Note to the Reader: These articles summarize the "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes," authored by Robert J. Snyder et al., published as a supplement to Ostomy Wound Management in April 2010.
Published as a supplement to the April 2010 issue of Ostomy Wound Management was a pivotal reference paper titled, "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes."1 The authors are a recognized group of leading experts in the field who convened the consensus panel.
The world's population with diabetes will increase from 171 million to 366 million by 2025.2 In the U.S., there are an estimated 24 million people with diabetes. Up to 25% of those with diabetes will develop a foot ulcer in their lifetimes.3 That translates roughly to 1-2% of the diabetic patients per year.
Diabetic foot ulcers (DFU) and lower extremity amputations (LEA) are a costly problem. In 2007, it was estimated that $30 billion was spent for the care of those two conditions.4
The recommendations from the consensus panel are important because they help to update the standard of care based on a review of 111 studies. The recommendations are divided into three categories: Assessment, Treatment, Advanced Therapies.
In this issue we will look at recommendations on assessment of the diabetic foot ulcer.
Recommendations on Assessment of the Diabetic Foot Ulcer
The team approach to assessment and management of the DFU is recognized as the standard of care. No physician "is an island", and the co-morbidities within the diabetic foot cross multiple physician disciplines. A thorough history should be performed. Since wound healing delays can occur with anemia, renal insufficiency, and uncontrolled blood sugar, a CBC and HbA1c should be performed at baseline. If osteomyelitis is suspected, erythrocyte sedimentation rate (ESR) and (CRP) should be ordered.
The patient's nutritional status should be assessed by history and serum pre-albumin. Historical concerns are unintentional weight loss, chronic alcohol use, and problems chewing or swallowing. Smoking is a risk factor for peripheral arterial disease (PAD) and delays wound healing. One should remember the four A's of smoking cessation: Ask about smoking, Advise to quit, offer Assistance, Arrange follow-up.
Neurologic screening should consist of 10 gram monofilament and 128-Hz tuning fork tests. Vascular evaluation is more complicated. There is no single test that can completely evaluate vascular health. Palpation of pulses or ante brachial index (ABI) cannot be relied upon in this population. The absence of pulses is a good indicator of poor flow, but the presence of pulses cannot rule out arterial insufficiency. The toe brachial index (TBI) is less susceptible to false readings due to diabetic arterial calcification. Skin perfusion pressure (SPP) measures capillary pressure in the skin and is very sensitive at uncovering vascular disease in diabetics as well as predicting wound healing. Transcutaneous oximetry (TCPO2) can validate referral for hyperbaric oxygen. Vascular imaging tests should be performed by an appropriate specialist if there is reasonable suspicion of underlying vascular disease.
The foot examination should include assessment of dermatologic changes, musculoskeletal deformities, and ulcer evaluation. Dermatologic changes can show inflammation by thermometry or thermography. Also, it can reveal ischemia by the presence of purpura, fat atrophy, loss of hair growth, or taut skin. The podiatrist is a key member of the team for understanding the biomechanical abnormalities that lead to ulceration. Range of motion of the ankle and first metatarsophalangeal joints should be assessed for restriction in dorsi-flexion. Inspect for deformities associated with Charcot joint disease.
Radiography is useful to help uncover osteomyelitis or deformities. The foot should be x-rayed at baseline and it is appropriate to perform bilateral x-rays for comparison.
The wound assessment and documentation includes size, depth, shape, probing, undermining, condition of the wound bed, and condition of the periwound area. One should use a standard wound classification scheme. The consensus panel recommends use of the University of Texas Classification.5
Infection is devastating to the diabetic foot and its evaluation is primarily clinical. Heat, redness, pain, and swelling are the classic symptoms. The diabetic neuropathic patient does not always exhibit all those signs, so one should be aware of secondary signs like exudate, delayed healing, discolored granulation tissue, and malodor. Culture should only be taken if the clinician suspects infection.
Showing posts with label diabetic ulcer. Show all posts
Showing posts with label diabetic ulcer. Show all posts
Tuesday, April 26, 2011
Thursday, March 3, 2011
A Closer Look At New Developments In Diabetes
The prevalence of diabetes is increasing rapidly and is expected to reach epidemic proportion over the next decade. Recent research estimates that the number of people diagnosed with diabetes will rise from 23.7 million to 44.1 million between 2009 and 2034.1 The Centers for Disease Control and Prevention (CDC) further predict that up to one-third of U.S. adults could have diabetes by 2050 if Americans continue to gain weight and avoid exercise.2
Diabetes is associated with a myriad of complications with foot ulcerations being the most common. An estimated 15 percent of all patients with diabetes will develop foot ulcers.3 About half of these ulcers become infected and 20 percent of those patients will end up with some form of lower extremity amputation.3 With the prevalence of diabetes dramatically increasing, billions of dollars are spent in the field of diabetes research for the early diagnosis, prevention and management of this disease.
With that said, here is a closer look at current research in the field of diabetes and emerging methods of disease management.
What You Should Know About Biomarkers For Diabetes
Researchers are constantly studying biomarkers to help predict the possibility of developing certain diseases. Biomarkers can indicate a change in the expression or state of a protein that correlates with the risk or progression of a disease, or with the susceptibility of the disease to a given treatment.
Recently, researchers from the United Kingdom have reported that microRNA (MiR) can help identify people who are likely to develop type 2 diabetes even before the onset of symptoms.4 MicroRNAs are classes of approximately 22 non-coding nucleotide regulatory ribonucleic acid (RNA) molecules that play important roles in controlling the developmental and physiological processes.5 Specifically, microRNAs regulate gene expression including differentiation and development by either inhibiting translation or inducing target degradation. MicroRNAs can also help serve as diagnostic markers to identify those who are at high risk of developing coronary and peripheral arterial disease.
In a study of 822 people, researchers identified five specific microRNA molecules with an abnormally low concentration in blood in people with diabetes and in those who subsequently went on to develop the disorder.6 One molecule in particular, microRNA 126 (MiR-126), was among the most reliable predictors of current and future diabetes. MiR-126 is known to help with angiogenesis and regulate the maintenance of vasculature. Healthy blood vessel cells are able to release substantial quantities of MiR-126 into the bloodstream.
However, when endothelial damage occurs, the cells retain MiR-126 and subsequently release less MiR-126 into the bloodstream. A decrease in plasma MiR-126 can therefore be an indicator of blood vessel damage and cardiovascular disease. Researchers also found that levels of MiR were lower when they gave large amounts of sugar to mice with a genetic propensity to develop diabetes.6 The MiR test can directly assess vascular endothelial damage secondary to diabetes and has a fairly low cost at around $3 per test. Clinicians may possibly be able to use this in conjunction with conventional tests in the near future.
Plasma thrombin activatable fibrinolysis inhibitor (TAFI) antigen is another biomarker that may participate in arterial thrombosis in cardiovascular diseases and may be involved in the mechanism of vascular endothelial damage in patients with diabetes.
Erdogan and colleagues investigated the association of plasma TAFI antigen level in the development of diabetic foot ulcers in people with type 2 diabetes.7 Specifically, researchers determined TAFI antigen levels in plasma samples in 50 patients with diabetic foot ulcers, 34 patients with diabetes but without diabetic foot ulcers, and 25 healthy individuals. The diabetic foot ulcer group and the diabetic non-ulcer group were similar in terms of mean age and sex distribution.
The researchers found TAFI levels to be significantly elevated in patients with diabetes with or without foot ulcers in comparison to the healthy controls. However, there was no difference in TAFI levels between the diabetic foot ulcer group and diabetic non-ulcer group, or between diabetic foot ulcer stages.
As research in this arena continues, a new class of blood markers may give additional insight to screen people who are at a higher risk of developing diabetes and intervene before the symptoms and the broad spectrum of associated complications occur.
Can An Artificial Pancreas System Enhance Glucose Control?
The artificial pancreas is a technology that is best described as a closed loop glucose management system that is intended to afford patients with diabetes better glucose control while averting the hypoglycemic state.8 With the advancement of technologies, newer artificial pancreas systems consist of a real-time continuous glucose monitoring (CGM) system. This system transmits information every one to five minutes from an under the skin sensor to a handheld receiver that can be integrated into a pump. The device also has an insulin pump with a pre-programmed algorithm that calculates appropriate insulin dosages based on the glucose ratings.
A potential imperfection to this CGM system is that the system reads glucose levels from the patient’s interstitial fluid as opposed to the actual blood glucose levels. The interstitial compartment has a lag time of eight to ten minutes and can affect the glucose readings, especially postprandial readings.
The insulin pump is a beeper-sized device that is flexibly attached via a tube in the tissue just under the skin and will release as per patient requirement. Some partial “half-loop” solutions are available in Europe and the FDA has recently approved three of the closed loop systems. Meticulous testing is still needed before the system can go on the market.9
Emerging Insights On Stem Cell Advances
With islet cell transplantation research quickly on the rise to help regenerate the disordered islet cells of the pancreas, we have seen much promise in stem cell research. Ideally, the in vitro generation of insulin-producing cells from stem or progenitor cells presents a promising approach to overcome the scarcity of donor pancreases for cell replacement therapy in people with diabetes.10
In an ongoing study, researchers at the Diabetes Research Institute are assessing the effects of biohybrid devices, also known as “scaffolds,” to house and protect the transplanted insulin producing cells.11 These “scaffolds” are designed to mimic the pancreatic environment and are being tested in different areas of the body that include the abdominal pouch, muscle tissue or subcutaneously. Furthermore, the “scaffolds” are also being tested to deliver favorable agents that may help promote the growth and viability of the transplanted islet cells.
Current studies are very optimistic in showing that these “scaffolds” co-transplanted with mesenchymal stem cell regenerative islet cells can help accelerate angiogenesis, which prolongs the longevity and functionality of islet cell regeneration.12
Encouraging Patient Adherence: What Recent Studies Reveal
Patient adherence is one of the many challenges in the treatment and management of diabetes. For years, physicians have been researching new methods in tracking patient adherence to glucose monitoring and management, and to pressure mitigation devices.
In an article published in the Annals of Family Medicine, researchers looked at the participation levels of patients with type 2 diabetes in their primary care check-up visits.13 Several offices sent questionnaires to these patients regarding their treatment goals and plans at the initial visit as well as follow-up visits. Researchers found that the more patients participated in their treatment decisions and management, the better they adhered to the prescribed medications and treatment. This resulted in better control of their diabetes.
Another study compared the efficacy of a reciprocal peer support program with that of nurse care management in 244 men with diabetes in two Veterans Affairs healthcare facilities.14 Researchers matched patients in the reciprocal peer support group with another age-matched peer patient and were encouraged to talk via telephone and participate in optional group sessions. Patients in the nurse care management group attended a 1.5-hour educational session and were assigned to a nurse care manager.
After six months, the mean hemoglobin A1C level for patients in the peer support program decreased from 8.02% to 7.73% while it increased from 7.93% to 8.22% in the nurse care management group.14 This was statistically significant.
Both studies support the notion that some patient empowerment in their treatment decisions and management may translate into better long-term outcomes.
In Conclusion
Diabetes is estimated to impose more than $174 billion dollars per year on United States healthcare. This astounding financial toll is expected to continue to rise as more and more people are diagnosed with this debilitating disease.2 In addition to being aware of the plethora of current research, patient education and preventative care are important strategies to emphasize. It is through innovative research, teamwork and preventative strategies that we continue to gain successful outcomes and improvement in the prevention and management of diabetes and its complications.
VOLUME: 24 PUBLICATION DATE: Jan 01 2011
Author(s):David A. Farnen, BS, and Stephanie C. Wu, DPM, MSc
Diabetes is associated with a myriad of complications with foot ulcerations being the most common. An estimated 15 percent of all patients with diabetes will develop foot ulcers.3 About half of these ulcers become infected and 20 percent of those patients will end up with some form of lower extremity amputation.3 With the prevalence of diabetes dramatically increasing, billions of dollars are spent in the field of diabetes research for the early diagnosis, prevention and management of this disease.
With that said, here is a closer look at current research in the field of diabetes and emerging methods of disease management.
What You Should Know About Biomarkers For Diabetes
Researchers are constantly studying biomarkers to help predict the possibility of developing certain diseases. Biomarkers can indicate a change in the expression or state of a protein that correlates with the risk or progression of a disease, or with the susceptibility of the disease to a given treatment.
Recently, researchers from the United Kingdom have reported that microRNA (MiR) can help identify people who are likely to develop type 2 diabetes even before the onset of symptoms.4 MicroRNAs are classes of approximately 22 non-coding nucleotide regulatory ribonucleic acid (RNA) molecules that play important roles in controlling the developmental and physiological processes.5 Specifically, microRNAs regulate gene expression including differentiation and development by either inhibiting translation or inducing target degradation. MicroRNAs can also help serve as diagnostic markers to identify those who are at high risk of developing coronary and peripheral arterial disease.
In a study of 822 people, researchers identified five specific microRNA molecules with an abnormally low concentration in blood in people with diabetes and in those who subsequently went on to develop the disorder.6 One molecule in particular, microRNA 126 (MiR-126), was among the most reliable predictors of current and future diabetes. MiR-126 is known to help with angiogenesis and regulate the maintenance of vasculature. Healthy blood vessel cells are able to release substantial quantities of MiR-126 into the bloodstream.
However, when endothelial damage occurs, the cells retain MiR-126 and subsequently release less MiR-126 into the bloodstream. A decrease in plasma MiR-126 can therefore be an indicator of blood vessel damage and cardiovascular disease. Researchers also found that levels of MiR were lower when they gave large amounts of sugar to mice with a genetic propensity to develop diabetes.6 The MiR test can directly assess vascular endothelial damage secondary to diabetes and has a fairly low cost at around $3 per test. Clinicians may possibly be able to use this in conjunction with conventional tests in the near future.
Plasma thrombin activatable fibrinolysis inhibitor (TAFI) antigen is another biomarker that may participate in arterial thrombosis in cardiovascular diseases and may be involved in the mechanism of vascular endothelial damage in patients with diabetes.
Erdogan and colleagues investigated the association of plasma TAFI antigen level in the development of diabetic foot ulcers in people with type 2 diabetes.7 Specifically, researchers determined TAFI antigen levels in plasma samples in 50 patients with diabetic foot ulcers, 34 patients with diabetes but without diabetic foot ulcers, and 25 healthy individuals. The diabetic foot ulcer group and the diabetic non-ulcer group were similar in terms of mean age and sex distribution.
The researchers found TAFI levels to be significantly elevated in patients with diabetes with or without foot ulcers in comparison to the healthy controls. However, there was no difference in TAFI levels between the diabetic foot ulcer group and diabetic non-ulcer group, or between diabetic foot ulcer stages.
As research in this arena continues, a new class of blood markers may give additional insight to screen people who are at a higher risk of developing diabetes and intervene before the symptoms and the broad spectrum of associated complications occur.
Can An Artificial Pancreas System Enhance Glucose Control?
The artificial pancreas is a technology that is best described as a closed loop glucose management system that is intended to afford patients with diabetes better glucose control while averting the hypoglycemic state.8 With the advancement of technologies, newer artificial pancreas systems consist of a real-time continuous glucose monitoring (CGM) system. This system transmits information every one to five minutes from an under the skin sensor to a handheld receiver that can be integrated into a pump. The device also has an insulin pump with a pre-programmed algorithm that calculates appropriate insulin dosages based on the glucose ratings.
A potential imperfection to this CGM system is that the system reads glucose levels from the patient’s interstitial fluid as opposed to the actual blood glucose levels. The interstitial compartment has a lag time of eight to ten minutes and can affect the glucose readings, especially postprandial readings.
The insulin pump is a beeper-sized device that is flexibly attached via a tube in the tissue just under the skin and will release as per patient requirement. Some partial “half-loop” solutions are available in Europe and the FDA has recently approved three of the closed loop systems. Meticulous testing is still needed before the system can go on the market.9
Emerging Insights On Stem Cell Advances
With islet cell transplantation research quickly on the rise to help regenerate the disordered islet cells of the pancreas, we have seen much promise in stem cell research. Ideally, the in vitro generation of insulin-producing cells from stem or progenitor cells presents a promising approach to overcome the scarcity of donor pancreases for cell replacement therapy in people with diabetes.10
In an ongoing study, researchers at the Diabetes Research Institute are assessing the effects of biohybrid devices, also known as “scaffolds,” to house and protect the transplanted insulin producing cells.11 These “scaffolds” are designed to mimic the pancreatic environment and are being tested in different areas of the body that include the abdominal pouch, muscle tissue or subcutaneously. Furthermore, the “scaffolds” are also being tested to deliver favorable agents that may help promote the growth and viability of the transplanted islet cells.
Current studies are very optimistic in showing that these “scaffolds” co-transplanted with mesenchymal stem cell regenerative islet cells can help accelerate angiogenesis, which prolongs the longevity and functionality of islet cell regeneration.12
Encouraging Patient Adherence: What Recent Studies Reveal
Patient adherence is one of the many challenges in the treatment and management of diabetes. For years, physicians have been researching new methods in tracking patient adherence to glucose monitoring and management, and to pressure mitigation devices.
In an article published in the Annals of Family Medicine, researchers looked at the participation levels of patients with type 2 diabetes in their primary care check-up visits.13 Several offices sent questionnaires to these patients regarding their treatment goals and plans at the initial visit as well as follow-up visits. Researchers found that the more patients participated in their treatment decisions and management, the better they adhered to the prescribed medications and treatment. This resulted in better control of their diabetes.
Another study compared the efficacy of a reciprocal peer support program with that of nurse care management in 244 men with diabetes in two Veterans Affairs healthcare facilities.14 Researchers matched patients in the reciprocal peer support group with another age-matched peer patient and were encouraged to talk via telephone and participate in optional group sessions. Patients in the nurse care management group attended a 1.5-hour educational session and were assigned to a nurse care manager.
After six months, the mean hemoglobin A1C level for patients in the peer support program decreased from 8.02% to 7.73% while it increased from 7.93% to 8.22% in the nurse care management group.14 This was statistically significant.
Both studies support the notion that some patient empowerment in their treatment decisions and management may translate into better long-term outcomes.
In Conclusion
Diabetes is estimated to impose more than $174 billion dollars per year on United States healthcare. This astounding financial toll is expected to continue to rise as more and more people are diagnosed with this debilitating disease.2 In addition to being aware of the plethora of current research, patient education and preventative care are important strategies to emphasize. It is through innovative research, teamwork and preventative strategies that we continue to gain successful outcomes and improvement in the prevention and management of diabetes and its complications.
VOLUME: 24 PUBLICATION DATE: Jan 01 2011
Author(s):David A. Farnen, BS, and Stephanie C. Wu, DPM, MSc
Tuesday, September 21, 2010
How Should a Diabetic Foot Ulcer Be Treated?
The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.
There are several key factors in the appropriate treatment of a diabetic foot ulcer:
Prevention of infection.
Taking the pressure off the area, called "off-loading."
Removing dead skin and tissue, called "debridement."
Applying medication or dressings to the ulcer.
Managing blood glucose and other health problems.
Not all ulcers are infected; however if the physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
There are several important factors to keep an ulcer from becoming infected:
Keep blood glucose levels under tight control.
Keep the ulcer clean and bandaged.
Cleanse the wound daily, using a wound dressing or bandage.
Do not walk barefoot.
For optimum healing, ulcers, especially those on the bottom of the foot, must be "off-loaded." Patients may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of "let the air get at it" is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.
Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. The physician can determine circulation levels with noninvasive tests.
There are several key factors in the appropriate treatment of a diabetic foot ulcer:
Prevention of infection.
Taking the pressure off the area, called "off-loading."
Removing dead skin and tissue, called "debridement."
Applying medication or dressings to the ulcer.
Managing blood glucose and other health problems.
Not all ulcers are infected; however if the physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
There are several important factors to keep an ulcer from becoming infected:
Keep blood glucose levels under tight control.
Keep the ulcer clean and bandaged.
Cleanse the wound daily, using a wound dressing or bandage.
Do not walk barefoot.
For optimum healing, ulcers, especially those on the bottom of the foot, must be "off-loaded." Patients may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of "let the air get at it" is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.
Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. The physician can determine circulation levels with noninvasive tests.
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