Incidence Of Diabetic Foot Ulcers Research Articles

Implementation of foot thermometry plus mHealth to prevent diabetic foot ulcers: study protocol for a randomized controlled trial

BackgroundDiabetic foot neuropathy (DFN) is one of the most important complications of diabetes mellitus; its early diagnosis and intervention can prevent foot ulcers and the need for amputation. Thermometry, measuring the temperature of the feet, is a promising emerging modality for diabetic foot ulcer prevention. However, patient compliance with at-home monitoring is concerning. Delivering messages to remind patients to perform thermometry and foot care might be helpful to guarantee regular foot monitoring. This trial was designed to compare the incidence of diabetic foot ulcers (DFUs) between participants who receive thermometry alone and those who receive thermometry as well as mHealth (SMS and voice messaging) over a year-long study period.Methods/designThis is an evaluator-blinded, randomized, 12-month trial. Individuals with a diagnosis of type 2 diabetes mellitus, aged between 18–80 years, having a present dorsalis pedis pulse in both feet, are in risk group 2 or 3 using the diabetic foot risk classification system (as specified by the International Working Group on the Diabetic Foot), have an operating cell phone or a caregiver with an operating cell phone, and have the ability to provide informed consent will be eligible to participate in the study. Recruitment will be performed in diabetes outpatient clinics at two Ministry of Health tertiary hospitals in Lima, Peru.Interventions: participants in both groups will receive education about foot care at the beginning of the study and they will be provided with a thermometry device (TempStat™). TempStat™ is a tool that captures a thermal image of the feet, which, depending on the temperature of the feet, shows different colors. In this study, if a participant notes a single yellow image or variance between one foot and the contralateral foot, they will be prompted to notify a nurse to evaluate their activity within the previous 2 weeks and make appropriate recommendations. In addition to thermometry, participants in the intervention arm will receive an mHealth component in the form of SMS and voice messages as reminders to use the thermometry device, and instructions to promote foot care.Outcomes: the primary outcome is foot ulceration, evaluated by a trained nurse, occurring at any point during the study.DiscussionThis study has two principal contributions towards the prevention of DFU. First, the introduction of messages to promote self-management of diabetes foot care as well as using reminders as a strategy to improve adherence to daily home-based measurements. Secondly, the implementation of a thermometry-based strategy complemented by SMS and voice messages in an LMIC setting, with wider implications for scalability.Trial registrationThis study is registered in ClinicalTrials.gov: Identifier NCT02373592.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1333-1) contains supplementary material, which is available to authorized users.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration.

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States.

安全型糖尿病足趾甲修剪钳的研制与应用*

Objective: To evaluate the clinical application effects of new type secure toenail clipper for diabetes patients. Methods: Combining advantages and abandoning shortcomings of common nail clippers and scissors, designed a new type toenail clipper for diabetes patients with abnormal and (or) hard toenails, and applied it in 450 diabetes patients. Results: Easy application with safety and effective pruning. After pruning, the pain and oppression feeling caused by abnormal and (or) hard toenails relieved, and no case had diabetic foot ulcer. Conclusions: The new type secure toenail clipper can effectively reduce the sense of pain and oppression, and decrease the incidence of diabetic foot ulcer.

Efficacy of topical application of beta urogastrone (recombinant human epidermal growth factor) in Wagner's Grade 1 and 2 diabetic foot ulcers: Comparative analysis of 50 patients.

Introduction:Diabetes mellitus is growing at epidemic proportions world wide and associated with this is an increase in incidence of diabetic foot ulcers. For better understanding and ease of management, diabetic foot ulcer severity is often classified using the Wagner system. In recent times, various treatment modalities have been put to test for getting early wound healing, including growth factors like human epidermal growth factor.Materials and Methods:The present study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana. The patients were divided into two groups of 25 patients each. Group 1 was the study group and patients in this group received topical application of beta urogastrone (rhEGF) gel. Group 2 was the control group and patients in this group received betadine dressing. The patients were followed up after every two weeks for eight weeks.Results:The age and sex were comparable in both groups. Mode of onset was either spontaneous or posttraumatic or following debridement. Initially in group A, 12 patients each had serous and seropurulent discharge respectively. I patient did not have any discharge. In group B, 15 patients had sero purulent discharge, 9 patients had serous discharge and 1 patient had purulent discharge. Initially, 13 patients in group A and 15 patients in group B had granulation tissue. Mean size at the beginning of the study in-group A was 19.56 sq cm and 21.20 sq cm in group B. Two patients from group A had incomplete healing at the end of the study as compared to 14 patients from group B.Conclusions:The application of rhEGF shortens the wound healing time significantly and the mean closure was significantly higher in the EGF group compared with placebo.

Low serum magnesium levels and diabetic foot ulcers

Magnesium plays an important role in glucose homeostasis and insulin sensitivity. The aim of this study was to investigate the association between serum magnesium levels and diabetic foot ulcers. A total of 147 subjects were included in this study. The participants were divided into three groups, including a study group of 49 patients with diabetes and foot ulcers, a control group of patients with diabetes without foot ulcers and a control group of 49 healthy subjects. Measurements and comparisons were made of the participants' magnesium levels, HBA1C percentages, serum fasting glucose levels, creatinine levels and serum lipid levels for all groups. MedCalc version 12.0 (MedCalc, Turkey) was used for the statistical analysis. The groups were similar in terms of age and sex (p=0.116 and 0.897, respectively). The magnesium levels of the patients with diabetes and foot ulcers were lower than those in the patients with diabetes without foot ulcers and the healthy subjects (p<0.001). There was a strong relationship between the serum magnesium levels and the incidence of diabetic foot ulcers (OR 5.9, Cl 95% 2.7-12.6, p<0.001). A low serum magnesium level is associated with diabetic foot ulcers. Therefore, the magnesium levels should be controlled in patients with diabetes (with or without foot ulcers) and magnesium supplementation can be a complimentary treatment in such cases.

Why Australia and Indian researchers should collaborate to advance wound management innovation?

In 2011, 366 million people suffered from diabetes worldwide, resulting in 4.6 million deaths at a cost of US$465 billion in direct healthcare expenditures1. India has the world’s second largest diabetic population at 61.8 million (8.3% of total population)1, while in Australia 8.1% of the population have been diagnosed with diabetes1. Diabetic foot ulcers (DFUs) affect up to 25% of diabetic patients, precipitating 85% of all diabetic amputations2,3. DFUs have significant social and economic impacts associated with increased hospitalisation rates, cost of care, and the reduced capacity of patients and carers to work. In isolated regions of Australia and India the incidence of DFU and associated infection is substantially increased, resulting in hospitalisation rates up to 4- fold that of major cities...

Risk of diabetic foot ulceration during treatment with insulin glargine and NPH insulin

To evaluate the effect of the long-acting basal insulin analog glargine compared with neutral protamine Hagedorn (NPH) insulin on the incidence of diabetic foot ulceration (DFU) in patients with diabetes in Germany. A retrospective cohort study was performed using a representative German database (IMS Disease Analyzer) of patients with type 2 diabetes, who started a basal insulin therapy with either insulin glargine or NPH insulin, between July 2000 and September 2007, and continued this therapy for at least 24 months, and whose data were continuously documented.The occurrence of DFU was recorded beginning in the third year after therapy initiation and Kaplan-Meier curves were generated and compared using log-rank tests. Cox proportional hazard models were used to estimate the adjusted hazard ratio (HR) and 95% confidence intervals (CI) for the incidence of DFU. Patients who fulfilled the inclusion criteria (n=23 395) had started either on insulin glargine (n=9638) or on NPH insulin (n= 13 757).After adjustment for demographic and clinical variables, it was demonstrated that the relative risk to diabetes patients of developing DFS is 64% lower with insulin glargine than with NPH insulin therapy (HR=0.6 I; p=0.0405). The results suggest that, compared with NPH insulin, insulin glargine therapy significantly reduces the risk of DFS in patients with diabetes under real life conditions. Prospective long-term trials are needed to confirm these secondary data analysis results. There were no external sources of funding for this study.The authors have no conflicts of interest to declare.

Foot care practice – The key to prevent diabetic foot ulcers in India

BackgroundThe magnitude of diabetic foot ulcers (DFUs) and the amputation rates due to DFUs remain high even in developing and developed countries. Yet, the influence of knowledge, attitude, and practice (KAP) of diabetic foot care (DFC) on DFU incidence is not studied much. ObjectiveTo study causal relationship between knowledge, attitude and practice (KAP) on DFC between diabetic patients with and without DFUs; and the risk factors associated with DFUs. MethodsA consecutive of 203 diabetic patients (103 with DFU and 100 without DFU) were included in the study. Their demographic details, medical history, and personal habits were recorded. KAP on DFC was assessed using a questionnaire. Responses were recorded, scored, and analyzed. ResultsOf the cohort, 67.5% were males, mean age: 59.9±11.4 years. Patients without DFU had good knowledge on DFC compared to those with DFU (86% versus 69.9%) (p<0.001). Incidence of DFU was 9% and 39.8% (p<0.001) among patients who practiced and not practiced DFC respectively. 88% patients with and without DFUs; showed favorable attitude toward adopting DFC. Risk factors – diabetic peripheral neuropathy, peripheral vascular disease, retinopathy, nephropathy, smoking, tobacco chewing and alcohol consumption were significantly (p<0.001) associated with DFUs. ConclusionsAn inverse relationship between DFU and foot care knowledge as well as practice was observed. Apart from tight glycemic control, diabetic patients must be educated and motivated on proper foot care practice and life style modifications for preventing DFUs.

Characteristics and Outcomes of Subjects With Diabetic Foot Ulceration

Foot ulcers are a major cause of morbidity and hospitalization in patients with diabetes. The incidence of diabetic foot ulceration is higher in developing countries because of various sociocultural factors. The majority of amputations in patients with diabetes are preceded by foot ulceration; hence it is important to identify patients at risk for this complication. Studies show that the prevalence of diabetic foot ulceration is between 4 and 10% in Pakistan (1), and the amputation rate following foot ulceration is 8–21% (1,2), depending on the methodology used for treating foot ulceration. We identified diabetic patients at risk for ulceration and compared the clinical and metabolic characteristics of patients with and without foot ulceration together with an analysis of outcomes following ulceration. We included 8,989 patients with diabetes attending the Baqai Institute of Diabetology and Endocrinology, a tertiary …

Custom-Made Orthesis and Shoes in a Structured Follow-Up Program Reduces the Incidence of Neuropathic Ulcers in High-Risk Diabetic Foot Patients

The objective of this study was to assess the impact of a structured follow-up program on the incidence of diabetic foot ulceration (DFU) in high-risk diabetic patients. A total of 1874 diabetic patients referred to the Diabetic Foot Unit of the University of Pisa were ranked based on the ulcerative risk score proposed by the International Consensus on Diabetic Foot. Out of 334 patients (17.8%) with a score ≥2, 298 accepted to participate in this prospective trial and were randomized into 2 groups: group A, which received standard treatment, and group B, in which the patients received, as a part of a structured prevention program, custom-made orthesis and shoes. Incidence of new DFUs was observed for no less than 1 year and in a subset of patients after 3 and 5 years, respectively. Incidence of new DFUs and recurrences were considered as primary endpoints to establish the effectiveness of the program; costs were also compared. Among the patients enrolled in this follow-up analysis, 46% had neuropathy and deformities, 20% had previous ulceration, 25% had previous minor amputation, and 9% had neuro-osteoarthropathy. During the first 12-month follow-up, 11.5% of patients in group B developed a DFU compared with 38.6% in group A (P < .0001). In the extended follow-up, the cumulative incidence of ulcer in group B compared with group A was 17.6% versus 61% (P < .0001) after 3 years and 23.5% versus 72% (P < .0001) after 5 years, respectively. The net balance at the end of the follow-up was highly in favor of the prevention program, with a saving of more than €100 000 per year. The implementation of a structured follow-up with the use of orthesis and shoes can reduce the incidence of DFU in diabetic patients who are at high ulcerative risk and its related costs.

Altered Molecular Mechanisms of Diabetic Foot Ulcers

The continuously increasing worldwide prevalence of diabetes will be accompanied by a greater incidence of diabetic foot ulcer, a complication in which many of the morphological processes involved in normal wound healing are disrupted. The highly complex and integrated process of wound healing is regulated by a large array of molecular factors. These often have overlapping functions, ensuring a certain degree of tolerance through redundancy. In diabetes, changes to the expression of a large number of molecular factors have been observed, overwhelming this inbuilt redundancy. This results in delayed healing or incomplete healing as in ulceration. Understanding the relationship between altered levels of molecular factors and the inhibited healing process in such ulcers will permit the development of targeted treatments aimed to greatly improve the quality of life of patients, at the same time helping to reduce the huge costs associated with treating this diabetic condition and its long-term consequences. This short review examines how changes in the expression of molecular factors are related to altered morphology in diabetic foot ulceration and very briefly considers treatment strategies at molecular level.

Conquer chronic wounds with wound bed preparation.

In Brief Acute wound healing follows an orderly sequence of biologic events requiring little intervention from the primary care provider. Chronic wounds fail to follow this progression and require wound bed preparation for healing. To manage chronic wounds, clinicians must understand and apply the biology of chronic wound healing. This article provides an evidence-based approach to guide clinicians in prescribing interventions to minimize, eliminate, or balance factors known to impair wound healing. Chronic wounds are an important health care problem. As more Americans are diagnosed with diabetes mellitus, the incidence of diabetic foot ulcers and nontraumatic lower-limb amputations will undoubtedly increase. The financial and emotional costs of chronic wounds are staggering.

The diabetic foot.

A comprehensive program focused on foot-specific patient education, skin and nail care, and protective footwear lowers the incidence of diabetic foot ulcers and lower extremity amputations. Orthopedic or podiatric consultations are warranted for those "at risk" or with foot ulcers.

Problem of amputations in patients with newly diagnosed diabetes mellitus

A reduction of 50 % or more in diabetes-related amputations is a primary target of the St Vincent Declaration. This is thought to be achievable because both primary and secondary preventative healthcare strategies are effective in reducing the incidence of diabetic foot ulceration and progression to amputation. Unfortunately there is a group who cannot benefit from preventative health care, that is, newly diagnosed diabetic patients with already established severe complications. Using our population-based district diabetes information system we investigated, during the period 1 January 1992 to 31 December 96, the incidence and prevalence of lower extremity amputations (LEAs) and the proportion occurring in patients newly or recently diagnosed as having diabetes. Seventy-nine diabetic patients (59 male, 20 female) were recorded as having had 94 LEAs, the incidence of diabetes-related LEA being 475 per 100 000 diabetic patient-years. Of these LEAs 16 (20.2 %) were performed within 1 year of diabetes being diagnosed. This study highlights an appreciable and previously unrecognized problem: patients presenting with established complications of diabetes who cannot benefit from secondary preventative healthcare. These patients pose a potential obstacle to achieving targets for reductions in diabetes-related amputations. © 1998 John Wiley & Sons, Ltd.

Problem of amputations in patients with newly diagnosed diabetes mellitus.

A reduction of 50% or more in diabetes-related amputations is a primary target of the St Vincent Declaration. This is thought to be achievable because both primary and secondary preventative healthcare strategies are effective in reducing the incidence of diabetic foot ulceration and progression to amputation. Unfortunately there is a group who cannot benefit from preventative health care, that is, newly diagnosed diabetic patients with already established severe complications. Using our population-based district diabetes information system we investigated, during the period 1 January 1992 to 31 December 96, the incidence and prevalence of lower extremity amputations (LEAs) and the proportion occurring in patients newly or recently diagnosed as having diabetes. Seventy-nine diabetic patients (59 male, 20 female) were recorded as having had 94 LEAs, the incidence of diabetes-related LEA being 475 per 100,000 diabetic patient-years. Of these LEAs 16 (20.2%) were performed within 1 year of diabetes being diagnosed. This study highlights an appreciable and previously unrecognized problem: patients presenting with established complications of diabetes who cannot benefit from secondary preventative healthcare. These patients pose a potential obstacle to achieving targets for reductions in diabetes-related amputations.

Diabetes mellitus. Prevention of amputation

Fifteen percent of individuals with diabetes will likely develop foot ulcers in their lifetime, and approximately 15% to 20% of these ulcers are estimated to result in lower extremity amputation. Techniques to prevent lower extremity amputation range from the simple but often neglected foot inspection to complicated vascular and reconstructive foot surgery. Appropriate management can prevent and heal diabetic foot ulcers, thereby greatly decreasing the amputation rate and medical care costs. Prevention is the key to treatment. The author discusses general guidelines for foot screening and identifies three specific goals for prevention of amputation: 1) identification of at risk individuals needing prevention and the specific factors placing them at risk; 2) protection of the foot against the adverse effects of external forces (pressure, friction, and shear); and 3) reduction of the incidence of diabetic foot ulcers through educational programs.

The Diabetic Foot

Diabetic foot lesions most commonly result from a combination of neuropathy and vascular disease in the lower extremity, and may be the presenting feature of diabetes in the older patient. Insufficient attention previously has been given to the careful clinical assessment of the foot, which enables the physician to recognize those patients who are at particular risk of ulceration. The high-risk patient requires education and frequent follow up to reduce the risk of lesions developing. If ulceration develops, healing is likely to occur if the vascular supply is adequate, infection and the blood glucose are controlled, and pressures that may have caused the ulcer are relieved. The ischemic foot requires full vascular assessment, involving colleagues from vascular surgery. The key to a future reduction in the incidence of diabetic foot ulceration is the setting up of a foot care team in which the skills of nurses, podiatrists, orthotists, physicians, and surgeons are combined. The most important members of the team, however, are the patients, who must be convinced that regular foot care will reduce their chances of developing ulceration and other catastrophic consequences, such as amputation.