we performed LDL-c tests that showed an average of 137,9mg/dl. The Systolic blood pressure average was 130,12mmHg and Diastolic blood pressure average was 79,17mmHg. 86,6% of the patients had foot at risk, 7,3% had ulcerated foot and 2,0% gangrened foot. Neuropathy was present in 52,9%, Vasculopathy 58,4% and Dermopathy 98,9%. The most frequent lesions in skin were: onicomicosis (76,8%), deformations (37,5%) and tripes (80,5%). Within the Chronic Complications: we found: diabetic Retinopathy in 27,9%, diabetic Nephropathy with more than 300 mg/24 hours of albuminuria in 27,2%, Chronic Coronary Disease in 31,7%, Peripheric vascular disease (Doppler) in 45,3% and Cerebrum vascular disease in 2,6%. Conclusion: The frequency of lesions in the diabetic foot was high, as well as inadequate metabolic control and the presence of chronic complications mainly Neuropathy, Vasculopathy and Dermopathy in the patients when they entered the Diabetic Foot Program.



2427 Prevalence of risk factors of diabetic foot syndrome in Moscow and Tatarstan. G. Strakhova, S. Agadjanian, P. Zykova, O. Udovichenko, F. Valeeva, Y. Suntsov, G. Galstian, I. Dedov; National Research Centre for Endocrinology, Moscow, Russian Federation. Aims: 1) To investigate the prevalence of diabetic foot syndrome (DFS) and DFS risk factors in diabetic population. 2) To compare frequencies of DFS risk factors in Moscow and in Republic of Tatarstan. 3) To assess quality of foot self-care by patients. Methods: During 2 weeks 90 patients with type 1 and type 2 diabetes were examined in Moscow and 119 patients in Tatarstan. In Moscow all patients who visited endocrinologists in 2 outpatient clinics during this period were examined. In Tatarstan patients from several cities were studied. Examined populations differed (p<0.05) by: males/females ratio (24:76% in Moscow, 43:57% in Tatarstan), average age (63 (19-90) and 52 (18-78) years respectively), duration of diabetes (9.2 (1-39) and 11.9 (1-38) years) and diabetes type 1 / type 2 ratio (8:92% and 20:80%). Symptoms, anamnesis, foot examination data, foot pulses and perception of 10 g monofilament were registered. To assess difference between groups Student�s t-test was used for parametric values, and chi-square test for non-parametric ones. Results: Among patients studied in Moscow no foot ulcers were found, but 7.78% of patients reported ulcers in anamnesis. In Tatarstan 5.9% of patients had ulcers, 1.7% undergone minor amputations and 16.0% had ulcers in past. Signs of moderate risk of DFS (hyperkeratosis, moderate foot deformities, nail thickening, mycosis, venous diseases, oedema, dry skin, etc.) were found in 93.3% cases in Moscow and 88.2% in Tatarstan. The average number of these signs per patient was 3.4 and 1.8 respectively (p0.05). Signs of high risk of DFS (hyperkeratoses with haematomas, significant foot deformities, skin injuries by nail clips or scissors, cracked skin, nails damaging skin of toes, venous insufficiency with trophic skin disturbances) was found in 10.0% and 21.8% respectively (p<0.05). Average number of high risk signs per patient was 0.1 and 0.3 respectively (p<0.05). These differences appeared to be a result of higher proportion of type 1 patients in Tatarstan: when only type 2 patients were compared, no significant difference was found. Significant diabetic neuropathy (with loss of protective sensation) was found in 8.1% patients, foot pulses were absent in 5.7%. Symptoms like feet pain were reported by 66.5% of patients. 29.5% of patients with such complaints and 15.7% without ones were in risk group of DFS. Sensitivity of pains as a predictor of DFS risk was 78.8%, specificity � 62.4%, accuracy � 47.8%. Average amount of risk factors concerned with poor quality of foot self-care by patients was 2.07 per patient in Moscow and 2.61 in Tatarstan (p<0.05). 14.4% and 13.9% of patients respectively couldn�t take care of their feet because of poor vision. 23% and 40% of latter couldn't rely on relatives' assistance in footcare. Conclusions. Significant prevalence of DFS risk factors was found in Moscow and Tatarstan populations. Patients with pain in feet have to be examined for causes of pain, and appropriate treatment should be advised. But presence or absence of pain can�t be a reliable sign of DFS risk. Quality of patients' foot self-care care in both regions is not adequate and has to be improved by special educational courses.



2428 Frequency of amputations due to diabetic foot ulcer (DFU) I hospitalised patients and patients of diabetic foot outpatient clinic (DFC). G. Rosinski, A. Krakowiecki, W. Karnafel; Gantroenterology and Metabolic Disease, University School of Medicine, Warsaw, Poland. Background and Aim: to determine the frequency of amputations due to DFU in patients of DFC and in patients hospitalised in our clinic. Materials and Methods: All 250 persons who began treatment for DFU in the 2002 were analysed. Among them 40 were initially hospitalised in our clinic (hospital group) and the remaining 210 formed the outpatient group. All subjects were classified as having neuropathy, ischemic or mixed ulcer. Ischemic foot criteria included the ankle-brachial index <0.9. Neuropathy ulcer was determined based on positive monofilament and neurotensiometer tests. If both ischemic and neuropathy parameters were present we diagnosed mixed foot ulcer. To describe the localisation of the lesion we used own foot scheme. Small (distal) amputations concerned only the foot, high (proximal) were the amputations above the ankle. We analysed the data at admission. Results: 90.7% of the patients had type 2 diabetes. Over 96% of subjects did not have a foot examination performed by a physician or a nurse prior to DFU problem. Hospital group was divided into ischemic and neuropathy DFU groups. The mean age was higher in the ischemic group (66.5/56, p<0.001). The time from diabetes onset, 15/12.4 years respectively, infection parameters and control of diabetes (HbA1c 8.2, 8.4%) were not significantly different. The percentage of smokers among persons with ischemic DFU was 34%, among those with neuropathy DFU - 4% (p<0.0001). Period of hospitalisation for ischemic DFU was 3.2 days longer then for neuropathy DFU. Amputation rate in ischemic DFU was 30%, in neuropathy DFU there were no amputations (p=0.003). Persons who had amputation were older (67.1 vs. 60.0, p<0.0001) and had a lower HbA1c level (7.9 vs. 9.8%, p=0.001). Time from onset and gender were not significant. In the outpatient group 3 groups were distinguished - neuropathy, ischemic and mixed DFU. Patients with mixed and ischemic DFU were older (63.9/58.9, p=0.007). Mean time from diabetes onset was 14.5 year, comparable in all groups. High amputations were performed in 9.5% of ischemic, 1% of neuropathy and 0% of mixed DFU; small amputations in 47.6% of ischemic, 27.1% of neuropathy and 35.7% of mixed DFU (p=0.012). Age and time for diabetes onset were not significant risk factors for amputations (p=0.76 and 0.43). We also noticed a seasonal pattern in DFU incidence (an increase in May-July) as well as typical localisation of ulceration. Conclusions: 1. Prior to treatment in the DFC 30% of patient underwent an amputation. 2. Ischemic type of DFU was more commonly associated with amputations. 3. Summer season constitutes a risk factor for ulcer formation. 4. Ischemic DFU occurred more often in smokers.



2429 Diabetic foot and major amputations: experience of a diabetic foot clinic. C. R. F. Horta1, J. Vilaverde1, C. Amaral1, J. Muras2, L. Serra2, J. Martins3, P. Sá Pinto3, R. Almeida3, R. Carvalho1, J. Dores1, B. Serra1; 1Endocrinology, Hospital Geral St. António, Oporto, Portugal, 2Orthopaedics, Hospital Geral St. António, Oporto, Portugal, 3Vascular Surgery, Hospital Geral St. António, Oporto, Portugal. Background and Aims: Eighty percent of all diabetes related lower limb amputations are preceded by a foot ulcer. Several studies have proven that amputation rate can be reduced by more than 50% if strategies like prevention, early diagnosis and multidisciplinary approach are implemented. The distinction between neuropathic and ischemic foot allowed us to reduce drastically the major amputations between 1985 and 1987, at the beginning of our Diabetic Foot Clinic's activity. Until 1995 the rate stabilized around 8,2%, but in our last review (1998-2000) we found a further reduction to 5,2%. The aim of our study was to know if there were further improvement in 2001. Materials and Methods: In a retrospective study we reviewed the clinical files of 434 new patients. Results: Among these patients, 314 presented us with a foot ulcer with or without infection. There were 185 patients (58,9%) with neuropathic ulcer and 129 (41,1%) with ischemic ulcer. Patients with neuropathic foot (44,3% males and 55,7% females) had type 1 diabetes (10,3%) with 16,6±9,8 years of diagnosis, or type 2 diabetes (89,7%) with 14,4±10,2 years of diagnosis. They presented us with a superficial ulcer or infection (55,1%), deep infection involving tendon, muscle or bone (23,3%), leg's ulcer (11,3%) or necrosis (10,3%). Patients with ischemic foot (55% males and 45 % females) had type 1 diabetes (9,3%) with 30,3±7,1 years of diagnosis or type 2 diabetes (90,7%) with 16,2 ±11 years of diagnosis. They presented us with a superficial ulcer or infection in 38%, deep infection involving tendon, muscle or bone in 6,2%, leg's ulcer in 9,3% and necrosis in 46,5%. Patients were treated with antibiotics, debridation of devitalized tissue when needed and metabolic control was always optimized. We performed minor amputations in 11,4% (n= 21) and major amputations in 0,5% (n=1), in patients with neuropathic ulcer. Twenty one patients (16,3%) with ischemic foot were treated with minor amputation and 25 (19,4%) with major amputation. Twenty six out of 314 patients (8,3%) with ulcer or infection were treated with major amputation. Overall, age, sex, type and duration of diabetes did not statistically modify the outcome. Necrosis was related with worse prognosis only in ischemic feet. Conclusions: There was a slight increase of the major amputation's rate. We emphasize that only one patient with neuropathic foot was amputated (Charcot- foot). Further improvement demands harder investment in prevention and primary health care.



2430 Diabetic foot care in France: what’s done? S. Clavel, Y. Khalfallah, A. Bodard, M.-L. Crenn, C. Denizot, R. Desbrosses, L. Deschamps, A. Desserprix, O. Evangelisti, K. Gras, C. Mourey, D. Paire, G. Troublat; Department of Diabetology, Podiatric Unit, Fondation Hotel-Dieu du Creusot, Le Creusot, France. Background and Aims: A questionnaire about their diabetic foot care habits was submitted to 99 practitioners (diabetologists , nurses and podiatrists) from 64 french different diabete care units. The aim was to investigate their practice in treating : diabetic plantar ulcer with (Wagner 3) (case I) and without (Wagner 4) (case II) infection ; first internal border head metatarsian superficial diabetic ulcer (Wagner 1) (case III), toe necrosis with diabetic neuropathy with or without arteriopathy caused by local infection (case IV). The results are : Washing with antiseptics 100 % (I) ; 62 % (II); 32,8 % (III) steril water 42,8 % (I) ; 28,7 % (II) ; 16 % (III) saline solution 100 % (I) , 69 % (II) ; 47,5 % (III) topic antibiotics 20,6 % (I) Draining {81, 5 % (I) ; 65,2 % (II)} with iodine gauze 92,5 % (I) ; 36,7 % (II) dry steril gauze 30,2 % (I) ; 33 % (II) moister steril gauze 56.6 % (I) (II). Debridement mecanical (61,5 %), chemical (47 %)(III) Dressing changes frequency : each day 83,9 % (I), 69 % (II), 66 % (III), every 2 days 6,5 % (I), 18,5 % (II), 28 % (II). Weight-bearing avoiding : 87 % (I) ; 76 % (II) � protective shoes 57 % (I); 49,3 % (II) � cushion insoles 19 % (I) ; 24,3 % (II) � plaster cast 7,5 % (I) ; 2,8 % (II). 74 % try auto-amputation with dry gangrene (IV) and 26 % suggest toe surgical amputation. The wide answers point out the missing of consensus in diabetic foot care and need for such a consensus in the management of diabetic foot.



2431 Clinical characteristics of patients with foot ulcers and diabetes mellitus. L. C. Nwabudike, C. Ionescu-Tirgoviste; N. Paulescu Institute, Bucharest, Romania. Background and Aims: The diabetic foot is thought to be caused by various factors. A knowledge of these factors is important in determining prophylactic and therapeutic approaches. We aimed to determine the clinical characteristics of patients with foot ulcers and diabetes mellitus. Materials and Methods: We studied 46 patients with diabetes mellitus and foot ulcers that presented consecutively to our outpatient department. The patients' ulcers were assessed together with a determination of probable cause of the ulcers. The Wagner category was assessed. Results: The group comprised 46 patients, 33 males and 13 females with average age of 59.9 yrs. and average duration of diabetes of 10.8yrs. There were 45 type 2 cases of diabetes. The 46 patients presented a total of 67 ulcers, an average of 1.45 ulcers per patient (range 1-6 ulcers per patient). The causes of the ulcers were neuropathy 32 (69.6%), arteriopathy 2 (4.3%), mixed ulcers 12 (26.0%), trauma and infection were associated factors in 5 (10.9%) and 7 (15.2%) of cases respectively. Of these 46 patients 5 (10.8%) had previous amputation while 41 (90.2%) had no associated previous amputation. The location of ulcers were toes 51 (76%), foot 4 (13.4%), 4 (5.9%), plantar area 2 (2.9%) and metatarsian area 1 (1.5%). According to the Wagner classification (W1-5) the ulcers were W1= 1 (2.1%), W2 = 21 (45.7%), W3 = 22(47.8%) and W4 = 2 (4.2%). Conclusions: From our results we could conclude that male sex (71.7%), type 2 diabetes (97.8%), older age (>59 yrs), toe area (76%) and neuropathy (69.6%) were major predisposing factors for foot ulceration. Most patients with foot ulceration (93.5%) presented with moderately severe foot ulcers. Previous amputation (10.8%), trauma (10.9%) and infection (15.2%) were significant associated factors. Educational programmes targeting the groups at risk would greatly reduce the number of patients that suffer from foot ulcerations.



2432 Charcot's arthropathy in diabetes – risk factors, treatment optimalisation. T. Koblik1, J. Sieradzki1, J. Friedlein2; 1Chair and Clinic of Metabolic Diseases, Collegium Medicum Jagellonian University, Krakow, Poland, 22nd Chair of Surgical Clinic, Collegium Medicum Jagellonian University, Krakow, Poland. Background and Aims: Charcot's joint is a chronic complication of diabetes. Its etiologic factors include neuropathy, vascular changes and recurrent overlooked by patient microinjuries. The aims of the study were: 1) assessment of risk factors for developing of Charcot's joint 2) identification of directly precipitating factor 3) elaboration of appropriate treatment regimen. Material and Methods: We analysed 27 patients with Charcot's arthropathy, 13 with type 1 diabetes and 14 with type 2 diabetes treated in Clinic of Metabolic Diseases UJ in years 1994-2002. Metabolic control of diabetes, the presence of other chronic complications, precipitating factor, the presence of ulceration, location and kind of bone changes were evaluated. The treatment regimen consisted of metabolic control of diabetes on normoglycemic level, immobilizing in plaster dressing, healing of ulceration if present (including skin transplantation), use of protective shoes and sometimes administration of bisphosphonates. Results: Type 1 diabetes Type 2 diabetes n = 13 n = 14 Age 38,69 +/- 11,51 55,57 +/- 9,44Diabetes duration (years) 19,69 +/- 7,47 10,43 +/- 8,48HbA1c (baseline) 9,75 +/- 2,77 8,90 +/- 2,59 Mechanical precipitating factor 8 11 Period of immobilizing until healed (days) 70,78 +/- 53,93 50,00 +/- 21,38 No leg amputation was noted. Conclusions: 1. Charcot's joint occurs in persons with longer duration of poorly controlled diabetes, particularly in type 1, with advanced other chronic complications. 2. The precipitating factor in majority of patients was the mechanical injury. 3. Mean period of immobilizing in plaster was in type 1 diabetes: 70,78 +/- 53,93 and in type 2 diabetes: 50,00 +/- 21,38 days. 4. The efficiency of proposed treatment regimen is confirmed by no observed cases of either amputation or permanent damage of limb.



2433 Charcot osteoarthropathy: specialities of peripheral neuropathy and potential risk factors. Y. Kotuhova, I. Gourieva; Diabetic Foot Center of Federal Institute Expertize and Rehabilitation, International Diabetes Program, Moscow, Russian Federation. Diabetic osteoarthropathy (DOAP) - is one of the most severe and least studied complication of diabetes mellitus: 70% of Charcot patients had symptoms of proliferative retinopathy and more than 39% had nephropathy with renal failure. Charcot foot affects patients with longterm neuropathic disease and leads to amputations, disamblements and poor life quality. Background and Aim: comparison the state of peripheral nervous system in diabetic patients with and without Charcot osteoarthropathy and valuation the potential risk factors of Charcot foot. Materials and Methods: we examined 134 diabetic patients: 103 patients with DOAP and 31 patients with signs and symptoms of neuropathy (N+), but without osteoarthropathy. Mean age of all patients was 49,3 +/-1,35 yrs (femalegender 84 (62,7%), malegender 50 (37,3%). The jority of patients 73 (54,5%) had type1; diabetes duration were 19,91 +/- 0,86 years (2-47 year). All patients from two groups were comparable for sex, age, type and diabetes duration. All patients were exposed clinical examination. The presence and severity of sensorymotor neuropathy was assessed using neuropathy deficit score � NDS,. autonomic neuropathy - ADS scale. For our analyses we introduce coefficient (K), as a ratio of small to large nerve fibers involvement (marks of NDS). K = small / large = (temper.+ pain) / (vibr.+ tactil.) Results: our results showed that DOAP group was characterized with significantly reduced function of small nerve fibers (7,65 +/- 0,12) in comparison with N+ (5,56 +/- 0,3, p<0,05). In N+ group reduced function large nerve fibers (5,71+/-0,33) was revealed. In DOAP group temperature (4,1 +/- 0,08) and pain (3,52 +/- 0,06) sensation was discovered to be decreased in comparison with. vibration (3,56+/-0,07) and tactile (2,85 +/-0,08) sensation. A strong correlation was found between small nerve fibers involvement (p=0,06, p<0,05) and DOAP. Coefficient (K) was 1,17+/-0,03 in DOAP group, and 0,97+/-0,02 in N+. We proved that the sum of the infringements of thermal and pain sensation is equal or more than 6 or K-value is equal or more than one may be used as a risk predictor of Charcot foot development with high accuracy, sensitivity and specificity. In addition, the patients with DOAP had significantly more sever neuropathy (NDS 20,45 +/- 0,26), compared to N+ (16,1 +/- 0,9, p<0,001). We proved that the NDS score can be used, as a predictor of Charcot foot with high level of sensitivity and specificity, if the sum of neurological deficit is equal or more than 15. Conclusion: the patients with Charcot foot had specific form of neuropathy, where small nerve fibers involvement was predominate accentuated. The severity of small nerve fibers dysfunction or evaluation of small to large nerve fibers ratio might be used as predictor for Charcot foot development.



2434 The use of the Ilizarov apparatus in the management of severe hindfoot deformities as a result of Charcot neuroarthropathy. N. Harris1, C. M. Amery2; 1Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom, 2Diabetes, Leeds General Infirmary, Leeds, United Kingdom. Background and Aims: Charcot neuroarthropathy affecting the ankle and sub-talar joint often results in severe deformity. Amputation rates as high as 40 % have been reported. We present our results using the Ilizarov apparatus in the surgical management of this difficult problem. Materials and Methods: We report on 6 cases of severe deformity of the ankle and hindfoot as a result of Charcot neuroarthropathy treated surgically using the Ilizarov external fixator. The Ilizarov system consists of tensioned wires attached to circular rings. There were two bilateral cases. The mean age of the patients was 74 years (range: 60-86 years). There were two women and two men. In 4 cases the deformity was corrected acutely and in 2 a gradual correction was achieved. Results: In all cases the foot position was improved and a stable arthrodesis achieved. Conclusion: We believe the use of the Ilizarov external fixator in the management of severe deformity of the ankle and sub-talar joint is an effective way of improving foot position and achieving a stable arthrodesis.



2435 Treatment of neuropathic fractures with casting prevents the development of the Charcot foot as long as ulceration and infection are avoided. N. L. Petrova, A. V. M. Foster, M. E. Edmonds; Diabetic Foot Clinic, King's College Hospital, London, United Kingdom. Background and Aims: The outcome of diabetic neuropathic fractures is not fully known. Do these fractures trigger the development of the Charcot foot or can they be treated successfully and heal without complications. The aim of this study was to investigate the outcome of 14 neuropathic fractures and to evaluate the occurrence of Charcot foot. Materials and Methods: We studied 14 patients who sustained a fracture and divided them into two groups according to the outcome of fracture: group 1- all fractures healed uneventfully and group 2 � patients who developed Charcot foot. There were 6 patients in group 1 (type 1 � 5 patients, type 2 � 1 patient, age 59± 8.4 years [mean ± SD], duration of diabetes 38± 15.7 years) and 8 patients in group 2 (type1 � 6 patients, type 2 � 2 patients, age 40± 13.3 years, duration of diabetes 18± 6.4 years). The outcome and treatment modalities of patients presenting with fracture were reviewed by means of clinical assessment, skin foot temperatures, X-ray and technetium diphosphonate bone scan. Results: In group 1, all 6 patients were treated promptly with a cast, did not develop any complications (ulcers and infection) when mobilised and fractures healed successfully. In group 2, five out of eight patients were treated with offloading. Initially they improved but their mobilisation was complicated by ulceration and infection and they developed Charcot foot. The remaining three cases did not have prompt initial offloading with cast and they also developed Charcot foot. Conclusion: This study has shown that diabetic patients with neuropathic fractures who are treated promptly with casting and have no complications of ulcer and infection do not develop Charcot foot. The patients who were casted but were complicated by infection developed a Charcot foot as did patients who were not promptly offloaded. Charcot foot may be prevented in patients with neuropathic fractures if they are casted promptly and treated intensively to avoid ulceration and infection.



2436 The assessment of static function of foot in diabetes in Type 1 patients. W. J. Zarzycki1, E. Mazuruk1, A. Glebocka1, B. Zarzycka1, J. Lewko2, J. R. Dabrowski3, J. Sidun³, I. Kinalska1; 1Department of Endocrinology, Diabetology and Internal Medicine, Medical University, Bialystok, Poland, 2Department of Rehabilitation, District Hospital, Bialystok, Poland, 3Faculty of Mechanical Engeeniring and Material Technology, Technical University, Bialystok, Poland, Background and Aims: Diabetic foot focuses in itself damage to all important tissues and all the resulting changes in their function and morphology. From the medical point of view it is an interesting issue for the specialists from different fields of medical science. Complex changes in the foot mechanics, which is from the physical point of view a type of multi-part two-arm weight-lifter, caused by changes in function and morphology of the tissues make both diagnosis and treatment of diabetic foot not strictly a medical problem but also a focus of interest for biomechanic engineers. The aim of thie study was the assessment of disturbances in the foot static as a � mechanical device� in diabetes t. 1 patients. Material and Methods:The study included 80 diabetes type 1 individuals aged 20 to 35 years with the duration of the disease from 1 year to 30 years in ¾ of the women who were admitted to the outpatient dept and reported no diabetic foot symptoms. The diagnosis of the foot static included plantocontourgraphy which meant outlining the traces of the bottom surface of the foot, its indices and angles in order to assess the static burden to the feet. The study was done using �Orthoprint� device. Clinical data concerning complications of the disease � retinopathy based on eye bottom assessment nephropathy based on the presence of albuminuria and the degree of the disease � the level of Hba1c and fasting and postprandial glicaemia. Additionally chosen anthropometric data were included in the analysis: body mass, height and foot size. Results: We found that the disturbances of the feet static are present almost in all examined persons (85%) while only in 47% of persons from the control group. We found that the number of disturbances to the foot static increases with the duration of the disease and does not depend on the actual indices of the satisfactory disease control. Conclusions: On the basis of the above results we may conclude that the disturbances of the foot static are common in type 1 diabetes and that their frequency increases with the duration of the disease. This finding indicates the necessity of implementing accurate prophylactic procedures in all diabetes type 1 patients irrespective of the reported.



2437 Plantar pressure analysis of diabetic subjects with ulceration risk. C. M. G. Marques1, A. Folador1, A. C. Amorim1, R. C. B. Sandoval2, M. H. C. Coral2, J. L. B. Marques3; 1Departamento de Ciências Biológicas, Universidade do Estado de Santa Catarina, Florianópolis - SC, Brazil, 2Grupo de Atendimento ao Diabético, Hospital Universitário - Universidade Federal de Santa Catarina, Florianópolis - SC, Brazil, 3Instituto de Engenharia Biomédica, Universidade Federal de Santa Catarina, Florianópolis - SC, Brazil. Background and Aims: Late complications of (DM) Diabetes Mellitus are the major cause of morbidity and mortality. One serious complication of DM is the �diabetic Foot� which is a public health problem due to its high prevalence and costs. The main risk factors involving foot ulcerations and amputations are peripheral neuropathy, biomechanical alterations, foot deformity, vascular peripheral disease, ulceration and previous amputation. The aim of this study was to analyse high foot pressure regions of diabetic individuals, with risk of ulceration. Materials and Methods: Twelve diabetic individuals, male and female 40 years of age, DM Type 2 diagnose more than 5 years, were previously selected by the Diabetic Nursing Team. Four risk levels were considered (0 = neuropathy absent; 1 = neuropathy present; 2 = neuropathy present and signs of peripheral vascular disease; 3 = previous ulceration/amputation). Maximum values of foot pressure (kg/cm2) were measured using a sensorised matrix mat (F-Mat) during a normal and comfortable walk without shoes. The F-Mat was calibrated according to each patient body weight. Eight areas of interest were analysed : (1) heel; (2) midfoot; (3) 5 metatarsal head; (4) 3 metatarsal head; (5) 5 metatarsal head; (6) 5 lesser toe; (7) 3 lesser toe; and (8) halux. Results: Table 1 shows peak values of plantar pressure for right and left feet related to the risk of ulceration. Maximum values of plantar pressure were not different when compared right and left foot (p>0,05). Table 1. Patients, Risk factors, Areas of Interest and Plantar pressure for both left and right feet. (abstract # 2437 continues on next page)



(abstract # 2437 continuation)

Left Foot Right Foot P Risk

Area Plantar Pressure Area Plantar Pressure1 1 1 2,3 8 2,2 2 2 4 3,9 8 4,8 3 2 4 2,9 4 3,3 4 2 4 3,0 4 3,8 5 2 4 3,1 4 3,5 6 0 8 4,1 3 4,5 7 3 3 2,5 4 3,5 8 1 4 2,9 5 3,6 9 0 8 3,8 8 3,8

10 2 1 3,0 4 4,0 11 0 5 5,0 5 5,3 12 0 8 2,0 4 2,4 Spearman Rank correlation test showed no correlation between right foot pressure and the risk (r= -0,15; p=0,63); and also no correlation between left foot pressure and risk (r= -0,25; p=0,44). Conclusion: Table 1 shows that peak foot pressure vary among different areas of interest. Diabetic patients foot pressure did not show a significant correlation to the risk factors of ulceration. Foot pressure values were not higher than 5 kg/cm2 and the risk factor were not high enough to show a significant correlation. Foot pressure values not over than 5 kg/cm2 seem to be a normal physiological value in specified areas. We concluded that the clinical screening and the feet care information provided by the Diabetic Nursing Team might have contributed to a better diabetic patient's feet health.



2438 Kind of executed amputations and foot pressure distribution in pedometer footprint at patients with diabetic foot syndrome (DFC). A. Krakowiecki, G. Rosinski, W. Karnafel; Gastroenterology and Metabolic Diseases, University School of Medicine, Warsaw, Poland. Background and Aim: Diabetic Foot Syndrome is one of the most frequent complication at persons treated from reason of diabetes. Incorrect foot pressure distribution is one of causes of foot ulcerations at diabetic patients. Aim of work was to prove dependence between kind of executed amputations and foot pressure distribution. Material and Methods: In year 2002 168 patients from Outpatient Clinic Of Diabetic Foot were directed to measurement of static plantar pressure. 42 (25%) persons with executed amputation in foot area were classified to investigation. Among studied patients 9 (21,4%) were type 1 diabetics and 33 (78,6%) persons were type 2 diabetics. Age of patients hesitated from 56 to 78 years old ( mean 62,1 years + 10,1). Investigations were performed with 1024-sensor static pedometer PEL-38 made by Midi Capteurs co-operating with software TWIN 99 version 2.06. The cartography of plantar pressure of every foot was divided into 8 fields: 1. fingers I and II; 2. fingers III, IV and V; 3. medial forefoot; 4. lateral forefoot; 5. medial part plantar arch; 6. lateral part of foot arch; 7. medial part of calcaneum; 8. lateral part of calcaneum. From every field maximum pressure was considered as a proportional value of maximum foot pressure. Patients were classified into two groups according to the kind of executed operation. Persons with amputation in field 1 were classified to the first group, person after amputation in field 2 to the second group. Results:

Patients with great toe amputations I II III IV V VI VII VIIImean 0,00 7,67 53,83 68,33 45,72 59,33 80,89 80,39standard deviation 0,00 11,62 21,51 19,84 16,52 23,11 18,10 17,14

Patients with toe amputations other than great toe I II III IV V VI VII VIIImean 10,35 3,75 53,15 65,35 36,75 52,40 89,40 88,25standard deviation 13,26 9,67 18,20 17,01 14,41 25,15 12,23 11,77p 0,001 0,135 0,458 0,312 0,42 0,191 0,52 0,57 Conclusions: Patients after great toe amputation have larger deformations revealed in pedometer footprint than patients after amputation in field 2 with intensified platypodia. Measurement of static plantar pressure is advantageous for persons without amputation to prevent from the next ulcerations.



2439 SISPED: a software to monitor foot complications and prevent foot amputation in diabetic patients. N. Melo1, M. Ribeiro2, Y. Lobão1, K. Rezende1, L. Silva2, D. Malerbi3; 1Departamento de Medicina, Universidade Federal de Sergipe, São Cristóvão-SE, Brazil, 2Departamento de Ciência da Computação, Universidade Federal de Sergipe, São Cristóvão-SE, Brazil, 3Departamento de Medicina, Universidade de São Paulo, São Paulo-SP, Brazil. Background and Aims: Diabetes Mellitus is a chronic-degenerative disease accepted as a worldwide epidemic.The diabetic foot is one of the most fearful complication of diabetic patients and is responsible for fifty percent of nom-traumatic lower-extremity amputations in general hospitals. Foot complications in diabetic patients can be prevented, in most of the cases, by educating patients and submitting them to systematic examination routines. In this paper we describe SISPED, a system whose main goal is to give support to medical routines applied to monitor diabetic patients. Materials and Methods: The SISPED system allows nurses and doctors working in primary care of diabetic patients. These professionals can fill information about the clinical features of the patients and can require statistical reports about the evolution of the disease in a particular patient and also in the overall population assisted. The system basically gives support to the tasks of collecting, storing and retrieving clinical data of the diabetic patients assisted by the project. The personal medical data of each patient are stored at the moment of entering in the program and along the follow up. Patient records can be searched by name or by the identification number. Information about the disease is collected by the usage of four forms: the General Disease Questionnaire (GDR), two Symptom Questionnaires (SQ) and the Physical Signs Records (PSR). GDQ includes information such as diabetes type, the degree of the disease control and the presence of other diabetes complications. SQs include questions about symptoms of sensory and autonomic neuropathy or peripheral vascular disease or both. PSR includes observations of skin temperature, limb reflexes, foot pulses and nylon monofilament test. Based on the data collected during the visit, the system automatically generates a patient report. Basically, this report informs the number of symptoms and signals that could suggest the presence of autonomic and sensorial neuropathy and peripheral vascular disease. Based on the values, an automatic diagnostic conclusion is generated. The examiner can insert his comments in the generated report in a blank field. A very useful functionality of SISPED is to provide statistical reports that allow doctors to monitor the evolution of the disease in a particular patient and in the overall population assisted is depicted. Results: About 8 patients with foot complications have been registered and in all cases the system has suggested a consistent diagnostic conclusion. Conclusion: SISPED is an innovative system to monitor foot complications in diabetic patients. The system is in use at the General Hospital of Universidade Federal de Sergipe, giving support to medical routines related to the project Saving the Diabetic Foot. We have been developing a Web version of the system and professionals of public clinics distributed in several cities of the state of Sergipe should use it. The main purpose is to massively prevent foot amputations in the diabetic patients of the whole state.



2440 Implementing a functional and sensorial assessment protocol in diabetic neuropathic patients from a university hospital. R. T. Cronfli1, I. C. N. Sacco2, S. M. A. João2, M. M. S. Bernik3, D. K. Ota2, D. Alignani2; 1Divisão de Clínica Médica, University Hospital - University of Sao Paulo, São Paulo - SP, Brazil, 2Physical Therapy, Speech, Occupational Therapy, University of Sao Paulo - School of Medicine, São Paulo, Brazil, 3University Hospital - University of Sao Paulo, São Paulo -SP, Brazil. Background and Aims: Diabetic neuropathic patients present a progressive loss of sensibility, pain, burning, distal numbness, specially in lower limbs. This progression can lead the patient to develop atrophy and weakness of the intrinsic foot and distal muscles, joint movement limitations and alterations in the foot structure. The present study aims to elaborate and to apply a protocol of functional evaluation of the lower limbs in a group of 21 clinically diagnosed diabetic neuropathic patients, from the University Hospital of the University of Sao Paulo. Materials and Methods: The protocol should allow us to identify lower limb mobility problems, skeletal functionality, lower limb motor function and somatosensorial alterations. The experimental procedures were approved by the ethical committee of the University Hospital. The evaluation protocol took approximately 45 min and was divided into 3 stages: (1) a preliminary investigation based on Feldman et al.(1994) to characterize and identify clinical relevant aspects of the diabetes and the peripheral neuropathy; (2) tests of muscular function (Kendall, 1995), range of joint motion (goniometry), a functional lower limb evaluation (Magee, 1997), and foot anthropometric measurement; (3) a somatosensorial evaluation of the foot: thermal, tactile and proprioceptive. Results: The mean age of the diabetic patients was 57 years. The diagnosis of diabetes was made about 13 years before. The mean glycaemia was 170 mg/dl. Typical neuropathic symptoms widely described in the literature, such as distal numbness and tingling / pricking were present in 62% and 67% of the patients, respectively, specially during night rest. We observed expressive alterations of tactile sensibility in 50% and of thermal sensibility in 40-60% over the heel of the patients. The worst responses in muscular function tests were in the triceps surae and in the intrinsic muscles of the foot. The longitudinal and the transversal arches of the foot were lowered in 50% of the patients and the range of joint motion was generally decreased when compared to normal expected values, specially in the ankle inversion (18-20 degrees) and in the ankle flexion (14 degrees). The observed alterations in the muscular function tests (Kendall, 1995) and in the range of joint motion could explain the poor results obtained in the lower limb function, specially in the functional activity of the ankle during flexion and eversion. Conclusion: The novel protocol elaborated in the present study could be easily applied in health care services because it demands little time, few and low cost equipments and could be well understood by the patients. The results and responses obtained in the protocol provided us a clear and deep characterization of the diabetic neuropathic patients evaluated, according to what is described in the literature. Actually, this fact reinforces the applicability of our protocol in the evaluation of diabetic neuropathy and its chronic motor and sensorial consequences.



2441 Microcirculation abnormalities in the diabetic foot as measured by a laser doppler instrument – final report. R. Maniewski1, M. Jasik2, W. Karnafel2, J. Juskowa3, A. Liebert1, A. Zbieć1; 1Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland, 2Gastroenterology and Metabolic Diseases, University School of Medicine, Warsaw, Poland, 3Institute of Transplantology, University School of Medicine, Warsaw, Poland. Background: The aim of this study was to investigate microvascular perfusion in insulin-dependent diabetic patients at various locations on the foot, and to determine which part of the foot is most sensitive to microangiopathic changes. All the parameters of postocclusive reactive hyperemia calculated from multichannel laser Doppler recordings were also evaluated to find the most valuable measure for diabetes examination. Material and Methods: Our study involved 65 subjects divided into four subgroups: male and female controls, and male and female IDDM patients without overt complications. The measurements were performed with a multichannel laser Doppler perfusion monitor using surface probes located in the distal parts of the lower limbs. The occlusion test was performed using a cuff located on the limb above the knee. Multivariate discriminatory analysis was used to evaluate the data. Results: The most valuable data were obtained by recordings from the laser-Doppler probes located on the hallex and the base of the little toe. The maximum hyperemic response for both sex subgroups was significantly lower in the diabetic patients. The time to peak flow was higher in male diabetics. The half-time for hyperemia was significantly longer in the male diabetic patients. Conclusions: The females showed smaller changes in foot perfusion than the males, probably due to protection by estrogens. The best locations for perfusion measurement are the most distal, especially the hallex and the base of the little toe. The most valuable parameters of postocclusive hyperemia were maximum response, time to peak flow, and half-time of hyperemia.



2442 Is monofilament 4.56 log a better predictor in early detection of peripheral neuropathy than 5.07 log? L.-L. Edwall; Norrmalm, Primary Care, Skövde, Sweden. Background and Aims:This cross-sectional study was completed at two primary care centres in west and middle of Sweden. The purpose was to investigate which one of two different Semmes Weinsteins monofilament (MF) (4gram/4.56 log or 10gram/5.07 log) corresponded most to the vibration test and estimate sensitivity, specificity and predictive value of MF 4.56 log. Materials and Methods:The sample consisted of 342 consecutive patients investigated during four months in 1999. The patients were routinely foot examined, once a year, by the diabetes nurse or they had newly got the diagnosis of diabetes type 2. A modified neuropathy symptom and sign score was used for neuropathy diagnosis. A structural protocol included sex, age, HbAIc, duration of diabetes and one open question regarding patients� previous and current foot problems during the last month. Sensibility tests were performed using MF 5.07 log and MF 4.56 log and vibration test with a Tuning fork (128 Hz) or a Biothesiometer. Ankle blood pressure was measured using a Pen Doppler. Results:The result showed difference in outcome between the vibration- and MF tests, where the vibration test proved to have the greater sensitivity (p < 0,001).The neuropathy occurrence was 21,1%. MF 4.56 log showed a sensitivity of 73,6% and a specificity of 86,3%. The positive predictive value was 58,9% and the negative predictive value was 92,5%. Nineteen out of 72 patients with neuropathy diagnosis were not discovered with MF 4.56 log and 37 of 270 patients were overdiagnosed. Corresponding values for MF 5.07 log were 31 and 15 patients respectively. Conclusion: In the screening of neuropathy the vibration test, followed by MF 4.56 log, showed the greatest sensitivity. MF 5.07 log showed the lowest sensitivity of the three tests methods. MF 4.56 log, therefore, is preferably to be used together with the vibration test in neuropathy screening, instead of MF 5.07 log.



2443 Prognosis of diabetic foot lesions using autonomic and sensorimotor neuropathic scores. Two years prospective study. I. Kuzina, I. Gourieva; Diabetic Foot Center of Federal Institute of Expertize and Rehabilitation, International Diabetes Program, Moscow, Russian Federation. Foot lesions in diabetes have a multifactorial genesis but the main predictive factor is neuropathy. Aim: The aim of this study was to assess the predictive value of the sensorimotor and autonomic nerve disfunction for the foot lesions. Materials and Methods: 120 patients with type 1 and 2 diabetes mellitus (66/54), aged 20-72 years and 4-41 years duration of diabetic duration took part in the study. Patients were divided into four groups: 61 patients with neuropathy but without foot lesions (N), 31 patients with neuropathy ulcers (NU), 32 with neuropathic ulcers (NU) (ABI >1,0), 14 with osteoarthropathy (OP) and 14 with neuroischemic ulcers (NIU) (ABI=0,65+/-0,24; M+/-m). The signs of sensorimotor neuropathywas assessed using Neuropathy Disability Score (NDS>4 considered to be abnormal). The signs of autonomic neuropathy assessed using Diabetic Autonomic Score: sum values of 5 cardiovascular reflex (DAS>1 considered to be abnormal). Results: NDS was significantly higher in NU (18,6+/-0,8; M+/-m) compared to N (14,3+/-1,3, p<0,01) and NIU (13,6+/-1,0, p<0,01). No statisticaly significant differences existed in the NDS of OP compared to N. Autonomic nerve disfunction was significantly higher in NU (7,2+/-0,6), OP (8,1+/-0,7) compared with N (2,8+/-0,8, p<0,01). Cut-off NDS=14 and cut-off DAS=4 were strongly associated ulcer formation with high validity (accuracy > 80%, sensitivity > 80%, specificity > 80%). Prospective two years study revealed first ulcer formation in 81% patients with NDS > 14 and 85% patients with DAS > 4. Cut-off DAS=7 were strongly associated osteoarthropathy with high validity (accuracy > 90%, sensitivity > 80%, specificity > 95%). Prospective two years study approved the calculations, osteoarthropathy started in all patients with DAS > 7. Conclusion: Semiquantative analysis of sensorimotor and autonomic nerve dysfunction showed good validity values for the prognosis of neuropathy foot lesions. Prospective two years follow up study revealed very high risk of first ulceration for NDS>14,DAS>4; OP manifestation for DAS > 7. NDS and DAS evaluations migh be used for the determination of short term ulcer and osteoarthropathy risk.



2444 Possibilities of detecting perfusion defects of lower limbs in diabetic patients by means of 99-mTc tetrophosmin perfusion scintigraphy and Laser Doppler. A. Adamikova1, J. Bakala2; 1Internal Clinic IPVZ, Bata Hospital, Zlin, Czech Republic, 2Bata Hospital, Zlin, Czech Republic. Background and Aims: The diagnostics of microangiopathy and mediocalcinosis of LL(lower limbs) are still difficult procedures despite the introduction of new methods of examination. For the detection of muscular perfusion in LL of diabetic patients without claudications we used 99-mTc Tetrophosmin in the performance of myocardial scintigraphy. We compared the findings with a Laser Doppler of the periphery of LL with thermal provocation. Material and Methods: We involved in the observation 11 diabetic patients, whom we divided into two groups: the first one without confirmed microvascular complications and the second one with confirmed microvascular complications. There were 6 patients in the first group (3 women, 3 men, Type 1 DM 3, Type 2 DM 3), group age 42,2 ± 10,3 years, length of duration of DM 11,5 ± 4,6, HbA1c 7,9 ± 0,7%. In the second group 5 patients (2 men, 3 women, Type 1 DM 4, Type 2 DM 1), group age 46 ± 6,6 years, length of duration of DM 23,5 ± 8,1, HbA1c 9,1 ± 1,2%, 3 patients had confirmed nonproliferative retinopathy and nephropathy, 1 autonomic neuropathy and 1 diabetic thick skin and tissue. All patients underwent examination by biothesiometer, color duplex sonography and Doppler with ABI (ankle brachial index) measurements. Perfusion periphery LL was evaluated by Laser Doppler with thermal provocation in the big toe area. Further exercise myocardial SPECT imaging was performed, followed by planar scintigraphy of LL on gamma camera AP(anteroposterior) and PA(posteroanterior) view. Rest scintigraphy followed by planar imaging was executed in the following stage. Results: In the first group without microvascular complications vibratory thresholds for right LL were found to be 17,8 ± 9,9 V, for left LL 17± 9,7 V, ABI for right LL 1,2 ± 0,2, for left LL 1,2 ± 0,3, sonographically 2x mediocalcinosis of the crural arteries, rest Laser Doppler 13 ± 7,8 PU (perfusion units), after thermal provocation 72,4 ± 49,6 PU, time for achieving maximum value of perfusion 2,3± 1,7 min. and rate 19,4 ± 12,6 PU/min. Scintigraphically after exercise 1 patient with mediocalcinosis was found to have defective perfusion of the calf. In the second group with confirmed microangiopathic complications vibratory thresholds for right LL were 24,4 ± 15,9 V, for left LL 24,8 ± 15,3,V, ABI for right LL 1,2 ± 0,2, for left LL 1,1 ± 0,3, 4x mediocalcinosis, rest Laser Doppler 8,7 ± 5,9 PU, after provocation 90,3 ± 41,3 PU, time for achieving maximum value 2,4 ± 0,7 min. (P = 0,9), rate 46,2 ± 29,9 PU/min (P = 0,1). Scintigraphy revealed:1 defect in the region of the calves, 3 patients with perfusion defects of the thighs and one patient with borderline rates for a perfusion defect of the thighs. Conclusion: Patients with confirmed microvascular complications manifested a lower rest perfusion of the periphery, a longer period for attaining the maximum value when examined by Laser Doppler, and these findings were correlated with proximal defects of thigh perfusion in scintigrams. The defective perfusion of calves after exercise may be a manifestation of silent macrovascular disease. Both methods appear to be adequate for more detailed noninvasive diagnostic procedures concerning vascular disease of the LL in patients with diabetes.



2445 Approach to neuropathic and neuroischaemic foot ulcers in diabetic patients using linearly polarised light therapy: preliminary report. F. Coce1, M. Korsic2, M. Martinac2; 1Vuk Vrhovac University Clinic, Zagreb, Croatia, 2Merkur Clinical Hospital, Zagreb, Croatia. Background and Aims: The aim of this prospective clinical study was to investigate the role of polarised light therapy in the treatment of neuropathic and neuroischaemic foot ulcers in diabetic patients. Materials and Methods: The study included 13 patients with non-insulin dependent diabetes and neuropathic or neuroischaemic foot ulcers. Median of patients� age was 54 years and diabetes duration 14 years. Ulcer classification was based on the classification by Armstrong and associates. Superficial ulcer without infection and ischaemia was present in one patient (7.7%), deep ulcer with infection in 69.2% and 23.1% of patients had deep ulcer with foot ischaemia. Mean ulcer duration prior to inclusion into the study was 5 months. Foot ischaemia was present in 23.0% of patients with mean ankle brachial index value of 0.46. Dycks Neuropathy Symptom Score and Neuropathy Impairment Score were used in the assessment of the degree of polyneuropathic impairment. 69.2% of patients had polyneuropathy of the 2nd degree, and 30.8% that of the 3rd degree. Ulcer infections were present in 69.2% of patients. All patients were followed at the Surgical Out-patient Unit of the Merkur Clinical Hospital. In addition to standard foot ulcer therapy (intensified insulin therapy, foot weight-bearing, local foot care, antiobiotic treatment), polarised light therapy was applied in all patients. Technical characteristics of the linearly polarised light source (BIOPTRON PRO, Mőchaltorf, Switzerland) were: wavelength 480-3400 nm; degree of polarisation >95%; power density 40 mW/cm2; light energy 2.4 J cm2/min. Polarised light therapy was performed for 8 min daily at a distance of 10 cm. Phototherapy was stopped when the ulcer had completely healed. Results: The average time to neuropathic ulcer closure was 6.6. weeks (range: 3.1-12.8 weeks). The average healing time of deep neuropathic ulcers affecting tendons or joint capsule was 5.8 weeks (range: 4.1-8.4 weeks), and 9.5 weeks (range: 7.8-12.8 weeks) in case of ulcers affecting joint or bone. Mean healing time of deep neuroischaemic foot ulcers affecting bone or joint was 7.4 weeks (range: 6.4-8.5 weeks). Conclusion: Although benefits of phototherapy in ulcer healing are still a matter of controversy, polarised light therapy, due to its various biological effects (stimulation of cell proliferation, release of growth factors, stimulation of collagen synthesis, faster epithelisation), might as a supportive therapy be useful for faster ulcer healing. Preliminary results of our study which began in October 2002 showed that polarised light irradiation resulted in shorter ulcer healing time. It may be hypothesized that healing time of ulcers would be even shorter provided that polarised light irradiation was applied several times a day. This will be examined when a control group of subjects has been included in the study.



2446 A simplified protocol to screen for distal polyneuropathy in Type 2 diabetic patients. L. A. Costa1, J. Maraschin1, J. H. X. Castro2, J. L. Gross1, R. Friedman1; 1Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, 2Neurology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. Background and Aims: The best strategy to prevent foot ulceration and to reduce lower limb amputations is to correctly diagnose and grade distal polyneuropathy (DPN) as early as possible. The diagnosis of DPN involves the detection of symptoms and signs of neurological dysfunction.The aim of this study was to analyse the diagnostic performance of a simplified protocol to screen for DPN in patients with type 2 diabetes (DM2). Methods: Eighty DM2 outpatients and 45 controls were evaluated by a motor and sensory symptom questionnaire, pin-prick, tuning fork, monofilament, ankle jerk, cold spatula, ability to walk on heels, cardiovascular autonomic tests and electroneurophysiological (EMG) study. Symptoms and motor signs were grouped in scores and analysed as a battery. DPN was diagnosed if an abnormal EMG study or autonomic neuropathy plus one symptom or one abnormal sensitive or motor finding was present. Results: Sixty patients were diagnosed with DPN. They were older, with longer duration of diabetes and a higher frequency of hypertension. Symptoms did not predict DPN, but inability to walk on heels or the presence of 3 abnormal tests (pin-prick, tuning fork, monofilament, ankle jerk, cold spatula) identified 27 of the patients with DPN (sensitivity 45%, specificity 100%) without the need of EMG study. In the other cases of DPN EMG was necessary. Conclusions: The presence of DPN was established when there was inability to walk on heels or 3 abnormal of the following tests: pin-prick, tuning fork, monofilament, ankle jerk or cold spatula. Patients who do not fulfil these criteria, but still have clinical suspicion should undergo EMG study.



2447 The comparison between pulse wave velocity and ankle-brachial index of diagnosis for diabetic foot. T. Nakanishi, H. Kobayashi, K. Nakagawa, N. Maekawa, R. Kamo, M. Ishii; Dermatology, Osaka City University Medical School, Osaka, Japan. Background and Aims: The dynamic evaluation of the major circulating status needs long time and complicate steps with usual method such as MRA (Magnetic resonance angiography), DSA (Degital subtraction angiography) or angiography. The contrast medium cannot be used for the patients with renal failure. Simple and non-invasive method or device is required to inspect the uncertain vascular status. ABI(ankle brachial index) is one of the conventional and traditional method of the evaluation for diabetic foot. However, in some cases with severe arteriosclerosis oblitrans, ABI is not able to detect. On the other hand, PWV(pulse wave velocity) show the stiffness of vascular system and reflect the status of arteriosclerosis. We compare with PWV and ABI as the suitable and reliable diagnostic method for the circulating status of the diabetic gangrene or skin ulcer. Material and Methods: The subjects for the study are diabetic patients consisting of 59 males and 30 females. The mean age of male patients is 62.5 years old (range 33-90), and the mean age in female is 65 years old (range 45-83). The subjects are divided three groups of the non-ulcerative, the ulcerative or bullous and the gangrene. The subject number of each group are 50 (28 males, 22 females), 27 (33 males, 4 females) and 12 (8 males, 4 females), respectively. The instrument. PWV and ABI were measured using the automatic detector of PWV and ABI ( VP-1000, COLIN CORPORATION, AICHI, JAPAN). Substitial analysis. The statistical significance among three groups is tested using one way-ANOVA, Kruskal-Wallis, Tukey and Sceffe method. Adjustment for sex and age PWV is shown as variation from the mean level of each sex and age. Results: 1. Concerning the right side ABI and both side PWV, the statistical significance among three groups of the non-ulcerative, the ulcerative or bullous, and the gangrene is recognized with one way ANOVA and Kruskal-Wallis method. 2. The gangrene group shows the statistical significance as follows; (1) The right side ABI shows in the lower level than the non-ulcerative group. (2) The right side PWV shows in the higher level than the non-ulcerative group and the ulcerative or bullous group. (3) The left side PWV shows in the higher level than the non-ulcerative group. 3. Eighty percent of the sample shows high PWV value exceeding over 1400 cm/s without distinction of the existence of foot disorder. 4. ABI is not obtained in case of severe arteriosclerosis obliterans. Conclusion: 1. In general, the detection is difficult in case of below 0.5 ABI. 2. Extremely high PWV is obtained for calcification of artery as far as no foot symptom. Such cases usually show high score of ABI because of the calcified artery which are recognizedthe calcified artery in the roentgenograph. 3. No significant statisitical difference was obtained on the left ABI in this study. 4. P value of PWV shows lower than that of ABI. 5.The detectable range of PWV is larger than that of ABI. These results suggest that the measurement of PWV is essential for the evaluation of the status of diabetic foot. Of course, the population variance of each group is relatively large in the study. Further case accumulation is important to improve the statistical accuracy.



2448 The potenial role of GlcNAc-T (UDP-Glc:Gal(Beta)1-3GalNAc(alpha)R(beta)-N-acetylglucoaminyltransferase [Core 2 Transferase] in diabetic peripheral neuropathy. M. C. Spruce1, B. M. Ben-Mahmud2, D. V. Coppini3, R. Chibber2; 1Postgraduate Department, University of Southampton, Southampton, United Kingdom, 2Cardiovascular and Endocrinology, Guy's Hospital, London, United Kingdom, 3Centre of Diabetes, Poole Hospital NHS Trust, Poole, United Kingdom. Background: Occlusion of the vasa nervosum has been implicated in the pathogenesis of diabetic peripheral polyneuropathy. Core 2 Transferase, a glycosylating enzyme responsible for the up-regulation of surface O-glycans, has been shown to effect increased leukocyte-vascular endothelial adhesion, expediting capillary occlusion. Whilst the PKC pathway may modulate the levels of Core 2 Transferase, its effective mediation by either hyperglycaemia or oxidative stress may be disrupted within diabetic individuals. Aim: To investigate whether levels of Core 2 Transferase are heightened in individuals with diabetic peripheral polyneuropathy (n=8), against a background of diabetic individuals without complications (n=4) and a control group (n=3). Method: Blood samples were drawn from age matched participants and the polymorphonuclear leukocytes isolated. The Core 2 Transferase activity in polymorphonuclear leukocytes was determined by laboratory analysis. In parallel, the HbA1c levels for each participant were measured and compared accordingly. Results: The diabetic neuropathic group showed significantly higher mean concentrations of Core 2 Transferase, in comparison to the aged matched control group (1003.860 ± SD 136.67 vs. 130.450 ± SD 28.34, P<0.05) - an eightfold difference. There was also a significant difference in enzyme activity between the diabetic neuropathic group and the diabetic group without complications (1003.860 ± SD 136.67 vs. 633.18 ± SD 89.10, P<0.05). Alternatively, no correlation was found between Core 2 Transferase levels and HbA1c values. Conclusions: Core 2 Transferase activity is increased in diabetic individuals and further raised in those with diabetic peripheral neuropathy. The stasis of polymorphonuclear leukocytes within the vasa nervosum and resultant hypoxic environment favours reactive oxygen species leading to the rapid coupling of superoxide and nitric oxide, potentuating the radical perioxynitrite, an extremely potent oxidant. A reduction in oxygen tension will also stimulate the release growth factors causing a potential increase in both nitric oxide levels and intercellular adhesion molecules.



2449 Serum Interleukin-1 alpha, but not Tumor Necrosis Factor-alpha or Interleukin-6 is raised in diabetic foot infections. I. Mantey1, J. Ochola2, M. E. Edmonds1, D. M. Kemeny2; 1Diabetes Centre, King´s College Hospital, London, United Kingdom, 2Immunology Department, King´s College Hospital, London, United Kingdom. Background and Aims: There is increased morbidity and long term cardiovascular mortality in patients with diabetic foot infections. The immune response in diabetic foot infection is poorly described and the cytokine response has not been investigated. Materials and Methods: We studied 52 diabetic patients with infected foot ulcerations (mean age 60 (± 12) years, 13 females 39 males, 11 with Insulin Dependent Diabetes Mellitus (IDDM), mean diabetes duration 18 (± 13) years) and compared them with 27 diabetic control patients, (mean age 63 (± 13) years , 9 females 18 males, 5 with IDDM, mean , Interleukin-6)diabetes duration 18 (± 11) years. Serum Interleukin-1α (IL-1α) (IL-6) and Tumour Necrosis Factor- alpha (TNF-α) were measured using a two site sandwich ELISA. Results: In the infected group, 12/52 patients had an IL-1α level of greater than 50 ng/ml, compared with 0/27 in the control group (p< 0.01, chi-squared test). IL-6 was detected in only 5 of the infected patients compared with one of the control patients (ns). Similarly, TNF-α was detected in only 3 patients in the infected group compared with one of the control patients (ns). Conclusion: This report shows that IL-1 α, but not IL-6 or TNF-α was increased in diabetic patients with foot infections compared with diabetic controls. These data suggest the involvement of cells of the monocyte/macrophage lineage in the pathogenesis of diabetic foot disease.



2450 Is the distribution of arterial disease in the diabetic limb different in Type 2 compared with Type 1 diabetes? I. Bommayya1, N. Petrova1, A. V. M. Foster1, P. Sinha2, M. Hemady2, H. Walters3, R. Edmondson3, H. Rashid3, M. Edmonds1; 1Diabetic Foot Department, King's College Hospital, London, United Kingdom, 2Department of Radiology, King's College Hospital, London, United Kingdom, 3Department of Vascular Surgery, King's College Hospital, London, United Kingdom. Background and Aims: The distal distribution of arterial disease in diabetes is well established but the cause is unknown. Is it related to the type of diabetes (Type 1 or Type 2) or is it common to both? The aim of this study was to compare the pattern of arterial disease in the lower limb between Type 1and Type 2 diabetic patients who presented with foot ulcer and/or gangrene. Materials and Methods: Thirty six limbs belonging each to Type 1 and Type 2 patients underwent transfemoral angiography with digital subtraction. The patients were sex matched and included 24 males and 12 females in each group. The arterial tree of the lower limb was divided into the following segments : iliac, common femoral, deep femoral, proximal superficial femoral, distal superficial femoral, popliteal and distal (tibial and peroneal).A score was given to each segment as follows : 0 � no disease ; 1 � less than 50 percent stenosis ; 2 � greater than 50 percent stenosis but not occlusion ; 3 � occlusion of the vessel. Results: The mean age of Type 1 patients was 66.3 ± 12.6 (mean ± SD) years and that of Type 2 patients was 73.7 ± 15.1 years, p<0.05 (t-test). The mean score in each arterial segment were as follows: iliac 0.36 (range 0-3) in Type 1 vs 0.14 (range 0-2) in Type 2, p = ns (Mann�Whitney test) ; common femoral 0.28 (0-3) vs 0.03 (0-1), p = 0.045 ; deep femoral 0.11 (0-1) vs 0, p = 0.041; proximal superficial femoral 0.64 (0-3) vs 0.5 (0-2), p = ns ; distal superficial femoral 0.97 (0-3) vs 1.12 (0-3), p = ns ; popliteal 1.08 (0-2) vs 1.11 (0-3), p = ns ; distal 1.53 (0-3) vs 1.61 (0-3), p = ns. Conclusion: Thus in Type 1 diabetes there was greater arterial disease in the common femoral and deep femoral segments but there was no difference between Type 2 and Type 1 diabetes in all other segments including the distal arteries. We conclude that the distal predilection of arterial disease below knee in diabetes is not related to its type.



2451 Widespread arterial inflammation in diabetic foot gangrene. X. Y. Ma, D. Q. Jing, J. S. Hu, H. Bai; Dept. of Endocrinology, Beijing 304 Hospital of PLA, Beijing, China. Background and Aims: To investigate the main risk factors which accelerated the changes from ischemic atherosclerotic (AS)angiopathy into gangrene in patients with DM foot problem. Materials and Methods: A cross-sectional study was used in 100 inpatients with diabetic foot problems in recent 12 years in our hospital. According to the complains and examinations, the cases were divided into 3 groups: Group A:29 patients with painful and cool feet. Group B: 17 patients with intermittent claudication. Group C: 54 patients with dry or/and moist gangrene feet. Those clinical data were analysed and compared. Results: In 3 groups there were no significant differences in age, sex, DMcourse, BP, HbA1c, FBG, TC, and TG, only the LDL levers in B and C groups were significant higher than that in A group(A:3.2±0.6,B:3.8±1.3,C:3.8±1.4mmol/l p<0.05).Dopple UW examinations showed that the culprit stenosis mainly was in proximal femoral arteria in B group, but in C group, although all the arteria in lower limbs showed AS lesions,but the culprit stenosis and close were in distal dorsal/politeal arteria, the C reactive protein(CRP),fibrinogen(Fib)and white blood cell (WBC)counts were significantely increased when compared with other 2 group(see table) ,at same times postprandial blood glucose(PBG) lever also rose significantly in C group although the HbA1cs were similar in 3 groups. Inflammationfactors A Group B Group C Group Fibrinogen(mmol/l) 2.4±0.7 2.8±0.6 3.4±0.9*∆CRP(mg/l) 3.1±4.8 2.0±1.4 7.1±3.2**∆WBC count(109/l) 7.1±3.2 7.2±3.9 9.3±3.8∆ **: C group compared with B group p/ 0.05, **: C group compared with B group P/ 0.01. ∆:C group compared with A group :P/ 0.01 The patients in C group had 6 fold high mortality from cardiocerebral vascular end-evends,20 fold high amputation rate and 1.5 fold more strock,2 fold of CHD and DM microvascular-complications in comparing with A、B groups. Conclusion: Widespread arterial inflammation in lower limbs of diabetic patients with foot problems accelerated feet gangrene. The high levers of LDL and PBG were risk factors for vascular AS progress.



2452 Diabetes foot complications – current management and proposals for improvement. P. R. Wraight1, S. M. Lawrence1, D. A. Campbell2, P. G. Colman1; 1Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Australia, 2Department of Clinical Epidemiology and Health Evaluation Unit, The Royal Melbourne Hospital, Melbourne, Australia. Background and Aims: Diabetes related foot complications are the leading cause of non traumatic lower limb amputations and the commonest reason for individuals with diabetes to be admitted to hospital. The impact of this complication is unlikely to improve in the foreseeable future, considering the increasing incidence of diabetes, an aging population, growing rates of childhood obesity and type 2 diabetes and the disappointing rates of adoption of primary prevention programs throughout the world. The Royal Melbourne Hospital undertook a clinical audit of the clinical management of individuals admitted with diabetes related foot complications. Materials and Methods: A 2 month prospective audit, 1/4/02 to 31/5/02, was undertaken by using a computer generated report to identify all new admissions. The in-patient records of all new admissions were manually examined to identify those admitted with diabetes related foot complications. If the documentation was inadequate then the feet of the identified individual were physically inspected. Information on individual patient assessment, investigation, management and clinical outcomes was collected. Results: There were 34 admissions for 32 individuals (79% male, 21% female). This corresponded to a 3 fold greater identification rate for admissions than was found in a previous retrospective audit. Average age was 68 years and mean diabetes duration 11.5 years. Patients were admitted under 10 different medical/surgical units. Peripheral pulses were examined in 61% and peripheral neurological examination performed in only 25%. The documentation of site, size, depth and general ulcer appearance was so poor that useful data could not be collected. Inter-departmental referral rates varied according to the admitting unit but ranged from an average of 2 to 5 referrals per patient. Of the 34 admissions, 5% underwent excision of infected bone, 25% had revascularisation and 55% received intravenous antibiotics. The average length of stay was 11 days with total bed occupancy of 2220 days/year. Seven percent of patients underwent minor amputations, 10% major amputations, the mortality rate was 10% and 19% required inpatient rehabilitation. Conclusion: In response to the highly variable clinical assessments, investigations and management plans in our institution we have established a multidisciplinary team and developed an evidenced based clinical guideline, with a novel diabetes specific wound classification system. It is hoped that these changes will lead to improvements in the clinical outcomes of patients with diabetes and acute foot complications. A post implementation audit is currently in progress.



2453 Clinical assessment hydropolymeric dressing on diabetic foot ulcers. J. L. Lázaro Martinez, G. Rivera San Martin, L. Ramos Blanco, L. Fernández Carmena, C. Gamella Pizarro, J. Sánchez Martos; Unidad Pie Diabético, Universidad Complutense de Madrid, Madrid, Spain. Introduction: Foams are among the most common dressing products used in management of diabetic foot ulcers. This circunstance will be required to investigate the efectiveness on diabetic foot lesions. Objective: To use an open prospective study to assess the behaviour and efficacy over 12 weeks of treatment of the new hydropolymeric dressings in the treatment of ulcers of the diabetic foot with moderate to high exudate, requiring a longer period of permanence in situ of the dressing. Materials and Methods: 23 patients (20 men and 3 women) with diabetes mellitus of which 13 (56,5%) were type 1 and 10 (43,5%) were type 2. The subjects had foot ulcers of wich 19 (82,6%) were Wagner 1 and 4 (17,4%) were Wagner 2 of 9,4 + 7 months ago. The ulcers were treated with polimeric foam dressings. All patients were evaluated for vascular and neuropatic status. They were 60,6 + 12,7 years old. Ulcer offloading performed in all cases. The wound bed were granulated at the treatment beginning.The surface area of each ulcer was measured by a gauge. The results introduced in SPSS 10.0. Results: 14 (58,3%) patients healed after 12 weeks. The mean of healed time were 39,5 + 22,3 days and the number of dressings were 9,6 + 6,6, which were changed each 4,7 + 2,0 days. 8 (33,3%) patients finished 12 weeks of study without healing, but the ulcer size reduced to 79,4 + 19,6% of baseline. Severity index reduced to 68,1 + 23,6%. This group ulcers progresses to Wagner 1. The results demostrated on digital pictures. Conclusions: All ulcers progress well after treatment. The maceration and hiperqueratosis of surroanding skin reduced significantlly. The use of foam dressings reduce the treatment costs because they reduce the treatment time and changing of dressings. Patients not healed after 12 weeks had worst ulcers and a poor vascular and neurological status. Physicians opinion were good (95,7%) and excelent (4,3%). Patients thought the treatment was excelent (34,8%) and good (65,2%).



2454 Microbiology and antibiotic treatment in the diabetic foot. A. Kowalska, M. Kasprowicz, J. Domienik, M. Jasik, W. Karnafel; Gastroenterology and Metabolic Diseases, University School of Medicine, Warsaw, Poland. Background and Aims: Among chronic complications the foot pathology in diabetic patients constitute a major medical problem. The aim of this study was to assess the microbiology of foot ulcer infections and use of antibiotics. Material and Methods: Forty type 1 diabetic with diabetic foot, hospitalized in the Department of Gastroenterology and Metabolic Diseases The Medical University of Warsaw in years: 1996-2001 were analyzed in the study: age (mean 55,8 years, known duration of diabetes 13,7±9,9 years, body mass index (BMI): 30,6 kg/m2). Material and Methods: The analysis was performed in 40 patients with type 2 diabetes (13 women, 27 men; middle age: 55,8; middle duration of diabetes 13,7+/-9,85; middle BMI 30,56 kg/m2). The subject of the analysis was: the microbiology of foot ulcer infections, antibiotics use, assessment of body mass, the values of blood pressure and the extent of metabolic control of diabetes, the occurrence of diabetic late complications, duration of hospitalization. Results: Staphylococcus aureus, Proteus mirabilis and Streptococcus sp., being the most frequent pathogen in diabetic foot. In majority cases were observed coincidental infections of few germs. The analysis of antibiotics' guidelines has shown that the most significant role in diabetic foot pharmacotherapy play B-lactams (62,5%), chinolons (27,5%), linkosamids, aminoglicosids, metronidazole and multiantibiotics connections. In the case of 50% patients occurred retinopathy, 25%-nephropathy, 70%-high blood pressure, 57,5%-ischaemic disease, 27,5%- myocardial infarction. 62,5% of patients have shown bad metabolic control of diabetes in last 4 months. In majority diabetic patients have revealed the occurrence of obesity. In the research group have observed the 45% longer time of hospitalization in comparison to patients without coexisting diabetic foot. Conclusions: Staphylococcus aureus is the most frequent pathogen in diabetic foot. Diabetic foot ulceration should be treated with broad-spectrum antibiotics. Diabetic foot ulceration coexists with other late complications of diabetes and obesity.



2455 Favourable outcome of serum creatinine in patients with diabetic foot infections treated aggressively with intravenous antibiotics. M. E. Edmonds, E. Hui; Diabetic Foot Clinic, King's College Hospital, London, United Kingdom. Background and Aims: Diabetic foot sepsis can result in impaired renal function. The aim of this study was to assess the outcome in serum creatinine in patients with foot infection which was treated intensively with intravenous antibiotics. Materials and Methods: We studied 106 patients who presented with foot infection. Creatinine levels were assessed on admission and monitored throughout the treatment. Patients were divided into two groups according to serum creatinine on admission: group 1 (n = 40) with high creatinine (> 120 micromols per litre) and group 2 (n = 66) with creatinine in normal range. Results: A favourable outcome in serum creatinine was observed in 93% of the patients. In group 1, 27 patients showed a fall in creatinine (160± 41 to 119 ± 35 micromols per litre, p < 0.001), and in 9 patients (with pre-existing renal impairment) the creatinine remained stable (215 ± 83 to 220 ± 80 micromols per litre, p > 0.05). Four patients only showed a rise in creatinine (172 ± 22 to 514 ± 201 micromols per litre) due to contrast nephropathy (2), septicaemia (1) and post-operative cardiac arrest (1). In group 2, 63/66 patients maintained a creatinine within normal range and only 3 patients showed a rise in creatinine (103 ± 4 to 170 ± 44 micromols per litre) due to nephrotic syndrome (1), dehydration secondary to vomiting (1), and contrast nephropathy (1). Thus, 7 patients only showed a rise in creatinine, and 6 of them responded to early intervention. Conclusion: Intensive management of foot infection results in a positive outcome in renal function.



2456 In the infected diabetic foot: relation between the severity of the lesion and the involved microbes. P. A. Makras, S. Koutmos, P. Angelis, T. Kounadi, A. Tsingou, N. Borboli, D. Bougiouklis, D. Papadogias, A. Stathopoulou, S. Tsirona, S. Bonovas, F. Katsaros, L. Zetou, K. Kossyvakis, T. Katsaros; Endocrinology and Diabetes Center, G.Gennimatas General Hospital of Athens, Athens, Greece. Background and Aims: The infections of the diabetic foot are common and may worsen rapidly 24-48 hours becoming limp-threatening or even life-threatening. Early therapeutic intervention is of paramount importance. The aims of this study were: the investigation of a possible prediction of the number and kind of the microbes involved; to investigate if the grade of the lesion should be taken into account; to help the selection of the best antibiotic treatment before the results of the cultures are obtained. Materials and Methods: From the lesions of 119 patients (75 males, 44 females, aged 43-80) with infected diabetic foot 325 microbes were isolated (2,8/patient). Grading of the lesion�s severity was accomplished according to the University of Texas classification. The clininical examination included the probe-to-bone test. Plain x-rays, doppler sonography and debridement of the lesions were also performed. Cultures were taken from the base of the lesions and the pus if present while blood cultures were also obtained. Results: Grade 1: Gram(+)=58(74%), Gram(-)=18(23%), Anaerobes=2(3%). Grade 2: Gram(+)=47(42%), Gram(-)=49(44%), Anaerobes=16(14%). Grade 3: Gram(+)=38(28%), Gram(-)=69(51%), Anaerobes=28(21%). Pearson Chi-squared(4df)=45,1, p-value<0.001. MRSA=30%, resistant to most antibiotics. Blood cultures were of no help, probably because of the previous use of antibiotics. Conclusion: In the infected diabetic foot, as the severity of the lesions increases the Gram(+) microbes tend to decrease and the Gram(-) and anaerobes tend to increase. In Grade 2&3 the empirical antibiotic treatment should cover Gram(+), Gram(-) and anaerobes. The resistance of MRSA to most antibiotics is alarming.



2457 Vancomycin therapeutic drug monitoring in patients with diabetic foot infection. F.-H. Liu1, M.-H. Lee1, S.-C. Niu2, C. Ho1, H.-Y. Chang1; 1Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan Republic of China, 2Pharmacy, Chang Gung Memorial Hospital, Linkou, Taiwan Republic of China. Background and Aims: Vancomycin remains the cornerstone of therapy for infection due to methicillin-resistant Staphylococcus aureus (MRSA). Most patients receiving vancomycin are monitored at the base of the limited and conflicting data; therefore, therapeutic drug monitoring (TDM) of vancomycin remains an area for debate. Also few data exist to correlate vancomycin serum levels with its efficacy or its presumed renal toxicity in diabetic patients. Thus, we aimed to investigate if the current practice of vancomycin TDM can apply to the patients with diabetic foot infection as well. Materials and Methods: We conducted a prospective study from January 2000 through December 2002. All the patients with diabetic foot infection due to MRSA in the Diabetic ward of Chang-Gung Memorial Hospital were enrolled to a protocol of TDM of vancomycin. Blood samples were taken for TDM after 4 doses of vancomycin therapy. Samples for trough levels were obtained just before the 5th dose was infused, and samples for peak serum levels were taken 2 h after the end of an infusion. The measured serum vancomycin levels, dosage, dose interval, and serum creatinine levels, along with patients' demographic information, were entered into a pharmacokinetic program. Results: A total 68 patients were enrolled in this study, including 22 cases in 2000, 21 in 2001 and 25 in 2002, respectively. In the first year, the dosage of vancomycin prescribed was based on the Mayo Clinic Center vancomycin dosing nomogram (Wilhelm et al, 1999) and we found the prescribed dosage led to a serum level tremendously higher than the recommended levels by the British National Formulary. We then adjusted the dosage of vancomycin by the age and renal function of each patient from the following year. Nevertheless, the dosage had to be adjusted again because the peak and trough levels were still higher than the recommended ones. We started a new modified therapeutic protocol according to the data collected in previous 2-year period. The new therapeutic dosage was lower than those used before, but the trough and peak levels were within the recommended range. 2000 2001 2002 Trough level (mg/L) 25.3±11.0 17.3±13.4 12.0±5.8Peak level (mg/L) 36.7±13.2 33.5±16.6 23.2±7.0Vancomycin dosage (mg/kg/day) 25.0±10.5 17.9±9.4 15.7±7.2 Using the Wilcoxon test, we compared the variables for those were receiving vancomycin within 3 different groups of the case patients. P < .05 was considered to be statistically significant. P < .05 was seen while comparing 2002 to 2000. Conclusion: The preliminary data of our new modified therapeutic protocol seemed satisfactory, and this new protocol could be practical and acceptable in diabetic patients in Taiwan. The dosage of vancomycin were lowered and with equal therapeutic efficacy. Thus, the cost-effectiveness for the reduced price of the medication will play a positive role to the public health care.



2458 The spectrum of healing of neuropathic foot ulcers. W. J. Jeffcoate, K. A. Treece, N. Pound, F. L. Game; Diabetes and Endocrinology, City Hospital, Nottingham, United Kingdom. Background and Aims: The rate of healing of neuropathic ulcers is generally modest - only 24.2% healed at 12 weeks and 30.9% at 20 weeks in one survey of management under trial conditions � even though dramatically better results have also been reported, with up to 89.5% healed by 12 weeks. Such variation may reflect aspects of management, but is also dependent on population selection. We have therefore examined the spectrum of healing time of neuropathic ulcers managed in a single specialist unit between 01/01/2000 and 01/07/2002 Materials and Methods: We have conducted a retrospective analysis of outcome in neuropathic ulcers using a comprehensive clinical database. Neuropathic ulcers were defined as those with loss of protective sensation (using Neurotips®), but with intact peripheral circulation (both foot pulses palpable). Results: A total of 125 uncomplicated neuropathic ulcers were referred. A further 27 with either cellulitis or osteomyelitis at referral were excluded from analysis. Ulcers were managed with regular sharp � but conservative � debridement, cleansing and dressing. Optimal off-loading acceptable to the patient was employed. All ulcers were reviewed on a regular (usually two to four weeks) basis. 114 (91.2%) healed; 1 limb was amputated, 10 ulcers were unhealed. There were no deaths. The rate of healing declined exponentially, with 57 (45.6%) healed by 3 months, and 92 (73.6%) by 6 months. Conclusion: A number of factors may contribute to the delayed healing in the remainder, but our data suggest that the management of ulcers which persist at 6 months should be critically reviewed.



2459 Prophylaxis of foot ulcer recurrences due to diabetes mellitus. A. Djuraeva, S. I. Ismailov; The Institute of Endocrinology of Uzbekistan, Tashkent, Uzbekistan. Purpose: To study effect of social factors on development and recurrence of diabetic foot ulcer. Materials and methods: Investigation was performed on 35 patients with diabetes mellitus having foot ulcer or amputation in the history of disease. The average age of patients was 62 years, one patient had diabetes mellitus, type 1, 34 patients � with diabetes mellitus, type 2, 18 patients were male and 17- female. In 10 patients (28,6%) there was no recurrences of foot ulcer. In twenty five patients (71,4%) there was found recurrence of foot ulcer in the same or in the contralateral extremity. Investigation was used questionnaire of S.Bradley for satisfaction of treatment assessment in diabetes mellitus. Results: The mean level of glycolized hemoglobin Hb A1c in patients without recurrences of foot ulcer was 8,7%+-0,8, and in patients with recurrences of foot ulcer was 10,1+-0,6%. In 6 patients 917,1%) the family did not take part in the treatment. In 12 patients (31,3%) supporting by family was moderate and in 17 patients (48,6%) there was noted active family participation in the treatment. 22 patients (62,9%) evaluated their social status was moderate level, 5 patients (14,3%) as low level and 8(22,6%) as high level. 19 patients 954,3%) had secondary special education, 17 (48,6%) had higher education. One patient had special shoes, 4(11,4%) patients moved on invalid carriage, 14 patients (40%) had ordinary shoes, 16(45,7%) had slippers. Of 35 patients 12 ones (34,3%) had knowledge about self-control and knew about main requirements for nursing of feet in diabetes mellitus and evaluated their knowledge about diabetes mellitus by scale > or = 3 balls. Twenty three patients (65,7%) were not informed about possible complications and evaluated their knowledge as , or = 3 balls. Conclusion: 1.The level of compensation was higher among patients without recurrences of foot ulcer. 2. The patients having foot ulcer or amputations of lower extremities had more social-psychological problems lowering life quality.



2460 Effect of several exercise regimen on plantar peak pressures in diabetic patients with peripheral neuropathy. F. Fallucca, A. Federici, G. Federici, U. Di Mario, S. Balducci; Department of Clinical Sciences, Università "La Sapienza", Roma, Italy. Background and Aims: Exercise is important in the management of diabetes. Diabetic complications of peripheral neuropathy (PN) and peripheral arterial disease (PAD) may compromise deambulation strategy and may induce abnormal foot pressures. These alterations could facilitate foot injuries and foot ulceration. Our aim was to evaluate the effect of several exercise regimen on plantar pressures in diabetic patients complicated from PN (electro diagnostically confirmed ) without either PAD or ulcer history. Materials and Methods: A prescript and supervised study of 11 (6 M, 5 F) diabetic patients with PN have been evaluated compared with 11 (6 M, 5 F) healthy volunteers. The subjects performed three different supervised exercises session on three different day: 1- Weight-bearing exercise (brisker walking program on treadmill); 2- Weight-bearing exercise without fly phase of gait ( agonist-antagonist muscle program on Cross Trainer); 3- Not Weight-bearing exercise (Cycle Recline ). A piezo-dynamometric platform was used to record peak plantar pressures at the beginning during and after 30 min at rest . Results: Peak plantar pressure in basal condition was significantly higher in PN than in control subjects (1.007±103 vs. 0.799±82 gr/cm2 p< 0.01). Only during and after brisker walking program on treadmill the peak plantar pressures increased significantly on PN 1 - (1.007±103 - 1.158±52 gr/cm2

p< 0.01; 1.007±103 - 1.280±102 gr/cm2 p< 0.05); 2- (1.036±98 - 1.047±52 gr/cm2 NS; 1.036±98 - 1.068±22 gr/cm2 NS); 3 - (0.985±68 - 0.992±32 gr/cm2 NS; 0.985±68 - 0.997±22 gr/cm2 NS). Conclusion: These results suggest that walking exercise program increase peak plantar pressures during and after exercise, in addition indicated that it may be possible to reduce peak plantar pressures using different type of exercise.



2461 Evaluation of transcutaneous oxygen tension measurement for predicting the wound healing after amputation in patients with osteomyelitis in diabetic foot. R. Bem1, B. Sixta2, A. Jirkovska1, P. Herdegen2, V. Fejfarova1; 1Centrum of Diabetology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic, 2Department of Surgery, Thomayer College Hospital of Charles University, Prague, Czech Republic. Background and Aims: Surgical bone resection and amputation are possibly approaches to treatment of osteomyelitis in diabetic foot. Aim of the study was to assess usefulness of transcutaneous oxygen tension measurement to predict the healing after amputation in patients with osteomyelitis in diabetic foot. Materials and Methods: We evaluated 86 patients (mean age 66±10.30 years, 86% Type 2 diabetes, 66% male) treated in our foot clinic and indicated for amputation due to osteomyelitis during the period 4/2000- 7/2002. Osteomyelitis was detected by x-ray. Measurement of transcutaneous oxygen tension on the dorsum of the forefoot before amputation was used for the assessment of ischaemia. Criterion for successful healing was healed wound under the metatarsal level; unsuccesseful healing was assessed as healed wound above the ankle or non-healed wound. The healing was evaluated after 6 months since primary amputation. Results: Successful healing was seen in 64/86 (74.4%) of patients and unsuccessful healing in 22/86 (25.6%) of patients- 10 (11.6%) healed above the ankle and 12 (14.0%) with non-healed wound during the study period. The mean healing time of all healed patients was 11.49±3.62 weeks. The transcutaneous oxygen tension before amputation was significantly higher in the group of successfully healed patients in comparison with the group of unsuccessfully healed patients (39.02±8.71 vs. 11.45±6.61mmHg; p<0.001). Conclusion: The results of our study support the premise that measurement of transcutaneous oxygen tension is helpful in predicting the prognosis after amputation in patients with osteomyelitis in diabetic foot.

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