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 The impact ofDiabetic foot ulcer on Quality of Life:As shown in table (6) Multivariate Analysis of Variance (MANOVA)was performed to test the effect of  variableson quality of life scales. As shown in table (6), the variables of gender,stressful life events, Peripheral Vascular Disease (PVD) and BMI weresignificant.In this study, females had significantly lower health-relatedquality of life with DFS-SF than males (P-value 0.038). Patient with stressfullife events had significantly lower health-related quality of life score usingDFS-SF scale or Physical and Mental Components Summaries scores using SF-8scale than patients without stressful life events in last year (P-values were0.

000 for DFS-SF, 0.013 PCS8 and 0.006 MCS8 respectively).Health-related quality of life score of DFS-SF as well as PhysicalComponent Summary-8 were significantly lower in diabetic patients with footulcer and PVD in comparison to those with foot ulcer without PVD (P-value 0.

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004for DFS-SF, 0.016 for PCS8 respectively). Additionally, obese patients withdiabetic foot ulcer had lower DSF-SF and physical component summary-8 scoresthan non-obese (p-values 0.

024, 0.036) respectively.As shown in table (7), femalesscored significantly lower than males on the Physical health and Negativeemotions DSF-SF subscales than men (P-values: 0.023, and 0.015 ) respectively. The study participants who had an educational level of more thanhigh school, were more worried about ulcer subscale in comparison to those witheducational level than high school (P-value 0.024). While those with familyincome more than 500 JD’s scored higher on physical health subscale incomparison with their counterparts (p-value= 0.

003).Scores in the most of DFS-SF subscales were lower in participantswho had stressful life events in the last year. P-values were (0.000) for Leisure/Enjoyinglife, (0.000) for Physical Health, (0.001) for Dependency/Daily life, (0.009)for Negative Emotions  and (0.

008) for Botheredby ulcer care.Our results also showed that patients who did not have ischemicfoot ulcer had a better health related quality of life for the followingsubscales: Dependency/Daily life and worried about ulcer (P-values: 0.005 and0.018) respectively.

Presence of retinopathywas associated with poor quality of life on leisure/ enjoying life as well asdependency subscales (p-values= 0.031 and 0.007) respectively.Finally, obeseparticipants scored lower on bothered by ulcer care subscale than non-obese participants(p-value= 0.

022).   DiscussionIn thisstudy, diabetic patients with foot ulcers had significantly low median (SD)Diabetic Foot Scale-Short Form score (DFS-SF) 42.1±17.0 as well as low medianPhysical and Mental Components Summary scales scores (PCS8 and MCS8) (39.3±9.9for PCS8 and 41.9±11.1 for MCS8 respectively) using the SF-8 healthquestionnaire for assessing health-related quality of life.

SF-8 Physicaland Mental Components Summary scale scores for quality of life in the studywere lower compared with the general population of North Jordan. SF-36population norms among the general population of North Jordan were establishedin a study conducted by Khader et al. (2001), which set the mean (SD) SF-36scale scores for the population of north Jordan. Physical Function was set at66.5 (28.3), Role-Physical was set at 60.4 (34.8), 56.

4 (26.7) for Bodily Pain,64.0 (18.5) for General Health, 55.7 (19.5) for Vitality, Social Functioningwas set at 66.4 (22.

2), 58.7 (40.2) for Role-Emotional and 61.

2 (22.2) forMental Health. Khader et al., study also found that males scored the highest(66.8) in Social Functioning and the lowest (55.

8) in Vitality. Women had thehighest score (69.8) in Physical Function, but their lowest score was in BodilyPain (54.6).(23)Similar toour findings are those of Ashford, who assessed quality of life of 21 DFUpatients. Ashford’s study reported that families of DFU patients were unable todo certain procedures, which led to family-related problems. Such problemsincluded wound dressing, moderate mobility reduction shopping and taking ashower, and had negative impact on patients’ quality of life.

(24) Thecross-sectional study by Goodridge et al. on 114 adult individuals withdiabetic foot ulcers established that patients with diabetic foot ulcers had apoorer physical quality of life than patients with unhealed ulcers.(25) Recent US and UK studies showed that diabeticfoot ulcers adversely affect the quality of life of patients.(26,27)Our datashowed that females had significantly lower health-related quality of life thanmales. Women are likely to be more concerned about their health conditions andtheir impact on family environment than men, particularly among housewives.

Inagreement with our finding most previous studies had shown that males hadbetter health than females. Lebanese women had a lower quality of life thanLebanese men.(19) Canadian men hadmarkedly higher scores than women in all SF-36 Health Survey domains.(28) Similarly, US men fared better thanwomen in all SF-36 domains.

(29) Exceptfor the General Health domain, British male scores were also higher thanfemales’.(30) Comparable to our findings are thosebased on different surveys conducted on Spanish patients. Those results provedthat women had a poorer quality of life. (31) PeripheralVascular Disease (PVD) and diabetes often entail neuropathy, foot ulcer, increasedrisk of developing gangrene, ischemia and amputation to lower extremities.

(32,33) Disabilityand inability to mobilize, and decreased physical functioning are furthercomplications of diabetes. As impaired lower extremity functioning may lead topoorer quality of life, it is considered an important predictor of futuredisability. Diabetes-based loss of mobility, placement at nursing facilitiesand possible disability may elevate in PVD patients. (34,35)Thisstudy showed that patients with both diabetic foot ulcers and PVD scoredsignificantly lower in terms of quality of life lower than patients withoutPVD. Consistent with our findings, are Dolan et al.’s (2002) also determinedthat diabetic patients with PVD had poorer lower limb function thannon-diabetic patients with PVD.

DM patients, when compared to non-diabeticpatients, were younger, had a higher BMI, had worse neuropathy scores, and hadgreater number of cardiovascular morbidities. Though diabetic patientsexpressed the presence of exertional leg pain, they were less prone to reportclassical symptoms of intermittent claudication.(36) Siersma et al., study (2013), alsoreported that such factors as limb-threatening ischemia, inability to stand orwalk independently, ulcer size and C-creative protein concentration mostimportantly contributed to health-related quality of life.(37) In addition,Lloyd et al.

, (2001) proved that PVD in diabetic patients associatedsignificantly with Lower Physical and Social Functioning scales scores, whereasCAD most frequently associated with significant reduction in health-relatedquality of life, particularly in the physical domains.(38)Our data alsoshowed that obese diabetic patients with foot ulcers had significantly lowerquality of life than non-obese diabetic patients with foot ulcers. Consistent withour result Redekop et al.

, study (2002) also showed that obesity, diabeticcomplications and insulin-based therapy associated with poorer quality of lifein T2DM patients.(39) Adeyemi et al., (2014) also concluded thatdiabetic patients who were obese or morbidly obese had significant associationswith lower Physical Component Summary-12 than DM patients of normal weight.(40)Our studyshowed that patients with diabetic foot ulcers and stressful life events scoredlower than those without stressful life events on health-related quality oflife. Stressful life events, linked to wound healing, will eventually mark anincrease in the negative mood and result in improper sleep patterns. (41)Recently, many Studies have illustrated the mechanism of stress in slowing thehealing rate of acute and chronic ulcers, which leads to long-term of ulcercare and this creates further burden, pressure and low quality of life (Itani, 2015).(42)To determine the link between stress and healthy human immunity, a meta-analysiswas conducted which found that consistent and prolonged stress resulting fromdivorce, bereavement, care-giving, and unemployment led to increasedcirculation of neutrophils and monocytes, as well as to a reduction in naturalkiller cell activity, and to decreased lymphocyte proliferation and antibodyproduction.

(43) In addition, stresswill increase glucocorticoid level, (44) thus decreasing growth factors andincreasing certain pro-inflammatory cytokines. This will result in excessiveactivation of matrix-metalloproteinase, marking the breakdown of extracellularmatrix molecules and growth factors. It will also inhibit the proliferation offibroblast and keratinocytes, ultimately leading to preventing wound healing. (45)Moreover,the release of catecholamine (epinephrine and norepinephrine) in response to stresscauses alterations of the immune cell function. Releasing catecholamine alsoelevates blood glucose levels, thus contributing delay in wound healing. (46)Our  result agreed with other results conducted byMargarita, et al., (2011),  and foundthat perceived social support and stressful life events have independentsignificant effects on the HRQoL in CAD patients, especially in femalepatients.(47) Also Walders-Abramson, et al.

, (2014), examined therelationship between stressful life events and physiological measures,medication adherence, depressive symptoms, and impaired quality of life inadolescents with T2DM. The odds of having clinically elevated depressivesymptoms or impaired QOL were associated with a two-fold increase among thosereporting at least one major stressful event. (48)ConclusionDiabetic footulcer patients have significantly low median (SD) Diabetic Foot Scale-ShortForm score (DFS-SF) 42.1±17.

0 as well as low median Physical and MentalComponents Summary scales (PCS8 and MCS8) (39.3±9.9 for PCS8 and 41.

9±11.1 forMCS8) using SF-8 health questionnaire for assessing health-related quality oflife. Female gender, obesity, presence of PVD and stressful life events werethe most important factors associated with lower quality of life in patientswith diabetic foot ulcer.

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