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1.  Diabetic Peripheral Neuropathy and Gait: Does Footwear Modify This Association? 
Background
Gait-related fall risk is the leading cause of mortality among patients with diabetes, especially those older than 65 years. Deterioration in balance and loss of protective sensation in lower extremities contribute significantly to fall risk in patients with diabetic peripheral neuropathy (DPN). This study aimed to explore the impact of neuropathy and foot ulcer on gait.
Methods
We recruited 39 participants (age, 56.9 ± 8.2 years; body mass index, 29.6.3 ± 4.7 kg/m2), including 15 DPN patients without foot ulcers, 16 DPN patients with foot ulcers, and 8 healthy aged-matched controls. Patients with active foot ulcers wore an offloading device during gait examination, including removable cast walker.
Results
Results suggest that neuropathy alters gait mainly by increasing gait initiation, gait variability (coefficient of variation of gait velocity), and double support (DS) time, while reducing knee range of motion and center of mass sway (p < .05). Interestingly, the presence of foot ulcer does not impact gait velocity (p > .1) but enhances some of the gait parameters such as gait variability and DS time.
Conclusions
This study demonstrates that neuropathy deteriorates gait, but the presence of foot ulcers does not alter gait parameters further than neuropathy. In addition, patients with foot ulcers demonstrated a better gait compared with DPN patients without ulcers. We speculate that offloading footwear may be enhancing the somatosensory feedback from sensate skin, thereby positively affecting gait parameters. A study with a larger sample is required to explore the effect of prescribed footwear in the DPN population in order to validate the findings of this research study.
PMCID: PMC3876356  PMID: 24124939
diabetes; foot ulcer; gait; offloading; wearable sensors
2.  Novel Wearable Technology for Assessing Spontaneous Daily Physical Activity and Risk of Falling in Older Adults with Diabetes 
Background
As baby boomers age and their expected life span increases, there is an unprecedented need to better manage the health care of elders with diabetes who are at increased risk of falling due to diabetes complications, frailty, or other conditions. New clinical and research tools are needed to measure functioning accurately and to identify early indicators of risk of falling, thus translating into more effective and earlier intervention.
Methods
The objective of this pilot study was to validate a significant change in hardware and algorithm to track activity patterns using a single triaxial accelerometer through validation of timed up and go and standard measures of balance and gait. We recruited a convenience sample of eight older adults with diabetes and peripheral neuropathy (age, 77 ± 7 years old) who were asked to wear the sensor for imposed daytime activity performed in our gait laboratory. Subjects were stratified into risk of falling categories based on Tinetti scores. We examined the accuracy of the suggested technology for discrimination of high- versus low-risk groups.
Results
The system was accurate in identifying the number of steps taken and walking duration (random error <5%). The proposed algorithm allowed accurate identification and stratification of those at highest risk of falling, suggesting that subjects with high risk of falling required a substantially longer duration for rising from a chair when compared with those with low risk of falling (p < .05).
Conclusions
Our new single triaxial accelerometer algorithm successfully tracked postural transition, allowing accurate identification of those at high risk of falling, and could be useful for intermittent or even continuous monitoring of older adults with diabetes. Other potential applications could include activity monitoring of the diabetes population with lower extremity disease and of patients undergoing surgical procedures or as an objective measure during rehabilitation.
J Diabetes Sci Technol 2013;7(5):1147–1160
PMCID: PMC3876357  PMID: 24124940
body-worn sensor; diabetes care; foot ulcer; home telemonitoring; physical activity monitoring; risk of falling; wearable technology
3.  Intraoperative Fluorescence Vascular Angiography: During Tibial Bypass 
Preventing amputations in persons with lower extremity complications of diabetes is a complex endeavor, particularly in those with concomitant ischemia and tissue loss. Fluorescence angiography (Novadaq SPY system) may provide a tool for objective evaluations of tissue viability in the diabetic foot, which is an important indicator of the ability of the diabetic ulcer to heal adequately. The SPY system uses a low-power laser coupled with a charge-coupled device camera and indocyanine green (ICG) to sequence perfusion at the surface of the skin. We present an illustrated example of the potential utility of ICG fluorescence angiography (ICGFA) before and after vascular intervention in a high-risk limb. ICGFA appeared to reveal demarcation between viable and nonviable tissue and real-time perfusion, specifically capillary fill. ICGFA clarified the extent of necessary debridement and provided an immediate indication of improvement in regional perfusion status following revascularization. Future studies involving ICGFA may include pre- and postdebridement and closure perfusion, comparison of tissue perfusion pre- and post-endovascular therapy, and lower extremity flap viability. Future works will also address the consistency of results with ICGFA by analyzing a larger cohort of patients being treated by our unit.
PMCID: PMC3320839  PMID: 22401340
diabetic foot ulcers; noninvasive imaging; peripheral vascular disease; tissue health; wound healing
4.  Methodology for Use of a Neuroprosthetic to Reduce Plantar Pressure: Applications in Patients with Diabetic Foot Disease 
PMCID: PMC3320844  PMID: 22401344
diabetic foot ulcers; functional electrical stimulation; neuroprosthetics; plantar pressure; wound healing
5.  Diabetic Foot Ulcers and Vascular Insufficiency: Our Population Has Changed, but Our Methods Have Not 
Diabetic foot complications are increasing in prevalence worldwide. Care and attention to these complications have improved greatly. Many advanced therapies are now being investigated or taken through final stages of clinical studies worldwide. However, the data upon which assumptions regarding morbidity, healing, and mortality have been based are grossly outdated. The purpose of this brief article is to report on current data regarding neuropathic and neuroischemic wounds and to propose that the latter category of advanced-stage diabetic foot wound may now be emerging as the most commonly encountered lesion in the developed world. Unfortunately, it is still systematically excluded from most clinical study criteria. Additionally, just as in the care of cancer, we call for therapy of these advanced-stage diabetic foot ulcers to be managed in similarly interdisciplinary centers where patients may have access to potentially beneficial clinical trials.
PMCID: PMC3262731  PMID: 22226282
amputation; diabetic foot ulcers; infection; ischemia; wound healing
6.  Use of Sugar on the Healing of Diabetic Ulcers: A Review 
With the advent of several innovative wound care management tools, the choice of products and treatment modalities available to clinicians continues to expand. High costs associated with wound care, especially diabetic foot wounds, make it important for clinician scientists to research alternative therapies and optimally incorporate them into wound care protocols appropriately. This article reviews using sugar as a treatment option in diabetic foot care and provides a guide to its appropriate use in healing foot ulcers. In addition to a clinical case study, the physiological significance and advantages of sugar are discussed.
PMCID: PMC2956799  PMID: 20920433
diabetic foot ulcers; sugar; wound healing
7.  Novel Use of Platelet-Rich Plasma to Augment Curative Diabetic Foot Surgery 
Autologous platelet-rich plasma (PRP) may enhance wound healing through the formation of a platelet plug that provides both hemostasis and the secretion of biologically active proteins, including growth factors such as platelet-derived growth factor, transforming growth factor (TGF)-β, TGF-β2, and epidermal growth factor. The release of these growth factors into the wound may create an environment more conducive to tissue repair and could accelerate postoperative wound healing. To our knowledge, there are no reports of combining the use of PRP with curative diabetic foot surgery. This article provides a summary of the literature regarding PRP and wound healing and presents a case of a 49-year-old man with diabetes and a three-month history of a deep, nonhealing plantar hallux wound in which PRP was combined with a first metatarsophalangeal joint arthroplasty. Through the use of the PRP and bioengineered tissue to supplement curative diabetic foot surgery, the patient healed uneventfully at seven weeks.
PMCID: PMC2956802  PMID: 20920431
diabetic; foot surgery; platelet rich plasma; wound
8.  Wound Inflammatory Index: A “Proof of Concept” Study to Assess Wound Healing Trajectory 
Diabetes around the globe results in one major limb amputation every 30 seconds, over 2500 limbs lost per day. The underlying pathophysiology sometimes leads to a chronic inflammatory stage, which may prevent appropriate healing, and therefore, the need for a clear strategy for assessing and classifying wounds and wound healing cannot be overstated. Temperature is a surrogate marker for inflammation. Quantitative thermography using a numerical index provides a useful way to assess wound healing. Advances in technology have afforded the availability of low-cost, high-resolution thermal imaging systems, which can be used to quantify sensitive changes on the skin surface and may be particularly useful to develop monitoring strategies for wounds. This article provides a standardized technique for calculating a thermal index (TI) supported with a case report from assessment of a diabetic foot ulcer. In this single case study, the TI/wound inflammatory index indicates a shift from negative to positive (p < .05) before it reaches zero.
PMCID: PMC2909505  PMID: 20663437
diabetic foot ulcers; thermal index; thermography; thermometry; wound healing
9.  Digital Planimetry Results in More Accurate Wound Measurements: A Comparison to Standard Ruler Measurements 
Background
Cutaneous wound measurements are important to track the healing of a wound and direct appropriate therapy. The most commonly used method to calculate wound area is an estimation by multiplying the longest length by the widest width. Other devices can provide an accurate and precise measurement of the true area (TA). This study aim was to compare wound areas calculated by computerized planimetry with standard area estimation by multiplying the longest length by the widest width (l × w).
Methods
We reviewed the wound records of 10 patients with circular or oval wounds and estimated the area with the l × w method. We compared this with the TA obtained by a specialized planimetric camera.
Results
Average wound size was 4.3 cm2 by l × w estimation and 3 cm2 by TA calculation. We found the l × w method overestimated wound area an average of 41%.
Conclusions
Standard, manual (l × w) measurement of cutaneous wounds inaccurately overestimates wound area by roughly 40%.
PMCID: PMC2909508  PMID: 20663440
planimetry; Silhouette; ulcer; wound measurement
10.  The Micrograft Concept for Wound Healing: Strategies and Applications 
The standard of care for wound coverage is to use an autologous skin graft. However, large or chronic wounds become an exceptionally challenging problem especially when donor sites are limited. It is important that the clinician be aware of various treatment modalities for wound care and incorporate those methods appropriately in the proper clinical context. This report reviews an alternative to traditional meshed skin grafting for wound coverage: micrografting. The physiological concept of micrografting, along with historical context, and the evolution of the technique are discussed, as well as studies needed for micrograft characterization and future applications of the technique.
PMCID: PMC2909510  PMID: 20663442
diabetic foot ulcers; micrografting; wound healing
11.  Novel Use of Insulin in Continuous-Instillation Negative Pressure Wound Therapy as “Wound Chemotherapy” 
Negative pressure wound therapy (NPWT) is frequently employed in the treatment of complex wounds. A variety of wound chemotherapeutic agents such as insulin, which acts as a growth factor, may prove helpful in treatment as well. We present a case report in which insulin was used as a chemotherapeutic agent in continuous-instillation NPWT. To our knowledge, this is the first report in the literature describing this method of delivery.
PMCID: PMC2909511  PMID: 20663443
diabetic foot ulcers; insulin; negative pressure wound therapy; wound chemotherapy
12.  Liquid Silicone to Mitigate Plantar Pedal Pressure: A Literature Review 
Disruption of the body’s plantar fat pad can occur as a result of one of three mechanisms: simple fat pad atrophy associated with age-related degeneration, steroid use, or collagen vascular disease. Actual or relative displacement in to the underlying osseous prominences may be seen in association with structural deformity of the foot. Disease states such as diabetes may alter the normal structural integrity of soft tissues through nonenzymatic glycation leading to increased stiffness and thus reduced attenuating capacity. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity, and financial losses. In situations where the patient is sensate, the resultant skin on bone situation is extremely painful, especially when walking.
PMCID: PMC2909515  PMID: 20663447
atrophy; augmentation; pressure; silicone

Results 1-12 (12)