The relationship between the healing of diabetic foot ulcers for patients admitted to Damascus Hospital during the Syrian crisis
Authors: Najjar Alma , Dulli Joud , Hammoud Taghrid 
Published: October 2022

Abstract
Introduction:
Diabetes mellitus is a term that describes a group of metabolic diseases with the common characteristic ‘’Hyperglycaemia’’ an increase in blood glucose level. The two most important representatives of the group are diabetes mellitus types 1 and 2. In the former, an autoimmune reaction leads to the destruction of the insulin-producing beta cells in the pancreas which leads to an absolute insulin deficiency. The more common type 2 diabetes mellitus has both a strong genetic component as well as a significant association with metabolic syndrome. A disturbed effect of the insulin on the body cells (insulin resistance) and an (initially increased compensatory and then reduced) insulin secretion of the beta cells lead to hyperglycemia. Unfortunately, this type of diabetes often remains clinically inapparent for many years, but already leads to serious organ damage, especially of the heart, circulatory system, kidneys, eyes and nervous system, due to the pathological metabolic situation via micro- and macroangiopathies.
Theoretically, weight normalization, physical activity and a balanced diet would often be sufficient in type 2 diabetics to prevent manifestation and progression of the disease. Unfortunately, this is extremely rare, so that glycemic control (in addition to dietary instructions) initially requires oral antidiabetics and, in the event of secondary failure, insulin injections. In the case of type 1 diabetes, on the other hand, it is necessary to compensate for the absolute lack of insulin through meal-controlled insulin administration, which corresponds to carbohydrate-defined food intake. Intensive patient training is required in order to avoid life-threatening hypoglycaemia and hyperglycaemia and to approach the goal of a normoglycaemic metabolic state. Diabetes is associated with macroangiopathic complications like coronary heart disease, arterial disease of the cerebral arteries (stroke), peripheral arterial disease as well as microangiopathic ones such as: diabetic nephropathy, retinopathy, neuropathy and diabetic foot syndrome. The latter is caused mainly due to a neuropathic disorder in the foot of the diabetic patient which is characterized by warm dry skin and decreased sensation in Sensitivity, vibration, Pain and temperature with vital foot pulses. A Cool, pale foot with absent foot pulses is a sign of the less common ischemic diabetic foot due to peripheral arterial disease. In extreme cases, ulcers can arise on the ground of a neuropathic diabetic foot, especially on the balls of the feet and heels. These are painless neuropathic ulcers, that can be a starting point for a life- threatening phlegmonous infections.
Methods:
A descriptive cross-sectional study was conducted on a group of diabetes patients with a history of diabetic foot ulcers between December 2021 and June 2022. We obtained a written consent from all patients in the group. All patients were older than 18 years old and they were all diagnosed with diabetic foot syndrome. The study excluded patients who didn’t complete the questionnaire. The study was approved by the Ethical Review Board (IRB) of the Faculty of Medicine in the Syrian Private University.
Results:
Out of the 120 participants in the study, 63.3% were male, and 36.7% were female. 38.3% of patients were smokers. Most of them have primary education level 30%. Most patients have peripheral neuropathy 85%, and hypertriglyceridemia 40%. Most patients have type 2 diabetes 78.3% and 21.7% type 1 diabetes. 40.7% were treated with oral hypoglycemic agents, and 30.5% were treated with insulin only. The mean SINBAD score was 3.1 out of 6, most of whom were grade 3 with 31.7%, and grade 4 with 25%. The results showed a relationship between the SINBAD score categories with demographic factors, family history of diabetes, complications of diabetes and ulcer characteristics (location, ischemia, associated neuropathy, the presence of bacterial infection.
Conclusion: Additional details regarding age, sex, predisposing factors and diabetes status of patients with hyperglycemia and inadequate control were obtained. These urges conducting better health programs and stresses the importance of conducting a periodic health assessment for patients with diabetes and diabetic foot in particular, while educating patients about the importance of taking care of diabetic foot in an optimal manner to avoid amputation as an advanced complication. It was also found that the incidence of diabetic ulcers with the worst prognosis was in patients of advanced ages who suffer from peripheral arterial disease with sensory neuropathy accompanying infection with ulcers being located on the soles of the feet as a high-risk factor that affects the healing and prognosis of ulcers. It requires more studies to follow up the condition and its recovery is better and in a shorter period.