Which diabetic patients should receive podiatry care? An objective analysis

INTRODUCTION: Diabetes is the leading cause of lower limb amputation in Australia. However, due to limited resources, it is not feasible for everyone with diabetes to access podiatry care, and some objective guidelines of who should receive podiatry is required. METHODS: A total of 250 patients with neuropathy (Biothesiometer; Biomedical Instruments, Newbury, Ohio, USA) ( > 30, age < 65)) but no active foot lesion, and 222 without neuropathy matched for age, type of diabetes, gender and duration, was followed prospectively for 2 years. Sensation was also tested using a 10 g Semmes Weinstein monofilament (Royal Prince Alfred Hospital Diabetes Centre). After the baseline examination, patients were contacted at 6 months and thereafter yearly to determine ulcer status. Incidence of foot ulceration across different risk categories was calculated using Kaplan-Meier survival curve. Log-rank test and Cox's proportional model were used to compare groups. The Number Needed to Treat (NNT) to prevent one ulcer per year was calculated using the standard formulae. RESULTS: During the follow-up period, 34 new ulcers occurred in the neuropathy group and three ulcers in the control group (chi2 (1df) = 21.3; P < 0.0001), equating to an annual incidence of 6.3% and 0.5%, respectively. Fifty-four per cent of the ulcers were due to trauma from footwear. Further stratification of the neuropathy group showed annual incidence of ulceration to be 4% for those with abnormal biothesiometer reading, but who could still feel the monofilament, 10% for those who cannot feel the monofilament and 26% for those with previous ulceration or amputation. Predictors of ulceration were past history of ulceration/amputation (chi2 = 27.8; P < 0.0001) and the presence of neuropathy (chi2 = 4.7; P = 0.03). Assuming a 55% relative risk reduction in ulceration from podiatry care (mean of estimates from 10 reports), the NNT to prevent one foot ulcer per year was: no neuropathy (vibration perception threshold (VPT) < 30)), NNT = 367; neuropathy (VPT > 30) alone, NNT = 45; +cannot feel monofilament, NNT = 18; +previous ulcer/amputation, NNT = 7. CONCLUSION: Provision of podiatry care to diabetic patients should not be only economically based, but should also be directed to those with reduced sensation, especially where there is a previous history of ulceration or amputation.     

老年糖尿病足坏疽患者的临床特征及其危险因素分析

目的了解老年人糖尿病足坏疽（ＤＦ）的临床特征及其危险因素。方法对２２１例老年和１６３例老年前期ＤＦ的患病率、各种诱因的百分比、ＤＦ和非ＤＦ患者胫后感觉神经传导速度、双下肢动脉管径和血流量等检测结果进行分析。结果（１）老年和老年前期ＤＦ患者的患病率（４９．５％和２７．４％）明显高于青中年组（１１．０％）；自发性溃疡、水疱破裂、穿鞋不当摩擦伤为ＤＦ的常见诱因；湿性坏疽为ＤＦ的主要类型。（２）老年和老年前期ＤＦ患者因周围神经病变致传导速度检测不能引出波形者分别占９２％和８２％、周围血管病变致动脉狭窄和闭塞者分别占９２％和７８％，显著高于非ＤＦ组。结论老年人糖尿病易合并ＤＦ；周围神经病变和周围血管病变在ＤＦ的发生和发展中起重要作用。     

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

Background: Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group. Methods: One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors. Results: Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end‐stage kidney failure. Conclusion: Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end‐stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.     

糖尿病足溃疡患者肌电图腓神经传导速度的差异及其影响因素分析

目的分析糖尿病足溃疡患者和未出现足部溃疡的糖尿病患者其肌电图检查腓神经传导速度的差异及影响因素。方法选取2016年1月—2019年1月该院100例糖尿病患者进行回顾性分析,其中50例糖尿病足溃疡患者为观察组,另50例糖尿病但未出现足部溃疡的患者为对照组,对比其腓神经传导速度的差异并分析其原因。结果观察组的腓神经传导速度慢于对照组,两组患者在白细胞计数、中性粒细胞比例、血红蛋白、白蛋白、踝肱指数(ABI)方面差异有统计学意义(P<0.05)。结论糖尿病患者出现足部溃疡的主要因素是周围神经出现病变,导致糖尿病患者周围神经病变的因素有血糖控制程度不好、胰岛功能较差、贫血等。因此,要想预防或改善糖尿病足溃疡,就要控制好血糖指标,增强患者的胰岛功能。     

The Prevalence of Foot Ulceration and its Correlates in Type 2 Diabetic Patients: a Population-based Study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34–90) years, diabetes duration 7.4 (0–50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or ≥ 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3–44.9%) and the prevalence of PVD, 11% (9.1–13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.     

Identification of patients at risk for diabetic foot: a comparison of standardized noninvasive testing with routine practice at community diabetes clinics

The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in six diabetes clinics over a 1-year period; 44 of these patients had active or previous foot ulcerations. We evaluated the differences between the routine diagnostic practice (based on the patient's medical history and a physical examination) and noninvasive testing of peripheral neuropathy [vibration perception threshold (VPT) and the Semmes-Weinstein 10-g monofilament wire system] and angiopathy [Doppler ankle/brachial index (ABI)]. Using receiver operating characteristic (ROC) analysis, we evaluated the sensitivity and specificity of noninvasive testing methods for identifying patients at risk and selecting the optimal diagnostic cutoff points. Patients with severe neuropathy, as determined by noninvasive testing (VPT > or =30 V and/or insensitivity to 10 g monofilament), had been diagnosed to have neuropathy in diabetes clinics in 54% of cases. Patients with angiopathy at risk of developing diabetic foot ulcers (ABI < or =0.8) had been diagnosed, in diabetes clinics, to have peripheral arterial disease in 50% (they reported claudications in 41%, had femoral artery bruits detected in 29% and nonpalpable peripheral pulsations in 12%). Our findings stress the importance of using standardized simple noninvasive testing methods to increase the accuracy of identifying patients at risk for the diabetic foot at the community level.     

Clinical profile of diabetic foot infections in south India--a retrospective study.

AIMS: The aim of the study was to determine the profile of diabetes foot infections in south Indian diabetic subjects. The causative factors for delayed wound healing and the recurrence of infection were also studied. METHODS: During a period of 6 months, 374 patients who had undergone some surgical procedure for foot infection were available for follow-up (M:F 227:147, mean age 54.9 +/- 9.4 years, diabetes duration 10.9 +/- 7.7 years). All of them had records of clinical and treatment details, laboratory data including biothesiometry, Doppler tests and electrocardiogram (ECG) records. Foot ulcers were classified according to Wagner's classification. RESULTS: Majority of the patients had grade II and III ulcers (50% and 26.5%, respectively), grade IV was seen in another 21.9%. The median healing time was 44 days. Recurrence of infection which occurred in 53% was more common in patients with neuropathy and peripheral vascular disease (PVD). CONCLUSIONS: Recurrence of foot infection was common among south Indian Type 2 diabetic subjects and was related to the presence of PVD and neuropathy. There is also a need for improvement in footwear and foot care education.     

A preventative foot care programme for people with diabetes with different stages of neuropathy

The aim of this study was to assess the efficacy of a preventative foot care programme, applied in a normal outpatient setting to decrease the incidence of foot ulcers in people with diabetes diagnosed as having neuropathy by neuropathy disability score (NDS), in relation to the severity of neuropathy based on the vibration perception threshold (VPT). A structured continuous preventative foot care programme was designed to ensure proper footwear, walking foot hygiene, callus care, nailcutting, water temperature checks, use of warming devices, bathroom surgery, foot care products and self-inspection. Continual foot-care education and treatment, including podiatry, were available. Evaluation was at least every 6 months. Diabetic patients (n=308) with neuropathy (NDS > or =6), 72.3+/-10.7 years old, 45% men, 10.9+/-8.8 years duration of diabetes, and HbA(1c) 6.5+/-1.3%, without a history of foot lesions were recruited over 3 years and followed-up for 4.6 (3-6) years. A low risk group (n=124) had a VPT<25 V while 184 had a VPT > or =25 V (high risk). In all 220 patients (71%) complied with the programme, compliance being 76 and 68% in low and high risk groups. The low risk group developed nine ulcers in nine patients, and the high risk group 24 ulcers in 19 patients. Of these eight and 19 ulcers, respectively, were in the non-compliant patient group, giving relative risk of 22 and eight compared with people attending the programme. Thus compliance with a preventative foot programme reduces the incidence of foot ulceration in people with diabetes with neuropathy. This decrease is relatively greater in patients with less severity of neuropathy. The simple design should be widely generalisable.     

Sudomotor dysfunction is associated with foot ulceration in diabetes

Aim To examine the relationship between sudomotor dysfunction and foot ulceration (FU) in patients with diabetes. Methods Ninety patients with either Type 1 or Type 2 diabetes [30 without peripheral sensorimotor neuropathy (PN), 30 with PN but without FU and 30 with FU] were recruited in this cross‐sectional study. Assessment of PN was based on neuropathy symptom score (NSS), neuropathy disability score (NDS) and vibration perception threshold (VPT). Sudomotor dysfunction was assessed using the sympathetic skin response (SSR). Cardiac autonomic nervous system activity was assessed by the battery of the classical autonomic function tests. Results Patients with foot ulcers had longer duration of diabetes, higher values of VPT and NDS and lower values of the autonomic functions tests in comparison with the other study groups. Sudomotor dysfunction and cardiac autonomic neuropathy were significantly more common in the FU group. Multivariate logistic regression analysis after adjustment for gender, body mass index, duration of diabetes and glycated haemoglobin (HbA_1c) demonstrated that the odds ratio (95% confidence intervals) of FU increased with measures of neuropathy such as NDS ≥ 6 (10.2, 6.2–17.3) and VPT ≥ 25 volts (19.8, 9.9–47.5), but was also significantly increased with absent SSR (15.3, 5.3–38.4). Conclusions Sudomotor dysfunction is associated with increased risk of FU and should be included in the screening tests for identification of diabetic patients at risk of ulceration.     

糖尿病周围神经病变和血管病变对糖尿病足溃疡的相互作用及相关性探讨

目的 探讨糖尿病足溃疡（DFU）发生的危险因素,分析糖尿病周围神经病变（DPN）和糖尿病血管病变（PAD）与DFU的相互作用.方法 选取T2DM患者278例,按其是否合并DFU分成糖尿病足溃疡组（DFU,102例）和糖尿病非足溃疡组（NDFU,176例）,回顾性分析两组生化特征和并发症情况.采用Logistic回归分析DFU发生的危险因素,并通过相对超额危险度比（RERI）,归因比（AP）和相互作用指数（S）评价DPN与PAD的相加相互作用.结果 与NDFU组比较,DFU组HbA1c和纤维蛋白原（FIB）水平,DR、DPN和PAD发生率均升高,血红蛋白（Hb）、血白蛋白（Alb）、TC和LDL-C降低（P＜0.05）.Logistic回归分析显示,DFU相关影响因素有：HbA1 c、DPN、PAD、Hb、Alb和FIB（OR分别为1.41、3.66、3.00、0.98、0.79和2.51）.DPN和PAD对DFU的相加相互作用指标RERI、AP和S分别为3.45（95％CI：1.22～8.56）、0.29（95％CI：0.02～0.58）和1.45（95％CI：1.03～4.96）.结论 血糖控制欠佳、合并DPN和PAD、营养不良及FIB代谢失衡是DFU发生的主要危险因素.DPN和PAD对DFU存在相加相互作用,同时患有DPN和PAD可增加DFU的患病风险.     

Diabetic foot ulcers: a quality of life issue

Foot ulcers are a serious complication of diabetes mellitus that are associated with adverse sequelae and high costs. In addition, such foot ulcers have a significant impact on quality of life (QoL). For example, the loss of mobility associated with foot ulcers affects patients' ability to perform simple, everyday tasks and to participate in leisure activities. These and other consequences of foot ulcers often lead to depression and poor QoL. Notably, several studies have shown that patients with diabetes mellitus and foot ulcers were more depressed and had poorer QoL than those who had no diabetic complications. Given the detrimental effect foot ulcers have on patients, it is essential that these foot ulcers are prevented or treated more effectively than at present. Evidence suggests that many foot ulcers can be prevented by using intensive interventions and adopting a multidisciplinary approach to treatment. In addition, preventative strategies may become more effective if new research into how patients with diabetes experience and interpret their health threats (e.g. diagnosis ‘loss of sensation’ or a foot ulcer episode) is taken into account. With regard to treatment, new options should enable ulcers to heal more quickly than with standard therapies. One area of interest is the use of growth factors. For example, recombinant platelet‐derived growth factor, in addition to good ulcer care, has been shown to improve the number of ulcers that heal and healing times significantly compared with good ulcer care alone. Other potential new treatments include the use of skin substitutes. In summary, improved preventative measures and wound treatment should reduce the potential for patients with diabetes mellitus to experience impaired QoL caused by foot ulcers. Copyright © 2001 John Wiley & Sons, Ltd.     

Foot complications in Type 2 diabetes: an Australian population-based study.

AIMS: To determine the prevalence and risk factors for neuropathy and peripheral vascular disease (PVD) in the Australian diabetic population and identify those at high risk of foot ulceration. METHODS: The Australian Diabetes Obesity and Lifestyle study included 11 247 adults aged >or= 25 years in 42 randomly selected areas of Australia. Neuropathy and PVD were assessed in participants identified as having diabetes (based on self report and oral glucose tolerance test), impaired fasting glucose, impaired glucose tolerance and in a random sample with normal glucose tolerance (total n = 2436). RESULTS: The prevalence of peripheral neuropathy was 13.1% in those with known diabetes (KDM) and 7.1% in those with newly diagnosed (NDM). The prevalence of PVD was 13.9% in KDM and 6.9% in NDM. Of those with diabetes, 19.6% were at risk of foot ulceration. Independent risk factors for peripheral neuropathy were diabetes duration (odds ratio (95% CI) 1.73 (1.33-2.28) per 10 years), height (1.42 (1.08-1.88) per 10 cm), age (2.57 (1.94-3.40) per 10 years) and uric acid (1.59 (1.21-2.09) per 0.1 mmol/l). Risk factors for PVD were diabetes duration (1.64 (1.25-2.16) per 10 years), age (2.45 (1.86-3.22) per 10 years), smoking (2.07 (1.00-4.28)), uric acid (1.03 (1.00-1.06) per 0.1 mmol/l) and urinary albumin/creatinine ratio (1.11 (1.01-1.21) per 1 mg/mmol). CONCLUSIONS: The prevalence of neuropathy and PVD was lower in this population than has been reported in other populations. This may reflect differences in sampling methods between community and hospital-based populations. Nevertheless, a substantial proportion of the diabetic population had risk factors for foot ulceration.     

Clinical outcome of diabetes patients hospitalized with foot ulcers, Dar es Salaam, Tanzania.

AIMS: To determine the prevalence rate, clinical features, risk factors, and clinical outcome of foot ulcers in diabetes patients admitted to Muhimbili National Hospital, Dar es Salaam, Tanzania. METHODS: A prospective cohort study of newly hospitalized, adult diabetes patients with foot ulcers was conducted during January 1997 to December 1998 (study period). Detailed clinical and epidemiological data were recorded for each patient, followed by a comprehensive physical examination. Clinical outcome was documented. RESULTS: Of 627 diabetes patients evaluated during the study period, 92 (15%) had foot ulcers. Of these 92 patients, 30 (33%) were selected for surgery (minor and major amputations); the rest were managed conservatively. Patients who underwent surgery were more likely than those who did not to have gangrene (P < 0.001) or neuropathy (P < 0.01). On stratification by severity of ulcers, patients with Wagner score > or = 4 were significantly more likely than those < 4 to have neuroischaemic foot lesions (P < 0.001) or delayed presentation to hospital (P < 0.001). The overall mortality rates for amputees and non-amputees were similar (29%); the highest in-patient mortality rate (54%) was observed among patients with severe (Wagner grade > or = 4) ulcers who did not undergo surgery. CONCLUSIONS: Diabetic foot ulcers are associated with significant morbidity and mortality in Tanzania. Mortality rates among patients with severe ulcers remain high despite surgery. Thus, surgery undertaken during the less severe stages of ulcers may improve patient outcome. Education of patients should underscore the importance of foot care and consulting a doctor during the early stages of foot ulcer disease.     

High Prevalence of Diabetes in Chronic Leg Ulcer Patients: a Cross-sectional Population Study

In a cross-sectional survey, designed to detect all patients with current chronic leg ulcers, 27% of the patients had diabetes mellitus. The outcome for the 104 examined diabetic patients has been evaluated and compared with the 278 nondiabetic patients. The purpose was to establish the prevalence of leg ulcers among diabetic patients and to assess potential causes. The point prevalence was calculated by extrapolating the leg ulcer frequency to the total diabetic population in the studied area. The point prevalence for active leg ulcers (including foot ulcers) in diabetic patients was 3.5% (95% CI 2.8–4.2). Ulcers above the malleoli were almost as common as foot ulcers. Peripheral vascular disease was present in 67% of all ulcerated legs in patients with diabetes compared to 42% in nondiabetic patients (p < 0.001). In 72% of foot ulcers in diabetic patients arterial impairment was judged to be a contributing aetiological factor and in nondiabetic patients 45% (p < 0.001). Ulcers solely attributed to possible neuropathy were less common (15%). Ulcers with multifactorial causes were common above the malleoli. This survey has given the size of the problem and indicates macroangiopathy to be the dominating factor responsible for slow or nonhealing ulcers in diabetic patients. Objective assessment of arterial circulation is mandatory and signs of arterial impairment require consultation with a vascular surgeon.     

Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross-sectional study

Aims The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in amputations, disability and reduced quality of life. DFS is preventable. The aim was to investigate the prevalence of the DFS at the primary care level in Germany. Methods This was a cross-sectional study of the prevalence of DFS, associated factors and glycaemic control at the primary care level in Germany. We examined an unselected sample of participants with known diabetes who were insured by Deutsche BKK, a large healthcare insurer. Results Three hundred and forty-one general practitioners examined 4778 participants with diabetes mellitus: 366 (7.7%) participants (mean age 49 ± 16 years) had Type 1 and 4412 participants (mean age 66 ± 10 years) had Type 2 diabetes. DFS was diagnosed in 138 patients, resulting in a prevalence of 3.6%[95% confidence interval (CI) 1.9, 6.0] in Type 1 and 2.8% (95% CI 2.3, 3.4) in Type 2 diabetes. DFS was independently associated with age, duration of diabetes, height, current smoking and insulin therapy. There was no significant effect of glycaemic control on the risk of DFS. The prevalence of other abnormal foot findings was: peripheral neuropathy 9.7%, peripheral arterial disease 14.8% (absent dorsalis pedis), 12.4% (absent tibialis posterior), acute diabetic foot ulcer 0.8%, amputations of lower extremities 1.5%, and amputations limited to toes 0.5%. Conclusions The prevalence of the DFS at the primary care level in Germany is 2.9%. Almost 50% of patients with DFS had major or minor amputations. Common risk factors such as hyperkeratosis and poor glycaemic control can be modified. Effective therapeutic approaches in addition to methods for primary and secondary prevention of DFS should be used more widely.     

Diabetes, hand and/or foot ulcers: a cross-sectional hospital-based study in Port Harcourt, Nigeria

OBJECTIVE: The study aimed to establish the prevalence of diabetes mellitus and the pattern of diabetic hand and foot ulcers in hospitalized adult patients in a teaching hospital in Port Harcourt, Nigeria. RESEARCH DESIGN AND METHODS: All medical admission at the University of Port Harcourt Teaching Hospital between January 2000 and April 2001 were included in this cross-sectional study. Diabetes mellitus was diagnosed based on a fasting venous plasma glucose >or=7.0 mmol/l or a 2-h post-prandial venous plasma glucose level of >or=11.1 mmol/L using the glucose oxidase method. Data was processed for the 60 diabetic patients with limb ulcers excluding ulcers from major trauma. RESULTS: The prevalence of diabetes mellitus was 38.1% (95% CI=34.8-41.4) among medical in-patients; while hand and foot ulcer was 19.1% among diabetic patients. The left lower limb ranked highest in ulcer involvement (32/60); hand ulcers were found in 5 cases (8.3%). Twenty (33.3%) of the patients had a previous limb ulcer. In 31 patients (51.7%) the ulcers evolved spontaneously without an identifiable cause (p-value=0.00). By Wagner's Grading System, Grade III lesions ranked highest (21/64). CONCLUSIONS: A high prevalence of hand and foot ulcers was confirmed among patients with diabetics, which are common indications for hospitalization, and usually associated with long hospital stay with adverse outcomes including amputation and death. Diabetes education needs to be stepped-up, with emphasis on foot care and early presentation to hospital in the event of limb ulceration.     

Elevation of von Willebrand factor in plasma in diabetic patients with neuropathic foot ulceration.

AIMS: The present study examines the relationship between markers of endothelial dysfunction and diabetic neuropathy or consequent neuropathic foot ulceration in patients with Type 2 diabetes mellitus. METHODS: We studied 65 Type 2 diabetic patients including 25 diabetic patients without neuropathy, 27 with neuropathy but no history of foot ulceration, and 13 with neuropathic ulceration. Plasma concentrations of von Willebrand factor (vWF) and soluble thrombomodulin (TM), measures of endothelial dysfunction, were determined by enzyme immunoassays. We performed various tests quantifying aspects of diabetic neuropathy including vibration perception threshold (VPT; for sensory neuropathy), coefficient of variation of R-R intervals (CVR-R; for cardiac autonomic neuropathy), and cold-induced vasodilation in the great toe for peripheral sympathetic neuropathy. RESULTS: CVR-R and cold-induced vasodilation were significantly diminished in patients with neuropathic foot ulceration compared with patients with neuropathy but no history of foot ulceration. Plasma vWF concentrations were positively correlated with VPT and cold-induced vasodilation test, and were inversely correlated with CVR-R. Multivariate analysis disclosed that VPT and percentage vasodilation were independent factors for plasma vWF. Plasma vWF was significantly elevated in patients with foot ulceration compared with patients without neuropathy or those with neuropathy but not foot ulceration. However, plasma TM concentrations did not differ between the three groups. CONCLUSIONS: Diabetic patients with neuropathic foot ulceration had severe impairment of cardiac autonomic and peripheral sympathetic nerves. Elevation of vWF in plasma was associated with neuropathic foot ulceration, linking endothelial dysfunction to foot ulceration.     

Prevention of foot ulcers in the at‐risk patient with diabetes: a systematic review

Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non‐controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot‐related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight‐bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self‐management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non‐existent for the prevention of a first foot ulcer and non‐plantar foot ulcer.     

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee‐high offloading device is the first choice of offloading treatment. A removable knee‐high and removable ankle‐high offloading device are to be considered as the second‐ and third‐choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth‐choice offloading treatment. If non‐surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.     

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention.

AIM: To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk. METHOD: A systematic review of interventions to prevent diabetic foot ulcers. RESULTS: Available studies are generally unsatisfactory in their ability to answer the important questions relating to prevention. However, where people with diabetes receive well-organized and regular care with rapid referral to appropriate specialist multidisciplinary teams when problems (or their precursors) occur, ulcer morbidity can be substantially reduced. CONCLUSION: Foot ulcers are common in people with diabetes and are costly in terms of both patient morbidity and the use of healthcare resources. Although it is nearly a decade since the St Vincent Declaration called for a marked reduction in morbidity to be achieved through better patient management, available evidence suggests that the process of care in Britain is still very variable in quality. Foot care for people with diabetes must be organized to provide monitoring, education and referral in a manner acceptable to patients and realistic for local healthcare providers.