Reasons for (non‐)adherence to self‐care in people with a diabetic foot ulcer

We aimed to explore reasons for (non‐)adherence to self‐care among people with diabetic foot ulcers, as well as barriers and solutions to improving their self‐care adherence. We performed a qualitative study, recruiting people with a diabetic foot ulcer from a community diabetic foot clinic. Semistructured interviews were held with participants. Data saturation occurred after 9 and was confirmed after 11 participant interviews. Interviews were audio‐taped, transcribed verbatim and analyzed using the framework approach. Findings were mapped and the World Health Organization's (WHO) adherence dimensions were applied to themes identified. The key themes identified were (1) participants performed recommended practices in self‐care; (2) participants relied heavily on care support; (3) motivations for self‐care came from “staying well”; and (4) there was a disparity between self‐care knowledge and understanding. Barriers identified included poor mobility and visibility, difficulty wearing offloading devices or using wound dressings, and frustration with lack of progress. Solutions to improve adherence included integrating self‐care as routine, improved education, more external help and improving visibility. All five WHO adherence dimensions played a role in (non‐)adherence to diabetic foot ulcer self‐care. We conclude that adherence to recommended diabetic foot ulcer self‐care was limited at best, and reasons for nonadherence were multidimensional. Based on the factors related to (non‐)adherence and the barriers and solutions described, we suggest clinicians obtain a broad view of a person's situation when aiming to improve self‐care adherence.     

Pathophysiology and treatment of diabetic foot ulcer

The etiology of diabetic foot ulcers is reviewed. A combination of neuropathy, angiopathy, and biomechanical forces are shown to cause foot ulcers in the diabetic patient. A treatment regimen for the resolution of these ulcers is proposed. Early detection with meticulous care and a high level of suspicion for infection expedites patient care. Metabolic control of diabetes mellitus will also encourage more rapid resolution of the diabetic foot ulcer. Patient education and compliance provides significant results and decreases the incidence of ulceration.     

个案管理师主导的糖尿病足部溃疡患者照护方案实施

目的 实施个案管理师主导的糖尿病足部溃疡患者照护方案,提高糖尿病足护理效果。方法 选取伤口治疗师担任个案管理师,依托创面治疗医生、康复师、骨科专科护士、糖尿病专科护士组成多学科协作团队,对146例糖尿病足部溃疡住院患者实施个案管理。结果 146例患者均没有新发足部溃疡,患者出院后6个月的Wagner分级较干预前显著改善(P<0.05);患者出院后6个月空腹血糖及糖化血红蛋白水平较出院前显著下降(均P<0.05)。患者出院后糖尿病自我管理活动评分、足部护理知识和行为得分较入院时显著提高(均P<0.05)。结论 实施个案管理师主导的照护方案可以有效提高糖尿病足部溃疡患者自我管理活动能力,改变其足部护理知识和行为,有效控制血糖,促进创面愈合。     

Incidence,risk factors for amputation among patients with diabetic foot ulcer in a North Indian tertiary care hospital

ObjectiveAim of this study was to evaluate the incidence and risk factors for amputation among patients with diabetic foot ulcer (DFU).Research design and methodsWe performed a prospective study of 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology centre of Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh, India during the period of December 2008–March 2011. Detailed history and physical examination was carried out for every subject. Risk factors for amputation were determined by univariate analysis with 95% of CI.ResultsThe overall amputation rate was 28.4%. On univariate analysis, male sex [OR 2.8, RR 1.28], hypertension [OR 2.83, RR 1.31], neuropathy [OR 3.01, RR 1.35], nephropathy [OR 2.24, RR 1.26], LDL-C (>100 mg/dl) [OR 2.53, RR 1.28], total cholesterol (>150 mg/dl) [OR 3.74, RR 1.52],HDLC(<40 mg/dl) [OR 1.19, RR 1.18], triglycerides (>200 mg/dl) [OR 5.44, RR1.76], previous antibiotic use [OR 9.12, RR 1.92], osteomyelitis [OR 6.97, RR 2.43] and biofilm infection [OR 4.52, RR 1.41] were significant risk factors.ConclusionThe risk factors for amputation were presence of PVD, leukocytosis, neuropathy, nephropathy, hypertension, dyslipidemia, over use of antibiotics, osteomyelitis, biofilm production and higher grade of ulcer.     

Amputation in diabetic foot ulcer: A treatment dilemma

Diabetic foot is a clinical manifestation of diabetes with a wide range of symptoms, including ulceration, osteomyelitis, osteoarticular destruction, and gangrene, as a consequence of advanced disease. Some diabetic foot cases present general indications for amputation, including dead limb, threat to the patient’s life, pain, loss of function, or nuisance. Various tools have been introduced to help decision-making in amputation for diabetic foot. However, it remains a conundrum because diabetic foot involves multiple pathomechanisms and factors that hinder its outcomes. Sociocultural issues often impede treatment from the patient’s side. We reviewed different perspectives in diabetic foot management, particularly related to amputation. In addition to deciding whether to amputate, physicians should address amputation level, timing, and ways to avoid patient deconditioning. Surgeons should not be autocratic in these circumstances and should be aware of beneficence and maleficence when considering whether to amputate. The main goal should be improving the patients’ quality of life rather than preserving the limb as much as possible.     

Incidence and risk factors of new foot ulcer among diabetic patients on peritoneal dialysis

Objective To study the incidence and risk factors of new foot ulcer among diabetic patients on peritoneal dialysis. Methods This is a single-center prospective cohort study. Clinically-stable diabetic patients on peritoneal dialysis in our renal division were recruited from January 2014 to June 2014. Baseline data including general information, biochemistry data, dialysis adequacy, the dorsalis pedis artery pulse, clinical symptoms of diabetic foot and ankle brachial index were recorded. All patients were followed till to Dec 31, 2015. The outcomes consisted of new foot ulcer, amputation due to foot ulcer or gangrene, and lower limb vascular blood supply revascularization. Results Totally 108 patients were recruited and followed up the average time (17.7±5.6) months. Among 108 patients, 16 cases had a history of diabetic foot ulcer, and 1 case had amputation. During the follow-up, 11 cases (10.2%) had new foot ulcer, 3 cases (2.8%) had amputation due to foot ulcers or gangrene, and 8 cases (7.4%) had lower limb vascular blood supply revascularization. A total of 13 cases (12%) had composite end points with 81.3 times/1000 patients of incidence. Univariate and multivariate Cox regression models showed that the history of foot ulcer was the only independent risk factors for new foot ulcers-related composite end points. Conclusion The incidence of new foot ulcer-related composite end points was 12%, which could be independently predicted by the history of diabetic foot ulcer.     

Health economics of diabetic foot ulcer and recent trends to accelerate treatment

Diabetic foot ulcer is a preventable complication of diabetes that imposes a significant burden on the community. It leads to amputation and increased disability if left untreated and thus bears profound implications on the individual, the community and the health system at large. Diabetic foot (DF) is an area of research interest where interdisciplinary researchers are trying to elucidate the best strategy to halt the progression of chronic diabetic wounds. It is an area where tissue engineering research is making a strong impact through the use of scaffolds and skin substitutes for diabetic wound healing. This review aims at discussing the geographical health economics, its impact on healing and factors influencing financial costs of DFU. The upcoming economic and clinical impacts due to disease outbreak such as the 2020 COVID-19 has also been discussed. Finally, it will discuss novel therapy available with emphasis on skin tissue engineering scaffolds with a cost-benefit analysis. The review aims at promoting better management of people with diabetes with emphasis on emerging treatments and technologies.     

糖尿病足溃疡复发因素及预防策略的研究进展

综述糖尿病足溃疡复发的影响因素包括足底压力、周围神经病变、周围血管病变、足部外伤、血糖控制不佳及其他(吸烟、日常活动负重、C-反应蛋白水平升高),预防复发的措施包括识别和筛查高危因素、卸载足部压力、选择合适的治疗鞋和鞋垫、手术卸载、自我护理、健康教育、信息化管理、依从性管理等,提出采取多种预防措施的综合性护理干预有助于减少糖尿病足溃疡的复发率。     

A systematic review of low‐level light therapy for treatment of diabetic foot ulcer

Diabetes mellitus (DM) is a significant international health concern affecting more than 387 million individuals. A diabetic person has a 25% lifetime risk of developing a diabetic foot ulcer (DFU), leading to limb amputation in up to one in six DFU patients. Low‐level light therapy (LLLT) uses low‐power lasers or light‐emitting diodes to alter cellular function and molecular pathways, and may be a promising treatment for DFU. The goal of this systematic review is to examine whether the clinical use of LLLT is effective in the healing of DFU at 12 and 20 weeks in comparison with the standard of care, and to provide evidence‐based recommendation and future clinical guidelines for the treatment of DFU using LLLT. On September 30, 2015, we searched PubMed, EMBASE, CINAHL, and Web of Science databases using the following terms: “diabetic foot” AND “low level light therapy,” OR “light emitting diode,” OR “phototherapy,” OR “laser.” The relevant articles that met the following criteria were selected for inclusion: randomized control trials (RCTs) that investigated the use of LLLT for treatment of DFU. Four RCTs involving 131 participants were suitable for inclusion based upon our criteria. The clinical trials used sham irriadiation, low dose, or nontherapeutic LLLT as placebo or control in comparison to LLLT. The endpoints included ulcer size and time to complete healing with follow‐up ranging from 2 to 16 weeks. Each article was assigned a level of evidence (LOE) and graded according to the Oxford Center for Evidence‐based Medicine Levels of Evidence Grades of Recommendation criteria. Limitations of reviewed RCTs include a small sample size (N < 100), unclear allocation concealment, lack of screening phase to exclude rapid healers, unclear inclusion/exclusion criteria, short (<30 days) follow‐up period, and unclear treatment settings (wavelength and treatment time). However, all reviewed RCTs demonstrated therapeutic outcomes with no adverse events using LLLT for treatment of DFU. This systematic review reports that LLLT has significant potential to become a portable, minimally invasive, easy‐to‐use, and cost effective modality for treatment of DFU. To enthusiastically recommend LLLT for treatment of DFU, additional studies with comparable laser parameters, screening period to exclude rapid healers, larger sample sizes and longer follow‐up periods are required. We envision future stringent RCTs may validate LLLT for treatment of DFU. Systematic review registration number: PROSPERO CRD42015029825.     

首发糖尿病足患者5年再发溃疡情况及相关因素分析

目的了解首发糖尿病足溃疡患者5年内复发情况,探讨其影响因素,为针对性干预提供参考。方法回顾性分析204例首次诊断为糖尿病足溃疡出院后5年内患者糖尿病足溃疡复发情况及影响因素。结果204例糖尿病足患者5年足溃疡复发率39.0%,再次发生足部溃疡距首发时间中位数36个月;再发溃疡的原因自发和外伤各为50.0%。吸烟、糖尿病足溃疡病程、糖尿病周围神经病变是糖尿病足患者再发溃疡的独立预测因素(RR为1.775~1.930,均P0.05)。结论糖尿病足患者首次发生溃疡后,易再次发生足部溃疡,其中外伤是导致再发溃疡的重要诱因。吸烟、糖尿病足溃疡病程≥2个月、有糖尿病周围神经病变患者再发糖尿病足溃疡风险较大,应给予针对性干预,避免再发溃疡。     

Hyperbaric oxygen in the treatment of a diabetic foot ulcer

Although simultaneous pancreas and kidney transplant improves most complications of type 1 diabetes, suppression of the immune system increases the risk for infection. The authors report the case of a patient who, despite receiving a simultaneous pancreas and kidney transplant, subsequently developed neuro-ischemic ulcers of his right foot requiring repeated amputations. He then developed an infected ulcer of his remaining right big toe, with significant implications for his mobility. This ulcer proved resistant to multiple courses of antibiotics and care in a specialist foot clinic but resolved completely following a course of hyperbaric oxygen therapy. The role of hyperbaric oxygen in diabetic foot ulcers is not yet fully established but should be considered in resistant cases with vascular insufficiency and a significant infective component.     

Statins may be associated with six‐week diabetic foot ulcer healing

Diabetic foot ulcers (DFUs) affect 1.5 million Americans annually, of which only a minority heal with standard care, and they commonly lead to amputation. To improve care, investigations are underway to better understand DFU pathogenesis and develop more effective therapies. Some currently used medications may improve healing. One small, randomized clinical trial found statins improve DFU healing. In this secondary analysis of a large multisite prospective observational cohort of 139 patients with DFUs receiving standard care, we investigated whether there was an association between 6‐week DFU wound size reduction and use of a variety of medications including alpha‐blockers, beta‐blockers, angiotensin converting enzyme inhibitors (ACEi) and statins. We found no significant (p < 0.05) association between six‐week wound reduction and use of any of the evaluated drugs; however, statins did trend toward an association (p = 0.057). This suggests a potential benefit of statins on DFU healing, and larger, targeted studies are warranted.     

Choice of wound care in diabetic foot ulcer: A practical approach

Diabetic foot ulcers are the consequence of multiple factors including peripheral neuropathy,decreased blood supply,high plantar pressures,etc.,and pose a significant risk for morbidity,limb loss and mortality.The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound.In addition to systemic antibiotics and surgical intervention,wound care is considered to be an important component of diabetic foot ulcer management.This article will focus on the use of different wound care materials in diabetic foot.From a clinical perspective,it is important to decide on the wound care material depending on the type and grade of the ulcer.This article will also provide clinicians with a simple approach to the choice of wound care materials in diabetic foot ulcer.     

Diabetic foot disease:From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease(DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy(DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.     

Influence of psychic comorbidity on the treatment process of patients with diabetic foot ulcer

Until now there are only few studies with small samples dealing with psychosocial aspects of patients with diabetic foot ulcer. The main interest concerns the quality of life of these patients. By reviewing the literature and our own clinical experience, the influence of psychic comorbidity on the treatment process will be demonstrated. Mobility and hospitalization are also related to problems of coping with diabetic foot ulcer and psychosocial problems (e.g., job, partnership, and social support). Therefore, disease management programs for patients with diabetes mellitus types I and II should include psychosomatic-psychotherapeutic diagnostics. The necessity for interdisciplinary work between orthopedics and psychosomatics is discussed.     

Ulcer‐free survival days and ulcer healing in patients with diabetic foot ulcers: A prospective cohort study

Healing rates may not give a complete indication of the effectiveness and management of diabetic foot ulcers because of high recurrence rates. The most important outcome for patients is remaining ulcer‐free; however, this has hardly been investigated. The aim of our study was to prospectively investigate ulcer‐free survival days and ulcer healing in patients with diabetic foot ulcers. This was a prospective cohort study of all referrals to our diabetic foot expertise centre from December 2014 to April 2017. Outcomes were determined after a minimum follow‐up period of 12 months. Primary outcomes were ulcer‐free survival days and 12‐month healing percentages. Predictors for ulcer‐free survival days and healing were investigated in multivariate analyses. A total of 158 patients were included. Median ulcer‐free survival days in the healed group were 233 days (interquartile range [IQR] 121‐312) and 131 days (IQR 0–298) in the overall population. The healing rate at 12‐month follow up was 67% (106/158), and the recurrence rate was 31% (33/106). Independent predictors of ulcer‐free survival days were duration of diabetes, peripheral artery disease (PAD), cardiovascular disease, end‐stage renal disease (ESRD), and infection. Ulcer‐free survival days are related to PAD and cardiovascular disease, and ulcer‐free survival days should be the main outcome when comparing the effectiveness of management and prevention of the diabetic foot ulcers.     

Rat bite as a cause of diabetic foot ulcer in sub‐Saharan Africa

There have been relatively few reports of foot ulcers in diabetes resulting from rat bite. The findings were derived from people attending a single specialist service in Dar es Salaam for diabetic foot ulcers (DFUs) between 1 January 1999 and 31 December 2016. Details from people presenting for the first time with an ulcer judged to be caused by rat bite were compared with those with from other causes of foot ulcer. There were 426 first recorded foot ulcer episodes (in 179 people) judged to be caused by rat bite. The affected population was significantly younger (mean 55.9 vs 57.5 years, P = .037) and had a lower body mass index (26.5 vs 27.9, P = .008) than controls with other types of foot ulcer. They also presented significantly sooner (7.8 vs 18.2 days, P < .001) and were more likely to heal (85.8 vs 5.5%, P < .001), even though there was also a trend towards an increased risk of death (9.1% vs 5.3%, P = .032). Rat bite is an uncommon cause of DFU, but is not rare. Although the incidence of ulcer healing is higher than in a general foot ulcer population, the incidence of death is also higher.