ArticleLiterature Review

Diabetic Foot Ulcers and Their Recurrence

Authors:
  • Keck School of Medicine of USC
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Abstract

Lower-extremity complications of diabetes such as foot ulcers constitute a substantial burden for people with diabetes. Once healed, foot ulcers frequently recur. This fact, coupled with demographic trends, requires a collective refocusing on prevention and a reallocation of resources from simply healing active ulcers to maximizing ulcer-free days for all patients with a history of diabetic foot ulceration. Aggressive therapy during active disease combined with a focus on improving care during remission can lead to more ulcer-free days, fewer inpatient and outpatient visits, and an improved quality of life.

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... Among these numerous complications of diabetes, foot ulcers are a significant concern that can lead to severe outcomes, including infection, hospitalisation, and even amputation (Armstrong, Boulton, and Bus, 2017). Ulceration is noted to be more common in patients with type-2 diabetes mellitus compared to patients with type-1 diabetes mellitus (Abid and Hosseinzadeh, 2024). ...
... Diabetic foot ulcers pose a significant health problem, leading to complications such as infection, gangrene, and amputation (Armstrong, Boulton, and Bus, 2017). Despite advancements in medical treatments, the prevalence and impact of DFUs remain substantial. ...
... Patients should also be taught to recognise warning signs and seek prompt medical attention for any concerning findings. Educating patients on proper foot care practices, regular blood glucose monitoring, and the identification of potential complications plays a pivotal role in DFU prevention and care (Armstrong et al., 2017). Also, glycaemic control through medication, diet, and exercise that can help prevent or delay the progression of neuropathy and vascular ...
Thesis
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Aim: This scoping review explores nurses' knowledge, attitudes, and practices regarding diabetic foot ulcer (DFU) care. Method. Using the Knowledge, Attitude and Practice as theoretical framework, this study reviews literature obtained from PubMed, CINAHL and Google Scholar. The review includes studies published between 2014 and 2024, published in English Language. The screening and study selection is reported using PRISMA-SCR flow diagram. Other ethical requirement based on the TENK/Novia educational Research Board criteria are observed. Result: The reviewed studies shows that nurses' knowledge about DFU management is important for effective patient care. The studies reveal significant knowledge gaps and deficiencies in training, leading to discrepancies between acquired knowledge and the nurses' attitude and practice. While nurses generally hold positive attitudes toward DFU care, perceiving it as time-consuming and challenging can hinder their commitment. Also, ongoing professional development is essential to bridge knowledge gaps, as nurses primarily rely on on-the-job training, peer learning, and formal education. Nurse-led interventions, including patient education and participation in multidisciplinary teams, play a vital role in improving DFU management and patient outcomes when knowledge is effectively applied. Conclusion: The review shows the need for continuous professional development and structured nurse-led interventions to bridge these gaps and enhance the management of diabetic foot ulcer. _________________________________________________________________ Language: English
... 11 The recurrence rate of DFU is also high, and the recurrence rate of DFU within 1, 3 and 5 years is 40%, 60% and 65%, respectively. 12 It is estimated that every 20 s worldwide, a patient's leg is amputated due to DFU. 8 The amputation rate within 1 year among patients hospitalized for DFU in China is as high as 13.4%. 13 At the same time, DFU will increase the death risk of patients, and the 5-year death risk of DFU patients is 2.5 times that of patients without DFU. ...
... The Questionnaire of Foot Care Knowledge and Behavior for Diabetic Patients developed by scholar Liu Jin et al. 25 was adopted in this study. The questionnaire includes 17 items in five dimensions, including foot and footwear inspection (items 1 and 10), foot cleaning and maintenance (items 2, 3, 4, 6), shoe and socks selection (items 8,9,12,13,15), foot injury risk behaviour (items 7, 11, 14, 16) and foot problem treatment (items 5, 17). The content validity index of this questionnaire was 0.976, the retest reliability was 0.808 and Cronbach and α coefficient were 0.519. ...
... Specifically, only 45.3% (115/254) of the patients know that 'when the foot skin of diabetes patients is dry, they need to apply moisturizer for moisturizing'. Only 18.5% (47/254) of patients know that they need to go to the hospital for regular foot examination after diabetes, so as to find foot lesions as soon as possible, which was similar to the results of Li Jao, Abu-Qamar, Dinesh et al. [28][29][30] Diabetic patients can reduce foot sweat due to autonomic neuropathy, which leads to dry or even cracked feet, 12 which is one of the important reasons for diabetic feet. The onset of diabetic foot is hidden, and if patients neglect to check their feet regularly, diabetic foot is often caused by unconscious foot injury or infection. ...
Article
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Good foot care knowledge and behaviour are very important to prevent the occurrence of diabetic foot, but there are few reports on the foot care knowledge and behaviour of older people with diabetes in the community. The purpose of this study was to understand the foot care knowledge and behaviour of older people with type 2 diabetes in Beijing community, and analyse its influencing factors, so as to provide reference for further intervention. We investigated 254 older people with type 2 diabetes in Xinjiekou community, Beijing, including their general information, chronic complications, foot care knowledge and behaviour. The results showed that the average scores of foot care knowledge and behaviour were 73.38 ± 12.25 and 49.70 ± 8.70, respectively. Multiple stepwise regression analysis showed that the factors affecting the total score of foot nursing knowledge of older people with diabetes in community were gender, duration of diabetes and whether they had received foot nursing education (p < 0.05). The factors influencing the total score of foot nursing behaviour were gender, duration of disease, whether they had received foot nursing education and peripheral vascular disease (p < 0.05). In conclusion, the knowledge of foot care of older people with diabetes in community is in the middle level, and the foot care behaviour is not optimistic. Community healthcare workers can improve patients' knowledge of foot care and improve their compliance with foot care behaviour through foot care health education. At the same time, we should pay more attention to men, those with a shorter duration of diabetes and diabetic patients with peripheral vascular disease to reduce the occurrence of diabetic foot.
... It has been reported that foot ulcers are more prevalent in type 2 diabetes [8], and they are difficult to treat due to impaired healing processes and decreased immune responses [9] Staphylococcus aureus is the most frequently isolated pathogen in diabetes-related infections [9][10][11]. S. aureus is a notorious pathogen that can cause many diseases including skin and soft tissue infection, pneumonia, and sepsis. ...
... It has been reported that foot ulcers are more prevalent in type 2 diabetes [8], and they are difficult to treat due to impaired healing processes and decreased immune responses [9] Staphylococcus aureus is the most frequently isolated pathogen in diabetes-related infections [9][10][11]. S. aureus is a notorious pathogen that can cause many diseases including skin and soft tissue infection, pneumonia, and sepsis. C-reactive protein (CRP) is rapidly synthesized in the liver as a part of the acute phase response following infection, injury, or trauma [10]. ...
Article
Diabetes mellitus (T2DM) is a risk factor for various skin and bacterial body infections and many other complications. Staphylococcus aureus is a major human pathogen that causes a variety of infections in both diabetic and non-diabetic patients. It is frequently isolated from diabetic patients and commonly colonizes in human nares, making it a common cause of infections in these patients.serum CRP has been found useful in detecting sepsis or organ dysfunction.Changes in CRP levels have been used to monitor the treatment response,whereas the decline of CRP level is one of the earliest markers of improved condition.Thus this study aimed to find the effect of staphylococcus aureus on serum CRP levels in T2DM.Material And Method:In this study,a total of 100 patients of both sexes,aged 25-75 years were taken from OPD of Medicine Department,SN Medical College,Agra,out of which 50 were T2DM patients and 50 were non-diabetic patients. Blood samples and nasal samples were collected from these patients at the Department of Biochemistry and Microbiology,Sarojini Naidu Medical College,Agra (U.P.) Blood sugar and serum CRP levels were analyzed through the standard kit method.Staphylococcus aureus was identified through the culture method.The data were analyzed through SPSS software. Results And Discussion: In this study we observed a higher nasal colonization of S. aureus in the DM patient compared to non-diabetic patients, suggesting that the nasal colonization of Staphylococcus might be affected by blood glucose levels.NCSA accounted for 60.1 % of T2DM patient groups,while the non-diabetic group accounted for 37.46 %.CRP level was also found significantly higher in the diabetic group than in the non-diabetic group and showed the presence and severity of infection in diabetes mellitus patients.
... 1,2 It is commonly developed after the healing previous foot ulcer. [3][4][5] Further, previous diabetes-related foot ulcers increase the risk of developing recurrent ulcers. [6][7][8] The risk of RDFUs is four times higher for people with diabetes who have had previous foot ulcers than for people with diabetes who have never had foot ulcers. ...
... Some investigators have used the recurrence concept without providing a clear conceptual definition of the recurrence concept, given that there is a lack of an attribute, 20,23,24 while others have used it interchangeably with other related concepts. 4,5,17,[25][26][27][28][29] Other related concepts include re-ulceration ( 17 and new ulcer (Lázaro-Martínez, Aragón-Sánchez, Álvaro-Afonso, García-Morales, García-Álvarez and Molines-Barroso. 30 However, related concepts are terms that have some association with the concept of interest but do not appear to have the same set of attributes. ...
Article
Abstract Background and Purpose There is inconsistency and lack of conceptual clarity regarding the concept of “recurrence” in diabetes-related foot ulcers. Therefore, the purpose of this concept analysis is to analyze the concept of recurrence-related to diabetes-related foot ulcer after the healing of a previous foot ulcer. Method The Rodger's evolutionary concept analysis method was employed to analyze the concept of recurrence in diabetes-related foot ulcers. Eight databases, including PubMed, EMBASE, CINAHL Plus with Full Text, MEDLINE with Full Text (EBSCO), Web of Science, Cochrane Library, PsychoINFO, and Scopus, were searched. Additionally, Google Scholar, bibliographies, and hand searching were conducted. The search spanned from inception through August 13, 2023, yielding 3290 studies. Among these, 3242 did not meet the inclusion criteria, leaving 46 articles that fulfilled the criteria. Findings In a majority of the studies (n = 20, 43%), diabetes-related foot ulcer recurrence occurred at the same site after the healing of previous foot ulcers. In contrast, in fourteen (20%) studies, the diabetes-related foot ulcer recurrence was described as not at the same site as the previous foot ulcer. In the other twelve (26%) studies, the attribute of recurrence was not identified. Conclusions The concept of recurrence-related to diabetes-related foot ulcer should be reserved for diabetes-related foot ulcers at the same site after the healing of previous foot ulcers.
... Some studies have reported that the global amputation rate of DF patients is about 10-25%. However, the prognosis is still unsatisfactory, and the mortality rate within 5 years after amputation can reach 50-68%, while the 10-year survival rate is only 24% [3][4][5]. Furthermore, the substantial expenses associated with managing DF and its complications impose a significant economic burden on patients and their families, making chronic pain in DF a social and medical problem of great concern [6]. Therefore, effective management of pain in DF is crucial, not just for enhancing patients' quality of life but also for minimizing healthcare resource utilization and related costs. ...
Article
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Chronic pain in the diabetic foot (DF) is a common complication of diabetes, bringing a significant burden to patients, their families, and even society. There is no very effective treatment for it, traditional treatments such as medication, lumbar sympathetic nerve block, and alternative therapies are often not very effective and have more adverse effects. The emergence of neuromodulation technology has brought new hope for the treatment of DF, among which spinal cord stimulation (SCS) is a hotspot in current research and has achieved remarkable efficacy in the study of DF treatment by blocking pain signaling and improving circulation and other mechanisms. This article reviews the SCS technique and clinical trails of SCS for chronic DF pain, and describes the prospects and current challenges of SCS.
... Worldwide, diabetes impacts 387 million individuals, with 28 million of those in the United States. Additionally, pre-diabetes affects 316 million globally and 86 million in the U.S. [2,3 ] Numerous studies have been conducted to grasp the intricate complexities involved in chronic wound formation. However, these investigations have yet to adequately elucidate the multi-faceted complexities tied to the development or healing of chronic diabetic wounds. ...
Article
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Biosensors have paved the way for significant advancements in the management of chronic wounds. Following Clarke's introduction of the oxygen electrode, biosensors have transformed into sophisticated bandages that autonomously release medications to address wounds based on physiological indicators, such as pH or glucose levels, that signify pathogenic threats. Aptamer based biosensors have been instrumental in detecting and characterizing harmful bacteria in wounds, which frequently develop antibiotic-resistant biofilms. Numerous functional polymers have played vital roles in the development of these biosensors. Starting with natural polymers like alginate, chitosan, and silk derived fibroin, known for their biodegradable and absorptive properties, progress has occurred in creating biocompatible synthetic polymers like polyurethane and polyethylene glycol, aimed at minimizing nonspecific binding of proteins and cells, thus making biosensors less painful or cumbersome for patients. Recently, polycaprolactone has been engineered, offering flexibility and an extensive surface-area-to volume ratio. There remains potential for further innovations in the production and application of biosensors for wound healing and this review emphasize the evolution from biomarker detection to smart dressings and the integration of machine learning in crafting personalized wound patches for prolonged use.
... In diabetic patients, wound healing is delayed and often incomplete, which is characterized by the loss of coordination between the processes that govern wound healing [9]. The resulting diabetic chronic wounds usually occur on the patient's feet and, in addition to their direct impact on quality of life, also represent an enormous economic burden [10,11]. Foot ulcers occur in up to 25% of patients with long-term diabetes [12] and are the most common cause of limb amputations [13]. ...
Article
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Diabetic foot ulcers have an enormous impact on patients’ quality of life and represent a major economic burden. The cause is delayed and incomplete wound healing due to hyperglycemia, reduced blood flow, infections, oxidative stress and chronic inflammation. Plasma-activated water (PAW) is emerging as a new therapeutic approach in wound treatment, as it has many of the advantages of cold atmospheric plasma but is easier to apply, thus allowing for widespread use. The aim of this study was to investigate the potential of PAW to improve wound healing in diabetic rats, with a focus on uncovering the underlying mechanisms. Two full-thickness wounds in control and diabetic animals were treated with PAW, and healing was monitored for 15 days at five time points. PAW improved wound healing in diabetic rats and mainly affected the inflammatory phase of wound healing. Application of PAW decreased the number of inflammatory cells, myeloperoxidase (MPO) and N-acetyl-b-D-glycosaminidase (NAG) activity, as well as the mRNA expression of proinflammatory genes in diabetic rats. Ten days after injury, PAW treatment increased collagen deposition in the diabetic animals by almost 10% without affecting collagen mRNA expression, and this is in correlation with a decrease in the Mmp-9/Timp-1 ratio. In conclusion, PAW treatment affects wound healing by reducing the inflammatory response and influencing extracellular matrix turnover, suggesting that it has great potential to accelerate the healing of diabetic wounds.
... [4], with a lifetime incidence of 19-34%. Furthermore, the recurrence rate is also high, with these ulcers found again in 40% within a year and 60% within 3 years [5]. With the rapid increase in the number of patients with diabetes, establishing measures to prevent DFUs is an urgent worldwide issue. ...
Article
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Background While there is an urgent need worldwide to establish methods that prevent diabetic foot ulcers, the effectiveness of a prevention protocol using thermography has been reported. As the number of diabetic patients in Indonesia is increasing, an online program for wound care specialists was developed to disseminate this protocol. The present study evaluated the impact of an online program on wound care specialists' knowledge of diabetic foot ulcer prevention using thermography. Methods This single-group quasi-experimental study was conducted in cooperation with the Indonesian Wound Enterostomal Continence Nurses Association with regard to curriculum and content design, and the evaluation methods of online education for thermography-based diabetic foot ulcer prevention using the learning management system. A questionnaire with 50 multiple-choice questions previously validated for content and readability on the knowledge of diabetic foot ulcer prevention using thermography was used for training evaluations. Results Of 106 Indonesian wound care specialists evaluated, the paired t-test revealed a significant difference between the before and after training questionnaire scores on knowledge (52.0 ± 10.3, 85.2 ± 10.6, respectively, p < 0.001). Repeated measures analysis of variance revealed interactions between time (before and after training) and gender, and between time and type of certificate ( p = 0.046, p = 0.014, respectively). Conclusions An asynchronous e-learning program is an effective method to increase wound care specialists' knowledge of diabetic foot ulcer prevention. These findings suggest that online educational interventions are effective and can be tailored to meet the needs of healthcare professionals, thereby ultimately contributing to better patient care outcomes in preventing DFUs.
... The healing process of diabetic wounds is hampered by multiple factors such as persistent oxidative stress in the wound, high glucose levels, pathogenic bacterial infection [8,9] and inflammation. Current clinical standards of care for DFU include pressure off-loading, sharp debridement, and wound moisture balance, along with infection control and management of peripheral arterial disease [10][11][12]. However, these treatments are often fail to achieve satisfactory outcomes and associated with adverse effects [13,14]. ...
Article
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Background Diabetic foot ulcers (DFU) are severe complications of diabetes, posing significant health and societal challenges. Accumulation of reactive oxygen species (ROS) and elevated glucose levels are primary factors affecting diabetic wound healing. Achieving effective treatment by reducing ROS alone is challenging, as high glucose levels continuously drive ROS production. The excellent glucose-consuming capacity of lactobacilli and the antioxidant function of hydrogen undoubtedly provide good therapeutic ideas. Herein, we combined probiotic Lactobacillus reuteri with acid-responsive hydrogen-producing nanoparticles to construct probiotic active gel LR&AB@CAH to enable a cascade of glucose consumption and hydrogen production. Lactobacillus reuteri consumed overproduced glucose and thereby released lactic acid to activate nanoparticle for hydrogen production, which could neutralize excess ROS and promote wound healing. Results In vitro experiments demonstrate that LR&AB@CAH has good biocompatibility, antioxidant capacity. LR&AB@CAH reduces excess ROS, decreases oxidative substances, and boosts antioxidant enzyme activity. In a diabetic wound mouse model, it functions as a glucose scavenger and antioxidant, reducing ROS and supporting wound healing. Conclusion LR&AB@CAH offers a novel strategy for the comprehensive treatment of DFU. This study provides an artificial-natural composite hydrogel for cascade therapy on diabetic wound healing, and suggests a complete management approach for diabetic oxidative stress.
... Due to reduced blood flow, people with diabetes frequently experience difficulties mending foot ulcers [3,4], which can worsen infections and ultimately require amputation. Approximately 40% of diabetic foot ulcers 9DFUs) recur after the first year and 60% within three years of initiation, which is an exceptionally high rate [5,6]. Such amputation wounds not only negatively impact the quality of life but are also prone to complications [7]. ...
Article
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Type 2 Diabetes mellitus (T2DM) patients are experiencing diabetic foot problems that heavily burden healthcare systems around the globe. Although there have been challenges with diagnosing and treating these problems using traditional approaches, the advent of machine learning technology signals the beginning of a new age in diabetic foot care, with the promise of improved precision and customized treatment plans. Machine learning is a beneficial tool for extracting essential insights from large, complicated datasets to improve the accuracy of diabetic foot diagnosis and therapeutic planning. This research aims to employ artificial intelligence to build a decision support system that will use clinical and demographic variables to predict the likelihood that individuals with mild, moderate, or severe peripheral neuropathy may develop diabetic foot syndrome in T2DM. Real-time processing of clinical information is made possible by a customized stacked ensemble model, which offers immediate peripheral neuropathy risk prediction with low computing latency. The system’s capacity to transform raw patients’ data into valuable insights in milliseconds supports quick clinical decision-making. Additionally, comparison and testing have been conducted on four deep learning algorithms: ResMLP, LSTM, DNN, and 1D-CNN. The predictions produced by the classifiers have been interpreted using three explainers: LIME, Eli5, and SHAP. Using the mutual information feature selection technique, the final stack reached a maximum accuracy of 99%. The three most significant markers that helped predict the onset of diabetic foot syndrome were area under pressure, vpt right, and vpt left; the encouraging findings point to the possibility of predicting diabetic foot condition with a decision system.
... According to the definition of the international working group on diabetic feet, DFU is the foot ulcer in person with currently or previously diagnosed diabetes mellitus (DM) and usually accompanied by neuropathy and/or peripheral artery disease in the lower extremity (2). DFU is found in 19% to 30% of the world's DM patients (3). Unlike other ulcers, DFU carries a high risk of amputation. ...
Article
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Objective Diabetic foot ulcer (DFU) is one of the common complications in patients with diabetes mellitus (DM). In order to find a method to monitor and treat the refractory DFU, the ferroptosis level in DFU and traumatic wounds (TW) was monitored and the difference between them was analyzed. At the same time, this study further analyzed the correlation of ferroptosis levels with DM severity and DFU’s healing. Methods A prospective cohort study was from January, 2021 to December, 2023 in the Second People’s Hospital of Gansu province, which included 59 patients with DFU and 42 patients with TW. We then used the kit to detect the indicators related to ferroptosis, including 4-Hydroxynonenal (4-HNE), Malondialdehyde (MDA) and reactive oxygen species (ROS), in the wound exudate of the two groups of patients. Results The DFU group had higher ferroptosis level than the TW group (4-HNE: P = 0.003, MDA: P<0.001, ROS: P<0.001). The severity of diabetes was significantly associated with ferroptosis level in DFU patients(r = 0.936, P <0.001). The results of multiple regression analysis showed that 4-HNE (β = -0.182, P = 0.008), MDA (β = -0.478, P <0.001) and ROS (β = -0.394, P<0.001) significantly negatively predicted the healing rate of DFU. Conclusion As a new monitoring and therapeutic target, ferroptosis level plays an important role in predicting the healing rate of DFU and assisting clinical treatment decision-making.
... Every year, an estimated 18.6 million people around the world develop a diabetic foot ulcer (DFU) [1]. Of the 537 million people living with diabetes worldwide [2], the lifetime incidence of developing a DFU is 34% [3], placing a substantial strain on the entire global healthcare system. In the United States, DFUs account for nearly one-third of the approximately $116 billion in direct costs related to diabetes [4], and precede more than 80% of all lower extremity amputations [5]. ...
... They can be caused by mechanical, physical or thermal damages or metabolic diseases and culminate in tissue necrosis, increased level of pain, disability or even death [1,2]. Moreover, a significant increase in the incidence of chronic skin wounds have been observed especially related to high prevalence of chronic diseases such as diabetes and vascular diseases in the worldwide population [3,4]. It is important to emphasize that, in general, chronic wounds are difficult to heal and due to this reason they are becoming an important global medical problem [5]. ...
Article
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The search for innovative materials for manufacturing skin dressings is constant and high demand. In this context, the present study investigated the effects of a 3D printed skin dressing made of spongin-like collagen (SC) extract from marine sponge (Chondrilla caribensis), used in 3 concentrations of SC and alginate (C1, C2, C3). For this proposal, the physicochemical, morphological and in vitro biological results were investigated. The results demonstrated that, after immersion, C2 presented a higher mass loss and C3 present a higher pH in experimental periods. Also, a higher porosity was observed for C1 and C2 skin dressings, with a higher swelling ratio for C2. For Fourier transform infrared, peaks of Amide A, –CH2, –COOH and C–O–C were seen. Moreover, the macroscopic image demonstrated a skin dressing with rough surface and grayish color that is naturally observed in Chondrilla caribensis. For scanning electron microscopy analysis the presence of pores could be observed for all skin dressings, with fibers disposed in layers. The in vitro analyses demonstrated the viability of HFF-1 and L929 cell lines 70% of the values found for cell proliferation compared to Control Group. Furthermore, the cell adhesion analysis demonstrated that both cell lines adhered to the 3 different skin dressings and non-cytotoxicity was observed. Taking together, all the results suggest that the skin dressings are biocompatible and present non-cytotoxicity in the in vitro studies, being considered a suitable material for tissue engineering proposals.
... Diabetic foot ulcer (DFU) has alarmingly high recurrence rates, with 40%-60% of patients experiencing recurrence within one year and over 70% within five years [15]. This trend not only exacerbates patient suffering but also imposes substantial burdens on healthcare systems, including increased hospital admissions and prolonged treatment durations. ...
Article
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Diabetic foot ulcer (DFU) is one of the most severe complications of diabetes, involving complex pathological mechanisms such as neuropathy, vascular abnormalities, and infections. In recent years, with advances in treatment technologies and the promotion of multidisciplinary team (MDT) care, DFU diagnosis and treatment have improved significantly. Traditional therapies, including dressings, debridement, and negative pressure wound therapy (NPWT), remain critical in basic treatment. Meanwhile, emerging therapies such as stem cell therapy, growth factor therapy, continuous oxygen diffusion therapy (CODT), and antimicrobial materials offer new hope for treating refractory ulcers. However, DFU's high recurrence rate and poor long-term prognosis remain major challenges, closely associated with blood glucose fluctuations, infections, and psychosocial factors. MDT approaches have significantly improved cure rates and quality of life but face limitations in implementation at primary healthcare levels. Future research should focus on large-scale, multicenter studies with long-term follow-up while strengthening psychological support and personalized management. This would promote comprehensive advancements in DFU diagnostic and therapeutic strategies, ultimately improving patient outcomes and quality of life.
... As a common complication of diabetes mellitus, DFUs can lead to severe outcomes, including infection, prolonged hospitalization, and even lower limb amputation [3][4][5]. The prevalence of DFUs is on the rise, with estimates suggesting that 12%-34% of patients with diabetes will develop a foot ulcer in their lifetime [6,7]. This not only imposes a substantial burden on healthcare systems but also profoundly impacts the quality of life of affected individuals. ...
Article
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Diabetic foot ulcers (DFUs) represents a significant public health issue, with a rising global prevalence and severe potential complications including amputation. Traditional treatments often fall short due to various limitations such as high recurrence rates and extensive resource utilization. This editorial explores the innovative use of acellular fish skin grafts as a transformative approach in DFU management. Recent studies and a detailed case report highlight the efficacy of acellular fish skin grafts in accelerating wound closure, reducing dressing changes, and enhancing patient outcomes with a lower socio-economic burden. Despite their promise, challenges such as limited availability, patient acceptance, and the need for further research persist. Addressing these through more extensive randomized controlled trials and fostering a multidisciplinary treatment approach may optimize DFU care and reduce the global health burden associated with these complex wounds.
... Since January 2022, a Consultant Podiatric Surgeon has been attending the diabetic foot MDT clinic. This results in surgical referrals to the podiatric surgery team to assist with the management of patients with chronic infection, necrosis, and ulceration who are ultimately at risk of below-knee amputation and early death (Armstrong et al., 2017). Diabetic foot MDTs have been shown to improve incidence and risk reduction in foot ulceration and decrease major lower limb amputation (Khan & Sapsed 2017). ...
... There remains significant potential for exploration regarding the clinical applications of this bioadhesive. Diabetic foot ulcers (DFUs) represent a severe complication of diabetes and are the leading cause of non-traumatic lower limb amputations [53], posing substantial threats to patient health [54]. The standard clinical management process for DFUs typically extends over a duration of 12 weeks or longer [20,55]. ...
Article
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Gelatin-based biomaterials have emerged as promising candidates for bioadhesives due to their biodegradability and biocompatibility. However, they often face limitations due to the uncontrollable phase transition of gelatin, which is dominated by hydrogen bonds between peptide chains. Here, we developed controllable phase transition gelatin-based (CPTG) bioadhesives by regulating the dynamic balance of hydrogen bonds between the peptide chains using 2-hydroxyethylurea (HU) and punicalagin (PA). These CPTG bioadhesives exhibited significant enhancements in adhesion energy and injectability even at 4 °C compared to traditional gelatin bioadhesives. The developed bioadhesives could achieve self-reinforcing interfacial adhesion upon contact with moist wound tissues. This effect was attributed to HU diffusion, which disrupted the dynamic balance of hydrogen bonds and therefore induced a localized structural densification. This process was further facilitated by the presence of pyrogallol from PA. Furthermore, the CPTG bioadhesive could modulate the immune microenvironment, offering antibacterial, antioxidant, and immune-adjustable properties, thereby accelerating diabetic wound healing, as confirmed in a diabetic wound rat model. This proposed design strategy is not only crucial for developing controllable phase-transition bioadhesives for diverse applications, but also paves the way for broadening the potential applications of gelatin-based biomaterials.
... The lifetime incidence of DFUs is estimated to be 19%-34% in individuals with diabetes. 8 Patients with diabetic neuropathy experience a loss of sensation and steadiness distally in the lower extremities; therefore, the systemic inflammatory state of DFUs is formed due to dysregulation of the protective sensation. 9 The pathophysiology of this chronic, non-healing wound infection is closely intertwined with microbial colonization, including aerobes, anaerobes, and fungi. ...
Article
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Wounds in patients with diabetes present significant physical and economic challenges due to impaired healing and prolonged inflammation, exacerbated by complex interactions between microbes. Especially, the development and healing of diabetic foot ulcers (DFUs) remain an urgent clinical problem. The human gut harbors a vast microbial ecosystem comprising intestinal flora and their metabolic products. Recent advancements in research have illuminated the concept of the “gut‐skin axis,” revealing intricate relationships between gut microbiota, microbiota‐derived metabolites, and various skin diseases, including DFUs. This review aims to unravel the formation and healing process of DFUs in the context of the gut‐skin axis. We reviewed the current research progress worldwide regarding to the gut‐skin axis, compared and discussed significant changes in the microbiota colonizing the skin and gut in patients with DFUs. The roles of microbiota‐derived metabolites such as lipopolysaccharides, short‐chain fatty acids, and trimethylamine‐N‐oxide in the development of DFUs are highlighted. We also reviewed treatment strategies currently employed in clinical practice and identified potential therapeutic targets such as probiotics for treating DFUs. The need for more comprehensive experimental designs to elucidate the intricate relationship between gut microbiota and its metabolites in the context of DFUs are therefore highlighted.
Article
Muscle strength, balance, performance, and gait speed of individuals diagnosed with diabetic foot wound are negatively affected. This study aimed to investigate the effects of wound localisation on balance, performance, muscle strength, and gait speed in individuals with diabetic foot wounds. Individuals (n = 48) with a mean age of 59.35 ± 11.28 years and were divided into two groups according to wound localisation as group 1 (n = 24) with forefoot wounds and group 2 (n = 24) with hindfoot wounds. Four Step Square Test was used for dynamic balance assessment, Timed Up and Go Test for performance, Manual Muscle Tests for muscle strength, and 10 Meter Walk Test for gait speed assessment. When compared in terms of muscle strength, there was a difference only between the injured side Gluteus Medius (p = 0.02), Gastrosoleus (p = 0.00), and Tibialis Anterior (p = 0.03) muscles. Other muscle groups strength, balance, performance, and gait speed were similar (p > 0.05). Loss of muscle strength can lead to serious negative consequences such as deformity and new wound formation if not intervened in time. The effects on balance and performance are similar in different wound localizations.
Chapter
This report details the advancement made in alcohol sensor testing within the context of an integrated system designed to enhance ulcer detection in the human body. The system has three sensors—alcohol, ammonia, and acetone—with a focus on improving the alcohol sensor’s testing procedures. This report offers a thorough examination of the approaches and methodology established to achieve more accurate and sensitive alcohol detection, even though extensive testing for the ammonia and acetone sensors is still something that needs to be done in the future. The study emphasizes the effective use of testing techniques that produced positive results for alcohol detection. The early detection and monitoring of ulcers in clinical practice may be revolutionized as a result of preliminary studies that point to significant increases in accuracy and sensitivity. This project highlights the potential for sensor integration to revolutionize ulcer diagnoses while also recognizing the need for ongoing research to properly utilize the integrated system’s capabilities. The integration of these sensors offers the possibility of earlier and more accurate ulcer detection, which is a significant advancement in medical diagnostics. This report establishes the groundwork for future developments in this important sector and encourages additional investigation into the potential of sensor integration in medical applications.
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This retrospective study aimed to evaluate diabetic foot ulcer (DFU) recurrence rates and associated risk factors, focusing on hemodialysis and specific amputation levels. Patients with diabetes treated for DFU between 2003 and 2019 at a wound-care center in Japan were studied. The primary outcome was DFU recurrence, and the factors evaluated included age, sex, hemodialysis treatment, revascularization type, and amputation level. Among 236 participants (mean age: 65 years; male: 73%; 33% on hemodialysis), DFU recurrence rates were 40.3% and 77.1% at 1 and 5 years, respectively. Hemodialysis was significantly associated with an increased DFU recurrence risk (hazard ratio: 1.92; 95% confidence interval: 1.40-2.64, P < .001). Revascularization did not significantly impact DFU recurrence rates after ulcer healing. Contralateral DFU recurrence was the most frequent, occurring in 45% of cases. Higher DFU recurrence rates were observed at adjacent toes on the same side in patients who underwent great toe amputation and at the treated site in patients who underwent transmetatarsal, Lisfranc, or Chopart amputations. These findings indicate that DFU recurrence poses a higher risk in patients undergoing hemodialysis. Tailored postoperative management focusing on both contralateral and ipsilateral recurrences is essential to minimize recurrence and improve long-term outcomes.
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More than three million people in the United States are treated for diabetic extremity wounds every year, with numerous physical, financial, and psychosocial impacts not only to patients but also their families who care for them. This study examined the experiences of families who care for adult members with a diabetic extremity wound. A qualitative multiple case study was conducted with four family cases recruited from an urban academic medical center in the Southeastern United States, with data collection consisting of individual interviews, demographic survey instruments, and family caregiving genogram construction. Individual- and cross-case synthesis was completed using reflexive thematic analysis. Themes related to impacts on family functioning, the caregiving experience, and formal health care utilization were identified. These findings provide insight into the experiences of families living with diabetic extremity wounds, as well as clinical and research directions for the future.
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Hyperglycemia exacerbates bacterial infections, disrupts angiogenesis, and perpetuates chronic inflammation in the wound. Therefore, the effective management of diabetic wounds necessitates a synergistic approach that integrates local wound microenvironment remodeling with systemic hyperglycemia regulation. Herein, an unprecedented hierarchical cobalt pyrophosphate/DNA (Co2PPi/DNA) nanocomposite is reported for this purpose. Unlike the stereotypical assembly of either enzymatically polymerized ultralong nucleic acids with Mg2PPi nanosheets at low assembly ratios or commercial homo‐oligonucleotides devoid of biofunctionalities in the presence of metal ions, this study represents the first demonstration on coordination‐driven high‐efficiency co‐assembly of biofunctional hetero‐oligonucleotides and non‐Mg2PPi nanosheets, specifically glucagon receptor (GCGR) aptamer and Co2PPi nanosheets. To improve the bioavailability of nanocomposites, a dissolvable microneedle patch is applied for their wound delivery. Thereafter, nanocomposites dissociate in the wound for sustained release of Co²⁺ ions and GCGR aptamer, from which Co²⁺ ions eliminate colonized bacteria and promote angiogenesis through stabilizing HIF‐1α, meanwhile, aptamer after circulating to liver reduces blood glucose levels by binding to hepatocyte GCGR. Importantly, this hypoglycemic effect promotes antibacterial and pro‐angiogenic efficacy and alleviates the inflammatory responses. This work highlights significant advancements in the coordination of biofunctional hetero‐oligonucleotides into a versatile nanocomposite architecture to remodel local pathological microenvironment facilitated by systemic factor regulation.
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Foot ulceration is a significant and growing health problem worldwide, particularly due to rises in diabetes mellitus (DM) and peripheral artery disease. The prediction of ulcer healing remains a major challenge. In patients with foot ulcers, medial arterial calcification (MAC) can be present as a result of concomitant DM or chronic kidney disease and is a prognostic factor for unfavorable outcome. This systematic review aimed to evaluate the prognostic reliability of bedside tests to predict ulcer healing and wound healing after minor amputation in patients prone to MAC, following PRISMA guidelines. Primary endpoints were the positive and negative likelihood ratios for ulcer healing. Methodological quality and risk of bias were assessed using the QUIPS-tool. A total of 35 studies were included, predominantly investigating transcutaneous oxygen pressure (TcPO 2 ), followed by ankle–brachial index and toe pressure. None of these bedside tests effectively provided an acceptable trade-off between predicting healing and nonhealing. A TcPO 2 below 30 mmHg was most closely associated with nonhealing of an ulcer. The same applied to wound healing after minor amputation, in which none of the bedside tests was able to sufficiently predict healing or nonhealing. To conclude, currently used bedside tests lack acceptable prognostic performance for ulcer healing and healing after minor amputation in patients prone to MAC. Future prospective studies should establish a clear definition of ulcer healing, utilize a standardized wound classification system, and minimize patient heterogeneity. A combined assessment of microvascular and macrovascular perfusion status could improve the prediction of wound healing.
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Introduction To compare the clinical outcomes and healthcare utilization of patients enrolled in the multidisciplinary Diabetic Foot in Primary and Tertiary (DEFINITE) Care program with a matched historical cohort and estimate the program’s long-term cost-effectiveness using simulation. Research design and methods This study consisted of two components: a 1-year observational outcome evaluation and a long-term simulation-based cost-effectiveness analysis (CEA). We conducted an observational study to analyze 2798 patients with diabetic foot ulcers (DFUs) enrolled in the program between June 2020 and June 2021 (DEFINITE Care group) and 5462 patients with DFUs from June 2016 to December 2017 as historical controls. One-to-one propensity score matching (PSM) with replacement was conducted to estimate the treatment effect of the program on clinical outcomes and healthcare utilization over 1 year. For the simulation component, a long-term CEA was performed using a Markov state transition model on a simulated cohort of 10 000 patients with DFUs over a 20-year period, assessing transitions between health states, including minor and major amputations and death. The incremental cost-effectiveness ratio (ICER) was calculated for the DEFINITE Care program relative to routine care. Results The estimation of average treatment effects based on propensity scores showed that the DEFINITE Care group exhibited a 9% lower mortality, 5% higher lower extremity amputation (LEA)-free survival, yet a 5% higher minor LEA rate compared with the matched historical controls. Additionally, they experienced fewer inpatient admissions (0.98 fewer episodes) and shorter hospital stays (5.5 fewer days) within 1 year (p-value <0.001). The ICER was US$22 707 (SE: 430) per quality-adjusted life year gained, indicating long-term cost-effectiveness. Probabilistic sensitivity analysis supported these findings. Conclusions The integrated multidisciplinary DEFINITE Care program improved LEA-free survival, reduced inpatient admissions and length of stay within 1 year and demonstrated long-term cost-effectiveness managing DFUs.
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romjene u klimi ali i u vremenskim obrascima poput: suša, toplinskih valova, poplava i jakih oborine sve se češće pojavljuju i u našem okruženju. No ono što je u ovom slučaju bitno je da sa sobom donose jako povoljne uvjete za razmnožavanje komaraca te pomažu širenju pojedinih vrsta u dijelove svijeta gdje ih do sada nije bilo. U svijetu postoji preko 3000 vrsta komaraca od čega je do sada u Hrvatskoj pronađeno 52 vrste od čega samo na području Zagreba obitava 32 vrste. No, ono što nas često zabrinjava je upravo razvoj bolesti koje komarci prenose. Najteže bolesti kao što su denga, chikungunya, zika i žuta groznica prenose samo dvije vrste komaraca - Aedes aegypti i Aedes albopictus, poznat kao azijski tigrasti komarac. Prema podacima Nastavnog zavoda za javno zdravstvo dr. Andrija Štampar, posljednjih 15 godina u Hrvatskoj je prisutan tigrasti komarac (Aedes albopictus), invazivna vrsta koja se proširila na cijelo područje Hrvatske. Ono što čini opasnu ovu vrstu je njena prilagodljivost, brzo razmnožavanje te širenje na nova područja gdje do sada nisu obitavali. Prema podacima Svjetske zdravstvene organizacije (WHO) bolesti koje prenose komarci ubiju više od milijun ljudi i zaraze do 700 milijuna svake godine što je gotovo jedna od deset osoba. Budući se naša planeta zagrijava može se zaključiti da zapravo klimatske promjene produljuju sezonu komaraca i oni se šire prema onim dijelovima svijeta gdje ih nije bilo do sada ili su bili vezani za kratka ljetna vremenska razdoblja. Sustav ranog upozoravanja na bolesti koje prenose komarci (EYWA) pokazuje uzlaznu putanju bolesti u Europi, s porastom slučajeva malarije za 62%, a denga groznice, zike i chikungunye za 700%. Danas je potvrđeno da klimatske promjene povećavaju rizik od bolesti koje prenose komarci, navodi dr. Katie Anders, epidemiologinja u Svjetskom programu za komarce (WMP). Naime, vektorske bolesti čine više od 17% svih zaraznih bolesti u Svijetu, uzrokujući više od 700 000 smrti godišnje. Mogu ih uzrokovati paraziti, bakterije ili virusi. Bolesti koje prenose komarci su denga groznica, virus koji se najbrže širi na svijetu, a zarazi više od 390 milijuna ljudi svake godine. WHO procjenjuje da je više od 3,9 milijardi ljudi u više od 129 zemalja u opasnosti od zaraze denga groznicom. Pri tome se navodi procjena da će u narednim godinama biti razvijeno 96 milijuna simptomatskih slučajeva i 40 000 smrtnih slučajeva svake godine. Ostale virusne bolesti koje prenose vektori su: chikungunya groznica, zika virusna groznica, žuta groznica, groznica zapadnog Nila i dr. Zika virus prenose komarci vrste Aedes, a većina zaraženih ljudi ne razvije simptome. Ipak, oni koji imaju simptome prepoznatljivi su kroz: osip, groznicu, konjunktivitis, bolove u mišićima i zglobovima, malaksalost i glavobolju i mogu trajati dva do sedam dana. Prema podacima Nastavnog zavoda za javno zdravstvo dr. Andrija Štampar na području grada Zagreba udomaćio se tigrasti komarac (Aedes albopictus), azijska invazivna vrsta komaraca koja može prenjeti zika virus. Za razliku od većine vrsta na našem području koje su aktivne predvečer i tijekom ranojutarnjih sati, tigrasti komarac je aktivan i bode tijekom cijelog dana.
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Promjene u klimi nisu što i vremenske promjene budući nastaju tijekom višegodišnjih razdoblja, ponekad se mjere kroz vremenski period od 20 ili 30 godina. Računajući prosječnu starost čovjeka očito je da ćemo svjedočiti promjenama u klimi. To je posebno izraženo u vremenima u kojima se nalazimo danas. U 2023. godini zabilježeni su najveći temperaturni pikovi ikada izmjereni što smo osjetili i u našim krajevima, a izgleda kako ni 2024. godina ne zaostaje. Generalno klimatski indikatori pokazuju povećane vrijednosti: Europa ima prosječno više temperature za 2.3°C od vremena predinstrijskog razvoja što je usko povezano i s brojem sunčanih dana. Već smo u prethodnim brojevima pisali o tome kako naše tijelo reagira u vremenima izraženih klimatskih promijena. Ovaj člank posvećujem našem oku. Oko je organ koji je gotovo u cijelosti otvoren utjecaju vanjskih čimbenika. Izložen je vjetru, suncu (UV zrakama), česticama prašine te se njegovo zdravlje usko veže i za izloženost klimatskim parametrima. Mnoga znanstvena istraživanja upućuju na činjenicu da hitno trebamo postaviti pitanje koji je utjecaj klimatskih promjena na zdravlje oka te kako i na koji način se možemo zaštiti. U literaturi se spominje preko 10 000 poveznica istraživanja oka i klimatskih promjena od kojih preko 150 relevantnih znanstvenih radova donosi istraživanja koja povezuju neke od klimatoloških faktora sa zdravljem oka. Najviše zastupljena istraživanja potječu iz istočne Azije: Kina, Taivan i Južna Korea te su ista aktualizirana od 2021. godine prema danas. U tom smislu treba promatrati klimatske indikatore te indikatore koji su vezani za anatomiju oka. Klimatski indikatori su: visoke temperature (UV zračenje), povećana koncentracija sitnih čestica PM 2,5 i PM 10 te različiti ekstremni vremenski uvjeti poput poplava, uragana i sl. U kontekstu naše izloženosti UV zrakama procjenjuje se da je približno 20% slučajeva katarakte (mrene) izravna posljedica prekomjerne izloženosti ultraljubičastom (UV) zračenju. No kako se izloženost UV zrakama bude povećavala te intenzitet zračenja moguće je povećanje učestalosti bolesti poput: akutnog fotokeratitisa, fotokonjuktivitisa i solarne retinopatije. Fotokeratitis se najjednostavnije može usporediti s opeklinama kože. Nastaje zbog prekomjernog izlaganja UV zrakama i obično zahvaća oba oka. Simptomi koji ga prate su bol ili crvenilo oka, suzenje očiju, zamagljen vid, oteklina oka, osjetljivost na svjetlo te osjećaj oštrice u očima. Veći rizik od dobivanja fotokeratitisa je ako provodite puno vremena vani na suncu, bavite se aktivnostima kao što su planinarenje, skijanje ili plivanje, koristite lampe za sunčanje, solarij ili radite ili provodite vrijeme u okruženjima gdje postoji izvor UV svjetla. Ako osjetite simptome nabolje je odmah otići u zatvoren i zamračen prostor, skinuti kontaktne leće ako ih nosite te izbjegavati trljanje očiju. Pri smanjenju simptoma i nelagode može pomoći odmaranje oka, umjetne suze ili hladan oblog preko zatvorenog oka no ako bolovi ne prođu kroz dan ili se dogodi gubitak vida svakako se treba potražiti liječničku pomoć. Fotokeratitis i fotokonjunktivitis dva su vrlo slična stanja, oba uzrokovana oštećenjem oka UV zrakama. Glavna razlika je u tome što je fotokeratitis upala rožnice, dok je fotokonjunktivitis upala konjunktive, odnosno membrane koja oblaže unutarnju stranu vjeđa i očne duplje. Fotokonjuktivitis može biti posljedica prekomjerne izloženosti UV zrakama te različitim alergenima poput peludi, prašine ili dima (čestice PM 2,5 i PM 10). Praćeno je jakim crvenilom oka, pojačanim suzenjem, osjećajem gorenja oka, zamagljenim vidom, osjetljivošću na svjetlo pa sve do iscjedka iz oka. Pogađa sve, od novorođenih beba do starije populacije. Solarna retinopatija ili oštećenje mrežnice, tankog tkiva u vašem oku koje osjeća svjetlost i usmjerava signale u vaš mozak kako biste mogli vidjeti, se povezuje s izravnim gledanjem u sunce pri čemu UV zrake oštećuju tkivo oka, a posebno je izražena prilikom promatranja sunca tijekom pomrčine. No može biti izazvana i gledanjem u jaka svjetla baklji za zavarivanje ili laserskih pokazivača. Najbolji način da spriječite ova bolna stanja oka je spriječiti UV zrake da dopru do vašeg oka. Da biste to učinili, trebali biste nositi sunčane naočale tijekom svih godišnjih doba, a naočale za snijeg kada ste na skijanju ili snowboardu zimi. Istraživači preporučuju sunčane ili zaštitne naočale koje blokiraju ili apsorbiraju 99% do 100% UV zraka ako provodite vrijeme vani. Najbolji izbor mogu biti sunčane naočale koje imaju bočnu zaštitu te na taj način blokiraju sve štetne UV zrake. Nosite šešir sa širokim obodom ili vizirom kada ste vani, koristite odgovarajuću opremu za zaštitu očiju ako ste na poslu izloženi UV zračenju, nosite kontaktne leće koje upijaju UV zračenje ako radite ili iz nekog razloga dulje boravite u sunčanom okruženju. Posebno vodite brigu o djeci jer prekomjerno izlaganje UV zrakama može izazvati neku od promjena stanja oka. Odsjaj snijega, pijeska ili vode može uzrokovati opekline vaših očiju čak i ako je oblačno ili polu oblačno vrijeme. I na kraju, nameće nam se zaključak kako prostor kugle zemaljske zahtjeva našu prilagodbu novim klimatološkim stanjima, jačanju prevencije oboljenja koja imaju direktnu poveznicu s klimatskim promjenama te razvoju naše svijesti kako UV zrake nisu samo uzročnik razvoja kožnih oboljenja već značajno utječu i na naše oko.
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One of the biggest medical issues facing healthcare practitioners in the twenty-first century is diabetes mellitus, which has emerged as a global healthcare emergency. Consequently, the numerous side effects associated with this illness are also at an all-time high, with diabetic peripheral neuropathy (DPN) topping the list. There is no denying the critical role orthotics play in the treatment of this debilitating condition. Medical experts can employ orthotic devices to help patients with their specific musculoskeletal, neuropathic, and biomechanical demands, therefore improving their quality of life. Because of the intricate clinical presentation of DPN, it is imperative that orthotic devices be customized for each patient in order to ensure the effectiveness of this treatment. Programs for patient education that emphasize the benefits of orthotic therapy and self-care practices are also essential. More research and innovation in the area of orthotics will open doors to a better management of diabetic peripheral neuropathy.
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目的 腺苷脱氨酶(adenosine deaminase,ADA)是嘌呤代谢过程中参与腺苷酸分解代谢的关键酶之一,在多种疾病的诊断和病情监测中扮演重要角色。本研究拟探讨血清ADA水平与2型糖尿病(type 2 diabetes mellitus,T2DM)患者发生糖尿病足溃疡(dibetic foot ulcer,DFU)风险的关系,为DFU的防治提供临床依据。 方法 回顾性收集2019年1月至2020年1月陆军军医大学第一附属医院确诊的T2DM患者2 719例,根据是否合并DFU分为非DFU组(n=1 952)和DFU组(n=767)。收集患者的血清ADA水平,并根据ADA四分位数将所有参与者分为最低四分位数(Q1)组、第2四分位数(Q2)组、第3四分位数(Q3)组、第4四分位数(Q4)组。采用Pearson相关性分析和多因素Logistics回归评估血清ADA水平与T2DM患者发生DFU风险的关系,并比较不同Wagner分级的DFU患者血清ADA水平的变化情况。 结果 在T2DM患者中,DFU的患病率为28.21%,随着血清ADA水平升高,DFU的患病率逐渐增加。多因素矫正的Logistic回归分析显示:血清ADA水平每增加1个单位,DFU风险增加3%(OR=1.03,95% CI 1.01~1.05;P=0.003);相比Q1组血清ADA,Q2(OR=1.77,95% CI 1.30~2.43;P<0.001)、Q3(OR=2.11,95% CI 1.54~2.89;P<0.001)和Q4(OR=2.27,95% CI 1.64~3.16;P<0.001)组患者发生DFU的风险升高。Wagner 0~5级的DFU患者血清ADA水平呈上升趋势(P<0.001)。 结论 T2DM患者的高血清ADA水平与DFU风险增加相关,提示血清ADA水平可能在T2DM患者DFU发生过程中起重要作用。
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Objective: To evaluate ambulatory clinical cases of diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs) in the U.S. from 2007 to 2013 and to assess outcomes of emergency department or inpatient (ED/IP) admission, number of clinic visits per year, and physician time spent per visit. Research design and methods: A cross-sectional historical cohort analysis was conducted by using the nationally representative Centers for Disease Control and Prevention National Ambulatory Medical Care Survey data from 2007 to 2013, including patients age ≥18 years with diabetes and either DFIs or DFUs. Study outcomes were analyzed by using generalized linear models controlling for key demographics and chronic conditions. Results: Across the estimated 5.6 billion ambulatory care visits between 2007 and 2013, 784.8 million involved diabetes and ∼6.7 million (0.8%) were for DFUs (0.3%) or DFIs (0.5%). Relative to other ambulatory clinical cases, multivariable analyses indicated that DFUs were associated with a 3.4 times higher odds of direct ED/IP admission (CI 1.01-11.28; P = 0.049), 2.1 times higher odds of referral to another physician (CI 1.14-3.71; P = 0.017), 1.9 times more visits in the past 12 months (CI 1.41-2.42; P < 0.001), and 1.4 times longer time spent per visit with the physician (CI 1.03-1.87; P = 0.033). DFIs were independently associated with a 6.7 times higher odds of direct ED referral or IP admission (CI 2.25-19.51; P < 0.001) and 1.5 times more visits in the past 12 months (CI 1.14-1.90; P = 0.003). Conclusions: This investigation of an estimated 6.7 million diabetic foot cases indicates markedly greater risks for both ED/IP admissions and number of outpatient visits, with DFUs also associated with a higher odds of referrals to other physicians and longer physician visit times.
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Diabetic foot ulceration poses a heavy burden on the patient and the health care system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this paper, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomised controlled trials, which include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%. This article is protected by copyright. All rights reserved.
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This study was designed to explore whether participant-driven patient education in group sessions, compared to provision of standard information, will contribute to a statistically significant reduction in new ulceration during 24 months in patients with diabetes and high risk of ulceration. This is an interim analysis after six months. A randomised controlled study was designed in accordance with CONSORT criteria. Inclusion criteria were: age 35–79 years old, diabetes mellitus, sensory neuropathy, and healed foot ulcer below the ankle; 657 patients (both male and female) were consecutively screened. A total of 131 patients (35 women) were included in the study. Interim analysis of 98 patients after six months was done due to concerns about the patients' ability to fulfil the study per protocol. After a six-month follow up, 42% had developed a new foot ulcer and there was no statistical difference between the two groups. The number of patients was too small to draw any statistical conclusion regarding the effect of the intervention. At six months, five patients had died, and 21 had declined further participation or were lost to follow up. The main reasons for ulcer development were plantar stress ulcer and external trauma. It was concluded that patients with diabetes and a healed foot ulcer develop foot ulcers in spite of participant-driven group education as this high risk patient group has external risk factors that are beyond this form of education. The educational method should be evaluated in patients with lower risk of ulceration. Copyright © 2011 FEND. Published by John Wiley & Sons, Ltd.
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OBJECTIVE To assess the efficacy of in-shoe orthoses designed based on shape and barefoot plantar pressure in reducing the incidence of submetatarsal head plantar ulcers in people with diabetes, peripheral neuropathy, and a history of similar prior ulceration.RESEARCH DESIGN AND METHODS Single-blinded multicenter randomized controlled trial with subjects randomized to wear shape- and pressure-based orthoses (experimental, n = 66) or standard-of-care A5513 orthoses (control, n = 64). Patients were followed for 15 months, until a study end point (forefoot plantar ulcer or nonulcerative plantar forefoot lesion), or to study termination. Proportional hazards regression was used for analysis.RESULTSThere was a trend in the composite primary end point (both ulcers and nonulcerative lesions) across the full follow-up period (P = 0.13) in favor of the experimental orthoses. This trend was due to a marked difference in ulcer occurrence (P = 0.007) but no difference in the rate of nonulcerative lesions (P = 0.76). At 180 days, the ulcer prevention effect of the experimental orthoses was already significant (P = 0.003) when compared with control, and the benefit of the experimental orthoses with respect to the composite end point was also significant (P = 0.042). The hazard ratio was 3.4 (95% CI 1.3-8.7) for the occurrence of a submetatarsal head plantar ulcer in the control compared with experimental arm over the duration of the study.CONCLUSIONS We conclude that shape- and barefoot plantar pressure-based orthoses were more effective in reducing submetatarsal head plantar ulcer recurrence than current standard-of-care orthoses but they did not significantly reduce nonulcerative lesions.
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OBJECTIVE Recurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention.RESEARCH DESIGN AND METHODS As part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence.RESULTSA total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98-27.57]), day-to-day variation in stride count (0.93 [0.89-0.99]), and cumulative duration of past foot ulcers (1.03 [1.00-1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01-23.96]), in-shoe peak pressure <200 kPa with footwear adherence >80% (0.43 [0.20-0.94]), barefoot peak pressure (1.11 [1.00-1.22]), and day-to-day variation in stride count (0.91 [0.86-0.96]).CONCLUSIONS The presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.
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Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.
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OBJECTIVE Custom-made footwear is the treatment of choice to prevent foot ulcer recurrence in diabetes. This footwear primarily aims to offload plantar regions at high ulcer risk. However, ulcer recurrence rates are high. We assessed the effect of offloading-improved custom-made footwear and the role of footwear adherence on plantar foot ulcer recurrence.RESEARCH DESIGN AND METHODS We randomly assigned 171 neuropathic diabetic patients with a recently healed plantar foot ulcer to custom-made footwear with improved and subsequently preserved offloading (∼20% peak pressure relief by modifying the footwear) or to usual care (i.e., nonimproved custom-made footwear). Primary outcome was plantar foot ulcer recurrence in 18 months. Secondary outcome was ulcer recurrence in patients with an objectively measured adherence of ≥80% of steps taken.RESULTSOn the basis of intention-to-treat, 33 of 85 patients (38.8%) with improved footwear and 38 of 86 patients (44.2%) with usual care had a recurrent ulcer (relative risk -11%, odds ratio 0.80 [95% CI 0.44-1.47], P = 0.48). Ulcer-free survival curves were not significantly different between groups (P = 0.40). In the 79 patients (46% of total group) with high adherence, 9 of 35 (25.7%) with improved footwear and 21 of 44 (47.8%) with usual care had a recurrent ulcer (relative risk -46%, odds ratio 0.38 [0.15-0.99], P = 0.045).CONCLUSIONS Offloading-improved custom-made footwear does not significantly reduce the incidence of plantar foot ulcer recurrence in diabetes compared with custom-made footwear that does not undergo such improvement, unless it is worn as recommended.
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Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.
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Because neuroischemic complications are associated with a high rate of recurrence, we propose a slight shift in the mechanism by which we counsel and communicate risk daily with our patients. If the epidemiology of this problem is comparable with that of cancer, and recurrences are common, then perhaps language commensurate with such risks should follow. After initial healing of an index wound, our unit now refers to patients not as being cured but rather as being "in remission." This concept is easy for the patient and the rest of the team to understand. We believe that it powerfully connotes the necessity for frequent follow-up and rapid intervention for inevitable minor and sometimes major complications.
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To evaluate the safety and efficacy of the pan metatarsal head resection (PMHR) compared with nonsurgical management of wounds in the forefoot in people with diabetes. The authors evaluated 92 patients with diabetes (66.3% male), with ulcers classified as University of Texas grade 1A or 2A at the plantar aspect of the forefoot using a case-control model. Cases were patients treated with multiple metatarsal head resections for multiple metatarsal head wounds, and controls received standard nonsurgical care. Both groups received standard off-loading and wound care. Outcomes included time to healing, reulceration, infection, and amputation. Patients in the surgery group (SG) healed significantly faster than those in the standard therapy group (ST; 84.2 ± 39.9 days for the ST vs 60.1 ± 27.9 days for the SG; P = .003) and had fewer recurrent ulcers (39.1% for the ST vs 15.2% for the SG; P = .02; odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.3-9.7) and infections during 1 year of follow-up (64.5% for the ST vs 35.5% for the SG; P = .047; OR = 2.4; 95% CI = 1.0-6.0). There was no significant difference in the proportion of patients receiving an incident amputation in the follow-up period (13.0% for the ST vs 6.5% for the SG; P = .5). The results of this study suggest that the PMHR may be associated with shorter times to healing and lower morbidity compared with standard care alone in patients without digital gangrene and with multiple plantar forefoot ulcers.
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Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of, and risk factors for, DFU recurrence after healing during 3-year follow-up period. At our site, 93 Eurodiale enrolled patients had a healed DFU. Among these, 14 died; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study we assessed: demographic factors (age, sex, distance from hospital); diabetes-related factors (duration, HbA1c levels); comorbidities (obesity, renal failure, smoking, alcohol abuse); and DFU-related factors (peripheral arterial disease, ulcer infection, c-reactive protein [CRP]; foot deformities). During the 3-year follow-up, a DFU recurred in 42 patients (57·5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location (odds ratio [OR] 8·62, 95% CI 2·2-33·2); presence of osteomyelitis (OR 5·17, 95% CI 1·4-18·7); HbA1c > 7·5% ([DCCT], OR 4·07, 95% CI 1·1-15·6); and CRP > 5 mg/l (OR 4·27, 95% CI 1·2-15·7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3-year follow-up, despite intensive foot care. The findings present at diagnosis of the initial DFU that were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) appear to define those at high risk for recurrence, but may be amenable to targeted interventions.
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Context: Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently become infected, cause great morbidity, engender considerable financial costs, and are the usual first step to lower extremity amputation. Objective: To systematically review the evidence on the efficacy of methods advocated for preventing diabetic foot ulcers in the primary care setting. Data sources, study selection, and data extraction: The EBSCO, MEDLINE, and the National Guideline Clearinghouse databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles were also searched, along with the Cochrane Library and relevant Web sites. We reviewed the retrieved literature for pertinent information, paying particular attention to prospective cohort studies and randomized clinical trials. Data synthesis: Prevention of diabetic foot ulcers begins with screening for loss of protective sensation, which is best accomplished in the primary care setting with a brief history and the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy with biothesiometry, measure plantar foot pressure, and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify 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. Conclusions: Substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration. These patients might benefit from certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.
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Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012 a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 - June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 papers were eligible for full text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients. This article is protected by copyright. All rights reserved.
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In 2007, the treatment of diabetes and its complications in the United States generated at least $116 billion in direct costs; at least 33% of these costs were linked to the treatment of foot ulcers. Although the team approach to diabetic foot problems is effective in preventing lower extremity amputations, the costs associated with implementing a diabetic foot care team are not well understood. An analysis of these costs provides the basis for this report. Diabetic foot problems impose a major economic burden, and costs increase disproportionately to the severity of the condition. Compared with diabetic patients without foot ulcers, the cost of care for patients with a foot ulcer is 5.4 times higher in the year after the first ulcer episode and 2.8 times higher in the second year. Costs for the treatment of the highest-grade ulcers are 8 times higher than for treating low-grade ulcers. Patients with diabetic foot ulcers require more frequent emergency department visits, are more commonly admitted to hospital, and require longer length of stays. Implementation of the team approach to manage diabetic foot ulcers within a given region or health care system has been reported to reduce long-term amputation rates from 82% to 62%. Limb salvage efforts may include aggressive therapy, such as revascularization procedures and advanced wound healing modalities. Although these procedures are costly, the team approach gradually leads to improved screening and prevention programs and earlier interventions, and thus seems to reduce long-term costs. To date, aggressive limb preservation management for patients with diabetic foot ulcers has not usually been paired with adequate reimbursement. It is essential to direct efforts in patient-caregiver education to allow early recognition and management of all diabetic foot problems and to build integrated pathways of care that facilitate timely access to limb salvage procedures. Increasing evidence suggests that the costs for implementing diabetic foot teams can be offset over the long-term by improved access to care and reductions in foot complications and in amputation rates.
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Therapeutic footwear for diabetic foot patients aims to reduce the risk of ulceration by relieving mechanical pressure on the foot. However, footwear efficacy is generally not assessed in clinical practice. The purpose of this study was to assess the value of in-shoe plantar pressure analysis to evaluate and optimize the pressure-reducing effects of diabetic therapeutic footwear. Dynamic in-shoe plantar pressure distribution was measured in 23 neuropathic diabetic foot patients wearing fully customized footwear. Regions of interest (with peak pressure>200 kPa) were selected and targeted for pressure optimization by modifying the shoe or insole. After each of a maximum of three rounds of modifications, the effect on in-shoe plantar pressure was measured. Successful optimization was achieved with a peak pressure reduction of >25% (criterion A) or below an absolute level of 200 kPa (criterion B). In 35 defined regions, mean peak pressure was significantly reduced from 303 (SD 77) to 208 (46) kPa after an average 1.6 rounds of footwear modifications (P<0.001). This result constitutes a 30.2% pressure relief (range 18-50% across regions). All regions were successfully optimized: 16 according to criterion A, 7 to criterion B, and 12 to criterion A and B. Footwear optimization lasted on average 53 min. These findings suggest that in-shoe plantar pressure analysis is an effective and efficient tool to evaluate and guide footwear modifications that significantly reduce pressure in the neuropathic diabetic foot. This result provides an objective approach to instantly improve footwear quality, which should reduce the risk for pressure-related plantar foot ulcers.
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To identify factors that influence survival after diabetes-related amputations. We abstracted medical records of 1,043 hospitalized subjects with diabetes and a lower-extremity amputation from 1 January to 31 December 1993 in six metropolitan statistical areas in south Texas. We identified mortality in the 10-year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11-84.18 and categorized as foot, below-knee amputation, and above-knee amputation and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate<60 ml/min and hemodialysis from Current Procedural Terminology (CPT) codes (90921, 90925, 90935, and 90937). We used χ2 for trend and Cox regression analysis to evaluate risk factors for survival after amputation. Patients with CKD and dialysis had more below-knee amputations and above-knee amputations than patients with no renal disease (P<0.01). Survival was significantly higher in patients with no renal impairment (P<0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (hazard ratio [HR] 3.9, 95% CI 3.07-5.0) and a 46% increase for CKD (HR 1.46, 95% CI 1.21-1.77). Subjects with an above-knee amputation had a 167% increase in hazard (HR 2.67, 95% CI 2.14-3.34), and below-knee amputation patients had a 67% increase in hazard for death. Survival after amputation is lower in diabetic patients with CKD, dialysis, and high-level amputations.
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To evaluate the frequency of foot prevention strategies among high-risk patients with diabetes. Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency with which patients received education, podiatry care, and therapeutic shoes and insoles as prevention services. Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than patients with a previous history of ulcer or amputation. Prevention services are infrequently provided to high-risk patients.
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To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population. This population-based study included 155 diabetic individuals with an HFU, 1,339 diabetic individuals without an HFU, and 63,632 nondiabetic individuals who were all followed for 10 years with mortality as the end point. During the follow-up period, a total of 49.0% of diabetic individuals with an HFU died, compared with 35.2% of diabetic individuals without an HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having an HFU was associated with more than a twofold (2.29 [95% CI 1.82-2.88]) hazard risk for mortality compared with that of the nondiabetic group. In corresponding analyses comparing diabetic individuals with and without an HFU, an HFU was associated with 47% increased mortality (1.47 [1.14-1.89]). Significant covariates were older age, male sex, and current smoking. After inclusion of A1C, insulin use, microalbuminuria, cardiovascular disease, and depression scores in the model, each was significantly related to life expectancy. AN HFU increased mortality risk among community-dwelling adults and elderly individuals with diabetes. The excess risk persisted after adjustment for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among individuals with an HFU, who may be particularly vulnerable to adverse outcomes.
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To study whether there is an association between cognitive impairment and the relapse rate of foot ulcers in diabetic patients and those with previous foot ulcers. This single-center prospective study assessed the association of cognitive function and risk for ulcer relapse in 59 patients with diabetes (mean age 65.1 years, diabetes duration 16.5 years, and A1C 7.4%), peripheral neuropathy, and a history of foot ulceration. Premorbid and current cognitive functions were measured (multiple-choice vocabulary test [Lehrl], number-symbol test, mosaic test [HAWIE-R], and trail-making tests A and B [Reitan]). Prevalence of depression was evaluated retrospectively (diagnoses in patient files or use of antidepressive medication). Patients were re-examined after 1 year. Three patients (5%) died during follow-up (one of sepsis and two of heart problems). The remaining 56 patients (48%) developed 27 new foot ulcerations (78% superficial ulcerations [Wagner stage 1]). Characteristics of patients with and without ulcer relapse were not different. In a binary logistic regression analysis, cognitive function is not predictive of foot reulceration. Cognitive function is not an important determinant of foot reulceration.
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This observer-blind, randomised controlled trial was designed to determine the effect of a foot care education programme in the secondary prevention of foot ulcers. People with newly healed foot ulcers attending one of three specialist clinics were allocated to receive either targeted, one-to-one education or usual care, using a computer-generated random allocation sequence that had been prepared in advance but which was concealed from the clinical researcher. The primary outcome was ulcer incidence at 12 months. Secondary outcomes were ulcer incidence at 6 months and incidence of amputation, mood (Hospital Anxiety and Depression Scale) and quality of life (Diabetic Foot Ulcer Scale) at 6 and 12 months. Protective foot care behaviours (Nottingham Assessment of Functional Footcare) were assessed at 12 months. There were 87 (mean [SD] age 63.5 [12.1] years) patients in the intervention group and 85 control patients (mean [SD] age 64.9 [10.9] years). The groups were comparable at baseline. No significant differences (p > 0.05) were observed between groups in ulcer incidence at either 6 months (intervention 30%, control 21%) or 12 months (intervention 41%, control 41%). Recommended foot care behaviours at 12 months were better in the intervention than in the control group (p = 0.03), but education had no significant (p > 0.05) effect on mood, quality of life or amputations. Even though the intervention was associated with improved foot care behaviour, there was no evidence that this programme of targeted education was associated with clinical benefit in this population when compared with usual care. The usefulness and optimal delivery of education to such a high-risk group requires further evaluation. ClinicalTrials.gov NCT00729456 Funding: Diabetes UK project grant RD02/0002535.
Article
Objective: We conducted a multicenter evaluation of a novel remote foot-temperature monitoring system to characterize its accuracy for predicting impending diabetic foot ulcers (DFU) in a cohort of patients with diabetes with previously healed DFU. Research design and methods: We enrolled 132 participants with diabetes and prior DFU in this 34-week cohort study to evaluate a remote foot-temperature monitoring system (ClinicalTrials.gov Identifier NCT02647346). The study device was a wireless daily-use thermometric foot mat to assess plantar temperature asymmetries. The primary outcome of interest was development of nonacute plantar DFU, and the primary efficacy analysis was the accuracy of the study device for predicting the occurrence of DFU over several temperature asymmetry thresholds. Results: Of the 129 participants who contributed evaluable data to the study, a total of 37 (28.7%) presented with 53 DFU (0.62 DFU/participant/year). At an asymmetry of 2.22°C, the standard threshold used in previous studies, the system correctly identified 97% of observed DFU, with an average lead time of 37 days and a false-positive rate of 57%. Increasing the temperature threshold to 3.20°C decreased sensitivity to 70% but similarly reduced the false-positive rate to 32% with the same lead time of 37 days. Approximately 86% of the cohort used the system at least 3 days a week on average over the study. Conclusions: Given the encouraging study results and the significant burden of DFU, use of this mat may result in significant reductions in morbidity, mortality, and resource utilization.
Article
Diabetic foot is a severe public health issue, yet rare studies investigated its global epidemiology. Here we performed a systematic review and meta-analysis through searching PubMed, EMBASE, ISI Web of science, and Cochrane database. We found that that global diabetic foot ulcer prevalence was 6.3% (95%CI: 5.4–7.3%), which was higher in males (4.5%, 95%CI: 3.7–5.2%) than in females (3.5%, 95%CI: 2.8–4.2%), and higher in type 2 diabetic patients (6.4%, 95%CI: 4.6–8.1%) than in type 1 diabetics (5.5%, 95%CI: 3.2–7.7%). North America had the highest prevalence (13.0%, 95%CI: 10.0–15.9%), Oceania had the lowest (3.0%, 95% CI: 0.9–5.0%), and the prevalence in Asia, Europe, and Africa were 5.5% (95%CI: 4.6–6.4%), 5.1% (95%CI: 4.1–6.0%), and 7.2% (95%CI: 5.1–9.3%), respectively. Australia has the lowest (1.5%, 95%CI: 0.7–2.4%) and Belgium has the highest prevalence (16.6%, 95%CI: 10.7–22.4%), followed by Canada (14.8%, 95%CI: 9.4–20.1%) and USA (13.0%, 95%CI: 8.3–17.7%). The patients with diabetic foot ulcer were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot ulceration. Our results provide suggestions for policy makers in deciding preventing strategy of diabetic foot ulceration in the future. • Key messages • Global prevalence of diabetic foot is 6.3% (95%CI: 5.4–7.3%), and the prevalence in North America, Asia, Europe, Africa and Oceania was 13.0% (95%CI: 10.0–15.9%), 5.5% (95%CI: 4.6–6.4%), 5.1% (95%CI: 4.1–6.0%), 7.2% (95%CI: 5.1–9.3%), and 3.0% (95% CI: 0.9–5.0%). • Diabetic foot was more prevalent in males than in females, and more prevalent in type 2 diabetic foot patients than in type 1 diabetic foot patients. • The patients with diabetic foot were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot.
Article
Background: An increased plantar pressure is a causative factor in the development of plantar foot ulcers in people with diabetes mellitus, and ulcers are a precursor of lower extremity amputation. Methods: In this article, the evidence is reviewed that relieving areas of increased plantar pressure (ie, offloading) can heal plantar foot ulcers and prevent their recurrence. Results: Noninfected, nonischemic neuropathic plantar forefoot ulcers should heal in 6 to 8 weeks with adequate offloading. Recent meta-analyses and systematic reviews show that nonremovable knee-high devices are most effective. This is probably because they eliminate the problem of nonadherence with the use of a removable device. Studies show a large discrepancy between evidence-based recommendations on offloading and what is used in clinical practice. Many clinics continue to use methods that are less effective or have not been proven to be effective, while ignoring evidence-based methods. Strategies are proposed to address this issue, notably the adoption and implementation of recent international guidelines by professional societies and a stronger focus of clinicians on expedited healing. For the prevention of plantar foot ulcer recurrence in high-risk patients, 2 recent trials have shown that the incidence of recurrence can be significantly reduced with custom-made footwear that has a demonstrated pressure-relieving effect through guidance by plantar pressure measurements, under the condition that the footwear is worn. Conclusion: This review helps to inform clinicians about effective offloading treatment for healing plantar foot ulcers and preventing their recurrence.
Article
Objectives: Patients presenting to a public hospital with critical limb ischemia (CLI) typically have advanced disease with significant co-morbidities. The purpose of this study was to assess the influence of revascularization on one year amputation rate of CLI patients presenting to Los Angeles County USC Medical Center, classified according to the SVS WIfI. Methods: A retrospective review of patients who presented to a public hospital with CLI from February 2010 to July 2014 was performed. Patients were classified according to the WIfI system. Only patients with complete data who survived at least 12 months after presentation were included. Results: 93 patients with 98 affected limbs were included. The mean age was 62.8. 82 (84%) had hypertension and 71 (72%) had diabetes. 50 (57.5%) limbs had Trans-Atlantic Inter-Society Consensus (TASC) C or D femoral-popliteal lesions and 82 (98%) had significant infra-popliteal disease. The majority had moderate or high WIfI amputation and revascularization scores. 84 (86%) limbs underwent open, endovascular or hybrid revascularization. Overall OYMA rate was 26.5%. In limbs with high WIfI amputation score, the OYMA was 34.5%: 21.4% in those who were revascularized and 57% in those who weren't. On univariable analysis, factors associated with increased risk of OYMA were: non-revascularization (P=0.005), hyperlipidemia (P=0.06), hemodialysis (P= 0.005), gangrene (P=0.02), ulcer classification (P=0.05), WIfI amputation score (P=0.026) and WIfI wound grade (P=0.04). On multivariable analysis, increasing WIfI amputation score (OR 1.84, 95% CI 1.0-3.39) was associated with increased risk of OYMA while revascularization (OR 0.24, 95% CI 0.07-0.80) was associated with decreased risk of OYMA. Conclusions: The OYMA rates in this population were consistent with those predicted by the WIfI classification system. In this population, revascularization significantly reduced the risk of amputation. Co-morbidities, including DM and TASC classification did not moderate the association of WIfI amputation score with risk of one-year major amputation.
Article
Custom-molded orthotic devices with soft insoles are thought to reduce recurrence after healing of diabetic foot lesions. The aim of the study was to investigate the influence of specially made shoes on the incidence of foot lesions after healing of a previous lesion and patient's discharge from hospital. Study design: 46 patients (age: 66,18 years (mean)) were examined 25,49 months (mean) after discharge from hospital. Group A (24 patients) used their orthotic device regularly, group B (22 patients) used regular shoes. Results: Incidence of recurrence of foot lesions was 37,5% for 2 years. Recurrence of foot lesions occurred in 10 patients of group A (41,7%) and in 8 patients of group B (36,4%). There was no amputation in group A and 2 amputations in group B (ray amputation in one case and a below the knee amputation in the other). Conclusions: Custom-molded orthotic devices do not necessarily reduce recurrences of diabetic foot lesions.
Article
Aims: The presence of diabetic foot ulcers is strongly associated with an increased risk of death. In this study, we investigate whether the effects of diabetes-associated complications can explain the apparent relationship between diabetic foot ulcers and death. Methods: We analysed data from 414 523 people with diabetes enrolled in practices associated with The Health Improvement Network in the United Kingdom. Our methods were designed to control for potential confounders in order to isolate the relationship between diabetic foot ulcers and death. Using proportional hazards models and the area under the receiver operator curve, we evaluated the effects of diabetic foot ulcers and the covariates on death. Results: Among the patients, 20 737 developed diabetic foot ulcers; 5.0% of people with new ulcers died within 12 months of their first foot ulcer visit and 42.2% of people with foot ulcers died within 5 years. After controlling for major known complications of diabetes that might influence mortality, the correlation between diabetic foot ulcers and death remained strong with a fully adjusted hazard ratio of 2.48 (95% confidence interval: 2.43, 2.54). Geographic variance existed but was not spatially associated. Conclusions: Diabetic foot ulcers are linked to an increased risk of death. This cannot be explained by other common risk factors. These results suggest that either there are major unknown risk factors associated with both diabetic foot ulcers and death, or that diabetic foot ulceration itself is a serious threat, which seems unlikely. A diabetic foot ulcer should be seen as a major warning sign for mortality, necessitating closer medical follow-up. This article is protected by copyright. All rights reserved.
Article
The International Working Group on the Diabetic Foot (IWGDF) recommends that auditing should be part of the organization of diabetic foot care; the efforts required for data collection and analysis being balanced by the expected benefits. In Germany legislature demands measures of quality management for in- and out-patient facilities and, in 2003, the Germany Working Group on the Diabetic Foot defined and developed a certification procedure for diabetic foot centers to be recognized as "specialized". This includes a description of management facilities, treatment procedures and outcomes, as well as the organization of mutual auditing visits between the centers. Outcome data is collected at baseline and 6- months on 30 consecutive patients. By 2014 almost 24.000 cases had been collected and analysed. Since 2005 Belgian multidisciplinary diabetic foot clinics could apply for recognition by health authorities. For continued recognition diabetic foot clinics need to treat at least 52 patients with a new foot problem (Wagner 2 or more or active Charcot foot) per annum. Baseline and 6-months outcome data of these patients are included in an audit-feedback initiative. Although originally fully independent of each other, the common goal of these two initiatives is quality improvement of national diabetic foot care and hence exchanges between systems has commenced. In future, the German and Belgian accreditation models might serve as templates for comparable initiatives in other countries. Just recently the IWGDF initiated a working group for further discussion of accreditation and auditing models (IWGDF AB(B)A Working Group).
Article
Background: Prevention of foot ulcers in patients with diabetes is extremely important to help reduce the enormous burden of foot ulceration on both patient and health resources. A comprehensive analysis of reported interventions is not currently available, but is needed to better inform caregivers about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to prevent first and recurrent foot ulcers in persons with diabetes who are at risk for ulceration. Methods: The available medical scientific literature in PubMed, EMBASE, CINAHL and the Cochrane database was searched for original research studies on preventative interventions. Both controlled and non-controlled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers. Results: From the identified records, a total of 30 controlled studies (of which 19 RCTs) and another 44 non-controlled studies were assessed and described. Few controlled studies, of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, multiple RCTs with low risk of bias show the benefit for the use of daily foot skin temperature measurements and consequent preventative actions, as well as for therapeutic footwear that demonstrates to relieve plantar pressure and that is worn by the patient. To prevent recurrence, some evidence exists for integrated foot care when it includes a combination of professional foot treatment, therapeutic footwear and patient education; for just a single session of patient education, no evidence exists. Surgical interventions can be effective in selected patients, but the evidence base is small. Conclusion: The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong, but is small for the use of other, sometimes widely applied, interventions and is practically nonexistent for the prevention of a first foot ulcer and non-plantar foot ulcer.
Article
Recommendations To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower‐extremity amputation, peripheral artery disease, foot deformity, pre‐ulcerative signs on the foot, poor foot hygiene and ill‐fitting or inadequate footwear. (Strong; Low) Treat any pre‐ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) To protect their feet, instruct an at‐risk patient with diabetes not to walk barefoot, in socks only, or in thin‐soled standard slippers, whether at home or when outside. (Strong; Low) Instruct an at‐risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) Instruct an at‐risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non‐plantar, or a recurrent non‐plantar foot ulcer. When a foot deformity or a pre‐ulcerative sign is present, consider prescribing therapeutic shoes, custom‐made insoles or toe orthosis. (Strong; Low) To prevent a recurrent plantar foot ulcer in an at‐risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure‐relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) To prevent a first foot ulcer in an at‐risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) To prevent a recurrent foot ulcer in an at‐risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re‐evaluated once every 1 to 3 months as necessary. (Strong; Low) Instruct a high‐risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high‐risk patient with diabetes, hammertoes and either a pre‐ulcerative sign or an ulcer on the distal toe. (Weak; Low) Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high‐risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at‐risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)
Article
Annual foot risk assessment of people with diabetes is recommended in national and international clinical guidelines. At present, these are consensus based and use only a proportion of the available evidence. We undertook a systematic review of individual patient data (IPD) to identify the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes. Studies were identified from searches of MEDLINE and EMBASE. The electronic search strategies for MEDLINE and EMBASE databases created during an aggregate systematic review of predictive factors for foot ulceration in diabetes were updated and rerun to January 2013. One reviewer applied the IPD review eligibility criteria to the full-text articles of the studies identified in our literature search and also to all studies excluded from our aggregate systematic review to ensure that we did not miss eligible IPD. A second reviewer applied the eligibility criteria to a 10% random sample of the abstract search yield to check that no relevant material was missed. This review includes exposure variables (risk factors) only from individuals who were free of foot ulceration at the time of study entry and who had a diagnosis of diabetes mellitus (either type 1 or type 2). The outcome variable was incident ulceration. Our search identified 16 cohort studies and we obtained anonymised IPD for 10. These data were collected from more than 16,000 people with diabetes worldwide and reanalysed by us. One data set was kept for independent validation. The data sets contributing IPD covered a range of temporal, geographical and clinical settings. We therefore selected random-effects meta-analysis, which assumes not that all the estimates from each study are estimates of the same underlying true value, but rather that the estimates belong to the same distribution. We selected candidate variables for meta-analysis using specific criteria. After univariate meta-analyses, the most clinically important predictors were identified by an international steering committee for inclusion in the primary, multivariable meta-analysis. Age, sex, duration of diabetes, monofilaments and pulses were considered most prognostically important. Meta-analyses based on data from the entire IPD population found that an inability to feel a 10-g monofilament [odds ratio (OR) 3.184, 95% confidence interval (CI) 2.654 to 3.82], at least one absent pedal pulse (OR 1.968, 95% CI 1.624 to 2.386), a longer duration of a diagnosis of diabetes (OR 1.024, 95% CI 1.011 to 1.036) and a previous history of ulceration (OR 6.589, 95% CI 2.488 to 17.45) were all predictive of risk. Female sex was protective (OR 0.743, 95% CI 0.598 to 0.922). It was not possible to perform a meta-analysis using a one-step approach because we were unable to procure copies of one of the data sets and instead accessed data via Safe Haven. The findings from this review identify risk assessment procedures that can reliably inform national and international diabetes clinical guideline foot risk assessment procedures. The evidence from a large sample of patients in worldwide settings show that the use of a 10-g monofilament or one absent pedal pulse will identify those at moderate or intermediate risk of foot ulceration, and a history of foot ulcers or lower-extremity amputation is sufficient to identify those at high risk. We propose the development of a clinical prediction rule (CPR) from our existing model using the following predictor variables: insensitivity to a 10-g monofilament, absent pedal pulses and a history of ulceration or lower-extremities amputations. This CPR could replace the many tests, signs and symptoms that patients currently have measured using equipment that is either costly or difficult to use. This study is registered as PROSPERO CRD42011001841. The National Institute for Health Research Health Technology Assessment programme.
Article
AimTo estimate the annual cost of diabetic foot care in a universal healthcare system.Methods National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010–2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in other admissions. Costs in other areas were estimated from published studies and data from individual hospitals.ResultsThe cost of diabetic foot care in 2010–2011 is estimated at £580m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307m) was spent on care for ulceration in primary and community settings. A total of 8.8% of hospital admissions with recorded diabetes included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43–2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m.Conclusions The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.This article is protected by copyright. All rights reserved.
Article
Le mal perforant plantaire est une complication classique et fréquente d’une pathologie élevée au rang de pandémie par l’OMS : le diabète. Bien que couramment rencontré dans la pratique médicale, le mal perforant reste mal compris dans sa physiopathologie. Son traitement est généralement long et décevant, se soldant trop souvent par une amputation. Paradoxalement, la littérature médicale est très pauvre, s’agissant des approches chirurgicales du mal perforant plantaire. En dehors des cas de lésions d’origine vasculaire qui nécessite surtout une technique de revascularisation, nous avons expérimenté une approche originale permettant le traitement chirurgical d’un mal perforant patent. Il s’agit de corriger l’architecture du pied afin de mieux répartir les points d’appui plantaires. Nous effectuons des ostéotomies de soustraction en amont du mal perforant afin de redresser l’axe osseux déformé. L’appui total est prescrit dès le lendemain de l’intervention dans la quasi-totalité des cas.
Article
The plantar neuropathic ulcer is a classical and frequent complication of a pathology recognized as pandemic by the WHO: diabetes. Even if frequently encountered during medical practice, the neuropathic ulcer remains poorly understood in its pathophysiology. Its treatment is usually long and disappointing, resulting too often in an amputation. Paradoxically, medical literature is particularly scarce on the subject of surgical approaches to the plantar neuropathic ulcer. Beyond the cases of vascular lesions requiring above all a technique of revascularization, we have tested out an original approach enabling the surgical treatment of an overt neuropathic ulcer. Our purpose was to correct the architecture of the foot for a superior distribution of foot support points. We performed subtraction osteotomies ahead of the neuropathic ulcer in order to redress the deformed bone axis. Standing with full weight on the foot is prescribed from the following day of the intervention in almost all cases. We have evaluated the effectiveness of this innovative conservative surgical treatment on neuropathic ulcers of metatarsal heads by comparing it with the usual medical treatment. Two groups of patients have thus been analysed for this retrospective comparative study in order to determinate whether the use of this surgical technique benefits the patient. The studied criteria were healing time, recurrence rate, amputation rate and overall failure rate of the treatment, represented by the occurrence of the event "recurrence or amputation". All the differences found were in favour of the surgical technique with, in particular, significant differences in healing time, amputation rate and occurrence rate of the event "recurrence or amputation". The difference in recurrence rate was also clearly in favour of the surgery group, but it was not significant. The conservative surgical treatment by proximal osteotomy is therefore an innovative technique enabling a significant improvement in healing time and treatment after-effects of neuropathic ulcers in non-arteritis diabetic patients.
Article
Purpose: To enhance the learner's competence with knowledge of the effectiveness of shear-reducing insoles for prevention of foot ulceration in patients with high-risk diabetes. Target audience: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. Objectives: After participating in this educational activity, the participant should be better able to:1. Demonstrate knowledge of foot ulceration risk, risk factors, incidence, and prevention.2. Apply knowledge gained from reviewing this study and a literature review about the use of shear-reducing insoles to patient scenarios. Objective: The objective of this study was to evaluate the effectiveness of a shear-reducing insole compared with a standard insole design to prevent foot ulceration in high-risk patients with diabetes. Research design and methods: A total of 299 patients with diabetic neuropathy and loss of protective sensation, foot deformity, or history of foot ulceration were randomized into a standard therapy group (n = 150) or a shear-reducing insole group (n = 149). Patients were evaluated for 18 months. Standard therapy group consisted of therapeutic footwear, diabetic foot education, and regular foot evaluation by a podiatrist. The shear-reducing insole group included a novel insole designed to reduce both pressure and shear on the sole of the foot. Insoles were replaced every 4 months in both groups. The primary clinical outcome was foot ulceration. The authors used Cox proportional hazards regression to evaluate time to ulceration. Results: There were 2 significant factors from the Cox regression model: insole treatment and history of a foot complication. The standard therapy group was about 3.5 times more likely to develop an ulcer compared with shear-reducing insole group (hazard ratio, 3.47; 95% confidence interval, 0.96-12.67). Conclusions: These results suggest that a shear-reducing insole is more effective than traditional insoles to prevent foot ulcers in high-risk persons with diabetes.
Article
From January 2007 to December 2009, 207 diabetic patients were consecutively admitted to our foot center because of osteomyelitis of a phalanx or metatarsal head. The removal of infected bone was performed by internal bone resection in 110 patients (group A) and amputation in 97 patients (46.9%; group B). Dehiscence occurred in 15 patients (13.6%) patients in group A and 10 patients (10.3%) in group B (p = 0.464). A total of 206 patients (99.5%) were followed up from January 1, 2007 to December 31, 2011. Ulcer relapse occurred in 12 patients (12.4%) in group A and 18 patients (16.4%) in group B (p = .437). A contralateral ulcer occurred in 10 group A patients (10.3%) and 14 group B patients (12.7%; p = .667). The results of the present study have demonstrated that bone resection with preservation of the soft tissue envelope is feasible in approximately one half of diabetic patients with forefoot osteomyelitis and does not result in any risk of major dehiscence or ulcer recurrence compared with ray or toe amputation.
Article
Improving ability to predict and prevent diabetic foot ulceration is imperative because of the high personal and financial costs of this complication. We therefore conducted a systematic review in order to identify all studies of factors associated with DFU and assess whether available DFU risk stratification systems incorporate those factors of highest potential value. We performed a search in PubMed for studies published through April 2011 that analysed the association between independent variables and DFU. Articles were selected by two investigators-independently and blind to each other. Divergences were solved by a third investigator. A total of 71 studies were included that evaluated the association between diabetic foot ulceration and more than 100 independent variables. The variables most frequently assessed were age, gender, diabetes duration, BMI, HbA1c and neuropathy. Diabetic foot ulceration prevalence varied greatly among studies. The majority of the identified variables were assessed by only two or fewer studies. Diabetic neuropathy, peripheral vascular disease, foot deformity and previous diabetic foot ulceration or lower extremity amputation – which are the most common variables included in risk stratification systems – were consistently associated with diabetic foot ulceration development. Existing diabetic foot ulceration risk stratification systems often include variables shown repeatedly in the literature to be strongly predictive of this outcome. Improvement of these risk classification systems though is impaired because of deficiencies noted, including a great lack of standardization in outcome definition and variable selection and measurement. Copyright