Outcome Of Diabetic Foot Ulcers Research Articles

Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital.

To determine major risk factors and management outcome of diabetic foot ulcers in order to prevent amputation. Cross-sectional descriptive study. Study was conducted at the Department of Medicine, Civil Hospital Karachi, from January 2005 to December 2006. One-hundred and sixteen consecutive diabetic patients, with foot ulcers of Wagner's grade 1 to 4 were assessed at baseline for demographic information, detailed history, neuropathy, peripheral pulses and frequency of diabetic complication. Glycemic control was determined on the basis of HbA1c levels. Appropriate medical and surgical treatments were carried out and patients were followed-up until healing or for 6 months as end point of study. Outcome was recorded as healed, incomplete healing and amputated. A majority of subjects had type 2 diabetes (95.7%) with male predominance (66%). The mean age was 54.29 +/- 7.71 years. Most of the patients were overweight, hyperglycemic and had diabetes > 10 years duration. Neuropathic ulcers were found in 91 (78.4%) patients, while rest of the 25 (22.6 %) had neuroischemic ulcers. Wound cultures revealed polymicrobial organisms. Foot ulcers of 89 (77.7%) patients healed without amputation and 17 (14.7%) patients had minor or major amputations. Long-duration of diabetes, poor glycemic control and type of foot ulcers had effect on prognosis (p<0.05). Effective glycemic control, optimal wound care, aggressive medical management and timely surgical intervention may decrease disabling morbidity with better outcome of diabetic foot ulcer.

Clinical outcome of diabetic foot ulcers treated with negative pressure wound therapy and the transition from acute care to home care

Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality-of-life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high-risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.

Use of the SINBAD Classification System and Score in Comparing Outcome of Foot Ulcer Management on Three Continents

To compare populations with and outcomes of diabetic foot ulcers managed in the U.K., Germany, Tanzania, and Pakistan and to explore the use of a new score of ulcer type in comparing outcomes among different countries. Data from a series of 449 patients with diabetic foot ulcers managed in the U.K. were used to evaluate the new simplified system of classification and to derive an aggregate score. The use of the score was then explored using data from series managed in Germany (n = 239), Tanzania (n = 479), and Pakistan (n = 173). A highly significant difference was found in time to healing between ulcers of increasing score in the U.K. series (Kruskal-Wallis test; P = 0). When data from all centers were examined, a step-up in days to healing was noted for those with scores of >or=3 (out of 6). Examination of baseline variables contributing to outcome revealed the following differences among centers: ischemia, ulcer area, and depth contributing to outcome in the U.K.; ischemia, area, depth, and infection in Germany; depth, infection, and neuropathy in Tanzania; and depth alone in Pakistan. Any system of classification designed for general implementation must encompass all the variables that contribute to outcome in different communities. Adoption of a simple score based on these variables, the Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) score, may prove useful in predicting ulcer outcome and enabling comparison among different centers.

The foot in perspective

The diabetic foot constitutes a tremendous challenge for patients, caregivers and the health care system. The International Consensus Document of 1999 was a milestone in the recognition of the importance and consequences of the diabetic foot. Since then, many original papers have been published in this area. Large cohort studies have given us a deeper understanding regarding factors related to the outcome of diabetic foot ulcers: according to these studies, the severity of diabetic foot ulcers is greater than previously reported. More than 50% of individuals' foot ulcers have signs of infection at admission, and one-third have signs of both peripheral artery disease (PAD) and infection. The co-morbidities increase significantly with increasing severity of the foot disease. However, the trend in all these studies is a successive improvement in healing rate (50-60% at 20 weeks follow-up, > 75% at 1 year). It is important to differentiate between neuropathic and neuro-ischaemic ulcers with regard to factors related to outcome and co-morbidities.Recent research has emphasized the importance of psychological factors in the development and outcome of diabetic foot ulcers. Studies have shown that perceptions of the individual's own risks based on symptoms, and their own beliefs in the efficacy of self-care, can affect foot-care practice.The importance and influence of the health care organization and reimbursement should not be underestimated, both in the prevention and management of diabetic foot lesions. The diabetic foot should be considered a lifelong condition, as having had one ulcer dramatically increases the risk of developing a new ulcer. In an individual with diabetes and a foot ulcer, the ulcer should be considered as a sign of multi-organ disease, and a holistic approach to both management and prevention is recommended.

Risk Factors for Recurrent Diabetic Foot Ulcers

The rate of recurrent ulceration in diabetic patients with a history of foot complications is high (1–6). The purpose of this study was to evaluate the outcome of diabetic foot ulcers and to study the risk factors for recurrent foot ulcers in a high-risk setting such as a specialized tertiary diabetic foot center. The study was set up as a prospective cohort study to evaluate risk factors for secondary diabetic foot ulcers. At enrollment, 81 subjects presented with an ulcer distal to the ankle and were sequentially enrolled from a high-risk foot clinic at an urban teaching institution. Patients without follow-up visit at the diabetic foot clinic were excluded from the study. All patients were assessed at the foot clinic at intervals necessary for either treatment or for regular care according to international standards (7). Part of the data of this cohort of patients has been previously published (8). Tactile, vibratory nerve function, three-step mean plantar pressure, range of motion, and multiple vascular parameters were assessed using previously described techniques (1,9–11). Plantar peak pressures >70 N/cm2 were defined as elevated (1,3,8,12–15). The presence of risk factors in the group of patients that developed an ulcer in the follow-up period was compared with the presence of these factors in the group of patients without a …

Guidelines for the treatment of arterial insufficiency ulcers

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

The correlation between asthma control and health status: the GOAL study

The present study examined the association between guideline-derived asthma control and health-related quality of life, assessed using the Asthma Quality of Life Questionnaire (AQLQ), in patients with uncontrolled asthma whose treatment was directed towards achieving the highest possible level of control. The present randomised, double-blind, parallel-group study compared the efficacy of fluticasone propionate (FP) and salmeterol/fluticasone propionate combination (SFC) in achieving two composite, guideline-derived measures of control: total control (TC) and well-controlled (WC) asthma. Not achieving these levels was classed as not well-controlled (NWC). Doses were augmented until patients achieved TC or reached the maximum dose. This dose was maintained for the remainder of the study. AQLQ was assessed at baseline and at each clinic visit. AQLQ scores improved throughout the study, reaching near-maximal levels in patients achieving TC and WC, and 52-week mean scores in the three control groups were statistically significantly different. Clinically meaningful improvements (mean change from baseline) were: TC group (SFC 1.9, FP 1.8), WC (SFC 1.5, FP 1.5) and NWC (SFC 1.0, FP 0.9). In conclusion, the treatment aimed at controlling asthma improves the health-related quality of life to levels approaching normal. The difference in Asthma Quality of Life Questionnaire scores between total control and well-controlled confirms that patients distinguish even between these high levels of control.

The DEPA scoring system and its correlation with the healing rate of diabetic foot ulcers

The purpose of this study was to examine the validity of a new scoring system in predicting the outcome of diabetic foot ulcers. The scoring system (DEPA score) includes the depth of the ulcer (D), the extent of bacterial colonization (E), the phase of ulcer healing (P) and the associated underlying etiology (A). The scoring system was validated against the clinical outcome in terms of healing and lower-limb amputations. Eighty-four patients were included in the study: 32 patients had a DEPA score of ≤6, 34 patients had a DEPA score of 7 to 9, and 18 patients had a DEPA score of ≥10. Using the Spearman nonparametric correlation test, DEPA scoring system was accurate in predicting the outcome of management (correlation coefficient, 0.78; 95% confidence interval, 0.68 to 0.86; P < .0001) at a mean follow-up of 20 weeks. The correlation was further validated by using a linear regression model ( r = 0.85; slope best-fit value, 0.51; 95% confidence interval, 0.41 to 0.59; P < .0001). All patients with DEPA scores ≤6 had excellent healing, whereas only 15% of those with a score of ≥10 had complete healing in <20 weeks. In conclusion, an increasing DEPA score is associated with increased risk of amputation and poor healing. Furthermore, inclusion of the phase of ulcer healing into the DEPA system increases the accuracy of predicting the outcome of diabetic foot ulcers.

Diabetic holiday foot syndrome – the dimension of the problem and patients' characteristics

AbstractFrequency, course and outcome of diabetic foot ulcers originating during foreign holidays, known as the recently described ‘diabetic holiday foot syndrome’, was investigated during an ongoing prospective study.Among 435 study patients, 17 (3.9%) experienced their foot lesions during a foreign holiday. Unaccustomed exercise and barefoot walking on the beach were the predominant causative events leading to the observed lesions. Patients suffering from the described condition were of younger age and had shorter known diabetes duration than patients with foot lesions of other origin. There was also a higher proportion of male patients, a lower prevalence of ischemic lesions, and a shorter delay of presentation to the foot clinic among the ‘holiday foot’ group. Severity of the lesions at presentation (Wagner classification) and frequency of unavoidable amputation were comparable for patients in both groups.Our results demonstrate the need for including preventative considerations during holiday travels and unaccustomed exercise in intensified education for diabetic patients at high risk for foot lesions. Copyright © 2001 John Wiley &amp; Sons, Ltd.

Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers.

The present study was undertaken to compare the predictive values of transcutaneous oxygen tension (TcPO2) and toe blood pressure (TBP) measurements for ulcer healing in patients with diabetes and chronic foot ulcers. Investigated prospectively were 50 diabetic patients (37 men) with chronic foot ulcers. The age was 61 +/- 12 (mean +/- SD), and the diabetes duration was 26 +/- 14 years. TBP (mmHg) was measured in dig I and TcPO2 (mmHg) at the dorsum of the foot. Ulcer healing was continuously evaluated by measuring the ulcer area every 4-6 weeks. After a follow-up time of 12 months, the patients were divided into three groups according to clinical outcome: healed with intact skin, improved ulcer healing, or impaired ulcer healing. Of the 13 patients who deteriorated, 11 had TcPO2 < 25 mmHg, while 34 of the 37 patients who improved had TcPO2 > or = 25 mmHg. The sensitivity and specificity for TcPO2 were 85 and 92%, respectively, when a cutoff level of 25 mmHg was used for determination of outcome of ulcer healing (healing or nonhealing). The corresponding values for TBP at 30 mmHg were 15 and 97%. Measurement of TcPO2 provided a higher positive predictive value (79%) than TBP (67%). The results indicate that TcPO2 is a better predictor for ulcer healing than TBP in diabetic patients with chronic foot ulcers, and that the probability of ulcer healing is low when TcPO2 is < 25 mmHg.

Predicting Outcome of Diabetic Foot Ulcer

Which patients with diabetic foot ulcers are destined to have poor outcomes? Duke University researchers prospectively assessed the prognostic value of

The association between clinical risk factors and outcome of diabetic foot ulcers

Objective. The aim of the study was to describe the association between clinical risk factors in diabetic patients with food ulcers in relation to outcome. Design. A prospective study of 314 consecutively presenting diabetic patients with foot ulcers referred to the Department of Internal Medicine between July 1, 1983 and June 30, 1987. All patients were followed to final outcome. Setting. All patients were treated by the same multi-disciplinary foot care team at the Department of Medicine, both as in- and out-patients. Healing was defined as intact skin for at least 6 months. Results. One hundred and ninety-seven patients healed primarily, 77 after amputation, and 40 died unhealed. Signs of macroangiopathy were more common among patients who healed after amputation. The outcome was strongly related to age, though 43% of the patients with an age over 80 years healed primarily. There was no difference in smoking habits between patients who healed primarily and those who required amputation to heal. Diabetic nephropathy was found in 26% of the patients and was strongly associated with amputation. Presence of retinopathy was found in 54% of the patients, but this finding was not related to the outcome. There were no differences in short-term metabolic control as assessed by hemoglobin A 1c levels between patients who healed primarily and those who healed after amputation. Conclusion. The presence of diabetic foot ulcers was strongly associated with age and diabetic complications such as multiple cardiovascular disease and nephropathy, which were important factors related to amputation.

The Importance of Peripheral Pulses, Peripheral Oedema and Local Pain for the Outcome of Diabetic Foot Ulcers

In a prospective study, peripheral pulses, claudication, peripheral oedema, and rest pain were evaluated in 314 sequentially presenting diabetic patients with foot ulcers. In the ulcerated limb pedal pulses were found to be present in 44% of the patients, peripheral oedema in 38%, and rest pain in 19%. Twelve per cent had claudication. Presence of pedal pulses was more common in patients whose ulcers underwent primary healing (56%) than in those who healed after amputation (23%) or died (25%, p less than 0.001). Eighty per cent of the patients with pedal pulses present underwent primary healing. However, 49% of patients with absence of pedal pulses also underwent primary healing and 12 patients developed gangrene despite presence of pedal pulses. Peripheral oedema was more common in patients who required amputation (58%) or died (55%) than in patients with primary healing (26%, p less than 0.001). A tentative predisposing factor was identified in 95% of the patients, the most common factors being neuropathy, congestive heart failure, and previous deep venous thrombosis. Rest pain was more common in patients who required amputation (48%) or died (23%) than in those with primary healing (7%; p less than 0.001). Only 50% of patients with gangrene had rest pain and of these patients, only one underwent primary healing. The presence of pedal pulses, oedema, and rest pain give valuable but imperfect information on the possible primary healing of foot ulcers in diabetic patients.

The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers

The influence of external precipitating factors and the presence of peripheral neuropathy on the development and outcome of foot ulcers were evaluated in 314 consecutive diabetic patients. All patients were treated by the same foot care team. Each patient was represented by one ulcer, and primary healing was defined as intact skin for at least six months. External precipitating factors were identifiable in 264 of 314 patients. The most common factors were ill fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia. The highest primary healing rates were seen in lesions caused by paronychia (84%) and stress ulcer (76%). Clinical signs of sensory and muscular disturbances were seen in the majority of patients (96%). Sensory neuropathy, evaluated with a biothesiometer, was more common among patients who had had amputations or, died subsequently compared to those who healed. This study suggests that a majority of diabetic foot ulcers might have been prevented, since a precipitating external factor was identified in four of five patients, stressing the importance of preventive foot care.

Wound Classification is More Important Than Site of Ulceration in the Outcome of Diabetic Foot Ulcers

The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer.

The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.