Risk Of Diabetic Foot Ulcers Research Articles

Psychosocial research in the diabetic foot: Are we making progress?

This review summarizes recent advances regarding the role of psychological factors in people with a diabetic foot ulcer (DFU). It describes the detrimental effects of diabeticfoot complications and in particular, Charcot Neuroarthropathy (CN), on health status and quality of life (QoL) and emphasizes the importance of utilizing DFU-specific assessment tools. Diabetic neuropathy (DN)-related postural instability is key in generating depression in high DFU risk patients and in predicting offloading non-adherence those with active DFUs. Patients' views of their own DFU risk are largely inconsistent with biomedical models, resulting in a lack of preventive foot self-care. Furthermore, DFUs are a source of specific emotional responses, with fear of amputation predominant. While fear of amputation is associated with better preventive foot self-care, it appears to be linked to DFU non-healing, though mechanisms are yet to be elucidated. Until now, systemically released stress hormones were recognized as the only biological mechanism through which psychological stress influences healing. Recently, the skin has been found to be an extra-adrenal site for glucocorticoid synthesis with local, tissue-specific cortisol implicated in DFU non-healing. These observations could potentially lead to future targets for therapeutic and psychological interventions.

Frequency of Diabetes Foot Ulcer and Related Factors Among Adult Diabetic Patients in the Diabetes Center of Kerman, Iran

Background: Diabetic Foot Ulcer (DFU) as one of the main complications of diabetes mellitus has serious outcomes such as infection, foot amputation, low quality of life, and premature death. Objectives: This study was conducted to assess the DFU prevalence and its related factors among diabetic patients. Methods: The population of this cross-sectional study included adult diabetic patients in the Diabetes Center of Kerman University of Medical Sciences. The data were recorded in a questionnaire using patients’ medical records, interviews with them, and physical examination. The collected data were imported to SPSS version 22 software and analyzed. Results: Of 400 diabetic patients enrolled in the study, 69% (n = 276) were female. The mean (± SD) of their age was 57.1 (± 11.9) years and 72% (n = 288) were younger than 65. The frequency of DFU during the total course of the disease and its annual prevalence were 17.3% (n = 69) and 11.8% (n = 49) among diabetic patients, respectively. More than one-third (37.7%) of the DFU patients and 6.6% of all the patients were admitted to a hospital due to DFU. Major or minor amputation was performed for 14.5% (n = 10) of the total DFU patients and 2.5% of the total patients. Having diabetes-related complications was determined as the strongest predictor of DFU (OR = 7.016, 95% CI = 2.67 - 18.38), followed by smoking (OR = 3. 80, 95% CI = 2.06 - 6.99) and age over 64 years (OR = 3.70, 95% CI = 1.299 - 10.568). Conclusions: The frequency of DFU was high among diabetic patients attending the Diabetes Center of Kerman University of Medical Sciences. Also, hospital admission and foot amputation due to DFU had a considerable frequency. Therefore, there is a crucial need to improve the quality of foot care services and emphasize foot self-care as essential components of diabetes self-management at all levels of the health service delivery system to decrease the risk of DFU.

Treatment of lower limb ischaemia in patients with diabetes.

Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.

Prediction of Diabetic Foot Ulceration: The Value of Using Microclimate Sensor Arrays.

Accurately predicting the risk of diabetic foot ulceration (DFU) could dramatically reduce the enormous burden of chronic wound management and amputation. Yet, the current prognostic models are unable to precisely predict DFU events. Typically, efforts have focused on individual factors like temperature, pressure, or shear rather than the overall foot microclimate. A systematic review was conducted by searching PubMed reports with no restrictions on start date covering the literature published until February 20, 2019 using relevant keywords, including temperature, pressure, shear, and relative humidity. We review the use of these variables as predictors of DFU, highlighting gaps in our current understanding and suggesting which specific features should be combined to develop a real-time microclimate prognostic model. The current prognostic models rely either solely on contralateral temperature, pressure, or shear measurement; these parameters, however, rarely reach 50% specificity in relation to DFU. There is also considerable variation in methodological investigation, anatomical sensor configuration, and resting time prior to temperature measurements (5-20 minutes). Few studies have considered relative humidity and mean skin resistance. Very limited evidence supports the use of single clinical parameters in predicting the risk of DFU. We suggest that the microclimate as a whole should be considered to predict DFU more effectively and suggest nine specific features which appear to be implicated for further investigation. Technology supports real-time in-shoe data collection and wireless transmission, providing a potentially rich source of data to better predict the risk of DFU.

Development and evaluation educational videos of diabetic foot care in traditional languages to enhance knowledge of patients diagnosed with diabetes and risk for diabetic foot ulcers

AimThis study aimed to develop an educational video for diabetic foot care in the traditional languages (Buginese and Makassarese) and evaluate the change in the patients’ knowledge level after they viewed the video. MethodsThe study was performed in the following three phases: development of the video content using a Delphi Study that involved wound-care nurses, evaluation of the video’s content validity by the expert panel, and evaluation of the video in the community setting by showing it to patients who spoke the traditional languages, were diagnosed with diabetes mellitus (DM), and were at risk of diabetic foot ulcers (DFU). ResultsFive themes emerged from the Delphi study, including observation of pre-ulcer signs, washing feet, cutting toenails, wearing socks, and checking footwear. Content validity evaluation recommended these items to be constructed for video education using the traditional languages. Evaluation in the community setting confirmed that there was a significant improvement (p = 0.001) in the knowledge about foot care among patients diagnosed with diabetes and at risk of DFU. ConclusionThis study produced an educational video that used the trans-cultural approach by using traditional languages to overcome the communication barrier in the process of knowledge transfer. We found that the educational video in traditional languages enhanced the patients’ knowledge about diabetic foot care and thus could enable them to detect the risks for DFU and prevent DFU.

Research progress on hierarchical management of diabetes

In the past 40 years, the prevalence of diabetes in China has been increasing year by year. The prevention and treatment of diabetes were very arduous. Hierarchical management is not only a major mode of chronic disease management in China, but also a research trend in recent years. The study reviewed the status of hierarchical management of diabetes including tertiary prevention, grading diagnosis and treatment, community grading intervention, diabetic foot ulcer and cardiovascular disease risk grading and management. And summarized the grading management indicators, methods, effects, existing problems and improvement measures. In order to provide a new direction for the development of diabetes management. Key words: Diabetes mellitus; Hierarchical management; Tertiary prevention; Risk management

635-P: Therapeutic Footwear Is the Main Way to Prevent Foot Ulcer Relapse, but Is Insufficiently Respected

Therapeutic footwear (TFW) is essential to prevent diabetic foot ulcer (DFU) relapse after healing. Our retrospective study aimed at investigating patient’s compliance with TFW 1 year after complete healing, and whether the respect of this TFW in real life conditions was associated with a decrease of DFU recurrence during a 1-year follow-up. This is a retrospective study in which all consecutive patients attending our ambulatory foot unit between 01.2015 and 01.2016, were included if they had a TFW prescription after complete healing. The primary study endpoint was the percentage of compliant patients, who wear the TFW at 1 year. The proportion of patient with DFU relapse was compared in compliant versus non-compliant patients (secondary endpoint). The use of TFW was assessed by analyzing the points of wear and cleanliness of the shoes by the same podiatrist. We included 117 consecutive patients: age 63 ± 13 years, women 29/117 (24,7%), type 2 diabetes: 108/117 (92%), diabetes duration: 17.5 ± 12.5 years. After 12 months, 28/117 patients (24%) were lost of follow-up. TFW was respected in 60/117 cases (51.2%). None of these factors influenced the TFW compliance: sex, age, type of diabetes, diabetic treatment, diabetic duration or complications, HbA1c level, peripheral artery disease, neuropathy, amputations, ulcer localization, healing time, TFW type nor the lack of social insurance. DFU recurrence was observed in 24/89 cases (27%) and was significantly higher in non-compliant patients: 16/29 (55%) vs. 8/60 (13.3%) (P=0.05). The only factor predictive of DFU relapse was non-compliance for TFW. After complete DFU healing, TFW prescription is respected only by half of the patients at 1 year. Non-compliant patients are at higher risk of DFU. Further surveys need to be designed to determine the reasons of non-compliance and to conceive more adapted educational programs. Disclosure M. Laloi-Michelin: None. T. Vidal-Trécan: Board Member; Self; Novo Nordisk Inc. F. Féron: None. J. Kevorkian: None. D. Acker: None. C. Bouche: None. J. Gautier: None. J. Riveline: Board Member; Self; Abbott, Lilly Diabetes, Novo Nordisk Inc. Consultant; Self; Novo Nordisk Inc. Research Support; Self; Air Liquide, Amgen Inc. Speaker's Bureau; Self; Abbott, Lilly Diabetes, Sanofi.

Clinical features and burden of new onset diabetic foot ulcers post simultaneous pancreas kidney transplantation and kidney only transplantation

BackgroundPatients with diabetes and kidney disease are at risk of diabetes-related foot ulcers (DFU). Whether this risk is modified post simultaneous pancreas-kidney (SPK) or kidney only (KO) transplant is unknown. MethodsWe evaluated the incidence of new onset DFU post SPK and KO transplant in 235 patients with diabetic kidney disease and diabetic neuropathy. In total 90 (51% male) SPK patients and 145 KO (66% male, 26% Type 1 DM) were evaluated in a single centre retrospective study. Median (range) follow up was 6 (3 to 13) years for both cohorts. ResultsWe observed that 16 (17%) of SPK and 22 (15%) KO patients respectively developed a DFU during follow up. In both cohorts a history of peripheral arterial disease [37.5% vs. 4%] and pre-transplant history of DFU were associated with post transplant DFU (p ≪ 0.05).In KO cohort, patients who developed a DFU were more likely to have T1DM than T2DM (29% vs. 10%), p ≪ 0.05. There was no impact of DFU on SPK transplant failure. In contrast patients with DFU post KO transplant had more than five fold increased hazard ratio (HR) of transplant failure as compared to those without DFU independent of other risk factors [HR 5.19 95% CI (2.05 to 13.18) p = 0.001]. ConclusionNearly 1 in 7 patients develop a new onset DFU post KO or SPK transplantation and DFU also significantly increases risk of failure of the transplanted kidney. Our results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Research in contextEvidence before this studyPatients with diabetes and kidney disease are at enhanced risk of diabetic foot ulcers (DFU). Whether this risk is modified post successful kidney only (KO) or simultaneous pancreas and kidney (SPK) transplantation is unknown. Small case series and studies with short term follow up report varied rates of incidence and are from historical cohorts before the use of modern anti-transplant medications and treatments. Short term studies also suggest that post SPK the resultant normoglycaemia may reverse some features and risk markers of DFU. There are no long term studies on the incidence and impact of diabetic foot ulcers in patients with diabetic kidney disease post SPK or KO transplantation.Added value of this studyWe report the long term follow up results on DFU incidence, clinical features and related impact on transplant viability in 235 patients with diabetic kidney disease and neuropathy post successful SPK and KO transplant at a single centre. We observed that nearly 1 in 7 patients developed a DFU during follow up and that in patients who received KO transplant onset of DFU was associated with more than 5 fold increase of transplant failure.Implications of all the available evidenceOur results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Despite normoglycaemia post SPK there is a residual burden and risk of DFU. Our work establishes a clinical rationale for further research to explore putative mechanisms that could explain the association between DFU and renal transplant dysfunction.

Unrecognized high risk for diabetic foot ulcer among hospitalized patients

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

The effect of transitional care on the prevention of diabetic foot ulcers in patients at high risk for diabetic foot

To study the effect of transitional care on the prevention of diabetic foot ulcers (DFU) in patients at high risk for diabetic foot. A total of 284 diabetic patients at high risk for DFU were randomly divided into case and control groups (142 cases in each group). The control group was provided with conventional care in hospital. The case group received the transitional care intervention, including individualized education about diabetes mellitus and DFU, instruction in foot care, and the assistant management of calluses and the evaluation on quality of life. Both groups were followed up for 2 years. The levels of blood glucose, blood pressure and serum lipids, and foot dorsal artery pulse, 10-g monofilament nylon fiber probe test, knowledge of foot care, and diabetes quality of life (DQOL) in two groups were compared before and after transitional care intervention. There were statistically significant improvements in the case group compared with the control group in plasma glucose and blood pressure levels, and in foot dorsal artery pulse, 10-g monofilament nylon fiber probe test, knowledge of foot care, and DQOL. The incidence of DFU was lower, and the ulcers also were milder in the case group than in the control group. Transitional care was beneficial to the prevention of DFU and could reduce the development of DFU and improve the patients’ quality of life.

Differences Between Patient-Reported Versus Clinician-Observed Nonulcerative Signs and Symptoms of the Foot in Patients With Diabetes Mellitus.

The primary aim of this study was to compare patient reported versus clinician-observed nonulcerative foot conditions in patients attending a diabetic foot clinic and deemed at risk for diabetic foot ulcers. Retrospective review of medical records. The medical records of 126 patients with diabetes mellitus and deemed at risk for developing diabetic foot ulcers were reviewed. All patients received care from a diabetic foot outpatient clinic in a university-based hospital in Tokyo, Japan, between November 2008 and October 2009. We compared patients' self-identified foot complaints with clinically observable conditions affecting the feet of these individuals with diabetes mellitus. Patients' medical records were retrieved, and patient complaints and identified preulcerative signs of the foot were documented. All clinical observations were made by nurse specialists with knowledge of diabetic foot conditions. Nonulcerative diabetic foot conditions we observed included calluses, corns, abnormal nails, fissures, tinea pedis, and tinea unguium. Patient sensitivity to correctly identify these signs was calculated using the following formula: patient-reported foot signs divided by clinically identified preulcerative signs. Patient sensitivity for identifying nonulcerative signs varied based on the foot condition was 51.4% for calluses, 47.8% for pincer nails, 44.4% for corns, 33.3% for fissures, 19.4% for nail abnormalities, 3.9% for scales/maceration between the toes, 2.6% for interdigital tinea pedis, and 18.2% for tinea unguium. These findings suggest that persons with diabetes vary in their awareness of conditions affecting their feet and enhancing their risk for the development of diabetic foot ulcers. We recommend additional education on foot-related self-care including how often to observe their feet and how to recognize symptoms that may elevate their risk for diabetic foot ulcers.

Strong association between vibration perception thresholds at low frequencies (4 and 8 Hz), neuropathic symptoms and diabetic foot ulcers.

AimsTo investigate whether multi-frequency measurement of vibration perception thresholds (VPTs) can identify individuals with a high risk of developing diabetic foot ulcer or neuropathic symptoms.MethodsVPTs were measured at six different frequencies (4, 8, 16, 32, 64 and 125 Hz) on metatarsal heads 1 and 5 on the sole of the foot using a standard VibroSense Meter device in 535 type 1 diabetic (T1DM) patients and 717 non-diabetic control subjects. VPTs in control subjects were used to establish normal values for five different age groups for male and female subjects respectively. Normal values were defined as a VPT below the mean plus 1.66 x standard deviation for each group. Various definitions of abnormal VPTs were tested using either all frequencies, only lowest VPT frequencies (4 and 8 Hz) or only highest VPT frequencies (64 and 125 Hz).ResultsThe VPTs were higher in T1DM patients than in non-diabetic control subjects matched for age and gender. The low frequencies, 4 and 8 Hz, particularly were associated with the risk of diabetic foot ulcer (OR 40.7 [5.4–308.4], p = 0.0003) and with difficulties in balance and or gait (OR 1.89 [1.04–3.46], p = 0.04) difficulties and weakness (OR 2.77 [1.25–6.16], p = 0.01). The VPTs at the 125 Hz frequency were higher in short duration (≤ 10 yrs.) T1DM patients compared to age- and gender-matched control subjects.ConclusionsVibration perception thresholds at low frequencies seem to be a better indicator of the risk of developing diabetic foot ulcers, gait or balance problems or weakness of the foot. The 125 Hz frequency, however, seemed to be impaired earlier and it was the only pathological VPT frequency in patients with short duration of diabetes.This study suggests that at least four different frequencies (4, 8, 64 and 125 Hz) should be included in any examination in order to obtain a complete evaluation of the risk factors for diabetic neuropathy and diabetic foot ulcers.

Validity of diagnostic codes and estimation of prevalence of diabetic foot ulcers using a large electronic medical record database.

To assess the validity of the diagnostic codes relating to diabetic foot ulcer (DFU) in the electronic medical records of a large integrated care provider and to assess the prevalence of DFU among its members. Data were obtained from the diabetes registry of Maccabi Healthcare Services (MHS), a 2.1-million-member sick-fund in Israel, which included 125665 patients in 2015. We randomly selected and reviewed ~400 patient files from each of the following categories during study period: (1) had a diagnostic code of DFU; (2) had a diagnostic code, or clinical condition suggestive of DFU including: leg-ulcer, amputation, DFU in quartiles proximate to 2015 or abnormality reported by nurse; (3) patients at high risk for DFU (age>35 and one of the following: peripheral artery disease, neuropathy, DFU during 2011-2014, eGFR<30mL/min/m2 or foot deformity). The patients' charts were reviewed by study physicians, and DFU was validated or refuted. Relying upon diagnostic codes entered by physicians, the positive predictive value (PPV) was 73.1% (95% CI 67.6-78.2), and the sensitivity was 48.2% (95% CI 45.8-50.7%). The PPV of the diagnostic codes listed by podiatrists were significantly lower, while that of codes listed by nurses was higher but with lower sensitivity. The estimated annual prevalence of DFU in the diabetes registry of MHS was 1.2% (95%CI 1.0-1.5%). Diagnostic codes alone cannot be used reliably to create a DFU registry. Nevertheless, the data collected provide an estimate of the prevalence of DFU among patients included in the MHS diabetes registry.

Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers.

SBP variability may be a target for mitigating end-organ damage associated with vascular disease. We evaluated the relationship between increased SBP variability and risk of incident diabetic foot ulceration. Using a nested case-control design, we followed patients diagnosed with diabetes and treated within the US Department of Veterans Affairs Healthcare system for development of a diabetic foot ulcer (event) between 2006 and 2010. Each case was randomly matched to up to five controls based on age, sex, race/ethnicity, and calendar time. SBP variability was computed using at least three blood pressure measurements from the year preceding the event. The association between SBP variability and foot ulceration was examined using conditional logistic regression. Potential protective effects of calcium channel blockers, which blunt SBP variability, were also explored. The study sample included 51 111 cases and 129 247 controls. Compared with those in quartile 1 (lowest variability), patients in quartiles 2-4 had higher adjusted odds ratios for diabetic foot ulcer development: 1.11 (95% CI 1.07-1.16), 1.20 (95% CI 1.15-1.25), 1.29 (95% CI 1.24-1.34) (P for trend <0.001). Calcium channel blockers were associated with reduced risks of ulceration for those without peripheral vascular disease (OR = 0.87, 95% CI 0.84-0.90, P < 0.001) or neuropathy (OR = 0.85, 95% CI 0.82-0.89, P < 0.001) in adjusted subgroup analyses. This study describes a graded relationship between SBP variability and risk of diabetic foot ulceration, providing a potential new and modifiable target to reduce this common complication.

Prevalence of diabetic complications and risk factors among diabetic foot ulcer patients: a retrospective hospital-based study

Background: Diabetic foot ulcer is a painful, demands increased health care utilization, and increases healthcare costs for the patients as well as the health care system. The purpose of this study was to analysis the prevalence of diabetic foot complications and risk factors among diabetic patients at tertiary care Hospital, Karimnagar.Methods: Total 60 sample sizes were included in the study. The study was conducted at General Surgery ward, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar from July 2017 to June 2018. Demographic, complications and risk factors were recorded, and outcomes were analyzed using SPSS statistics version 21.0.Results: The Mean age of the study group is 50.31±14.26 years. The male to female distribution is 47 (78.3%) and 13 (21.7%) respectively. The mean duration of illness in days is 96.68±289.21, while mean HbA1C is 9.44±9.02. The mean fasting blood sugar and postprandial blood sugar is 159.78±70.01 and 157.78±86.28 which shown no significance difference (p = 0.87). Odds ratio with 95% confidence interval was computed to the level of significant.Conclusions: There was no significant outcome was found in diabetic foot ulcer. Patient with high risk complications need as early detection, foot care education, moderate physical, exercise, fitted foot wear and diabetic diet should be decrease the risk of diabetic foot ulcers.

Characteristics of diabetic foot disease and risk factors in Benghazi, Libya

Introduction: Diabetic foot ulcer and amputation are associated with an increased incidence of morbidity and mortality. Diabetic foot ulcer can be prevented by screening for risk factors and proper interventions. Objectives: We aimed to determine the risk of diabetic foot ulcer and amputation among patients with type 2 diabetes at Benghazi Medical Center diabetic clinic. Patients and Methods: A cross-sectional study of diabetic foot status and risk factors in diabetic patients attending a specialist diabetes clinic in Benghazi, Libya. Results: Eighty-seven (84.5%) patients wear inappropriate shoes, 37 (35.9%) had Tinea pedis, 26 (25.2%) had foot deformity, 13 (12.6%) patients had bilateral hallux valgus deformity, 8 (7.8%) patients had clawing of feet, 2 (1.9%) patients had Charcot joint, and one patient (0.97%) had amputated toes. Dorsalis pedis and posterior tibial arteries pulsations were not palpable in six (5.8%) patients, there was a loss of protective sensation among 20 (19.4%) patients, vibration sense was absent in 15 (14.6%) patients, and joint position sense was lost in five (4.9%) patients. According to Scottish Intercollegiate Guideline Network system, 59 (57.3%) patients were in the low-risk category, 18 (17.5%) were in the moderate-risk, 22 (21.4%) were in the high-risk, and 4 (3.9%) were in the active disease categories. Conclusions: We conclude that the prevalence of diabetic foot risk factors is high among the studied group.

Association of MCP-1 rs1024611 polymorphism with diabetic foot ulcers.

Monocyte chemotactant protein-1 (MCP-1), a pro-inflammatory cytokine, plays an important role in inflammatory process. In present study, we evaluated the association of MCP-1 gene rs1024611 polymorphism with risk and clinical characteristics of diabetic foot ulcers (DFUs).This study recruited 116 patients with DFUs, 135 patients with diabetes mellitus (DM) without complications (non-DFU), and 149 healthy controls (HCs). MCP-1 gene rs1024611 polymorphism was genotyped by direct sequencing. The expression of MCP-1 was analyzed using quantitative real-time polymerase chain reaction. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to assume the association strength.Individuals with rs1024611 AG and GG genotypes exhibited significantly higher susceptibility to DFUs, in the comparison with HCs (AG vs AA, OR = 2.364, 95% CI = 1.021–5.470; GG vs AA, OR = 2.686, 95% CI = 1.154–6.255). Meanwhile, G allele was associated with increased DFUs susceptibility (OR = 1.457, 95% CI = 1.014–2.093). Besides, rs1024611 SNP was slightly correlated with increased DFUs susceptibility in patients with DM. GG genotype of rs1024611 was significantly correlated with higher epidermal thickness and lower dermis thickness in patients with DFUs (P < .01). Patients with DFU exhibited upregulation of MCP-1 mRNA, and GG genotype was correlated with enhanced MCP-1 expression in DFU and non-DFU groups.Rs1024611 polymorphism was significantly associated with MCP-1 expression and individual susceptibility to DFUs.

Predictive diabetic foot ulcer risk factors correlated with elevated forefoot peak plantar pressure

Polyneuropathy and foot deformity, such as Claw and hammer-toes (CHT), together with hyperkeratosis, are predictive diabetic foot ulcer (DFU) factors. These factors are correlated with increased forefoot peak plantar pressure (PPP). Increased PPP at metatarsal heads is correlated with forefoot DFU development. The aim of this study was to observe that the presence of CHT, hyperkeratosis and polyneuropathy is correlated with high forefoot PPP (FPPP). An observational transversal survey with 103 diabetic patients, with or without CHT, hyperkeratosis and polyneuropathy, and without peripheral arterial disease, previous or current DFU and lower limb amputation was conducted. Mean age was 74 years old, 41 male and 62 women. Variables were CHT, hyperkeratosis, polyneuropathy and FPPP of each foot. PPP was obtained through the BIOFOOT/IBV baropodometric system. An analysis of difference between means of two samples was performed. “Hyperkeratosis” is correlated with higher FPPP than “CHT and hyperkeratosis”, and both with higher FPPP than those who had none of these features. There is no significant difference between FPPP of the groups without and with polyneuropathy, both without hyperkeratosis. Hyperkeratosis is correlated with higher FPPP, independently of polyneuropathy. The mean FPPP of up to 840 KpPa may be considered as indicative of a lower risk of DFU, in this sample and with this baropodometric system.

Risk of Foot Ulcer and Lower Extremity Amputation among Participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC)

We examined whether prior intensive glycemic control during the DCCT reduced the risk of diabetic foot ulcer (DFU) and lower extremity amputation (LEA) among participants with type 1 diabetes in the EDIC study. DFU and LEA occurrence were determined by physical examination during annual EDIC follow-up visits that began about one year following DCCT completion. We also assessed DFU and LEA risk by neurovascular measurements, diabetes characteristics, and clinical factors. Data were available from 23 years of EDIC follow-up. Recurrent DFU was defined if reported on a different limb in subsequent years or the same limb in non-consecutive years. Multivariable Cox models were used to estimate the association of intensive glycemic control and other time-updated risk factors with incident or total (incident + recurrent) DFU or incident LEA. Incident DFU was observed in 86 of the 699 former intensive and 109 of the 7former conventional treatment participants (HR 0.78, 95% CI 0.59 to 1.03). Total DFU numbered 117 in intensive (7.3/1000 person-years (p-y)) and 153 in conventional treatment participants (9.6/1000 p-y) for a significant risk reduction (HR 0.76, 95% CI 0.60 to 0.97, p=0.03). Incident LEA occurred in 15 intensive (1.0/1000 p-y) compared to 21 conventional treatment participants (1.4/1000 p-y, HR 0.70, 95% CI 0.36 to 1.36, p=0.30). Greater HbA1c, lower eGFR, albuminuria, confirmed clinical neuropathy, lower nerve conduction velocity, abnormal cardiovascular autonomic function, proliferative retinopathy, and macular edema were independently associated (p&amp;lt;0.05) with higher risk of incident DFU and LEA. Current smoking was associated with higher risk of LEA only. Ankle-brachial index measured continuously was not associated with risk of either outcome. We conclude that intensive glycemic control decreases the risk of DFU, the most important antecedent in the causal pathway to LEA. Disclosure E.J. Boyko: None. L. Zelnick: None. B. Braffett: None. R. Pop-Busui: Research Support; Self; AstraZeneca. C.C. Cowie: None. G.M. Lorenzi: Advisory Panel; Self; Intarcia Therapeutics, Inc.. R. Gubitosi-Klug: None. B. Zinman: Consultant; Self; Novo Nordisk A/S, Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Sanofi, Merck &amp; Co., Inc., Abbott. I. de Boer: Research Support; Self; Medtronic, Abbott. Consultant; Self; Boehringer Ingelheim GmbH, Ironwood Pharmaceuticals, Inc..

Temperature Regulating Shoes for Prevention of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) continue to burden Americans with over 100,000 amputations every year. We believe that better understanding of the etiology and a multi-factorial approach that combines in-shoe temperature regulation along with plantar stress reduction could dramatically improve this outcome. Previous research indicated that soft tissue is prone to ulceration at warmer temperatures. Likewise, animal studies indicate higher tissue resistance to break-down when cooled to 25 °C to 28 °C. Insulated diabetic footwear and load-bearing activity lead to high plantar tissue temperatures and increased risk of DFU. The purpose of this study was to design/develop a novel temperature regulating footwear and test cooling effectiveness. An extra-depth diabetic shoe was instrumented with temperature control apparatus set to cool to 28 °C. Three subjects wore this shoe and a non-cooling (control) shoe while walking for 10 minutes. Post-walking thermographs of the regulated foot revealed: forefoot temperatures below 28 °C; heel temperatures around 28 °C with a 3.9 °C bilateral cooling effect; midfoot regions 2.9 °C less than the control foot but still over 28 °C, perhaps due to poor contact with the cooling insole or a need for increased localized control of cooling. These results suggest feasibility of in-shoe temperature regulation. Further research is needed to improve our design and ultimately explore DFU prevention in a clinical trial. Disclosure A. Ersen: Other Relationship; Self; Vivonics Inc. L.S. Adams: Other Relationship; Self; Vivonics, Inc. R.T. Myers: Employee; Self; Vivonics, Inc. G.B. Hirschman: Stock/Shareholder; Self; Vivonics, Inc.. Employee; Self; Vivonics, Inc.. Board Member; Self; Vivonics, Inc. L.A. Lavery: Speaker's Bureau; Self; Osiris Therapeutics, Inc., Integra LifeSciences. Research Support; Self; Cardinal. Speaker's Bureau; Self; Smith &amp; Nephew. Research Support; Self; EO2. Consultant; Self; Aplion, Harbor MedTech, Boehringer Ingelheim GmbH, Medline Industries, Inc. M. Yavuz: Research Support; Self; Derma Sciences, PulseFlow Technologies. Other Relationship; Self; vivonics.