A foot care program for diabetic unilateral lower-limb amputees

Health-related quality of life among Spanish patients with diabetic foot ulcer according to Diabetic Foot Ulcer Scale - Short Form

AIM

The aim of this study was to investigate the health-related quality of life of Spanish outpatients with diabetic foot ulcer using the Diabetic Foot Scale-Short Form (DFS-SF).

MATERIALS AND METHODS

This cross-sectional observational study included 141 outpatients with diabetic foot ulcers (DFU). The DFS-SF was applied in personal interviews conducted by a trained investigator to assess health-related quality of life (HRQoL).

RESULTS

The domain related to "worried about ulcers" had the lowest in score [50 (27.5-65.0)], and the highest score was in the physical health domain [76 (60.0-88.0)]. There was a statistically significant difference in the ulcer type and the physical health subscale, finding the lowest values in the physical health subscale in patients with ischaemic diabetic foot ulcers [58 (39.0-70.0), p = 0.007]. In the multivariable analysis the domains Leisure (OR 0.98, 95% CI 0.97-0.99) and worried about ulcers/feet (OR 0.98, 95% CI 0.96-0.99) were identified as significant independent domains in patients with the experience of a previous minor amputation. A significant negative correlation was observed between the SINBAD DFU score and leisure (r = -0.181, p = 0.032), physical health (r = -0.202, p = 0.016), dependence/daily life (r = -0.232, p = 0.006), and the "bothered by ulcer care" (r = -0.239, p = 0.004) domains of the DFS-SF. The ulcer duration had a significant negative correlation with all the domains of DFS-SF.

CONCLUSION

The DFS-SF survey is a specific instrument that could be implemented in diabetic foot units as part of the management of patients with DFU to evaluate HRQoL. The domain of "worried about ulcers" had the lowest score in our population suggesting that clinicians should try to work on the emotional state of patients with DFU. The mean duration of DFU was the most influential factor related to worse scores followed by previous amputations. The SINBAD score had significant negative correlations suggesting that HRQoL may be related to the severity of DFU in this study population.

Patient and health care provider knowledge of diabetes and diabetic microvascular complications: a comprehensive literature review

Diabetic retinopathy, neuropathy, and nephropathy occur in more than 50% of people with diabetes, contributing substantially to morbidity and mortality. Patient understanding of these microvascular complications is essential to ensure early recognition and treatment of these sequalae as well as associated symptoms, yet little is known about patient knowledge of microvascular sequalae. In this comprehensive literature review, we provide an overview of existing knowledge regarding patient knowledge of diabetes, retinopathy, neuropathy, and nephropathy. We also discuss health care provider's knowledge of these sequalae given that patients and providers must work together to achieve optimal care. We evaluated 281 articles on patient and provider knowledge of diabetic retinopathy, neuropathy, and nephropathy as well as predictors of improved knowledge and screening practices. Results demonstrated that patient and provider knowledge of microvascular sequalae varied widely between studies, which may reflect sociocultural or methodologic differences. Knowledge assessment instruments varied between studies with limited validation data and few studies controlled for confounding. Generally, improved patient knowledge was associated with greater formal education, longer diabetes duration, and higher socioeconomic status. Fewer studies examined provider knowledge of sequalae, yet these studies identified multiple misconceptions regarding appropriate screening practices for microvascular complications and the need to screen patients who are asymptomatic. Further investigations are needed that use well validated measures, control for confounding, and include diverse populations. Such studies will allow identification of patients and providers who would benefit from interventions to improve knowledge of microvascular complications and, ultimately, improve patient outcomes.

Effects of a Catechol-Functionalized Hyaluronic Acid Patch Combined with Human Adipose-Derived Stem Cells in Diabetic Wound Healing

Introduction: Chronic inflammation and impaired neovascularization play critical roles in delayed wound healing in diabetic patients. To overcome the limitations of current diabetic wound (DBW) management interventions, we investigated the effects of a catechol-functionalized hyaluronic acid (HA-CA) patch combined with adipose-derived mesenchymal stem cells (ADSCs) in DBW mouse models. Methods: Diabetes in mice (C57BL/6, male) was induced by streptozotocin (50 mg/kg, >250 mg/dL). Mice were divided into four groups: control (DBW) group, ADSCs group, HA-CA group, and HA-CA + ADSCs group (n = 10 per group). Fluorescently labeled ADSCs (5 × 10⁵ cells/100 µL) were transplanted into healthy tissues at the wound boundary or deposited at the HA-CA patch at the wound site. The wound area was visually examined. Collagen content, granulation tissue thickness and vascularity, cell apoptosis, and re-epithelialization were assessed. Angiogenesis was evaluated by immunohistochemistry, quantitative real-time polymerase chain reaction, and Western blot. Results: DBW size was significantly smaller in the HA-CA + ADSCs group (8% ± 2%) compared with the control (16% ± 5%, p < 0.01) and ADSCs (24% ± 17%, p < 0.05) groups. In mice treated with HA-CA + ADSCs, the epidermis was regenerated, and skin thickness was restored. CD31 and von Willebrand factor-positive vessels were detected in mice treated with HA-CA + ADSCs. The mRNA and protein levels of VEGF, IGF-1, FGF-2, ANG-1, PIK, and AKT in the HA-CA + ADSCs group were the highest among all groups, although the Spred1 and ERK expression levels remained unchanged. Conclusions: The combination of HA-CA and ADSCs provided synergistic wound healing effects by maximizing paracrine signaling and angiogenesis via the PI3K/AKT pathway. Therefore, ADSC-loaded HA-CA might represent a novel strategy for the treatment of DBW.

Diabetes self-care behaviors in adults with disabilities: A systematic review

AIM

The integrated evidence on diabetes self-care behaviors in people with a disability is not commensurate with the growing number of people with both diabetes and a disability. This study aims to identify factors influencing self-care behaviors in adults with diabetes and a disability based on a thorough review of the current evidence.

METHODS

This review followed the Cochrane guidelines for systematic review research and complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. To find eligible articles, five electronic databases-PubMed, Embase, CINAHL, Psych-articles, and the Cochrane Library-were searched, from the beginning of the chronological period covered by each database to June 2017. Four researchers independently conducted study selections, extracted data, and assessed the data quality.

RESULTS

Twenty studies were reviewed to identify barriers to and facilitators of diabetes self-care behaviors. For people with developmental disabilities, the most prominent facilitator of self-care behaviors was the support they received for the behaviors. For people with visual impairments, that facilitator was the use of helpful assistive devices that take advantage of another sense. The main barriers to self-care behaviors were mobility limitation for people with physical disabilities and lack of accessibility for people with visual impairments.

CONCLUSIONS

This review has identified barriers to and facilitators of diabetes self-care behaviors by type of disability. Healthcare services need to be tailored to these facilitators and barriers, and differentiated by type of disability.

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis

Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower extremity amputations (LEAs), but there is heterogeneity between team members and interventions. Podiatrists have been suggested as “gatekeepers” for the prevention and management of DFUs. The purpose of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a systematic review of available literature. Data’s heterogeneity about DFU outcomes made it impossible for us to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for MDTs that include podiatry. We found statistical significance in favour of an MDT approach including podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54–0.89, I² = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23–0.90, I² = 67%, P < 0.02). Our systematic review, with a standard search strategy, is the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for DFU management. Our observations support the literature that MDTs including podiatrists have a positive effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in team approach in daily practice and in published literature.

Health-Related Quality of Life and Self-Care Management Among People With Diabetic Foot Ulcers in Northern Thailand

Diabetic foot ulcers (DFUs) are a common complication of diabetes that impacts on the health-related quality of life (HRQOL). Foot care is an important factor in the self-care management of patients with DFUs. The objective of this study was to investigate the HRQOL and foot care management of people with DFUs. A cross-sectional study involving 41 people with DFUs was conducted at a large tertiary hospital in Northern Thailand. The Diabetic Foot Ulcer Scale-Short Form and the VA-Diabetes Foot Care Survey were used to assess the HRQOL and foot care management among people with DFUs. The majority of the participants were female (n = 24, 58.5%), and the mean age was 62.13 years. The scores for HRQOL in the six domains were as follows: leisure (66.95 ± 28.03), physical health (68.93 ± 28.51), dependence or daily life (80.08 ± 25.23), negative emotions (71.23 ± 29.48), worried about ulcers (62.20 ± 31.97), and bothered by ulcer care (69.36 ± 25.20). High scores indicate a high (good) HRQOL. Less than a third of the participants reported that they had received education about foot care management. Almost all participants reported that they washed their feet daily; however, a large proportion did not test the water temperature or use lubricants on their feet. Most of the participants did not have a mirror for checking under their feet (48.8%), and there was a lack of knowledge about how to use a mirror for foot inspections (51.2%). This study provides guidance for clinicians on the content and delivery of diabetes education programs for people with diabetes (and DFUs) in Northern Thailand. The findings provide guidance on existing knowledge and the need for programs to address barriers to foot self-care management both in terms of skills and attitudes.

Low-level laser irradiation modifies the effect of hyperglycemia on adhesion molecule levels

Endothelium plays a key role in maintaining vascular homeostasis by secreting active factors involved in many biological processes such as hemostasis, angiogenesis, and inflammation. Hyperglycemia in diabetic patients causes dysfunction of endothelial cells. Soluble fractions of adhesion molecules like sE-selectin and vascular cell adhesion molecule (sVCAM) are considered as markers of endothelial damage. The low-level laser therapy (LLLT) effectively supports the conventional treatment of vascular complications in diabetes, for example hard-to-heal wounds in patients with diabetic foot syndrome. The aim of our study was to evaluate the effect of low-energy laser at the wavelength of 635 nm (visible light) and 830 nm (infrared) on the concentration of adhesion molecules: sE-selectin and sVCAM in the supernatant of endothelial cell culture of HUVEC line. Cells were cultured under high-glucose conditions of 30 mM/L. We have found an increase in sE-selectin and sVCAM levels in the supernatant of cells cultured under hyperglycemic conditions. This fact confirms detrimental influence of hyperglycemia on vascular endothelial cell cultures. LLLT can modulate the inflammation process. It leads to a decrease in sE-selectin and sVCAM concentration in the supernatant and an increase in the number of endothelial cells cultured under hyperglycemic conditions. The influence of LLLT is greater at the wavelength of 830 nm.

Anti-Inflammatory Effects of Rosiglitazone in Obesity-Impaired Wound Healing Depend on Adipocyte Differentiation

Combined diabetes-obesity syndromes severely impair regeneration of acute skin wounds in mouse models. This study assessed the contribution of subcutaneous adipose tissue to exacerbated wound inflammatory conditions. Genetically obese (ob/ob) mice showed an increased expression of positive transcriptional effectors of adipocyte differentiation such as Krüppel-like factor (KLF)-5 and peroxisome proliferator-activated receptor (PPAR)-γ and an associated expression of leptin and fatty acid-binding protein (FABP)-4, but also CXCL2 in isolated subcutaneous fat. This observation in obese mice is in keeping with differentially elevated levels of KLF-5, PPAR-γ, leptin, FABP-4 and CXCL2 in in vitro-differentiated 3T3-L1 adipocytes. Notably, CXCL2 expression restrictively appeared upon cytokine (IL-1β/TNF-α) stimulation only in mature, but not immature 3T3-L1 adipocytes. Of importance, the critical regulator of adipocyte maturation, PPAR-γ, was merely expressed in the final phase of in-vitro induced adipocyte differentiation from 3T3-L1 pre-adipocytes. Consistently, the PPAR-γ agonist rosiglitazone suppressed cytokine-induced CXCL2 release from mature adipocytes, but not from early 3T3-L1 adipocyte stages. The inhibitory effect of PPAR-γ activation on CXCL2 release appeared to be a general anti-inflammatory effect in mature adipocytes, as cytokine-induced cyclooxygenase (Cox)-2 was simultaneously repressed by rosiglitazone. In accordance with these findings, oral administration of rosiglitazone to wounded obese mice significantly changed subcutaneous adipocyte morphology, reduced wound CXCL2 and Cox-2 expression and improved tissue regeneration. Thus, our data suggest that PPAR-γ might provide a target to suppress inflammatory signals from mature adipocytes, which add to the prolonged wound inflammation observed in diabetes-obesity conditions.

Diabetes Nurse Educators' Prioritized Elder Foot Care Behaviors

Purpose

The purpose of this study was to identify diabetes nurse educators' perceptions of the most important foot care behaviors for elderly people to enact in daily care.

Methods

A structured, open-ended questionnaire was mailed to a regionally stratified random sample of 90 diabetes nurse educators. Subjects were asked to identify and rank order 8 foot care behaviors perceived important for elderly people with diabetes to enact daily. Data were transcribed and coded into categories and domains using descriptive content analysis.

Results

Forty-seven diabetes nurse educators responded with a total of 346 foot care behaviors perceived important for elders. Twenty-one major foot care behavior content categories were grouped into 4 domains of descending importance: foot/nail care, footwear/shoes, general health, and foot emergencies.

Conclusions

Diabetes nurse educators generated a range of baseline data for developing a reliable, valid, and patient foot care knowledge outcome measure to support national diabetes patient education and self-management program guidelines.

Low-level laser irradiation effect on endothelial cells under conditions of hyperglycemia

Diabetes mellitus is considered to be a very serious lifestyle disease leading to cardiovascular complications and impaired wound healing observed in the diabetic foot syndrome. Chronic hyperglycemia is the source of the endothelial activation. The inflammatory process in diabetes is associated with the secretion of inflammatory cytokines by endothelial cells, e.g., tumor necrosis factor-alpha (TNF-α) and interleukin 6 (IL-6). The method of phototherapy using laser beam of low power (LLLT-low-level laser therapy) effectively supports the conventional treatment of diabetic vascular complications such as diabetic foot syndrome. The aim of our study was to evaluate the effect of low-power laser irradiation at two wavelengths (635 and 830 nm) on the secretion of inflammatory factors (TNF-α and IL-6) by the endothelial cell culture-HUVEC line (human umbilical vein endothelial cell)-under conditions of hyperglycemia. It is considered that adverse effects of hyperglycemia on vascular endothelial cells may be corrected by the action of LLLT, especially with the wavelength of 830 nm. It leads to the reduction of TNF-α concentration in the supernatant and enhancement of cell proliferation. Endothelial cells play an important role in the pathogenesis of diabetes; however, a small number of studies evaluate an impact of LLLT on these cells under conditions of hyperglycemia. Further work on this subject is warranted.

Shedding light on a new treatment for diabetic wound healing: a review on phototherapy

Impaired wound healing is a common complication associated with diabetes with complex pathophysiological underlying mechanisms and often necessitates amputation. With the advancement in laser technology, irradiation of these wounds with low-intensity laser irradiation (LILI) or phototherapy, has shown a vast improvement in wound healing. At the correct laser parameters, LILI has shown to increase migration, viability, and proliferation of diabetic cells in vitro; there is a stimulatory effect on the mitochondria with a resulting increase in adenosine triphosphate (ATP). In addition, LILI also has an anti-inflammatory and protective effect on these cells. In light of the ever present threat of diabetic foot ulcers, infection, and amputation, new improved therapies and the fortification of wound healing research deserves better prioritization. In this review we look at the complications associated with diabetic wound healing and the effect of laser irradiation both in vitro and in vivo in diabetic wound healing.

The regenerative potential of fibroblasts in a new diabetes-induced delayed humanised wound healing model

Cutaneous diabetic wounds greatly affect the quality of life of patients, causing a substantial economic impact on the healthcare system. The limited clinical success of conventional treatments is mainly attributed to the lack of knowledge of the pathogenic mechanisms related to chronic ulceration. Therefore, management of diabetic ulcers remains a challenging clinical issue. Within this context, reliable animal models that recapitulate situations of impaired wound healing have become essential. In this study, we established a new in vivo humanised model of delayed wound healing in a diabetic context that reproduces the main features of the human disease. Diabetes was induced by multiple low doses of streptozotocin in bioengineered human-skin-engrafted immunodeficient mice. The significant delay in wound closure exhibited in diabetic wounds was mainly attributed to alterations in the granulation tissue formation and resolution, involving defects in wound bed maturation, vascularisation, inflammatory response and collagen deposition. In the new model, a cell-based wound therapy consisting of the application of plasma-derived fibrin dermal scaffolds containing fibroblasts consistently improved the healing response by triggering granulation tissue maturation and further providing a suitable matrix for migrating keratinocytes during wound re-epithelialisation. The present preclinical wound healing model was able to shed light on the biological processes responsible for the improvement achieved, and these findings can be extended for designing new therapeutic approaches with clinical relevance.

A combination of 670 nm and 810 nm diode lasers for wound healing acceleration in diabetic rats

OBJECTIVES

To study the effects of the combination of 670 nm and 810 nm diode lasers on diabetic wound healing parameters in rats.

BACKGROUND

An alternative to traditional treatment modalities for diabetic ulcers is low-level laser therapy (LLLT). A number of published studies demonstrate the beneficial effects of LLLT, although several other studies also exist which indicate results to the contrary.

METHODS

Four groups were present in our study: Diabetic-laser (n = 5), Diabetic-control (n = 4), Nondiabetic-laser (n = 5) and Nondiabetic-control (n = 5) groups. Two intervention (laser) groups underwent low level laser therapy using 670 nm diode laser (500 mW, 10 J, 48 s) in the wound context, and 810 nm diode laser (250 mW, 12 J, 50 s) to the wound margins. The wound area was measured using computer software after digital microscopic photography on days 0, 3, 6, 9, 12, 15, 20, and 24.

RESULTS

There were no statistically significant differences between the diabetic and non-diabetic groups in the wound area, percentage of open wound area, and wound healing rate throughout the repeated measurements of the study. After seven days of low level laser therapy in the non-diabetic group, urine excretion was significantly increased in comparison with the control group.

CONCLUSION

Overall, our study showed results of measured wound healing parameters that were not significantly different in the LLLT group compared with the control group. The urine volume increase in non-diabetic rats after LLLT was an incidental observation that warrants future study.

Wound healing in mice with high-fat diet- or ob gene-induced diabetes-obesity syndromes: a comparative study

In the past, the genetically diabetic-obese diabetes/diabetes (db/db) and obese/obese (ob/ob) mouse strains were used to investigate mechanisms of diabetes-impaired wound healing. Here we determined patterns of skin repair in genetically normal C57Bl/6J mice that were fed using a high fat diet (HFD) to induce a diabetes-obesity syndrome. Wound closure was markedly delayed in HFD-fed mice compared to mice which had received a standard chow diet (CD). Impaired wound tissue of HFD mice showed a marked prolongation of wound inflammation. Expression of vascular endothelial growth factor (VEGF) was delayed and associated with the disturbed formation of wound margin epithelia and an impaired angiogenesis in the reduced granulation tissue. Normal wound contraction was retarded and disordered. Wound disorders in obese C57Bl/6J mice were paralleled by a prominent degradation of the inhibitor of NFκB (IκB-α) in the absence of an Akt activation. By contrast to impaired wound conditions in ob/ob mice, late wounds of HFD mice did not develop a chronic inflammatory state and were epithelialized after 11 days of repair. Thus, only genetically obese and diabetic ob/ob mice finally developed chronic wounds and therefore represent a better suited experimental model to investigate diabetes-induced wound healing disorders.

Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study

OBJECTIVE

To evaluate the long-term prognosis of critical limb ischemia (CLI) in diabetic patients.

RESEARCH DESIGN AND METHODS

A total of 564 consecutive diabetic patients were hospitalized for CLI from January 1999 to December 2003; 554 were followed until December 2007.

RESULTS

The mean follow-up was 5.93 +/- 1.28 years. Peripheral angioplasty (PTA) was performed in 420 (74.5%) and bypass graft (BPG) in 117 (20.6%) patients. Neither PTA nor BPG were possible in 27 (4.9%) patients. Major amputations were performed in 74 (13.4%) patients: 34 (8.2%) in PTA, 24 (21.1%) in BPG, and 16 (59.2%) in a group that received no revascularization. Restenosis occurred in 94 patients, bypass failures in 36 patients, and recurrent ulcers in 71 patients. CLI was observed in the contralateral limb of 225 (39.9%) patients; of these, 15 (6.7%) required major amputations (rate in contralateral compared with initial limb, P = 0.007). At total of 276 (49.82%) patients died. The Cox model showed significant hazard ratios (HRs) for mortality with age (1.05 for 1 year [95% CI 1.03-1.07]), unfeasible revascularization (3.06 [1.40-6.70]), dialysis (3.00 [1.63-5.53]), cardiac disease history (1.37 [1.05-1.79]), and impaired ejection fraction (1.08 for 1% point [1.05-1.09]).

CONCLUSIONS

Diabetic patients with CLI have high risks of amputation and death. In a dedicated diabetic foot center, the major amputation, ulcer recurrence, and major contralateral limb amputation rates were low. Coronary artery disease (CAD) is the leading cause of death, and in patients with CAD history the impaired ejection fraction is the major independent prognostic factor.

Akt1 controls insulin-driven VEGF biosynthesis from keratinocytes: implications for normal and diabetes-impaired skin repair in mice

Here we investigated the potential role of protein kinase B (Akt) in normal or diabetes-impaired wound healing in mice. Interestingly, Akt1 was predominant in skin, wound tissue, and human keratinocytes cell line. Acute skin repair was characterized by an increase of Akt1 phosphorylation in wound margin keratinocytes. By contrast, phosphorylated Akt1 was nearly completely absent and paralleled by a poor phosphorylation of the eucaryotic initiation factor 4E-binding protein 1 (4E-BP1) and reduced levels of vascular endothelial growth factor (VEGF) protein in chronic wounds of diabetic ob/ob mice. Inhibition of the phosphatidyl-inositol-3 kinase/Akt pathway by wortmannin and specific abrogation of Akt1 protein using small-interfering RNA revealed a regulatory function of Akt1 in insulin-mediated VEGF biosynthesis in keratinocytes. Insulin-induced VEGF protein biosynthesis in keratinocytes was mediated by Akt1 from a constitutive VEGF-encoding mRNA pool at the posttranscriptional level through a downstream phosphorylation 4E-BP1. Moreover, transfection experiments introducing a constitutively active mutant of Akt1 into keratinocytes revealed the mammalian target of rapamycin kinase as a downstream mediator of Akt1-linked 4E-BP1 phosphorylation and translational control. Our data suggest that the endocrine hormone insulin contributes to VEGF release in skin wounds through an Akt1-mediated posttranscriptional mechanism in keratinocytes.

Cellular Damage in Diabetic Wounded Fibroblast Cells following Phototherapy at 632.8, 830, and 1064 nm

Objective. This study aimed to establish if laser irradiation induces cellular and genetic damage. Background. Phototherapy has been shown to induce wound healing in diabetic wounds, however little information is known regarding light-induced damage. Methods. Diabetic wounded fibroblasts were irradiated with 5 or 16 J/cm2 at 632.8, 830, and 1064 nm. Damage was assessed by measuring membrane and DNA damages. Cellular migration was determined by microscopy. Results. Cells irradiated with 5 J/cm2 at 632.8 and 830 nm showed a significant decrease in DNA damage while all cells irradiated with a fluence of 16 J/cm2 showed an increase in membrane and DNA damages. Conclusion. This study showed that the comet assay and LDH release were sensitive enough to pick up changes in laser-irradiated cells. This study also showed that cellular and genetic damage inflicted on diabetic wounded cells was dependent on dose and wavelength and that cells are able to recover and respond.

A model to analyse costs and benefit of intensified diabetic foot care in Austria

RATIONALE, AIMS AND OBJECTIVES

The diabetic foot is a common late complication among diabetic patients and due to its consequences an important financial burden for society. Intensified treatment has proved to reduce amputation rates, but in Austria so far no data have been available about financial implications and long-term effects of intensified treatment. The objective was to retrieve cost data for intensified treatment of diabetic foot ulcers and to estimate the long-term outcome.

METHODS

A retrospective data analysis of 119 ulcers was done to get outcomes and costs for intensified treatment in a specialized outpatient hospital department in an Austrian setting. One-year results were categorized according to the San Antonio wound classification. Using a Markov model upon these data, long-term outcomes and costs for intensified treatment and for standard care were calculated.

RESULTS

Costs for intensified treatment until healing vary from euro 1071 (range: 99-4089) per case to euro 7844 (range: 104-25 615) depending on the lesion's grade. One-year healing rates are 85.2% for grade A and 71.7%, 84.6% and 33.3% for the grades B, C and D respectively. The model-based comparison for treatment costs shows a cost reduction of 29.8% per patient year in grade A ulcerations and 49.7% in grade D for intensified versus standard treatment due to lower amputation rates.

CONCLUSIONS

These results are the first cost data for diabetic foot care in Austria and demonstrate the advantages of intensified care over standard care in terms of patient-oriented outcome and financial impact pleading for the implementation of specialized foot care facilities and referral guidelines to standardize and improve treatment.

Irradiation with a 632.8 nm helium-neon laser with 5 J/cm2 stimulates proliferation and expression of interleukin-6 in diabetic wounded fibroblast cells

BACKGROUND

The use of lasers has been shown to stimulate wound healing in vivo and in vitro. There is an increase in wound closure, cell viability, proliferation, and cytokine expression. If laser parameters can be optimized and standardized, and the underlying mechanisms better understood, this phototherapy can become an alternative safe treatment to slow-to-heal wounds, such as in patients with diabetes. This study aimed to determine the effect on cellular proliferation, migration, and cytokine [interleukin-6 (IL-6)] expression in diabetic and diabetic wounded fibroblast cells (WS1) post-laser irradiation.

METHODS

Diabetic and diabetic wounded WS1 cells were irradiated at 632.8 nm (23 mW) with 5 J/cm(2) or 16 J/cm(2). IL-6 level, cellular proliferation (neutral red assay), and morphology were then determined.

RESULTS

Diabetic cells irradiated with 5 J/cm(2) showed no significant change, while diabetic wounded cells showed an increase in IL-6 level, proliferation, and migration. On the other hand, diabetic and diabetic wounded cells irradiated with 16 J/cm(2) showed a significant decrease in proliferation and evidence of cellular damage, and wounded cells showed no migration.

CONCLUSION

This study showed that phototherapy at the correct fluence stimulates IL-6 expression, proliferation, and cellular migration in diabetic wounded cells. A fluence of 5 J/cm(2) stimulates diabetic wound healing in vitro, while 16 J/cm(2) is inhibitive.

Incidence of critical limb ischemia and amputation outcome in contralateral limb in diabetic patients hospitalized for unilateral critical limb ischemia during 1999-2003 and followed-up until 2005

We studied the incidence of critical limb ischemia (CLI) and amputation outcome of the contralateral limb in 533 diabetic patients hospitalized in our diabetic foot centre because of CLI from 1999 to 2003 and followed-up until 2005. The cumulative incidence rate during the 6-year period reached 49.8% (CI confidence interval=40.6-59.6). All patients underwent arteriography and in 181 (98.4%) the revascularization was performed without different feasibility (p=0.077) compared to that (95.3%) in the initial patients. The severity of lesion evaluated with Wagner grade was lower (chi(2)=33.5, p<0.001) and also the frequency of midfoot and above-the-ankle amputations was lower (p<0.001 and p=0.022, respectively) in contralateral patients. There was no evidence from the logistic analysis to support the association between any of the investigated variables and incidence of CLI in the contralateral limb. Over a 6-year period, almost 50% of the diabetic patients with unilateral CLI developed a CLI in the contralateral limb: however, both severity of foot lesion and amputation level was significantly lower. This fact can be due to prompt therapeutic interventions, made possible thanks to an increased patient awareness acquired by training during the treatment of the unilateral limb.

A computer tool for the fusion and visualization of thermal and magnetic resonance images

The measurement of temperature variation along the surface of the body, provided by digital infrared thermal imaging (DITI), is becoming a valuable auxiliary tool for the early detection of many diseases in medicine. However, DITI is essentially a 2-D technique and its image does not provide useful anatomical information associated with it. However, multimodal image registration and fusion may overcome this difficulty and provide additional information for diagnosis purposes. In this paper, a new method of registering and merging 2-D DITI and 3-D MRI is presented. Registration of the images acquired from the two modalities is necessary as they are acquired with different image systems. Firstly, the body volume of interest is scanned by a MRI system and a set of 2-D DITI of it, at orthogonal angles, is acquired. Next, it is necessary to register these two different sets of images. This is done by creating 2-D MRI projections from the reconstructed 3-D MRI volume and registering it with the DITI. Once registered, the DITI is then projected over the 3-D MRI. The program developed to assess the proposed method to combine MRI and DITI resulted in a new tool for fusing two different image modalities, and it can help medical doctors.

The diabetic foot

Diabetic foot problems are common throughout the world, resulting in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures assist in identifying the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with irremovable casting, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patients' adherence to the effectiveness of pressure relief.

In Vitro Exposure of Wounded Diabetic Fibroblast Cells to a Helium-Neon Laser at 5 and 16 J/cm2

OBJECTIVE

The aim of the present investigation was to assess morphological, cellular, and molecular effects of exposing wounded diabetic fibroblast cells to He-Ne (632.8 nm) laser irradiation at two different doses.

BACKGROUND DATA

An alternative treatment modality for diabetic wound healing includes low-level laser therapy (LLLT). Although it's used in many countries and for many medical conditions, too many health care workers are unaware of this therapy, and there is still controversy surrounding its effectiveness.

METHODS

Normal human skin fibroblast cells (WS1) were used to simulate a wounded diabetic model. The effect of LLLT (632.8 nm, 5 and 16 J/cm(2) once a day on two non-consecutive days) was determined by analysis of cell morphology, cytotoxicity, apoptosis, and DNA damage.

RESULTS

Cells exposed to 5 J/cm(2) showed a higher rate of migration than cells exposed to 16 J/cm(2), and there was complete wound closure by day 4. Exposure of WS1 cells to 5 J/cm(2) on two non-consecutive days did not induce additional cytotoxicity or genetic damage, whereas exposure to 16 J/cm(2) did. There was a significant increase in apoptosis in exposed cells as compared to unexposed cells.

CONCLUSION

Based on cellular morphology, exposure to 5 J/cm(2) was stimulatory to cellular migration, whereas exposure to 16 J/cm(2) was inhibitory. Exposure to 16 J/cm(2) induced genetic damage on WS1 cells when exposed to a He-Ne laser in vitro, whereas exposure to 5 J/cm(2) did not induce any additional damage.

The neuropathic diabetic foot

Diabetic foot problems are common throughout the world, and result in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are likely to be of neuropathic origin and, therefore, are eminently preventable. Individuals with the greatest risk of ulceration can easily be identified by careful clinical examination of their feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb-threatening, or life-threatening. Infection is defined clinically, but wound cultures assist in identification of causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with nonremovable casts, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patient's adherence to the strategy used for pressure relief.

Vibration perception threshold--a valuable assessment of neural dysfunction in people with diabetes

Diabetic peripheral neuropathy (DPN) has been identified as a key element in the causal pathway to foot ulceration and other lower-extremity complications, impaired quality of life and increased mortality. Early detection is essential to optimise effective risk management, including adequate foot care, patient education, and future pharmacological therapy. However, data suggest that screening has been mostly sub-optimal, and many physicians remain unfamiliar with non-invasive screening tests. There is evidence in the literature to suggest that vibration perception threshold (VPT) measures can be used to easily and accurately identify at-risk diabetic patients, including those with early neuropathic deficits. These measures have been used in population-based studies and are associated with an increased risk of severe and expensive outcomes, such as ulcers and amputations. Incorporating VPT testing into clinical practice has the potential to significantly improve the outcomes in patients with DPN, thereby substantially reducing the socio-economic burden of this common and challenging disease.

Severely impaired insulin signaling in chronic wounds of diabetic ob/ob mice: a potential role of tumor necrosis factor-alpha

Wound-healing disorders are major complications of diabetes mellitus. Here, we investigated insulin-mediated signaling in nonwounded skin and in cutaneous tissue regeneration of healthy C57BL/6 and diabetes-impaired leptin-deficient obese/obese (ob/ob) mice. The insulin receptor (InsR) was abundantly expressed in wound margins and granulation tissue during acute healing in healthy mice. Remarkably, active signaling from the InsR, as assessed by phosphorylation of downstream targets such as protein tyrosine phosphatase-1B, glycogen synthase (GS), and GS kinase, was nearly absent in nonwounded and acutely healing skin from ob/ob mice. Systemic leptin administration to ob/ob mice reverted the diabetic phenotype and improved tissue regeneration as well as the impaired expression of InsR, insulin receptor substrate-1 and insulin receptor substrate-2, and downstream signaling (phosphorylation of GS kinase and GS) in late wounds and nonwounded skin of ob/ob mice. Importantly, tumor necrosis factor (TNF)-alpha was a mediator of insulin resistance in keratinocytes in vitro and in ob/ob wound tissue in vivo. Systemic administration of a monoclonal anti-TNF-alpha antibody (V1q) in wounded ob/ob mice attenuated wound inflammation, improved re-epithelialization, and restored InsR expression and signaling in wound tissue of ob/ob mice. These data suggest that InsR signaling in diabetes-impaired wounds is sensitive to inflammatory conditions and that anti-inflammatory approaches, such as anti-TNF-alpha strategies, improve diabetic wound healing.

Building a successful support group for post-amputation patients

The purpose of this article is to identify five steps to attain a successful amputee support group and share the process for establishing and maintaining a peer visitation program for in-patient amputees. Whatever the cause, losing a limb is a life-changing event that one should not go through alone. Support groups can assist patients and their families through this transition in a positive and healthy way.

The diabetic foot: from art to science. The 18th Camillo Golgi lecture

Diabetic foot ulceration represents a major medical, social and economic problem all over the world. While more than 5% of diabetic patients have a history of foot ulceration, the cumulative lifetime incidence may be as high as 15%. Ethnic differences exist in both ulcer and amputation incidences, with both being less common in patients of Indian subcontinent origin living in the UK. Foot ulceration results from the interaction of several contributory factors, the most important of which is neuropathy. With respect to the management of acute Charcot neuroarthropathy in diabetes, recent studies suggest that bisphosphonates reduce disease activity as judged not only by differences in skin temperature, but also by assessing markers of bone turnover. The use of the total-contact cast is demonstrated in the treatment of acute Charcot feet and of plantar neuropathic ulcers. Histological evidence suggests that pressure relief results in chronic foot ulcers changing their morphological appearance by displaying some features of an acute wound. Thus, repetitive stresses on the insensate foot appear to play a major role in maintaining ulcer chronicity. It is hoped that increasing research activity in foot disease will ultimately result in fewer ulcers and less amputation in diabetes.

Evaluation of the impact of chiropodist care in the secondary prevention of foot ulcerations in diabetic subjects

OBJECTIVE

To evaluate the influence of regular chiropodist care on the recurrence rate of diabetic foot ulcers within 1 year.

RESEARCH DESIGN AND METHODS

Ninety-one diabetic outpatients with healed foot ulcers (age 65 +/- 11 years, 40 women and 51 men, diabetes type 1 (n = 6) or 2 (n = 85), BMI 28.5 +/- 4.4, diabetes duration 16 +/- 11 years, HbA(1c) 8.4 +/- 1.6%) were randomized to a group that received monthly remunerated routine chiropodist care (n = 47) or a control group (n = 44).

RESULTS

Within a median follow-up of 386 days, ulceration recurred in 18 patients in the chiropodist group and 25 patients in the control group (hazard ratio [HR] 0.60; 95% CI, 0.32, 1.08; P = 0.09). Analysis of ulceration per foot demonstrated a significant reduction (20 vs. 32 ulcerations; Cox relative risk [Cox RR] 0.52; 95% CI, 0.30, 0.93; P = 0.03) in favor of chiropodist care. Per protocol, analysis of patients who actually underwent chiropodist foot care on a regular basis also indicates the beneficial influence of chiropodist care with ulceration in 13 vs. 30 patients (HR, 0.53; 95% CI, 0.30-1.01; P = 0.05) and in 15 vs. 37 feet (Cox RR, 0.46; 95% CI, 0.24-0.90; P = 0.02) for the intervention and control groups, respectively. Minor amputation was required in two patients in the intervention group and one patient in the control group. Four patients in the control group and two patients in the intervention group died during the trial.

CONCLUSIONS

These data suggest that secondary preventive measures by a chiropodist may reduce recurrence of foot ulcers in diabetic patients.

Can motor nerve conduction velocity predict foot problems in diabetic subjects over a 6-year outcome period?

OBJECTIVE

This study examined motor nerve conduction velocity (MNCV) and other peripheral nerve and vascular tests as predictors for foot ulceration, amputation, and mortality in diabetes over a 6-year follow-up period.

RESEARCH DESIGN AND METHODS

We recruited 169 diabetic subjects (without significant peripheral vascular disease with an ankle brachial pressure index [ABPI] >/=0.75) for the study and separated them into groups (to ensure diversity of nerve function). The control group consisted of 22 nondiabetic people. At baseline, all subjects underwent assessment of MNCV; vibration, pressure, and temperature perception thresholds; peripheral vascular function; and other diabetes assessments.

RESULTS

Over the 6-year outcome period, 37.3% of the diabetic subjects developed at least one new ulcer, 11.2% had a lower-limb amputation (LLA) (minor or major), and 18.3% died. Using multivariate Cox's regression analysis (RR [95% CI] and removing previous ulcers as a confounding variable, MNCV was found to be the best predictor of new ulceration (0.90 [0.84-0.96], P = 0.001) and the best predictors of amputation were pressure perception threshold (PPT) (5.18 [1.96-13.68], P = 0.001) and medial arterial calcification (2.88 [1.13-7.35], P = 0.027). Creatinine (1.01 [1.00-1.01], P < 0.001), MNCV (0.84 [0.73-0.97], P = 0.016), and skin oxygen levels (14.32 [3.04-67.52], P = 0.001) were the best predictors of mortality.

CONCLUSIONS

This study shows that MNCV, which is often assessed in clinical trials of neuropathy, can predict foot ulceration and death in diabetes. In addition, tests of PPT and medial arterial calcification can be used in the clinic to predict LLA in diabetic subjects.

Neurovascular disease, antioxidants and glycation in diabetes

People with diabetes are ten to fifteen times more likely to have a lower limb amputation (LLA) than non-diabetic individuals. Fifteen percent of people with diabetes will develop a foot ulcer during their lifetime, the rate of major amputation amongst diabetic individuals continues to rise, foot problems remain the commonest reason for diabetes-related hospitalisation and recurrence rates in patients with previous foot ulcers are 50% or more. Hyperglycaemia-induced oxidative stress has been shown to result in decreased nerve conduction velocity, and decreased endoneural blood flow-both precursors for neuropathy. Vitamin antioxidants have been shown to be effective therapy in experimental models in reducing free radical species and inhibiting the oxidative process in diabetes subjects. Little work has been published, however, regarding the dietary use of antioxidants from foods, and their specific effects on neurovascular disease and glycation within the diabetes population. Aetiological and prevention studies with dietary antioxidants from foods aimed at the complex nature of foot problems in diabetes are needed.