The Diabetic Foot: New Challenges in Management and Care| Stephy Publishers

 


SOJ Cardiology and Current Trends in Surgery - (SOJCCTS)| Stephy Publishers

Mini Review

Diabetic foot ulcers (DFUs) remain difficult to heal and notoriouslytend to relapse, approximately 40% at 1 year and 65% at 5years.1 In this context, progress is needed in 6 areas:

Improved early diagnosis of neuropathy

Early diagnosis of diabetic polyneuropathy (DPN) is importantfor several reasons.1,2 First, careful and regular medical follow-upshould be offered to avoid neuropathic DFUs.1,2 Secondly, optimisedglycaemic control and correction of other vascular risk factors (e.g.hypertension, dyslipidaemia etc) should be diligently pursued.1,2Finally, daily foot hygiene and appropriate footwear are indispensable.1 A number of practical bedside clinical tools contribute toimproved early diagnosis, such as the indicator test Neuropad assessingsweat production in the feet, Vibra Tip, the portable NC-statDPN Check device and others.2 Neuropad has been extensively studiedand confirmed as an excellent, highly reproducible and practicalscreening tool with very high sensitivity and negative predictivevalue for DPN, which renders itself even for patient self-examination.2 Vibra Tip is a pocket-sized portable device which measuresvibration perception at the hallux, whose diagnostic utility has recentlybeen confirmed.3 NC-stat DPN Check is a special device forautomated nerve conduction study of the sural nerve, which maybe used by all health care professional after minimal training.2 Wehave shown that it yields very high diagnostic performance (sensitivity,specificity, positive and negative predictive value) in bothdiabetes types.4,5

Improved early identification of patients at high risk

Dryness of foot skin, as assessed by the indicator test Neuropad,has very recently been identified as an independent predictorof foot ulceration at 5 years.6 To this important purpose, the testyielded high sensitivity (86%) but low specificity (49%).6 Widerutilisation of this new screening tool is expected and should be encouraged.

Improved detection and appreciation of Ischaemia

Peripheral arterial disease (PAD) is common and may be formidablein diabetes mellitus7. Ankle brachial index (ABI) is widely employed,yet it may not detect distal but clinically relevant ischaemia.The latter, as demonstrated in a recent study, may more reliably beidentified by the toe brachial index (TBI) in subjects with DFUs.7Using arterial waveforms as a reference method, TBI had a higherAUC (area under the curve of the receiver operating characteristiccurve) than ABI, suggesting that it can detect PAD even if ABIis normal.7 These findings may prove useful and lead to change ofdiagnostic work-up and guidelines.

Improved organisation of diabetic foot clinics

Modern diabetic foot clinics need to be re-organised to copewith the increasing burden of DFUs.8 Expert multidisciplinary careneeds to be offered more quickly, especially in complex situationsor multi-morbid patients.8 Timely debridement and administrationof broad spectrum antibiotics, as well as urgent correction of ischaemiawhen needed, are of paramount importance in this endeavour.9,10 Limb-threatening Ischaemia and extensive infection withgangrene represent real emergencies, for which care should be offeredas quickly as for stroke or myocardial infarction.10 This holdsespecially true for subjects with end-stage renal disease, in whomfoot outcomes are, generally, more sinister.11

Improved use of new/adjunctive modalities

New therapeutic modalities are still being sought. Among these,hyperbaric oxygen therapy (both systemic and, more recently, local) may improve wound healing in selected subjects with ischaemia.12–14 Improving nutrition is also thought to promote healingof DFUs.15 A well-balanced diet and healthy food habits under dieteticconsultation contribute to improve healing.15

Another issue relates to chronic administration route for antibiotics.Intravenous use is less practical and may require prolongedhospitalisation, increasing health costs. A recent trial has shownthat switch to oral antibiotics after a brief initial intravenous therapyis equally efficacious as long-term intravenous administration.16

In terms of wound care, several materials are considered asdressings for DFUs. One of these is sucrose octasulfate dressing.17This has been shown safe and superior to standard wound care inhealing of neuroischaemic DFUs at 20 weeks.17

A more recent approach is the use of adipose-derived mesenchymalcells (AMSCs) to enhance angiogenesis in subjects withdiabetes and PAD.18 Experimental evidence suggests that AMSCsenhance wound healing, accelerate granulation tissue formationand increase re-epithelialisation and neovascularisation. However,clinical trials are needed before its efficacy can be fully delineated.


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