Keywords
evaluación del riesgo
prevención primaria
enfermera entrenada
equipo de atención en salud
Diabetic Foot
Risk Assessment
Primary Prevention
Nurse Practitioners
Patient Care Team
How to Cite
Abstract
Introducción: El pie diabético es un problema de salud pública debido a su elevada frecuencia, severidad y a su impacto económico. En la etapa prepatogénica, el pie presenta alteraciones funcionales y estructurales que de no detectarse a tiempo pueden progresar a la úlcera. Sin embargo, el examen de los pies no se realiza en la mayoría de las consultas. La prevención primaria y la detección oportuna deben tener lugar en el primer nivel de atención.
Objetivo: Desarrollar y validar un instrumento simple y práctico para clasificar de manera temprana el pie del paciente diabético en riesgo por parte de la enfermera entrenada antes de la visita a su médico tratante, teniendo en cuenta todos los elementos patogénicos.
Métodos: Estudio transversal. Se creó una escala a partir de la experiencia clínica en donde se califican ocho factores de riesgo para desarrollar ulceración: tiempo de diabetes desde el diagnóstico, control metabólico, presencia de síntomas de neuropatía diabética, diagnóstico de la neuropatía por monofi- lamento, presencia de claudicación intermitente y ausencia de pulsos periféricos, presencia de deformidades, presencia de infecciones locales e historia anterior de úlceras que sanaron, amputaciones menores o pie de Charcot. Los puntajes fueron asignados según gravedad. Esta herramienta fue aplicada a un grupo de 204 diabéticos con ulceración y 207 pacientes diabéticos sin ulceración.
Resultados: El promedio de edad fue de 65 años, el 42,8% de los pacientes eran hombres. La edad y todos los ítems de la escala, excepto hemoglobina glucosilada, fueron asociados con la presencia de úlcera. Usando un punto de corte de 10 puntos, la herramienta tuvo una sensibilidad del 100% y una especificidad del 73,4% para el diagnóstico de úlcera, con un área bajo la curva ROC de 0,992(IC 95%, 0,986 A 0,998).
Conclusión: La herramienta “pie risk” es útil para la calificación y valoración del riesgo de pie diabético.
Abstract
Background: The diabetic foot is a public health problem due to its frequency, severity and economic impact. In prepathogenic phases, the foot presents structural and functional alterations that, if not detected opportunely, will progress to an ulcer. However, a thorough examination of the diabetic patient’s feet is often eluded in routine health controls.
Objective: To develop and validate a simple and practical instrument for early classification of the diabetic foot risk that can be easily applied by a trained nurse before the medical visit.
Methods: Cross-sectional study. Based on clinical expertise, a scale with eight risk factors for foot ulcer was developed: time from diagnosis, glycosylated hemoglobin, neuropathy symptoms, monofilament test, absent pulses or claudication; deformities, local infection and history of either amputation, ulceration or Charcot foot. Item scores were assigned based on severity. The tool was tested in a group of 204 ulcerated diabetic patients and 207 of non-ulcerated diabetic patients.
Results: Median age was 65 years, 42.8% of patients were male. Age and all scale items except glycosylated hemoglobin were statically associated with ulcer presence. Using the proposed cut point of 10 points, the scale has 100% sensitivity and73.4% specificity for ulcer diagnosis, with an area under the ROC curve of 0.992 (95% CI 0.986 to 0.998).
Conclusions: ‘Pie risk’ is a useful tool for the evaluation and risk assessment of the diabetic patient.
References
2. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin dependent diabetes mellitus. N Engle J Med, 1993;329;977-86.
3. United Kingdom Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998;352:837-53.
4. Aschner et al, Guias ALAD de diagnostico, control y tratamiento de la diabetes y sus complicaciones. Revista ALAS 2006 ; 4(3):1-78. Med 1994 : 11-166-169.
5. Aschner PJ, Ruiz AJ, Metabolic memory for vascular disease in Diabetes. Diabetes thecnol.Ther, 2012 Jun; 14 Suppl 1:s68-74.doi:10.1089/ dia.2012.0012.
6. Ragnarson Tennvall G, Apelqvist J. Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes Complications [Internet]. 2000 Sep [cited 2015 Aug 26];14(5):235–41. Available from: http://linkin- ghub.elsevier.com/retrieve/pii/S1056872700001331.
7. Demet K, Martinet N, Guillemin F, Paysant J, André J-M. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil [Internet]. Taylor & Francis; 2003 Jan 11 [cited 2015 Aug 26];25(9):480–6. Available from: http://www.tandfonline.com/ doi/full/10.1080/0963828031000090434.
8. Gilbert MP. Screening and Treatment by the Primary Care Provider of Common Diabetes Complications. Med Clin North Am [Internet]. 2015 Jan;99(1):201–19. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0025712514001503
9. McCulloch DK. Evaluation of the diabetic foot. In: Post TW, editor. UpToDate [Internet]. Waltham, MA; 2014. Available from: http://www.uptodate.com/ contents/evaluation-of-the-diabetic-foot.
10. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: Post TW, editor. UpToDate [Internet]. Waltham, MA; 2014. Available from: http://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-management- of-diabetic-infections-of-the-lower-extremities.
11. Alayón AN, Altamar-López D, Banquez-Buelvas C, Barrios-López K. Complicaciones crónicas, hipertensión y obesidad en pacientes diabéticos en Cartagena, Colombia. Rev Salud Pública (Bogota) [Internet]. 2009 Dec [cit- ed 2015 Aug 18];11(6):857–64. Available from: http://www.ncbi.nlm.nih. gov/pubmed/20379659.
12. Villegas Perrasse A, Abad SB, Faciolince S, Hernández N, Maya C, Parra L, et al. El control de la diabetes mellitus y sus complicaciones en Medellín, Colombia, 2001–2003. Rev Panam Salud Publica. 2006;20(6):393–402.
13. Pinilla AE, Sánchez AL, Mejía A, del Pilar Barrera M. Primary-care prevention activities in outpatients suffering from diabetic foot care. Rev Salud Pública [Internet]. Instituto de Salud Publica, Faculdad de Medicina - Universidad Nacional de Colombia; [cited 2015 Aug 27];13(2):262–73. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0124- 00642011000200008&lng=en&nrm=iso&tlng.
14. Mythili A, Kumar KD, Subrahmanyam KA V, Venkateswarlu K, Butchi RG. A Comparative study of examination scores and quantitative sensory testing in diagnosis of diabetic polyneuropathy. Int J Diabetes Dev Ctries [Internet].
2010 Jan [cited 2015 Aug 26];30(1):43–8. Available from: http://www. pubmedcentral.nih.gov/articlerender.fcgi?artid=2859284&tool=pmcentre z&rendertype=abstract.
15. Peters EJ, Lavery LA. Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care [Internet]. 2001 Aug [cited 2015 Aug 27];24(8):1442–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11473084.
16. Júbiz Y, Brugés J, Orduz A, Bohórquez L, Calderón C, Díaz A, Escobar I, et al. Guías colombianas para la prevención, diagnóstico y tratamiento del pie diabético: un manejo integral [Internet]. 1st ed. Bogotá: COLPEDIS Grupo Colombiano de Pie Diabético; 2012. 96 p. Available from: http://issuu.com/ presidenciafdc/docs/guias_pie_diabetico.
17. Jirkovská A, Bou?ek P, Wosková V, Bartoš V, Skibová J. Identification of patients at risk for diabetic foot: A comparison of standardized noninvasive testing with routine practice at community diabetes clinics. J Diabetes Complications. 2001;15(2):63–8.
18. Brownrigg JRW, Hinchliffe RJ, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, et al. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review [Internet]. London: International Working Group on the Diabetic Foot; 2015. p. 26. Available from: http://www.iwgdf.org/files/2015/PADdi- agnosis.pdf.
19. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg [Internet]. Elsevier; 2010 Sep 9 [cited 2015 Apr 21];52(3 Suppl):17S – 22S. Available from: http:// www.jvascsurg.org/article/S0741521410013248/fulltext.
20. Tsourdi E, Barthel A, Rietzsch H, Reichel A, Bornstein SR. Current aspects in the pathophysiology and treatment of chronic wounds in diabetes mellitus [Internet]. BioMed Research International. 2013. p. 6. Available from: http://dx.doi.org.10.1144/2013/385641.
21. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, et al. 2012 infectious diseases society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clinical Infectious Diseases. 2012. p. 1679–84.
22. Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: A systematic review. Diabetes/Metabolism Research and Reviews. 2012. p. 574–600.
23. American Diabetes Association. Microvascular complications and foot care. Diabetes Care [Internet]. 2015;38(Suppl 1):S58–66. Available from: http:// care.diabetesjournals.org/content/38/Supplement_1/S58.full.
24. Dorresteijn J a N, Kriegsman DMW, Valk GD. Complex interventions for preventing diabetic foot ulceration. Cochrane Database Syst Rev.
2010;(1):CD007610.
25. Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane database Syst Rev [Internet]. 2014 Jan [cited 2015 Jul 28];12:CD001488. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/25514250.
26. National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management [Internet]. 2015. 46 p. Available from: nice. org.uk/guidance/ng19.
27. Fan L, y col , Feasibility, Acceptability and Effects of a Foot Self-Care Educa- tional Interventionon Minor Foot Problems in Adult Patients with Diabetes at Low Risk for Foot Ulceration: A Pilot Study . Canadian journal of diabetes. March 2013.Journal homepage: www.canadianjournalofdiabetes.com
28. Corbett C. y col . A rambdomized pilot study of improving foot care in home health patients with diabetes. The diabetes educator , vol 29 ,number 2, March 2003.
Authors must state that they reviewed, validated and approved the manuscript's publication. Moreover, they must sign a model release that should be sent. A copy may be reviewed here