Y HQC VlgT NAM THANG 3 - s 6 1/2013 Nghien cffu cua R. Salani
UTBMBT tai phat cho thdi gian benh trung binh la 50 thang.
Ket qua nghien cffu cua ngoai cho thdi glan song them benh cao hdn ket qua trong chiing toi co the vi benh nhan ciia hp dffdc phat hien tal phat qua dieu trj cung tot hdn,
va cdng sff [7] ve sdng them khdng cac tac gla nffdc toan bd va khdng nghien cuff ciia trong nghien cffu sdm hdn nen ket
V. KET LUAN
Qua nghien cffu 60 BN UTBMBT tai phat tai Benh vien K, chung tdi rut ra mdt sd ket luan nhff sau:
Da 50 BN (83%) dffdc phat hien tal phat tffdng ddi mudn, khi da cd bieu hien lam sang, Chl cd 17% BN dffdc phat hien khi chffa cd tneu chffng lam sang. Thdi gian tai phat sau dieu tri bffdc 1 trung binh la 17,4 ± 9,8 thang. Thdi gian sdng them toan bd trung binh sau dieu trj bffdc 2 la 23,4 ± 2,2 thang, thap nhat 3 thang, cao nhat 57 thang. Sdng them khdng benh trung binh la 18,1±2,2 thang.
TAI LIEU T H A M K H A O
1. Nguyen Bd Dii'c (2010), "Ung thi/ buSng tnJYig", Dik tn n0i khoa binh ung thU. Nha xuSt ban Y hpc, tr.lB9 197.
2. Nguyen V i n Hieu (2010), "Ung thU buong tmng', Diiu tn phiu thuat benh ung tttu; Nha xuat ban y hgc, Hk Noi, 346-355.
3. Antonios-Apostolos K Tentes (2010}, Cytoreductlve surgery and penoperative intrapentoneal chemotherapy in recurrent ovanan cancer", Tumori, 96:411-416.
4 Chi Denis S, McCaughty K, Diaz JP (2006),
"Guidelines and selection cntena for s^ndary cytoreductlve surgery in patients with recurrent pfatlnum-sensitive epithelial ovanan caranoma". Cancer 2006;106(9):1933
5 Ertg-Hseon Tay, Peter T Grant (2002), "Seconctary cytoreducttve surgery for recurrent epithelial ovarian cancer", Obstetncs & Gynecology, Vol.99, No.6,June 2002.
6 Menczer J, Chetrit A, et al (2006), "Rillow-up ovanan and pnmary pentoneal carcinoma: the value tf physical examination in patients with pretreatment elevated CA 125 levels" Gynecol Oncol, 2006;103:137- 140.
', Ruti Salani, Antonio Santillan (2007), "Secor^ry cytoreductive surgery for localized recurrent epithtelial ovarian cancer", American cancer soaety. Publish online I I January 2007
NHAN XET CAC YEU TO LIEN QUAN DEN BENH LY BAN CHAN GT BENH NHAN DAI THAO DUtTNG CAO TUOI
Vu Thj Thanh Huyen^ ^ N g u y e n Tien Dung^, Pham Thang^
TOM T A T
Muc tieu. Nhan xet cac yeu to hen quan den benh ly ban chan d benh nhan DTD cao tuoi. Doi tddng vi phddng phip nghien ctiir. Mo ta c3t ngang tren 300 benh nhan DTD typ 2 tren 60 tuoi tff 3/2011- 9/2011. Kei qua: Ton thu'ong ban chan do DTD la 64%. Cac yeu to nguy cO gay ton thffOng ban chan DTD bao gom thdi gian mac benh, mffc dp kiem soat du'dng mau, hiit thuoc. Bien chffng vi mach nhff bien chffng tai than co nguy cO cao hOn 2,6 I3n, bien chffng m§t nguy cP cao hOn 4,2 fan, chi so ABI thap nguy cd cao hdn 18 lan. Ket luan. Ty le bien chffng ban_chan do DTD d ngu'cJi cao tuoi rat cao, ty le mac ty le thuan vdi thdi gian m3c benh, hut thuoc la^ bien chffng vi mach va mffc do kiem soat dffdng mau.
Tu' khoa: Dai thao dudng, benh ly ban chan do DTO
* Trddng dai hgc YHa Noi, ^Benh vien Lio khoa tmng ddng Phan bl0n khoa hpc: PGS.TS. Dang Thj Ngpc Dung
SUMMARY
FACTORS RELATED TO DIABETIC FOOT IN ELDERLY DIABETIC PATIENTS Objectives, to identify some factors related to diabetic foot in elderly patients. Methods.
observational study on 300 elderly diabetic patients from March to September 2011. Results: Jhe rateof diabebc foot complications among diabetic elderly patients was 64%. Risk factors of diabetic foot diseases are duration of diagnosed diabetes, levels of blood glucose control, micro-vascular complication, smoke. Higher risk for diabetic foot disease with micro- vascular complications such as rena Icomplications, eye complications and low ABI. Conclusion: the prevalence of diabetic foot in older ages was ralher high and increased with the duration of diabetes, level
Y HQC VlgT NAM THANG 3 • s 6 1/2013 of blood glucose control, micro-vascular complication.
Key wort/s;diabetes, diabetic foot disease
I.
OAT VANoi
Benh ly ban chan do dai thao dffdng (OTD) la hau qua cua nhleu yeu to phoi hdp: ton thffdng than kinh ngoai bien, ton thffdng mach mau, cac yeu to cd hgc va yeu to nhiem triing lam nang them benh ly ban chan. Mac du co nhieu tien bo trong phffdng phap phong va dieu trj nhffng van co khoang 10 -15 % cac benh nhan dai thao dffdng phai cat cut chi trong suot cupc ddi hp [1,2]. Van de dieu tri cac benh nhan OTO khl CO bien chffng loet ban chan rat kho khan, ton kem tien bac lan cong sffc bdi thdi gian nam vien dai, chi phi thuoc men va cham soc.
Cac yeu to chinh gay ra benh ly ban chan OTD la benh ly than kinh ngoai vi va benh ly mach mau ngoai vi. 6 benh nhan OTD cac mang vffa xd mach d cac mach mau chi du6l thffdng xuat hien hai ben, nhieu doan va d phia ngpn chi, bao gom cac dpng mach tff goi trd xuong gay ra thieu mau cue bo.
Trong thffc hanh lam sang co rat nhieu cac yeu td lam tang nguy cd ton thffdng ban chan do OTO ma CO the dff phdng va kiem soat 6\idc. Cho den nay d Viet Nam da cd mpt so cong trinh nghien cffu ve benh ly ban chan do DTD nhffng cac danh gia ve moi lien quan giife cac yeu to nguy cd va cac ton thuWng ban chan trong benh ly DTD d ngffdi cao Uioi thi cdn rat khiem ^ n , vi vay chung toi tien hanh
de tai vdl muc beu: Nhan xet cac yeu to lien quan den benh ly ban chan d benh nhan DTD cao tuol.
II. o 6 t TUpNG VA PHUONG P H A P NGHIEN djTU 2 . 1 . D o i t u ' a n g n g h i e n c u ' u : Cac benh nhan dffdc chan doan DTD theo tieu chuan cua to chffc y te the gldl (WHO) 2003 [3] dieu trj tai Vien Lao Khoa.
2.2. Phu'dng p h a p n g h i e n c i h i : Mo ta c i t ngang, thu thap cac thdng tin ve dac diem djch te, ty le xuat hien cac benh ly, trieu chffng lam sang, can lam sang chfnh ve ton thffdng ban chan d benh nhan dffdc chan doan la OTO dieu tri tai Benh Vien Lao Khoa trung ffdng tff thang 3/2011- 9/2011. Benh nhan dffdc ghi nhan nhffng thong tin theo mau benh an thdng nhat, di sau tim hieu nhffng van de sau: tuoi, gidi, trinh dp hpc van, thdi gian bj benh OTD ti'nh tff khi dffdc cha'n doan xac djnh (ti'nh bang nam), cac benh ly kem theo nhff THA, RLCH lipid mau, hut thuoc la, uong rffpu, thdi gian xuat hien cac hinh thai ton thffdng ban chan OTD. Tham kham mach mau ngoai vi. Kham chuyen khoa mat; phat hien cac bien chimg vong mac ciia OTO va phan dp ton thffdng.
Xet nghiem cac chi sd dffdng mau doi, sau an 2 gid, HbAic, microalbumin nieu (MAU), cac thong so ve lipid mau, do chi so co chan canh tay (ABI)
2.3. Xur ly so' lieu: xff ly sd lieu theo chffdng trinh SPSS 16.0. Cac so lieu dffdc tinh toan vdi dp bn cay 95% (mffc y nghTa thong ke la 5%).
111. KET Q U A
Trong tong sd 300 benh nhan OTO tham gia nghien cffu cd 6 4 % cd ton thffdng ban chan va 36%
khdng cd td'n thffdng ban chan, so Iffdng benh nhan nff la (58%) cao hdn nam (42%), tuoi trung binh la 67,0 ± 8,8.
Bangl:{^n quan glife tuoi, thdi gian mac, trinh dp hpc van BMI va thoi quen hiit thuoc la ciia benh nhan DTD vcff benh ly ban chan DTO
Cac bien so nghien cu'u Nhom
tuoi (nam) Thdi gian
mac (nam) Trinh do hoc van BMI Hftttmoc
la 6 0 - 6 9 7 0 - 7 9
>80
< 1 2-3 4-10
> 10
< cap 2
> cap 3
< 2 3
> 2 3 Co Khonq
Co ton thu'dng N 105
72 13 25 35 84 46 133
57 101 89 63 127
64,4
%
59,5 81,3 48,0 53,0 66,7 81,1 61,0 69,5 67,3 59,3 75,0 58,8
Khonq ton thu'ong N
58 49 3 27 31 42 10 85 25 49 61 21 89
35,6
%
40,5 18,8 52,0 47,0 33,3 17,9 39,0 30,5 32,7 40,7 25,0 41,2
Tonq N 163 121 16 52 66 126 56 218 82 150 150 84 216
100
%
100 100 100 100 100 100 100 100 100 100 100 100
OR
3,290
18,077
0,686 1,413 2,102
P
0,193
< 0,001
0,169 0,15 0,008
Y HQC VlgT NAM THANG 3 - sg 1/2013
NhSn xet: Ket qua cho thay cd moi lien quan chat giffa thdi gian mac OTD, thdi quen hitt thuoc la vdi benh ly ban chan OTD, thdi gian mac cang lau thi nguy cd mSc benh ly ban chan do OTD cang cao (OR = 18,077, p < 0,05), benh nhan hut thuoc la thi ty le mac bien chffng ban chan cao hdn (OR
= 2,102, p < 0,008). Khong cd moi lien quan giu'a tuoi, trinti dp hpc van, chi so BMI va benh ly ban chan OTD (p > 0,05).
Bang2:Uen quan giii'a di/d
Cac bign so nghiencu'u DMcfdi
Dt^lsau an 2h Chisd HbA,c RLCH lipid Tang HA
S6,l 6,1 - 7,0
>7
<10
>10 S 6,5 6,6 - 7,5
> 7,5 Co Khonq
Co Khonq
iq mau, \
C6 ton thu'dngN 74 56 60 102 88 72 81 37 U l 79 131 59
»/o 60,2 61,9 70,6 55,1 76,5 58,5 61,8 80,4 59,3 69,9 61,8 67,0
uyet ap va pid mau vd Khdng ton thu'dng
N 49 36 25 83 27 51 50 J 9 76 34 81 29
"/o 39,8 38,1 29,4 44,9 23,5 41,5 38,2 19,6 40,7 30,1 38,2 33,0
benh ly 3a n cha
Tonq N 12392 85 185 115 123 131 46 187 113 212 88
»/o 100 100 100 100 100 100 100 100 100 100 100 100
I D T O OR
2,755
0,377 7,708 0,629 0,795
P
0,252
< 0,001 0,021
OfiM
0,388
Nhan xet: Ket qua cho thay cd mdi lien quan chat giffa dffdng mau sau an 2 gid, HbAjc, IU.CH lipid vdi benh ly ban chan do DTO (p < 0,05). Khong cd moi lien quan giffa dffdng mau ddi, tang HA va benh ly ban chan OTO (p > 0,05).
Bang 3: Lien quan giffa ton thffdng vi mach vdi benh ly ban chan OTD:
Cac bien so nghien cu'u B/cmSt
MAU Chi so ABI
Co Khonq
> 30q/dl
< 30q/dl
<0,9
> 0,9
Co ton thu'dng N 22 25 64 126 88 102
33,3
%
10.7 78,0 57,8 94,6 49,2
Khonq ton thu'dng N
44 209 18 92 5 105
66,7
%
89,3 22,0 42,2 5,4 50,8
Tong N 66 234 82 218 93 207
100
%
100 100 100 100 100
OR 4,180
2,596 18,118
P
< 0,001
< 0,001
< 0,001
Nhan xet: Cd mdi lien quan chat giffa benh ly ban chan do DTD vdi cac ton thffdng vl mach nhff bien chffng mat (OR = 4,180, p < 0,05), microalbumin nieu (OR = 2,596, p < 0,05) va chi so ABI (0R = 18,118, p<0,05).
IV. BAN LUAN
4.1. Lien quan giu'a thdi gian mac benh vdi benh ly ban chan OTO
Ket qua nghien cffu ciia chiing tdi cho thay cd moi lien quan chat giffa thdi gian mac benh va ty le ton thffdng ban chan do DTO (Bang i ) thdi gian phat hien benh cang lau thi ti le ton thffdng ban chan cang tang len, dieu nay cQng tffdng tff cac tac gia Fatma [4] hay Samann [5] cung da chi ra rang thdi gian mac benh la mpt trong nhffng yeu to nguy cd chinh dan den ton thffdng ban chan^do DTO bao gdm ca ton thffdng than kinh va ton thffdng mach mau ngoai vi.
4.2. Lien quan giu'a hut thuoc la va ton thu'dng ban chan OTO
Hilt thuoc la gay tang cholesterol toan phan.
tang trigiycerid va LDL - cholesterol dong thtfi lam giam HDL - cholesterol. Sff thay doi nay dan den tang nguy cd vuB xd mach mau va lam t3ng bien chiTng mach mau trong DTO [2,4]. Trong nghien cffu ciia chung toi (Bang 1) cho thay nhffng benh nhan OTD hut thuoc la cd ti le ton thffdng cao hdn nhffng benh nhan khong hiit thuoc la 2,1 lan (OR = 2,102, p = 0,008). So sanh vdi nghien cffu tai Dffc ciia Samann va cs [5] khong chi ra moi lien quan giiJa hut thuocia va ton thffdng ban chan do DTO (p = 0,113} tuy nhien tac gia cung cho rang so Iffdng benh nhan hilt thudc la qua ft trong quan the nghien ciili tai Dffc (568/4412) va day cd le la do sai so trong qua trinh tuyen chpn benh nhan.
4.3 Lien quan giu'a tuoi, trinh dp hoc
Y HOC VI$T NAM T H A N G 3 - SO 1/2013 van, B M I va benh ly ban chan OTO
Nghien cffu ciia chiing toi khong thay co sff khac biet ve tuoi vdi ton thffdng ban chan DTD (p > 0,05) (Bang 1). Nghien cuXi Fatma va cs [4]
cho thay co moi lien quan chat giffa tuoi ciia doi tffdng nghien cffu va ty le t6n thffdng ban chan OTO, nhdm tuol cang cao thi t i le mac benh tang cang cao, sff khac biet nay cd the do sff khac nhau ve dd tuoi ciia doi tffdng nghien cffu. Trong nghien cirtj ciia nhdm tac gla tren cac do! tffdng benh nhan cd bien dp giao dpng ve dp tud'i ldn (thap nhat 38 tuoi, cao nhat 93 tuoi), cdn trong nghien ciiu ciia chiing tdi la nhdm nhffng benh nhan cao tuoi (tren 60 tuo'i) do dd sff khac biet giiJa cac nhdm tuoi chffa dffdc the hien ro.
Chung toi khong thay cd moi lien quan giffa trinh dd hpc van va benh ly ban chan DTO (Bang 1). Trong nghien ciiXi tren quan the benh nhan tai Tieu vffdng quoc A rap thdng nhat ciia Fatma va cs [ 4 ] , nhdm tac gia nay cho thay cd mdi lien quan chat giffa hpc van va benh ly ban chan OTO. Sff khac biet nay la do dac diem xa hpi ciia nhdm doi tffdng nghien ciru. Trong nghien cffu cua tac gia tren ti le khong biet chff len tdi 62,8%, cung trong nghien cffu nay tac gia da neu len mpt each cu the nhffng benh nhan khdng biet chff cd mffc dp kiem soat dffdng mau, sff tuan thil dieu tri va nhan thffc dff phdng ton thffdng ban chan d mffc kem dan den ti le ton thffdng trong nhdm ddi tffdng nay rat cao va thffdng la nhffng tdn thffdng ban chan tram trpng. Trong khi dd trong quan the nghien cffu ciia chiing tdi chi cd 0,3% la khdng biet chff.
Trcing benh OTD ndi chung va benh ly ton thffdng ban chan DTO ndi neng, chi so BMI ludn dffdc quan tam va danh gia. Nghien cirtJ ciia Edward J va cs [6] da danh gia rieng biet sff anh hffdng ciia chieu cao va can nang tren nhffng benh nhan da cd bien chffng ban chan tien trien va thay rang chieu cao, can nang co anh hffdng den tien trien ciia ton thffdng ban chan OTO.
Cdn trong nghien cffu ciia chung tdi cung nhff ciia Samann va cs [5] khdng thay cd mdi lien quan giffa chi so BMI va tdn thffdng ban chan DTD. Dieu nay cd the dffdc ly gial la chi so BMI cd anh hffdng nhieu hdn den sff tien trien nang len cua cac ton thffdng ban chan OTO khi da cd bien dang cau true glai phau ban chan, hoac cac tdn thffdng da tien tnen den loet hoac hoai tff.^
4.4. Uen quan g i u ^ kiem scat du'dng mau, h u y a ap, lipid m a u va benh ly ban d i a n OTO
HbAic la thdng sd phan anh viec kiem soat
dffdng mau trong mgt khoang thdi gian 2-3 thang, cho biet gia t n trung binh cua dffdng mau ddi va sau an 2 gid, do d d phan anh tffdng ddi chinh xac qua trinh kiem soat dffdng mau ciia benh nhan. Trong nghien cffu ciia chiing tdi (Bang 2) cho thay cd mdi lien quan chat giffa chi so HbAic vdi benh iy ban chan OTO (p < 0,05).
Nghien cuXi tffdng tff ciia cac tac gia Fatma [ 4 ] , Samann [5] va Edgar J [7] deu cd sff thdng nhat vdi nghien cuXi cua chiing tdi khi nhan djnh ve vai trd anh hffdng ciia HbAic trong benh ly DTO.
Mat khac theo Hdi Npi tiet hoc Hoa ky (2002) neu chi sd HbAic giam di 1 % thi bien chffng mach mau nhd (bao gdm ca bien chffng than kinh ngoai vi) giam di 30 - 35%. Ben canh do, ket qua nghien cffu (Bang 2) cung cho thay cho thay co mdi lien quan chat giffa mffc dp kie'm soat dffdng mau sau an 2 gid vdi benh ly ban chan OTO. Ket qua nay gdp phan ciing co cho nhan dlnh tren ve anh hffdng ciia dffdng huyet vdi ton thffdng ban chan OTO. Tuy nhien chiing tdi khong tim thay mdi lien quan giffa dffdng mau ddi va benh ly ban Chan DTD (p > 0,05) (Bang 2). Sd di cd sff khac biet nay la do cac benh nhan tron nghien cffu chii yeu dieu trj ngoai tru nen dffdng mau ddi chi la thdng so tai thdi diem benh nhan den kham benh chff khdng phai dffdng mau ddi trung binh. Tuy nhien, cac tac gia nay deu thong nhat rang kiem soat dffdng mau la yeu t d quan trpng lam giam nguy cd bien chffng ban chan DTO, dieu nay cung hoan toan phii hdp ve mat cd che benh smh ciia bien chffng ban chan DTO.
Cac benh nhan OTO thffdng cd rdi loan chuyen hda lipid mau di kem, vdi benh ly mach mau RLCH lipid ndi rieng cdn la mdt nguyen cd ddc lap dan den benh ly vffa xd mach mau lam cac ton thffdng mach mau tien trien nang them [2,4], Tuy nhien ket qua thu dffdc trong nghien cffu ciia chiing tdi (Bang 2) chi ra xu hffdng nhffng benh nhan cd RLCH lipid thi tang nguy cd xuat hien bien chffng ban chan OTO (p = 0,064).
Tffdng tff, trong nghien cffu ciia Fatma [4] RLCH lipid cung dffdc nhac den nhffng cung khong thay cd mdi lien quan, cd le do dac diem quan the nghien cffu ciia chung tdi la benh nhan ngffdi cao tud'i OTD, ngoai cac rdi loan do tinh trang tang dffdng mau cdn cd hen quan den qua trinh lao hda tac ddng vao cac tdn thffdng vi mach va than kinh ngoai vi.
Trong nghien cffu ciia nhdm tac gla Fatma [4] khi danh gia rieng ve anh hffdng ciia tang huyet ap vdi ton thffdng mach mau ngoai vi
Y HQC VlgT NAM THANG 3 - SO" 1/2013 trong b?nh ly ban chan dai thao dffdng cho thay
tSng huyet ap la mdt yeu td lam tSng nguy cd mac benh ly ban chan do DTD vdi p = 0,015, dieu nay khdng thay ro d qua ket qua nghien culi ciia chiing toi (p > 0,05) (Bang 2). Nguyen nhan dan den sff khac biet nay cd the do ddi tffdng nghien cu\i khac nhau. Trong nghien ciru ciia chiing tdi nhffng benh nhan cd tdn thffdng ban chan la bao gdm tap hdp tat ca nhffng benh nhan cd tdn thffdng theo cd che than kinh va tdn thffdng theo cd che mach mau cdn ket qua cua nhdm tac gla tren chi danh gla trong nhdm doi tffdng cd tdn thffdng mach mau.
4.5. Lien quan giu'a ton thu'dng vi mach vdi ton thu'crng b^n chan OTO;
Ton thffdng vi mach do OTD dffdc danh gia thdng qua cac bien chiTng tai than va mSt. Bien chffng than la mdt trong nhffng bien chffng quan trpng trong sd nhffng bien chffng man tinh do OTO ma MAU la bieu hien sdm cua ton thffdng than do OTD do cd che ton thffdng vi mach.Ket qua thu dffdc cho thay nhffng benh nhan DTD cd MAU thi CO nguy cd bj ton thffdng ban chan cao hdn nhffng benh nhan DTO chffa cd MAU 2,6 lan (OR = 2,596, p = 0,001) (Bang 3). Trong nghien cirtJ ciia tac gia Fatma [4] cung cho thay nhffng benh nhan cd MAU thi ti le bj bien chffng ban chan cao hdn han so vdi nhffng benh nhan khdng cd MAU (p = 0,012).
Thdi gian mac OTD cang dai thi ti le mac benh ly vdng mac cang tang, bang 3 cho thay nhffng benh nhan co ton thffdng mat do DTO thi ti le ton thffdng ban chan tang vffdt trdi so vdi nhffng benh nhan khdng cd ton thffdng mat do DTO (p < 0,05). Oieu nay cung tffdng tff nhff ket qua ciia Edward J va cs [6] cho thay cd mdi lien quan chat giffa ton thffdng tai mat do DTD vdl bien chffng ban chan DTO.
V. KET LUAN
Nghien cffu 300 benh nhan OTO typ 2 tren 60 tudi cho thay ty le cd ton thffdng ban chan do OTD la 64%. Cac yeu to nguy cd gay ton thffdng ban chan DTD bao gom thdi glan mSc benh, mii'c dp kiem so^t dffdng mau, hut thuoc. Bien chffng vi mach nhff bien chufng tai than cd nguy cd cao hdn 2,6 lan, bien chffng mSt nguy cd cao hdn 4,2 lan, chi sd ABI thap nguy cd cao hdn 18 lan.
TAI LIEU THAM KHAO
1. Bill Minh Dffc (2002)."Nghien cuU cac ton thutfiig loet bdn chan d b^nh nhan dai thao dudng^Liiln vSn thac sy y hpc, Tn/ftng Dai hpc Y Ha N^i.
2. Oo Trung Quan (2006). "B^nh ly ban chan dai thao du'dng". Bien chffng b^nh dai th^o du'dng va dieu tri. Nha xuat ban Y hpc. Ha Npi, tr. 174 - 198.
.... WHO/IDF (2006), "Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia".
Printed by the WHO Document Production Sen/ices, Geneva, Switzerland.
-I. Fatma Al - Maskari, Mohammed El-Sadig (2007}
"Prevalence of nsk factors diabetic foot complications". BMC Family Practice 2007, 8:59.
J. Samann A, Tajiyeva O, Muller N, Tschauner T, Hoyer H, Wolf G, Miiller UA (2008). "Prevalence of the diabetic foot syndrome at the primery care level in Germany a cross sectional study". Diabet Med; 25(5): 557-563.
6. Edward 3 et al. (1999), "A prospective study of risk factors fix diabetic foot UVJETS", Diabetes care, Volume 22, Number 7, July 1999, pp. 1036 - 1042.
7. Edgar J et al (2001) "Effectiveness of the diabetic foot risk classirication system of the intematkmal working group on the diabetic foot". Diabetes Care, volume 24, number 8.
