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。     

A podiatrist's view of community diabetic foot management

The diabetic foot is an enormous burden to the patient, society and to the NHS. This article offers a podiatrist's view of the diabetic foot: the principles behind the disease process, the management of diabetic foot complications and how problems can be avoided. The major contributing factors of diabetic foot ulcers are discussed, the role of the podiatrist described, and the principles of screening and community-based management of ulcers outlined. Education and communication are highlighted as key elements in successful diabetic foot management.     

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。     

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。     

Understanding diabetic foot ulcers. 1: Pathophysiology

This is the first part of a two-part unit on diabetic foot ulcers. It describes the pathophysiology, risk factors and signs and symptoms of diabetic foot ulcers.     

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.     

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.     

Leukocyte scanning with 111In is superior to magnetic resonance imaging in diagnosis of clinically unsuspected osteomyelitis in diabetic foot ulcers.

OBJECTIVE--To compare the accuracies of MRI and leukocyte scanning in diagnosing clinically unsuspected osteomyelitis in diabetic foot ulcers. RESEARCH DESIGN AND METHODS--A prospective study of 16 diabetic foot ulcers in 12 patients, including both ambulatory and hospitalized patients, was performed at a university medical center. Pedal images were obtained by leukocyte scanning with [111In]oxyquinoline and MRI. Definitive diagnosis of osteomyelitis then was determined by bone biopsy for culture and histology. RESULTS--Biopsy-proven osteomyelitis was present in 7 (44%) of the 16 foot ulcers. The diagnosis was suspected clinically in 0%. Leukocyte scanning was 100% sensitive, whereas MRI was only 29% sensitive in diagnosing osteomyelitis in diabetic foot ulcers. Specificities were 67 and 78%, respectively. The positive and negative predictive values (70 and 100%, respectively) for the leukocyte scan also were greater than those of MRI (50 and 58%, respectively). CONCLUSIONS--Leukocyte scanning is superior to MRI in detecting clinically unsuspected osteomyelitis in diabetic foot ulcers.     

Spontaneous calcaneal fracture in patients with diabetic foot ulcer: Four cases report and review of literature

Spontaneous calcaneal fractures in diabetic patients without obvious trauma may occur, sometimes accompanying diabetic foot ulcers. In the current study we report four cases who were hospitalized for diabetic foot ulcer with concomitant calcaneal fractures. There were four diabetic patients (one type 1 and three type 2) who registered with diabetic foot ulcers with coexisting calcaneal fractures, all of which were classified as Type A according to Essex Lopresti Calcaneal Fracture Classification. Two of the patients with renal failure were in a routine dialysis program, as well as vascular compromise and osteomyelitis in all of the patients. The diabetic foot ulcer of the 61 years old osteoporotic female patient healed with local debridement, vacuum assisted closure and then epidermal growth factor while the calcaneal fracture was then followed by elastic bandage. In two patients could not prevent progression of diabetic foot ulcers and calcaneal fractures to consequent below-knee amputation. The only patient with type 1 diabetes mellitus improved with antibiotic therapy and split thickness skin grafting, while the calcaneal fracture did not heal. In the current study we aimed to emphasize the spontaneous calcaneal fractures as possible co-existing pathologies in patients with diabetic foot ulcers. After all the medical treatment, amputation below knee had to be performed in 2 patients. It should be noted that other accompanying conditions such as impaired peripheral circulation, osteomyelitis, chronic renal failure, and maybe osteoporosis is a challenge of the recovery of calcaneal fractures and accelerate the progress to amputation in diabetic patients.     

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.     

Implementing Diabetic Foot Care in the Primary Care Setting

Patients with diabetes mellitus are at risk for foot ulcers and subsequent amputations. The outpatient diabetic population could benefit from services to prevent factors that lead to the development of foot ulcers and further complications. The purpose of this project was to evaluate the effectiveness and feasibility of implementing a foot care program in the primary care setting. An evaluation of the outcomes supported these foot care services. Future studies showing the effectiveness of foot care services in the primary care setting would further substantiate the benefits of providing diabetic foot care in primary care practice.     

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.     

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.     

Assessment and treatment of diabetic foot ulcer

BACKGROUND AND OBJECTIVES: Foot ulcers are one of the main complications in diabetes mellitus, with a 15% lifetime risk in all diabetic patients. The rate of lower extremity amputation among diabetic patients is 17-40 times higher than in non-diabetics. A critical triad of neuropathy, minor foot trauma and foot deformity was found in > 63% of diabetic foot ulcers (DFU). Peripheral vascular disease (PVD) has been identified in 30% of foot ulcers. We present a comprehensive assessment and the treatment of DFUs. We also want to notify physicians not to ignore foot assessment and examinations in patients with diabetes. METHODS: We conducted this study on DFU on the basis of: pathogenesis and risk factors, assessment and physical examination, paraclinic assessment, treatment, cost and mortality and prevention. RESULTS AND FINDINGS: Approximately 20% of hospital admissions among diabetic patients are the result of foot problems. Diabetic foot assessment should include dermatological, vascular, neurological and musculoskeletal systems. There are three basic treatments for management of DFU: (i) debridement; (ii) antibiotics and (iii) revascularization. The cost to treat one simple ulcer is $5000 to $8000. CONCLUSION: Awareness of physicians about foot problems in diabetic patients, clinical examination and paraclinical assessment, regular foot examination, patient education, simple hygienic practices and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50%.     

中西医结合护理糖尿病足疗效的Meta分析

目的评价中西医结合护理糖尿病足的疗效,以期做出客观可信的评价,指导临床护理。方法检索中国生物医学文献数据库、中国学术期刊全文数据库、Medline数据库及维普期刊数据库中关于中西医结合护理糖尿病足效果的随机对照试验(randomized controlled trial,RCT),检索时间从2005年1月至2011年3月,采用RevMan5.0对符合纳入标准的文献进行Meta分析。结果共有8篇临床试验文献,860例患者满足纳入标准。中西医结合护理糖尿病足有效率的合并检验分析结果为:Z=9.74,P<0.01;合并后的OR值为12.32,95%可信区间为7.43～20.43。结论中西医结合护理糖尿病足是一种有效的方法。     

中西医结合治疗糖尿病足溃疡60例临床护理

目的:探讨中西医结合治疗糖尿病足溃疡的护理方法.方法:将100例糖尿病足溃疡患者随机分为治疗组60例和对照组40例,两组均予以常规内科综合治疗、全身及足局部护理,足溃疡面均给予西药湿敷;治疗组除以上治疗外口服中药汤剂,足溃疡面中药制剂湿敷,比较两组疗效.结果:治疗组总有效率93.3%,治愈时间(17.7±6.5) d;对照组总有效率80.0%,治愈时间(23.4±7.5) d.治疗组疗效明显优于对照组(P<0.01).结论:中西医结合治疗及加强护理治疗糖尿病足溃疡疗效显著,值得推广.     

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.     

超声清创术联和智能负压创伤治疗技术治疗糖尿病足溃疡的护理

目的 探讨应用超声清创术和智能负压创伤治疗技术(INPWT)治疗糖尿病足溃疡的有效性和规范化护理措施。 方法 将80例糖尿病足溃疡Wangner分级2、3级患者分为负压组53例和常规组27例。负压组给予超声清创术和智能负压创伤治疗技术治疗,同时,实施规范化的护理。常规组按传统方法每天予以创面换药。 结果 负压组治疗总有效率高于常规组。 结论 应用超声清创术和智能负压创伤治疗技术治疗糖尿病足溃疡可提高治愈率;实施规范化的护理能够防止并发症,保障负压治疗的完成。     

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.