Chapter One

Introduction

Introduction
Diabetes mellitus is a metabolic disease characterized by elevated levels of glucose in the Blood
(hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. Insulin is a
hormone produced by the pancreas, controls the level of glucose in the blood by Regulating the

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production and storage of glucose. In the diabetic state, the cells may stop Responding to insulin
or the pancreas may stop producing insulin entirely, this leads to hyperglycemia.

According to the World Health Organization Palestine as many other developing countries is
going through an epidemiological transition with its associated rise in chronic diseases which
increased by 31.1% in 2004-2006. At the same time the health system is facing the challenges of
controlling the incidence of some communicable diseases. In 2007, the health system was able to
reduce the mortality rates of infectious disease to 27.8 per 100 000 population (who, 2008).

According to the World Health Organization(WHO ,2013), 347 million people Worldwide have
diabetes , in Palestinian Ministry of Health( 2014) published that the number of diabetes
reviewers in primary health care clinics were 134,336 revisers, and the percentage of male
revisers to diabetes clinics (45.9%),while the percentage of females revisers to diabetes clinics
were (54.1%). The number of new diabetes patients who are enrolled in the primary health care
diabetic clinics were 4,816 patients of whom 2,679 females (54.1%) and 2,137 males (45.9%).
(92.3%) of new diabetes patients age 35 years and older. The highest number of new diabetic
patient in Hebron 2,216 new patient (46.1%), followed by Nablus 591 new patient (12.5%), then
Jenin 480 new patients (10%) of the registered cases. (4.3%) of diabetic patient with type 1
insulin-dependent and (64.8%) of diabetic with type 2 treated by oral tablet, (20.6%) using
insulin, (9.9%) take oral tablet and insulin together, and (0.4%) only exercising and diet(MOH,
2014).

Diabetes increases the risk of long-term complications which is believed to develop after many
years of the disease onset. The major long-term complications are related to damage to blood
vessels which is doubled by diabetes is the risk of cardiovascular disease. The main
"macrovascular" diseases are ischemic heart disease , stroke and peripheral vascular disease.
Diabetic retinopathy, which affects blood vessel in the retina of the eye, can lead to visual
symptoms, reduced vision, and potentially blindness. Diabetic neuropathy is the impact of
diabetes on the nervous system, most commonly causing numbness, tingling and pain in the feet
and also increasing the risk of skin damage due to altered sensation. Together with vascular

 2
disease in the legs, neuropathy contributes to the risk of diabetes-related foot problems (such as
diabetic foot ulcers) that can be difficult to treat and occasionally require amputation.
The quality of life of a person with type 2 diabetes is influenced by several factors, this include
awareness of the complication and risk-factors of diabetes, and age of the patient, duration of the
disease, and BMI of the patient.(Kalda, Ratsep et al. 2008) .

Older age, lower education, being unmarried, obesity, hypertension and hyperlipidemia were
also associated with impaired Quality of life ( QOL) .Effective type 2 diabetes management and
improved quality of life of individuals and prevent diabetes complication as amputation are
interrelated. The measurement of quality of life is an important component in continuous
improvement of chronic disease management in primary care settings.

Patient education, understanding, and participation is vital, since the complications of diabetes
are far less common and less severe in people who have well-managed blood sugar levels
(Stahl F, Johansson R. 2008). Attention is also paid to other health problems that may accelerate
the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity,
high blood pressure, and lack of regular exercise (Hosseinpanah, F et al. 2007).

Amputation is the surgical removal of all or part of a limb or extremity such as an arm, leg, foot,
hand, toe, or finger. About 1.8 million Americans are living with amputations. Amputation of the
leg -- either above or below the knee -- is the most common amputation surgery.
Reasons for Amputation:
There are many reasons for amputation; the most common is poor circulation because of damage
or narrowing of the arteries, called peripheral arterial disease that lead to inadequate blood flow
which deprive body's cells from oxygen and nutrients, as a result, the affected tissue begins to die
and infection is the absolute result.
Other causes for amputation may include:
Severe injury (from a vehicle accident or serious burn, for example)
Cancerous tumor in the bone or muscle of the limb
Serious infection that does not get better with antibiotics or other treatment
Thickening of nerve tissue, called a neuroma Frostbite
Recovery from Amputation

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 Recovery from amputation depends on the type of procedure and anesthesia used.
Phantom pain (a sense of pain in the amputated limb) or grief over the lost limb, is the most
common post amputation pain, when it's occur the doctor will prescribe medication and/or
counseling, as necessary. Ideally, the wound should fully heal in about four to eight weeks. But
the physical and emotional adjustment to losing a limb can be a long process. Practice with the
artificial limb may begin as soon as 10 to 14 days after surgery. Physiotherapy, beginning with
gentle, stretching exercises, often begins soon after surgery.

Long-term recovery and rehabilitation will include:

 Exercises to improve muscle strength and control
 Activities to help restore the ability to carry out daily activities and promote independence
 Use of artificial limbs and assistive devices
 Emotional support, including counseling, to help with grief over the loss of the limb and
adjustment to the new body image .

Significance of study:
During our clinical training it is observed that there is a significant proportion of diabetic patients
with amputation with different reactions to the experiences of patients who have amputation that
varies from the psychological and psychosocial and emotional responses (stress, depression,
withdrawal, isolation and a sense of stigma). In spite of the great impact of amputation on the
diabetic patient psychosocial status and the effects on their quality of life, there is lack of studies
about the lived experience for patient with Diabetes after amputation in Palestine, especially in
North of West Bank. For that it is believed that it is believed that it is of great importance to
conduct this study to determine the lived experience of diabetic patients after amputation, and to
know some of the burden that can worsen the quality of life for those patients.

Problem statement:

 4
It is believed that it is of great importance to investigate the lived experience of diabetic patients
after amputation in the north of west bank, also to highlight the view of patients and their
families about amputation.

Aims of the Study:

To investigate the lived experience (psychosocial and emotional status) of diabetic patient after
an amputation, and their coping mechanisms they used.

The diabetes-related amputation occurs every 30 seconds, and 85% of these amputations are
precipitated by a minor foot injury such as a blister or a callus. But unfortunately these injuries
are often ignored because diabetes causes peripheral neuropathy (nerve damage to the feet). But
nowadays foot health and diabetes education campaign is successful, (Rogers, 2005).

Patients with DM have statistically significant impairment of all aspects of QOL, not simply
physical functioning. DM put a substantial burden on affected individuals by influencing
physical, psychological and social aspects of QOL. (Porojan, Poanta et al. 2012)

A lower limb amputation is a surgical procedure that results from a serious medical condition
such as diabetes, trauma or neoplasm affecting the individual’s well-being, quality of life, and
autonomy. Anxiety, depression, body-image anxiety and social discomfort have been pointed out
as frequent consequences of a lower limb amputation (Hugo, et al. 2005).

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 Chapter two
Literature review

Literature review

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A study was conducted in Irish, (2015), about Management of diabetic foot disease and
amputation in the Irish health system: a qualitative study of patients’ attitudes and experiences
with health service, the sample was 10 men participated in the study who had either active foot
disease or a lower limb amputation as a result of diabetes, were recruited from the Prosthetic,
Orthotic and Limb Absence Rehabilitation (POLAR) Unit of an Irish hospital. One-to-one
interviews were conducted in the POLAR unit using a semi-structured topic guide. Thematic
analysis was used to identify, analyze and describe patterns within the data. The result was most
participants expressed a need for emotional support alongside the medical management of their
condition. There were substantial differences between participants with regard to the level of
education and information they appeared to have received regarding their illness. There were
also variations in levels of service received. Transport and medication costs were considered
barriers. Having a medical card, which entitles the holder to free medical care, eased the burden
of the patient’s illness. A number of participants attributed some of the problems they faced with
services to the health care system as whole rather than health care professionals.( Andrew
Hanrahan,. et al. 2015).

A study was conducted in USA,( 2012), about How long to treat with antibiotics following
amputation in patients with diabetic foot infections? Are the 2012 IDSA DFI guidelines
reasonable, aimed To the best of our knowledge, there has been no published study designed to
identify the most appropriate duration of antibiotic therapy in lower extremity skin and skin
structure infections in diabetic patients [aka “diabetic foot infections” (DFI)] post-amputation.
However, recent guidelines published by the Infectious Diseases Society of America (IDSA)
provide recommendations for treatment duration in these patients. Therefore, our objective is to
review the literature evaluating antibiotic treatment in DFI to determine if the IDSA guidelines
are reasonable, Evidence for the use of antibiotics after amputation comes largely from
preoperative surgical prophylaxis studies evaluating the rate of infection after amputation. Three
such studies were identified; 2 found a 5-day course of antibiotics post amputation resulted in a
reduction of infection rate, while 1 Found no additional benefit. Comparative antibiotic studies in
DFI also offers evidence for treatment duration, of which, 10 studies were identified. Five

 7
included patients who received amputations; however, only 1 reported treatment outcomes in a
subset of diabetics requiring amputation. In this study, the authors concluded that antibiotic
treatment is likely necessary after amputation. The result was we recommend that post-operative
treatment duration be individualized, and, until further studies are done, it seems reasonable to
adhere to the recommendation provided by the 2012 IDSA DFI guidelines for a 2–5 day course
of antibiotic therapy postoperatively when no residual infected tissue remains. (D. B. May, et al,.
2012).

A study was conducted in Singapore,(2013) , about Distal amputations for the diabetic foot ,
aimed to Minor amputations in diabetic patients with foot complications have been well studied
in the literature but controversy still remains as to what constitutes successful or non-successful
limb salvage. In addition, there is a lack of consensus on the definition of a minor or distal
amputation and a major or proximal amputation for the diabetic population. In this article, the
authors review the existing literature to evaluate the efficacy of minor amputations in this
selected group of patients in terms of diabetic limb salvage and also propose several definitions
regarding diabetic foot amputations, the results was Minor amputations in patients with diabetic
foot problems have been shown to be effective in limb salvage and reducing morbidity and
mortality in patients. The authors have proposed several definitions regarding diabetic foot
amputations while further studies are needed for a consensus on the definition on a successful
versus non successful diabetic limb salvage surgery.( Aziz Nather, 2013).

A study was conducted in Philadelphia , (2005) . about Risk of amputation in patients with
diabetic foot ulcers: a claims-based study, The objective of this study was to undertake a
retrospective analysis of claims data of diabetic foot ulcer (DFU) patients to determine the rates
of amputation and identify the risk and protective factors. The eligible cohort consisted of all
patients with two or more ICD-9 diagnostic claims16 for a DFU and evidence of diabetes based
on a relevant diagnostic code or prescription data indicating use of insulin or oral hypoglycemic
therapy. The index date was the day of the first DFU diagnosis and patients were also required to

 8
have 3 months of data prior to this date without any medical claims indicating a primary or
secondary DFU diagnosis or any LEA. In addition, patients were required to have continuous
eligibility for in- and outpatient coverage during the pre- and post diagnosis periods. The results
was In the 5911 patients with DFU, 116 individuals who had LEAs were identified as cases
yielding a crude amputation rate of 1.96%. The incidence density rate was 0.02298 per person-
year (or 2.30 per 100 person-years), based on a total person-time of 5046.9 years in the eligible
subjects. Assuming a Poisson distribution, a 95% CI around this estimate would be 0.0191–
0.0277 per person-year (or 1.91 to 2.77 per 100 person-years). (David J. Margolis,. 2005).

A study was conducted in China , ( 2013) , about patients with chronic diabetic foot ulcers,
hyperbaric oxygen reduces major amputations, aimed to Included studies compared usual care
(e.g., control of glycemia, revascularization, debridement, off-loading, and metabolic and
infection controls) plus HBO with usual care alone in patients with type 1 or type 2 diabetes and
chronic lower-extremity ulcers attributable to diabetes. Outcomes included ulcer healing
(complete epithelialization of the wound), major (above the ankle joint) or minor (below the
ankle joint) amputation, and adverse events. Using MEDLINE and EMBASE/Excerpta Medica
(both to Apr 2012); Cochrane Library (2012); reference lists; abstracts of major diabetes,
endocrinology, and plastic surgery meetings (2003 to Apr 2012); and trial Web sites, were
searched for randomized controlled trials (RCTs) and nonrandomized controlled trials. 13 trials
(n = 624), including 7 RCTs (n = 359, mean age range 53 to 72 y; follow-up range 2 to 92 wk),
met selection criteria. No RCT reported allocation concealment, 2 had blinding, 3 used a
random-number generator, and all reported loss to follow up. Only the results of RCTs are
presented here.the results was In patients with chronic diabetic foot ulcers, adding hyperbaric
oxygen to usual care reduces major amputations. (Boden G, et al, 2013)

A study was conducted in Sourasky Medical Center, Tel Aviv, Israel,( 2012) , about
Rehabilitation outcome of post-acute lower limb geriatric amputees,the purposed was To
characterize the lower-limb elderly amputee patients admitted to a post-acute rehabilitation
program, assess their 1-year survival rate, estimate rate of prosthetic fit and report rate and
factors associated with 1-year post-discharge prosthetic use, Most elderly amputees in our
country are referred to a post-acute care facility for rehabilitation and assessment for potential

 9
prosthetic fit. The current study was performed in a university affiliated 300-bed major post-
acute geriatric rehabilitation centre, admitting older patients from major acute hospitals in nearby
cities. Half of the patients are admitted for rehabilitation after orthopedic surgery, stroke or
deconditioning due to prolonged hospitalization. The other half are admitted for medical care,
encompassing treatment for severe pressure ulcers, management of advanced heart failure,
terminal cancer, chronic ventilation, etc. All admitted patients carry full medical coverage
provided by four health maintenance organizations (HMOs) conforming to the following
admission criteria: >60 years old, functionally dependent, lack of social support system, or living
in an unfitted home environment (i.e. no elevator or narrow doorways leading to the bathroom).
Since post-acute amputees have a low rehabilitation potential (low survival rate and low rate of
prosthesis fit) we suggest that: (a) – rehabilitation efforts should best be targeted depending on
need, and (b) – rehabilitation professionals should make educated estimates of outcomes at the
beginning of rehabilitation based on the characteristics of the patients (level of amputation and
functional level on admission).( Avital Hershkovitz, Israel Dudkiewicz, Shai Brill, 2013).

A study was conducted in New York, (2009) , about Mechanism of Sustained Release of
Vascular
Endothelial Growth Factor in Accelerating
Experimental Diabetic Healing , aimed to we hypothesize that local sustained release of vascular
endothelial growth factor (VEGF), using adenovirus vector (ADV)-mediated gene transfer,
accelerates experimental wound healing. This hypothesis was tested by determining the specific
effects of VEGF165 application on multiple aspects of the wound healing process, that is, time to
complete wound closure and skin biomechanical properties. After showing accelerated wound
healing in vivo, we studied the mechanism to explain the findings on multiple aspects of the
wound healing cascade, including epithelialization, collagen deposition, and cell migrate
Intradermal treatment of wounds in non-obese diabetic and db/db mice with ADV/VEGF165
improves healing by enhancing tensile stiffness and/or increasing epithelialization and collagen
deposition, as well as by decreasing time to wound closure, using Construction of an ADV
expressing bioactive human VEGF for murine study Human umbilical vein endothelial cells
(HUVECs) were homogenized and total RNA was extracted. The full-length human VEGF165

 10
cDNA was amplified by PCR with appropriate primers containing restriction sites (HindIII and
XbaI) for subcloning into pBluescript (Stratagene, La Jolla, CA). After sequence confirmation,
the human VEGF-165 cassette was cloned into the multiple cloning site of an adenovirus shuttle
vector (pXC1) containing adenovirus type 5 sequences (bp 22–5,790) and a Rous sarcoma virus
promoter. This same vector was used as the positive control Dl-312 in the experiments. For the
rescue of the recombinant adenovirus, we successfully used the two-plasmid co-transfection
system (Microbix Biosystems, Inc., Toronto, Ontario, Canada). Virus particle titer was
determined by optical absorbance at 260 nm, and plaque-forming unit titer (pfu ml1 ) was
quantified by standard agarose overlay plaque assay on 293 cells. Plaque-forming unit (pfu)
determination can vary up to one order of magnitude when the same batch of virus is used in
different assays, causing a significant variation in particle measurement. To prevent this problem
and to keep the viral loads constant, the same batch of virus was used for all in vitro and in vivo
experiments. The results was ADV/VEGF165 accelerates time to closure in db/db mice To
determine whether ADV/VEGF165 accelerates wound healing, time to wound closure was
determined using four different doses of ADV/VEGF165. Wounds treated with ADV/VEGF165
healed 6.6 days sooner than controls (Figure 1). Treated wounds healed in 27.2±1.4 days. Saline-
treated wounds healed in 34.2±7.0 days, whereas wounds that were treated with the virus vector
alone healed in 33.5±6.5 days. Statistical significance (Po0.05) was noted after comparison of
the 5 1011 vp per wound VEGF165-treated group and control groups (Table 2). However, such
high doses of VEGF165 may have a toxic effect in the mice used in the study, as the incidence of
mortality in the high-dosage VEGF165-treated group was greater than in other groups. A
minimum 10% increase in mortality relative to controls was found at ADV/VEGF doses of 5
109 vp per wound and higher.( Alan D.Weinberg, et al, . 2012).

A study was conducted in USA ,( 2001) , about Fluorescein dermofluorometry for the assessment
of diabetic microvascular disease, the aim was Fluorescein dermofluorometry can be used to
relate the uptake of fluorescein in the skin to blood flow. We have characterized the uptake of

 11
fhe dye by a wash-in time constant that is inversely proportional to the local blood flow. The
purpose of this study was to explore the use of dermofluorometry in the assessment of patients
wifh diabetic microvascular disease, using Ruorescein dermofluorometry was performed in four
groups of patients: non-diabefic control patients, diabetic control patients, diabetic patients with
chronic foot ulcers, and diabetic patients with acute foot ulcers. The outcomes of the patients
with foot ulcers were documented 4-14 months after participation. Following an intravenous
injection of sodium fluorescein, the change in the fluorescein signal with time was continuously
measured at the plantar surface of the foot. Both the initial slope of the signal and the wash-in
time constant were calculated in each subject. The results was The fluorescein wash-in time
constant demonstrated better correlation with the presence of diabetic microvascular disease than
did the initial slope of the signal. Differences in the wash-in time constants of non-diabetic and
diabetic subjects support the hemodynamic hypothesis for the development of microvascular
disease. The indication of early wash-out of the fluorescein signal may also be useful in the
prediction of ulcer healing.( Deborah K. Oh, et al, .2001).

A study was conducted in Brazil , ( 2015 ) , about Development of the Tardivo Algorithm to
Predict Amputation Risk of Diabetic Foot, aimed to Diabetes is a chronic disease that affects
almost 19% of the elderly population in Brazil and similar percentages around the world.
Amputation of lower limbs in diabetic patients who foot complications is a common occurrence
with a significant reduction of life quality, and heavy costs on the health system. Unfortunately,
there is no easy protocol to define the conditions that should be considered to proceed to
amputation. The main objective of the present study is to create a simple prognostic score to
evaluate the diabetic foot, which is called Tardivo Algorithm. Calculation of the score is based
on three main factors: Wagner classification, signs of peripheral arterial disease (PAD), which is
evaluated by using Peripheral Arterial Disease Classification, and the location of ulcers. The
final score is obtained by multiplying the value of the individual factors. Patients with good
peripheral vascularization received a value of 1, while clinical signs of ischemia received a value
of 2 (PAD 2). Ulcer location was defined as forefoot, midfoot and hind foot. The conservative
treatment used in patients with scores below 12 was based on a recently developed
Photodynamic Therapy (PDT) protocol. 85.5% of these patients presented a good outcome and

 12
avoided amputation. The results showed that scores 12 or higher represented a significantly
higher probability of amputation (Odds ratio and logistic regression-IC 95%, 12.2–1886.5). The
Tardivo algorithm is a simple prognostic score for the diabetic foot, easily accessible by
physicians. It helps to determine the amputation risk and the best treatment, whether it is
conservative or surgical management. Using 62 patients with diabetic foot, from March 2011 to
March 2013 were used to develop the scoring method. The patients were treated at the Center for
Diabetic Foot at Hospital Anchieta (CeDiFo), served by the Faculdade de Medicina do ABC
(FMABC), which is coordinated by Dr. Tardivo. The study was approved by the research ethics
committee at FMABC and participants signed a consent form. The clinical investigation was
conducted according to the principles expressed in the Declaration of Helsinki. The results was
Patients with diabetic foot need to be treated using a multidisciplinary approach. Diabetes does
not have cure and the risks to patients may persist throughout life. The Tardivo algorithm is a
fundamental tool for predicting whether the diabetic foot has a higher chance of healing or a
higher chance of requiring amputation and may be a useful for guiding treatment. The proposed
score classification system for the diabetic foot may enable better quality of life for diabetic
patients and promote better low-cost care for millions of individuals worldwide. The adoption of
this score associated with antimicrobial photodynamic therapy could reduce amputations in
diabetics in over 80% of cases, resulting in lower costs, fewer hospitalizations and no side
effects. (Fernando Adami, et al, . 2015).

A study was conducted in Canada , ( 2015) , about Tool for Rapid & Easy Identification of High
Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot
Screening Tool, aimed to Most diabetic foot amputations are caused by ulcers on the skin of the
foot i.e. diabetic foot ulcers. Early identification of patients at high risk for diabetic foot ulcers is
crucial. The ‘Simplified 60-Second Diabetic Foot Screening Tool’ has been designed to rapidly
detect high risk diabetic feet, allowing for timely identification and referral of patients needing
treatment. This study aimed to determine the clinical performance and inter-rater reliability of
‘Simplified 60 Second Diabetic Foot Screening Tool’ in order to evaluate its applicability for
routine screening. Using The tool was independently tested by n=12 assessors with n=18
Guyanese patients with diabetes. Inter-rater reliability was assessed by calculating Cronbach’s

 13
alpha for each of the assessment items. A minimum value of 0.60 was considered acceptable.
Reliability scores of the screening tool assessment items were: ‘monofilament test’ 0.98; ‘active
ulcer’ 0.97; ‘previous amputation’ 0.97; ‘previous ulcer’ 0.97; ‘fixed ankle’ 0.91; ‘deformity’
0.87; ‘callus’ 0.87; ‘absent pulses’ 0.87; ‘fixed toe’ 0.80; ‘blisters’ 0.77; ‘ingrown nail’ 0.72; and
‘fissures’ 0.55. The item ‘stiffness in the toe or ankle’ was removed as it was observed in only
1.3% of patients. The item ‘fissures’ was also removed due to low inter-rater reliability. Clinical
performance was assessed via a pilot study utilizing the screening tool on n=1,266 patients in an
acute care setting in Georgetown, Guyana. In total, 48% of patients either had existing diabetic
foot ulcers or were found to be at high risk for developing ulcers, the results was Clinicians in
low and middle income countries such as Guyana can use the Simplified 60- Second Diabetic
Screening Tool to facilitate early detection and appropriate treatment of diabetic foot ulcers.
Implementation of this screening tool has the potential to decrease diabetes related disability and
mortality.( Brian Ostrow, et al, . 2015).

A study was conducted in Singapore, 2014, about The modified Pirogoff’s amputation in treating
diabetic foot infections: surgical technique and case series, aimed to This paper describes the
surgical technique of a modified Pirogoff’s amputation performed by the senior author and
reports the results of this operation in a single surgeon case series for patients with diabetic foot
infections, using Six patients with diabetic foot infections were operated on by the National
University Hospital (NUH) diabetic foot team in Singapore between November 2011 and
January 2012. All patients underwent a modified Pirogoff’s amputation for diabetic foot
infections. Inclusion criteria included the presence of a palpable posterior tibial pulse, ankle
brachial index (ABI) of more than 0.7, and distal infections not extending proximally beyond the
midfoot level. Clinical parameters such as presence of pulses and ABI were recorded.
Preoperative blood tests performed included a glycated hemoglobin level, hemoglobin, total
white blood cell count, C-reactive protein, erythrocyte sedimentation rate, albumin, and
creatinine levels. All patients were subjected to 14 sessions of hyperbaric oxygen therapy
postoperatively and were followed up for a minimum of 10 months. The results was The
modified Pirogoff’s amputation has been found to show good results in carefully selected
patients with diabetic foot infections. The selection criteria included a palpable posterior tibial

 14
pulse, distal infections not extending proximally beyond the midfoot level, ABI of more than 0.7,
hemoglobin level of more than 10 g/dL, and serum albumin level of more than 30 g/L. (Amaris
Shumin Lim, et al, . 2014).

A study was conducted in UK , (2010) , about Matching the numerator with an appropriate
denominator to demonstrate low amputation incidence associated with a London hospital
multidisciplinary diabetic foot clinic, the purposed was To establish a method to assess
amputation incidence that addresses the problems matching a numerator with an appropriate
denominator in London and to demonstrate low amputation incidence associated with the activity
of our multidisciplinary diabetic foot clinic, using Hospital-coded inpatient data was examined to
derive the numerator: the number of non-traumatic amputations performed on subjects with
diabetes each financial year where the Primary Care Trust commissioner code was our main
local Primary Care Trust. Denominators were derived from the main local Primary Care Trust’s
Quality and Outcomes Framework data sets. Not all Primary Care Trust subjects with diabetes
receive inpatient care at our hospital, so that the denominators were corrected for the hospital’s
percentage market share for the provision of inpatient diabetes care for the Primary Care Trust
each financial year, derived from the Dr Foster database. The results was We report for the first
time amputation incidence in a London population. Acknowledging the limitations of accurately
defining incidence in London, we demonstrate low amputation incidence associated with our
multidisciplinary diabetic foot clinic. (C. D. Bicknell, et al, . 2010).

A study was conducted in Netherlands , (2010) , about Differences in minor amputation rate in
diabetic foot disease throughout Europe are in part explained by differences in disease severity at
presentation, aimed to . We evaluated minor amputation rate, the determinants of minor
amputation and differences in amputation rate between European centres. Using In the Eurodiale
study, a prospective cohort study of 1232 patients (1088 followed until end-point) with a new
diabetic foot ulcer were followed on a monthly basis until healing, death, major amputation or up
to a maximum of 1 year. Ulcers were treated according to international guidelines. Baseline

 15
characteristics independently associated with minor amputation were examined using multiple
logistic regression modelling. Based on the results of the multivariable analysis, a
disease severity score was calculated for each patient. The results was Minor amputationis
performed frequentlyin diabetic foot centres throughout Europe andis determined by depth of the
ulcer, peripheral arterial disease, infection and male sex. There are important differences
inamputation rate between the European centres, which can be explained in part by severity of
disease at presentation. This may suggest that early referral to foot clinics can prevent minor
amputations.( A. Jirkovska, et al,. 2010).

A study was conducted in Denmark , ( 2013) , about Reduced incidence of lower-extremity

amputations in a Danish diabetes population from 2000 to 2011, the aim was to estimate time
trends in the incidence of lower-extremity amputations in Danish people with Diabetes, using
We studied major and minor lower-extremity amputations from 2000 to 2011 among 11 332
people with diabetes from the Steno Diabetes Center. Amputations were identified by linkage of
the electronic medical system with the National Patient Registry. Sex-specific incidence rates of
amputations by age, diabetes duration, calendar time and diabetes type were modelled by
Poisson regression. The results was . The incidence of major lower-extremity amputations
reduced significantly from 2000 to 2011 in Danish people with diabetes followed at a diabetes
specialist centre. (K. Færch, et al,. 2013).

A study was conducted in Pennsylvania, ( 2010) , about The differential effect of angiotensin-
converting enzyme inhibitors and angiotensin receptor blockers with respect to foot ulcer and
limb amputation in those with diabetes, aimed to This was a retrospective cohort study using the
general medical practices of The Health Information Network (THIN). By agreement, patient
data are recorded and stored in THIN as if it were an electronic medical record including all past
and current medical diagnoses (acute and chronic) using Read codes and information on
prescribed medications, using British National Formulary (BNF) codes. All laboratory values,
aspects of the physical exam, hospitalizations, consultations, and prescription medications are

 16
electronically entered into THIN datasets. Subjects in THIN have been shown previously to be
demographically comparable to the general UK population.12 The THIN database includes
records for more than 4.7 million patients, with approximately 2.26 million active patients from
300 practices in England and Wales. The annual estimated number of subjects lost to followup is
small (3%). Our study was reviewed and accepted by the Institutional Review Board of the
University of Pennsylvania. Using To be included in our inception cohort, a subject had to have
at least two separate medical records for diabetes noted between January 1995 and August 2006.
We used this algorithm to assure that the subject truly had diabetes. In addition, the subject had
to be at least age 35 at the time of diagnosis, could not have had a pervious history of venous leg
ulcer, DFU or LEA, and must have used an ARB and/or ACEi, which was first prescribed
between 1995 and 2006. the results was Based on our selection criteria, we identified 78,178
individuals with diabetes. ACEi or ARB were used by 40,342 individuals (51%). From this
group, 35,153 individuals were treated with ACEi, 12,437 individuals with ARB, and 7,248 were
exposed to both drugs. The total number of evaluable exposures was 47,590. One hundred and
seven individuals were excluded from our analysis because they were treated with both agents at
the same time. The mean age of our subjects was 64.4 (95% CI: 64.2, 64.5) years with a median
of 64.4 years. Females represented 45% (18,281) of the cohort. The mean total duration of
diabetes was 6.3 years (median 5.98) and total person-time of 216,070 years. There were some
statistical differences in covariates based on whether they received ACEi or ARB. (Arturo R.
Maldonado, et al,. 2010).

 17
Year Author Study title Purpose Subject Result
2015 Sarah Management Diabetes is an A purposive sample of Results suggest that
Aug Delea1*, of diabetic increasingly individuals who had rehabilitation services
Claire foot disease prevalent either active foot should place a strong focus
Buckley1, and chronic illness disease or a lower on psychological as well as
2, Andrew amputation that places a limb amputation as a physical adjustment to
Hanrahan in the Irish huge burden on result of diabetes were active foot disease or lower
3 , Gerald health the individual, recruited from the limb amputations. The
McGreal3 system: a the Prosthetic, Orthotic delivery of services needs
, Deirdre qualitative health system and Limb Absence to be
Desmond study of and society. Rehabilitation standardised to ensure
4 and patients’ Patients with (POLAR) Unit of an equal access to medical
Sheena attitudes and active foot Irish hospital. One-to- care and supplies among
McHugh experiences disease and one interviews were people with or at risk of
with health lower limb conducted in the lower extremity
services amputations POLAR unit using a amputations. The wider
due to diabetes semi-structured topic social circumstances of
have a guide. patients should be taken
significant Thematic analysis was into consideration by
amount of used to identify, health care
interaction analyse and describe professionals to provide
with the health patterns within the effective support while
care services. data patients adjust to this
The purpose of potentially life changing

 18
 this study was complication. The
to explore the patient’s perspective
attitudes and should also be used to
experiences of inform health service
foot care managers and health
services in professionals on ways to
Ireland among improve services.
people with
diabetes and
active foot
disease or
lower limb
amputations.
13 S. W. How long to To the best of Evidence for the use Given the general lack of
Septe Johnson*† treat with our knowledge, of antibiotics after data, we
mber PharmD, antibiotics there has been amputation recommend that post-
2012, R. H. following no published comes largely from operative treatment
Accep Drew*‡ amputation study designed perioperative surgical duration be individualized,
ted 13 PharmD in patients to identify the prophylaxis studies and, until further studies
Nove MS and with diabetic most evaluating the rate of are done, it seems
mber D. B. foot appropriate infection after reasonable to
2012 May*‡ infections? duration of amputation. Three adhere to the
PharmD Are the 2012 antibiotic such studies recommendation provided
*Campbel IDSA DFI therapy in were identified; 2 by the 2012 IDSA DFI
l guidelines lower found a 5-day course guidelines for a 2–5 day
University reasonable extremity of antibiotics course of antibiotic therapy
College of skin and skin postamputation postoperatively
Pharmacy structure resulted in a reduction when no residual infected
and infections in of infection rate, while tissue remains.
Health diabetic 1
Sciences, patients [aka found no additional

 19
 Buies “diabetic foot benefit. Comparative
Creek, infections” antibiotic studies in
†Forsyth (DFI)] post- DFI also offers
Medical amputation. evidence for treatment
Center, However, duration, of which, 10
Winston- recent studies were
Salem, guidelines identified. Five
and ‡ published by included patients who
Duke the Infectious received
University Diseases amputations; however,
Medical Society only 1 reported
Center, of America treatment outcomes in
Durham, (IDSA) a
NC, US provide subset of diabetics
recommendatio requiring amputation.
ns for In this study, the
treatment authors concluded that
duration in antibiotic treatment is
these patients. likely necessary
Therefore, after amputation.
are reasonable.
 May Aziz Distal Minor Minor amputations in
2013; Nather, amputations amputations in patients with diabetic foot
Revis FRCS* for the diabetic problems
ed: 3 and Keng diabetic foot patients with have been shown to be
June Lin foot effective in limb salvage
2013; Wong, complications and
Accep MRCS have been well reducing morbidity and
ted: studied in the mortality in patients. The
24 literature but authors
June controversy have proposed several

 20
2013; still remains as definitions regarding
Publis to what diabetic foot
hed: constitutes amputations while further
16 successful or studies are needed for a
July non-successful consensus on the definition
2013 limb salvage. on a successful versus
In addition, nonsuccessful
there is diabetic limb salvage
a lack of surgery.
consensus on
the definition
amputations
Septe Jeffrey S. Risk of The eligible cohort In the 5911 patients with
mber Markowit amputation consisted of all DFU, 116 individuals who
21, z, DrPH1 in patients patients with two or had
2004 ; Elane M. with diabetic more ICD-9 diagnostic LEAs were identified as
Accep Gutterman foot ulcers: claims16 for a DFU cases yielding a crude
ted in , PhD1 a claims- and evidence amputation
final ; Glenn based study of diabetes based on a rate of 1.96%. The
form Magee, relevant diagnostic incidence density rate was
Augus MBA2 code or prescription 0.02298 per
t 12, ; David J. data indicating use of person-year (or 2.30 per
2005 Margolis, insulin or oral 100 person-years), based
MD, hypoglycemic on a total
PhD3 therapy. The index person-time of 5046.9
date was the day of the years in the eligible
first subjects. Assuming
DFU diagnosis and a Poisson distribution, a
patients were also 95% CI around this
required to have 3 estimate would be 0.0191–
months of data prior to 0.0277 per person-year (or

 21
 this date without any 1.91
medical to 2.77 per 100 person-
claims indicating a years).
primary or secondary
DFU diagnosis
or any LEA. In
addition, patients were
required to have
continuous eligibility
for in- and outpatient
coverage during
the pre- and
postdiagnosis periods.
20 Liu R, Li In patients Included MEDLINE and In patients with chronic
Augus L, Yang with chronic studies EMBASE/Excerpta diabetic foot ulcers, adding
t 2013 M, Boden diabetic compared Medica (both to Apr hyperbaric
G, Yang foot ulcers, usual care 2012); oxygen to usual care
G. hyperbaric (e.g., control of Cochrane Library reduces major amputations.
oxygen glycemia, (2012); reference lists;
reduces revascularizati abstracts of major
major on, diabetes,
amputations debridement, endocrinology, and
off-loading, plastic surgery
and metabolic meetings (2003 to Apr
and 2012);
infection and trial Web sites
controls) plus (www.clinicaltrials.go
HBO with v,
usual care www.novonordisktrial
alone in s.com,
patients and

 22
 with type 1 or www.clinicalstudyresu
type 2 diabetes lts.org) were searched
and chronic for
lower- randomized controlled
extremity trials (RCTs) and
ulcers nonrandomized
attributable to controlled
diabetes. trials. 13 trials (n =
Outcomes 624), including 7
included ulcer RCTs (n = 359, mean
healing age range 53 to 72 y;
(complete follow-up range 2 to
epithelializatio 92 wk), met selection
n of the criteria. No RCT
wound), major reported allocation
(above the concealment, 2 had
ankle joint) or blinding,
minor (below 3 used a random-
the ankle joint) number generator, and
amputation, all reported loss to
and adverse followup.
events. Only the results of
RCTs are presented
here

May Avital Rehabilitatio To characterize Most elderly amputees Since post-acute amputees
2012 Hershkovi n outcome of the lower-limb in our country are have a low rehabilitation
tz1,2, post-acute elderly referred to a potential
Israel lower limb amputee post-acute care facility (low survival rate and low
Dudkiewi geriatric patients for rehabilitation and rate of prosthesis fit) we
cz2,3 & amputees admitted to a assessment for suggest
Shai post-acute potential prosthetic fit. that: (a) – rehabilitation

 23
Brill1,2 rehabilitation The current study was efforts should best be
program, performed in a targeted
assess university affiliated depending on need, and (b)
their 1-year 300-bed major post- – rehabilitation
survival rate, acute geriatric professionals
estimate rate of rehabilitation should make educated
prosthetic fit centre, admitting older estimates of outcomes at
and patients from major the beginning
report rate and acute of rehabilitation based on
factors hospitals in nearby the characteristics of the
associated with cities. Half of the patients
1-year post- patients are admitted (level of amputation and
discharge for rehabilitation after functional level on
prosthetic use orthopedic surgery, admission).
stroke or
deconditioning
due to prolonged
hospitalization. The
other half are
admitted for medical
care, encompassing
treatment for severe
pressure ulcers,
management of
advanced heart failure,
terminal
cancer, chronic
ventilation, etc. All
admitted patients
carry full medical
coverage provided by

 24
 four health
maintenance
organizations (HMOs)
conforming to the
following
admission criteria:
>60 years old,
functionally
dependent,
lack of social support
system, or living in an
unfitted home
environment (i.e. no
elevator or narrow
doorways leading to
the bathroom)..
12 Harold Mechanism In this study, Construction of an ADV/VEGF165
March Brem1 of Sustained we hypothesize ADV expressing accelerates time to closure
2009 , Arber Release of that local bioactive human in db/db mice
Kodra1 Vascular sustained VEGF for To determine whether
, Michael Endothelial release of murine study ADV/VEGF165
S. Growth vascular Human umbilical vein accelerates wound
Golinko1 Factor in endothelial endothelial cells healing, time to wound
, Hyacinth Accelerating growth factor (HUVECs) were closure was determined
Entero1 Experimental (VEGF), using homogenized using four
, Olivera Diabetic adenovirus and total RNA was different doses of
Stojadino Healing vector (ADV)- extracted. The full- ADV/VEGF165. Wounds
vic2 mediated gene length human treated with ADV/
, Vincent transfer, VEGF165 cDNA was VEGF165 healed 6.6 days
M. Wang3 accelerates amplified by PCR sooner than controls
, experimental with appropriate (Figure 1).

 25
Claudia wound healing. primers Treated wounds healed in
M. This containing restriction 27.2±1.4 days. Saline-
Sheahan4 hypothesis was sites (HindIII and treated
, Alan D. tested by XbaI) for subcloning wounds healed in 34.2±7.0
Weinberg determining into days, whereas wounds that
5 the specific pBluescript were
, Savio effects of (Stratagene, La Jolla, treated with the virus
L.C. VEGF165 CA). After sequence vector alone healed in
Woo6 application on confirmation, 33.5±6.5 days.
, H. Paul multiple the human VEGF-165 Statistical significance
Ehrlich7 aspects of the cassette was cloned (Po0.05) was noted after
and wound healing into the multiple comparison
Marjana process, that is, cloning of the 5 1011 vp per
Tomic- time to site of an adenovirus wound VEGF165-treated
Canic2 complete shuttle vector (pXC1) group and
wound closure containing adenovirus control groups (Table 2).
and skin type 5 sequences (bp However, such high doses
biomechanical 22–5,790) and a Rous of
properties. sarcoma virus VEGF165 may have a
After showing promoter. toxic effect in the mice
accelerated This same vector was used in the
wound healing used as the positive study, as the incidence of
in vivo, we control Dl-312 in the mortality in the high-
studied the experiments. For the dosage
mechanism to rescue of the VEGF165-treated group
explain the recombinant was greater than in other
findings on adenovirus, we groups. A
multiple successfully used the minimum 10% increase in
aspects of the two-plasmid co- mortality relative to
wound transfection system controls was
healing (Microbix found at ADV/VEGF

 26
cascade, Biosystems, Inc., doses of 5 109 vp per
including Toronto, Ontario, wound and higher.
epithelializatio Canada). Virus
n, collagen particle titer was
deposition, and determined by optical
cell migration. absorbance at 260 nm,
Intradermal and plaque-forming
treatment of unit titer (pfu ml1
wounds in ) was quantified by
non-obese standard agarose
diabetic and overlay
db/db mice plaque assay on 293
with cells. Plaque-forming
ADV/VEGF16 unit (pfu)
5 improves determination
healing by can vary up to one
enhancing order of magnitude
tensile when the same batch
stiffness and/or of virus
increasing is used in different
epithelializatio assays, causing a
n and collagen significant variation in
deposition, as particle
well as by measurement. To
decreasing prevent this problem
time to wound and to keep the viral
closure loads
constant, the same
batch of virus was
used for all in vitro
and in vivo

 27
 experiments.
22 , Deborah Fluorescein Fluorescein Ruorescein The fluorescein wash-in
Augus K. Oh\ dermofluoro dermofluorome dermofluorometry was time constant demonstrated
t 2000 Richard metry for the try can be used performed in four better correlation with the
N. Jones^ assessment to relate the groups of patients: presence of diabetic
William of diabetic uptake of non-diabefic control microvascular
Marshall^ microvascula fluorescein in patients, diabetic disease than did the initial
and r disease the skin to control slope of the signal.
Richard L. blood flow. patients, diabetic Differences
Magin^ We patients with chronic in the wash-in time
have foot ulcers, and constants of non-diabetic
characterized diabetic and diabetic subjects
the uptake of patients with acute support the hemodynamic
fhe dye by a foot ulcers. The hypothesis for the
wash-in time outcomes of the development
constant patients with of microvascular disease.
that is foot ulcers were The indication of early
inversely documented 4-14 wash-out of the
proportional to months after fluorescein signal may also
the local blood participation. be useful in the prediction
flow. The Following an of ulcer
purpose of this intravenous injection healing.
study was to of sodium fluorescein,
explore the use the
of change in the
dermofluorome fluorescein signal with
try time was continuously
in the measured at the
assessment of plantar surface of the
patients wifh foot. Both the initial
diabetic slope

 28
 microvascular of the signal and the
disease wash-in time constant
were calculated in
each subject.
Recei João Development Diabetes is a 62 patients with Patients with diabetic foot
ved: Paulo of the chronic disease diabetic foot, from need to be treated using a
May Tardivo1, Tardivo that affects March 2011 to March multidisciplinary approach.
24, 2, Algorithm to almost 19% of 2013 were used to Diabetes does
2015 Maurício Predict the elderly develop the scoring not have cure and the risks
Accep S. Amputation population in method. The patients to patients may persist
ted: Baptista3 Risk of Brazil and were treated at the throughout life. The
July *, João Diabetic Center for Diabetic Tardivo algorithm is a
26, Antonio Foot Foot at Hospital fundamental tool for
2015 Correa1 Anchieta predicting whether the
Publis , Fernando (CeDiFo), served by diabetic foot has a higher
hed: Adami1 the Faculdade de chance of healing or a
Augus , Medicina do ABC higher chance of requiring
t 17, Maria (FMABC), which is amputation and may be a
2015 Aparecida coordinated by useful for guiding
Silva Dr. Tardivo. The study treatment.
Pinhal1 was approved by the The proposed score
research ethics classification system for
committee at FMABC the diabetic foot may
and participants enable better quality of
signed a consent form. life for diabetic patients
The clinical and promote better low-
investigation was cost care for millions of
conducted according individuals worldwide.
to the principles The adoption of this score
expressed in the associated with
Declaration of antimicrobial

 29
 Helsinki. photodynamic therapy
could
reduce amputations in
diabetics in over 80% of
cases, resulting in lower
costs, fewer
hospitalizations
and no side effects.
June M. Gail Tool for Most diabetic The tool was Clinicians in low and
29, Woodbury Rapid & foot independently tested middle income countries
2015 1 Easy amputations by n=12 assessors such as Guyana can use the
, R. Gary Identification are caused by with n=18 Guyanese Simplified 60-
Sibbald2 of High ulcers on the patients with Second Diabetic Screening
*, Brian Risk skin of the foot diabetes. Inter-rater Tool to facilitate early
Ostrow2 Diabetic i.e. diabetic reliability was detection and appropriate
, Reneeka Foot: foot assessed by treatment of diabetic foot
Persaud3 Validation & ulcers. Early calculating ulcers. Implementation of
, Julia M. Clinical Pilot identification Cronbach’s alpha for this screening tool has the
Lowe2 of the of patients at each of the potential to decrease
Simplified high risk for assessment items. A diabetes related disability
60 Second diabetic foot minimum value of and mortality.
Diabetic ulcers is 0.60 was considered
Foot crucial. The acceptable. Reliability
Screening ‘Simplified scores
Too 60-Second of the screening tool
Diabetic Foot assessment items
Screening were: ‘monofilament
Tool’ has been test’ 0.98; ‘active
designed to ulcer’ 0.97;
rapidly detect ‘previous amputation’
high 0.97; ‘previous ulcer’

 30
risk diabetic 0.97; ‘fixed ankle’
feet, allowing 0.91; ‘deformity’ 0.87;
for timely ‘callus’
identification 0.87; ‘absent pulses’
and referral of 0.87; ‘fixed toe’ 0.80;
patients ‘blisters’ 0.77;
needing ‘ingrown nail’ 0.72;
treatment. and ‘fissures’
This study 0.55. The item
aimed to ‘stiffness in the toe or
determine the ankle’ was removed as
clinical it was observed in
performance only 1.3% of
and inter-rater patients. The item
reliability of ‘fissures’ was also
‘Simplified removed due to low
60 Second inter-rater reliability.
Diabetic Foot Clinical performance
Screening was assessed via a
Tool’ in order pilot study utilizing
to evaluate its the screening tool on
applicability n=1,266 patients in
for routine an acute care setting in
screening. Georgetown, Guyana.
In total, 48% of
patients either had
existing
diabetic foot ulcers or
were found to be at
high risk for
developing ulcers

 31
Recei Aziz The modified This paper Six patients with The modified Pirogoff’s
ved: Nather, Pirogoff’s describes the diabetic foot infections amputation has been found
14 FRCS amputation surgical were operated on by to show good results in
Nove (Ed)*, in treating technique of a the National carefully selected
mber Keng Lin diabetic modified University Hospital patients with diabetic foot
2013; Wong, foot Pirogoff’s (NUH) diabetic foot infections. The selection
Revis MRCS infections: amputation team in Singapore criteria included a palpable
ed: 8 (Ed), surgical performed by between November posterior tibial pulse, distal
March Amaris technique the senior 2011 and January infections not extending
2014; Shumin and case author and 2012. All patients proximally beyond the
Accep Lim, Med. series reports the underwent midfoot level, ABI of more
ted: Student, results of this a modified Pirogoff’s than 0.7, hemoglobin level
10 Dennis operation in a amputation for of
March Zhaowen single surgeon diabetic foot more than 10 g/dL, and
2014; Ng, case series for infections. Inclusion serum albumin level of
Publis MMed patients with criteria included the more than 30 g/L
hed: 3 (Ortho) diabetic foot presence of
April and infections a palpable posterior
2014 Hwee tibial pulse, ankle
Weng brachial index (ABI)
Hey, of more than 0.7, and
MMed distal infections not
(Ortho) extending proximally
beyond the midfoot
level. Clinical
parameters such as
presence of pulses and
ABI were
recorded. Preoperative
blood tests performed
included a glycated

 32
 hemoglobin level,
hemoglobin, total
white
blood cell count, C-
reactive protein,
erythrocyte
sedimentation rate,
albumin, and
creatinine levels. All
patients were
subjected to 14
sessions of hyperbaric
oxygen therapy
postoperatively and
were followed up for
a minimum of 10
months.
2 July J. Matching the To establish a Hospital-coded We report for the first time
2010 Valabhji, numerator method to inpatient data was amputation incidence in a
R. G. J. with an assess examined to derive the London population.
Gibbs*, L. appropriate amputation numerator: the number Acknowledging the
Bloomfiel denominator incidence that of non-traumatic limitations of
d†, S. to addresses the amputations accurately defining
Lyons†, demonstrate problems performed on subjects incidence in London, we
D. low matching a with diabetes each demonstrate low
Samarasin amputation numerator with financial year where amputation incidence
ghe‡, P. incidence an the Primary Care Trust associated with our
Rosenfeld associated appropriate commissioner code multidisciplinary
§, with a denominator in was our main local diabetic foot clinic.
C. M. London London and to Primary Care Trust.
Gabriel–, hospital demonstrate Denominators were

 33
 D. multidiscipli low derived from the main
Hogg** nary diabetic amputation local Primary Care
and C. D. foot clinic incidence Trust’s Quality and
Bicknell* associated with Outcomes Framework
the activity of data sets. Not all
our Primary Care Trust
multidisciplina subjects with diabetes
ry diabetic foot receive inpatient care
clinic at our hospital, so that
the denominators were
corrected for the
hospital’s percentage
market share for the
provision of inpatient
diabetes care for the
Primary Care Trust
each
financial year, derived
from the Dr Foster
database.
4 P. van Complicatio The incidence In the Eurodiale study, Minor amputationis
Nove Battum*, ns of minor a prospective cohort performed frequentlyin
mber N. Differences amputation study of 1232 patients diabetic foot centres
2010 Schaper*, in minor may vary (1088 followed until throughout Europe andis
L. amputation significantly, end-point) with a new determined by depth
Prompers rate in and diabetic foot ulcer of the ulcer, peripheral
*, J. diabetic foot determinants were followed on a arterial disease, infection
Apelqvist disease of minor monthly basis until and male sex. There are
†, E. throughout amputation healing, death, major important differences in
Jude‡, A. Europe are in have not been amputation or up to a amputation rate between
and M. part studied maximum of 1 year. the

 34
 Huijberts* explained by systematically. Ulcers were treated European centres, which
differences We evaluated according to can be explained in part by
in disease minor international severity of disease at
severity at amputation guidelines. Baseline presentation. This may
presentation rate, the characteristics suggest that early referral
determinants independently to
of minor associated with minor foot clinics can prevent
amputation and amputation were minor amputations.
differences in examined using
amputation multiple logistic
rate between regression modelling.
European Based on the results of
centres. the multivariable
analysis, a
disease severity score
was calculated for
each patient.
Accep M. E. Complicatio Diabetic foot We studied major and . The incidence of major
ted 18 Jørgensen, ns disease and minor lower-extremity lower-extremity
Septe T. P. Reduced amputations amputations from amputations reduced
mber Almdal incidence of severely 2000 to 2011 among significantly from 2000 to
2013 and K. lower- reduce quality 11 332 people with 2011 in Danish
Færch extremity of life and diabetes from the people with diabetes
amputations have major Steno Diabetes Center. followed at a diabetes
in a economic Amputations were specialist centre.
Danish consequences. identified by linkage
diabetes The of the electronic
population aim of this medical system with
from 2000 to study was to the National Patient
2011 estimate time Registry. Sex-specific
trends in the incidence rates of

 35
 incidence of amputations by age,
lower- diabetes duration,
extremity calendar time and
amputations in diabetes type were
Danish people modelled by Poisson
with regression.
diabetes
Manu David J. The This was a To be included in our Based on our selection
script Margolis, differential retrospective inception cohort, a criteria, we identified
receiv MD, effect of cohort study subject had to 78,178 individuals
ed: PhD1 angiotensin- using the have at least two with diabetes. ACEi or
March ; Ole converting general separate medical ARB were used by 40,342
29, Hoffstad, enzyme medical records for diabetes individuals (51%). From
2010 MA2 practices of noted between this group, 35,153
inhibitors
Accep ; Stephen The Health January 1995 and individuals
and
ted in Thom, Information August 2006. We were treated with ACEi,
angiotensin
final MD, Network used 12,437 individuals with
receptor
form: PhD3 (THIN). By this algorithm to ARB, and
blockers with
June ; Warren agreement, assure that the 7,248 were exposed to
respect to
14, Bilker, patient data are subject truly had both drugs. The total
2010 PhD2 recorded and diabetes. number of
foot ulcer
; stored in THIN In addition, the evaluable exposures was
and limb
Arturo R. as if it were an subject had to be at 47,590. One hundred and
amputation
Maldonad electronic least age 35 at the seven
in those with
o, MD4 medical record time individuals were
diabetes
; Robert including all of diagnosis, could excluded from our
M. Cohen, past and not have had a analysis because they
MD5 current pervious history of were treated with both
; Bruce J. medical venous agents at the same time.
Aronow, diagnoses leg ulcer, DFU or The mean
PhD6 (acute LEA, and must have age of our subjects was

 36
 ; Timothy and chronic) used an ARB 64.4 (95% CI: 64.2, 64.5)
Crombleh using Read and/or ACEi, which years
olme, codes and was first prescribed with a median of 64.4
MD4 information on between 1995 and years. Females
prescribed 2006. represented 45%
medications, (18,281) of the cohort.
using British The mean total duration
National of diabetes
Formulary was 6.3 years (median
(BNF) codes. 5.98) and total person-
All laboratory time of
values, aspects 216,070 years. There
of the physical were some statistical
exam, differences in
hospitalization covariates based on
s, whether they received
consultations, ACEi or ARB
and
prescriptionis
small (3%).
Our study was
reviewed and
accepted

2008 Ruth Predictors of This study 200 patients with type

The mean age of the
Kalda,1 quality of examines the 2 diabetes were
respondents was 64.7
Anneli life of factors that studied in Estonia in
(±11.1) years and the mean
Rätsep,1 patients with most strongly 2004–2005. A patient
duration of the diabetes
and type 2 influence the blood sample, taken
was 7.5 (±1.8) years.
Margus diabetes quality of life during a visit to the
Logistic regression
Lember2 of patients with family doctor, was
analysis showed that

 37
 type 2 collected. The family
quality of life was most
diabetes. doctor also provided
significantly affected by
data on each patient’s
awareness of the
body mass index
complications and risk-
(BMI), blood pressure,
factors of diabetes, and by
and medications for
the age, duration of the
treatment of type 2
disease, and BMI of the
diabetes. Patients
patient. Patients who were
completed a SF-36
less aware had a
during a doctor visit,
significantly higher quality
and also a special
of life score (p < 0.001 in
questionnaire which
all cases). The age and
we provided to study
BMI of the patients as well
their awareness about
as the duration of the
diabetes type 2.
diabetes all lowered the
score of the quality of life.

2005 Singh N1, Preventing To The EBSCO,

Prevention of diabetic foot
Armstron foot ulcers in systematically MEDLINE, and the
ulcers begins with
g DG, patients with review the National Guideline
screening for loss of
Lipsky diabetes. evidence on Clearinghouse
protective sensation, which
BA. the efficacy of databases were
is best accomplished in the
methods searched for articles
primary care setting with a
advocated for published between
brief history and the
preventing January 1980 and
Semmes-Weinstein
diabetic foot April 2004 using
monofilament. Specialist
ulcers in the database-specific
clinics may quantify
primary care keywords.
neuropathy with
setting. Bibliographies of
biothesiometry, measure
retrieved articles were
plantar foot pressure, and
also searched, along

 38
with the Cochrane
assess lower extremity
Library and relevant
vascular status with
Web sites. We
Doppler ultrasound and
reviewed the retrieved
ankle-brachial blood
literature for pertinent
pressure indices. These
information, paying
measurements, in
particular attention to
conjunction with other
prospective cohort
findings from the history
studies and
and physical examination,
randomized clinical
enable clinicians to stratify
trials.
patients based on risk and
to determine the type of
intervention. Educating
patients about proper foot
care and periodic foot
examinations are effective
interventions to prevent
ulceration. Other possibly
effective clinical
interventions include
optimizing glycemic
control, smoking cessation,
intensive podiatric care,
debridement of calluses,
and certain types of
prophylactic foot surgery.
The value of various types
of prescription footwear
for ulcer prevention is not
clear.

 39
2012 Porojan Assessing The purpose of The study group
Patients with DM have
M1, health related the study was consisted of 50
statistically significant
Poantă L, quality of to analyze the patients, males and
impairment of all aspects
Dumitraşc life in quality of life females, aged 60 (+/-
of QOL, not simply
u DL. diabetic in a group of 6), diagnosed with
physical functioning. DM
patients diabetic type 2 DM and
put a substantial burden on
patients followed up at an
affected individuals by
without major outpatient clinic. The
influencing physical,
complications. Romanian version of
psychological and social
the SF-36
aspects of QOL. The
questionnaire was
progressive nature of type
used as a health survey
2 DM and the real risk for
tool to measure the
developing chronic
quality of life (QOL)
complications certifies that
of patients in the
insulin use will be a reality
study.
for most diabetic patients,
but its use did not seem to
have a negative impact
upon QOL. Glycemic
control becomes an
important measurement for
preventing long-terms
complications and provides
a better QOL to diabetic
patient. This end-point
should be a much more
important target for
healthcare interventions.

 40
 Chapter three
Methodology

Methodology

 41
3.1. Study Design:

Qualitative narrative design was used in this study. We mean by narrative analysis uses field
texts, such as stories, autobiography, journals, field notes, letters, conversations, interviews,
family stories, photos (and other artifacts), and life experience.

Semi-structured interview and open-ended questions was used to get required information. Pen
and notebook, and recorder were used while making an interview, and then make documentation
for analysis the interviews that helped us to cover the lived experience after amputation. The
guideline includes questions about (demographic data about the participant and questions about
lived experience after amputation.

3.2. Sampling:

The setting for this study was Palestinian diabetes patient who have amputation in Nablus.
Purposeful sampling was used to collect data. The sample size included 7 participants 40 to 80
years old who experienced an amputation as a result of diabetes. Participant should be able to
speak and understand Arabic, be willing to provide written informed consent, agree to participate
in a 20-45 minute interview, and agree to have the interview digitally recorded. Before signing a
consent form, the purpose of the study was explained to the participants. Participants were
informed of their right to withdraw from the study at any time without reprisal and the right to
have any recorded data on the digital tape or transcript excluded from the data analysis process.

3.3 Inclusive criteria:

Both gender (male and female) are equally included, and ages between (40-80) years, who had
amputation as a result of diabetes mellitus, will be included for the purpose of the current study.

3.4Exclusion:

* Any patients less than 40 years and more than 80years.

* And who have an amputation as a result of other reasons.

3.5 Selection of the Study Instruments

 42
The interview process was done using a semi-structured interview guide with different themes
and underlying issues designed from the study purpose and research questions. The interview
guide acted as a support to ensure that the important issues were not forgotten during the
interview. It also served to organize the discussion by designating the order in which different
themes were addressed. The interview guide was used as a checklist to ensure that all the themes
were addressed instead of letting the interview questions guide the conversation. This allowed
the interviewees to generally feel relaxed and natural, rather than formal.

3.6. Data collection process:

After taking permission from the patients to do interview in their homes in Nablus, the sample
will be convenient and it’s definition (Convenience sampling is a non-probability sampling
technique where subjects are selected because of their convenient accessibility and proximity to
the researcher The subjects are selected just because they are easiest to recruit for the study and
the researcher did not consider selecting subjects that are representative of the entire population )

Firstly , consent form is read to the participants then they signed after he /she accepted to
participate in the study, one face-to-face interviews lasting between 20 and 45 minutes were
performed with each patient in private room. Demographical and clinical data were collected
using a self-developed questionnaire with simple closed questions. And then we asked them
question about their lived experience . and data was collected be same group one to ask question
,two to take note about patient and other to redirector the interview if need . and the data was
analyzed by Barden approach.

3.7 Ethical consideration:

We will take the IRB to our research from An-Najah National University ,and then we will take
permission from ministry of health, to make our research in Palestinian center of diabetes in
Nablus. The participants will sign and accept the consent form that we give to them. Participants
will be informed that all these data will be secret, and kept in private office at the university.
Subject name will be written in form of symbols to make sure that the aim is to gather
information about our study not for sharing the information with others.

 43
3.8 Data Analysis

Phenomenological psychologists analyze their data by using a systematic and rigorous process.
Data analysis consists of four consecutive steps that must be undertaken in their order (Robinson,
2007). Prior to the analysis, each interview was transcribed verbatim. All steps in the analysis
were performed within the phenomenological reduction (Giorgi, 1997).

In order to present the study in writing, the method, purpose, and research questions were
considered as coherent and not as separate parts. The analysis of the material began from the
time of the beginning of the data collection. The understanding of how to analyze the collected
material has been evident to the researcher since making the choice to utilize a qualitative
method. The interview guide has been designed as a breakdown of the various themes in addition
to background information.

All steps in the analysis were performed within the phenomenological reduction (Robinson &
Englander 2007; Giorgi, 1985, 1997).

"Step 1: Getting the sense of the whole statement by reading the entire description.

Step 2: Discriminating meaning units within a psychological perspective.

Step 3: Transforming the subject’s every day expressions into psychological language.

Step 4: Synthesizing transformed meaning units into a consistent statement of the structure of the
phenomenon”.

Step 1: Getting the sense of the whole statement by reading the entire description

The entire interview protocol was read several times in order to get a sense of the whole
experience. The idea was to obtain a description, not to explain or construct (Giorgi, 1989).
Wertz (1985) suggest that readers should see raw data as well as processed data

 44
The first reading be done in the natural attitude (i.e., the everyday attitude) told the researcher to
more actively identify and critically examine their own interests, creditors learned, theories,
hypotheses and existential assumptions about the phenomenon and then set them in brackets
(Giorgi, 2005).

If certain passages of the collected material unclear, it is important that the author does not
padding with their own interpretation, but instead goes back to the interviewee and ask for
clarification descriptions. If the author is unable to collect further information about them will be
later forced to describe the uncertainties that exist in the data. Ambiguities and contradictions in
the data may not reduce or declared the basis of possible interpretations, but must always be
described as such. (Robinson & Englander 2007), (Giorgi, 1985, 1997

Step 2: discriminating meaning units within a psychological perspective

After going through the first step, Giorgi (1986) suggests that the whole description should be
broken into several parts to determine the meaning of the experience and these are expressed by
the slashes in the texts (Giorgi, 1985) or by numbering of lines (Wertz,1985 ). Parts that were
relevant to the phenomenon that is being studied were then identified. The process of delineating
parts is referred to as meaning units, they express the participant’s own meaning of the
experience, and they only become meaningful when they relate to the structure of all units
(Ratner, 2001). A word, a sentence or several sentences may constitute a meaning unit.

Each meaning unit is constituent and therefore focuses on the context of the text (Giorgi, 1985).
The meaning units are correlated with the researcher’s perspective and therefore two researchers
may not have identical meaning units (Giorgi & Giorgi, 2003a). This process takes place within
what is called reduction. It is important in phenomenological psychology to withhold the
existential judgment about the experience of the participant.

 45
Step 3: Transforming the subject’s every day expressions into psychological language

The researcher returns to all of the meaning units and interrogates them for what they reveal
about the phenomenon of interest. Once the researcher grasps the relevance of the subject's own
words for the phenomenon, Researcher expresses this relevance in as direct manner as possible.
This is called the transformation of the subject's lived experience into direct psychological
expression. This step that makes it clears through the description of the intrinsic meaning in the
material. Furthermore, the researcher must make clear the implicit meaning of meanings which
the text points to, i.e., make explicit what is implicitly given. For that transformation must be
kept at a descriptive level, it is essential, however, does not go beyond what is directly given in
the data

Step 4: Synthesising transformed meaning units into a consistent statement of the structure
of the phenomenon.

- Making the meanings units coherent and syntheses by relating them to each other to have
meaning statements.

Specific statements are written for individual participants and a process of analysis is used
whereby common themes across these statements are elicited and Then form a general structural
description which becomes the outcome of the research. , the actual sentence structure on the
investigated phenomenon described (Robinson & Englander 2007), (Giorgi 1985, 1997).

Sentence structure consists of the elements identified in the previous step and understood
through their relationships and the way in which they are related to each other. Sentence
structure is achieved by the researcher as in step three make use of imaginary variations to arrive
at the final sentence structure that cannot vary. All data must be considered and the researcher
must also have been sticking to a purely descriptive language. If there are contradictions or
ambiguities in the material shall be described but not explained or understood in terms of
interpretations, theories, hypotheses or other existential assumptions. If the context and other
contextual factors are relevant to the phenomenon must also be described. There are three levels
at which the structure can be described. The first level is the individual structure that is based on

 46
a description from an informant. The second level is the general structure that can be achieved by
having multiple descriptions (usually three). At the third level we find the universal structure,
which is located on a philosophical level. To find the general structure is always desirable when
it can be generalized to other people experiencing the same type of phenomenon

Once the description of the psychological structure of each individual had been identified, the
researcher looked at statements that can be taken as true in most cases.

8.9 Credibility and dependability

Matters relating to the implementation of interviews and analysis can say something about the
survey's reliability. Before the interviews, the authors write down what they expected to find in
the survey and be conscious of how their backgrounds might be to color the survey. The authors
could thus greater curb their expectations, bracketing (Robson, 2002).
The authors may, by making themselves aware of their own attitudes, become a better listener
who trying to put themselves aside and take the dialogue partner seriously.

All interviews will be recorded on a tape and transcribed verbatim. This makes survey more
credible than if the authors had only taken notes during the interview (Robson, 2002).
Credibility of the data may be related to whether respondents tell the authors truth (Malterud,
2003). In this study authors are looking for experiences to mothers of schizophrenic patient. An
experience is subjective and thus true for the one who tells it.
The mothers will be asked if the authors really got something out of this when she had told its
history. It is important that the analysis and presentation of findings will be made in a credible
manner.
The authors will follow analysis model to Giorgi (1985) as described and will try to be true to the
stories of mothers and teachers. The authors selected in this study using phenomenological
approached to the theme, this will give the authors more aspects of the findings. Using a
developed analytical model, will give opportunity to test the analysis that will be done (Robson,
2002).

 47
8.10 Evaluating the quality of phenomenological research

When presenting phenomenological research, its value is established by honoring concrete

individual instances and demonstrating some fidelity to the phenomenon (Wertz, 2005).
Research reports may, for example, contain raw data such as participants’ quotations providing
an opportunity for readers to judge the soundness of the researcher’s analysis.

The quality of any phenomenological study can be judged in its relative power to draw the reader
into the researcher’s discoveries allowing the reader to see the worlds of others in new and
deeper ways. Polkinghorne (1983) offers four qualities to help the reader evaluate the power and
trustworthiness of phenomenological accounts: vividness, accuracy, richness and elegance. Is
the research vivid in the sense that it generates a sense of reality and draws the reader in? Are
readers able to recognize the phenomenon from their own experience or from imagining the
situation vicariously? In terms of richness, can readers enter the account emotionally? Finally,
has the phenomenon been described in a graceful, clear, poignant way

 48
Chapter four
The Result

 49
 The result

Introduction

This chapter serves to outline the outcomes of the in-depth interviews with key informants.
Following analysis of the in-depth interview, five main themes emerged after the categorization
of the various concepts expressed by the key informants. These were: a psychological aspect,
Changes in lifestyle, Adaptation and adjustment, Rehabilitation and nursing and professionals
care.

Demographic data :

The number of interview was seven

Mean of age was 57± 5 years old

gender Frequency Percent

Male 5 71%
Female 2 29%

Period from discovery of Diabetic

Frequency Percent

Less than 10 years 2 29%

10-20 years 4 58%

More than 20 years 1 13%

Level of education

 50
degree Frequency Percent

Illiterate 2 29%

Primary 3 42%

High school 2 29%

Themes and subthemes

Theme Sub themes

 51
 3.1 Psychological aspect Emotional disturbances after amputation
Positive psychological impact
Negative psychological impact
Body image
feeling of Pain
3.2 Changes in lifestyle Be dependent
Social identity
The life become hard
3.3 Adaptation and adjustment Ability to adapt
Adjustment to new situation
3.4 social support social support
3.4 Rehabilitation Rehabilitation
needed facilities
3.5 nursing and professionals care nursing and professionals care

4.1 Psychological aspect

Psychologically the participants dealt with a lot of hardships following a lower limb amputation.
The new life experience, having to face the world without a limb brought different psychological

 52
reactions. Participants went into a state of shock and disbelief. The reality of not knowing what
to expect following an amputation was a concern. Not knowing what the difference will be now
that they had to live with an amputation and how the amputation was going to impact on their
lives was a concern. In these situations, they did not know what adjustments they needed to make
and what adaptation they had to make in order to factor the amputation smoothly into their lives.
They did not know what difficulties they had to face and there were perceived uncertainties
about life in the future.

4..1.1 Emotional disturbances after amputation

“Initially it was a big shock. I was feeling crushed, I really cried so much.”1

“This is unbelievable that one tell you that you will continue your life without your leg, but the
worst thing become really.”2

“I didn’t realize I would have an amputation’ I didn’t realize the restrictions … It is sad that it
happened because of the diabetes, I blame my self for not adapt with regulation of diabetes.”3

“In the beginning I think in my life how will be like, I feel depressed, nervous, I hoped that I am
died before this moment.” 4

“I didn’t realize that my leg wasn’t there, this was the biggest shock in my life.”5

“Initially I found it very hard to understand to terms amputation, this term mean that the cure is
become amputee person, I feel my life will end.”6

“In the first I can’t understand the thought that I will be without leg, its like magic.”7

4.1.2 Positive psychological impact

 53
Some of the participants were able to draw positive inspirations from the amputation. They tried
to live a positive life, keeping a positive attitude. They were able to see that there is still a life
after the amputation. There is still a lot to live for. Some even modified their lifestyles.

Every human mind is different, not everyone thinks alike. Some people get disheartened . ..There
were some who gave up and passed away within a fortnight, for me my life continue as in the
past. 2

In the first I ask myself, why me? What I did in my life? but I do things like I did before, the
difference is that it is time consuming, it now takes long to do an activity but not much has
changed5 ‫ الحمد هلل على كل حال‬.. ‫قدر هللا وما شاء فعل‬

I want to make sure that it looks good, especially if I’m wearing a dress. 7

4.1.3 Negative psychological impact

I feel that the time for the strong man ended.1

“I have been cheated out of a lot of things. I feel that I miss out of a lot of Things, it’s the worst
thought, there is a lot of things that go through my mind, everything is disorganized.”3

For me it was hard, one leg gone, I will never get it again, I will be disable person. It made me
feel inferior, because I could no longer be my family’s breadwinner 4

“When I was still in the hospital, I usually think, what will the people say? How they will look to
me? 6

4.1.4 Body image

Almost of Participants connecting lower limb amputation with disability but all of them are
conscious about their image . A lower limb amputation changes ones’ physical appearance so
much that they feel that the general public will perceive them differently.

The first thought in my brain that I will be disable person. 1

I feel that me less of a person now that I have this disability.6

 54
You need to show for all that you are still strong, unfortunately this is hard with amputation
leg.7

4.1.5 Feeling of Pain

All limitations were generally of mobility with stability and balance challenges rather than pain
inhibiting their function. In this study, some participants experienced a great deal of pain and
discomfort following lower limb amputations. This may include rest pain in the stump or even
pain from ischemic changes of the contralateral leg. This is also the case in participants with
peripheral vascular disease where the other leg is starting to show signs of vascular disease while
the participant is recovering from the leg that was amputated. The pain is unbearable and so
uncomfortable that it can have an impact on sleep and result in sleep disturbances. According to
Resnick at al, (2004), participants are likely to experience pain following a lower limb
amputation.

The pain wakes me up in the middle of the night. I sit up, I was scream like a baby.1

“Actually, since my leg amputation. Initially, I don’t sleep well, and now I have lots of pain and
numbness at night.”3

I experienced many type of discomfort, pain, numbness.4

No pains, I don’t feel anything else. 5

Pain was after surgery while I am in the hospital, after that no pain or any discomfort
sensations.7

4.2 Changes in lifestyle

People with a lower limb amputation faced challenges and limitations including social
interaction during their time of reintegration to the society of origin. At times they were unable
to join fellow family members in social outings and events. In other instances they loved doing
certain activities together before they had an amputation and after the amputation they were
unable to continue with shared activities.

 55
4.2.1 Be dependent

One of the changes in life style after amputation as participant said that they have to depend on
other in their daily activates, this are some examples.

It’s very difficult! You have to depend on many people. I hate it when I can’t do something
myself 1

I could no longer be my family’s breadwinner 2

I depend on my son in all thing.4

I can’t do all of my activates in home without assistance.5

All want to help me but I don’t like this, this give you feeling of disable.

This is the life, after I care for them (her sons and daughters), they care for me now.6

4.2.2 Social identity

All Participants were seen to have strong relationships with their sons, daughters and relatives
following a lower limb amputation, this result in strong support from family and friends.

Certain things like walking, shopping and standing. .. The worst thing of them all is not being
able to visit neighbor, friends. 2

I think just in terms of moving around, having to get up for pray in early morning I have to find
out crutches first. And make sure that the light on I need to walk in the dark without knocking
into anything. 5

I’m a women. I like to socialize but since I have amputation I’m out of it. 3

4.2.3 The life become hard

Really after amputation, I can’t do normal things that I was doing it and I have to use a
wheelchair all the time. 1

Sitting in a wheelchair, go to the toilet, it’s not be easy thing this now a long story,
ooooooooooh.4

 56
In any place the first thing that you think to be sure you will not fall because its will be an
embarrassment more than any thing else.6

4.3 Adaptation and adjustment

Participants may have accepted the new condition gradually. Participants may be withdrawn, feeling
that coping in their new chapter of life will be overwhelming.

4.3.1 Ability to adapt

There is always a solution to most things 1

This situation annoying me because I don’t want it to win … I don’t want my left leg or lack of
leg to rule me.2

2 .‫ بس انا ما رح خلي فقداني لقدمي اليسرى او اني اعيش بدون قدم يقيدني‬.. ‫هاد الوضع بالنسبة لي مزعج‬

Now I am in realty, I start think how to facilitate my life and how to depend on my self, I would
wear clothes that easy to put on e.g. trouser with elastic rather than the belt.5

Losing a leg is not a problem. I help myself with whatever. Life will goes on. I feel good, leg
amputation had no effect on my life. It hadn’t made difference for me.7

“I am coping well, I move around, I do bath myself and do some cooking, ‫ ربنا يديم‬,‫الحمد هلل‬
4 ‫علينا الصحة والعافية‬

4.3.2 Adjustment to new situation

some participants had accepted the amputation and stating that there are have varying ways of
adjusting, coping and adapting to a lower limb amputation.

Other ways of coping, staying positive and avoiding destructive situations involved managing
and handling stress well. Some participants made every effort to depend on themselves.

Some of the Participants also felt that they did not have a choice but to accept the current status
and not accepting it will result in more struggle.

 57
If I could get back to my previous function everything would be normal. 1

Now my inseparable friend is my pair of crutches.2

Until now I still in denial about my leg amputation or this just thing difficult thing to believe in
my mind, now or later I must to accept, realizing that there are some of the difficulties that I
should deal with it in my future.6

“It [the experience of an amputation] brought me closer to God. It made me realize God was by
my side all along. 3

In the first I had must to learn to live with this and that’s all, the God give us the power to adapt.
4

4.4 social support

My family have been giving me a lot of support, helped me to trust myself again and to cope with
this situation. 1

In this age what we need rather than go to pray, there is multi cars, ‫هللا يرضى عليهم اوالدي مش‬
1 ‫منقصين علي شي‬

My sons, daughters, friends give me support from the beginning until now, without them I don’t
know how to do. 2

My friends and neighbors still coming to me, my sons and Grandsons always near me.3

My daughter despite her responsibilities in her home, she would make sure that she makes food
at home and send them to me, to make sure that I have enough to eat. 3

All family members are supportive, I don’t feel alone in any time.4

My family are supportive and very helpful. They also hire someone to help me. 5

My daughter and wife help with all needs and they get me feeling shy and cooking Washing my
clothes and making bed.6

 58
4.4 Rehabilitation

4.4.1 Rehabilitation

Rehabilitation is important because it is helping me to return to do my daily life. 1

What means of rehabilitation, I never have it.3

I don’t go to special center.4

Rehabilitation has helped me, but it’s very hard for me, and I don’t know if I’ll be able to walk
alone!. . . I can’t accept this situation because it’s revolting being like this . . . without driving,
walking, working . . . it’s very sad depending on others . . . I was a very dynamic man before this
happened. 5

No one tell me about this. 6

After my leg amputation what will help, I am still alive.7

7 .‫ هينا عايشين والحمد هلل‬.. ‫شو رح ينفع شي‬...‫بعد ما راحت رجلي‬

4.4.2 needed facilities

We don’t need thing rather than Satisfaction of God. 1

If they offer to me Electric wheelchair, to able go around. 2

The government not offer prosthesis, I hope to have one.3

I need financial support.4

4.5 nursing and professionals care

“While in hospital I don’t found any emotional support from health professionals at all. They
don’t give me any information on the procedure, or how this will affect your life and how to
adapt or cope . 1

 59
“I cannot complain about anything. When I was in hospital, I had good support because I had
doctors, nurses. .. They were all supportive. They were always there to help change my dressings
[following the amputation] and provided for my needs. 2

Nurses and doctors do what they can do, thanks for them. 3

3 .‫ والباقي على هللا وهاد الي مكتوب علينا‬... ‫االطباء والممرضين عملو الي عليهم يخلف عليهم ما قصرو معي‬

Some of them are supportive, and some are careless.4

Thanks to all. 5

They don’t understand how its hard to person to loss part of his body, how he complain, some of
them are easily become nervous.6

 60
 Chapter five
Discussion

Discussion

Introduction

This study has provided insight into these participants’ experiences of living with an amputation
and has revealed factors that may influence whether people experience post amputation, how
they adapt, what they need, and their hopes.

Psychological aspect

 61
In the initial stages participants went through feeling of loss, grief, crying and miserable
moments of trying to live with the amputation. They had to cope with the idea of not having a
leg, trying to come to terms with it.

Some Participants found it stressful to deal with the amputation. They found the amputation
limiting in terms of involvement and participation in normal activities.

Participants found it hard to go through, especially because it’s a new experience in their lives. In
some instances there was uncertainty about their health status.

Some participant felt that the amputation will potentially put them at a disadvantage while
exploring their ambitions during the process of reintegration into society.

Pain

In this study, participants did not seem to establish any relationship between pain and functional
limitation. All them Experience pain directly after amputation in hospital or after discharge but
this last for short time after amputation.

The second discomfort the patient face is numbness, some of them still complaining of it until
now.

Body image

Almost of Participants with a lower limb amputation are conscious about their image. A lower
limb amputation changes ones’ physical appearance so much that they feel that the general
public will perceive them differently. Some, therefore, tried to preserve their normal physical
appearance to the best of their ability. They insisted on ensuring that they wore long pants with
the prostheses to make sure that when they go out, people who do not know would not notice.

About their life after amputation some participant said that they can adapt and having no
problem but the most of them their life become harder they had a fear of falling and tried to
avoid being embarrassed by falling in public. They imagined themselves falling in and people
feeling sorry for them. Apart from the emotional impact, falls can also result in injuries,
especially to the stump. During these periods, participants developed various coping mechanism.
These included learning to fall safer, e.g. on their back rather than the stump, having two pairs of

 62
crutches if they live in a double storey house, where one pair is kept on each floor and they move
on their bottom on the staircase to the next floor to eliminate the risk of falling (Zidarov et al,
2009).

Positive adaptation

Some people felt that nothing much had changed in their lives except not having two legs. They
at times saw that the operation had to be done for their own survival and the betterment of their
lives. This form of acknowledgement and acceptance was also a finding in the study by Mac
Neill et al, (2008) showed that, participants coped well following a lower limb amputation.

Participants also felt that they did not have a choice but to accept the current status and not
accepting it will result in more struggle.

Social support

In this study, the families and relatives were very supportive. They tried their utmost best to be
there for the participants. This included the sons, daughters , the and friends. These close people
intervened very early and then gave continued and valuable support to the participants. The
nature of this support ranged from psycho-emotional to physical demands. Participants lost skills
like driving, particularly a car. This is just one of the few examples where a spouse or a friend
had to pick up and drop them to various places to engage in their usual activities. Participants
appreciated this but they also expressed that they did not like being dependent and it was very
inconvenient at times.

In this study, some participants tended to put their faith in God. They felt that God had decided
that they had to get the amputation and therefore God will take care of them. They did not see the
need to question anything and they said that God had all the answers. They felt that through
praying, they will overcome. This coping skill was expressed in a way that suggested that they
did not have much to worry about as far as the amputation was concerned as God will lead the
way.

This study has revealed the benefits of social support from family and friends, as long as it was
considered appropriate and focussed on the needs of the person. It is known that this has a
protective benefit and that it is beneficial in terms of general adjustment to amputation with

 63
greater life satisfaction, mobility and more engagement in meaningful activity. Social support is
clearly crucial to the process of adjustment in the social context, but in the persons work
environment, there may have to be additional adjustments

Conclusion

Participants had varying psychological reactions after the lower limp amputation . Some were
battling with issues of body image, pain, disability and poor functional independence. Others
were reported to be coping well. Both negative and positive coping strategies were demonstrated
by the participants

 64
The participants had supportive families and friends. They also had complain poor rehabilitation
services resources and this had a negative impact of their ability to recover. Some participants
had given their lives to God, so they would be responsible for the well-being.

The health professional team varies in deal with patient having amputation, some of them are
supportive and other are not.

Recommendations

 We recommend that people with chronic disease who require a planned amputation have
counselling which includes family and close friends from an early stage. This has the
potential to aid adjustment after the amputation through ensuring that family and social

 65
 support is appropriate, allows for the development of independence and maintains
identity as much as possible.
 support of family members and friends have for these participants is crucial in their
longer term recovery and adjustment over time. It is also important that longer term
counselling should be available also by health care professionals according to the persons
changing needs over time and in relation to both their amputation and their chronic
disease.
 Most of participant has deficit knowledge about rehabilitation, so the health professionals
should increase their awareness about rehabilitation and the government should offer
specialized center for them.
 Future studies should attempt to gather enough and useful data on the items related to the
impact of financial resource, compliance with medical treatment, rehabilitation and
prosthetics issuing to see if that could explain the outcome of these participants

Limitation of the study

This study aimed to explore the experience of undergoing amputation due to diabetes/peripheral
vascular disease.

 66
 The planed site for research not be accessible due to not have permission from the
administrative of the clinic, so we switch to individualized interview at homes.
 Ideally, the participants would have been same period post amputation, but time
restrictions for the research made this impossible.
 A perceived limitation could be seen to be the sample size. However, it was not the
intention to survey a large and diverse population in order to be generalisable with the
results but to gain indepth insight into the participants experiences
 The research limited to diabetic, Further research is required to look at other distinct
groups.

 67
 References

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A. Ratsep, Kalda, R., et al. (2008). "Predictors of quality of life of patients with type 2
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Appendix A

Interview Questions

 71
 ‫‪What‬‬
‫‪How nurses‬‬ ‫‪What‬‬
‫‪youother‬‬
‫‪and‬‬ ‫‪is‬‬
‫‪need‬‬
‫‪thehealth‬‬
‫‪How‬‬ ‫‪to‬‬
‫‪first‬‬
‫‪make‬‬
‫‪feeling‬‬
‫‪amputation‬‬‫‪its easer‬‬
‫‪you‬‬ ‫‪have‬‬
‫‪professionals‬‬‫‪for‬‬
‫‪affect‬‬ ‫‪you‬‬
‫‪your‬‬‫‪experience‬‬
‫‪treat‬‬ ‫‪to adapt‬‬
‫‪life‬‬
‫‪you‬‬ ‫‪at hospital‬‬
‫‪What What‬‬ ‫‪about‬‬
‫‪changed‬‬ ‫‪in Who‬‬
‫‪yourlife‬‬
‫‪your‬‬ ‫‪are‬‬
‫‪journey‬‬
‫‪your supporter‬‬
‫‪of rehabilitation‬‬
‫‪experienced‬‬ ‫‪after amputation‬‬

‫‪Appendix A‬‬

‫جامعة النجاح الوطنية‬

‫استمارة الموافقة على المشاركة بالبحث‬

‫اقر أنا ‪ ......................‬بأني اطلعت على بيان مفصل عن البحث المقدم من الطلبة (عامر سليلة ‪ ,‬باهر عبيدات ‪ ,‬حسام‬
‫العيسى ‪ ,‬امين ابو هنية )‬

‫بكلية التمريض في جامعه النجاح الوطنية ‪.‬‬

‫وأوافق طواعية على المشاركة في هذا البحث الذي يهدف إلي الكشف عن السلوك الحياتي للمرضى بعد إجراء جراحة بتر‬
‫أحد األطراف أو كالهما وأثر ذلك على تطور حالتهم المرضية ‪,‬وكيفيه التعديل على هذه السلوكيات ألخذ أفضل نتيجة‬
‫صحية ممكنة للمريض ‪.‬‬

‫وانه تم إبالغي بخطوات البحث والفوائد المرتبة عليه‪ ,‬وانه ال يترتب على عدم موافقتي على االستمرار فيه أي أضرار من‬
‫قبل الباحثين ‪.‬‬

‫مع العلم بأن المعلومات المأخوذة من المريض ال تستخدم لغرض أخر غير البحث العلمي ‪.‬‬

‫وانأ أوافق على تسجيل المقابلة للغرض العلمي‪.‬‬

‫لقد قرأت المعلومات السابقة أو تليت علي وكانت لي الفرصة للسؤال عما أريد وأجيبت أسئلتي كلها بما أرضاني‬

‫‪ 72‬‬
 73