Previous Diabetic Foot Ulcers Research Articles

A Review of Foot pressure Measurement of Diabetic and Analysis Patients

Peripheral neuropathy, the main risk factor for diabetic foot ulcers (DFU), causes loss of protective feeling and is linked to very high plantar pressures. The goal of DFU preventive techniques is to lower these elevated plantar pressures. However, there are a number of limitations to the evidence that supports the connection between plantar pressure and DFUs, which could account for the poor prediction accuracy found in prospective studies. Most research measures the vertical, as opposed to the shear, barefoot plantar pressure in lab settings as opposed to in real-world activities. Previous DFU location-specific pressure was not well studied. Prior research has mostly concentrated on walking; however activity tracking studies indicate that more time is spent on other weight-bearing tasks, when a longer duration of lower "peak" plantar pressure may be applied. This suggests that a measure of the cumulative pressure applied over time might be more pertinent than peak pressure, however more investigation is required. Further research is needed, however studies have shown that delivering pressure feedback may lessen plantar pressures. This is an emerging potential use of smart technology. To increase our knowledge of the pressures that lead to DFUs and the efficacy of therapies, more pressure assessments pertaining to location-specific pressures pertaining to all weight-bearing activities are needed.

Analysing patient factors and treatment impact on diabetic foot ulcers in South Africa

In the South African public healthcare sector, 28% of diabetic patients present to primary healthcare clinics with diabetic foot ulcers (DFUs), often presenting in advanced stages of ulcer severity. In this study, we aimed to categorise factors predisposing individuals to developing a DFU and to identify the potential shortcomings in existing treatment plans in the South African healthcare system. In addition, the use of preventative measures in the management of DFUs was examined as well as the influence of past treatment practices. A total minimum sample size of 50 DFUs was required for this study. Participants who were selected for this study had their past records reviewed in order to determine the likelihood of previous DFU infections, as well as to determine the occurrence of co-morbidities. The treatment protocol implemented was recorded. Twelve-month patient records were used to identify the infection frequency and past treatment protocols. A total of 48.9% of patients reported that they did not make use of any preventative measures. The most frequent concurrent medical conditions were hypertension, dyslipidaemia, and peripheral neuropathy. Polypharmacy was prevalent, with 55% of the population prescribed five or more medications. Potential medication interactions were examined and a total of 210 interactions were documented. An analysis of past and current treatment practices revealed that 52.1% of the treatment protocols did not comply with local treatment guidelines. This study highlights the urgent need for updated DFU treatment protocols in relation to the overall management of DFUs, taking into account existing international guidelines.

Prevalence and risk factors of diabetes foot ulcers in Kano, northwestern Nigeria

BackgroundFoot complications account for more hospital admissions than any other diabetes mellitus (DM) complications with adverse outcomes being foot ulcers and amputation.ObjectiveTo determine the prevalence and risk factors of diabetic foot ulcers in Kano, Northwestern Nigeria.MethodsA descriptive cross-sectional study was conducted in the diabetes outpatient clinics and medical and surgical wards of two hospitals in Kano, Nigeria. Data were collected on socio-demographic characteristics, type, and duration of DM. The study subjects were assessed for the presence of and risk factors for foot ulcers.ResultsWe recruited 394 patients with DM (163 males and 231 females) with a mean (SD) age and duration of DM of 50.8 ± 12.5 years and 7.72 ± 6.65 years respectively. Type 2 DM was present in 95% of the study subjects. Diabetic foot ulcer (DFU) was present in 57 (14.5%) of the patients. Risk factors associated with DFU assessed using univariate analysis were older age, longer duration of DM, presence of peripheral neuropathy (PN), peripheral arterial disease (PAD), diabetic retinopathy, nephropathy, foot deformities, previous DFU, and poor glycemic control. The independent determinants of DFU were previous DFU, foot deformities, retinopathy, PN, PAD, and poor glycemic control.ConclusionDFU can be found in our setting and the predominant risk factors for DFU are common and remain unchanged in our environment. This study, therefore, buttresses the effect of early detection and treatment of DM in preventing the complications that arise from the disease.

Exploring barriers and enablers of self-management behaviours in patients with diabetic foot ulcers: A qualitative study from the perceptions of patients, caregivers, and healthcare professionals in primary care.

Exploring barriers and enablers of self-management behaviours in patients with diabetic foot ulcers: A qualitative study from the perceptions of patients, caregivers, and healthcare professionals in primary care.

Examination Findings of Type 2 Diabetes Patients’ Feet with and without Ulcers

Objective: We conducted this study to determine the factors that cause foot ulcers in patients with type 2 diabetes mellitus (DM) with or without diabetic foot ulcer (DFU). Methods: This cross-sectional, descriptive study compared the feet examination results of 43 Type 2 DM patients with or without DFU. The study data were collected using a patient identification form and a diabetic foot examination form. Data are presented as percent, mean, and standard deviation. Chi-square and Fisher’s exact tests were used for statistical analysis. The statistical significance level was taken as p<0.05. Results: Of the patients, 63% were male, 79% were married, their mean age was 63.16±9.43, and the mean diabetes year was 18.44±7.77. 74% of the patients had a previous DFU. Of the existing DFU, 58% were on the right foot, 49% were on the toes, 49% were Wagner grade 2, and 37% were infected. There was edema and warmth in the DFU foot (p<0.05). DFU foot had a weaker sense of touch and vibration than the other. Ankle-Brakial Index was below 0.9. Foot pulses were weak, and there were deformities. Conclusion: Patients with DFU feet have an increased risk of recurrent ulcer formation. These patients should be followed periodically and educated about ulcer formation and signs and symptoms of infection.

Development and validation of a risk prediction model for the recurrence of foot ulcer in type 2 diabetes in China: A longitudinal cohort study based on a systematic review and meta-analysis.

To develop and validate a risk prediction model for Chinese patients with type 2 diabetes with the recurrence of diabetic foot ulcers (DFUs) based on a systematic review and meta-analysis. A prospective analysis was performed with 1333 participants and followed up for 60months. Three models were analysed using a derived cohort. The risk factors were screened using meta-analysis and logistic regression, and the missing variables were interpolated by multiple imputation. The internal validation was performed using the bootstrap procedure, and the validation cohort was applied to the external validation. The performance of the model was evaluated in the area under the discrimination Receiver Operating Characteristic Curve (ROC). Calibration and discrimination methods were used for the validation cohort. The variables were selected according to their clinical and statistical importance to construct the nomograms. Three models were developed and validated. Model 1 included seven social and clinical indicators like sex, diabetes mellitus duration, previous DFU, location of ulcer, smoking, history of amputation, and foot deformity. Model 2 included four more indicators besides those in Model 1, which were statin agents used, antiplatelet agents used, systolic blood pressure, and body mass index. Model 3 added further laboratory indicators to Model 2, such as LDL-C, HbA1C, fibrinogen, and blood urea nitrogen. In the derivation cohort, 20.1% (206/1027) participants with DFU recurred as compared to the validation cohort, which was 38.2% (117/306). The areas under the curve in the derivation cohort for Models 1-3 were 0.781 (0.744-0.817), 0.843 (0.813-0.873), and 0.899 (0.876-0.922), respectively. The Youden indexes for Models 1-3 were 0.430, 0.559, and 0.653, respectively. Model 3 showed the highest sensitivity and specificity. All models performed well for both discrimination and calibration. Models 1-2 were non-invasive, which indicate their role in general screening for patients at a high risk of recurrence of DFU. However, Model 3 offers a more specific screening due to its best performance in predicting the risk of DFU recurrence amongst the three models.

Albuminuric diabetic kidney disease predicts foot ulcers in type 2 diabetes

Diabetic Foot Ulcers (DFU) are feared among individuals with diabetic kidney disease (DKD), but it is unclear whether they are more frequent, especially in normoalbuminuric DKD.Five hundred and twenty patients admitted in our diabetology ward from 2007 to 2017 were followed up during 54 ± 26 months. New DFUs were registered, and their relationship with the initial renal status was analyzed by LogRank and multivariate Cox regression analysis.The 520 subjects were mainly men (57.9 %), 62 ± 9 years old, with a duration of diabetes of 14 ± 10 years, HbA1c: 8.7 ± 1.8 % (72 ± 19 mmol/mol), and complications: 33.7 % macroangiopathies, 22.1 % previous foot ulcers, 44.8 % DKD, 26.9 % retinopathies. Fifty-seven new DFU occurred, mainly in subjects with DKD. DKD was related to later DFU (HR: 1.79; 95%CI: 1.05–3.07), this relationship stayed significant adjusted for age, gender, and a history of previous DFU (HR: 3.61; 95%CI: 2.11–6.18), and further adjusted for the duration of diabetes, HbA1c, BMI, arterial hypertension, and dyslipidemia. Among the 233 subjects with DKD, 129 (55.3 %) had an isolated AER > 30 mg/24H, 41 (17.6 %) had an isolated eGFR<60 mL/min/1.73 m2, and 63 (27.0 %) cumulated both abnormalities. By Cox regression analysis adjusted for age and gender, albuminuric DKDs were related to later DFU: with eGFR≥60: HR: 1.91; 95%CI: 1.02–3.59, with eGFR<60: HR: 2.53; 95%CI: 1.25–5.10, whereas normoalbuminuric DKD was not: HR: 1.04; 95%CI: 0.35–3.07, despite similar rates of neuropathies, peripheral arterial diseases, and retinopathies.In people with type 2 diabetes, albuminuric DKD was associated with two to three folds increased risk of DFUs, whereas normoalbuminuric DKD was not.

Assessment of the Knowledge and Quality of the Practice of Proper Foot Care in Iranian Patients With Type 2 Diabetes

Background: Uncontrolled diabetes can lead to a high rate of complications. Diabetic foot ulcer (DFU) leads to significant morbidity. However, DFU can be prevented and managed through foot care education for patients. Objectives: The current study aimed to evaluate the knowledge and practice routines of patients with type 2 diabetes (T2DM) regarding foot care. Methods: A questionnaire was designed to obtain patients’ demographic data, evaluate their risk for a foot ulcer, and assess their level of knowledge and practice about daily foot care. After confirming the validity and reliability of the questionnaire, 200 T2DM patients were interviewed. Results: The mean age was 61.1±11.7 years, and 64% were males. Forty-five percent of patients were previously educated regarding foot care. More than 50% of patients answered questions correctly. Calculations demonstrated the mean score of knowledge and practice as 6.3±2 (out of 11) and 14.2±3.4 (out of 20), respectively. There was no correlation between the patient’s age, gender, or history of previous DFU and their knowledge and practice level. However, patients’ higher level of education or employment status was associated with a higher level of knowledge and practice than their other respective groups. Conclusion: In this study, patients had a medium to low level of foot care knowledge and a medium to a high level of daily foot care practice. However, these results also emphasize the importance of the need for organized and structured educational programs for diabetic patients regarding diabetic foot care.

IDF21-0223 Diabetic foot ulcers’ impact on survival: an association study using the conditional inference tree approach

Background: Up to a third of people with diabetes worldwide will develop a diabetic foot ulcer (DFU) during their lifetime. DFUs precede 80% of limb amputations (LEA). At five years, mortality after diabetes-related LEA exceeds 70%, and the risk of death for people living with DFU is 2.5 times the risk for those without one. However, risk factors are still not fully understood. Aim: To study the association between DFU and mortality in adults with diabetes adjusted for modifiable and non-modifiable risk factors. Method: Cohort with 595 adults with diabetes who attended a Podiatry appointment at a Portuguese Diabetic Foot Outpatient Clinic, from January 2010 to March 2013, and followed up to 31 December 2020, or death. The conditional inference tree (CIT) was used to identify predictors of mortality. CIT is a nonparametric statistical model used for making classifications or predictions based on tree-structure recursive partitioning. The variables considered were: age, gender, diabetes duration, insulin therapy, glycemic control, living alone, retinopathy, physical impairment, visual impairment, nephropathy, lower limb revascularization, diabetic peripheral neuropathy (DPN), cardiovascular disease, previous DFU, previous LEA, hypolipidemic and anticoagulant agents. All the statistical analyses were carried out using the package partykit, in R software. Results: At baseline, diabetes median duration was 15 (IQ [inter-quartile] range 10-23) years, with the participants' median age of 67.3 (59.2-75.4) years. Participants were mostly male (57.1), with previous DFU (54.4%), with DPN (56.5%) and cardiovascular disease (83.4%); 10.7% had previous LEA, 46.4% had retinopathy, 19.3% nephropathy. During a median follow-up of 8.1 (IQ range 3.9-9.3) years, there were 318 (53.4%) deaths. The predictors of all-cause mortality identified by the CTI were previous DFU, age, and retinopathy. At the end of eight years of follow-up, the estimated survival probability (95% CI [confidence interval]) was 47.5 (35.6-63.4) % for people without a previous DFU, aged older than 65 years, and with retinopathy. For those without retinopathy, it was 73.7 (64.6-84.0) %. For people with a previous DFU and older than 65, the eight-year estimated survival probability was 25.0 (19.6-31.9) %, while for the younger ones, it was 56.9 (48.5-66.6) %. Retinopathy did not impact the survival probability for people with previous DFU. Discussion: In this cohort of adults with diabetes, age, previous DFU, and retinopathy were the risk factors with a significant association with mortality. For participants with previous DFU, the highest mortality was observed for those aged older than 65. However, for adults with no previous DFU, mortality was associated not only with being older than 65 years but also with retinopathy. Retinopathy and DFU, both frequent, preventable and markers of diabetes control, significantly affected survival after adjustment for age.

An intelligent insole system with personalised digital feedback reduces foot pressures during daily life: An 18-month randomised controlled trial

AimsHigh plantar pressure is a major risk factor in the development of diabetic foot ulcers (DFUs) and recent evidence shows plantar pressure feedback reduces DFU recurrence. This study investigated whether continued use of an intelligent insole system by patients at high-risk of DFUs causes a reduction in plantar pressures. MethodsForty-six patients with diabetic peripheral neuropathy and previous DFU were randomised to intervention (IG) or control groups (CG). Patients received an intelligent insole system, consisting of pressure-sensing insoles and digital watch. Patients wore the device during all daily activity for 18-months or until ulceration, and integrated pressure was recorded continuously. The device provided high-pressure feedback to IG only via audio-visual-vibrational alerts. High-pressure parameters at the whole foot, forefoot and rearfoot were compared between groups, with multilevel binary logistic regression analysis. ResultsCG experienced more high-pressure bouts over time than IG across all areas of the foot (P < 0.05). Differences between groups became apparent >16 weeks of wearing the device. ConclusionsContinuous plantar pressure feedback via an intelligent insole system reduces number of bouts of high-pressure in patients at high-risk of DFU. These findings suggest that patients were learning which activities generated high-pressure, and pre-emptively offloading to avoid further alerts.

267-OR: Assessing Patient Knowledge about Diabetic Foot Ulcer Offloading

Introduction: Standard of care for diabetic foot ulcers (DFU) includes wound debridement, dressing changes, diabetes control, and offloading. Despite this, half of all patients fail to heal when standard of care is met. Offloading DFU is critical to promote wound healing, yet patient adherence is undesirably low and contributes to failed wound healing. We evaluated patient knowledge of DFU offloading through a voluntary telephone survey. Methods: Participants were recruited from a tertiary care center podiatry department and completed a 21-item telephone survey. All subjects had a history of diabetes and were included regardless of DFU history. Descriptive statistics and chi square were calculated to evaluate survey responses. Results: Currently 92 of 167 subjects (55.1%) completed the telephone survey. All subjects regardless of DFU history correctly identified DFU increases risk of amputation (DFU95.7%; n=88/92). All subjects regardless of DFU history identified “offloading” and “pressure relief” as important factors to improve DFU healing (97.8%; n=90/92; 98.9%; n=91/92, respectively). Only a minority (43.5%; n=40/92) of participants were able to correctly identify the best offloading strategy, regardless of DFU history (DFU history 48.5%; n=16/33 vs. No DFU history 40.7%; n=24/59; p=0.5155). Discussion: We hypothesized people with a history of a DFU would understand the concept of offloading better, but yet patients who had a history of a DFU were as likely to misunderstand the term “offloading” compared to patients who have no history of a previous DFU. Our findings importantly identify a gap in patient education surrounding an essential component of DFU standard of care. Disclosure R. A. Burmeister: None. C. Holmes: None. C. Jarocki: None. T. Strom: None. G. M. Torrence: Research Support; Self; Kent Imaging. B. M. Schmidt: None.

Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: A randomized controlled trial.

Background: Novel approaches to reduce diabetic foot ulcers (DFU) in low- and middle-income countries are needed. Our objective was to compare incidence of DFUs in the thermometry plus mobile health (mHealth) reminders (intervention) vs. thermometry-only (control). Methods: We conducted a randomized trial enrolling adults with type 2 diabetes mellitus at risk of foot ulcers (risk groups 2 or 3) but without foot ulcers at the time of recruitment, and allocating them to control (instruction to use a liquid crystal-based foot thermometer daily) or intervention (same instruction supplemented with text and voice messages with reminders to use the device and messages to promote foot care) groups, and followed for 18 months. The primary outcome was time to occurrence of DFU. A process evaluation was also conducted. Results: A total of 172 patients (63% women, mean age 61 years) were enrolled; 86 to each study group. More patients enrolled in the intervention arm had a history of previous DFU (66% vs. 48%). Follow-up for the primary endpoint was complete for 158 of 172 participants (92%). Adherence to ≥80% of daily temperature measurements was 87% (103 of 118) among the study participants who returned the logbook. DFU cumulative incidence was 24% (19 of 79) in the intervention arm and 11% (9 of 79) in the control arm. After adjusting for history of foot ulceration and study site, the hazard ratio (HR) for DFU was 1.44 (95% CI 0.65, 3.22). Conclusions: In our study, conducted in a low-income setting, the addition of mHealth to foot thermometry was not effective in reducing foot ulceration. Importantly, there was a higher rate of previous DFU in the intervention group, the adherence to thermometry was high, and the expected rates of DFU used in our sample size calculations were not met. Trial registration: ClinicalTrials.gov NCT02373592 (27/02/2015).

Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: A randomized controlled trial

Background: Novel approaches to reduce diabetic foot ulcers (DFU) in low- and middle-income countries are needed. Our objective was to compare incidence of DFUs in the thermometry plus mobile health (mHealth) reminders (intervention) vs. thermometry-only (control). Methods: We conducted a randomized trial enrolling adults with type 2 diabetes mellitus at risk of foot ulcers (risk groups 2 or 3) but without foot ulcers at the time of recruitment, and allocating them to control (instruction to use a liquid crystal-based foot thermometer daily) or intervention (same instruction supplemented with text and voice messages with reminders to use the device and messages to promote foot care) groups, and followed for 18 months. The primary outcome was time to occurrence of DFU. A process evaluation was also conducted. Results: A total of 172 patients (63% women, mean age 61 years) were enrolled; 86 to each study group. More patients enrolled in the intervention arm had a history of previous DFU (66% vs. 48%). Follow-up for the primary endpoint was complete for 158 of 172 participants (92%). Adherence to ≥80% of daily temperature measurements was 87% (103 of 118) among the study participants who returned the logbook. DFU cumulative incidence was 24% (19 of 79) in the intervention arm and 11% (9 of 79) in the control arm. After adjusting for history of foot ulceration and study site, the hazard ratio (HR) for DFU was 1.44 (95% CI 0.65, 3.22). Conclusions: In our study, conducted in a low-income setting, the addition of mHealth to foot thermometry was not effective in reducing foot ulceration. Importantly, there was a higher rate of previous DFU in the intervention group, the adherence to thermometry was high, and the expected rates of DFU used in our sample size calculations were not met. Trial registration: ClinicalTrials.gov NCT02373592 (27/02/2015)

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review.

The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory‐based environments, rather than during daily activity. Few studies investigated previous DFU location‐specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight‐bearing activities, where a lower “peak” plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight‐bearing activities, referring to location‐specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.

640-P: Willingness to Adopt Devices for Prevention of Foot Ulcers in High-Risk Diabetic Patients

The objective was to evaluate whether high risk diabetic patients are willing to implement wearable technology to prevent diabetic foot ulcer (DFU) formation. There is increasing evidence that self-monitoring devices for DFU prevention may be effective. However, there is a paucity of literature assessing the willingness of patients to employ these technologies for DFU prevention. We analyzed patient interest around advancing wearable technology through an anonymous, voluntary survey. Adult diabetic patients 18 years or older with a history of peripheral neuropathy, foot deformity, and those with and without DFU who presented to a tertiary care center were included. Surveys were performed consecutively. Descriptive statistics were calculated to describe survey responses. We used a combination of t-tests and chi-square tests to compare the responses of diabetic patients with and without DFUs. One hundred and forty-nine patients met the inclusion criteria for this study. One hundred patients completed the questionnaire, a response rate of 67%. Fifty-four patients had a history of a previous DFU, while 46 patients had no history of previous ulceration. Patients with no history of a prior DFU were significantly more interested in preventing foot ulcers (p=0.003) when compared to those with a prior history of a DFU. Patients without a history of ulcer formation were significantly more likely to obtain a self-monitoring device compared to patients with a prior history of a DFU (86.97% v 68.52%, p=0.02) Our results suggest that diabetic patients with no history of a prior DFU are more motivated to prevent foot ulcers and more likely to adopt technologies. However, since home-monitoring devices are most efficacious in those with a history of a previous foot ulcer, providers should develop strategies to better educate these high-risk patients. Our findings strongly support that inclusion of advancing self-monitoring technology in the management of diabetic foot ulcer prevention is warranted. Disclosure T. Novice: None. C. Vemuri: Consultant; Self; Cook Medical. C. Gilbert: None. A.J. Fici: None. E.F. Vanwieren: None. B.M. Schmidt: None.

Incidence and risk factors for developing infection in patients presenting with uninfected diabetic foot ulcers.

ObjectiveThere is a paucity of research on patients presenting with uninfected diabetic foot ulcers (DFU) that go on to develop infection. We aimed to investigate the incidence and risk factors for developing infection in a large regional cohort of patients presenting with uninfected DFUs.MethodsWe performed a secondary analysis of data collected from a validated prospective state-wide clinical diabetic foot database in Queensland (Australia). Patients presenting for their first visit with an uninfected DFU to a Diabetic Foot Service in one of thirteen Queensland regions between January 2012 and December 2013 were included. Socio-demographic, medical history, foot disease history, DFU characteristics and treatment variables were captured at the first visit. Patients were followed until their DFU healed, or if their DFU did not heal for 12-months, to determine if they developed a foot infection in that period.ResultsOverall, 853 patients were included; mean(standard deviation) age 62.9(12.8) years, 68.0% male, 90.9% type 2 diabetes, 13.6% indigenous Australians. Foot infection developed in 342 patients for an overall incidence of 40.1%; 32.4% incidence in DFUs healed <3 months, 55.9% in DFUs healed between 3–12 months (p<0.05). Independent risk factors (Odds Ratio (95% confidence interval)) for developing infection were: DFUs healed between 3–12 months (2.3 (1.6–3.3)), deep DFUs (2.2 (1.2–3.9)), peripheral neuropathy (1.8 (1.1–2.9)), previous DFU history (1.7 (1.2–2.4)), foot deformity (1.4 (1.0–2.0)), female gender (1.5 (1.1–2.1)) and years of age (0.98 (0.97–0.99)) (all p<0.05).ConclusionsA considerable proportion of patients presenting with an uninfected DFU will develop an infection prior to healing. To prevent infection clinicians treating patients with uninfected DFUs should be particularly vigilant with those presenting with deep DFUs, previous DFU history, peripheral neuropathy, foot deformity, younger age, female gender and DFUs that have not healed by 3 months after presentation.

A model to estimate cost-savings in diabetic foot ulcer prevention efforts

BackgroundSustained efforts at preventing diabetic foot ulcers (DFUs) and subsequent leg amputations are sporadic in most health care systems despite the high costs associated with such complications. We sought to estimate effectiveness targets at which cost-savings (i.e. improved health outcomes at decreased total costs) might occur. MethodsA Markov model with probabilistic sensitivity analyses was used to simulate the five-year survival, incidence of foot complications, and total health care costs in a hypothetical population of 100,000 people with diabetes. Clinical event and cost estimates were obtained from previously-published trials and studies. A population without previous DFU but with 17% neuropathy and 11% peripheral artery disease (PAD) prevalence was assumed. Primary prevention (PP) was defined as reducing initial DFU incidence. ResultsPP was more than 90% likely to provide cost-savings when annual prevention costs are less than $50/person and/or annual DFU incidence is reduced by at least 25%. Efforts directed at patients with diabetes who were at moderate or high risk for DFUs were very likely to provide cost-savings if DFU incidence was decreased by at least 10% and/or the cost was less than $150 per person per year. ConclusionsLow-cost DFU primary prevention efforts producing even small decreases in DFU incidence may provide the best opportunity for cost-savings, especially if focused on patients with neuropathy and/or PAD. Mobile phone-based reminders, self-identification of risk factors (ex. Ipswich touch test), and written brochures may be among such low-cost interventions that should be investigated for cost-savings potential.

The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk

AimsTo estimate 3-year risk for diabetic foot ulcer (DFU), lower extremity amputation (LEA) and death; determine predictive variables and assess derived models accuracy. Material and MethodsRetrospective cohort study including all subjects with diabetes enrolled in our diabetic foot outpatient clinic from beginning 2002 until middle 2010. Data were collected from clinical records. Results644 subjects with mean age of 65.1 (±11.2) and diabetes duration of 16.1 (±10.8) years. Cumulative incidence was 26.6% for DFU, 5.8% for LEA and 14.0% for death. In multivariate analysis, physical impairment, peripheral arterial disease complication history, complication count and previous DFU were associated with DFU; complication count, foot pulses and previous DFU with LEA and age, complication count and previous DFU with death. Predictive models’ areas under the ROC curves ranged from 0.80 to 0.83. A simplified model including previous DFU and complication count presented high accuracy. Previous DFU was associated with all outcomes, even when adjusted for complication count, in addition to more complex models. ConclusionsDFU seems more than a marker of complication status, having independent impact on LEA and mortality risk. Proposed models may be applicable in healthcare settings to identify patients at higher risk of DFU, LEA and death.

Validation and comparison of currently available stratification systems for patients with diabetes by risk of foot ulcer development

There are five systems to stratify the risk for the development of a diabetic foot ulcer (DFU). This study aimed to prospectively validate all of them in the same cohort of participants to allow their direct comparison. A retrospective cohort study was conducted on all patients with diabetes but without an active DFU attending our podiatry section (n=364) from January 2008 to December 2010. Participants' characteristics and all variables composing the stratification systems were assessed at baseline. Follow-up was performed for 1 year or until DFU occurred. Participants had a mean age of 64 years; 99.7% had type 2 diabetes and 48.6% were male. Median follow-up was 12 months (1-12) during which 33 subjects (9.1%) developed a DFU. Age, diabetes duration, foot deformity, peripheral vascular disease, diabetic peripheral neuropathy, previous DFU, and previous lower extremity amputation were associated with DFU occurrence. All systems presented greater DFU occurrence frequency as the risk group was higher (χ(2), P<0.001) and showed good diagnostic accuracy values, especially negative predictive value (≥ 95%) and area under the receiver operating curve (≥ 0.73). The lowest performance concerned positive predictive value (≤ 29.5%). All the currently available stratification systems show high accuracy to detect which patients will develop a DFU with no significant differences among them. Therefore, for diabetic foot screening and resource allocation, it would be desirable to have a single unified system, combining the available systems, prospectively validated in a multicenter context and testing the inclusion of novel predictive variables' pertinence.