To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population.
RESEARCH DESIGN AND METHODS
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.
Diabetes mellitus is becoming pandemic, particularly affecting Sub-Saharan Africa, and the prevalence of complications is increasing. Diabetic foot disorders are a major source of morbidity and disability. Delay in the health care process due to patients’ beliefs may have deleterious consequences for limb and life in persons with diabetic foot ulcers. No previous studies of beliefs about health and illness in persons with diabetic foot ulcers living in Africa have been found. The aim of the study was to explore beliefs about health and illness among Ugandans with diabetic foot ulcers that might affect self-care and care seeking behaviour. In an explorative study with consecutive sample semi-structured interviews were held with 14 Ugandan men and women, aged 40-79, with diabetic foot ulcer. Knowledge was limited about causes, management and prevention of diabetic foot ulcers. Foot ulcers were often detected as painful sores, perceived to heal or improve, and led to stress and social isolation due to smell and reduced mobility. Most lacked awareness of the importance of complete daily foot care and seldom practised self-care. Health was described as absence of disease and pain. Many feared future health and related it to contact with nurses in the professional sector from whom they sought information, blood tests and wound dressings and desired better organised diabetes clinics offering health education and more opening hours. Many have an underutilised potential for self-care and need education urgently, delivered in well-organised diabetes clinics working to raise awareness of the threat and prevent foot ulcers.
Africans; attitudes to health/illness; beliefs about health/illness; care-seeking behaviour; diabetes mellitus complications; foot ulcer; self-care.
Foot ulceration is a major health problem for people with diabetes. To minimise the risk of ulceration, patients are advised to perform preventive foot self-care.
To explore beliefs about diabetic foot complications and everyday foot self-care practices among people with type 2 diabetes.
Design of study
Qualitative study using one-to-one interviews.
A suburban primary care health centre.
Semi-structured interviews with a purposive sample of adults with type 2 diabetes but with no experience of foot ulceration.
Most participants were unsure of what a foot ulcer is and unaware of the difficulties associated with ulcer healing. Prevention of accidental damage to the skin was not considered a priority, as few participants knew that this is a common cause of foot ulceration. Although it was recognised that lower-limb amputation is more common in people with diabetes, this was perceived to be predominantly caused by poor blood supply to the feet and unrelated to foot ulceration. Therefore, preventive foot care focused on stimulating blood circulation, for example by walking barefoot. Consequently, some of the behaviours participants considered beneficial for foot health could potentially increase the risk of ulceration. In some cases the uptake of advice regarding preventive foot care was hampered because participants found it difficult to communicate with health professionals.
Patients with type 2 diabetes may have beliefs about foot complications that differ from medical evidence. Such illness beliefs may play a role in foot-related behaviours that have previously been unrecognised. Health professionals need to explore and address the beliefs underlying patients' foot self-care practices.
diabetes mellitus; foot complications; foot self-care; illness beliefs; ulcer prevention
To test whether depression is associated with an increased risk of incident diabetic foot ulcers.
The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000–2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 (PHQ-9) were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio (HR) and 95% CI for incident diabetic foot ulcers, comparing patients with major and minor depression to those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin (HbA1c), diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes.
Compared to patients without depression, patients with major depression by PHQ-9 had a two-fold increase in the risk of incident diabetic foot ulcers (adjusted HR 2.00, 95% CI: 1.24, 3.25). There was no statistically significant association between minor depression by PHQ-9 and incident diabetic foot ulcers (adjusted HR 1.37, 95% CI: 0.77, 2.44).
Major depression by PHQ-9 is associated with a two-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders and/or mediators.
diabetes; depression; foot ulcers; complications
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.
RESEARCH DESIGN AND METHODS
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.
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 com-mon-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.
diabetes; ulcer; prevention; infection; amputation
Religious connectedness is common phenomenon in Saudi Arabia and adjacent Gulf countries. An observational case control study was designed, enrolling 180 adult patients to report the association between religious connectedness and health-related quality of life (HRQL) in people with and without diabetes and foot ulcers. Sixty diabetic patients with foot ulcers (Group I) were compared with sixty diabetic patients without foot ulcer (Group II) and sixty healthy subjects (Group III) for assessment of their HRQL by using SF-36 questionnaire. The effect of religious connectedness was assessed using intrinsic/extrinsic religious connectedness scale. HRQL was found to be significantly lower in Group I compared with Group II and III as well as in group II compared with group III (P < 0.001). Group I patients showed a poorer HRQL with increased severity, duration and multiplicity of foot ulcers. There was a strong positive relationship between religious connectedness and HRQL as indicated by a positive correlation between religious connectedness scale and mental, physical component summary scores (r = 0.66 and 0.59 respectively and P < 0.001). While quality of life is generally poor in people with diabetic foot ulcers, there exists a strong positive relationship between religious connectedness and higher HRQL. These findings may have implications on improving outcomes.
Diabetes; Foot ulcers; Religious; Connectedness
We tested the effects of structured health care for the diabetic foot in one region in Germany aiming to reduce the number of major amputations.
Research design and methods
In a prospective study we investigated patients with diabetic foot in a structured system of outpatient, in-patient and rehabilitative treatment. Subjects were recruited between January 1st, 2000 and December 31, 2007. All participants underwent a two-year follow-up. The modified University of Texas Wound Classification System (UT) was the basis for documentation and data analysis. We evaluated numbers of major amputations, rates of ulcer healing and mortality. In order to compare the effect of the structured health care program with usual care in patients with diabetic foot we evaluated the same parameters at another regional hospital without interdisciplinary care of diabetic foot (controls).
684 patients with diabetic foot and 508 controls were investigated. At discharge from hospital 28.3% (structured health care program, SHC) vs. 23.0% (controls) of all ulcers had healed completely. 51.5% (SHC) vs. 49.8% (controls) were in UT grade 1.
Major amputations were performed in 32 subjects of the structured health care program group (4.7%) vs. 110 (21.7%) in controls (p<0.0001). Mortality during hospitalization was 2.5% (SHC) vs. 9.4% in controls (p<0.001).
With the structured health care program we achieved a significant reduction of major amputation rates by more than 75% as compared to standard care.
Recurrent headache co-occurs commonly with psychological distress, such as anxiety or depression. Potentially traumatic interpersonal events (PTIEs) could represent important precursors of psychological distress and recurrent headache in adolescents. Our objective was to assess the hypothesised association between exposure to PTIEs and recurrent migraine and tension-type headache (TTH) in adolescents, and to further examine the potential impact of psychological distress on this relationship.
Population-based, cross-sectional cohort study. The study includes self-reported data from youth on exposure to potentially traumatic events, psychological distress and a validated interview on headache.
The adolescent part of the Nord-Trøndelag Health Study 2006–2008 (HUNT), conducted in Norway.
A cohort of 10 464 adolescents were invited to the study. Age ranged from 12 to 20 years. The response rate was 73% (7620), of whom 50% (3832) were girls.
Main outcome measures
Data from the headache interview served as the outcome. Recurrent headache was defined as headache recurring at least monthly during the past year, and was subclassified into monthly, weekly and daily complaints. Subtypes were classified as TTH, migraine, migraine with TTH and/or non-classifiable headache, in accordance with the International Classification of Headache Disorders criteria, second edition.
Multiple logistic regression analysis, adjusted for sociodemographics, showed consistently significant associations between exposure to PTIEs and recurrent headache, regardless of the frequency or subtype of headache. Increasing exposure to PTIEs was associated with higher prevalence of recurrent headache, indicating a dose–response relationship. The strength of associations between exposure to PTIEs and all recurrent headache disorders was significantly attenuated when psychological distress was entered into the regression equation.
The empirical evidence of a strong and cumulative relationship between exposure to PTIEs, psychological distress and recurrent headache indicates a need for the integration of somatic and psychological healthcare services for adolescents in the prevention, assessment and treatment of recurrent headache. Prospective studies are needed.
To investigate and compare the influence of a previous history of foot ulcers on plantar pressure variables during gait of patients with diabetic neuropathy.
Foot ulcers may be an indicator of worsening diabetic neuropathy. However, the behavior of plantar pressure patterns over time and during the progression of neuropathy, especially in patients who have a clinical history of foot ulcers, is still unclear.
Subjects were divided into the following groups: control group, 20 subjects; diabetic neuropathy patients without foot ulcers, 17 subjects; and diabetic neuropathy patients with at least one healed foot ulcer within the last year, 10 subjects. Plantar pressure distribution was recorded during barefoot gait using the Pedar-X system.
Neuropathic subjects from both the diabetic neuropathy and DNU groups showed higher plantar pressure than control subjects. At midfoot, the peak pressure was significantly different among all groups: control group (139.4±76.4 kPa), diabetic neuropathy (205.3±118.6 kPa) and DNU (290.7±151.5 kPa) (p=0.008). The pressure-time integral was significantly higher in the ulcerated neuropathic groups at midfoot (CG: 37.3±11.4 kPa.s; DN: 43.3±9.1 kPa.s; DNU: 68.7±36.5 kPa.s; p=0.002) and rearfoot (CG: 83.3±21.2 kPa.s; DN: 94.9±29.4 kPa.s; DNU: 102.5±37.9 kPa.s; p=0.048).
A history of foot ulcers in the clinical history of diabetic neuropathy subjects influenced plantar pressure distribution, resulting in an increased load under the midfoot and rearfoot and an increase in the variability of plantar pressure during barefoot gait. The progression of diabetic neuropathy was not found to influence plantar pressure distribution.
Biomechanics; Gait; Diabetic Neuropathies; Pressure; Foot ulcer
Patients with diabetes are often prescribed foot orthoses to help prevent foot ulcer formation. Orthotics are used to redistribute normal and shear stress. Shear stresses are not easily measurable and considered to be responsible for skin breakdown. Local elevation of skin temperature has been implicated as an early sign of impending ulceration especially in regions of high shear stress. The purpose of this study was to measure the effects of commonly prescribed insole materials on local changes in plantar foot temperature during normal gait.
Six commonly used foot orthosis materials were tested using the Thermo Trace™ infrared thermometer to measure foot temperature. Ten healthy adult volunteers without any history of diabetes or abnormal sensation participated in the study. During each trial the subject walked on a treadmill with the test material in the dominant foot's shoe, for six minutes at a speed of four miles per hour and rested for six minutes between trials. Four locations on the foot (hallux, first and fifth metatarsal heads, and heel) and the contralateral bicep temperatures were measured at 0, 1, 3, 5 minutes during the rest period. The order of material and skin location testing was randomized.
Significant differences were found between baseline temperatures and foot temperatures for all materials. However, no differences were found between materials for any location on the foot.
Previous studies have attempted to characterize materials based on laboratory and clinical testing, while other studies have attempted to characterize the effect of pressure on skin temperature. However, no study has previously attempted to characterize foot orthosis materials based on foot temperatures. This study compared foot temperatures of healthy adults based on the material tested. Although this study was unable to distinguish between materials based on foot temperatures, it was able to show a rise in foot temperature with any material used. This study demonstrates a need to a larger study on a population with diabetes.
Objective: This study was designed to evaluate the association between skin autofluorescence (AF), an indicator of advanced glycation end-products (AGEs), and foot ulcers in subjects with diabetes. Methods: In this study, 195 Chinese diabetic subjects were examined. Their feet were examined regardless of whether an ulcer was present or not. Skin AF was measured with an AGE reader. Demographic characteristics and blood data were recorded. Results: The mean values of skin AF were 2.29±0.47 for subjects without foot ulcers, and 2.80±0.69 for those with foot ulcers, a significant difference (P<0.05). Skin AF was strongly correlated with age and duration of diabetes. After adjusting for these factors, multivariate logistic regression showed that skin AF was independently associated with foot ulcerations. Conclusions: Skin AF is independently associated with diabetic foot ulcerations. It might be a useful screening method for foot ulceration risk of diabetic patients.
Advanced glycation end-products (AGEs); Diabetic foot ulcerations; Screening
Diabetic foot complications are a leading cause of lower extremity amputation. With the increasing incidence of diabetes mellitus in the Arab world, specifically in the Kingdom of Saudi Arabia, the rate of amputation will rise significantly. A diabetic foot care program was implemented at King Abdulaziz Medical City in Riyadh, Saudi Arabia, in 2002. The program was directed at health care staff and patients to increase their awareness about diabetic foot care and prevention of complications. The purpose of this study was to perform a primary evaluation of the program’s impact on the rate of lower extremity amputation due to diabetic foot complications.
This pilot study was the first analysis of the diabetic foot care program and examined two groups of participants for comparison, ie, a “before” group having had diabetic foot ulcers managed between 1983, when the hospital was first established, and 2002 when the program began and an “after group” having had foot ulcers managed between 2002 and 2004, in the program’s initial phase. A total of 41 charts were randomly chosen retrospectively. A data sheet containing age, gender, medical data, and the presentation, management, and outcome of diabetic foot cases was used for the analysis.
The before group contained 20 patients (17 males) and the after group contained 21 patients (16 males). There was no difference between the two groups with regard to age and comorbidities. The rate of amputation was 70% in the before group and 61.9% in the after group. There was a decrease in the percentage of toe amputation in the after group and an increase in the percentage of below-knee amputation in the before group. However, these changes were not significant.
The program, although evaluated at an early stage, has increased the awareness of both patients and health care staff about the prevention and management of diabetic foot disease, and decreased the rate of lower extremity amputation. We believe that the statistical proof of its impact will be evident in the final evaluation.
diabetic foot; prevention; complications; lower limb amputation
Outcome data on individuals with diabetic foot ulcers are scarce, especially in those with peripheral arterial disease (PAD). We therefore examined the clinical characteristics that best predict poor outcome in a large population of diabetic foot ulcer patients and examined whether such predictors differ between patients with and without PAD.
Analyses were conducted within the EURODIALE Study, a prospective cohort study of 1,088 diabetic foot ulcer patients across 14 centres in Europe. Multiple logistic regression modelling was used to identify independent predictors of outcome (i.e. non-healing of the foot ulcer).
After 1 year of follow-up, 23% of the patients had not healed. Independent baseline predictors of non-healing in the whole study population were older age, male sex, heart failure, the inability to stand or walk without help, end-stage renal disease, larger ulcer size, peripheral neuropathy and PAD. When analyses were performed according to PAD status, infection emerged as a specific predictor of non-healing in PAD patients only.
Predictors of healing differ between patients with and without PAD, suggesting that diabetic foot ulcers with or without concomitant PAD should be defined as two separate disease states. The observed negative impact of infection on healing that was confined to patients with PAD needs further investigation.
Co-morbidities; Diabetes; Foot ulcer; Infection; Non-healing; Outcome; Peripheral arterial disease; Predictive model
Diabetic neuropathy consists of multiple clinical manifestations of which loss of sensation is most prominent. High temperatures under the foot coupled with reduced or complete loss of sensation can predispose the patient to foot ulceration. The aim of this study was to look at the correlation between plantar foot temperature and diabetic neuropathy using a noninvasive infrared thermal imaging technique.
Infrared thermal imaging, a remote and noncontact experimental tool, was used to study the plantar foot temperatures of 112 subjects with type 2 diabetes selected from a tertiary diabetes centre in South India.
Patients with diabetic neuropathy (defined as vibration perception threshold (VPT) values on biothesiometry greater than 20 V) had a higher foot temperature (32–35 °C) compared to patients without neuropathy (27–30 °C). Diabetic subjects with neuropathy also had higher mean foot temperature (MFT) (p = .001) compared to non-neuropathic subjects. MFT also showed a positive correlation with right great toe (r = 0.301, p = .001) and left great toe VPT values (r = 0.292, p = .002). However, there was no correlation between glycated hemoglobin and MFT.
Infrared thermal imaging may be used as an additional tool for evaluation of high risk diabetic feet.
diabetic neuropathy; infrared thermal imaging; mean foot temperature; serum cholesterol; type 2 diabetes
As the number of persons with diabetes is projected to double in the next 25 years in the US, an accurate method of identifying diabetic foot ulcers in population-based data sources are ever more important for disease surveillance and public health purposes. The objectives of this study are to evaluate the accuracy of existing methods and to propose a new method.
Four existing methods were used to identify all patients diagnosed with a foot ulcer in a Department of Veterans Affairs (VA) hospital from the inpatient and outpatient datasets for 2003. Their electronic medical records were reviewed to verify whether the medical records positively indicate presence of a diabetic foot ulcer in diagnoses, medical assessments, or consults. For each method, five measures of accuracy and agreement were evaluated using data from medical records as the gold standard.
Our medical record reviews show that all methods had sensitivity > 92% but their specificity varied substantially between 74% and 91%. A method used in Harrington et al. (2004) was the most accurate with 94% sensitivity and 91% specificity and produced an annual prevalence of 3.3% among VA users with diabetes nationwide. A new and simpler method consisting of two codes (707.1× and 707.9) shows an equally good accuracy with 93% sensitivity and 91% specificity and 3.1% prevalence.
Our results indicate that the Harrington and New methods are highly comparable and accurate. We recommend the Harrington method for its accuracy and the New method for its simplicity and comparable accuracy.
To identify the differences in a socioeconomic profile between two cohorts of diabetic patients – one with diabetic foot problems and another without diabetic foot problems.
Materials and methods
The cohort with diabetic foot problems (including cellulitis, abscess, osteomyelitis, septic arthritis, gangrene, ulcers, or Charcot joint disease) consisted of 122 diabetic patients, while the other cohort without foot problems consisted of 112 diabetic patients. Both were seen at the National University Hospital from January to April 2007. A detailed protocol was designed and the factors studied included patient profile, average monthly household income, education, compliance to diabetic medication, attendance at clinics for diabetic treatment, exercise, smoking, alcohol consumption, gender, and glycosylated haemoglobin (HbA1C) level. These were studied for significant differences using univariate and stepwise multivariate logistic regression analysis.
With multivariate analysis, Malay ethnicity (p<0.001), education of up to secondary school only (p=0.021), low average monthly household income of less than SGD $2,000 (p=0.030), lack of exercise (at least once a week, p=0.04), and elevated HbA1C level (>7.0%; p=0.015) were found to be significantly higher in the cohort with diabetic foot problems than the cohort without.
There are significant differences in the socioeconomic factors between diabetic patients with diabetic foot problems and those without.
diabetic foot; social conditions; patient compliance; income; HbA1c
People with diabetes and peripheral neuropathy often do not implement the foot-care behavioural strategies that are suggested by many health professionals. The concept of self-efficacy has been shown to be an effective predictor of behaviour in many areas of health. This study investigated the relationships between foot-care self-efficacy beliefs, self-reported foot-care behaviour and history of diabetes-related foot pathology in people with diabetes and loss of protective sensation in their feet.
Ninety-six participants were included in this cross-sectional study undertaken in a regional city of Australia. All participants had diabetes and clinically diagnosed loss of protective sensation in their feet. The participants completed a self-report pen-paper questionnaire regarding foot-care self efficacy beliefs (the "Foot Care Confidence Scale") and two aspects of actual foot-care behaviour-preventative behaviour and potentially damaging behaviour. Pearson correlation coefficients were then calculated to determine the association between foot-care self-efficacy beliefs and actual reported foot-care behaviour. Multiple analysis of variance was undertaken to compare mean self-efficacy and behaviour subscale scores for those with a history of foot pathology, and those that did not.
A small positive correlation (r = 0.2, p = 0.05) was found between self-efficacy beliefs and preventative behaviour. There was no association between self-efficacy beliefs and potentially damaging behaviour. There was no difference in self-efficacy beliefs in people that had a history of foot pathology compared to those that did not.
There is little association between foot-care self-efficacy beliefs and actual foot-care behaviour. The usefulness of measuring foot-care self-efficacy beliefs to assess actual self foot-care behaviour using currently available instruments is limited in people with diabetes and loss of protective sensation.
Foot ulceration remains a major health problem for diabetic patients and has a major impact on the cost of diabetes treatment. We tested a hyperspectral imaging technology that quantifies cutaneous tissue hemoglobin oxygenation and generated anatomically relevant tissue oxygenation maps to assess the healing potential of diabetic foot ulcers (DFUs).
RESEARCH DESIGN AND METHODS
A prospective single-arm blinded study was completed in which 66 patients with type 1 and type 2 diabetes were enrolled and followed over a 24-week period. Clinical, medical, and diabetes histories were collected. Transcutaneous oxygen tension was measured at the ankles. Superficial tissue oxyhemoglobin (oxy) and deoxyhemoglobin (deoxy) were measured with hyperspectral imaging from intact tissue bordering the ulcer. A healing index derived from oxy and deoxy values was used to assess the potential for healing.
Fifty-four patients with 73 ulcers completed the study; at 24 weeks, 54 ulcers healed while 19 ulcers did not heal. When using the healing index to predict healing, the sensitivity was 80% (43 of 54), the specificity was 74% (14 of 19), and the positive predictive value was 90% (43 of 48). The sensitivity, specificity, and positive predictive values increased to 86, 88, and 96%, respectively, when removing three false-positive osteomyelitis cases and four false-negative cases due to measurements on a callus. The results indicate that cutaneous tissue oxygenation correlates with wound healing in diabetic patients.
Hyperspectral imaging of tissue oxy and deoxy may predict the healing of DFUs with high sensitivity and specificity based on information obtained from a single visit.
Subclinical inflammation is an important risk factor for type 2 diabetes and diabetes complications. However, data on the association between inflammation and acute diabetic foot syndrome are scarce. The aim of this study was to compare systemic immune mediators in diabetic patients with and without an ulcer and to identify modulating factors.
RESEARCH DESIGN AND METHODS
Circulating levels of acute-phase proteins, cytokines, and chemokines were measured in diabetic patients with an ulcer (n = 170) and without an ulcer (n = 140). Of the patients, 88% had type 2 diabetes.
Patients with an acute foot ulcer had higher levels of C-reactive protein (CRP), fibrinogen, interleukin (IL)-6, macrophage migration inhibitory factor, macrophage inflammatory protein-1α, and interferon-γ–inducible protein-10 as well as lower levels of RANTES (regulated on activation normal T-cell expressed and secreted) (all P < 0.01). No differences were found for IL-8, IL-18, and monocyte chemoattractant protein-1. Most of these associations persisted after adjustment for demographic and anthropometric data, metabolic confounders, and diabetes complications. In multivariate models, size of ulcer according to the University of Texas classification but not the grade of infection was independently associated with three markers of subclinical inflammation (CRP, IL-6, and fibrinogen).
We demonstrate in our cross-sectional study that acute foot ulcers and their severity are associated with a marked upregulation of acute-phase proteins, cytokines, and chemokines independently of the concomitant infection. Further studies should investigate whether an activation of the immune system precedes the development of foot ulcer and whether anti-inflammatory therapies might be effective.
Amongst the many identified mechanisms leading to diabetic foot ulceration, ill-fitting footwear is one. There is anecdotal evidence that people with diabetic peripheral neuropathy wear shoes that are too small in order to increase the sensation of fit. The aim of this study was to determine whether people with diabetic sensory neuropathy wear appropriate length footwear.
A case–control design was used to compare internal shoe length and foot length differences between a group of people with diabetes and peripheral sensory neuropathy and a group of people without diabetes and no peripheral sensory neuropathy. Shoe and foot length measurements were taken using a calibrated Internal Shoe Size Gauge® and a Brannock Device®, respectively.
Data was collected from 85 participants with diabetes and 118 participants without diabetes. The mean difference between shoe and foot length was not significantly different between the two groups. However, a significant number of participants within both groups had a shoe to foot length difference that lay outside a previously suggested 10 to 15 mm range. From the diabetic and non-diabetic groups 82% (70/85) and 66% (78/118), respectively had a foot to shoe length difference outside this same range.
This study shows that although there is no significant difference in shoe-length fit between participants with and without neuropathy, a significant proportion of these populations wear shoes that are either too long or too short for their foot length according to the 10 to 15 mm value used for comparison. The study has highlighted the need for standardised approaches when considering the allowance required between foot and internal shoe length and for the measurement and comparison of foot and shoe dimensions.
A number of studies have demonstrated that health-related quality of life (HRQoL) is negatively affected by diabetic foot ulcers. The aim of this study was to compare HRQoL in diabetic patients with and without foot ulcers and to determine demographic and clinical factors influencing HRQoL.
There were no variables affecting HRQoL except for gender in diabetic patients without foot ulcers. Demographic and clinical variables were recorded and HRQoL was evaluated using the Short Form 36 (SF-36) survey for all participants. The summary physical component score (PCS) and mental component score (MCS) and eight domains of HRQoL were compared in the two groups. Linear regression analysis was also used to investigate sociodemographic and clinical characteristics as predictors of quality of life as measured by SF-36.
The overall score, PCS, and MCS, were significantly higher in patients without diabetic foot ulcers. Except for gender, none of the variables affected HRQoL in diabetic patients without foot ulcers. Male gender had a higher score in all domains of quality of life than female gender in diabetic patients without foot ulcers. Living alone, a low educational level, and having at least one complication were all associated with a lower HRQoL score in patients with foot ulcers. High-grade ulcers determined by Wagner’s classification and poor glycemic control as measured by HbA1C predicted HRQoL impairment in patients with diabetic foot ulcers.
Because Wagner’s grade was one of the strongest variables associated with HRQoL, this scale is recommended for monitoring of patients with diabetic foot ulcers in order to prevent continuing deterioration of HRQoL by treatment of foot ulcers at an earlier stage.
quality of life; diabetics; foot ulcer
Background: Foot health is an important issue in older people. Inappropriate shoes increase the risk of callous and ulcer formation, as well as increasing the risk of falls. There are no data defining the size of this problem.
Objective: The aim of the study was to investigate the proportion of elderly people on a general rehabilitation ward wearing incorrectly sized shoes and to look for the presence of complications.
Methods: Sixty five consecutive patients (mental state questionnaire score >6) admitted to a rehabilitation ward had their foot length and width measured, and the size of their current footwear recorded. Sensation was tested with a standard 10 g monofilament. The presence of ulceration was noted. Foot pain was recorded by the patient on a visual analogue scale. Any history of diabetes mellitus, peripheral vascular disease, or peripheral neuropathy was noted.
Results: The median age of the subjects was 82 (range 64–93). Six (9%) had a history of diabetes, seven (11%) had symptomatic peripheral vascular disease, and 17 (26%) had sensory impairment. Ten patients (15%) had foot ulceration present, and 47 patients (72%) had ill fitting shoes (a discrepancy in length of more than half a British shoe size fitting or more than one British width fitting, 7 mm).
Incorrect shoe length was significantly associated with the presence of ulceration (odds ratio (OR) = 10.04, p = 0.016). Presence of ulceration was significantly associated with a history of peripheral vascular disease (OR = 11.56, p = 0.008). Pain was significantly associated with incorrect shoe length (p = 0.0238) and with sensory impairment (p = 0.0314).
Conclusion: Most older people on a rehabilitation ward wore ill fitting shoes. An association was found between ill fitting shoes and self reported pain, and between ill fitting shoes and ulcer formation.
A straightforward assessment of footwear in older people could improve comfort and avoid preventable foot disorders.
This study tests the hypotheses that health-related quality of life (HRQOL) in prevalent dialysis patients with diabetes is lower than in dialysis patients without diabetes, and is at least as poor as diabetic patients with another severe complication, i.e. foot ulcers. This study also explores the mortality risk associated with diabetes in dialysis patients.
HRQOL was assessed using the Short Form-36 Health Survey (SF-36), in a cross-sectional study of 301 prevalent dialysis patients (26% with diabetes), and compared with diabetic patients not on dialysis (n = 221), diabetic patients with foot ulcers (n = 127), and a sample of the general population (n = 5903). Mortality risk was assessed using a Kaplan-Meier plot and Cox proportional hazards analysis.
Self-assessed vitality, general and mental health, and physical function were significantly lower in dialysis patients with diabetes than in those without. Vitality (p = 0.011) and general health (p <0.001) was impaired in diabetic patients receiving dialysis compared to diabetic patients with foot ulcers, but other subscales did not differ. Diabetes was a significant predictor for mortality in dialysis patients, with a hazard ratio (HR) of 1.6 (95% CI 1.0-2.5) after adjustment for age, dialysis vintage and coronary artery disease. Mental aspects of HRQOL were an independent predictor of mortality in diabetic patients receiving dialysis after adjusting for age and dialysis vintage (HR 2.2, 95% CI 1.0-5.0).
Physical aspects of HRQOL were perceived very low in dialysis patients with diabetes, and lower than in other dialysis patients and diabetic patients without dialysis. Mental aspects predicted mortality in dialysis patients with diabetes. Increased awareness and measures to assist physical function impairment may be particularly important in diabetes patients on dialysis.
Dialysis; Diabetes; Foot Ulcers; QOL; Mortality
OBJECTIVE—The long-term outcome and functional status of subjects hospitalized for diabetic foot ulcers have been poorly studied and thus are the topics of this study.
RESEARCH DESIGN AND METHODS—Ninety-four consecutive diabetic subjects hospitalized for diabetic foot ulcers between January 1998 and December 2000 were prospectively followed for mean ± SD 79.5 ± 13.3 months. We calculated rates of primary healing, new ulcers, amputations, mortality, and disability and evaluated the global therapeutic success (GTS) of foot care management as defined by the association of primary healing without recurrence or disability at the end of follow-up.
RESULTS—Follow-up was successful in 89 of 94 subjects (63 men and 31 women; age 63.7 ± 10.8 years). Of these, 69 (77.5%) experienced primary healing without major amputation, 39 (43.8%) underwent amputation (24 minor and 15 major), and 46 died (51.7%), including 23 from cardiovascular events. Forty-two of 69 patients who experienced primary healing (60.9%) had ulcer recurrence. At the end of the follow-up period, 25 patients (28.1%) were dependent and 40 subjects (44.9%) had achieved GTS. Multivariate analysis showed the role of age as an independent predictor of GTS (P < 0.05) and of impaired renal function/albuminuria as independent predictors of healing failure, first amputation, and mortality (P < 0.01).
CONCLUSIONS—Despite a satisfactory initial healing rate, the global long-term outcome of patients hospitalized for diabetic foot ulcers was poor. Nephropathy appears to be an important predictor of long-term outcome. Further studies are needed to establish recognized criteria for therapeutic success going beyond just the evaluation of healing rate in the management of diabetic foot ulcers.