Diabetic foot ulcers: prevention, diagnosis and classification

Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.     

The Charcot foot in diabetes: six key points

The Charcot foot commonly goes unrecognized, particularly in the acute phase, until severe complications occur. Early recognition and diagnosis, immediate immobilization and a lifelong program of preventive care can minimize the morbidity associated with this potentially devastating complication of diabetic neuropathy. If unrecognized or improperly managed, the Charcot foot can have disastrous consequences, including amputation. The acute Charcot foot is usually painless and may mimic cellulitis or deep venous thrombosis. Although the initial radiograph may be normal, making diagnosis difficult, immediate detection and immobilization of the foot are essential in the management of the Charcot foot. A lifelong program of patient education, protective footwear and routine foot care is required to prevent complications such as foot ulceration.     

Risk of foot complications in long-term diabetic patients with and without ESRD: a preliminary study

OBJECTIVE: The purpose of this preliminary study was to generate hypotheses for future research about the relationship between ESRD and foot complications in patients with long-term diabetes. DESIGN: A cross-sectional prevalence study was conducted comparing a sample of long-term diabetic patients with ESRD to a sample of long-term diabetic patients without ESRD. SAMPLE/SETTING: A convenience sample of 132 patients with long-term diabetes (> 15 years), with (N = 60) and without (N = 72) ESRD, was selected from ambulatory care settings and dialysis units. METHODS: Data were collected by chart audit, structured interview, and physical examination. RESULTS: Foot complications were greater in individuals with diabetes and ESRD (25%) than in diabetic individuals without ESRD (10%) (p = 0.02). Neither neuropathy, past or current smoking, race, gender, nor age were significantly associated with current foot complications (either current infection, ulcer, gangrene, or amputation). CONCLUSIONS: Research is needed to better understand foot complications in persons with long-term diabetes and ESRD so that the effectiveness of nursing and medical interventions to stabilize or prevent foot complications can be evaluated.     

Clinical and radiographic findings that lead to intervention in diabetic patients with foot ulcers. A nationwide survey of primary care physicians

OBJECTIVE: To determine which elements of clinical history, physical examination, and diagnostic tests are important to primary care physicians in their management of foot ulcers in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted a national mail survey of 600 primary care physicians to determine which patient characteristics and diagnostic test results were important in their decisions to seek radiographic studies, surgical referrals, and hospitalization for diabetic patients with foot ulcers. RESULTS: The case characteristics most likely to influence physicians to order advanced diagnostic or therapeutic interventions are the presence of osteomyelitis on plain radiographs, the failure of the ulcer to improve with conservative therapy, and the presence of visible bone, crepitus, or necrosis within the ulcer (P < 0.001). Information from the initial clinical history was less likely to influence physicians to order advanced diagnostic or therapeutic interventions (P < 0.001) than was information from the physical examination. CONCLUSIONS: We conclude that 1) the patient's history is relatively unimportant to primary care physicians in their management of diabetic foot ulcers; 2) the failure of conservative management is a major reason that primary care physicians order surgical referral, hospitalization, or radiographic testing for diabetic patients with foot ulcers; and 3) primary care physicians rely heavily on plain X ray of the foot, a test with poor sensitivity and specificity, in deciding whether to order further interventions for their diabetic patients with foot ulcers.     

Evaluation and treatment of the infected foot in a community teaching hospital

More inpatient hospital days are used for the care of diabetic foot infection than for any other diabetic sequela. Both the number of lower extremity amputations and the overall treatment cost of treating diabetic infections may be reduced by using a team approach in the care of the infected diabetic pedal wound. The authors propose an evaluation and treatment protocol of infected pedal ulcerations in an urban, community teaching institution when admitted to an established, multidisciplinary diabetic foot care team. The hospital course of 111 patients admitted with a primary diagnosis of infected pedal ulceration are retrospectively reviewed. Results revealed an average-length hospital stay of 7.4 days with a 96% limb-salvage rate. The authors suggest that in the treatment of the infected pedal wound, a diabetic foot care team with a well developed treatment protocol may yield a consistently favorable outcome and a cost-effective hospital course.     

Care of patients with diabetic nephropathy

Diabetic nephropathy is one of the main causes of chronic renal failure in developed countries. The genesis and development of diabetic nephropathy is associated in both types of diabetes with a more rapid progression of other secondary complications and an increased mortality, in particular cardiovascular mortality. The main causes of development of diabetic nephropathy are prolonged hyperglycaemia along with a so far not elucidated inborn disposition. The course of diabetic nephropathy is characterized more clearly in type 1 diabetes. The clinically manifest stage is already irreversible and in the course of years it develops into chronic renal failure. Preventive and curative measures include maintenance of optimal metabolic control, systematic control of blood pressure, in particular by ACE-inhibitors, and a reduction of protein intake. Systematic multidisciplinary collaboration in care for patients with diabetic nephropathy helps to prevent the progression of other secondary complications such as diabetic foot and diabetic retinopathy. At present in the Czech Republic dialysis methods substituting renal function are available to practically all patients with diabetic nephropathy. As regards survival time and quality of life the optimal method of renal function replacement for patients in the terminal stage of diabetic nephropathy is transplantation.     

Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects

OBJECTIVE: To evaluate the influence of podiatrist activities on the outpatient care of diabetic patients in terms of knowledge of diabetic foot care, self-care, and minor foot problems. RESEARCH DESIGN AND METHODS: There were 733 patients, aged 10-79 years, identified from the national diabetes register. Patients without recent visits to a podiatrist and without an obvious need for foot care were randomized into a podiatric care group (education and primary prevention measures, n = 267) and a control group (written instructions only, n = 263). The patients were examined by an independent study podiatrist at baseline and after 1 year. RESULTS: Patients in the podiatrist group had greater improvement in knowledge of diabetic foot care (P = 0.004) and self-care (P < 0.001) scores compared with control subjects. The prevalence of callosities in regions other than the calcaneal region decreased more (P = 0.009) in the podiatrist group (from 54.5 to 39.5%) than in the control group (from 51.3 to 48.2%), and the size of the callosities decreased more (P < 0.001) in the podiatrist group than in the control group. Reduction in the prevalence of callosities was associated with younger age (< 50 years). CONCLUSIONS: Education and primary preventive measures provided individually by a podiatrist result in significant improvements in knowledge and foot self-care scores and in improvements in the prevalence of some minor foot problems. Long-term studies are needed to evaluate whether the intervention of podiatrists starting at an early phase would lead to a reduction in major foot problems.     

Management of the diabetic patient: causes of leg ulceration

The diabetic patient is at risk of developing numerous complications, including foot ulceration. The ulcer may contain a neuropathic and ischaemic element. Regular preventive checks can assist in early detection of foot problems. Failing eye sight and absence of sensation often result in patients relying on the healthcare professional detecting abnormalities on their behalf. The long-term effects of foot ulceration in the diabetic patient are immobility, septicaemia and amputation. Treatment options exist for the neuropathic and ischaemic foot but they vary in complexity. Accurate assessment and early recognition of the clinical signs of neuropathy and ischaemic ulceration will ensure early detection and optimum treatment interventions for the diabetic patient.     

Quality of care of patients with diabetic foot problems in Barbados

In Barbados diabetics with foot problems account for 80% of the patients in the female and 50% of those in the male general surgery wards, and many patients have major amputations for preventable problems. A six month prospective study was undertaken of all cases admitted with foot problems to the general surgical wards of the Queen Elizabeth Hospital (QEH) in order to determine the quality of foot care, particularly among diabetics. 67.5% of the 195 patients (55% female) admitted to the study were diabetic, most of whom were diagnosed 10 to 19 years previously. Most of the patients were 70 to 80 years old, but significantly more diabetics than non-diabetics were 40 to 70 years old. Foot problems in diabetics were precipitated by events that are considered trivial in non-diabetic patients. 87 (58%) of 150 responding patients had their feet inspected by health personnel in the previous year. 47 (63.5%) of the 74 who responded about the care of their nails said that they took care of their nails themselves. Nearly 40% of diabetic and non-diabetic patients had no reported source of care before their admission. 14 patients (10 diabetic) sought care the same day and 11 (nine diabetics) the day after noticing foot problems. Most patients presented with infection as part of their problem; recognition of the early signs of infection should be an integral part of the education of the diabetic patient. Educational efforts for patients must be continually reinforced because many patients said they had had no education about the care of their feet in the previous year.     

Esophageal electrochemical burns due to button type lithium batteries in dogs

Microalbuminuria is a significant risk factor associated with nephropathy, retinopathy, and cardiovascular disease; however, there are no previous reports on the relationship of microalbuminuria with diabetic foot ulcers or stroke, despite the fact that microalbuminuria is a marker of vascular damage. The purpose of this study was to determine the relationship of microalbuminuria with diabetic foot ulcers in type II diabetes patients. In this, cross-sectional clinical study, outpatients of the offices at first level medical care in Durango, Mexico, were included in one of two groups; (a) patients with diabetic foot ulcers and (b) control of group patients without diabetic foot ulcers. Diabetic foot diagnosis was established on the basis of clinical criteria and pletismography. Patients diagnosed with renal disease, urinary tract infection, acute febrile illness, or heart failure and those receiving angiotensin-converting enzyme inhibitors were excluded from the study. Microalbuminuria was measured, on a 24-h urine collection, by precipitation with sulfasalicylic acid, and turbidity was determined by measuring absorbance with a spectrophotometer. The study included 670 diabetic patients. Using both odds ratio and logistic regression analyses, diabetes duration, cigarette smoking, aging, and microalbuminuria showed a strong relationship with diabetic foot ulcers. Microalbuminuria should be considered as an independent risk factor for diabetic foot ulcers.     

Clinical and economic impact of implementing a comprehensive diabetes management program in managed care

Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America's Diabetes NetCare, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCare achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbAlc tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program. These data suggest that implementation of a comprehensive healthcare management program for people with diabetes can lead to substantial improvements in costs and clinical outcomes in the short-term. It is expected that improvements will increase over time, with continuing improvements in health status and a reduction in the number of future diabetic complications.     

Air bubbles in the subclavian or internal jugular veins: a common finding on contrast-enhanced CT

BACKGROUND: Foot complications in diabetes incur huge human and medical costs. There is a high incidence of complicated diabetes mellitus in Far North Queensland, particularly in the indigenous communities. METHODS: An audit of 51 patients admitted to Cairns Base Hospital from July 1992 to December 1994 with diabetic foot complications requiring surgical intervention was performed. RESULTS: The majority of surgical procedures were for serious infections in neuropathic feet precipitated by minor trauma. Surgical procedures included debridement/drainage, minor amputation, major amputation and arterial bypass. Half of the patients required more than one procedure and/or multiple admissions. Average length of stay was 48 days. Indigenous patients were overrepresented in this audited group. CONCLUSIONS: Prevention or minimization of diabetic foot complications can be achieved only through improvement in education and vigilance at all levels of the treatment process from community to hospital. Special attention to the needs of indigenous communities with a high incidence of diabetes must be a feature of any future initiatives.     

Preventive foot care in people with diabetes

A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.     

Know how--diabetic foot ulceration

Diabetes is a complex metabolic disease which can give rise to many tissue complications. The foot is particularly vulnerable to circulatory and neurological disorders, so that even minor trauma can lead to ulceration and infection. Careful observation and assessment of these wounds is essential to ensure the integrity of the limb is not threatened, which could result in amputation. A multidisciplinary team approach is the key to successful management of diabetic foot ulceration.     

Audit of public sector primary diabetes care in Cape Town, South Africa: high prevalence of complications, uncontrolled hyperglycaemia, and hypertension

This study was undertaken to investigate the prevalence of diabetes complications and level of glycaemic and blood pressure control in Black African patients at the primary care level in the public sector Cape Town, South Africa. A stratified random sample of 300 patients attending the three largest ambulatory diabetes clinics in community health centres in Black African residential areas of Cape Town (100 patients from each) during the last 6 months of 1992 was selected. Each patient had a clinical examination, interview, and 1 year retrospective record review. Eighty-one per cent of the sampled patients were reviewed, 90% were non-insulin-dependent (NIDDM) and 10% were treated with insulin. The mean duration of diabetes was 8 (range 0-28) years. Acceptable glycaemic control was present in 49.4% (95% Confidence Intervals 45.6-53.5) of patients while 38.5% (CI 24.8-52.2) of hypertensive patients had acceptable blood pressure control. The prevalence of any grade of retinopathy was 55.4% (CI 48.90-62.9), proliferative and preproliferative retinopathy 15.6% (CI 8.5-22.8), cataracts 7.9% (CI 4.4-11.4), peripheral neuropathy 27.6% (CI 15.2-39.4), absent foot pulses 8.2% (CI 5.2-12.6), amputations 1.4% (CI 0.4-2.4), persistent proteinuria 5.3% (CI 2.5-8.1) and an elevated albumin-creatinine ratio 36.7% (CI 29.0-44.4). The complications were not documented in the clinic records of the preceding year with the exception of 1 patient with absent foot pulses and the 12 patients with proteinuria. The high prevalence of suboptimal glycaemic and blood pressure control as well as complications of diabetes, largely unrecorded in the preceding years' clinic notes, demonstrates the deficiency of and need for preventative diabetes care at the primary care level. The design, institution, and evaluation of effective intervention programmes are a priority to improve the quality of care provided and the health of diabetic patients.     

The diabetic foot. Optimal prevention and treatment can halve the risk of amputation

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved quality of life not taken into consideration).     

Locations of crossover breakpoints within the CMT 1 A-REP repeat in patients with hereditary neuropathy with liability to pressure palsy--detection by recombinant chromosome-specific polymerase chain reaction

The "short Achilles tendon" syndrome, characterised by limited dorsiflexion of the tibiotarsal joint, is not well-known but could be a disposing factor for trophic disorders and plantar ulcer related to hypersupport in the diabetic subject. We report two cases of multicomplicated diabetic patients treated during several months for plantar ulcer superinfected with underlying osteoarthrits, whose course became rapidly favourable after tenotomy of the Achilles tendon. This simple surgical act can be performed in ambulatory conditions under local anaesthesia. Functional disability is negligible. The benefit of this treatment as part of the curative or preventive therapeutic arsenal for care of the diabetic foot remains to be evaluated.     

Functional insulin therapy and pregnancy

Pregnant type-I diabetic women have to be treated in an experienced diabetes center where optimal cooperation and exchange of knowledge between obstetrician, diabetologist and neonatologist is guaranteed. Given optimal preconceptional metabolic control and thorough guidance throughout pregnancy maternal and fetal risk of type-I diabetic patients without severe diabetic late complications is similar to that of healthy pregnant women. "Near-normoglycemic" metabolic control and meticulous prevention of severe and long-standing hypoglycemic episodes can be achieved throughout pregnancy by functional insulin therapy employing a basis-bolus regime of insulin administration with frequent blood glucose self control (more than 6 times a day). Non-compliant diabetic patients and those with severe diabetic late complications represent a high-risk group for complications in pregnancy. To avoid such risks special care and preconceptional information is mandatory.     

Alpha B-crystallin is associated with intermediate filaments in astrocytoma cells

To achieve the optimal management program for the diabetic vasculopathic patient, a multidisciplinary approach incorporating the necessary major elements is required. The endocrinologist is essential in tight metabolic control of blood sugars and diet modifications. The podiatrist is indispensable in the early detection of foot ulcerations and preventive care. Visiting nurses function as a vital component in outpatient wound assessment and daily care. With this approach, the vascular surgeon is ensured of the most favorable outcome with conservative measures.