The utility of Vibratip in accurate identification of loss of protective sensation in the contralateral foot of patients admitted with a diabetic foot ulcer

Background and aimsDiabetic foot ulcer (DFU) is a debilitating complication of type 2 DM. Complexity of foot examination often precludes proper clinical assessment of the foot during routine evaluation. We assessed the utility of novel device, vibratip, both singly and in combination with standard bedside tools for assessment of loss of protective sensation.Methods75 patients admitted with DFU were included in the study. Clinical examination of the contralateral foot was done - temperature perception, vibration, pinprick sensation, Achilles tendon reflex and Neuropathy disability score were assessed. Testing using 10 g Monofilament, Vibratip and biothesiometer were also done. Considering the biothesiometer as the reference standard, three bedside tests (Vibratip, 10 g monofilament and 128 Hz tuning fork) were compared against it singly and in combinations.ResultsWhen compared against biothesiometer, vibratip performed significantly well with a positive predictive value of 90.3% and specificity of 84.2%. Sensitivity, however, was only 50%. On combining bedside tests, the best combination strategy was seen with vibratip and 10 g monofilament, which improved the sensitivity to 62.5%. Combining all three bedside tests further improved sensitivity to 64.3%.ConclusionAll the patients with an at-risk foot may not be identified with vibratip alone. Nevertheless, an abnormal result is almost always associated with loss of protective sensation, and such persons should be suitably educated.LimitationsDue to small size of the study population, it is not possible to generalize the findings to all patients with diabetes mellitus. A larger study would be required to provide more confirmatory findings.     

Association of the functional A118G polymorphism of OPRM1 in diabetic patients with foot ulcer pain

BackgroundDiabetic foot ulcer (DFU) patients may experience moderate or severe pain. A single-nucleotide polymorphism, at nucleotide 118 for opioid receptor mu 1 (OPRM1), has been reported to alter the opioid effects to relieve acute or chronic pain. The purpose of this study was to elucidate the correlation between nucleotide 118 variants and foot ulcer pain in DFU patients.MethodsSixty-five DFU patients with Grade 2–5 Wagner–Meggitt classification were enrolled. The occurrence of pain in activities was categorized into five grades. Patients were allocated either into the painless DFU group, with a visual analog scale (VAS) pain score ≦3, or into the painful DFU group, with a VAS pain score ≧4 and Grades 3–5 of occurrence of pain in daily activities. DNA was extracted from blood samples of analyzed patients. Using the polymerase chain reaction–single-strand conformation polymorphism analysis and DNA sequencing of nucleotide 118, we identified the genotype distribution and allelic frequencies in DFU patients. The sequences of the forward and the reverse primer are designed as follows: 5′-TAATACGACTCACTATAGGG-3′ and 5′-ACGCACACGATGGAGTAGAG-3′, respectively.ResultsFifteen patients were classified into the painful DFU group and 50 patients were classified into the painless DFU group. The amplified DNA fragments showed 26 homozygous (AA), 34 heterozygous (AG), and 5 mutant homozygous (GG) genotypes, with overall A and G allelic frequencies of 66.2% and 33.8%, respectively. The painful DFU group included 10 AA subjects, 4 AG subjects, and 1 GG subject, while the painless DFU group had 16 AA, 30 AG, and 4 GG subjects (P=.038).ConclusionThe A118G polymorphism of mu-opioid receptor may be closely associated with DFU pain in 34 out of 50 patients in the painless group and in 5 out of 15 patients in the painful group. This indicates that the nucleotide 118 variant patients may suffer less DFU pain.     

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.     

Incidence and characteristics of diabetic foot ulcers in subjects with type 2 diabetes in Catalonian primary care centres: An observational multicentre study

AimsThe main objective was to assess the incidence of diabetic foot ulcers in type 2 diabetes individuals from primary care centres in Catalonia, Spain.MethodsProspective observational study in 36 Primary Care centres in Catalonia during February 2018 and July 2019 was conducted. We included participants with type 2 diabetes and a new foot ulcer. We estimated the annual foot ulcer incidence and described the characteristics: presence of comorbidities, clinical parameters and the characteristics of the diabetic foot ulcers (DFU) at inclusion in the study.ResultsThe incidence of a new DFU during the 12-month recruitment period was 0.42%. The mean age of the participants was 72.2 years (± 12.7), the majority of them were males (n = 178; 69.5%). Overall, 43.8% of DFUs were located on the dorsal aspect of toes or interdigital spaces. A percentage of 43.4% of the participants had ulcers of less than 1 cm2 surface. Further, 44.1% of the participants had a neuroischemic, 20.3% a neuropathic, 20.3% an ischemic ulcer. A 25.3% of ulcers with a concomitant peripheral artery disease were infected.ConclusionsAlthough the incidence found was low, our study shows the great complexity of patients with foot ulcers treated in primary care.     

Mesenchymal stem cells ameliorate impaired wound healing through enhancing keratinocyte functions in diabetic foot ulcerations on the plantar skin of rats

Aims/hypothesisAlthough the initial healing stage involves a re-epithelialization in humans, diabetic foot ulceration (DFU) has been investigated using rodent models with wounds on the thigh skin, in which a wound contraction is initiated. In this study, we established a rodent model of DFU on the plantar skin and evaluated the therapeutic efficacy of bone-marrow-derived mesenchymal stem cells (BM-MSCs) in this model.MethodsThe wounds made on the hind paws or thighs of streptozotocin induced diabetic or control rats were treated with BM-MSCs. Expression levels of phosphorylated focal adhesion kinase (pFAK), matrix metaroprotease (MMP)-2, EGF, and IGF-1, were evaluated in human keratinocytes, which were cultured in conditioned media of BM-MSCs (MSC-CM) with high glucose levels.ResultsRe-epithelialization initiated the healing process on the plantar, but not on the thigh, skin. The therapy utilizing BM-MSCs ameliorated the delayed healing in diabetic rats. In the keratinocytes cultured with MSC-CM, the decreased pFAK levels in the high glucose condition were restored, and the MMP2, EGF, and IGF-1 levels increased.Conclusions/interpretationOur study established a novel rat DFU model. The impaired healing process in diabetic rats was ameliorated by transplantation of BM-MSCs. This amelioration might be accounted for by the modification of keratinocyte functions.     

Barriers to diabetic foot care in a disadvantaged population: A qualitative assessment

ObjectiveWe explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD).MethodsParticipants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs.ResultsForty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU.ConclusionWe found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.     

Footwear interventions for foot pain,function, impairment and disability for people with foot and ankle arthritis: A literature review

ObjectiveTo conduct a literature review on the effectiveness of footwear on foot pain, function, impairment and disability for people with foot and ankle arthritis.MethodsA search of the electronic databases Scopus, Medline, CINAHL, SportDiscus and the Cochrane Library was undertaken in September 2017. The key inclusion criteria were studies reporting on findings of footwear interventions for people with arthritis with foot pain, function, impairment and/or disability. The Quality Index Tool was used to assess the methodological quality of studies included in the qualitative synthesis. The methodological variation of the included studies was assessed to determine the suitability of meta-analysis and the grading of recommendations, assessment, development and evaluation (GRADE) system. Between and within group effect sizes were calculated using Cohen’s d.Results1440 studies were identified for screening with 11 studies included in the review. Mean (range) quality scores were 67% (39–96%). The majority of studies investigated rheumatoid arthritis (n = 7), but also included gout (n = 2), and 1st metatarsophalangeal joint osteoarthritis (n = 2). Meta-analysis and GRADE assessment were not deemed appropriated based on methodological variation. Footwear interventions included off-the-shelf footwear, therapeutic footwear and therapeutic footwear with foot orthoses. Key footwear characteristics included cushioning and a wide toe box for rheumatoid arthritis; cushioning, midsole stability and a rocker-sole for gout; and a rocker-sole for 1st metatarsophalangeal joint osteoarthritis. Between group effect sizes for outcomes ranged from 0.01 to 1.26. Footwear interventions were associated with reductions in foot pain, impairment and disability for people with rheumatoid arthritis. Between group differences were more likely to be observed in studies with shorter follow-up periods in people with rheumatoid arthritis (12 weeks). Footwear interventions improved foot pain, function and disability in people with gout and foot pain and function in 1st metatarsophalangeal joint osteoarthritis. Footwear interventions were associated with changes to plantar pressure in people with rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and walking velocity in people with rheumatoid arthritis and gout.ConclusionFootwear interventions are associated with reductions in foot pain, impairment and disability in people with rheumatoid arthritis, improvements to foot pain, function and disability in people with gout and improvements to foot pain and function in people with 1st metatarsophalangeal joint osteoarthritis. Footwear interventions have been shown to reduce plantar pressure rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and improve walking velocity in rheumatoid arthritis and gout.     

Randomized trial of custom orthoses and footwear on foot pain and plantar pressure in diabetic peripheral arterial disease

Aim Custom‐made foot orthoses reduce plantar pressure, ulceration and amputation in patients with diabetes mellitus. There is limited evidence of their effect on foot pain. In a randomized, single‐blind, sham‐controlled trial, the efficacy of custom orthoses on foot pain and plantar pressure in diabetic patients with peripheral arterial disease was investigated. Methods Sixty‐one participants were randomly assigned to either custom foot orthoses (n = 30) or sham insoles (n = 31). Both groups also received standardized walking footwear. Outcomes included foot pain and function, mean pressure, toe‐brachial index, average daily steps, disability, comfort, quality of life, adherence and adverse events. A multivariate predictive model was constructed to explore factors contributing to pain relief during the trial. Results At 8 weeks, 95% of participants provided follow‐up data, adherence was high and there were few adverse events. Foot pain and function scores significantly improved at 8 weeks with both custom orthoses and the sham, but there was no significant difference between groups. Custom orthoses reduced pressure significantly more than the sham. There were no significant differences between groups for toe‐brachial index, daily steps, disability, comfort or quality of life. Regression modelling identified inappropriate pre‐trial footwear as the strongest predictor of foot pain relief during the trial. Conclusions Custom foot orthoses significantly reduced plantar pressure compared with the sham, but there were no significant differences between groups for pain or function. The high‐quality walking footwear provided to both groups may explain this finding. Footwear should have greater emphasis as the clinical intervention.     

Prevalence and risk factors for diabetic peripheral neuropathy,neuropathic pain and foot ulceration in the Arabian Gulf region

Aims/IntroductionThis study determined the prevalence and risk factors for diabetic peripheral neuropathy (DPN), painful DPN and diabetic foot ulceration (DFU) in patients with type 2 diabetes in secondary healthcare in Qatar, Kuwait and the Kingdom of Saudi Arabia.Materials and MethodsAdults aged 18–85 years with type 2 diabetes were randomly enrolled from secondary healthcare, and underwent clinical and metabolic assessment. DPN was evaluated using vibration perception threshold and neuropathic symptoms and painful Diabetic Peripheral Neuropathy was evaluated using the Douleur Neuropathique 4 questionnaire.ResultsA total of 3,021 individuals were recruited between June 2017 and May 2019. The prevalence of DPN was 33.3%, of whom 52.2% were at risk of DFU and 53.6% were undiagnosed. The prevalence of painful DPN was 43.3%, of whom 54.3% were undiagnosed. DFU was present in 2.9%. The adjusted odds ratios for DPN and painful DPN were higher with increasing diabetes duration, obesity, poor glycemic control and hyperlipidemia, and lower with greater physical activity. The adjusted odds ratio for DFU was higher with the presence of DPN, severe loss of vibration perception, hypertension and vitamin D deficiency.ConclusionsThis is the largest study to date from the Middle East showing a high prevalence of undiagnosed DPN, painful DPN and those at risk of DFU in patients with type 2 diabetes, and identifies their respective risk factors.     

Cross-sectional analysis of foot function, functional ability, and health-related quality of life in older people with disabling foot pain

Objective

To determine whether disabling foot pain is associated with foot function characteristics, functional ability, and health‐related quality of life (HRQOL) in older adults.

Methods

The Manchester Foot Pain and Disability Index was used to establish the presence of foot pain in 312 community‐dwelling men and women age >60 years. Ankle dorsiflexion strength and flexibility, foot reaction time, hallux and lesser toe flexor strength, and spatiotemporal gait parameters were measured to characterize foot function. Participants completed postural sway tasks and the Short Form 36 Health Survey (SF‐36) as a measure of HRQOL. Participants with disabling foot pain, classified using both the original and conservative (at least 1 item scored as “most/every day”) definitions, were then compared to those without pain, adjusting for sex and body mass index.

Results

Participants with foot pain scored significantly lower on the total SF‐36 and all subcomponents. Ankle dorsiflexion strength, hallux strength, stride length, step length, and walking speed were significantly reduced in those with foot pain. After applying a more conservative cutoff for disabling foot pain, reduced toe flexor strength, increased foot reaction time, increased postural sway, increased time in double support, and reduced time in single support emerged as additional characteristics of those with disabling foot pain.

Conclusion

Older people with disabling foot pain exhibit reduced HRQOL, functional impairment, and alterations to foot function that may contribute to an increased risk of falling. Providing interventions to older people to reduce foot pain and improve foot function may play a role in improving mobility and quality of life.     

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.     

Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons

OBJECTIVES: To examine whether common musculoskeletal disorders of feet are associated with pain and foot-related functional limitation. DESIGN: A cross-sectional study using stratified random sampling. Setting: A residential community. PARTICIPANTS: Ethnically diverse sample of elderly persons (n=784). MEASUREMENTS: Foot disorders (hallux valgus/bunion, pes planus (flat foot), pes cavus (high arch), hammertoe, mallet toe, claw toe, overlapping toes, bunionette, and plantar fasciitis), foot pain, the foot health functional status (FHFS, range 0-100, 100=no problems) scale, and walk time score (range 0-4, 4=fastest). RESULTS: Most commonly assessed musculoskeletal disorders, including hallux valgus and toe deformities, were not associated with pain or function limitation. Plantar fasciitis and, to a lesser extent, pes cavus were associated with worse FHFS scores; foot pain partially explained this association. Neither foot disorders nor foot pain were significantly associated with slower walk times. CONCLUSION: Many foot disorders had little relationship with foot pain or function and may not require clinical attention when asymptomatic. Risk factors and preventive and therapeutic interventions for plantar fasciitis require further longitudinal investigation.     

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)

AimsThe objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors.MethodsWe assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation ± DFU and debridement, and no foot conditions.ResultsOverall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR = 0.21; 95% CI: 0.10, 0.46) or DFU (OR = 0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications.ConclusionIn managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.     

Differences in foot sensitivity and plantar pressure between young adults and elderly

ObjectiveThe understanding of foot sensitivity and plantar pressure contributes to the design of insoles, shoes, as well as to guide therapeutic interventions. Here we investigate differences in plantar pressure and foot sensitivity between young adults and community-dwelling elderly.MethodsThirty-eight participants (19 young adults and 19 elderly) underwent clinical assessment of foot sensitivity and upright standing with eyes open and closed for measurement of plantar pressure in each foot. Data were compared between feet, groups, and visual conditions.ResultsFoot sensitivity was lower in the elderly and, in contrast to young adults, differed between the foot regions (loss of sensitivity was primarily seen at the heel). Elderly shift plantar pressure to more distal foot zones, namely towards midfoot and forefoot. Asymmetries in foot sensitivity and plantar pressure were not observed. Visual condition did not influence plantar pressure distribution.ConclusionsThe forward shift in plantar pressure (away from the insensitive heel) constitutes a strategy of elderly to maintain balance.     

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.     

Correlation between plantar foot temperature and diabetic neuropathy: a case study by using an infrared thermal imaging technique

Background

Diabetic neuropathy consists of multiple clinical manifestations of which loss of sensation is most prominent. High temperatures under the foot coupled with reduced or complete loss of sensation can predispose the patient to foot ulceration. The aim of this study was to look at the correlation between plantar foot temperature and diabetic neuropathy using a noninvasive infrared thermal imaging technique.

Methods

Infrared thermal imaging, a remote and noncontact experimental tool, was used to study the plantar foot temperatures of 112 subjects with type 2 diabetes selected from a tertiary diabetes centre in South India.

Results

Patients with diabetic neuropathy (defined as vibration perception threshold (VPT) values on biothesiometry greater than 20 V) had a higher foot temperature (32–35 °C) compared to patients without neuropathy (27–30 °C). Diabetic subjects with neuropathy also had higher mean foot temperature (MFT) (p = .001) compared to non-neuropathic subjects. MFT also showed a positive correlation with right great toe (r = 0.301, p = .001) and left great toe VPT values (r = 0.292, p = .002). However, there was no correlation between glycated hemoglobin and MFT.

Conclusion

Infrared thermal imaging may be used as an additional tool for evaluation of high risk diabetic feet.     

The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital

AimWound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70–80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU).Materials and methodsData from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula.ResultsThe study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions.ConclusionsThe results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.     

Foot and ankle risk factors for falls in older people: a prospective study

BACKGROUND: Foot problems are common in older people and are associated with impaired balance and functional ability. Few prospective studies, however, have been undertaken to determine whether foot problems are a risk factor for falls. METHODS: One hundred seventy-six people (56 men and 120 women, mean age 80.1, standard deviation 6.4 years) residing in a retirement village underwent tests of foot and ankle characteristics (including foot posture, range of motion, strength, and deformity) and physiological falls risk factors (including vision, sensation, strength, reaction time, and balance) and were followed for 12 months to determine the incidence of falls. RESULTS: Seventy-one participants (41%) reported falling during the follow-up period. Compared to those who did not fall, fallers exhibited decreased ankle flexibility, more severe hallux valgus deformity, decreased plantar tactile sensitivity, and decreased toe plantarflexor strength; they were also more likely to have disabling foot pain. Discriminant function analysis revealed that decreased toe plantarflexor strength and disabling foot pain were significantly and independently associated with falls after accounting for physiological falls risk factors and age. CONCLUSIONS: Foot and ankle problems increase the risk of falls in older people. Interventions to address these factors may hold some promise as a falls prevention strategy.     

Amputation-free survival in patients with diabetic foot ulcer and peripheral arterial disease: Endovascular versus open surgery in a propensity score adjusted analysis

AimsThe aim of the present study was to compare outcomes of endovascular surgery versus open vascular surgery in patients with diabetic foot ulcer (DFU) and peripheral arterial disease (PAD).MethodsBetween 1984 and 2006, 1151 patients with DFU were admitted to the diabetic foot care team. Three hundred seventy-six patients with 408 limbs were consecutively included at a multidisciplinary foot center, 289 limbs were treated with endovascular surgery and 119 limbs with open vascular surgery first strategy. A propensity score adjusted analysis was performed to compare outcomes for type of revascularization.ResultsMajor amputation rates at 3 years were 17.0% and 16.8% (p = 0.97) and mortality at 3 years were 43.1% and 46.5% (p = 0.55) after endovascular surgery and open vascular surgery, respectively. In the propensity score adjusted analysis, patients undergoing endovascular surgery first had similar outcomes in terms of major amputation, mortality, combined major amputation/mortality compared to those undergoing open vascular surgery. Longer time to intervention (p = 0.003) was associated with increased major amputation rate in the multivariable Cox regression analysis.ConclusionThe endovascular surgery first and open vascular surgery first strategies were associated with similar long-term results in a large cohort of patients with DFU and PAD undergoing revascularization. Rapid revascularization reduces the risk of amputation.     

Diabetes-related foot ulcers and associated factors: Results from the Nord-Trøndelag Health Survey (HUNT3) (2006–2008)

AimTo determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.MethodsIn 2006–2008, all inhabitants in Nord-Trøndelag County aged ≥ 20 years were invited to take part in this population-based study; 54% (n = 50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3 weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.ResultsAmong participants with diabetes, 7.4% (95% confidence interval (CI) 6.2%–8.6%) reported a DFU. The median healing time was 6.0 weeks. In the final model, factors associated with a DFU were age ≥ 75 years (odds ratio (OR) 2.3, 95% CI 1.4–3.7), male sex (OR 2.0, 95% CI 1.3–3.1), waist circumference ≥ 102 cm (men) or 88 cm (women) (OR 1.95, 95% CI 1.2–3.2), insulin use (OR 2.1, 95% CI 1.3–3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1–2.8).ConclusionsThe proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥ 75 years, male sex, waist circumference ≥ 102 cm (men) or 88 cm (women), insulin use and any macrovascular complication. The median healing time was 6 weeks.