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Prevention of Diabetic Foot Ulcers at Primary Care Level

December 2018
Dermatology - Open Journal 3(1):4-9

DOI:10.17140/DRMTOJ-3-129

Authors:

Badriya Al- Lenjawi

Hamad Medical Corporation

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General Steps to Examine the Diabetic Feet

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General Changes Observed in the Nails of Diabetic Foot Patient

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General Changes Observed in the Skin of Diabetic Foot Patient

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Prevention of Diabetic Foot Ulcers at Primary Care Level

Review

Josephine Priyadarshini, RN; Seham Abdi, RN; Azza Metwaly, RN; Badria Al-Lenjawi, MD; Janelle San Jose, RN;

Hashim Mohamed, MD*

Weill Cornell Medicine-Qatar, Doha, Qatar

*Corresponding author

Hashim Mohamed, MD

Associate Professor, Weill Cornell Medicine-Qatar, Doha, Qatar; E-mail: fmcc2000@gmail.com

Article information

Received: January 9th, 2018; Revised: January 30th, 2018; Accepted: February 6th, 2018; Published: February 6th, 2018

Cite this article

Priyadarshini J, Abdi S, Metwaly A, Al-Lenjawi B, Jose JS, Mohamed H. Prevention of diabetic foot ulcers at primary care level. Dermatol Open J. 2018; 3(1): 4-9.

doi: 10.17140/DRMTOJ-3-129

Review | Volume 3 | Number 1|

ABSTRACT

Diabetic foot ulcer (DFT) prevention is best achieved at primary care level and should begin with education, appropriate pro-

tective footwear, glycaemic control and regular screening for loss of protective sensation. In the west, specialized diabetic or

podiatry clinics may assess and quantify neuropathy with many tools including monolaments, biothesiometry, corneal confocal

microscopy and nerve conduction studies. Vascular assessment can be done via measuring ankle-brachial index, duplex ultrasound

studies and toe pressure. Other foot assessment may include measuring plantar foot pressure using computerized dynamic foot

studies (computerized insole sensor system). The ability to stratify patients based on risks is carried out on the basis of a thorough

medical and surgical history in conjunction with these measurements thereby allowing clinicians to determine the type of inter-

vention. Effective strategies for foot ulceration prevention include educating patients, their families, and healthcare workers about

adequate foot care and regular foot examinations along with optimal glycaemic control and smoking cessation. Other effective

clinical interventions may include, foot hygiene, debridement of calluses, management of foot deformities which may at times

require prophylactic foot surgery. Counseling patients regarding daily proper footwear and hygiene should be stressed during each

clinic visit. Educating, screening and managing patients with diabetic foot ulceration and or complications is an essential primary

healthcare strategy to prevent unnecessary morbidity and mortality related to diabetic foot. An integrated (interdisciplinary) ap-

proach including, family physicians with special interest in the diabetic foot, diabetic educators, nurses and family members is a

vital component in this regard.

Keywords

Diabetic foot ulcer (DFU); Neuropathy; Glycaemic control.

INTRODUCTION

Diabetic foot ulcer (DFT) is the most common and neglected

complications of diabetes. The risk of death for those with

foot ulcers is 12.1 per 100 person-years of follow-up compared

with 5.1 in those without foot ulcers.1 Similarly, the risk for ampu-

tation in patients with diabetes is 15 times greater than for the non-

diabetic population and the majority of amputations are preceded

by DFU.2 It is documented that subjects with foot ulcers have a

poor quality of life and nearly 15% of all diabetics will develop

foot ulcers. It is also estimated that 15% of all diabetics who get

admitted to hospital do so mainly due to foot problems.3

In the US, direct hospital costs for the treatment of dia-

betic foot infections exceeds $200 million per year and that for am-

putation related to diabetes exceeds $350 million annually.4 How-

ever diabetic foot ulcer is preventable by appropriate education,

evidence-based counseling and preventative strategy.

PREVENTION AND TREATMENT OF NEUROPATHY

Neuropathy is the main cause that gives rise to diabetic foot ul-

cer especially the insensate foot. Patients might not be aware of it

in the early stages, as they might not feel the pain.5 Furthermore,

neuropathic wound does not heal fast as it is not protected by pain

sensation. Optimal glycaemic control can reduce the incidence of

neuropathy and thereby foot ulcer.6 Foot deformities, on the other

hand, can also cause foot ulcers because of the abnormal pressure.7

In diabetes, deformity due to Charcot neuroarthropathy

Mohamed H, et al

Dermatol Open J. 2018; 3(1): 4-9. doi: 10.17140/DRMTOJ-3-129

PUBLISHERS

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is increasingly recognized.8 It is very important to prevent defor-

mity in diabetic subjects by the use of adequate footwear. Similarly,

acute Charcot neuroarthropathy should be aggressively treated

to maintain the normal architecture of the foot.8 There has been

no controlled trial on surgical correction of deformity in the pre-

vention of ulcers but it is worth considering. Recently, surgery to

lengthen the Achilles tendon has been shown to be useful in the

prevention of ulceration of metatarsal heads.9 If there is recur-

rence of ulceration over a bony prominence or on an abnormal

weight-bearing part, surgical correction may be indicated.

Key Interventions

• Regular follow-up and surveillance for diabetic retinopathy for

adults with diabetes is required and early laser treatment for

those identied with retinopathy is vital.

• Patients having microalbuminuria should be treated with an-

giotensin converting enzyme (ACE) inhibitors and their rate of

progression to diabetic nephropathy.

• Strict blood pressure and blood glucose control in people with

diabetic nephropathy can reduce the rate of deterioration in

their renal function, as well as their risk of cardiovascular dis-

ease.

Specic Foot Care Advice Given to Patients with High-Risk Feet

in Order to Prevent DFU

• Wash your feet daily with mild soaps and keep it moisturized.

• Avoid walking barefoot indoors.

• Inspect your feet daily.

• Contact your doctor or podiatrist if there is redness or swelling

or a minor cut.

• Wear well-tting shoes which should offer enough room to

move your toes freely.

• If needed wear special shoes if you have been supplied with

them.

• Never self-treat your own corn or callus. Consult a doctor in-

stead.

• Avoid using a hot water bottle.

• Wear woolen socks in bed if needed.

General Advice Necessary to Help you Protect your Feet

(Figure 1)

Foot Examination

1. Check your feet daily because some people may not feel injury

if the nerves in their feet are not working properly.

2. So, you should look for:

• Red spots.

• Cuts.

• Blisters.

• Wet or white areas in between the toes.

• Sores.

• Any skin change.

• You should use a mirror to see the bottom of your feet.

3. If you see thickened skin area (callus) consult your doctor be-

cause it means the pressure in that area is high; therefore, you

need a special insert or shoe to relieve the pressure and your

doctor may want to remove the callus.

4. If your feet feel cold don’t use hot water bottle because you

may burn your feet without even feeling it.

How Can I Take Care of my Feet?

1. Wash your feet daily using warm water (test it by your elbow),

a mild soap and dry using a towel especially the areas between

your toes.

2. Do not soak your feet because this will dry out the skin and

do not use whirlpool – water if you suffer from cold feet but

rather wear socks made of cotton and wool to keep your feet

warm.

3. Use a moisturizer (10% urea cream) because dry skin cracks

and if this happens it can lead to infection and ulcer forma-

tion.

4. Dry up between your toes after washing your feet.

5. Cutting your nails regularly once a week is usually enough

but if your nails are thick; don’t attempt to cut them because

you may injure yourself. Your doctor can help you by using a

special scissor. Nails should be cut across and not in a semi-

circular fashion and use a nail clipper instead of scissor & do

not cut nails too close to the skin.

FOOTWEAR CARE

1. Never walk barefoot even inside the house, socks should be

worn (cotton) all the time to keep skin moist and shoes must

also be worn, to avoid injury to your feet.

2. Check your shoes before you wear them because you may nd

foreign bodies such pieces of stones inside.

Figure 1. General Steps to Examine the Diabetic Feet

Mohamed H, et al

Dermatol Open J. 2018; 3(1): 4-9. doi: 10.17140/DRMTOJ-3-129

PUBLISHERS

6Review | Volume 3 | Number 1|

3. Wear socks which are made of cotton or wool.

4. Shoes should be round in the front, made of leather top or

canvas to let your feet breath. Remember, that you should buy

shoes at the end of the day because feet swell up as the day

goes on. Remember that if shoes are comfortable, when your

feet are swollen at night they will be comfortable all day.

5. Avoid high heels shoes which may put extra pressure on the

bottom of your feet.

6. If you want to exercise you need to wear soft tennis shoes and

check your feet before and after exercise.

7. Sandals should not be worn nor should you wear nylon socks.

Consult your doctor: Consult your doctor before buying a new

pair of shoes and if you do, you need to wear it 1 hour daily initially

until it softens up slowly over several days

1. Let your healthcare provider check your feet on a yearly basis

at least, but if you are suffering from one of the following you

need to be checked more often:

A. Suffering from numbness or pins and needles in your feet.

B. Burning sensation in your feet.

C. Pain in your feet or back of your leg.

D. Cold sensation in your feet.

2. If you have abnormal looking toes.

Skin care: To help you have moist skin you need to

1. Use a moisturizer such as 10% urea cream or Lanolin.

2. Avoid barrier creams and ointments such as Vaseline because

it will not moisturize your feet.

3. Avoid applying a moisturizer in between your toes.

4. Avoid Henna because it will dry your skin & cause the skin to

crack.

If you see any of the following changes in the nail please consult

your doctor (Figure 2).

Similarly, if you see the following changes in your skin please con-

sult your doctor (Figure 3).

Things you need to take care of:

1. Keep your blood sugar under control since this will help in

preventing complications and speeds up healing. This can be

an achieved by eating a healthy and balanced diet, exercise and

proper medical follow-up.

2. Avoid smoking.

3. Have a regular follow-up with your doctor regarding foot care.

4. Report any change in your skin no matter how trivial it may

look.

PREVENTION AND TREATMENT OF PERIPHERAL

VASCULAR DISEASE

The lack of blood supply or ischemia is one of the major reasons

for diabetic foot ulcers and thereafter amputations. Atherosclerotic

lesions are more diffuse and distal in diabetics.10 The risk of vascu-

lar diseases in diabetics can be reduced, by lifestyle modications

including daily exercise and avoiding smoking. Many drugs are out

in the market promoted as being useful in the prevention of DFU

and peripheral vascular disease; however, adequate controlled trials

supporting these claims are lacking. Despite this, an argument for

the use of aspirin, clopidogrel, statins, brates, ACE inhibitors and

folic acid in diabetics can be made in the light of these pieces of

evidence.11-14 On the other hand, agents such as naftidrofuryl and

cilostazol, although helpful in controlling symptoms of intermit-

tent claudication, have not found widespread use in diabetics with

peripheral vascular disease as there is paucity of data on preven-

tion of DFU or amputation.15,16 If a leg is fully ischaemic, vascular

surgery could improve the blood supply.17

GLYCAEMIC CONTROL

Normal glucose level is the rst line of defense against chronic

complications of diabetes. Optimal glycaemic control may prevent

the development of neuropathy. Intensive blood glucose control

reduced the development of neuropathy by 40% in patients with

type II diabetes18 and by about 60% in patients with type 1 diabe-

tes.19 Raised HbA1c has also been associated with DFU, amputa-

tions and peripheral vascular disease. Therefore, it is very impor-

tant to optimize glycaemic control to prevent DFU in the long run.

REGULAR PODIATRY

Podiatry services are essential in the prevention and treatment of

DFU.20 Patients should avoid self-treating corns and calluses and

Figure 2. General Changes Observed in the Nails of Diabetic Foot Patient

Figure 3. General Changes Observed in the Skin of Diabetic Foot Patient

Mohamed H, et al

Dermatol Open J. 2018; 3(1): 4-9. doi: 10.17140/DRMTOJ-3-129

PUBLISHERS

should avoid nail clippings especially if there is retinopathy or the

nails are thick, dystrophic along with the history of the peripheral

vascular disease. If a callus or corn is present it ultimately leads to

unnecessary shear forces and results in high pressure in the foot.21

At each visit, it’s the clinician utmost responsibility to examine the

foot and also reinforce foot care education. Prescription footwear

is of paramount importance, as it prevents pressure sores and ul-

cers. A shoe that allows free movement of toes is a way of identify-

ing rightly tting shoes.

Patients with low or medium risk of ulceration should

be advised to buy good quality shoes but those with high risk and

in subjects who already developed DFU, custom-made prescrip-

tion footwear should be prescribed as these have been shown to

prevent recurrences of DFU.22 Orthotists are of great help in de-

signing appropriate footwear especially when there is a severe foot

deformity.23 Patients should be advised to ensure that shoes are in a

good state of repair and check for any foreign objects before they

are worn.

FOOT CARE EDUCATION

The patient should be taught about foot care. The patient or their

care taker should examine the feet at least once a day if needed

with the help of a mirror to look into the under surface. A proper

foot care education program has been shown to reduce the risk

of ulceration.24,25 Patients usually become more receptive to medi-

cal advice after rst ulceration, so a thorough counseling with the

physician or podiatrist or specialist nurse should be arranged to

discuss foot care.

DETECTION OF HIGH-RISK FEET WITH SCREENING

Screening programs are available in various parts of the world. It’s

better to screen patients in 3 months after diagnosing patients with

diabetes. All diabetic subjects should be offered a comprehensive

foot-screening program. The patients are classied into high, me-

dium and low-risk categories by the screening clinician depending

upon previous foot ulcers, neuropathy, ischemia, deformity, smok-

ing habit, and vision. If the patients are high or medium risk, they

are screened annually by the podiatrist, but patients with low-risk

feet are screened by their diabetes care provider and can be re-

ferred to podiatrist if their risk status changes.

GENERAL PATIENT EDUCATION

There has not been any study to specically look into various life-

styles and the development of DFU. In view of available knowl-

edge based on the general population, the following changes can

be advocated.

Smoking

Smoking increases the morbidity and mortality of people with dia-

betes. Epidemiological studies revealed that diabetic subjects who

smoke may have an increased risk of foot complications. All pa-

tients should be encouraged to stop smoking.

Diet

Maintenance of adequate and balanced diet is the main treatment

for diabetes to improve glycaemic control. Obesity should be

prevented. These subjects should be actively encouraged to lose

weight if they are obese. This will not only improve the diabetes

control but will also reduce the pressure on the foot. Similarly, a

low-fat diet is important to reduce cardiovascular disease.26

Exercise

Exercise is the cornerstone and prevents peripheral neuropathy.

Exercise or activity is benecial for people with diabetes. Physio-

therapy can correct the gait abnormality and possibly prevent the

development of DFU.27

Alcohol

Excessive intake of alcohol has been associated with the devel-

opment of diabetic neuropathy.28 On the other hand, moderate

consumption has been shown to improve diabetes control and

mortality in general population including diabetic subjects.29 Men

should drink no more than 21 units and women no more than 14

units each week.

CONCLUSION

It is essential to screen diabetic patients to identify those at risk for

foot ulceration. Prevention of diabetic foot ulcer is best achieved

through effective health education30 and evidence-based counsel-

ing to the patient and family, early identication, regular assess-

ment and proper foot examination. Specialized clinics such as po-

diatric clinic use advanced foot assessment methods to determine

the type of clinical intervention which proves benecial for dia-

betic patients.

CONFLICTS OF INTEREST

The authors declare that they have no conicts of interest.

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Full-text available

Dec 2023

Objective to validate the content of the Educational Technology (LISTEN, SEE, DO) for the prevention of foot alterations in people with Diabetes Mellitus. Method methodological research for content validation. Judges were selected from the Lattes/Conselho Nacional de Desenvolvimento Científico e Tecnológico Platform using the expression “diabetic foot” and including advanced search filters, resulting in 51 potential judges, of which 32 judges responded. The results were analyzed in relation to the Committee's Concordance Rate (CCR) and the Content Validity Index (CVI) of its sub-items. Results all items of the educational technology reached the previously established indices with experts' agreement on the evaluated content (CCR) being higher than 96% in each item, and the CVI being higher than 0.90 in each sub-item. Conclusion and implications for practice the Educational Technology LISTEN, SEE, DO met the previously established criteria for content validation and was considered by judges to have appropriate item composition, with clear and relevant sub-items. The validated technology provides material for preventing diabetic foot using innovative strategies that stimulate people in an auditory, visual, and kinesthetic way.

Factors associated with wound healing outcome among Diabetic Foot patients- A cross sectional Study

Article

Mar 2021

Diabetic foot ulcer (DFU) has been identified as the leading reason for hospitalization among patients with diabetes. Patients with diabetes are at greater risk of complications, the most important of them are diabetic neuropathy and peripheral vascular disorders leading to the development of foot ulcers. The problem is generally faced and as well is considered as one among the most common complications of diabetes that affect millions of people all over the world. The current study, aimed to document the clinical profile and healing outcome of diabetic foot ulcer management which may become guidance for further improvement in wound management among diabetic foot ulcer patients. Cross sectional descriptive study was conducted over one-year period of time. A total of 246 Diabetic patients with a foot ulcer of Grade 1 to 3 participated in the study. Patients with higher grade ulcers of Grade 4 and 5 were excluded from the study. Final data analysis of 160 patients was done using SPSS version 20. The prevalence of Grade 2 and 3 ulcers were observed 54.37% and 31.8 % while Grade 1 ulcer was observed 13.75%. No risk factors were found to be significantly associated with diabetic foot ulcer. Wound was healed well in 50 % and partially healed in 21 % of the participants. Wound remains unchanged in 3 % of study participants, while 8% of participants underwent toe amputation. Foot ulceration is a preventable in many diabetic patients with adequate education, routine foot care and attention to foot wear.

Sudomotor disfonksiyonu olan diyabetik hastalarda ayak bakım eğitimi etkinliğinin değerlendirilmesiThe evaluation of the foot care training event on diabetic patients with sudomotor dysfunction

Article

Full-text available

Oct 2022

Amaç: Araştırmada, ayak nem ölçümüyle sudomotor disfonksiyonu belirlenen diyabetik hastalarda verilen ayak bakım eğitiminin ayak sağlığı üzerine etkilerinin hastaların diyabet yönetimine ilişkin öz-etkililikleri ve diyabet hastalarında ayak bakım alışkanlıklarına etkisinin değerlendirilmesi amaçlanmıştır. Yöntem: Araştırmada, Çanakkale Onsekiz Mart Üniversitesi tıp fakültesi hastanesi endokrinoloji polikliniğine temmuz 2012- mart 2013 tarihlerinde başvuran 597 diyabet hastasından, amaçlı örneklem doğrultusunda vaka seçim kriterlerine uyan ve araştırmaya katılımda gönüllü olan 112 hasta değerlendirildi. Çalışma örneklemini oluşturan hastaların 59’una (deney grubu) eğitim verilirken, 53 kişiye (kontrol grubu) eğitim verilmedi. Deney grubundaki hastalara araştırmacı tarafından ayak bakım eğitimi verildi. Araştırma verileri için hasta bilgi formu, metabolik değişkenler formu, ayak değerlendirme formu, diyabet yönetimine ilişkin öz-etkililik ölçeği, diyabet hastalarında ayak bakım alışkanlığı formu kullanıldı. Veriler SPSS 16.0 paket programı kullanılarak karşılaştırma testleri ve tanımlayıcı istatistiksel yöntemlerle analiz edildi. Bulgular: Öz-etkililik ölçeği puan ortalamaları açısından araştırmanın başlangıcında ve sonundaki fark deney grubunda istatistiksel olarak anlamlı bulundu (p

The Development, Implementation, and Evaluation of a Social Media-Based Patient Diabetic Foot Self-Management Education and Support Program in Canada: A Multi-Method Feasibility Study

Thesis

Full-text available

Nov 2022

Helen Obilor

Background: Diabetic foot ulcer (DFU) is a costly complication associated with high disability and mortality rates. Most diabetic foot care education programs are didactic and limited in providing people with diabetes (PWD) with the ongoing empowerment vital in reducing DFU incidence. The advancement in social media offers an innovative approach to empowering patients to prevent DFU. Aim: This study aimed to determine the feasibility of social media as an alternative method to engage PWD in DFU prevention in Canada. Methods: A multimethod approach was utilized to develop, implement, and evaluate a social media DFU prevention-based intervention. The study intervention development and implementation phase involved a participatory design that included health care professionals and PWD. The evaluative phase entailed a randomized control trial and qualitative content analysis. Data collection involved a structured questionnaire administered through QualtricsXM survey software at baseline, one, and three-month post-intervention with a telephone interview. Results: A peer-led diabetic foot-based self-management education and support program named Diabetic Foot Care Group (DFCG) on Facebook was developed for the daily empowerment of PWD. The intervention covered ten education topics with eight categories of support/engagement activities. Thirty-two PWD were enrolled. The DFCG acceptability and efficacy rates were 84.2% and 88.9%, respectively. The participants had a positive learning experience and social interactions in DFCG. Five themes emerged to describe how DFCG helped participants change their foot self-care practice - in-depth knowledge, perceived susceptibility, sense-making, informed decision, and self-motivation. Conclusion: Based on the findings from this study, social media is a feasible platform for the engagement of PWD in DFU prevention. PWD Engagement in the DFCG was associated with improved foot self-care efficacy, foot self-care adherence, community resources awareness, communication with health care professionals, foot health, and physical health status. Thus, health care professionals could utilize social media as a virtual option for patient education and support programs.

Automated Category and Trend Analysis of Scientific Articles Using Large Language Models (LLMs): An Application in Ophthalmology (Preprint)

Article

Full-text available

Sep 2023

Objective: In this paper, we present an automated method for article classification, leveraging the power of Large Language Models (LLM). The primary focus is on the field of ophthalmology, but the model is extendable to other fields. Methods: We have developed a model based on Natural Language Processing (NLP) techniques, including advanced LLMs, to process and analyze the textual content of scientific papers. Specifically, we have employed zero-shot learning (ZSL) LLM models and compared against Bidirectional and Auto-Regressive Transformers (BART) and its variants, and Bidirectional Encoder Representations from Transformers (BERT), and its variant such as distilBERT, SciBERT, PubmedBERT, BioBERT. Results: The classification results demonstrate the effectiveness of LLMs in categorizing the large number of ophthalmology papers without human intervention. To evaluate the LLMs, we compiled a dataset (RenD) of 1000 ocular disease-related articles, which were expertly annotated by a panel of six specialists into 15 distinct categories. The model achieved a mean accuracy of 0.86 and a mean F1 of 0.85 based on the RenD dataset. Conclusions: The proposed framework achieves notable improvements in both accuracy and efficiency. Its application in the domain of ophthalmology showcases its potential for knowledge organization and retrieval in other domains too. We performed trend analysis that enables the researchers and clinicians to easily categorize and retrieve relevant papers, saving time and effort in literature review and information gathering as well as identification of emerging scientific trends within different disciplines. Moreover, the extendibility of the model to other scientific fields broadens its impact in facilitating research and trend analysis across diverse disciplines.

Effect of topical olive oil dressing on the healing of grades 1 and 2 diabetic foot ulcers: An assessor-blind randomized controlled trial in type 2 diabetes patients

Article

Nov 2022

Background and aims We aimed to compare the effect of topical olive oil dressing plus standard care with standard care alone on the treatment of grades 1 and 2 diabetic foot ulcers (DFUs) in type 2 diabetes mellitus (T2DM) patients. Methods This assessor-blind randomized controlled trial included 60 T2DM patients with DFU referred to the Diabetes Clinic of Shahid Mohammadi Hospital, Bandar Abbas, Iran, from February 21 to August 22, 2017. Patients were randomly assigned to intervention (n = 30) and control (n = 30) groups. The intervention group received standard care including wound irrigation with normal saline and oral antibiotics plus daily topical olive oil dressing for 4 weeks, and the control group only received standard care. Wound healing assessment scale (wound degree, color, drainage, and surrounding tissue healing) was recorded weekly and the total wound status was determined at the end of the study. Results Treatment with olive oil led to significantly higher scores of ulcer degree, color, drainage, and surrounding tissue healing at weeks 1, 2, 3 and 4 in the olive oil group than in the control group (P < 0.001). Also, the total wound status score was higher in the olive oil group compared to the control group (P < 0.001). The proportions of completely healed, partially healed and unhealed wounds were 76.6%, 23.3% and 0% in the intervention group, and 0%, 93.3% and 6.7% in the control group, respectively. Conclusions Topical olive oil promoted the healing of DFU and it can be recommended as a safe and effective method in this regard. Trial registration Iranian Registry of Clinical Trials (IRCT), IRCT20150607022585N4. Registered 05/12/2018. Retrospectively registered, https://www.irct.ir/trial/19460.

Improving Diabetic Foot Ulcer Healing with Adjuvant Bitter Melon Leaf Extract (Momordica charantia L.)

Article

Full-text available

Jan 2022

BACKGROUND: Diabetes mellitus is a serious disease that affects more than 340 million people and causes approximately 20% of diabetic ulcer cases worldwide. Wound healing is a complex and dynamic process in restoring cellular structures and tissue layers. It consists of four continuous overlapping phases that are precisely programmed AIM: This study aims to examine the adjuvant administration of bitter melon leaf extract to increase the healing of diabetic foot ulcers (DFU). METHODS: This study used a randomized, double-blind, and placebo-controlled trial. A total of 30 DFU patients with a perfusion, extent, depth, infection, and sensation (PEDIS) score of 1–8 who met the criteria were divided into two groups, namely, the treatment group with adjuvant administration of bitter melon leaf extract at a dose of 6 g/day as many as 15 patients and the control group 15 patients with placebo. This intervention was carried out for 4 weeks. DFU cure was measured by PEDIS scores at baseline, weeks 2, 3, and the end of week 4. Data were analyzed using paired t-test and independent t-test. RESULTS: After 4 weeks of treatment, the PEDIS score in the treatment group decreased at week 2 (0.9 ± 1.8), but not significant (p = 0.19), decreased at week 3 (1.9 ± 1.9) and significant (p = 0.01), decreased in week IV (2.3 ± 2.1) and significantly (p = 0.001). The control group experienced a decrease in week 2 (0.3 ± 2.3), but not significant (p = 0.71), decreased in week 3 (1.2 ± 2.5), but not significant (p = 0.18), decreased in week 4 (1.9 ± 2.7) and significantly (p = 0.03), and there was an effect of adjuvant administration of bitter melon leaf extract on the cure of DFU (p = 0.004). CONCLUSION: Adjuvant administration of bitter melon leaf extract has been shown to increase the healing of DFU.

Assessment of Knowledge and Practices of Diabetic Patients Regarding Diabetic Foot Care

Article

Full-text available

Jan 2017
JFMHC

Background: 20.5% of Saudis between 20 and 79 years are diabetics. Diabetic foot is a chronic complication of diabetes. The incidence of non-traumatic lower extremity amputations is at least 15 times greater in those with diabetes than non-diabetics. Patient education is important to reduce lower extremity complications. Objective: To assess the knowledge and practices of the diabetic patients regarding foot care and diabetic foot complications. Methods: In Makkah hospitals, 350 diabetic patients who met the inclusion criteria were involved in this cross sectional study. Interviewing questionnaire and patients' charts review were used to collect the data. Results: Mean age of patients was 53.0083±13.1 years, and mean duration of diabetes was 11.24±8.7 years. 35.1% had history of foot ulcer while 25.7% had ulcer on the time of interview. 11.7 % had history of amputation and 83.1% had numbness. 77.1 % examine their feet while 49.1% received foot care education and 34% read handouts on foot care. 34% walk around in bare feet. There is a significant statistical association between foot education, practices and diabetic foot ulcer (p-value < 0.05). Conclusion: Patient knowledge and practices regarding diabetic foot care is significantly associated with the reduction of diabetic foot ulcer.

Increased Mortality in Diabetic Foot Ulcer Patients: The Significance of Ulcer Type

Article

Full-text available

Apr 2016

Diabetic foot ulcer (DFU) patients have a greater than twofold increase in mortality compared with nonulcerated diabetic patients. We investigated (a) cause of death in DFU patients, (b) age at death, and (c) relationship between cause of death and ulcer type. This was an eleven-year retrospective study on DFU patients who attended King’s College Hospital Foot Clinic and subsequently died. A control group of nonulcerated diabetic patients was matched for age and type of diabetes mellitus. The cause of death was identified from death certificates (DC) and postmortem (PM) examinations. There were 243 DFU patient deaths during this period. Ischaemic heart disease (IHD) was the major cause of death in 62.5% on PM compared to 45.7% on DC. Mean age at death from IHD on PM was 5 years lower in DFU patients compared to controls (68.2 ± 8.7 years versus 73.1 ± 8.0 years, P = 0.015 ). IHD as a cause of death at PM was significantly linked to neuropathic foot ulcers (OR 3.064, 95% CI 1.003–9.366, and P = 0.049 ). Conclusions. IHD is the major cause of premature mortality in DFU patients with the neuropathic foot ulcer patients being at a greater risk.

Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?

Article

Full-text available

May 2015

One of the most common and serious complications of diabetes mellitus is ulceration of the foot. Among persons with diabetes, 12%-25% will present to a healthcare institution for a foot disorder during their lifespan. Despite currently available medical and surgical treatments, these are still the most common diabetes-related cause of hospitalization and of lower extremity amputations. Thus, many adjunctive and complementary treatments have been developed in an attempt to improve outcomes. We herein review the available literature on the effectiveness of several treatments, including superficial and deep heaters, electro-therapy procedures, prophylactic methods, exercise and shoe modifications, on diabetic foot wounds. Overall, although physical therapy modalities seem to be useful in the treatment of diabetic foot wounds, further randomized clinical studies are required.

Current Antiplatelet Treatment Strategy in Patients with Diabetes Mellitus

Article

Full-text available

Apr 2015

Patients with diabetes mellitus (DM) have accelerated atherosclerosis with an increased risk for atherothrombotic cardiovascular complications. A state of high platelet reactivity and activation, hypercoagulability (prothrombotic state) and a subdued response to standard antiplatelet agents may explain high rate of adverse cardiovascular events in patients with DM. Several antithrombotic treatment strategies have been developed to control the prothrombotic state in patients with DM: dose modification of commonly used agents; use of potent agents; and addition of a third antithrombotic drug (triple therapy) to commonly prescribed dual antiplatelet therapy of aspirin and a P2Y12 inhibitor. The present review aims to provide an overview of the current knowledge on platelet abnormalities in patients with DM, focusing on the challenges and perspectives of antiplatelet treatment strategies in this population.

Literature review on the management of diabetic foot ulcer

Article

Full-text available

Feb 2015

Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it's suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.

Comparison of lower extremity atherosclerosis in diabetic and non-diabetic patients using multidetector computed tomography

Article

Full-text available

Sep 2014
BMC Cardiovasc Disord

Background Lower extremity atherosclerosis (LEA) is among the most serious diabetic complications and leads to non-traumatic amputations. The recently developed dual-source CT (DSCT) and 320- multidetector computed tomography (MDCT) may help to detect plaques more precisely. The aim of our study was to evaluate the differences in LEA between diabetic and non-diabetic patients using MDCT angiography. Methods DSCT and 320-MDCT angiographies of the lower extremities were performed in 161 patients (60 diabetic and 101 non-diabetic). The plaque type, distribution, shape and obstructive natures were compared. Results Compared with non-diabetic patients, diabetic patients had higher peripheral neuropathy, history of cerebrovasuclar infarction and hypertension rates. A total of 2898 vascular segments were included in the analysis. Plaque and stenosis were detected in 681 segments in 60 diabetic patients (63.1%) and 854 segments in 101 non-diabetic patients (46.9%; p <0.05). Regarding these plaques, diabetic patients had a higher incidence of mixed plaques (34.2% vs. 27.1% for non-diabetic patients). An increased moderate stenosis rate and decreased occlusion rate were observed in diabetic patients relative to non-diabetic patients (35.8% vs. 28.3%; and 6.6% vs. 11.4%; respectively). In diabetic patients, 362 (53.2%) plaques were detected in the distal lower leg segments, whereas in non-diabetic patients, 551 (64.5%) plaques were found in the proximal upper leg segments. The type IV plaque shape, in which the full lumen was involved, was detected more frequently in diabetic patients than in non-diabetic patients (13.1% vs. 8.2%). Conclusion Diabetes is associated with a higher incidence of plaque, increased incidence of mixed plaques, moderate stenosis and localisation primarily in the distal lower leg segments. The advanced and non-invasive MDCT could be used for routine preoperative evaluations of LEA.

Midfoot Charcot arthropathy in diabetic patients: Complication of an epidemic disease

Article

Full-text available

Oct 2012

Objectives: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. methods: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. Results: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. Conclusion: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

Effect of Custom-Made Footwear on Foot Ulcer Recurrence in Diabetes

Article

Full-text available

Oct 2013

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.

Adherence to Wearing Prescription Custom-Made Footwear in Patients With Diabetes at High Risk for Plantar Foot Ulceration

Article

Full-text available

Jan 2013

OBJECTIVE Prescription custom-made footwear can only be effective in preventing diabetic foot ulcers if worn by the patient. Particularly, the high prevalence of recurrent foot ulcers focuses the attention on adherence, for which objective data are nonexisting. We objectively assessed adherence in patients with high risk of ulcer recurrence and evaluated what determines adherence.RESEARCH DESIGN AND METHODS In 107 patients with diabetes, neuropathy, a recently healed plantar foot ulcer, and custom-made footwear, footwear use was measured during 7 consecutive days using a shoe-worn, temperature-based monitor. Daily step count was measured simultaneously using an ankle-worn activity monitor. Patients logged time away from home. Adherence was calculated as the percentage of steps that prescription footwear was worn. Determinants of adherence were evaluated in multivariate linear regression analysis.RESULTSMean ± SD adherence was 71 ± 25%. Adherence at home was 61 ± 32%, over 3,959 ± 2,594 steps, and away from home 87 ± 26%, over 2,604 ± 2,507 steps. In 35 patients with low adherence (<60%), adherence at home was 28 ± 24%. Lower BMI, more severe foot deformity, and more appealing footwear were significantly associated with higher adherence.CONCLUSIONS The results show that adherence to wearing custom-made footwear is insufficient, particularly at home, where patients exhibit their largest walking activity. This low adherence is a major threat for reulceration. These objective findings provide directions for improvement in adherence, which could include prescribing specific off-loading footwear for indoors, and they set a reference for future comparative research on footwear adherence in diabetes.

Foot Ulcers in the Diabetic Patient, Prevention and Treatment

Article

Full-text available

Feb 2007

Lower extremity complications in persons with diabetes have become an increasingly significant public health concern in both the developed and developing world. These complications, beginning with neuropathy and subsequent diabetic foot wounds frequently lead to infection and lower extremity amputation even in the absence of critical limb ischemia. In order to diminish the detrimental consequences associated with diabetic foot ulcers, a common-sense-based treatment approach must be implemented. Many of the etiological factors contributing to the formation of diabetic foot ulceration may be identified using simple, inexpensive equipment in a clinical setting. Prevention of diabetic foot ulcers can be accomplished in a primary care setting with a brief history and screening for loss of protective sensation via the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy, plantar foot pressure, and assess vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, may enable clinicians to stratify patients based on risk and help determine the type of intervention. Other effective clinical interventions may include patient education, optimizing glycemic control, smoking cessation, and diligent foot care. Recent technological advanced combined with better understanding of the wound healing process have resulted in a myriad of advanced wound healing modalities in the treatment of diabetic foot ulcers. However, it is imperative to remember the fundamental basics in the healing of diabetic foot ulcers: adequate perfusion, debridement, infection control, and pressure mitigation. Early recognition of the etiological factors along with prompt management of diabetic foot ulcers is essential for successful outcome.