Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists

The Effects of Bariatric Surgery on Renal, Neurological, and Ophthalmic Complications in Patients with Type 2 Diabetes: the Taiwan Diabesity Study

Background

Bariatric surgery has been shown to improve glycemic control in patients with type 2 diabetes. However, less is known whether it can also reduce diabetic renal, neurological, and ophthalmic complications.

Methods

This prospective multicenter cohort study compared renal, ophthalmic, and neurological complications between 49 patients with obesity/overweight receiving bariatric surgery and 338 patients receiving standard medical treatment after follow-up for 2 years. Patients received neurological examinations including toe tuning fork vibration test, ankle tendon reflex test, 10-g monofilament test, and ophthalmic examinations including visual acuity measurement and fundus examinations. Multiple regressions, propensity score weighting, and matching were employed to adjust for baseline differences.

Results

After 2 years of follow-up, patients with type 2 diabetes receiving bariatric surgery had greater reduction in BMI, HbA1c, and urine albumin–creatinine ratio, greater improvement in estimated glomerular filtration rate, and greater increase in tuning fork test score of right and left toes compared with the medical group. However, there is no improvement in 10 g-monofilament test, visual acuity, diabetic non-proliferative retinopathy, and proliferative retinopathy. Similar results were obtained using multiple regression adjustment, propensity-score weighting, or comparing age-, sex-, and BMI-matched subjects.

Conclusions

After 2-year follow-up, patients with obesity/overweight and type 2 diabetes receiving bariatric surgery have increased glomerular filtration rate, reduced albuminuria, and improved tuning folk vibration sensation.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04859-9) contains supplementary material, which is available to authorized users.

Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease

Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.

Optimised cushioning in diabetic footwear can significantly enhance their capacity to reduce plantar pressure

BACKGROUND

Plantar pressure reduction with the use of cushioning materials play an important role in the clinical management of the diabetic foot. Previous studies in people without diabetes have shown that appropriate selection of the stiffness of such materials can significantly enhance their capacity to reduce pressure. However the significance of optimised cushioning has not been yet assessed for people with diabetic foot syndrome.

RESEARCH QUESTION

What is the potential benefit of using footwear with optimised cushioning, with regards to plantar pressure reduction, in people with diabetes and peripheral neuropathy?

METHODS

Plantar pressure distribution was measured during walking for fifteen people with diabetic foot syndrome in a cohort observational study. The participants were asked to walk in the same type of footwear that was fitted with 3D-printed footbeds. These footbeds were used to change the stiffness of the entire sole-complex of the shoe; from very soft to very stiff. The stiffness that achieved the highest pressure reduction relative to a no-footbed condition was identified as the patient-specific optimum one.

RESULTS

The use of the patient-specific optimum stiffness reduced, on average, peak pressure by 46% (±14%). Using the same stiffness across all participants lowered the footwears' capacity for pressure reduction by at least nine percentile points (37% ± 17%); a statistically significant difference (paired samples t-test, t(13) = -3.733, p = 0.003, d = 0.997). Pearson correlation analysis indicated that patient-specific optimum stiffness was significantly correlated with the participants' body mass index (BMI), with stiffer materials needed for people with higher BMI (rs(14) = 0.609, p = 0.021).

SIGNIFICANCE

This study offers the first quantitative evidence in support of optimising cushioning in diabetic footwear as part of standard clinical practice. Further research is needed to develop a clinically applicable method to help professionals working with diabetic feet identify the optimum cushioning stiffness on a patient-specific basis.

A ‘Speed-Dating’ Model of Wound Care? Rapid, High-Volume Assessment of Patients With Diabetes in a Multidisciplinary Foot Wound Clinic

Background Diabetes is a major risk factor for foot ulceration and leg amputation, but the effect of intensive glycaemic control on wound healing is unknown. While an interdisciplinary approach has been shown to be important in the management of diabetic foot ulcer (DFU), there is no standardised definition of such an interdisciplinary team.

Objective To investigate the role of an opportunistic, rapid-access, inter-disciplinary model of diabetes care at a foot wound clinic.

Methods A retrospective case-control study of patients with DFUs attending a diabetes foot wound clinic over a 6-month period. Outcomes in patients who were seen by a rapid-access interdisciplinary team (RAIT) consisting of an endocrinologist, diabetes educator and dietician during the standard wound care those who were not seen by this team were compared.

Results Fifty-five patients were seen by the RAIT and 64 control patients were not seen by this team during their attendance of a diabetes foot wound clinic. Patients in the intervention group had non-significantly higher baseline HbA1c and a significantly larger proportion were active cigarette smokers. Both groups achieved comparable reduction in the total number of DFUs per patient (p=0.971). Patients in the intervention group had a 60.1% reduction in wound size compared to 52.4% reduction in control group (p=0.526).

Conclusion Our study shows that the use of a rapid-access interdisciplinary team to assess and manage patients’ diabetes in a foot wound clinic is feasible. Patients with higher-risk diabetes foot wounds exposed to RAIT had comparable wound healing outcomes to lower risk patients.

Distal Symmetric and Cardiovascular Autonomic Neuropathies in Brazilian Individuals with Type 2 Diabetes Followed in a Primary Health Care Unit: A Cross-Sectional Study

The paucity of epidemiological data regarding diabetes complications in Brazil motivated us to evaluate the prevalence rates of distal symmetric polyneuropathy (DSP) and of cardiovascular autonomic neuropathy (CAN) in individuals with type 2 diabetes (T2D) followed in a primary care unit. A total of 551 individuals (59.3% women, 65 years old; diabetes duration of 10 years; HbA1c of 7.2%, medians) were included in this cross-sectional study. DSP was diagnosed by sum of the Neuropathy Symptoms Score (NSS) and Modified Neuropathy Disability Score (NDS) and by the Semmes-Weinstein monofilament. CAN was diagnosed by cardiovascular autonomic reflex tests combined with spectral analysis of heart rate variability. The prevalence rates of DSP were 6.3% and 14.3%, as evaluated by the sum of NSS and NDS and by the Semmes-Weinstein monofilament, respectively. Those with DSP diagnosed by monofilament presented longer diabetes duration, worse glycemic control and a higher stature. The prevalence rates of incipient and definitive CAN were 12.5% and 10%, respectively. Individuals with definitive CAN presented a higher frequency of hypercholesterolemia and of arterial hypertension. The higher prevalence rate of DSP with the use of the monofilament suggests that it may be a more appropriate tool to diagnose DSP in the primary care setting in Brazil.

Duration from Wound Occurrence to Referral to a Vascular Center in Japanese Patients with Critical Limb Ischemia

Objective: Clinical guidelines have long recommended referring patients with clerical limb ischemia (CLI) to a vascular specialist early in the course of their disease to plan for revascularization options. However, no data were so far available on how promptly CLI patients were referred to a vascular center in the real-world settings in Japan. This study aimed to survey the duration from wound occurrence to referral to a vascular center in CLI patients in Japan. Materials and Methods: We analyzed a database of a prospective, multicenter registry in Japan, including 428 CLI patients presenting ischemic wounds and referred to vascular centers. The duration of the wound occurrence was surveyed at registration. Results: The wound duration exceeded 1 month in 58.2% [95% confidence interval: 53.2% to 63.1%] of the patients, and 3 months (i.e., one season) in 15.9% [12.4% to 19.4%]. No clinical features were significantly associated with the wound duration. The wound duration was independently associated with the wound severity evaluated using the Wound, Ischemia, and foot Infection classification system (P=0.030). Conclusion: A substantial number of CLI patients referred to vascular centers had a long duration of wounds, i.e., time from wound occurrence to the referral.

Adaptação transcultural do instrumento para exame do pé diabético em 3 minutos

Introdução: O “How to do a 3-minute diabetic foot exam”, elaborado por Armstrong et al foi projetado para fornecer aos profissionais de saúde uma forma aprofundada, resumida e facilmente aplicável para avaliar os pés do paciente diabético na Atenção Primária à Saúde. Objetivo: Traduzir para a língua portuguesa, adaptar ao contexto cultural brasileiro e testar as propriedades de medidas deste instrumento. Métodos: Seguindo orientação padrão da literatura, o instrumento foi traduzido para o português, adaptado culturalmente e testado em relação à reprodutibilidade, validade de face, conteúdo e construto. Nas etapas de adaptação cultural e validação foram entrevistados 30 profissionais de saúde e 60 pacientes, respectivamente. Resultados: O instrumento foi adaptado ao contexto linguístico e cultural da população mantendo todas as características essenciais do instrumento original em Inglês e sendo preservadas as equivalências idiomática, semântica, conceitual e cultural. Todos os itens do instrumento apresentaram concordância calculado pelo Índice de Validade de Conteúdo (IVC) > 0,9. O α de Cronbach foi de 0,67. O Coeficiente de Correlação Intraclasse interobservador foi de 0,73 (IC95%:0,58-0,85) e intraobservador foi de 0,65 (IC95%: 0,45-0,81), demostrando uma reprodutibilidade satisfatória. O instrumento e o teste do monofilamento apresentaram correlação positiva com significância estatística (ρ = 0,41; p <0,01). Conclusão: Este trabalho traduziu para a língua portuguesa, adaptou ao contexto cultural brasileiro e testou as propriedades de medidas do instrumento americano: “How to do a 3-minute diabetic foot exam”. 

Comparison of two pixelated insoles using in-shoe pressure sensors to determine percent offloading: case studies

Objective:

The gold standard for offloading neuropathic forefoot and midfoot wounds is the total contact cast (TCC). However, in practice TCC is rarely used and is contraindicated in patients with fluctuating oedema, poor perfusion, lack of adequate tissue oxygenation and morbid obesity. It can also be too restrictive for patients, inevitably resulting in treatment rejection and delayed healing. This paper examines the role of shoe-based offloading devices as an alternative in reducing plantar pressure and optimising the healing of neuropathic ulcers.

Method:

Healthy subjects were recruited and fitted for two types of pixelated insoles: PegAssist (PA) insole system (Darco International, US) and FORS-15 (FORS) offloading insole (Saluber, Italy). An area of discreet, elevated high pressure was created by adding a 1/4-inch-thick felt pad to the plantar skin under the first metatarsal head. Subjects walked barefoot in surgical shoes with standard insoles (Condition 1), barefoot in pixelated insoles (Condition 2), barefoot with pixels removed (Condition 3). Dynamic plantar pressures were measured using F-Scan and the results were analysed to determine plantar pressure changes in each condition.

Results:

Using PA, the percentage reduction of plantar pressure (kPa) under the first metatarsal between Condition 1 and Condition 2 was 10.54±15.81% (p=0.022), between Condition 2 and Condition 3 was 40.13±11.11% (p<0.001), and between Condition 1 and Condition 3 was 46.67±12.95 % (p<0.001). Using FORS, the percentage reduction between Condition 1 and Condition 2 was 24.25±23.33% (p=0.0029), between Condition 2 and Condition 3 was 23.61±19.45% (p<0.001), and between Condition 1 and Condition 3 was 43.39±18.70% (p<0.001). A notable difference in the findings between the two insoles was the presence of a significant edge effect associated with PA, indicating that the offloading was not entirely successful. No edge effect was detected with FORS.

Conclusion:

Our current analysis shows that pixelated insoles exhibit potential for supplemental offloading in surgical shoes. These devices could provide an alternative way for physicians to offload plantar wounds and expedite closure for patients that cannot tolerate a TCC or other restrictive devices.

Variability in the clinical diagnosis of diabetic peripheral neuropathy

AIMS

The aims of this study are to assess the variability in the prevalence of diabetic peripheral neuropathy (DPN), according to the diagnostic and clinical guidelines used.

METHODS

A cross-sectional observational study was conducted of 111 patients with diabetes mellitus. The presence/absence of DPN was determined according to 12 different criteria stipulated in various clinical guidelines (ADA 2018, IWGDF 2016, IDF 2012 and CONUEI 2018). The Cohen's kappa coefficient (κ) was performed to determine the degree of agreement for DPN diagnosis among the different criteria.

RESULTS

The recorded prevalence of DPN ranged from 13.1% (criterion ADA 2018) to 68.5% (criterion IDF 2012). The sensory parameter that was most commonly affected was the non-perception of vibration (68.5%) and the absence of Achilles reflexes (59.4%). IWGDF, based on the use of a monofilament, cotton wisp and tuning fork, was the test with more agreements, presenting good agreement with 2 criteria from ADA 2018 (k=0.845), 1b2 (k=0.817), 2 criteria from IWGDF 2016 (k=0.933), (k=0.817), 1 criteria from IDF 2012 (k=0.845) and 1 criteria from CONUEI 2018 (k=0.860), all p<0.001.

CONCLUSION

The IWGDF criterion based on the use of a monofilament, cotton wisp and tuning fork for the diagnosis presented the highest level of concordance with the other criteria (>0.8).

Educating patients of diabetes mellitus for diabetic foot care

Background and Purpose

Diabetes mellitus (DM) is a global pandemic. Among the spectrum of diabetic complications, diabetic foot is a leading cause of morbidity and hence awareness and education regarding primary healthcare inclusive of self-care pertaining to diabetic foot care is of paramount importance.

Aim

The aim of the study was to educate patients of DM regarding the disease and its associated complications, specifically pertaining to diabetic foot care.

Methodology

The study was carried out in three phases, first was to assess the diabetic patients related to their awareness on disease complications and diabetic foot care, through pretest questionnaire, the second phase was to sensitize patients and educate them on the same, the third phase was to re assess the knowledge gained by the patients through posttest assessment.

Results

The study evaluated the absolute and relative learning gain regarding the awareness and knowledge of foot care among diabetic individuals. The absolute learning gain was 40.92% and the relative learning gain was 76.48% and normalized learning gain was 0. 88, the normalized gain was assessed to be high.

Conclusion

The study concluded that training and sensitizing individuals with diabetes will definitely help reduce morbidity of diabetic foot and hence the medical and paramedical staff need to spread awareness regards the same.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability

BACKGROUND

Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes.

METHODS

Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined.

RESULTS

Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57).

CONCLUSION

We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.

Prevalence and associated factors of foot ulcer among diabetic patients in Ethiopia: a systematic review and meta-analysis

Background

Diabetes and its complications including foot ulcer constitute a global public health challenge attributing to a significant cause of morbidity and mortality. Foot ulcer is one of the long-term complication of diabetes mellitus which lead to infection and amputation of lower extremities. In Ethiopia, findings from few studies were inconsistent and there is a need to systematically pool existing data to determine the magnitude of foot ulcer in diabetics and factors contributing to it.

Methods

We identified articles through electronic databases such as Medline, Hinari, Pub Med, Cochrane library, the Web of Science and Google Scholar. Accordingly, we identified 95 published and one unpublished article. Finally, eleven studies which fullfilled eligibility criteria were included in final systematic review and meta-analysis. Data were extracted using a standardized data extraction checklist and the analyses were conducted using STATA version 14. The Cochrane Q test statistic and I² tests were used to assess heterogeneity.

Results

The overall magnitude of foot ulcer was 12.98% (95%CI: 7.81–18.15) in diabetic patients in Ethiopia. Sub-group analyses revealed highest prevalence in Addis Ababa (19.31% (95%CI: 2.7. 41.37)). Foot ulcer was significantly associated with rural residence (OR = 2.72, 95%, CI: 1.84–4.01)), presence of callus on the feet ((OR = 12.67, 95%, CI: 6.47–24.79)), a body mass index of ≥24.5 ((OR = 2.68, 95%, CI: 1.58–4.56)), poor self- care practice ((OR = 1.47, 95%CI: 1.25–1.73)), type I diabetes mellitus ((OR = 0.42, 95%, CI: 0.22–0.79)), staying with DM for < 10 years ((OR = 0.23, 95%, CI: 0.11–0.50)), and age < 45 years ((OR = 0.44, 95%, CI: 0.21–0.92)).

Conclusion

The prevalence of diabetic foot ulcers in Ethiopia is relatively low, although its trend is increasing from time to time. Socio-demographic factors, body weight, and healthcare practice contribute to the development of diabetic foot ulcers. Appropriate interventions towards patient self-care practice, lifestyle modification and follow-up are wanted to prevent diabetic foot ulcers.

Clinical guidelines for type 1 diabetes mellitus with an emphasis on older adults: an Executive Summary

We present a summary of a guideline produced by an international group of experts for managing type 1 diabetes in adults with an emphasis on the special needs of older people with this condition. The rationale for delivering high-quality diabetes care for adults with type 1 diabetes, why it is important to include older people in our considerations, and the key underpinning principles of the guideline are included. The structure of the recommendations given is described and consists of 'general' recommendations followed by 'specific' recommendations according to three categories depending on the characteristics of adults addressed, such as functional level or self-management ability. Recommendations are provided in the areas of: clinical diagnosis, establishing management plans and glucose regulation, diabetes self-management education, nutritional therapy, physical activity, exercise and lifestyle modification, insulin treatments and regimens, use of technology in diabetes management, hypoglycaemia, managing cardiovascular risk, management of microvascular risk, and inpatient management of type 1 diabetes and ketoacidosis.

Fall Risk and Balance Confidence in Patients With Diabetic Peripheral Neuropathy: An Observational Study

OBJECTIVE

Individuals with diabetic peripheral neuropathy (DPN) have functional deficits that increase their risk of falling. However, psychological aspects such as loss of confidence in undertaking activities could also contribute to this risk. We examined correlations between balance confidence and fall risk among individuals with DPN.

METHODS

This was a cross-sectional study of 146 individuals with DPN. Elevated fall risk was determined by timed up-and-go test with standard cut-off time of 13.5 seconds, and balance confidence was measured by 16-item Activities Specific Balance Confidence scale. Functional parameters assessed included functional reach, body sway velocity during quiet standing and muscle strength at ankle and toe.

RESULTS

Twenty percent of the DPN patients were at increased risk of falls. Every unit increase in balance confidence was associated with 9% (95% confidence interval: 0.88, 0.95; p<0.001) reduced odds of falling, after adjusting for socio-demographic, health and functional characteristics. No other functional parameters had significant associations with fall risk in adjusted analyses.

CONCLUSIONS

Psychological factors like balance confidence appear to be more important for fall risk among DPN patients, compared to objective functional performance. Interventions targeting balance confidence may be beneficial in reducing the risk of falls in this population.

Is it possible to substitute the monofilament test for the Ipswich Touch Test in screening for peripheral diabetic neuropathy?

BACKGROUND

This study aimed to assess the agreement and efficacy of the Ipswich Touch Test compared to the monofilament test in individuals with type 2 diabetes.

MATERIALS AND METHODS

A cross-sectional and analytical study was conducted. The inclusion criteria were patients with type II diabetes (n = 250) who did not present ulcers or amputation in either foot. The exclusion criteria were as follows: patients who presented sequelae of cerebrovascular disease or other neurological pathologies, as well as diagnoses of malignancy, alcohol abuse, liver cirrhosis, hepatitis B, AIDS, hypothyroidism, chronic kidney disease or lupus erythaematosus, as these clinical conditions could influence or bias the results (Won and Park in Endocrinol Metab 31:230-238, 2016). Sensitivity, specificity, predictive values, likelihood ratios, and Kappa index were calculated. Other factors assessed were glycated haemoglobin and body mass index.

RESULTS

Most of the participants were female (71.2%), and glycated haemoglobin (HbA1c) was greater than 7% in 54.4% of the patients. The mean age was 59.43 years, and the mean time since diagnosis was 12.38 years. The Kappa index was 0.819 (p < 0.001), and the Ipswich Touch Test had a sensitivity of 83.33%, a specificity of 97.66%, a positive predictive value of 85.71%, a negative predictive value of 97.21%, a positive likelihood ratio of 30.19%, and a negative likelihood ratio of 0.17%. The level of significance was 5% in this study.

CONCLUSION

The Ipswich Touch Test resented good agreement and efficacy compared to the gold standard-the 10 g monofilament test.

SENSORIMOTOR ALTERATIONS AND ASSOCIATED FACTORS IN DIABETES MELLITUS PATIENTS

ABSTRACT Objective: to evaluate sensorimotor alterations in the extremities of the lower limbs and associated factors in Diabetes Mellitus patients. Method: this was a cross-sectional and analytical study, conducted in a Basic Health Unit, in Teresina (Brazil) with a sample of 102 participants between April and July 2018, by means of a semi-structured form. For the statistical analyses, the Pearson's chi-square and Fisher's exact tests were performed. Results: among the study participants, 99 (97.1%) presented alterations, 73 (71.6%) on the skin and 40 (39.2%) on nails. The sensorimotor examination identified 40 (39.22%) individuals with tactile sensitivity alterations and 13 (12.7%) with reduced vibratory sensitivity, using the 128 Hz tuning fork. The factors associated with sensorimotor alterations detected by the 10 gram monofilament were the following: time of disease over ten years; absence of periodic foot evaluation (p=0.003); impaired visual acuity (p=0.001); presence of pain or discomfort (p=0.003); pain worsening at night (p=0.008); moderate pain intensity (p=0.012) and relief at rest (p=0.015). Conclusion: sensory alterations in the lower limbs showed their relationship with some of the research variables, such as time of disease, foot evaluation, glycemic value, presence of pain or discomfort (worsening and relief shifts, and intensity), skin coloring and vibratory sensitivity evaluation with a tuning fork.

Choosing a Vibratory Test to Pair With Semmes Weinstein Monofilament Testing for Evaluating Lower Extremity Sensation in Patients With Diabetes: A Comparison of Three Vibratory Methodologies

BACKGROUND

Numerous guidelines recommend pairing Semmes-Weinstein monofilament (SWM) testing with a secondary clinical test when screening for diabetic peripheral neuropathy, yet time is very limited in clinical practice. This study compared the time to complete and the diagnostic agreement of three vibratory sensation tests.

METHODS

Sixty-five individuals (42% male; aged: 61 ± 12 years) were recruited. A single investigator administered the following tests bilaterally: 10-site SWM, traditional tuning fork (TTF), electronic tuning fork (ETF), and vibration perception threshold (VPT) via biothesiometer. Times to physically administer the tests were compared with a one-way repeated measures ANOVA. Cochran's Q test was used to compare the varied tests' diagnostic agreement.

RESULTS

The ANOVA indicated there were significant (P < .001, partial eta squared = .442) differences in time to complete the varied tests. Sidak post hoc comparisons indicated the VPT (21.2 ± 14.3) testing took an intermediate time to complete, while the ETF (9.7 ± 6.5) and TTF (10.1 ± 7.5) tests took the least amount of time, and the SWM (28.6 ± 8.4) test took the longest time. There were also numerous significant differences (P ≤ .001) between the different tests in regards to neuropathy diagnoses.

CONCLUSIONS

Tuning fork methods required 11 seconds less to administer than VPT testing. Although that may seem trivial, it is worth noting peripheral neuropathy screening often fails to occur in the precious few minutes clinicians are allotted per patient. Considering ETF's intrinsic control of stimulus amplitude and its ease of use with an embedded timer, the ETF is recommended over the TTF. Clinicians should also be mindful that different tests yield different diagnostic conclusions.

Describing Normative Foot Temperatures in Patients With Diabetes-Related Peripheral Neuropathy

BACKGROUND

Prior research shows increased foot temperatures are predictive of diabetes-related foot complications. Our aim was to describe normative skin foot temperatures for individuals with diabetic peripheral neuropathy to better inform new technologies. We also explored for potential risk factors which correlate with changes in foot temperatures.

METHODS

We conducted a retrospective chart review of adult patients >18 years of age with diabetes mellitus and clinically diagnosed diabetic peripheral neuropathy with pedal digital thermometry performed between 2009 and 2018. A total of 58 patients met these criteria. Univariate modeling was based on covariates that may affect foot temperature including age, peripheral arterial disease, toe pressure, seasonality of measurement, smoking pack-years, caffeine use, insulin use, and calcium channel blocker use.

RESULTS

In patients with diabetic peripheral neuropathy, mean toe temperatures of 27.67°C (6.300°C), forefoot of 28.58°C (5.36°C), midfoot of 29.21°C (3.81°C), and rearfoot of 29.88°C(3.83°C) were demonstrated. A modest negative correlation between seasonality and toe and metatarsal temperatures (r = -0.38, P < .05; r = -0.43 P < .01, respectively) was demonstrated. Midfoot temperatures were modestly and positively correlated to the presence of small fiber symptoms (r = 0.33, P = .03). Positive modest correlation with rearfoot temperatures and amount of pack-year history (r = 0.30, P = .03) was seen.

CONCLUSION

Normative foot temperatures in neuropathic patients were found to be inversely associated with seasonality at the toe and metatarsal level. Smoking and pack-year history demonstrate modest correlation previously unseen in temperature analyses and warrant further exploration. Normative temperatures in neuropathic patients can better inform new technologies for the prevention of diabetic foot ulcer and Charcot neuroarthropathy.

11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Glycemic Variability and Diabetic Neuropathy in Young Adults With Type 1 Diabetes

Background: Glycemic variability (GV) may attribute to the pathogenesis of diabetic neuropathy. The aim of this cross-sectional study was to investigate the association between GV and distal symmetric polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN) in a Danish population of young adults with type 1 diabetes. Methods: Young adults between 18 and 24 years with type 1 diabetes were included in this cross-sectional study. CAN was assessed by cardiovascular autonomic reflex tests (CARTs) and heart rate variability (HRV). DSPN was assessed by light pressure, pain and vibration perception, electrochemical skin conductance, sural nerve conduction velocity (SNCV), and amplitude potential (SNAP). GV were obtained by continuous glucose monitoring including coefficient of variation (CV), SD, continuous overall net glycemic action (CONGA), and mean amplitude of glucose excursions (MAGE). Results: The study comprised 133 young adults (43.6% males), mean age of 22 years (SD 1.6). Unadjusted, higher CV was associated with a decreased risk of sural nerve conduction (P = 0.03), abnormal SNAP (P = 0.04) and incidents of definite CAN (P = 0.04). Likewise, higher CONGA was associated with increasing incidents of subclinical DSPN (P = 0.03), abnormal SNAP (P = 0.01), and SNCV (P = 0.02). However, both associations were not statistically significant in the fully adjusted model. Higher MAGE was associated with slightly increasing measures of HRV (P = 0.03) but only when fully adjusted. When correcting for multiple tests significance was lost. A significant association was found between HbA1c and measures of both DSPN (P < 0.02) and HRV (P < 0.03) in fully adjusted models. Conclusions: No significant associations between GV and diabetic neuropathy were found after adjusting for risk factors and multiple tests. This suggests that GV may not be a risk factor for diabetic neuropathy in young adults with type 1 diabetes. However, long-term effects of GV excursions may still play a role in the pathogenic mechanisms leading to neuropathy in later life.

The prevalence of peripheral neuropathy severe enough to cause a loss of protective sensation in a population-based sample of people with known and newly detected diabetes in Barbados: a cross-sectional study

AIMS

To determine the prevalence and potential risk factors for diabetic peripheral neuropathy with a loss of protective sensation in Barbados.

METHODS

A representative population sample aged > 25 years with previously diagnosed diabetes or a fasting blood glucose ≥ 7 mmol/l or HbA_1c ≥ 48 mmol/mol (6.5%) was tested by 10 g monofilament at four plantar sites per foot and a 28 Hz tuning fork and neurothesiometer at the hallux. Data were adjusted to the age structure of people with diabetes in Barbados. Multivariable logistic regression assessed associations with peripheral neuropathy with a loss of protective sensation.

RESULTS

Of 236 participants [74% response rate, 33% men, 91% black, median age 58.6 years, mean BMI 30.1 kg/m² , mean HbA_1c 54 mmol/mol (7.1%)], 51% had previously diagnosed diabetes. Foot examination demonstrated that 25.8% (95% CI 20.2 to 31.5) had at least one insensate site with monofilament testing, 14.8% (95% CI 10.2 to 19.4) had an abnormal tuning fork test and 10.9% (95% CI 6.9 to 14.9) had a vibration perception threshold > 25 V. Peripheral neuropathy with a loss of protective sensation prevalence was 28.5% (95% CI 22.7 to 34.4) as indicated by monofilament with ≥ 1 insensate site and/or vibration perception threshold > 25 V. With previously diagnosed diabetes the prevalence was 36.4% (95% CI 27.7 to 45.2) with 98.4% of cases identified by monofilament testing. Increasing age, previously diagnosed diabetes, male sex and abdominal obesity were independently associated with peripheral neuropathy with a loss of protective sensation.

CONCLUSIONS

Over a third of people with previously diagnosed diabetes had evidence of peripheral neuropathy with a loss of protective sensation. Monofilament testing alone may be adequate to rule out peripheral neuropathy with a loss of protective sensation. Monofilament and neurothesiometer stimuli are reproducible but dependent on participant response.

The role of soluble urokinase plasminogen activator receptor (suPAR) in the diagnostics of diabetic foot infection

Background: To investigate the role of soluble urokinase plasminogen activator receptor (suPAR) in the diagnosis of diabetic foot infection and to determine whether it is superior to other infection markers like leukocyte, neutrophil, erythrocyte sedimentation rate, c-reactive protein and procalcitonin.Methods: The present prospective study consisted of four groups: Group 1, healthy volunteers (n = 38); Group 2, patients without diabetic foot ulcers (n = 40); Group 3, diabetic patients with uninfected foot ulcers (n = 33); and Group 4, patients who had diabetic foot infection (n = 48). In each group, the leukocyte, neutrophil, erythrocyte sedimentation rate, c-reactive protein and procalcitonin and suPAR levels were examined. The results were then statistically compared. In addition, the patients in Group 4 were further divided according to the presence of mild, moderate, and severe infection. Also osteomyelitis were evaluated in Group 4 and statistically compared.Results: All infection markers were significantly higher in group 4 patients than those in the other three groups (p < .05). Similarly, all infection markers in the severe diabetic foot infection group were statistically higher than mild diabetic foot infection group (p < .05); however, only suPAR and erythrocyte sedimentation rate were significantly high in cases with osteomyelitis (p < .05). In the receiver operating characteristic analysis, the optimal cut-off value for suPAR was determined to be 2.8 ng/ml, and the sensitivity and specificity above this value were 95.8% and 82.8%, respectively.Conclusions: The current study demonstrated that suPAR might be used as a supportive diagnostic method for the diagnosis of diabetic foot infections.

Comparison of neurosensory devices in detecting cutaneous thresholds related to protective sensibility: A cross-sectional study in São Paulo, Brazil

AIMS

To quantify the static and moving cutaneous sensibility threshold of diabetic patients using a neurosensory device for quantitative pressure detection.

METHODS

Three hundred thirty-four (n = 334) patients with type 2 diabetes and no previous history of wounds on the feet were studied using the one- and two-point static (1SP;2 SP) and one- and two-point moving (1MP;2 MP) tests through the pressure-specified sensory device (PSSD) on the cutaneous territory of the dorsal first web, hallux pulp, and medial calcaneal. In addition, patients were evaluated using the Semmes-Weinstein monofilament (SWM) No. 5.07 and tuning fork (128 Hz), which were used as normality parameters to detect the loss of protective sensibility. The same examinations were used to assess the control group (228 nondiabetic).

RESULTS

Altered values were observed for the static and moving tests over the three studied nerve territories. In comparing the sensibility threshold between diabetic patients who were sensitive and nonsensitive to SWM 5.07, we observed that this filament is not the most indicated for identifying the loss of sensibility in these patients. The prevalence of patients at risk varied between 85 and 89%. The biochemical marker associated with these high rates was HbA1c (p = 0.02).

CONCLUSIONS

Numeric quantification of the pressure threshold allowed us to determine the functional deficit of nerve fibers. Our findings suggest that the neurosensory device should be used as an adjuvant tool to evaluate the degree of loss of sensation on the skin.

Evaluating a Program Process Change to Improve Completion of Foot Exams and Amputation Risk Assessments for Veterans with Diabetes

A quality improvement initiative significantly increased the number of veterans receiving thorough foot exams and amputation risk assessments as well as the number of appropriate podiatry referrals.

Platelet to lymphocyte ratio correlates with diabetic foot risk and foot ulcer in patients with type 2 diabetes

Diabetic foot ulcer is a major complication in patients with diabetes. Platelet-lymphocyte ratio (PLR) has been reported to have a predictive effect to some diabetic complications in recent years. However, it has not been fully elucidated about the relationship between diabetic foot risk or diabetic foot ulcer and PLR in patients with type 2 diabetes. Therefore, we aimed to evaluate this relationship. In this cross-sectional study, we evaluated the relationships between patient's diabetic foot risk with the criteria of the International Working Group on the Diabetic Foot (IWGDF) and prevalent foot ulcer, and PLR in 453 consecutive patients with type 2 diabetes. Propensity score analysis was used to adjust the difference of covariates; age, sex, duration of diabetes, body mass index (BMI), HbA1c, current smoking, hypertension, dyslipidemia, neuropathy, PAD, foot deformity and history of foot ulcers. PLR was higher in patients with high risk diabetic foot or foot ulcer (117 ± 40 vs. 107 ± 31, p = 0.003 and 148 ± 65 vs. 113 ± 56, p < 0.001). A receiver-operating characteristic curve demonstrated that PLR of 130.6 constitutes the cut-off value for prevalent foot ulcer with sensitivity 0.85 and specificity 0.70. Multivariate logistic regression analysis revealed that PLR was positively correlated with prevalent foot ulcer (odds ratio, 1.02; 95% confidence interval 1.01-1.04, p = 0.003) after adjusted for several variables with propensity score analysis. Our results demonstrated that PLR can be a marker for high risk diabetic foot and diabetic foot ulcer in patients with type 2 diabetes.

Interim Results of the Remede d'Or Study: A Multicenter, Single-Blind, Randomized, Controlled Trial to Assess the Safety and Efficacy of an Innovative Topical Formulation of Erythropoietin for Treating Diabetic Foot Ulcers

Objective: To inform on the interim results of the Remede d'Or study, which is a prospective, multicenter, single-blind, randomized, controlled clinical study on the safety and efficacy of RMD-G1, a topical carbopol-based hydrogel with a fibronectin matrix whose active pharmaceutical ingredient is erythropoietin (EPO), for treating diabetic foot ulcers (DFU). Approach: The trial will comprise 20 patients with type 2 diabetes mellitus with neuroischemic DFUs who will be randomized into two groups: (1) a control group in which standard-of-care (SOC) will be used to treat the DFUs, and (2) a test group in which SOC and RMD-G1 will be used to treat the DFUs. On day 0, all participants will be randomized to receive either RMD-G1 and SOC treatment or SOC alone. The primary endpoint of the study is complete closure of the DFU within the 12-week study period following daily treatments and dressing changes. Results: Interim results reveal that those DFUs which were treated with RMD-G1 responded positively: there was a significant reduction in the wound areas. In contrast, the condition of those DFUs which were treated with only SOC deteriorated. Innovation: To date, no topical therapies with proven efficacy for treating DFUs exist. Topical application of EPO-based RMD-G1 in conjunction with SOC to a DFU accelerates their healing and closure. Conclusions: The interim results of this trial indicate that topical RMD-G1 is a safe adjunctive therapy to SOC, which accelerates the closure of a DFU. RMD-G1 is safe pharmaceutical because EPO has a proven safety profile.

Ultrasound-assisted debridement of neuroischaemic diabetic foot ulcers, clinical and microbiological effects: a case series

OBJECTIVE

To evaluate the clinical and microbiological effects of sequential wound debridement in a case series of neuroischaemic diabetic foot ulcers (DFUs) using an ultrasound-assisted wound debridement (UAW) device.

METHOD

A prospective, single-centre study, involving a case series of 24 neuroischaemic DFUs, was conducted to evaluate sequential wound debridement with UAW during a six-week treatment period. Soft tissue punch biopsies were taken every second week of treatment, both before and after wound debridement sessions. Qualitative and quantitative microbiological analysis was performed and wounds were assessed at patient admission, and before and after each debridement procedure.

RESULTS

Wound tissue quality scores improved significantly from a mean score of 2.1±1.3 points at patient inclusion, to 5.3±1.7 points (p=0.001). Mean wound sizes were 4.45cm² (range: 2-12.25cm²) at week zero, and 2.75cm² (range: 1.67-10.70cm²) at week six (p=0.04). The mean number of bacterial species per culture determined at week zero and at week six was 2.53±1.55 and 1.90±1.16, respectively (p=0.023). Wound debridement resulted in significant decreases in bacterial counts (1.17, 1.31 and 0.77 log units in colony forming units (CFU) for week zero, three and six, respectively). The average bacterial load in tissue samples before and after wound debridement after the six-week treatment was Log 5.55±0.91CFU/g and Log 4.59±0.89CFU/g, respectively (p<0.001).

CONCLUSIONS

The study results showed a significant bacterial load reduction in DFU tissue samples as a result of UAW debridement, independent of bacterial species, some of which exhibited antibiotic-resistance. Significant bacterial load reduction was correlated with improved wound conditions and significant reductions of wound size.

Calf muscle stretching is ineffective in increasing ankle range of motion or reducing plantar pressures in people with diabetes and ankle equinus: A randomised controlled trial

BACKGROUND

Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes.

METHODS

Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention.

FINDINGS

68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:-0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:-2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:-10.0 to 12.9, p = 0.803) or barefoot peak pressures (-19.1 kPa, 95% CI:-96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up.

INTERPRETATION

Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus.

The role of amputative and non-amputative foot deformities severity in the risk for diabetic ulceration classification systems building: a cross-sectional and case-control pilot investigation

Introduction

Foot deformities and amputations are parameters that have been studied as risk factors for diabetic foot ulceration (DFU). However, inclusion of "foot deformities" and "amputations" in a single, broad variable and with reference to the severity of these deformities, may better characterize subjects who are prone to develop DFU.

Methods

The objective of the study was the examination of amputative and non-amputative foot deformities severity as risk factor for DFU in relation with the other established risk factors. A cross-sectional and case-control study was conducted from October 2005 to November 2016. One hundred and thirty-four subjects with type 1 and 2 diabetes, with and without active foot ulcers, participated. A structured quantitative interview guide was used. Univariate logistic regression analysis for the literature's established risk factors was performed, as well as for two versions of the "amputative and non-amputative foot deformities severity" variable. Subsequently, multivariate logistic regression analysis (MLRA) for three models and receiver operating characteristic (ROC) curve analysis were carried out.

Results

From the MLRA, only PAD (peripheral arterial disease) was significant (OR 3.56, 95% CI 1.17-10.82, P=0.025 and OR 3.33, 95% CI 1.02-10.08, P=0.033). Concerning the ROC curve analysis of the models, the one with the three categories amputative and non-amputative foot deformities severity variable, had the greatest area under the ROC curve (0.763, P<0.001).

Conclusion

A united variable for lower extremity amputations and other foot deformities with reference to their severity, could be more helpful to the clinicians in identifying patients with diabetes at risk for foot ulceration.

Estimating the economic value of emerging technologies in chronic wound therapy

Estimating the economic value of emerging technologies in clinical medicine presents a number of problems. New technologies may have a limited clinical history, few supportive peer‐reviewed publications, and only anecdotal evidence as they enter the market and seek clinician approval and reimbursement from payers. Although clinical efficacy/effectiveness research is a minimal starting point for making the case for adoption of a product, establishing a competitive cost‐effectiveness position against other products and establishing the case for economic value must be made as well when presenting to health plans or other payers. Economic valuation methods have been well developed in the business community. Reviewed here are the components of a well‐crafted case for the economic value of a product in general and in the wound industry specifically, in a multidomain approach to demonstrate values using demographic, clinical, financial, operational, and intangible assessments.

An unusual cause of foot ulcer in a patient with diabetes mellitus

A diabetic foot ulcer is the leading cause of nontraumatic amputation worldwide. The most important predisposing factor for diabetic foot ulcer is peripheral neuropathy. Rat bites are an uncommon but important cause of ulcer in patients with diabetes, especially in lower socioeconomic strata. A 56-year-old male from southern India, a known patient with type 2 diabetes for the past 15 years with severe peripheral neuropathy, presented to our center with multiple bite marks on bilateral feet and destroyed nails. He was initially managed with local measures and injection tetanus toxoid; however, he rapidly worsened over the next 5 days to develop bilateral cellulitis of the feet and right great toe osteomyelitis. His biochemistry showed uncontrolled diabetes (HbA1c: 9.9) and radiology confirmed right great toe osteomyelitis. He underwent transmetatarsal amputation of the right first toe along with intravenous antibiotics followed by oral antibiotics (amoxicillin with clavulanic acid) for a total duration of 6 weeks and optimization of glycemic control. He improved completely over the next 1 month. Rat bites are a rare but readily preventable cause of foot ulcer in diabetic patients. Primary care and family physician play a vital role in educating patients about preventive aspects such as avoidance of using vegetable oil as a moisturizer that may attract rodents and insects.

Painful and non-painful diabetic polyneuropathy: Clinical characteristics and diagnostic issues

Diabetic neuropathy (DN) is a common complication of diabetes and can be either painful or non-painful. It is challenging to diagnose this complication, as no biomarker or clear consensus on the clinical definition of either painful or non-painful DN exists. Hence, a hierarchical classification has been developed categorizing the probability of the diagnosis into: possible, probable or definite, based on the clinical presentation of symptoms and signs. Pain is a warning signal of tissue damage, and non-painful DN therefore represents a clinical and diagnostic challenge because it often goes unnoticed until irreversible nerve damage has occurred. Simple clinical tests seem to be the best for evaluation of DN in the general care for diabetes. Screening programs at regular intervals might be the most optimal strategy for early detection and interventions to possibly prevent further neuronal damage and to lower the economic burden of this complication.

Temperature as a Causative Factor in Diabetic Foot Ulcers: A Call to Revisit Ulceration Pathomechanics

BACKGROUND

Diabetic foot ulcers (DFUs) are a major burden to patients and to the health-care systems of many countries. To prevent or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development.

METHODS

Thirty-seven individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 nonneuropathic control participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperatures were determined in four anatomical regions-hallux and medial, central, and lateral forefoot-and separate linear models with specified contrasts among the DFU, DN, and DC groups were set to reveal mean differences for each foot region while controlling for group characteristics.

RESULTS

The mean temperature reading in each foot region was higher than 30.0°C in the DFU and DN groups and lower than 30.0°C in the DC group. Mean differences were greatest between the DFU and DC groups, ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux.

CONCLUSIONS

Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in patients with previous ulcers, may easily reach hazard thresholds indicated by previous pressure ulcer studies. The results necessitate further exploration of temperature in the diabetic foot and how it may contribute to ulceration.

Feasibility of a Low-Intensity, Technology-Based Intervention for Increasing Physical Activity in Adults at Risk for a Diabetic Foot Ulcer: A Mixed-Methods Study

BACKGROUND

Among adults with diabetes, 19-34% will develop a diabetic foot ulcer (DFU), which increases amputation risk and health care costs, and worsens quality of life. Regular physical activity, when increased gradually, may help prevent DFUs. In this mixed-methods study, we examined the feasibility of a low-intensity, technology-based behavioral intervention to increase activity in adults at risk for DFUs.

METHOD

Participants at risk for a DFU (n = 12; 66% female; mean age = 59.9 years) received four in-person exercise and behavioral counseling sessions over 2-3 weeks, supplemented with use of an activity monitor (to track steps) and text messages (to reinforce behavioral strategies) for an added 8 weeks. Pre- and postintervention assessments of accelerometer measured activity, daily mobility, and glycemic control (A1C) were completed. Treatment acceptability was assessed by questionnaire and via key informant interview.

RESULTS

The program appears feasible since all but one participant attended all four sessions, all used the activity monitor and all responded to text messages. Treatment acceptability (scale: 1 = very dissatisfied, 5 = extremely satisfied) was high; average item ratings were 4.79 (SD = 0.24). Participants increased their steps by an average of 881.89 steps/day (d = 0.66). A1C decreased on average by 0.33% (d = 0.23). Daily mobility did not change. Interview results suggest that participants perceived benefits from the intervention. Participant recommended improvements included providing more physical activity information, addressing pain, and intervention delivery in a podiatry clinic.

CONCLUSION

Individuals at risk for a DFU might benefit from a minimally intensive, technology-based intervention to increase their physical activity. Future research comparing the intervention to usual care is warranted.

Vibrotactile display design: Quantifying the importance of age and various factors on reaction times

Numerous factors affect reaction times to vibrotactile cues. Therefore, it is important to consider the relative magnitudes of these time delays when designing vibrotactile displays for real-time applications. The objectives of this study were to quantify reaction times to typical vibrotactile stimuli parameters through direct comparison within a single experimental setting, and to determine the relative importance of these factors on reaction times. Young (n = 10, 21.9 ± 1.3 yrs) and older adults (n = 13, 69.4 ± 5.0 yrs) performed simple reaction time tasks by responding to vibrotactile stimuli using a thumb trigger while frequency, location, auditory cues, number of tactors in the same location, and tactor type were varied. Participants also performed a secondary task in a subset of the trials. The factors investigated in this study affected reaction times by 20-300 ms (reaction time findings are noted in parentheses) depending on the specific stimuli condition. In general, auditory cues generated by the tactors (<20 ms), vibration frequency (<20 ms), number of tactors in the same location (<30 ms) and tactor type (<50 ms) had relatively small effects on reaction times, while stimulus location (20-120 ms) and secondary cognitive task (>130 ms) had relatively large effects. Factors affected young and older adults' reaction times in a similar manner, but with different magnitudes. These findings can inform the development of vibrotactile displays by enabling designers to directly compare the relative effects of key factors on reaction times.

Clinical and Antimicrobial Efficacy of a Silver Foam Dressing With Silicone Adhesive in Diabetic Foot Ulcers With Mild Infection

The use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period. The study aim was to evaluate the clinical and microbiological efficacy of a silver foam dressing in the management of diabetic foot ulcers. We conducted a single-center, prospective, open, noncontrolled study involving 21 outpatients with diabetic foot ulcers with mild infection. All patients received standard of care for their wounds and a silver foam dressing with silicone adhesive was applied twice per week for wound management during a 6-week treatment period. Soft tissue punch biopsies were taken every second week for qualitative and quantitative microbiological analysis. Wounds were assessed at patient admission, and wound bed tissue was evaluated for presence, quality, and consistency of granulation tissue. Clinical evaluation revealed improvements in wound conditions as a result of treatment with the silver dressing. Wollina wound scores improved significantly, from a mean score of 3.9 ± 1.6 points at inclusion to 6.1 ± 1.3 points at the end of the study (n = 19, P < .001). Treatment with the silver dressing resulted in significant decreases in the bioburden of classically considered diabetic foot ulcer pathogenic organisms such as Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus, Enterobacteriaceae species, Pseudomonas aeruginosa, and other nonfermenting gram-negative bacilli. Findings revealed that the use of silver foam dressing significantly reduced the pathogenic bacterial load and markedly improved the clinical outcome in patients with diabetic foot ulcer with mild infection over a 6-week treatment period.

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

INTRODUCTION

Loss of sensation due to diabetes-related neuropathy often leads to diabetic foot ulceration. Several test instruments are used to assess sensation, such as static and moving 2-point discrimination (S2PD, M2PD), monofilaments, and tuning forks.

METHODS

Mokken scale analysis was applied to the Rotterdam Diabetic Foot Study data to select hierarchies of tests to construct measurement scales.

RESULTS

We developed 39-item and 31-item scales to measure loss of sensation for research purposes and a 13-item scale for clinical practice. All instruments were strongly scalable and reliable. The 39 items can be classified into 5 hierarchically ordered core clusters: S2PD, M2PD, vibration sense, monofilaments, and prior ulcer or amputation.

DISCUSSION

Guided by the presented scales, clinicians may better classify the grade of sensory loss in diabetic patients' feet. Thus, a more personalized approach concerning individual recommendations, intervention strategies, and patient information may be applied.

Molecular Changes in Diabetic Wound Healing following Administration of Vitamin D and Ginger Supplements: Biochemical and Molecular Experimental Study

BACKGROUND

Circulating micro-RNAs are differentially expressed in various tissues and could be considered as potential regulatory biomarkers for T2DM and related complications, such as chronic wounds.

AIM

In the current study, we investigated whether ginger extract enriched with [6]-gingerol-fractions either alone or in combination with vitamin D accelerates diabetic wound healing and explores underlying molecular changes in the expression of miRNA and their predicted role in diabetic wound healing.

METHODS

Diabetic wounded mice were treated with [6]-gingerol-fractions (GF) (25 mg/kg of body weight) either alone or in combination with vitamin D (100 ng/kg per day) for two weeks. Circulating miRNA profile, fibrogenesis markers, hydroxyproline (HPX), fibronectin (FN), and collagen deposition, diabetic control variables, FBS, HbA1c, C-peptide, and insulin, and wound closure rate and histomorphometric analyses were, respectively, measured at days 3, 6, 9, and 15 by RT-PCR and immunoassay analysis.

RESULTS

Treatment of diabetic wounds with GF and vitamin D showed significant improvement in wound healing as measured by higher expression levels of HPX, FN, collagen, accelerated wound closure, complete epithelialization, and scar formation in short periods (11-13 days, (P < 0.01). On a molecular level, three circulating miRNAs, miR-155, miR-146a, and miR-15a, were identified in diabetic and nondiabetic skin wounds by PCR analysis. Lower expression in miR-155 levels and higher expression of miR-146a and miR-15a levels were observed in diabetic skin wounds following treatment with gingerols fractions and vitamin D for 15 days. The data showed that miRNAs, miR-146a, miR-155, and miR-15a, correlated positively with the expression levels of HPX, FN, and collagen and negatively with FBS, HbA1c, C-peptide, and insulin in diabetic wounds following treatment with GF and /or vitamin D, respectively.

CONCLUSION

Treatment with gingerols fractions (GF) and vitamin D for two weeks significantly improves delayed diabetic wound healing. The data showed that vitamin D and gingerol activate vascularization, fibrin deposition (HPX, FN, and collagen), and myofibroblasts in such manner to synthesize new tissues and help in the scar formation. Accordingly, three miRNAs, miR-155, miR-146a, and miR-15, as molecular targets, were identified and significantly evaluated in wound healing process. It showed significant association with fibrin deposition, vascularization, and reepithelialization process following treatment with GF and vitamin D. It proposed having anti-inflammatory action and promoting new tissue formation via vascularization process during the wound healing. Therefore, it is very interesting to consider miRNAs as molecular targets for evaluating the efficiency of nondrug therapy in the regulation of wound healing process.

Preparation and in vivo evaluation of a topical hydrogel system incorporating highly skin-permeable growth factors, quercetin, and oxygen carriers for enhanced diabetic wound-healing therapy

PURPOSE

We created and evaluated an enhanced topical delivery system featuring a combination of highly skin-permeable growth factors (GFs), quercetin (QCN), and oxygen; these synergistically accelerated re-epithelialization and granulation tissue formation of/in diabetic wounds by increasing the levels of GFs and antioxidants, and the oxygen partial pressure, at the wound site.

METHODS

To enhance the therapeutic effects of exogenous administration of GFs for the treatment of diabetic wounds, we prepared highly skin-permeable GF complexes comprised of epidermal growth factor (EGF), insulin-like growth factor-I (IGF-I), platelet-derived growth factor-A (PDGF-A), and basic fibroblast growth factor (bFGF), genetically attached, via the N-termini, to a low-molecular-weight protamine (LMWP) to form LMWP-EGF, LMWP-IGF-I, LMWP-PDGF-A, and LMWP-bFGF, respectively. Furthermore, quercetin (QCN)- and oxygen-carrying 1-bromoperfluorooctane (PFOB)-loaded nanoemulsions (QCN-NE and OXY-PFOB-NE) were developed to improve the topical delivery of QCN and oxygen, respectively. After confirming the enhanced penetration of LMWP-GFs, QCN-NE, and oxygen delivered from OXY-PFOB-NE across human epidermis, we evaluated the effects of combining LMWP-GFs, QCN-NE, and OXY-PFOB-NE on proliferation of keratinocytes and fibroblasts, and the chronic wound closure rate of a diabetic mouse model.

RESULTS

The optimal ratios of LMWP-EGF, LMWP-IGF-I, LMWP-PDGF-A, LMWP-bFGF, QCN-NE, and OXY-PFOB-NE were 1, 1, 0.02, 0.02, 0.2, and 60, respectively. Moreover, a Carbopol hydrogel containing LMWP-GFs, QCN-NE, and OXY-PFOB-NE (LMWP-GFs/QCN-NE/OXY-PFOB-NE-GEL) significantly improved scratch-wound recovery of keratinocytes and fibroblasts in vitro compared to that afforded by hydrogels containing each component alone. LMWP-GFs/QCN-NE/OXY-PFOB-NE-GEL significantly accelerated wound-healing in a diabetic mouse model, decreasing wound size by 54 and 35% compared to the vehicle and LMWP-GFs, respectively.

CONCLUSION

LMWP-GFs/QCN-NE/OXY-PFOB-NE-GEL synergistically accelerated the healing of chronic wounds, exerting both rapid and prolonged effects.

Influence of Patient Setting and Dedicated Limb Salvage Efforts on Outcomes in Charcot-Related Foot Ulcer

Charcot neuroarthropathy is a devastating consequence of diabetes mellitus and peripheral neuropathy. Because of its rarity, the condition is often misdiagnosed or poorly managed. When misadventure occurs, patients with Charcot neuroarthropathy can suffer ulceration, infection, amputation, and death. When patients have Charcot-related foot ulcers, the risks are amplified. Utilizing advanced electronic medical record analysis, a 30-month investigation was undertaken to determine if patients with diabetes mellitus and a concomitant diagnosis of Charcot-related foot ulcer were at greater risk of complications because of location setting of initial treatment for their condition. Charcot foot-related ulcers that are diagnosed in the outpatient setting had established foot specialist care. The outpatient management of the condition lead to a significant reduction in the amount of admissions to a higher acuity setting. However, patient outcomes did not vary once established and dedicated limb salvage efforts were employed. In this large contemporary population managed in a tertiary health system, patients with Charcot-related foot ulcer had negative outcomes when they were initially treated in an inpatient setting and had a significantly greater likelihood of readmission as compared with individuals who had established focused limb salvage care.