American Diabetes Association Annual Meeting, 1997. Endothelial dysfunction, neuropathy and the diabetic foot, diabetic mastopathy, and erectile dysfunction.
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Breast Diseases↗
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Problems of the diabetic foot. Diabetes and amputations.
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Amputation, Surgical↗
Vascular assessment in the neuropathic diabetic foot.
Diabetic foot infections, a common source of morbidity and mortality, often have been related to vasculopathy and neuropathy in its etiopathogenesis, especially in the elderly person with diabetes. However, blood flow in the neuropathic diabetic foot has not been evaluated extensively, and there is evidence of abnormal blood flow patterns in the neuropathic diabetic foot unrelated to ischemia. The authors studied young persons with diabetes, with varying degrees of neuropathy, to assess the extent of vasculopathy in their lower limbs. Twelve young persons with insulin-dependent (Type I) diabetes (mean age, 36.1 +/- 1.975 years) and peripheral neuropathy, all of whom had previous surgery for diabetic foot infections, were identified. Confirmatory evidence of neuropathy was made using electromyographic studies and clinical tests that showed severe peripheral neuropathy. The results of vascular assessment of both lower limbs did not reveal any change in the pulse wave velocities from the popliteal to the digital vessels of the big toe as compared with correspondingly matched controls. There also was no significant stenosis in any of the vessels studied as far as the level of the dorsalis pedis and posterior tibial vessels. The normal triphasic pattern of arterial blood flow was lost. A monophasic pattern was present in all patients with prolonged diastolic flow at the level of the dorsalis pedis and posterior tibial arteries and distally. The pulsatility index was 3.14 +/- 0.81 as compared with 9.85 +/- 4.2. Mean toe pressures in the patient with diabetes was 64.17 +/- 20.87 mm Hg as compared with 98.23 +/- 10.12 mm Hg in controls. A linear correlation of decreasing toe pressures with increasing severity of neuropathy was seen (R = 0.7). The data suggest that changes exist in the blood flow patterns in young patients with diabetes and neuropathy, even in the absence of lower limb ischemia.
Adult↗
[Surgical management of the diabetic foot].
Diabetic foot is one of challenging diseases in vascular surgery. This is based on uncontrolled diabetes mellitus and its true character is the neuropathic gangrene due to microangiopathy. Diabetic foot, however, is sometimes accompanied by peripheral arterial occlusive disease, which true status is macroangiopathy. Therefore, the strategy for diabetic foot is as follows;the first step is the infection control by minor amputation and/or drainage, the second step is the assessment of the limb ischemia, and the final is the complete vascular reconstruction. To salvage these diabetic feet, it is important that doctors, who concern to diabetics, understand these strategies and also that they have a settled opinion for the diabetic foot.
English Abstract↗
Saving the diabetic foot.
Diabetic foot ulceration is both preventable and treatable. The management of diabetic foot disease is best achieved through implementation of local protocols involving the primary care team, community care and the multidisciplinary diabetic team. It is important that the feet the assessed as part of the overall assessment of a diabetic patient at any clinical presentation. The initial management of the acute diabetic foot may present to a general practitioner or general physician, and involves the urgent assessment and treatment of infection, foot elevation, wound debridement and, where appropriate, referral for urgent vascular assessment in a specialist centre.
Amputation, Surgical↗
[Diabetic angiopathy: the role of microvascular exploration in routine practice. Consequences of a new algorithm for care of the diabetic foot].
Diabetes mellitus is the chief medical cause of amputation. The risk of amputation is 15-fold higher in diabetic subjects and 5 out of 6 amputees are diabetic. There are three types of clinical presentation of diabetes-neurological, infectious and ischemic. In clinical practice, these three forms are often intertwined but the most frequent clinical sequence of events is neuropathy --> ulceration --> infection --> amputation. In this sequence, ischemia is not mentioned. The explanation is that the ischemic component of the diabetic foot is only recognized when ankle pulses are missing and when duplex scanning shows stenosis or occlusion of the main arterial trunks of the legs. This manner of diagnosing the ischemic component of diabetic foot is wrong as it fails to recognize the possibility of distal diabetic arteritis. Some experts in diabetology deny the existence of this arteritis which is obvious for those who measure systolic toe pressure. This distal arteritis is present in about 15% of all diabetic patients without trophic changes and in 35% of those with trophic changes. This foot arteritis is closely related to neuropathy. Toe pressure is not usually mentioned in text books or in consensus conferences concerning the diabetic foot. This is the main explanation for the calamitous number of amputations among diabetic patients. Nothing will change as long as physicians do not include toe pressure as a useful diagnostic tool in patients with diabetes. We present here a four-stage algorithm including toe pressure measurement for the management of the diabetic foot.
Algorithms↗
Comprehensive care of the diabetic foot.
Diabetes mellitus is a chronic illness with several serious long-term complications. Ranking high among these disabling complications are diabetic foot ulcers, which often become infected and lead to amputation. Once amputation in one limb has occurred, the opposite limb's prognosis becomes poor. Angiopathy and neuropathy are common complications in the diabetic foot and increase susceptibility to chronic ulcers. In this article, the pathophysiology of diabetes mellitus affecting the foot has been reviewed, and multiple treatment plans have been outlined, including conservative and surgical. Nurses are logical health care coordinators for clients with diabetic foot ulcers, with a focus on early screening, assessment, and education.
Diabetes Complications↗
The international consensus and practical guidelines on the management and prevention of the diabetic foot.
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.
Consensus↗
[Revascularization of the diabetic foot].
Diabetes is an important risk factor for atherosclerosis. The diabetic foot is characterised by the association of arteriopathy and neuropathy. The vascular damage associates a non-occlusive microangiopathy and a macroangiopathy. The first principles of treatment are the control of pain, of an eventual infection, and the restoration of pulsatile blood flow in case of ischemia. Angiologic investigation must be undertaken, as well as an arteriography, in order to plan the revascularisation. The treatment options are angioplasty with or without stenting and surgery. Distal reconstructions with anastomosis to the leg or pedal arteries have a satisfactory limb-salvage rates. This aggressive and systematic approach to the diabetic foot is economically sound, allows hope for limb salvage and improves the quality of life.
Angiography↗
The neuropathic diabetic foot.
Diabetic foot problems are common throughout the world, and result in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are likely to be of neuropathic origin and, therefore, are eminently preventable. Individuals with the greatest risk of ulceration can easily be identified by careful clinical examination of their feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb-threatening, or life-threatening. Infection is defined clinically, but wound cultures assist in identification of causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with nonremovable casts, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patient's adherence to the strategy used for pressure relief.
Algorithms↗
[The methodology and planning of an educational intervention in diabetic foot].
Diabetic foot is considered one of the most threatening and disabling complications for a diabetic patient: lesions of the extremities can become so severe that the person may risk the amputation of the toe, foot or leg. Methodology of planning and implementation of an educational intervention for the prevention of the diabetic foot is presented in its various steps: from the identification of priorities and contents to the problems and difficulties encountered in the implementation of the program.
Diabetes Complications↗
The diabetic foot.
Diabetic foot lesions most commonly result from a combination of neuropathy and vascular disease in the lower extremity, and may be the presenting feature of diabetes in the older patient. Insufficient attention previously has been given to the careful clinical assessment of the foot, which enables the physician to recognize those patients who are at particular risk of ulceration. The high-risk patient requires education and frequent follow up to reduce the risk of lesions developing. If ulceration develops, healing is likely to occur if the vascular supply is adequate, infection and the blood glucose are controlled, and pressures that may have caused the ulcer are relieved. The ischemic foot requires full vascular assessment, involving colleagues from vascular surgery. The key to a future reduction in the incidence of diabetic foot ulceration is the setting up of a foot care team in which the skills of nurses, podiatrists, orthotists, physicians, and surgeons are combined. The most important members of the team, however, are the patients, who must be convinced that regular foot care will reduce their chances of developing ulceration and other catastrophic consequences, such as amputation.
Diabetes Complications↗
[Diabetic foot].
Diabetic foot ulcers are a frequent and severe complication of diabetes mellitus. A multidisciplinary approach (in-patient and out-patient care) improves prognosis and reduces the amputation rate. Risk factors are well defined and easily identified. High-risk patients (sensory loss, vascular disease, previous ulcer, foot deformities) have to be detected. In France, comprehensive foot-care programs, including education and regular foot examination, must be developed. The reduction of the economical and human burden needs the urgent formation of more multidisciplinary teams (to take care of patients properly and very early), foot care networks, and prevention programs.
Black or African American↗
Infections of the diabetic foot.
Diabetic foot infections are frequently much worse than the initial clinical appearance would indicate. Altered immune response, peripheral vascular disease, and neuropathy are key factors in the production of infection. Treatment must be based upon careful bacteriologic analysis and individualized antibiotic therapy. Surgical debridement, when indicated, is the mainstay of treatment. Partial foot amputation and salvage are always preferred over higher amputation when possible.
Amnion↗
[Diabetic foot].
Diabetes is a chronic disease secondary to the interaction of the hereditary and environmental factors and is characterized by an abnormal secretion of insulin or by an ineffective use of this hormone. The result is the elevation of glycemia rate (N < 126 mg/dl). Untreated hyperglycemia can lead to serious complications like retinopathy, nephropathy, neuropathy, atherosclerosis, foot lesions (ulcer, infections, Charcot's arthropathy), even to amputations. The diabetes is a worldwide pandemic: 150 million people in the world, which will double in the next twenty-five years. The diabetes foots have a tremendous social and economic impact. The mechanisms which are implicated in development of the diabetic foot are the neuropathy and the arteriopathy. Lesions appear in the presence of the triggering factors. Diabetes is a disease in which several specialities are implicated. They should work together when treating these patients. Prevention is essential. The patient must be educated, then the complications of diabetes can be avoided.
Diabetic Foot↗
[The diabetic foot].
Diabetic patients are concerned with foot complications when a peripheral neuropathy is present. Screening of predisposed patients may be annually assessed using monofilament testing. Peripheral arterial disease, when associated, increases amputation risk. Ideal treatment requires a multidisciplinary approach with a first-line medical treatment including an optimal off-loading of the diabetic ulcer, ulcer dertersion, glycemic control, and if necessary antibiotic therapy. In case of associated osteomyelitis, a limited surgical resection of the infected bone may be performed. In case of associated arterial disease, a revascularization procedure precede bone resection.
Anti-Bacterial Agents↗
Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.
BACKGROUND: There has been a broad interest in the use of growth factors to treat patients with chronic nonischemic diabetic ulcers. STUDY DESIGN: One hundred eighteen patients were studied in a randomized, prospective, double-blind, multicenter trial comparing treatment with topically applied recombinant human platelet-derived growth factor (rhPDGF) or placebo (vehicle) and were treated until completely healed or to 20 weeks. All patients had aggressive sharp debridement of their ulcers before randomization and repeat debridement of callus and necrotic tissue as needed. The influence of debridement was evaluated by reviewing the records of the office visits where debridement was performed. RESULTS: Forty-eight percent of patients treated with rhPDGF healed compared with 25 percent of patients who received placebo (p = 0.01). The mean percentage of office visits where debridement was performed was comparable for the two treatment groups: 46.8 percent (rhPDGF) and 48.0 percent (placebo). In general, a lower rate of healing was observed in those centers that performed less frequent debridement. The improved response rate observed with more frequent debridement was independent of the treatment group. However, for any given center, the percentage of patients who healed was greater with rhPDGF than placebo. CONCLUSIONS: Wound debridement is a vital adjunct in the care of patients with chronic diabetic foot ulcers.
Anticoagulants↗
Work-up of the diabetic foot.
Diabetes is a common disease with potentially devastating complications affecting the foot and ankle. A combination of vascular disease, peripheral neuropathy, and immunopathy results in a cascade of conditions including ischemia and infarction, tendinopathy, atrophy, edema, deformity, neuropathic osteoarthropathy, callus, ulceration, and infection. MRI is useful for evaluation of these complications, and assists the clinician in medical or surgical planning.
Diabetic Foot↗