| 1. |
- Brownrigg, J R W, et al.
(författare)
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Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review.
- 2015
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552.
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Tidskriftsartikel (refereegranskat)abstract
- Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus (DM) are important to estimate the risk of amputation, ulceration, wound healing and presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another. To evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction-angiography, colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies (QUADAS) instrument. Of 6629 studies identified, 10 met the criteria for inclusion. In these studies the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/ infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy the NLR of the ABI was generally higher (2 out of 3 studies) indicating poorer performance, and ranged between 0.3-0.5. A toe brachial index (TBI) <0.75 was associated with a median PLR and NLR of 3 and ≤0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with DM is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that TBI, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There was insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies. This article is protected by copyright. All rights reserved.
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| 2. |
- Brownrigg, J R W, et al.
(författare)
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Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.
- 2016
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 32:Suppl S1, s. 128-135
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Tidskriftsartikel (refereegranskat)abstract
- Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/ or major amputation among patients with active diabetic foot ulceration. Two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies (QUIPS) instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥45 mmHg), and TcPO2 ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ABI < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation. This article is protected by copyright. All rights reserved.
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| 3. |
- Hinchliffe, R J, et al.
(författare)
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Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review.
- 2015
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552.
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Tidskriftsartikel (refereegranskat)abstract
- Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012 a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 - June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 papers were eligible for full text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients. This article is protected by copyright. All rights reserved.
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| 4. |
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| 5. |
- Hinchliffe, R. J., et al.
(författare)
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A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease
- 2012
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 28:Suppl. 1, s. 179-217
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Tidskriftsartikel (refereegranskat)abstract
- In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 8090%), and following endovascular revascularization, these rates were 78% (70.585.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients. Copyright (C) 2012 John Wiley & Sons, Ltd.
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| 6. |
- Schaper, N. C., et al.
(författare)
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Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot
- 2012
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 28:Suppl. 1, s. 218-224
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Tidskriftsartikel (refereegranskat)abstract
- The International Working Group on the Diabetic Foot (IWDGF) has produced in 2011 a guideline on the diagnosis and treatment of peripheral arterial disease in patients with diabetes and a foot ulcer. This document, together with a systematic review that provided the background information on management, was produced by a multidisciplinary working group of experts in the field and was endorsed by the IWDGF. This progress report is based on these two documents and earlier consensus texts of the IWDGF on the diagnosis and management of diabetic foot ulcers. Its aim is to give the clinician clear guidance on when and how to diagnose peripheral arterial disease in patients with diabetes and a foot ulcer and when and which treatment modalities should be considered, taking both risks and benefits into account. Copyright (C) 2012 John Wiley & Sons, Ltd.
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| 7. |
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| 8. |
- Apelqvist, Jan, et al.
(författare)
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Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer
- 1989
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Ingår i: Diabetes Care. - : American Diabetes Association. - 1935-5548 .- 0149-5992. ; 12:6, s. 373-378
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Tidskriftsartikel (refereegranskat)abstract
- The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.
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| 9. |
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| 10. |
- Apelqvist, Jan, et al.
(författare)
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The Diabetic Foot Syndrome Today : A Pandemic Uprise
- 2017
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Ingår i: The Diabetic Foot Syndrome. - : S. Karger AG. - 0251-5342. - 9783318061451 ; 26, s. 1-18
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Bokkapitel (refereegranskat)abstract
- Diabetes mellitus is growing at epidemic proportions worldwide; currently 415 million adults are estimated to have diabetes and by 2040, this number is estimated to increase to 642 million. As a consequence, the prevalence of diabetes-related complications is bound to increase. Diabetic foot disorders are common throughout the world, resulting in major medical, social and economic consequences for the patients, and a public health problem. The risk for ulceration and amputation is much higher in individuals with diabetes compared to that of the non-diabetic population: it is estimated that every 20 s an amputation is performed on an individual with diabetes somewhere in the world. Foot ulceration is the commonest major end point among diabetic complications. More than 5% of diabetic patients have a history of foot ulceration and the cumulative lifetime incidence may be as high as 25%. Incidence and prevalence figures related to both foot ulcerations and lower extremity amputations have been reported worldwide. There is a substantial global variation in the incidence and prevalence of amputation and diabetic foot ulcer (DFU). The variation may be partially explained by differences in the measurement of amputation and DFU, as well as the ascertainment of diabetes, demographic factors, setting or other confounders. There is an urgent need to determine a standardized way to report the incidence and prevalence of diabetes-related amputation and foot ulcer in order to be able to be used as a marker of quality of care.
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| 11. |
- Apelqvist, Jan, et al.
(författare)
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Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers
- 1989
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Ingår i: Diabetic Medicine. - 1464-5491. ; 6:6, s. 526-530
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Tidskriftsartikel (refereegranskat)abstract
- The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.
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| 12. |
- Bakker, K, et al.
(författare)
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The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus.
- 2016
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 32:Supplement S1, s. 2-6
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Tidskriftsartikel (refereegranskat)abstract
- Foot problems complicating diabetes are a source of major patient suffering and societal costs. Investing in evidence-based, internationally appropriate diabetic foot care guidance is likely among the most cost-effective forms of healthcare expenditure, provided it is goal-focused and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has been publishing and updating international Practical Guidelines since 1999. The 2015 updates are based on systematic reviews of the literature, and recommendations are formulated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. As such, we changed the name from "Practical Guidelines" to "Guidance". In this article we describe the development of the 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes. This Guidance consists of five documents, prepared by five working groups of international experts. These documents provide guidance related to foot complications in persons with diabetes on: prevention; footwear and offloading; peripheral artery disease; infections; and, wound healing interventions. Based on these five documents, the IWGDF Editorial Board produced a summary guidance for daily practice. The resultant of this process, after review by the Editorial Board and by international IWGDF members of all documents, is an evidence-based global consensus on prevention and management of foot problems in diabetes. Plans are already under way to implement this Guidance. We believe that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved management of foot problems in persons with diabetes and a subsequent worldwide reduction in the tragedies caused by these foot problems. This article is protected by copyright. All rights reserved.
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| 13. |
- Becker, F., et al.
(författare)
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Definitions, Epidemiology, Clinical Presentation and Prognosis
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 4-12
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Tidskriftsartikel (refereegranskat)abstract
- The concept of chronic critical limb ischaemia (CLI) emerged late in the history of peripheral arterial occlusive disease (PAOD). The historical background and changing definitions of CLI over the last decades are important to know in order to understand why epidemiologic data are so difficult to compare between articles and over time. The prevalence of CLI is probably very high and largely underestimated, and significant differences exist between population studies and clinical series. The extremely high costs associated with management of these patients make CLI a real public health issue for the future. In the era of emerging vascular surgery in the 1950s, the initial classification of PAOD by Fontaine, with stages III and IV corresponding to CLI, was based only on clinical symptoms. Later, with increasing access to non-invasive haemodynamic measurements (ankle pressure, toe pressure), the need to prove a causal relationship between PAOD and clinical findings suggestive of CLI became a real concern, and the Rutherford classification published in 1986 included objective haemodynamic criteria. The first consensus document on CLI was published in 1991 and included clinical criteria associated with ankle and toe pressure and transcutaneous oxygen pressure (TcPO(2)) cut-off levels (<= 50 mmHg, <= 30 mmHg and <= 10 mmHg respectively). This rigorous definition reflects an arterial insufficiency that is so severe as to cause microcirculatory changes and compromise tissue integrity, with a high rate of major amputation and mortality. The TASC I consensus document published in 2000 used less severe pressure cut-offs (<50-70 mmHg, <30-50 mmHg and <30-50 mmHg respectively). The thresholds for toe pressure and especially TcPO(2) (which will be also included in TASC II consensus document) are however just below the lower limit of normality. It is therefore easy to infer that patients qualifying as CLI based on TASC criteria can suffer from far less severe disease than those qualifying as CLI in the initial 1991 consensus document. Furthermore, inclusion criteria of many recent interventional studies have even shifted further from the efforts of definition standardisation with objective criteria, by including patients as CLI based merely on Fontaine classification (stage III and IV) without haemodynamic criteria. The differences in the natural history of patients with CLI, including prognosis of the limb and the patient, are thus difficult to compare between studies in this context. Overall, CLI as defined by clinical and haemodynamic criteria remains a severe condition with poor prognosis, high medical costs and a major impact in terms of public health and patients' loss of functional capacity. The major progresses in best medical therapy of arterial disease and revascularisation procedures will certainly improve the outcome of CLI patients. In the future, an effort to apply a standardised definition with clinical and objective haemodynamic criteria will be needed to better demonstrate and compare the advances in management of these patients. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 14. |
- Brownrigg, J. R. W., et al.
(författare)
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Evidence-based Management of PAD & the Diabetic Foot
- 2013
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 45:6, s. 673-681
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Forskningsöversikt (refereegranskat)abstract
- Diabetic foot ulceration (DFU) is associated with high morbidity and mortality, and represents the leading cause of hospitalization in patients with diabetes. Peripheral arterial disease (PAD), present in half of patients with DFU, is an independent predictor of limb loss and can be difficult to diagnose in a diabetic population. This review focuses on the evidence for therapeutic strategies in the management of patients with DFU. We highlight the importance of timely referral of patients presenting with a new foot ulcer to a multidisciplinary team, which includes vascular surgeons and interventional radiologists. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 15. |
- Cao, P., et al.
(författare)
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Diagnostic Methods
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42, s. 13-32
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Tidskriftsartikel (refereegranskat)abstract
- Non-invasive vascular studies can provide crucial information on the presence, location, and severity of critical limb ischaemia (CLI), as well as the initial assessment or treatment planning. Ankle-brachial index with Doppler ultrasound, despite limitations in diabetic and end-stage renal failure patients, is the first-line evaluation of CLI. In this group of patients, toe-brachial index measurement may better establish the diagnosis. Other non-invasive measurements, such as segmental limb pressure, continuous-wave Doppler analysis and pulse volume recording, are of limited accuracy. Transcutaneous oxygen pressure (TcPO(2)) measurement may be of value when rest pain and ulcerations of the foot are present. Duplex ultrasound is the most important non-invasive tool in CLI patients combining haemodynamic evaluation with imaging modality. Computed tomography angiography (CIA) and magnetic resonance angiography (MRA) are the next imaging studies in the algorithm for CLI. Both CTA and MRA have been proven effective in aiding the decision-making of clinicians and accurate planning of intervention. The data acquired with CIA and MRA can be manipulated in a multiplanar and 3D fashion and can offer exquisite detail. CIA results are generally equivalent to MRA, and both compare favourably with contrast angiography. The individual use of different imaging modalities depends on local availability, experience, and costs. Contrast angiography represents the gold standard, provides detailed information about arterial anatomy, and is recommended when revascularisation is needed. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 16. |
- Dick, F., et al.
(författare)
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Follow-up after Revascularisation
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 75-90
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Tidskriftsartikel (refereegranskat)abstract
- Structured follow-up after revascularisation for chronic critical limb ischaemia (CLI) aims at sustained treatment success and continued best patient care. Thereby, efforts need to address three fundamental domains: (A) best medical therapy, both to protect the arterial reconstruction locally and to reduce atherosclerotic burden systemically; (B) surveillance of the arterial reconstruction; and (C) timely initiation of repeat interventions. As most CLI patients are elderly and frail, sustained resolution of CLI and preserved ambulatory capacity may decide over independent living and overall prognosis. Despite this importance, previous guidelines have largely ignored follow-up after CLI; arguably because of a striking lack of evidence and because of a widespread assumption that, in the context of CLI, efficacy of initial revascularisation will determine prognosis during the short remaining life expectancy. This chapter of the current CLI guidelines aims to challenge this disposition and to recommend evidentially best clinical practice by critically appraising available evidence in all of the above domains, including antiplatelet and antithrombotic therapy, clinical surveillance, use of duplex ultrasound, and indications for and preferred type of repeat interventions for failing and failed reconstructions. However, as corresponding studies are rarely performed among CLI patients specifically, evidence has to be consulted that derives from expanded patient populations. Therefore, most recommendations are based on extrapolations or subgroup analyses, which leads to an almost systematic degradation of their strength. Endovascular reconstruction and surgical bypass are considered separately, as are specific contexts such as diabetes or renal failure; and critical issues are highlighted throughout to inform future studies. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 17. |
- Diehm, N., et al.
(författare)
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Management of Cardiovascular Risk Factors and Medical Therapy
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 33-42
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Tidskriftsartikel (refereegranskat)abstract
- Critical limb ischaemia (CLI) is a particularly severe manifestation of lower limb atherosclerosis posing a major threat to both limb and life of affected patients. Besides arterial revascularisation, risk-factor modification and administration of antiplatelet therapy is a major goal in the treatment of CLI patients. Key elements of cardiovascular risk management are smoking cessation and treatment of hyperlipidaemia with dietary modification or statins. Moreover, arterial hypertension and diabetes mellitus should be adequately treated. In CLI patients not suitable for arterial revascularisation or subsequent to unsuccessful revascularisation, parenteral prostanoids may be considered. CLI patients undergoing surgical revascularisation should be treated with beta blockers. At present, neither gene nor stem-cell therapy can be recommended outside clinical trials. Of note, walking exercise is contraindicated in CLI patients due to the risk of worsening pre-existing or causing new ischaemic wounds. CLI patients are oftentimes medically frail and exhibit significant comorbidities. Co-existing coronary heart and carotid as well as renal artery disease should be managed according to current guidelines. Considering the above-mentioned treatment goals, interdisciplinary treatment approaches for CLI patients are warranted. Aim of the present manuscript is to discuss currently existing evidence for both the management of cardiovascular risk factors and treatment of co-existing disease and to deduct specific treatment recommendations. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 18. |
- Game, F. L., et al.
(författare)
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A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes
- 2012
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 28:Suppl. 1, s. 119-141
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Tidskriftsartikel (refereegranskat)abstract
- The outcome of management of diabetic foot ulcers is poor, and there is continuing uncertainty concerning optimal approaches to management. It was for these reasons that in 2006 the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing undertook a systematic review of the evidence to inform protocols for routine care and to highlight areas which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between December 2006 and June 2010. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae and hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; hyperbaric oxygen therapy (HBOT); compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound; other systemic therapies which did not fit in the above categories. Heterogeneity of studies prevented pooled analysis of results. Of the 1322 papers identified, 43 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic review, but the conclusion is similar: that with the exception of HBOT and, possibly, negative pressure wound therapy, there is little published evidence to justify the use of newer therapies. This echoes the conclusion of a recent Cochrane review and the systematic review undertaken by the National Institute for Health and Clinical Excellence Guidelines Committee in the UK. Analysis of evidence presents considerable difficulties in this field particularly as controlled studies are few and the majority are of poor methodological quality. Copyright (C) 2012 John Wiley & Sons, Ltd.
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| 19. |
- Game, F L, et al.
(författare)
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Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review.
- 2015
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552.
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Tidskriftsartikel (refereegranskat)abstract
- The outcome of management of diabetic foot ulcers remains a challenge and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012 the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies which did not fit in the above categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews and the conclusion is similar: that with the possible, exception of negative pressure wound therapy in post operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality. This article is protected by copyright. All rights reserved.
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| 20. |
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| 21. |
- Hinchliffe, R J, et al.
(författare)
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A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes
- 2008
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552 .- 1520-7560. ; 24:S1, s. 119-144
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Forskningsöversikt (refereegranskat)abstract
- The outcome of management of diabetic foot ulcers is poor and there is uncertainty concerning optimal approaches to management. We have undertaken a systematic review to identify interventions for which there is evidence of effectiveness. A search was made for reports of the effectiveness of interventions assessed in terms of healing, ulcer area or amputation in controlled clinical studies published prior to December 2006. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network (SIGN) criteria. Selected studies fell into the following categories: sharp debridement and larvae; antiseptics and dressings; chronic wound resection hyperbaric oxygen (HBO); reduction of tissue oedema; skin grafts; electrical and magnetic stimulation and ultrasound. Heterogeneity of studies prevented pooled analysis of results. Of the 2251 papers identified, 60 were selected for grading following full text review. Some evidence was found to support hydrogels as desloughing agents and to suggest that a systemic (HBO) therapy may be effective. Topical negative pressure (TNP) may promote healing of post-operative wounds, and resection of neuropathic plantar ulcers may be beneficial. More information was needed to confirm the effectiveness and cost-effectiveness of these and other interventions. No data were found to justify the use of any other topically applied product or dressing, including those with antiseptic properties. Further evidence to substantiate the effect of interventions designed to enhance the healing of chronic ulcers is urgently needed. Until such evidence is available from robust trials, there is limited justification for the use of more expensive treatments and dressings.
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| 22. |
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| 23. |
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| 24. |
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| 25. |
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| 26. |
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| 27. |
- Larsson, J, et al.
(författare)
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Distal blood pressure as a predictor for the level of amputation in diabetic patients with foot ulcer
- 1993
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Ingår i: Foot and Ankle. - 0198-0211. ; 14:5, s. 247-253
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Tidskriftsartikel (refereegranskat)abstract
- The predictive value of distal blood pressure measurements for the level of amputation was studied prospectively in 161 consecutive diabetic patients with foot ulcers. The patients were treated as outpatients except for periods of surgery and when complications requiring hospital care occurred. All patients were treated pre- and postoperatively by the same multidisciplinary foot care team. Either ankle or toe blood pressure measurement was available in 86% of the patients. Incompressible arteries, ulcer or gangrene at the measuring site, previous amputation, poor general condition, and an emergency situation were factors that excluded standardized ankle and toe blood pressure measurements in 24% and 27% of the patients, respectively. An absolute lower ankle pressure level of 50 mm Hg was found, below which a minor amputation was never sufficient to achieve healing. An ankle pressure below 75 mm Hg was seldom sufficient, and at or above that pressure level, the ankle pressure had no predictive value in this respect. At a toe pressure below 15 mm Hg, a minor amputation was seldom sufficient. Ankle and toe pressure indices gave no further information.
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| 28. |
- Lepantalo, M., et al.
(författare)
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Diabetic Foot
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 60-74
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Tidskriftsartikel (refereegranskat)abstract
- Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 29. |
- Pickwell, K., et al.
(författare)
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Minor amputation does not negatively affect health-related quality of life as compared with conservative treatment in patients with a diabetic foot ulcer : An observational study
- 2017
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Ingår i: Diabetes/Metabolism Research and Reviews. - : Wiley. - 1520-7552. ; 33:3
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Tidskriftsartikel (refereegranskat)abstract
- Background: Health-related quality of life (HRQoL) is poor in patients with persistent diabetic foot ulcers and poor HRQoL predicts worse outcomes in these patients. Amputation is often considered a treatment failure, which is why conservative treatment is generally preferred over amputation. However, it is unclear whether minor amputation negatively affects HRQoL compared with conservative treatment in patients with diabetic foot ulcers. Methods: In the cohort of the multicenter, prospective, observational Eurodiale study, we determined difference in change of HRQoL measured by EQ-5D between patients with a diabetic foot ulcers that healed after conservative treatment (n = 676) and after minor amputation (n = 145). Propensity score was used to adjust for known confounders, attempting to overcome lack of randomization. Results: Baseline HRQoL was not significantly different between patients treated conservatively and undergoing minor amputation. In addition, there was no difference in the change of HRQoL between these groups. In patients who healed 6 to 12 months after the first visit, HRQoL on the anxiety/depression subscale even appeared to improve more in those who underwent minor amputation. Conclusions: Minor amputation was not associated with a negative impact on HRQoL in patients with a diabetic foot ulcers. It may therefore not be considered treatment failure in terms of HRQoL but rather a viable treatment option. A randomized controlled trial is warranted to further examine the influence of minor amputations on health-related quality of life.
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| 30. |
- Schaper, Nicolaas C., et al.
(författare)
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Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)
- 2020
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Ingår i: Diabetes/Metabolism Research and Reviews. - : Wiley. - 1520-7552 .- 1520-7560. ; 36:S1
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Tidskriftsartikel (refereegranskat)abstract
- Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.
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| 31. |
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| 32. |
- Setacci, C., et al.
(författare)
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Treatment of Critical Limb Ischaemia
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 43-59
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Tidskriftsartikel (refereegranskat)abstract
- Recommendations stated in the TASC II guidelines for the treatment of peripheral arterial disease (PAD) regard a heterogeneous group of patients ranging from claudicants to critical limb ischaemia (CLI) patients. However, specific considerations apply to CLI patients. An important problem regarding the majority of currently available literature that reports on revascularisation strategies for PAD is that it does not focus on CLI patients specifically and studies them as a minor part of the complete cohort. Besides the lack of data on CLI patients, studies use a variety of endpoints, and even similar endpoints are often differentially defined. These considerations result in the fact that most recommendations in this guideline are not of the highest recommendation grade. In the present chapter the treatment of CLI is not based on the TASC II classification of atherosclerotic lesions, since definitions of atherosclerotic lesions are changing along the fast development of endovascular techniques, and inter-individual differences in interpretation of the TASC classification are problematic. Therefore we propose a classification merely based on vascular area of the atherosclerotic disease and the lesion length, which is less complex and eases the interpretation. Lesions and their treatment are discussed from the aorta downwards to the infrapopliteal region. For a subset of lesions, surgical revascularisation is still the gold standard, such as in extensive aorto-iliac lesions, lesions of the common femoral artery and long lesions of the superficial femoral artery (>15 cm), especially when an applicable venous conduit is present, because of higher patency and limb salvage rates, even though the risk of complications is sometimes higher than for endovascular strategies. It is however more and more accepted that an endovascular first strategy is adapted in most iliac, superficial femoral, and in some infrapopliteal lesions. The newer endovascular techniques, i.e. drug-eluting stents and balloons, show promising results especially in infrapopliteal lesions. However, most of these results should still be confirmed in large RCTs focusing on CLI patients. At some point when there is no possibility of an endovascular nor a surgical procedure, some alternative non-reconstructive options have been proposed such as lumbar sympathectomy and spinal cord stimulation. But their effectiveness is limited especially when assessing the results on objective criteria. The additional value of cell-based therapies has still to be proven from large RCTs and should therefore still be confined to a research setting. Altogether this chapter summarises the best available evidence for the treatment of CLI, which is, from multiple perspectives, completely different from claudication. The latter also stresses the importance of well-designed RCTs focusing on CLI patients reporting standardised endpoints, both clinical as well as procedural. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 33. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study
- 2009
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Ingår i: Diabetologia. - : Springer Science and Business Media LLC. - 1432-0428 .- 0012-186X. ; 52:3, s. 398-407
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Tidskriftsartikel (refereegranskat)abstract
- We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 +/- 15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.
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| 34. |
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| 35. |
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| 36. |
- Apelqvist, Jan, et al.
(författare)
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Long-term prognosis for diabetic patients with foot ulcers
- 1993
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Ingår i: Journal of Internal Medicine. - 1365-2796. ; 233:6, s. 485-491
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. DESIGN. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. SETTING. A multidisciplinary foot-care team. POPULATION. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. MAIN OUTCOME MEASURES. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. RESULTS. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. CONCLUSION. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation.
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| 37. |
- Apelqvist, Jan, et al.
(författare)
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Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds.
- 2008
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Ingår i: The American Journal of Surgery. - : Elsevier BV. - 1879-1883 .- 0002-9610. ; 195, s. 782-788
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: To evaluate resource utilization and direct economic costs of care for patients treated with negative-pressure wound therapy (NPWT), using the Vacuum-Assisted Closure (V.A.C.) system, compared to standard moist wound therapy (MWT). METHODS: A total of 162 diabetic patients with post-amputation wounds (up to the trans-metatarsal level) entered a 16-week, randomized clinical trial. Patients randomized to V.A.C. (n = 77) received therapy with dressing changes every 48 hours. Control patients (n = 85) received standard MWT. Resource utilization, procedures, and direct costs were calculated and analyzed in this post hoc retrospective study. RESULTS: There was no difference between groups for in-patient hospital stay (number of admissions or length of stay). More surgical procedures (including debridement) were required in the MWT group (120 vs 43 NPWT, P <.001). The average number of dressing changes performed per patient was 118.0 (range 12-226) for MWT versus 41 (6-140) for NPWT (P = .0001). The MWT group had 11 (range 0-106) outpatient treatment visits during the study versus 4 (range 0-47) in the NPWT group (P <.05). The average direct cost per patient treated for 8 weeks or longer (independent of clinical outcome) was $27,270 and $36,096 in the NPWT and MWT groups, respectively. The average total cost to achieve healing was $25,954 for patients treated with NPWT (n = 43) compared with $38,806 for the MWT group (n = 33). CONCLUSION: Treatment of diabetic patients with post amputation wounds using NPWT resulted in lower resource utilization and a greater proportion of patients obtaining wound healing at a lower overall cost of care when compared to MWT.
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| 38. |
- Apelqvist, J, et al.
(författare)
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The effect of the non-ionic contrast medium iohexol on glomerular and tubular function in diabetic patients
- 1996
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Ingår i: Diabetic Medicine. - 1464-5491. ; 13:5, s. 487-492
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Tidskriftsartikel (refereegranskat)abstract
- The effect of the non-ionic contrast medium iohexol (Omnipaque) on renal function was investigated in diabetic patients with signs of peripheral ischaemia. Forty-six patients, 70 +/- 11 years (mean +/- SD) old, age at diabetes diagnosis 53 +/- 17 years, and with varying degrees of diabetic nephropathy were studied before 1, 2, and 30 days after aortobifemoral arteriography. Serum creatinine, creatinine clearance, urinary excretion of immunoglobulin G, albumin collagen IV (NC1), kappa and lambda chains, alpha-1 microglobulin and Tamm-Horsfall protein were evaluated. Within 1 month before and 30 days after arteriography, the glomerular filtration rate was measured by clearance of iohexol. The acute effect of the radiocontrast medium was an increase in the serum creatinine level in 41 (89%) patients, with a more than 25% increase in 12 (26%) patients. The excretion rates of immunoglobulin G and albumin decreased, whereas the proximal and distal tubular function and the excretion of collagen IV did not change. The increment in serum creatinine was associated with the preangiographic renal function (p < 0.05), a history of heart failure (p < 0.01), but not with age, duration and type of diabetes, gender, systolic or diastolic blood pressure, glycated haemoglobin (HbAlc) or blood glucose levels. The increase of serum creatinine was associated with a pre-existing proximal tubular dysfunction and a worsening of distal tubular function. No changes in the parameters measured persisted 30 days after angiography. In summary, a transient increment in serum creatinine level after arteriography occurred in 89% of diabetic patients. It was associated with the preangiographic renal function, a history of heart failure and signs of preexisting proximal tubular dysfunction and worsening of distal tubular function. However, these changes were reversible.
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| 39. |
- Apelqvist, Jan, et al.
(författare)
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The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers
- 1990
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Ingår i: Diabetic Medicine. - 1464-5491. ; 7:7, s. 590-594
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Tidskriftsartikel (refereegranskat)abstract
- In a prospective study, peripheral pulses, claudication, peripheral oedema, and rest pain were evaluated in 314 sequentially presenting diabetic patients with foot ulcers. In the ulcerated limb pedal pulses were found to be present in 44% of the patients, peripheral oedema in 38%, and rest pain in 19%. Twelve per cent had claudication. Presence of pedal pulses was more common in patients whose ulcers underwent primary healing (56%) than in those who healed after amputation (23%) or died (25%, p less than 0.001). Eighty per cent of the patients with pedal pulses present underwent primary healing. However, 49% of patients with absence of pedal pulses also underwent primary healing and 12 patients developed gangrene despite presence of pedal pulses. Peripheral oedema was more common in patients who required amputation (58%) or died (55%) than in patients with primary healing (26%, p less than 0.001). A tentative predisposing factor was identified in 95% of the patients, the most common factors being neuropathy, congestive heart failure, and previous deep venous thrombosis. Rest pain was more common in patients who required amputation (48%) or died (23%) than in those with primary healing (7%; p less than 0.001). Only 50% of patients with gangrene had rest pain and of these patients, only one underwent primary healing. The presence of pedal pulses, oedema, and rest pain give valuable but imperfect information on the possible primary healing of foot ulcers in diabetic patients.
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| 40. |
- Apelqvist, Jan, et al.
(författare)
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The ulcerated leg: when to revascularize
- 2012
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 28:Suppl. 1, s. 30-35
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Tidskriftsartikel (refereegranskat)abstract
- The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing. Copyright (C) 2012 John Wiley & Sons, Ltd.
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| 41. |
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| 42. |
- Boulton, A J M, et al.
(författare)
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The global burden of diabetic foot disease
- 2005
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Ingår i: The Lancet. - 1474-547X. ; 366:9498, s. 1719-1724
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Forskningsöversikt (refereegranskat)abstract
- Diabetic foot problems are common throughout the world, resulting in major economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable, in developing countries, which will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years. Costing should therefore include not only the immediate ulcer episode, but also social services, home care, and subsequent ulcer episodes. A broader view of total resource use should include some estimate of quality of life and the final outcome. An integrated care approach with regular screening and education of patients at risk requires low expenditure and has the potential to reduce the cost of health care.
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| 43. |
- Elgzyri, T, et al.
(författare)
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Can duplex arterial ultrasonography reduce unnecessary angiography?
- 2008
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Ingår i: Journal of Wound Care. - : Mark Allen Group. - 0969-0700 .- 2052-2916. ; 17:11, s. 497-500
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To assess the value of arterial duplex ultrasound, which assesses the location and severity of arterial disease, in determining whether invasive vascular intervention is required.METHOD: A total of 166 consecutive diabetic patients presenting at a multidisciplinary foot clinic with severe peripheral vascular disease, with or without a foot ulcer, were included in this prospective study. The choice of vascular intervention was based on the results of a duplex ultrasound examination. Subjects were followed up for two years, and their clinical management, vascular assessments and interventions given, and patient outcomes were recorded in a specially designed protocol.RESULTS: Based on findings of the duplex ultrasound, it was recommended that 55 patients (33%) should undergo angioplasty (percutaneous transluminal angioplasty [PTA] and/or subintimal recanalisation), 64 patients (39%) diagnostic angiography and 47 patients (28%) medical treatment only, thereby avoiding unnecessary angiography and its potential complications. Diagnostic angiography was recommended when the duplex ultrasound results were inconclusive. Fifty-two of the 55 patients recommended angiography with simultaneous angioplasty had an angiography; of these, 42 (81%) then had an angioplasty. Fifty-seven of the 64 patients with inconclusive results had an angiography. Of these, 23 (40%) subsequently had angioplasty, only 10 (18%) had reconstructive surgery and 24 (42%) had a diagnostic angiography only.CONCLUSION: Arterial duplex ultrasound may assist evaluations of the need for and type of invasive vascular intervention in patients with an ischaemic diabetic foot. It can thus help avoid diagnostic angiographies that do not result in vascular intervention. However, such decision-making remains at the discretion of the vascular surgeon and radiologist.
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| 44. |
- Elgzyri, Targ, et al.
(författare)
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Early Revascularization after Admittance to a Diabetic Foot Center Affects the Healing Probability of Ischemic Foot Ulcer in Patients with Diabetes.
- 2014
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 48:4, s. 440-446
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Tidskriftsartikel (refereegranskat)abstract
- There is limited information about whether time from recognition of decreased perfusion to revascularization affects the probability of healing in a patient with a diabetic foot ulcer. The aim of the present study was to examine whether time to revascularization after referral to a multidisciplinary foot center was related to the outcome of foot ulcers in patients with diabetes and severe peripheral arterial disease (PAD).
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| 45. |
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| 46. |
- Eliasson, B, et al.
(författare)
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Debriding effect of amino acid-buffered hypochlorite on hard-to-heal wounds covered by devitalised tissue: pilot study
- 2021
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Ingår i: Journal of wound care. - : Mark Allen Group. - 0969-0700 .- 2052-2916. ; 30:6, s. 455-464
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Tidskriftsartikel (refereegranskat)abstract
- Wounds such as lower extremity ulcers are serious, costly and frequently hard to heal. Guidelines conclude that new dressings and treatments generally fail to show superiority compared with standard of care. Several mechanisms are probably responsible for impaired healing of hard-to-heal wounds, including inflammation and infection. Amino acid-buffered hypochlorite has presumed antiseptic and antibacterial properties and has been shown to be useful in the treatment of diabetic foot ulcers (DFUs). We evaluated the debriding effect of amino acid-buffered hypochlorite (ChloraSolv) on full skin hard-to-heal lower extremity ulcers covered with devitalised tissue (≥50%), with six applications over 5 weeks and follow-up at 12 weeks. Method: This was an open-label, single-arm, multicentre, pre-market pilot investigation. We recruited subjects with a lower extremity ulcer, covered with devitalised tissue (≥50%), who were candidates for cleansing and debridement/desloughing. There was a weekly application of the investigational device for five weeks. Follow-up for wound status evaluation was performed at 12 weeks from baseline. Results: We evaluated 57 subjects (33 males, 24 females, median age 73 years, range 51–90 years) (intention-to-treat). Of these, 61.4% had a leg ulcer and 38.6% a foot ulcer. The median wound size at baseline was 7.7cm2 (range 2.1–52cm2) with devitalised tissue coverage of 76.5%. After 5 weeks, a decrease of 72.7% in devitalised tissue was seen, and 71.4% of the subjects showed a decrease in devitalised tissue of ≥50% (evaluated independently using PictZar). At 12 weeks' follow-up the decrease in devitalised tissue was 84.4%. Wound-related pain was reported by ten subjects, resulting in 17 adverse events (AEs). Among these, 12 AEs from eight subjects were recorded as possibly or probably related to the investigational device and one AE was reported to have a causal relationship with the investigational device. Conclusion: This clinical study suggests that amino acid-buffered hypochlorite can be effective and well tolerated in the treatment of hard-to-heal lower extremity ulcers to dissolve and remove devitalised tissue.
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| 47. |
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| 48. |
- Forsmo, S.P.E., et al.
(författare)
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Binding mechanisms in wet iron ore green pellets with a bentonite binder
- 2006
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Ingår i: Powder Technology. - : Elsevier BV. - 0032-5910 .- 1873-328X. ; 169:3, s. 147-158
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Tidskriftsartikel (refereegranskat)abstract
- Fundamental research during the past decade has been focussed on understanding the role of viscous forces on agglomerate deformability and strength. Much of this work has been done on glass spheres using Newtonian liquids as a binder. In this work, we show the variations in plasticity and strength of magnetite iron ore green pellets with varying liquid saturations and binder dosages (viscosities). For this purpose, a new measuring instrument was built to analyze the green pellet wet compression strength, plastic deformation and breakage pattern. Industrial iron ore green pellets are over-saturated and a supporting "network" of viscous liquid is formed on the green pellet surface. At least half, probably more, of the total binding force appeared to be due to the cohesive force of the network. The other half (or less) of the total compression strength can be explained by the capillary force. Due to irregularities on green pellet surfaces, both fully developed concave pore openings and saturated areas are expected to be found at the same time. Wet green pellets started showing plastic behaviour as they became over-saturated. In over-saturated green pellets, an explosive increase in plasticity with increasing moisture content was seen, due to the contemporary increase in porosity. Plasticity is an important green pellet property in balling and should gain the status of a standard method in green pellet characterization. It is suggested that the control strategy for the balling circuits be based on plastic deformation and compression strength of green pellets instead of the rather inaccurate drop number. The results also point out the importance of knowing whether the balling process should be controlled by adjusting the moisture content (plasticity) or by adjusting the bentonite dosage (viscosity). These two operations are not interchangeable-even if they would compensate in growth rate, the green pellet properties would differ. A new green pellet growth mechanism is suggested, based on the measured over-saturation. Firstly, green pellet plasticity needs to exceed a minimum level to enable growth. This limiting plasticity defines the material-specific moisture content needed in balling. Secondly, it is suggested that the growth rate be controlled by the viscosity of the superficial water layer rather than by the mobility of the pore water.
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| 49. |
- Glaser, J., et al.
(författare)
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Preventing kidney injury among sugarcane workers: Promising evidence from enhanced workplace interventions
- 2020
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Ingår i: Occupational and Environmental Medicine. - : BMJ. - 1351-0711 .- 1470-7926. ; 77:8, s. 527-534
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: To assess if improvement of working conditions related to heat stress was associated with improved kidney health outcomes among sugarcane harvest workers in Chichigalpa, Nicaragua, a region heavily affected by the epidemic of chronic kidney disease of non-traditional origin. Methods: Based on our findings during the 2017-2018 harvest (harvest 1), recommendations that enhanced the rest schedule and improved access to hydration and shade were given before the 2018-2019 harvest (harvest 2). Actual work conditions during harvest 2 were then observed. Serum creatinine (SCr) was measured before and at end-harvest, and cross-harvest changes in estimated glomerular filtration rate (eGFR) and incident kidney injury (IKI, ie, SCr increase by ≥0.30 mg/dL or ≥1.5 times the baseline value) were compared between harvest 1 and harvest 2 for three jobs with different physical workloads using regression modelling. Workers who left during harvest were contacted at home, to address the healthy worker selection effect. Results: In burned cane cutters, mean cross-harvest eGFR decreased 6 mL/min/1.73 m2 (95% CI 2 to 9 mL/min/1.73 m2) less and IKI was 70% (95% CI 90% to 50%) lower in harvest 2 as compared with harvest 1 data. No such improvements were seen among seed cutters groups with less successful intervention implementation. Conclusion: Kidney injury risk was again elevated in workers with strenuous jobs. The results support further efforts to prevent kidney injury among sugarcane workers, and other heat-stressed workers, by improving access to water, rest and shade. The distinction between design and implementation of such interventions should be recognised. © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
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| 50. |
- Gottrup, Finn, et al.
(författare)
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Antimicrobials and Non-Healing Wounds. Evidence, controversies and suggestions-key messages
- 2014
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Ingår i: Journal of Wound Care. - : Mark Allen Group. - 0969-0700 .- 2052-2916. ; 23:10, s. 477-477
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Tidskriftsartikel (refereegranskat)abstract
- This article constitutes an extraction of key messages originally presented in the Document:Antimicrobials and Non-Healing Wounds. Evidence, controversies and suggestions written by the European Wound Management Association (EWMA), and originally published by the Journal of Wound Care in 2013.All sections are shortened and some not included. For further details please refer to in the original document which can be downloaded via www.ewma.org.
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