Incidence, outcomes, and cost of foot ulcers in patients with diabetes

OBJECTIVE: To determine the incidence of foot ulcers in a large cohort of patients with diabetes, the risk of developing serious complications after diagnosis, and the attributable cost of care compared with that in patients without foot ulcers. RESEARCH DESIGN AND METHODS: Retrospective cohort study of patients with diabetes in a large staff-model health maintenance organization from 1993 to 1995. Patients with diabetes were identified by algorithm using administrative, laboratory, and pharmacy records. The data were used to calculate incidence of foot ulcers, risk of osteomyelitis, amputation, and death after diagnosis of foot ulcer, and attributable costs in foot ulcer patients compared with patients without foot ulcers. RESULTS: Among 8,905 patients identified with type 1 or type 2 diabetes, 514 developed a foot ulcer over 3 years of observation (cumulative incidence 5.8%). On or after the time of diagnosis, 77 (15%) patients developed osteomyelitis and 80 (15.6%) required amputation. Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of age- and sex-matched diabetic patients without foot ulcers (P < 0.001). The attributable cost for a 40- to 65-year-old male with a new foot ulcer was $27,987 for the 2 years after diagnosis. CONCLUSIONS: The incidence of foot ulcers in this cohort of patients with diabetes was nearly 2.0% per year. For those who developed ulcers, morbidity, mortality, and excess care costs were substantial compared with those for patients without foot ulcers. The results appear to support the value of foot-ulcer prevention programs for patients with diabetes.     

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology

OBJECTIVE: Foot ulcers and their complications are an important cause of morbidity and mortality in diabetes. The present study aims to examine the long-term outcome in terms of amputations and mortality in patients with new-onset diabetic foot ulcers in subgroups stratified by etiology. RESEARCH DESIGN AND METHODS: Patients presenting with new ulcers (duration <1 month) to a dedicated diabetic foot clinic between 1994 and 1998 were studied. Outcomes were determined until March 2000 (or death) from podiatry, hospital, and district registers. Baseline clinical examination was done to classify ulcers as neuropathic, ischemic, or neuroischemic. Five-year amputation and mortality rates were derived from Kaplan-Meier survival analysis curves. RESULTS: Of the 185 patients studied, 41% had peripheral vascular disease (PVD) and 61% had neuropathy; 45%, 16%, and 24% of patients had neuropathic, ischemic, and neuroischemic ulcers, respectively. The mean follow-up period was 34 months (range 1-65) including survivors and patients who died during the study period. Five-year amputation rates were higher for ischemic (29%) and neuroischemic (25%) than neuropathic (11%) ulcers. Five-year mortality was 45%, 18%, and 55% for neuropathic, neuroischemic, and ischemic ulcers, respectively. Mortality was higher in ischemic ulcers than neuropathic ulcers. On multivariate regression analysis, only increasing age predicted shorter survival time. CONCLUSIONS: All types of diabetic foot ulcers are associated with high morbidity and mortality. The increased mortality appears to be independent of factors increasing ulcer risk-that is, neuropathy and PVD-in patients with established foot ulcers.     

不同肾脏功能状态对糖尿病足部溃疡疗效及预后的影响

目的探讨肾脏功能对糖尿病足部溃疡疗效及预后的影响。方法采用前瞻性研究的方法，对126例Ⅰ～Ⅴ期糖尿病足部溃疡患者在治疗前检查肾脏功能后，进行全身综合治疗及溃疡局部彻底清创，外敷黄芪提取液加适量短效胰岛素，观测溃疡部位肉芽组织出现时间（GT）、溃疡愈合时间（HT）及溃疡治愈率、截肢率。结果糖尿病肾病从Ⅰ期逐渐过渡到Ⅴ期，相同程度糖尿病足部溃疡患者的GT和HT逐渐延长，其中糖尿病肾病Ⅰ～Ⅲ期相同程度足部溃疡患者GT和HT均显著短于糖尿病肾病Ⅳ期（临床蛋白尿期）和Ⅴ期（终末期肾病）相同程度足部溃疡患者的GT和HT（P〈0．05或P〈0．01）；糖尿病足部溃疡患者的GT和HT与糖尿病肾病病情程度问呈显著正相关（r1=2．344和r2=2．563，P均〈0．05）；糖尿病肾病Ⅰ～Ⅲ期糖尿病足部溃疡患者的截肢率显著少于糖尿病肾病Ⅳ期和Ⅴ期相应程度的足部溃疡患者（P〈0．05），治愈率也显著高于后者（P〈0．05）。结论糖尿病肾病病情的轻重在很大程度上影响了糖尿病足部溃疡的治疗效果及预后，提示对糖尿病足部溃疡患者注重和尽可能改善肾功能状态是非常必要的。     

综合康复治疗对糖尿病足疗效的影响

目的：探讨康复治疗对糖尿病足溃疡的愈合及复发的疗效。方法：108例确诊为糖尿病足溃疡患者分为2组，均按内科常规药物治疗，康复组62例同时康复介入。治疗前后对足溃疡愈合及复发情况进行比较。结果：经过15—20d的治疗，康复组患者足溃疡愈合率高于常规组（P〈0．01），且溃疡平均愈合时间明显缩短（P〈0．01）；溃疡复发率、截肢率与常规组比较均显著降低（P〈0．01）。结论：糖尿病足溃疡患者采用药物及康复介入综合治疗能显著提高疗效，降低残疾率。     

Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach?

OBJECTIVE—Pressure mitigation is crucial for the healing of plantar diabetic foot ulcers. We therefore discuss characteristics and considerations associated with the use of offloading devices.RESEARCH DESIGN AND METHODS—A diabetic foot ulcer management survey was sent to foot clinics in all 50 states and the District of Columbia in 2005. A total of 901 geographically diverse centers responded. The survey recorded information regarding usage frequency and characteristics of assessment and treatment of diabetic foot ulcers in each center.RESULTS—Of the 895 respondents who treat diabetic foot ulcers, shoe modifications (41.2%, P < 0.03) were the most common form of pressure mitigation, whereas total contact casts were used by only 1.7% of the centers.CONCLUSIONS—This study reports the usage and characteristics of offloading devices in the care of diabetic foot ulcers in a broadly distributed geographic sample. Less than 2% of specialists use what has been termed the “gold standard” (total contact cast) for treating the majority of diabetic foot ulcers.In the treatment of diabetic foot ulcers, pressure modulation, commonly referred to as “offloading,” is most successful when pressure is mitigated at an area of high vertical or shear stress (1). Common methods to offload the foot include bed rest, wheel chair, crutch-assisted gait, total contact casts, felted foam, half shoes, therapeutic shoes, and removable cast walkers (2). Although it is well known that pressure mitigation through offloading devices is crucial for the healing of plantar diabetic foot ulcers, there are, to the best of our knowledge, no reports in the literature that describe the characteristics and considerations associated with the use of pressure mitigation devices in a broad geographically diverse sample of specialists. Therefore, the purpose of this study was to describe the characteristics and considerations associated with the use of offloading devices in foot clinics in the U.S.     

Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.

OBJECTIVE: To determine the frequency and constellations of anatomic, pathophysiologic, and environmental factors involved in the development of incident diabetic foot ulcers in patients with diabetes and no history of foot ulcers from Manchester, U.K., and Seattle, Washington, research settings. RESEARCH DESIGN AND METHODS: The Rothman model of causation was applied to the diabetic foot ulcer condition. The presence of structural deformities, peripheral neuropathy, ischemia, infection, edema, and callus formation was determined for diabetic individuals with incident foot ulcers in Manchester and Seattle. Demographic, health, diabetes, and ulcer data were ascertained for each patient. A multidisciplinary group of foot specialists blinded to patient identity independently reviewed detailed abstracts to determine component and sufficient causes present and contributing to the development of each patient's foot ulcer. A modified Delphi process assisted the group in reaching consensus on component causes for each patient. Estimates of the proportion of ulcers that could be ascribed to each component cause were computed. RESULTS: From among 92 study patients from Manchester and 56 from Seattle, 32 unique causal pathways were identified. A critical triad (neuropathy, minor foot trauma, foot deformity) was present in > 63% of patient's causal pathways to foot ulcers. The components edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Callus formation was associated with ulcer development in 30% of the pathways. Two unitary causes of ulcer were identified, with trauma and edema accounting for 6 and < 1% of ulcers, respectively. The majority of the lesions were on the plantar toes, forefoot, and midfoot. CONCLUSIONS: The most frequent component causes for lower-extremity ulcers were trauma, neuropathy, and deformity, which were present in a majority of patients. Clinicians are encouraged to use proven strategies to prevent and decrease the impact of modifiable conditions leading to foot ulcers in patients with diabetes.     

Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes who have a high risk for lower extremity complications. RESEARCH DESIGN AND METHODS: In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to standard therapy, structured foot examination, or enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook. If standard therapy or structured foot examinations identified any foot abnormalities, subjects were instructed to contact the study nurse immediately. Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six foot sites each day. Temperature differences >4 degrees F (>2.2 degrees C) between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized. RESULTS: The enhanced therapy group had fewer foot ulcers than the standard therapy and structured foot examination groups (enhanced therapy 8.5 vs. standard therapy 29.3%, P = 0.0046 and enhanced therapy vs. structured foot examination 30.4%, P = 0.0029). Patients in the standard therapy and structured foot examination groups were 4.37 and 4.71 times more likely to develop ulcers than patients in the enhanced therapy group. CONCLUSIONS: Infrared temperature home monitoring, in serving as an "early warning sign," appears to be a simple and useful adjunct in the prevention of diabetic foot ulcerations.     

Sustained silver-releasing dressing in the treatment of diabetic foot ulcers

This study investigated the clinical performance and safety of a sustained silver-releasing foam dressing, Contreet Foam, in the treatment of diabetic foot ulcers. Twenty-seven patients with diabetic foot ulcers of grade I or II (Wagner's classification) were followed for six weeks: one week run-in using Biatain dressings, four weeks' treatment with Contreet dressings. Four ulcers healed during the four-week treatment with Contreet 56% in average. Contreet Foam showed good exudate management properties and was considered easy to use. Only two infections occurred showed that all six of the non-study ulcers developed an infection during the study. All ulcers (study ulcers as well as non-study ulcers) were treated according to good practice of diabetic wound care. There were no directions for the treatment of secondary wounds. No device-related adverse events were observed. This study demonstrated that Contreet Foam is safe and easy to use and effectively supports healing and good wound progress of diabetic foot ulcers.     

Cognitive Function Is Not Associated With Recurrent Foot Ulcers in Patients With Diabetes and Neuropathy

OBJECTIVE

To study whether there is an association between cognitive impairment and the relapse rate of foot ulcers in diabetic patients and those with previous foot ulcers.

RESEARCH DESIGN AND METHODS

This single-center prospective study assessed the association of cognitive function and risk for ulcer relapse in 59 patients with diabetes (mean age 65.1 years, diabetes duration 16.5 years, and A1C 7.4%), peripheral neuropathy, and a history of foot ulceration. Premorbid and current cognitive functions were measured (multiple-choice vocabulary test [Lehrl], number-symbol test, mosaic test [HAWIE-R], and trail-making tests A and B [Reitan]). Prevalence of depression was evaluated retrospectively (diagnoses in patient files or use of antidepressive medication). Patients were re-examined after 1 year.

RESULTS

Three patients (5%) died during follow-up (one of sepsis and two of heart problems). The remaining 56 patients (48%) developed 27 new foot ulcerations (78% superficial ulcerations [Wagner stage 1]). Characteristics of patients with and without ulcer relapse were not different. In a binary logistic regression analysis, cognitive function is not predictive of foot reulceration.

CONCLUSIONS

Cognitive function is not an important determinant of foot reulceration.Diabetic patients and those with a history of foot ulcers are at risk for foot reulceration (1,2). Although cognitive function is known to be impaired in patients with diabetes compared with that in nondiabetic control subjects (3), no studies have examined the potential role of cognitive impairment, an important factor for educational success (4), in the development or recurrence of diabetic foot ulcers. Our hypothesis is that cognitive function is associated with the relapse rate of foot ulcers in patients with diabetes and previous foot ulcers.     

Use of liquid crystal thermography in the evaluation of the diabetic foot

Liquid crystal thermography (LCT) was used to determine temperature variations on the plantar surface of feet. The purpose was to identify thermal emission patterns associated with diabetic foot ulcers. Three population groups were screened: group I, 16 nondiabetic controls; group II, 21 diabetic patients with no history of pedal ulcers; and group III, 28 diabetic patients with active pedal ulceration or history of foot ulcerations. The results demonstrate a generalized increase in plantar foot temperature in group III compared with groups I and II. Temperature readings under metatarsal heads 1-5, great toe, heel, and lateral band were significantly increased (P less than .01) in group III. Additionally, the warm lateral surface displayed by group III patients was not significantly different in temperature from the medial arch of the foot. In groups I and II, the lateral band was significantly cooler (P less than .01) than the medial arch. In group III patients with active ulceration on only one foot, no significant difference in temperature was found between the foot with active ulceration compared with the contralateral nonulcerated foot. When patients with active pedal ulceration were compared with patients with a history of foot ulcers, no significant difference in temperature was seen at five of seven sites tested. A warm concentric color band surrounding active plantar ulcers was identified in group III. This pattern extended from the center of the ulcer to a distance of 8 mm. A significant change in temperature (P less than .01) was noted at 6- and 8-mm distances from the center of the ulcer. In addition, a mottled thermographic pattern was observed more frequently in group III patients than in groups I and II.(ABSTRACT TRUNCATED AT 250 WORDS)     

Management of the diabetic foot ulcer: exercising control

The incidence of diabetes is increasing and therefore patients with diabetic foot ulcers will become increasingly common in the community. The NHS model of Health and Social Care (Department of Health (DH), 2005) places a high emphasis on self care and disease management, and, as a long-term condition, diabetes mellitus requires efficient and effective management. The supervision and organization of the care of diabetic patients is multi-factorial and for this reason, a multi-disciplinary approach is essential for effective care, without which patients with diabetic foot ulcers are at high risk of complications. Diabetic wounds present differently to other chronic wounds; unless these are adequately assessed and treated, there may be devastating consequences for the patient--the most serious being major amputation and/or death. In the first article, accurate assessment was discussed; in this second article, the management of diabetic foot ulcers is explored.     

Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes

Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.     

Wound management for 287 patients with chronic leg ulcers demands 12 full-time nurses. Leg ulcer epidemiology and care in a well-defined population in southern Sweden

OBJECTIVE: To study the prevalence, aetiology and treatment of chronic leg and foot ulcers, and to estimate the nurse's time in wound management. DESIGN: A structured questionnaire with 19 questions about chronic ulcers and wound management was sent to all district and community nurses in the county during 1 week in March 1998. A similar questionnaire has been administered regularly since 1986. SETTING: Primary and community care in the county of Blekinge, Sweden, with a population of 1,51,610. PATIENTS: 287 patients with chronic leg and foot ulcers were identified during the week studied. MAIN OUTCOME MEASURES: Prevalence of leg and foot ulcers, ulcer aetiology, treatment of ulcers and wound management time. RESULTS: The estimated prevalence of chronic leg and foot ulcers was 0.19%. Venous ulcers were the most common (38%), of which 87% were treated with some form of compression therapy. Seven percent of the nurse's workload was devoted to ulcer care. During the period 1986 to 1998, ulcers with missing or unknown aetiology decreased from 31% to 6% and ulcers with a duration of more than 2 years from 44% to 27%, while treatment time per ulcer decreased from 2.1 to 1.7 hours/week. CONCLUSION: Monitoring standards for ulcer aetiology through repeated questionnaires seems to ensure more accurate diagnoses. Thorough and detailed information about treatment time documents the workload for wound management.     

Managing leg and foot ulcers: the role of Kerraboot

Foot and leg ulcers are chronic wounds characterized by slow or non-healing breakdown of epidermal and dermal tissue on the foot or below the knee. The prevalence is high and ulcers are a significant drain on the NHS in terms of nursing time and cost of dressings, and are incredibly burdensome to the individual patient. This article reviews the evidence for a new wound management system, Kerraboot, designed for the management of leg and foot ulcers. It is a boot-shaped dressing that completely surrounds the ulcer, creating an optimum healing environment. In clinical investigations, Keraboot offered patients relief from pain, was comfortable, easy to use and effectively controlled embarrassing odour, while also saving nursing time. Currently Kerraboot is recommended for the management of diabetic foot ulcers and venous ulcers where the patient is unable to tolerate compression therapy.     

Diabetic foot ulcers: pathogenesis and management

Foot ulcers are a significant complication of diabetes mellitus and often precede lower-extremity amputation. The most frequent underlying etiologies are neuropathy, trauma, deformity, high plantar pressures, and peripheral arterial disease. Thorough and systematic evaluation and categorization of foot ulcers help guide appropriate treatment. The Wagner and University of Texas systems are the ones most frequently used for classification of foot ulcers, and the stage is indicative of prognosis. Pressure relief using total contact casts, removable cast walkers, or "half shoes" is the mainstay of initial treatment. Sharp debridement and management of underlying infection and ischemia are also critical in the care of foot ulcers. Prompt and aggressive treatment of diabetic foot ulcers can often prevent exacerbation of the problem and eliminate the potential for amputation. The aim of therapy should be early intervention to allow prompt healing of the lesion and prevent recurrence once it is healed. Multidisciplinary management programs that focus on prevention, education, regular foot examinations, aggressive intervention, and optimal use of therapeutic footwear have demonstrated significant reductions in the incidence of lower-extremity amputations.     

介入疗法治疗糖尿病足患者膝以下动脉病变

目的 探讨糖尿病足患者膝以下动脉的血管病变特点及血管介入治疗的方法 和临床价值.方法 用 Seldinger技术,经股动脉顺行或逆行穿刺插管,对36例患者43条患肢行对比剂跟踪数字减影血管造影(DSA),然后对膝以下病变动脉行球囊成型术.结果 糖尿病足血管病变范围广,膝以下血管以重度乃至完全闭塞为主,同时累及双支及三支血管者38条,约占88.37%;43条患肢膝以下血管介入总成功率88.37%;所有手术成功患肢血流均明显改善,疼痛、麻木感缓解,皮温及ABI指数明显升高,溃疡愈合加快.结论 经皮血管球囊成型术微创、安全、有效,对糖尿病足膝以下动脉介入治疗近期疗效满意,可明显改善患肢血供.     

Full nursing assessment of patients at risk of diabetic foot ulcers

A common complication of diabetes is the occurrence of foot ulcers. Good foot care can, in many instances, prevent ulcers or increase the potential to heal in those patients who do ulcerate. All healthcare professionals working with patients with diabetes should reinforce the importance of caring for the feet each time they see the patient. A focus on foot care reiterates to the patient the importance of self care and prevention of ulceration. Examination of the feet and timely referral to appropriate specialist teams are of particular importance.     

2型糖尿病合并恶性黑色素瘤误诊为糖尿病足溃疡1例

肢端型恶性黑色素瘤是我国黑色素瘤的主要类型,以足底病变多见。由于临床表现相似,易被误诊为糖尿病足溃疡等疾病。本文报道1例糖尿病合并恶性黑色素瘤患者,因足部溃疡被误诊为糖尿病足溃疡,从而延误了治疗。若糖尿病患者足部皮损表现为不典型溃疡且溃疡迁延不愈时,应行病理检查以排除恶性黑色素瘤的可能性。