Tag Archives: diabetic foot ulcers

Doctor-turned-businesswoman uses technology to help diabetics save their feet

When Dr. Breanne Everett began training to become a plastic surgeon she was shocked by the number of foot problems, including amputations, she was seeing among diabetic patients. She decided to look for a solution.

That led the 32-year-old physician to put her medical training on hold and make the transition into business and technology.

She invented a device to alert diabetic patients before a sore spot on their foot turned into a wound that could cause severe complications.

The Calgary company she founded — Orpyx — developed pressure-sensitive insole technology to feed information to patients and prevent the kinds of wounds that can lead to amputations in diabetics with peripheral neuropathy, which can cause numbness in the feet.

The company’s smart-sole foot protection system is attracting attention around the world with ongoing clinical trials in both the U.S. and U.K. The product is available through the company, which calls it the only device of its type on the market.

Read more at Ottawa Citizen

Reduction of 50% in Diabetic Foot Ulcers With Stem Cells

MUNICH — Local injection of mesenchymal stem cells derived from autologous bone marrow shows promise in healing recalcitrant neuropathic diabetic foot ulcers, a novel study from Egypt shows.

Presenting the results at the European Association for the Study of Diabetes (EASD) 2016 Annual Meeting, Ahmed Albehairy, MD, from Mansoura University, Egypt, said: “In patients who received the mesenchymal stem cells, ulcer reduction was found to be significantly higher compared with patients on conventional treatment after both 6 weeks and 12 weeks of follow-up. This is despite the fact that initial ulcer size was larger in the stem-cell–treated group.” Continue reading »

Clinical Notes—May/June 2016

Moldable skin barrier effective for elderly patients with ostomy

A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.

The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.

Risk factors for severe hypoglycemia in older adults with diabetes identified

Risk factors associated with severe hypoglycemia in older adults with Type 1 diabetes” include glucose variability and greater lack of awareness of hypoglycemia.

Participants in the case-control, multi-center study, published in Diabetes Care, were age 60 or older and had a history of diabetes dating back 20 years or more.

Thermal imaging via smartphone helps detect inflammation

Early detection of inflammation in wounds promotes early treatment, and clinicians may have an additional assessment tool available to them. A recent study published in the Journal of Wound Care concludes the FLIR ONE, a thermography device that connects to a smartphone, can be successfully used to assess subclinical inflammation in patients with pressure ulcers and diabetic foot in clinical settings.

Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study” included 16 thermal images from eight patients and found good criterion-related validity and inter-rater reliability when the FLIR ONE results were compared to those from a handheld device. The findings may open the door to more thermal imaging assessment at the bedside.

Role of skin substitutes in treatment of diabetic foot ulcers analyzed

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers,” published in Wound Repair and Regeneration, concludes that skin substitutes “can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcer.”

The authors caution, however, that long-term effectiveness, including limb salvage and recurrence, is not known, and cost-effectiveness is not clear. The review included 17 randomized clinical trials, with a total of 1,655 patients.

Tap water safe alternative for wound cleaning

“Tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting,” concludes a study in the Journal of Wound, Ostomy and Continence Nursing.

Tap water versus sterile normal saline in wound swabbing: A double-blind randomized controlled trial” studied 22 people with 30 wounds. Half were in the tap water group and half in the sterile normal saline group. Researchers found no differences in the proportion of wound infection and healing between the two groups.

Review of skin grafting in patients with chronic leg ulcers

Autologous split-thickness skin grafting remains the gold standard in terms of safety and efficacy for chronic leg ulcers, according to a review article in International Wound Journal.

Skin grafting for the treatment of chronic leg ulcers—a systematic review in evidencebased medicine” also found that skin grafts are more successful in patients who have chronic venous leg ulcers, compared to other types. The researchers noted that skin tissue engineering is “rapidly expanding” and holds promise for better outcomes when treating patients with long-lasting chronic wounds.

C difficile may be risk factor for pouch failure after reconstruction

Patients with a history of preoperative Clostridium difficile colitis may be at higher risk for pouch failure after ileal pouchanal anastomosis reconstruction following total proctocolectomy for ulcerative colitis, according to a study in Inflammatory Bowel Disease.

The authors of “Clostridium difficile infection in ulcerative colitis: Can alteration of  the gut-associated microbiome contribute to pouch failure?” defined pouch failure as permanent ostomy diversion or pouch excision. Of 417 patients in the study, 28 (6.7%) developed pouch failure.

Lymphedema education lacking

Researchers of a study in the Journal of Cancer Education report that only 19.9% of 180 women with lymphedema after breast cancer surgery reported they had received education or information about the condition postoperatively.

The importance of awareness and education in patients with breast cancer-related lymphedema” also reports that, “The degree and duration of lymphedema were lower in patients who had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant.”

Color charts help improve pressure ulcer risk assessment

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development,” published in the Journal of Advanced Nursingconcludes that the color charts provide a “more objective measurement of skin tone than demographic categories.”

The researchers state that use of the charts can improve pressure ulcer risk assessment when current clinical guidelines are less effective.

Pros and cons of hydrocolloid dressings for diabetic foot ulcers

Diabetic foot ulcers stem from multiple factors, including peripheral neuropathy, high plantar pressures, decreased vascularity, and impaired wound healing. Contributing significantly to morbidity, they may cause limb loss and death. (See Foot ulcers and diabetes.)

Initially, hydrocolloid dressings were developed to function as part of the stomal flange. Based on their success in protecting peristomal skin, they were introduced gradually into other areas of wound care. They contain wafers of gel-forming polymers, such as gelatin, pectin, and cellulose agents, within a flexible water-resistant outer layer. The wafers absorb wound exudate, forming a gel and creating a moist healing environment.

The wide range of hydrocolloid dressings available include fibrous and matrix dressings. Commercially available products include DuoDerm®, Granuflex®, Comfeel®, Cutimed® Hydro, and CovaWound™.

Benefits

Hydrocolloid dressings are occlusive, retaining wound exudate and promoting the moist environment that’s optimal for wound healing. They also promote autolytic wound debridement, removing necrotic tissue—a barrier to wound healing—from the wound bed. Wet or moist wound environments promote re-epithelialization, reduce inflammatory reactions, and decrease scar formation. Hydrocolloid dressings also aid wound healing by retaining growth factors in the exudate, promoting granulation tissue formation and epithelialization. (View hydrocolloid dressings)

Although these dressings are contraindicated for patients with infected ulcers, they’re useful in preventing wound infection, serving as a barrier that prevents bacterial entry into diabetic foot ulcers. In addition, they promote a low pH, which reduces or even eradicates certain bacteria (namely Pseudomonas aeruginosa) from the wound bed.

Hydrocolloid dressings are self-adherent and easy to apply. The second most popular dressing for diabetic foot ulcers, they can be left intact up to 7 days, depending on the amount of wound exudate. The need for less frequent dressing changes can reduce disruption of healing, improve patient compliance, and decrease cost.

Disadvantages

Controversy exists over the use of hydrocolloid dressings for treating diabetic foot ulcers. Many wound care experts suspect they may increase the infection risk because they retain bacteria and purulent wound exudate, create a hypoxic wound environment, and lead to less frequent wound monitoring. Given these concerns, hydrocolloid dressings are contraindicated for infected wounds.

Use these dressing with care in diabetic patients. Make sure to obtain bacterial cultures before starting treatment, and change the dressing more often than in patients without diabetes.

Also, because they’re occlusive, hydrocolloid dressings may lead to an overly moist wound environment, with excess moisture causing dressing separation and periwound maceration. Experts recommend using them only for wounds with low to moderate amounts of wound exudate.

In addition, the hypoxic environment created by these dressings may delay and impede wound healing and raise the infection risk. Leukocytes phagocytize bacteria but can’t kill them in hypoxic environments because of the low oxygen tension; this significantly increases infection risk. Collagen maturation, endothelium development, keratinocyte migration, and granulation tissue formation depend on oxygen and may be inhibited by hypoxic wound bed conditions. (See Patient compliance factors.)

More research needed

Although many studies show hydrocolloid dressings are effective in treating diabetic foot ulcers, a 2012 systematic review by Dumville et al. found no evidence that they’re more effective than basic wound contact dressings. Also, according to a 2013 review of randomized controlled trials, hydrocolloid dressings aren’t more effective than basic wound contact dressings, foam dressings, alginate dressings, and topical treatments in managing diabetic foot ulcers. However, these studies produced sparse

data and included research with risk of bias.

Consequently, proper patient selection is crucial. We need further research to evaluate the safety and effectiveness of hydrocolloid dressings for diabetic foot ulcers and to establish further guidelines for their use.

Kristine Hoffman practices podiatry at the Boulder Valley Foot and Ankle Clinic in Boulder, Colorado.

Selected references

Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association. Diabetes Care. 1999;22(8):1354-60.

Cuschieri L, Debosz J, Miiller P, et al. Autolytic debridement of a large, necrotic, fully occluded foot ulcer using a hydrocolloid dressing in a diabetic patient. Adv Skin Wound Care. 2013;26(7):300-4.

Dumville JC, Soares MO, O’Meara S, et al. Systematic review and mixed treatment comparison: dressings to heal diabetic foot ulcers. Diabetologia. 2012;55(7):1902-10.

Dumville JC, Deshpande S, O’Meara S, et al. Hydrocolloid dressings for healing diabetic foot ulcers. Cochrane Database Syst Rev. 2013;8:CD009099.

Fisken RAD. Which dressings for diabetic foot ulcers? J Br Podiatr Med. 1997;52:20-2.

Hampton SC, Collins F. Tissue Viability: A Comprehensive Guide. Hoboken, NJ: Wiley; 2002:76-132.

Kavitha KV, Tiwari S, Purandare VB, et al. Choice of wound care in diabetic foot ulcer: a practical approach. World J Diabetes. 2014;5(4):546-56.

Korting HC, Schöllmann C, White RJ. Management of minor acute cutaneous wounds: importance of wound healing in a moist environment. J Eur Acad Dermatol Venereol. 2011;25(2):130-7.

Monsen C, Acosta S, Mani K, et al. A randomised study of NPWT closure versus alginate dressings in peri-vascular groin infections: quality of life, pain and cost. J Wound Care. 2015;24(6):252, 254-6, 258-0.

Ono I, Gunji H, Zhang JZ, et al. Studies on cytokines related to wound healing in donor site wound fluid. J Dermatol Sci. 1995;10(3):241-5.

Reiber GE. Epidemiology and health care costs of diabetic foot problems. In: Veves A, Giurini JM, LoGerfo FW, eds. The Diabetic Foot: Medical and Surgical Management. New York, NY: Humana Press; 2002:35-58.

Sen CK. Wound healing essentials: let there be oxygen. Wound Repair Regen. 2009;17(1):1-18.

Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-28.

Uccioli L, Izzo V, Meloni M, et al. Non-healing foot ulcers in diabetic patients: general and local interfering conditions and management options with advanced wound dressings. J Wound Care. 2015;24(4 Suppl):35-42.

Clinical Notes

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Modified Braden risk score proposed

A study in Ostomy Wound Management states the risk classification of patients using Braden Scale scores should comprise three (rather than five) levels: high risk, with a total score ≤11; moderate risk, with a total score of 12 to 16; and mild risk, with a total score ≥17.

The retrospective analysis of consecutively admitted patients at risk for pressure ulcer to an acute-care facility included 2,625 patients, with an age range from 1 month to 98 years; 3.1% developed a pressure ulcer.

The authors of “A retrospective analysis of pressure ulcer incidence and modified Braden Scale score risk classifications” conclude that the modified Braden Scale “may be more convenient and feasible in clinical practice.”

CN_DialysisAmputations and foot-related hospitalization in dialysis patients

Amputations and foot-related hospitalisations disproportionately affect dialysis patients,” even though the incidence of foot ulcers is the same in dialysis patients and patients with an ulcer history.

The study in International Wound Journal included 150 consecutive patients with diabetes who were on dialysis and 150 patients with a history of foot ulceration. Each patient was followed for 30 months.

CN_FootPlantar shear plays important role in foot ulcers

Considering both plantar shear and pressure, as opposed to pressure alone, is more effective in preventing foot ulcers, according to a study in Diabetes Care.

Peak plantar shear and pressure and foot ulcer locations: A call to revisit ulceration pathomechanics” notes that pressure is a poor predictor of foot ulcer in patients with diabetes, and pressure-reducing therapeutic footwear has minimal effect in preventing recurrent ulceration.

The authors write that their findings indicate that plantar shear has a “clinically significant role in ulceration” and that ulcers at different sites may have different pathologies. They also call for more research on plantar shear.

CN_amputationLower extremity amputation in patients with diabetes

A longitudinal study in Diabetes Care reports that people with diabetes who have undergone lower-extremity amputation “are more likely to die at any given point in time” compared to those who have not experienced amputation.

Diabetes, lower-extremity amputation, and death” notes that complications from diabetes account for only some of the variation.

CN_CPRAHA releases new CPR guidelines

The American Heart Association has published the “2015 Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)” in the journal Circulation. The guidelines recommend chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2 inches (avoiding depths greater than 2.4 inches). Other recommendations include having clinicians perform steps simultaneously to reduce the time to the first chest compression.

Bystanders should use mobile phones to immediately call 911, placing the phones on speaker, so the dispatcher can offer assistance. Untrained bystanders should provide Hands-Only CPR, and bystanders who are trained in CPR should add breaths in a 30:2 compressions-to-breath ratio.

CN_diabetesDiabetes increases risk of fracture

Type 1 diabetes is associated with an increased risk of fracture across the life span: A population-based cohort study using The Health Improvement Network (THIN)” included patients with and without diabetes, who were matched on parameters such as age and sex.

The risk of fracture was lowest in males and females younger than 20 years and highest in men ages 60 to 69, according to the study, which was published in Diabetes Care. Lower extremity fractures accounted for a higher proportion of incident fractures in participants with diabetes compared to those without. Secondary analyses for incident hip fractures identified the highest hazard ratio of 5.64 in men ages 60 to 69 and the highest hazard ratio of 5.63 in women ages 30 to 39.

CN_ostomyNurses play important role in quality of life for ostomy patients

Analysing the role of support wear, clothing and accessories in maintaining ostomates’ quality of life,” published in Gastrointestinal Nursing, notes that nurses with expertise in stoma care can help patients with ostomies achieve optimal quality of life by using their expertise to guide patients in making decisions that will help them return to the activities, sports, hobbies, and lifestyle they enjoyed before surgery.

Liposuction may be helpful for lymphedema

Complete reduction of arm lymphoma following breast cancer—A prospective twenty-one years’ study” concludes that liposuction is effective for treating chronic, nonpitting leg lymphedema in patients who don’t respond to conservative treatment.

The study, published in Plastic and Reconstructive Surgery, included 146 women, with a mean age of 63 and a mean duration of arm swelling of 9 years. It notes that reduced volume is maintained through constant use of compression garments.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clinical Notes : March-April

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Guidelines for optimal off-loading to prevent diabetic foot ulcers

The management of diabetic foot ulcers through optimal off-loading,” published in the Journal of the American Podiatric Medical Association, presents consensus guidelines and states the “evidence is clear” that off-loading increases healing of diabetic foot ulcers.

The article calls for increased use of off-loading and notes that “current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities.” The authors reviewed about 90 studies.

Updated diabetes standards released

Diabetes Care has publishedStandards of Medical Care in Diabetes—2015” from the American Diabetes Association. The recommendations include screening, diagnostic, and therapeutic actions.

Standards of Medical Care in Diabetes—2015: Summary of revisions” provides a synopsis of key changes by section. Of particular interest to wound care clinicians is that the standards emphasize that all patients with insensate feet, foot deformities, or a history of foot ulcers should have their feet examined at every visit so problems can be identified early.

Medical honey and silver dressings don’t interfere with each other

A study in Wounds reports that medical grade honey gel and dressings containing silver don’t interfere with each other.

Medical honey and silver dressings do not interfere with each other’s key functional attributes” found that the in vitro antibacterial barrier activity seen with silver-containing dressings doesn’t decrease with the addition of medical honey, and in some cases increases.

Fecal transplants help patients with Clostridium difficile infection

Medscape Gastroenterology has published “Fecal transplants bring hope to patients, challenge the FDA,” which states that fecal microbiota transplant (FMT) has a nearly 90% success rate in patients with recurrent Clostridium difficile infection.

The article discusses developments in FMT, including manufactured FMT products, stool banks, use of frozen rather than fresh stool, and biosynthetic alternatives.

Most coated stents effective in PAD 3 years after insertion

According to a study presented at the 2015 International Symposium on Endovascular Therapy, nearly three-quarters of patients with peripheral artery disease (PAD) who were treated with peripheral angioplasty and stents still had patent arteries 3 years after treatment.

The results are from the STROLL trial, a multicenter, nonrandomized, single-arm prospective trial studying the safety and efficacy of a nitinol self-expanding stent called the SMART Stent, manufactured by Cordis Corporation.

Ultrasound may help in healing venous leg ulcers

Adding 40 kHz noncontact, low-frequency ultrasound (NLFU) treatments three times per week for 4 weeks to standard care reduces pain and wound size, according to a study in Ostomy Wound Management.

A prospective, randomized, controlled trial comparing the effects of noncontact, low-frequency ultrasound to standard care in healing venous leg ulcers” included 112 patients. The average wound size reduction was 62% in the group who received NLFU, compared to 45% in those who received only standard care.

Moldable skin barriers effective in preventing peristomal skin complications

The effects of using a moldable skin barrier on peristomal skin condition in persons with an ostomy: Results of a prospective, observational, multinational study” reports that this type of barrier is effective in preventing and healing peristomal skin complications and is rated as good or  excellent by most patients.

The study, published in Ostomy Wound Management, included 561 patients from 90 centers in three countries. In the patients with a new stoma, 90% had intact skin at baseline, 96% had intact skin after 2 months, and 98% rated overall satisfaction with the barrier as good or excellent.

In patients with an existing stoma, intact skin was observed in 39.5% at baseline and 86% after 2 months, with 96.5% of patients rating overall satisfaction with the barrier as good or excellent.

Recommendations to prevent lymphedema questioned

According to data presented at the 2014 San Antonio Breast Cancer Symposium, recommendations given to patients to reduce their risk of lymphedema may not be effective.

Blood draws, injections, and blood pressure measurements in the at-risk arm and air travel without a compression sleeve did not increase the risk of lymphedema. The researchers did find that axial lymph node dissection and a higher preoperative body mass index were significantly associated with the development of lymphedema.