Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : PC01 - PC06 Full Version

Clinical Grading of Diabetic Foot Ulcer Infection and its Predictors among Type 2 Diabetes Mellitus Patients: A Cross-sectional Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56302.16333
Jiwesh Kumar Thakur, Saroj Kumar, Sasthi Narayan Chakraborty, Rakesh Kumar, Debasis Basu, Pinki Kumari, Deval Parekh, Sudip Ghosh

1. Associate Professor, Department of General Surgery, IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, India. 2. Assistant Professor, Department of General Surgery, IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, India. 3. Associate Professor, Department of Community Medicine, Santiniketan Medical College, Bolpur, West Bengal, India. 4. Professor and Head, Department of Community Medicine, IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, India. 5. President, Diabetes Awareness and You (DAY), Kolkata, West Bengal, India. 6. Associate Professor, Department of Microbiology, Phulo Jhano Medical College, Dumka, Jharkhand, India. 7. Specialist Pathologist, Department of Pathology, Central Hospital, Eastern Coalfield Limited, Asansol, West Bengal, India. 8. Statistician cum Assistant Professor, Department of Community Medicine, IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, I

Correspondence Address :
Dr. Rakesh Kumar,
Flat-F, 2nd Floor, MC-6, IQ City Campus, Durgapur, West Bengal, India.
E-mail: dr.rakeshkr082@gmail.com

Abstract

Introduction: Globally, about 425 million people are living with diabetes mellitus. Diabetic Foot Ulcers (DFU) are one of the severe complications of poorly controlled diabetes and over the time, about 50% of DFUs become infected which may require hospitalization.

Aim: To find out the DFU infection severity pattern and its predictors among T2DM patients.

Materials and Methods: This cross-sectional study was conducted at Integrated Diabetes and Gestational Diabetes Clinic (IDGDC), IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, India, among Type 2 Diabetes Mellitus (T2DM) patients from June 2018 to November 2018. Total 1534 T2DM patients attended IDGDC during data collection period of 4 months and 132 of them had diabetic foot ulcer. After taking written informed consent, detailed data were collected from 132 of study participants using pre-designed, semi structured and pre tested schedule developed with the help of Infectious Disease Society of America (IDSA) and International Working Group on the Diabetic Foot (IWGDF/IDSA) classification system. Socio-demographic characteristic like age, sex, education, residence were recorded along with clinical data like glycated haemoglobin (HbA1c), duration of diabetes, treatment modalities Anthropometric measurements were taken as per World Health Organization (WHO) guidelines. T2DM was defined and classified as per American Diabetes Association (ADA) Guidelines. DFU infection severity was classified into uninfected, mild infection, moderate infection and severe infection as per IWGDF/IDSA guidelines. Chi-square test was used to show association between categorical variable. One-way Analysis of Variance (ANOVA) with Tukey's post-hoc test was used to show association between mean HbA1c level and DFU infection severity. The p-value ≤0.5 was considered significant.

Results: Proportion of DFU was found to be 8.6%. As per the IWGDF/IDSA classification of DFU infection severity was found to be moderate in 59 (44.7%) of the study participants and mild in 32 (24.2%) of the study participants. 22 (16.7%) of study subjects had severe infection and required hospitalization for optimal care. Only 14.4% of study subjects did not have DFU infection. Increasing age (p-value=0.023), rural residence (p-value=0.015), poor education (p-value=0.001), obesity (p-value=0.001), central obesity (p-value=0.001), longer duration of diabetes (p-value=0.028), and poor glycemic control (p-value=0.001) was found to be significant risk factors for severe infection in DFU.

Conclusion: Routine clinical assessment of DFU infection may help in making clinical decision of treatment modalities and help in saving lower limb as well as life of people with T2DM.

Keywords

Foot infection, Diabetic foot infection, Diabetic foot ulcer, Foot amputation

Diabetes Mellitus (DM) is a chronic metabolic disorder resulting from either insulin resistance and/or relative or absolute insulin deficiency (1). Globally, About 425 million people are living with diabetes mellitus. India is home of about 72.9 million diabetes mellitus patients and popularly known as “world diabetes capital” (2). DM itself is associated with high mortality and morbidity, the poorly controlled DM further increases the chronic complications of diabetes (3),(4),(5). Diabetic Foot Ulcer (DFU) is one such common and important complication of poorly controlled diabetes mellitus which affects about 7-24% of People with Diabetes (PwD) (6),(7). Diabetic foot ulcers are one of the severe complications of poorly controlled diabetes and are now one of the frequent causes for diabetes related hospitalization (8),(9).(10). Causes of DFU are multifactorial and important risk factors include foot deformity, peripheral neuropathy, peripheral arterial disease, high planter pressure, poor glycemic control, male gender, infection and long duration of diabetes (11).

Over the time, about 50% of DFUs become infected which may require hospitalization (12). The severity of DFUs infection ranges from mild to limb threatening and sometimes even life threatening. Most of the lower limb amputations even in developed countries are due to diabetes related complications and infection plays as precipitating factor in about 90% of these amputations (12),(13),(14). Although, DFU is a serious complication, a multidisciplinary team approach can reduce incidence of DFU by 50% and lower limb amputations by 85% (15),(16). Optimal treatment of DFU infection requires thorough evaluation of ulcer, appropriate antimicrobial therapy.

Sometimes, DFU infection may require surgical intervention in Outpatient Department and even hospitalization in case of severe infection. Identifying the severity of infection is one of the important decision making factor for clinicians, it helps them in deciding the mode and urgency of treatment required (17). Various guidelines are in place for the classification of DFU (18),(19),(20),(21),(22),(23),(24) and few guidelines are also there for the assessment of severity of DFU infection (25),(26). Despite having different guidelines to assess the severity of DFU infection only two classification systems helps in clinical decision making (27). One such DFU infection severity classification system based on the clinical signs and symptoms were published by the Infectious Disease Society of America (IDSA) (17) and International Working Group on the Diabetic Foot (IWGDF) (28). IWGDF/IDSA classification system was originally developed as part of the PEDIS (perfusion, extent, depth, infection and sensation) and it consists of four grades of severity of DFU infections (28).

Although there are numerous studies on the microbiological growth pattern of DFUs (29),(30),(31), the study on the severity of DFU is very few in India (32). Keeping in mind the importance of the grading of wound infection severity in the management of DFU, this study was conducted with an aim to find out the DFU infection severity pattern and its predictors at a chronic care model based diabetes clinic at a tertiary health care facility of Eastern India.

Material and Methods

This cross-sectional study was conducted among Type 2 Diabetes Mellitus (T2DM) patients at Integrated Diabetes and Gestational Diabetes Clinic (IDGDC), IQ City Medical College and Multispecialty Hospital, Durgapur, West Bengal, India, from June 2018 to November 2018. The ethical clearance was obtained from Institutional Ethics Committee (IEC) of IQ City Medical College and Multispecialty Hospital {Ref. No.IQMC/IEC/LTR/18/04/23 (11)}.

Non probability, consecutive sampling technique was used. All T2DM patients who attended Integrated Diabetes and Gestational Diabetes Clinic (IDGDC), IQ City Medical College and Multispecialty Hospital, during data collection period of 4 months (June 2018 to September 2018) were screened for any diabetic foot ulcer and recruited as study participants if they had foot ulcer and consented to participate in study. Out of 1534 attendees of IDGDC only 132 attendees had diabetic foot ulcer and they were recruited as study participants.

Inclusion criteria: Age ≥ 18 years and duration of diabetes ≥ 6 months were included in the study.

Exclusion criteria: Known case of neurological disorders, stress induced hyperglycemia, hyperglycemia in pregnancy, patients on steroids and critically ill patients were excluded from the study.

Procedure

Total 1534 T2DM patients attended IDGDC during data collection period of 4 months. Out of 1534 T2DM patients 132 had diabetic foot ulcer. After taking written informed consent, detailed data were collected from 132 of study participants using pre-designed, semi structured and pre tested schedule developed with the help of IWGDF/IDSA classification system (28). Data on socio-demographic characteristic like age, sex, education, residence were recorded along using schedule and relevant medical records were also reviewed to get clinical data like glycated haemoglobin (HbA1c), duration of diabetes, treatment modalities. Anthropometric measurements were taken as per World Health Organization (WHO) guidelines (33) and Body Mass Index (BMI) was classified as per WHO guidelines (34). T2DM was defined and classified as per American Diabetes Association (ADA) Guidelines (35),(36). DFU infection severity was classified into uninfected, mild infection, moderate infection and severe infection as per IWGDF/IDSA guidelines (Table/Fig 1) (28).
Statistical Analysis

Data were codified and analyzed using Statistical Package for Social Sciences (SPSS) version 20.0 for windows. Frequency of clinic-social variables were calculated and presented as frequency distribution tables. Chi-square test was used to show association between categorical variable. One-way Analysis of Variance (ANOVA) with Tukey's post-hoc test was used to show association between mean HbA1c level and DFU infection severity. The P-value ≤0.5 was considered significant.

Results

The minimum and maximum age of study population was 35 years and 72 years respectively and the mean age was 54.66±9.79 years. It was observed that 68.9% of study population was male and 31.1% were female (Table/Fig 2).

Proportion of Diabetic Foot Ulcer (DFU) was found to be 8.6% (total DFU=132/total screened population=1534x100). As per the IWGDF/IDSA classification of DFU infection severity was found to be moderate in 59 (44.7%) of the study participants and mild in 32 (24.2%) of the study participants (Table/Fig 3), (Table/Fig 4). Patients with mild and moderate DFU infections were treated in Outpatient Department setting with wound debridement and oral antibiotics for 10 days and follow-up was done after 10 days or earlier if they feel worsening of infection. Total 22 (16.7%) of study subjects had severe infection and required hospitalisation for optimal care (Table/Fig 3), (Table/Fig 5).

Increasing age (p-value=0.023), rural residence (p-value=0.015), poor education (p-value=0.001), obesity (p-value=0.001), central obesity (p-value=0.001) was found to be significant risk factors for severe infection in DFU. Longer duration of diabetes was associated with significant (p-value=0.028) higher risk of severe DFU infection. Poor glycemic (HbA1c>7%) was found to be a significant (p-value=0.001) risk factor for severe diabetic foot ulcer infection (Table/Fig 6).

There was a significant mean HbA1c difference between grades as determined by one-way ANOVA statistics [F(132,3)= 5.577, p-value<0.001] (Table/Fig 7). It was found that mean HbA1c as dependent variables in the standard ANOVA model are significantly predictive of the independent variables grading of diabetic foot ulcer infection category (No Infection, Mild Infection, Moderate Infection, Severe Infection). Mean plot of HbA1c against infection severity shows significant increase in DFU infection severity with increase in mean HbA1c (Table/Fig 8). To see the between group difference, one-way ANOVA was further extended with “Tukeys post-hoc test” to do multiple comparison. After post-hoc analysis, it was noted that there was significant difference in mean HbA1c level between no infection vs moderate infection (10.30±2.27, p-value=0.023) and no infection vs severe infection (11.29±1.67, p-value=0.001).

Discussion

In the present study, prevalence of DFU was found to be 8.6%. Slightly lower 6.6% and slightly higher 9.5% prevalence of DFU was reported by Thakur JK et al., (1) and Gupta SK et al., (37) respectively. Few other studies reported a 9.8- 12% prevalence of DFU (38),(39). Using the IWGDF/IDSA classification (28), proportion of DFU infection in present study was found to be 85.2%. It was observed that 44.7% of the study population had moderate infection followed by about 24.2% and 16.7% of the study population who had mild infection and severe infection requiring hospitalization for treatment respectively.

A similar study using IWGDF/IDSA classification system done by Lavery LA et al., (17) reported 47.0% proportion of mild infection followed by 34.0% and 17.9% proportion of moderate and severe DFU infection respectively. Although the proportion of severe infection in present study (16.7%) and study done by Lavery LA et al., (17) (17.9%) are comparable the overall proportion of DFU infection in present study is slightly higher which can be attributed to the setting of the present study which is a dedicated diabetes clinic of a tertiary health care facility which is bound to get more complicated cases. Although, there are limited studies ascertaining the clinical severity of DFU infection, there are numerous studies on the incidence of DFU infection which shows an incidence of 26% to 61% of infection in DFU (14), (26), (40),(41),(42),(43),(44).

In the present study, increasing age was found to be significant risk factor for severe DFU infection. More severe infection with increasing age may be because of the increase in risk factors for DFU like peripheral neuropathy, peripheral artery disease and reduced immunity. Study by Jia L et al., (45) reported younger age as a risk factor for severe DFU infection and Leibovitch M et al., (46) reported a similar trend in DFU infection with increasing age which is consistent with our study findings. In the present study a non significant female preponderance of severe DFU infection was found but Lavery LA et al., (17) and Jia L et al., (45) reported a significant male preponderance of DFU infections. While rural residence was found to be significant risk factor for DFU infection in the present study there are studies which reported nnon significant rural area preponderance of DFU (1), (37) and non significant association of residence with DFU infection (45).

Significant high proportion of severe infection among study participants from rural area may be due to the less access of quality diabetes care among rural area residents. Poor educational status was found to be significant risk factors for developing severe DFU infection. Poor educational status may have resulted in poor understanding of the disease process, its treatment and progression leading to poor compliance and consequent complications of poorly controlled T2DM. Severe DFU infections were found to be significantly higher among overweight, obese and study participants having central obesity.

Various studies reported significant high prevalence of DFU among overweight and obese people with T2DM (1),(37),(47),(48),(49). More duration of T2DM was found to be significant risk factors for having severe DFU infections. While studies done by Thakur JK et al., (1) and Gupta SK et al., (37) reported significant risk of DFU with increasing duration of T2DM, Jia L et al., (45) reported non significant role of T2DM duration on the severity of DFU infection. Treatment with insulin based regimen was significantly high among severe DFU infections. This may be due to the fact that most guidelines recommend insulin based treatment of diabetes mellitus during acute illness or hospitalization (50).

Significantly high proportion of severe DFU infection was found among study participants having poor glycemic control (HbA1c ≥7%). In present study, the mean HbA1c was found to be significantly high among those who had severe and moderate DFU infections than those who had no infection. Poor glycemic control is a known risk factor for reduced immunity, increased risk for DFU and non healing of DFU (1), (37). The present study is probably the first of its kind at least in Eastern India which is reporting the importance of clinical grading of DFU infection severity and its predictors.

Limitation(s)

Failure to include few important risk factors for DFU like smoking, tobacco, alcohol addiction in the present study. Few other confounding factors for DFU like CKD, burgers disease and history of previous revascularization surgery were also not included in present study. Results of the present study cannot be generalized because this study was done at an advanced diabetes care clinic which is bound to get complicated and referred cases.

Conclusion

Increasing age, rural residence, poor education, obesity, central obesity, longer duration of diabetes, and poor glycemic control was found to be significant risk factors for severe infection in DFU. Routine clinical assessment of DFU infection may help in making clinical decision of treatment modalities and help in saving lower limb as well as life of people with T2DM.

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DOI and Others

DOI: 10.7860/JCDR/2022/56302.16333

Date of Submission: Mar 12, 2022
Date of Peer Review: Mar 31, 2022
Date of Acceptance: Apr 23, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 13, 2022
• Manual Googling: Mar 23, 2022
• iThenticate Software: Apr 18, 2022 (16%)

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