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Query: UMLS:C0011849 (diabetes)
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Diabetic foot ulcers should be treated to maintain health status, improve quality of life, reduce the number of amputations and lower costs. Many centres that treat diabetic foot ulcers use a multidisciplinary team approach, which comprises medical staff, nurses, podiatrists and an orthotist. At the Manchester Diabetes Centre, larval therapy has been used for several years to debride sloughy diabetic foot ulcers. This case history demonstrates the adverse effects of diabetes on feet, and the multidisciplinary team's contribution to successful treatment and healing of a complex foot lesion.
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PMID:Management of a diabetic foot ulcer using larval therapy. 1197 31

The worldwide increase in prevalence of type 2 diabetes has resulted in a parallel increase in diabetic foot ulcers--a pervasive and significant problem associated with this disease [2]. Currently, an estimated 10.3 million people have been diagnosed with diabetes, while an additional estimated 5.4 million people with diabetes remain undiagnosed, representing a sixfold increase in the incidence of diabetes over the past four decades [9]. Approximately 15% (more than 2 million individuals, based on these estimates) of all people with diabetes will develop a lower-extremity ulcer during the course of the disease [10-12]. While most of these ulcers can be treated successfully on an outpatient basis, some will persist and become infected. Ultimately, between 14% and 20% of patients with lower-extremity diabetic ulcers will require amputation of the affected limb [13-15]. Diabetic foot ulcers can result in staggering financial burdens for both the healthcare system and the patient. For example, analysis of the 1995 Medicare claims revealed that lower-extremity ulcer care accounted for $1.45 billion in Medicare costs and contributed substantially to the high cost of care for diabetics, compared with Medicare costs for the general population [5]. Therapies that promote rapid and complete healing and reduce the need for expensive surgical procedures would impact these costs substantially. Results of this analysis suggest that becaplermin may ultimately be more cost-effective for the treatment of chronic diabetic foot ulcers than other treatment modalities, despite its higher initial dollar cost. This finding may be attributed to a combination of factors. First, expenses incurred in more prolonged treatment, such as office visits and the need for additional dressings, can be avoided when healing completes in a shorter period. Second, rapid and complete ulcer healing may reduce the incidence of significant morbidities (such as amputation or infection) and premature mortality; consequently, the financial burden associated with these complications would be reduced. Finally, the value of improved quality of life in patients with healed ulcers and the reduction in financial burden for patients who return to work cannot be ignored. These promising results warrant further investigation in larger controlled clinical studies to define more clearly the cost-effectiveness of becaplermin in this patient population.
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PMID:Cost-effective management of recalcitrant diabetic foot ulcers. 1247 56

Ulceration of the foot in diabetes is common and disabling and frequently leads to amputation of the leg. Mortality is high and healed ulcers often recur. The pathogenesis of foot ulceration is complex, clinical presentation variable, and management requires early expert assessment. Interventions should be directed at infection, peripheral ischaemia, and abnormal pressure loading caused by peripheral neuropathy and limited joint mobility. Despite treatment, ulcers readily become chronic wounds. Diabetic foot ulcers have been neglected in health-care research and planning, and clinical practice is based more on opinion than scientific fact. Furthermore, the pathological processes are poorly understood and poorly taught and communication between the many specialties involved is disjointed and insensitive to the needs of patients.
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PMID:Diabetic foot ulcers. 1465 37

Diabetic foot complications are the most common cause of nontraumatic lower extremity amputations in the industrialised world. Unsatisfactory healing requires advanced therapeutic strategies, such as the use of skin grafts, which may represent a helpful option for wound coverage. Alternatively, a method using autologous keratinocytes grown to thin sheet grafts is available. The purpose of this pilot study was to investigate the application of autologous human keratinocytes cultured on membranes composed of benzyl ester of hyaluronic acid (Laserskin autograft) to diabetic foot ulcers. We studied 14 patients with type 2 diabetes mellitus and a nonhealing diabetic foot lesion, defined as existing longer than 6 months or with no wound healing apparent for 12 weeks. Between 7 and 64 days after the transplantation (depending on the size of the ulceration), 11/14 of the lesions were completely healed. The transplantation of autologous keratinocytes may allow faster closure of diabetic foot lesions and subsequently reduce length of hospitalization. This method can easily be planned with regard to logistics and time, and furthermore, this therapy option can be carried out by the diabetologist.
J Diabetes Complications
PMID:Autologous human keratinocytes cultured on membranes composed of benzyl ester of hyaluronic acid for grafting in nonhealing diabetic foot lesions: a pilot study. 1281 Feb 43

This study analyzed risk factors for feet complications on people with diabetes assisted in an outpatient unit. Data were collected by means of semi-structured interviews, feet evaluation and laboratory tests. Risks were analyzed according to Zavala and Braver and the Classification System of the International Consensus on the Diabetic Foot based on descriptive statistics. Results showed that the mean age was 53.3 +/- 13 years old, the duration of the disease was 12.9 +/- 9 and 58% of the patients had incomplete elementary education. Among the risks, the following were identified: microvascular complications, arterial hypertension, inadequate glycemic level, sedentarism and the use of inappropriate shoes in addition to dermatological ad structural alterations. Concerning risks for ulcers, 19.1% were obtained in categories 2 and 3. The results reinforce the need for primary care with emphasis on risk evaluation and patient education.
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PMID:[Risk factors for complications in the lower extremities in people with diabetes mellitus]. 1281 34

Diabetic foot and pressure ulcers are chronic wounds by definition. They share similar pathogeneses; i.e., a combination of increased pressure and decreased angiogenic response. Neuropathy, trauma, and deformity also often contribute to development of both types of ulcers. Early intervention and proper treatment should result in complete healing of non-ischemic diabetic foot and pressure ulcers, as defined by 100% epithelialization and no drainage (if no osteomyelitis is present). The authors developed the following paradigm, which has proved to be highly effective for complete healing of these wounds: 1) recognition that all patients with limited mobility are at risk for a sacral, ischial, trochanteric, or heel pressure ulcer; 2) daily self-examination of the sacral, ischium, buttocks, hips, and heels of all bed-bound patients and the feet of patients with diabetes with risk factors (e.g., neuropathy); 3) initiation of a treatment protocol immediately upon recognition of a break in the skin (i.e., emergence of a new wound); 4) objective measurement by planimetry of every wound (at a minimum, weekly) and documentation of its progress; 5) establishment of a moist wound-healing environment; 6) relief of pressure from the wound; 7) debridement of all non-viable tissue in the wound; 8) elimination of all drainage and cellulitis; 9) cellular therapy or growth factors for patients with wounds that do not heal rapidly after initial treatment; and 10) continuous physical and psychosocial support for all patients. If this paradigm is followed, most diabetic foot and pressure ulcers are expected to heal.
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PMID:Wound-healing protocols for diabetic foot and pressure ulcers. 1293 Dec 88

Diabetic foot ulcers pose a great burden on both the patient and the health care system. A multifactorial approach is necessary in diagnosing and treating these patients, with the input of many different specialists. These different view points and approaches were the basis for the International Consensus on the Diabetic Foot, resulting in a worldwide network of professionals involved in the management of diabetic patients with foot problems. Moreover, several consensus texts were produced and the project resulted in many (local) national initiatives. These activities, which are a continuous process and which are embedded in the International Diabetes Federation, are described in the article.
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PMID:The international consensus and practical guidelines on the management and prevention of the diabetic foot. 1461 43

The purpose of this study was to quantify differences in joint range of motion, foot deformity, and foot morphology among pes cavus, neutrally aligned, pes planus rigid, and pes planus flexible feet. A cohort of 1047 veterans with diabetes (contributing 2047 feet) was enrolled in a prospective study of diabetic ulcer risk factors (the Seattle Diabetic Foot Study). Significant differences between foot types were found. Pes cavus feet had an increased percentage of prominent metatarsal heads, bony prominences, and hammer/claw toes (p < .0001), as well as significantly increased amounts of hallux dorsiflexion and decreased amounts of hallux plantarflexion (p < .0001) with a total range of motion equal to the other foot types (p = .3). Neutrally aligned feet had a lower percentage of intrinsic muscle atrophy, bony prominences, and hammer/claw toes (p < .0001). Pes planus feet had an increased lateral talometatarsal angle (p < .0001) and an increased second metatarsal length. These data demonstrate structural differences between foot types in a population with diabetes.
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PMID:Biomechanical differences among pes cavus, neutrally aligned, and pes planus feet in subjects with diabetes. 1465 89

Diabetic foot osteomyelitis is among the most common and serious complications in patients with diabetes mellitus. It is often a polymicrobial infection. We report the first case of foot osteomyelitis in a diabetic patient caused by Fusarium solani.
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PMID:Fusarium osteomyelitis of the foot in a patient with diabetes mellitus. 1472 75

Foot problems continue to be a major cause of morbidity, disability, and mortality for individuals with diabetes. According to Rothman's model of causation, as interpreted by Pecoraro, Reiber, and Burges (1990), each amputation related to diabetes implies the existence of a completed causal pathway of predisposing factors. The purpose of this descriptive retrospective study was to evaluate foot care provided to residents in a 179-bed long-term care facility. The charts of all 17 eligible residents with a diagnosis of diabetes mellitus were reviewed for documentation of assessment and care of their feet. All data were collected by the investigator using the Minimum Data Set (MDS) 2.0 Assessment of Diabetic Foot Care Instrument and a demographic and foot care history instrument. Foot problems were documented for 59% of the participants. Podiatrist-documented foot examination was found in only one of the charts reviewed; however, six residents had been referred to podiatrist. Throughout the charts reviewed, no documentation of protective sensation using the Semmes-Weinstein monofilament or vibration test was found. The findings of this study are consistent with previous research that showed a gap exists between the established standard and the degree to which the standards are met (Fain & Melkus, 1994; Wylie-Rosett et al., 1995). Adequate attention to the problem by health care providers, efforts to increase awareness of foot care standards, and early intervention may be steps to close the gap. Nurses must identify patients at risk for foot problems and actively intervene to prevent complications from occurring.
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PMID:Diabetic foot care in a long-term facility. 1510 42


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