A decision pathway for the staged management of foot problems in diabetes mellitus.

This review describes a decision pathway for the conservative management of foot problems in persons with diabetes mellitus. The decision pathway was developed by the Louisiana State University Health Sciences Center Diabetes Foot Program as part of the Statewide Diabetes Disease Management Initiative to standardize foot care in a medically underserved population. The pathway describes the prevention and/or management of foot problems through 5 clinical subpathways: injury prevention, warm swollen foot, ulcer, osteomyelitis, and remodeling. The pathway provides physiatrists and other rehabilitation practitioners with a framework to evaluate and manage neuropathic foot problems in a multidisciplinary setting.

Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population.

OBJECTIVE: To compare patient outcomes 1 year before and 1 year after enrollment in a comprehensive diabetes lower-extremity amputation prevention program. RESEARCH DESIGN AND METHODS: Outcome data were obtained on 197 patients enrolled in the Louisiana State University Health Sciences Center Diabetes Foot Program, which provides foot care to a predominantly low-income African-American population in Louisiana. Data were obtained using a structured interview administered by a registered nurse. Recordings were made of number of days with an open foot ulcer, number of times hospitalized for a foot problem, number of days spent in the hospital for a foot problem, number of visits to the emergency room for a foot problem, number of times an antibiotic was prescribed for a foot problem, number of all foot operations, number of lower-extremity amputations, and number of missed workdays for a foot problem. Data were obtained on all patients at the initial visit and at the 1-year follow-up. RESULTS: Analysis of data showed a reduction in foot-related ulcer days (-49%), hospitalizations, (-89%), hospital days (-90%), emergency room visits (-81%), antibiotic prescriptions, (-57%), foot operations (-87%), lower-extremity amputations (-79%), and missed workdays (-70%) after 1 year of comprehensive foot care compared with the 1-year period before treatment. CONCLUSIONS: This single cohort outcome study showed a large reduction in foot-related complications after the first year of comprehensive preventive foot care.

Factors associated with ulceration and amputation in the neuropathic foot.

The purpose of this paper is to review selected literature on the relationship of neuropathy and other related factors in foot ulceration and lower extremity amputation. There is strong evidence that sensory loss and mechanical stress are the primary cause of foot ulceration and common factors in the pathway to lower extremity amputation. Foot stress results from extrinsic factors such as footwear and intrinsic factors such as deformity and limited joint mobility. Understanding the interplay of these factors is valuable in identifying persons whose feet are at risk, effectively preventing and treating foot ulcerations and ultimately preventing lower extremity amputation.

Public health applications of Hansen's disease research and treatment.

Because of the similarities in causative agents of Hansen's disease and tuberculosis, Hansen's disease research is now being used in the identification, treatment, and prevention of tuberculosis. Numerous studies are under way to screen and develop new drugs to combat the threat of multiple drug-resistant tuberculosis. Additional studies focus on factors to reduce the transmission of tuberculosis and on the development of techniques for early diagnosis and identification of drug resistance. Advances in Hansen's disease research and treatment also are being applied to the prevention of ulcers and amputations in diabetics and others without protective sensation in their feet. The Lower Extremity Amputation Prevention Program, developed at the Gillis W. Long Hansen's Disease Center in Carville, LA, is a multidisciplinary approach that includes screening, risk assessment, and the development of a treatment plan with an emphasis on patient involvement. Expected to prevent up to 90 percent of diabetes-related amputations, the program is being implemented in Jackson, MS, in a community-based diabetic foot program and will be replicated throughout the United States.

Healing rates of plantar ulcers in leprosy and diabetes.

Comparison was made of wound healing time in a consecutive series of leprosy and diabetic patients with plantar ulceration. In the leprosy group, 66 of 70 (94%) ulcers healed in a mean time of 42.7 (+/- 36.1) days, and in the diabetic group, 75 of 80 (94%) ulcers healed in a mean time of 39.7 (+/- 32.1) days. Analysis of all healed ulcers using a general linear model found wound depth (p < 0.03), and wound diameter (p < 0.05) significantly related to ulcer healing time. Diagnosis, healing devices (cast, splint and cut-out sandal), age and sex were not significant. In diabetic subjects a regression model including depth, diameter and age explained 36% of the variation in healing time. A meaningful regression model was not found in leprosy patients.

Management of the insensitive foot in diabetes: lessons learned from Hansen's disease.

Diabetes mellitus is the number one cause of lower extremity amputation (LEA) in the United States, accounting for about 60,000 cases per year. While the combination of reduced blood supply and the loss of sensation to the foot in a diabetic are responsible for the high incidence of LEAs, in most cases it is the loss of sensation that is primarily responsible for the initial foot wound and its failure to heal. The authors review the four mechanical causes for foot ulceration and eventual amputation. Based on an understanding of how feet ulcerate, the National Foot Treatment Center in Carville, LA has developed an insensitive foot screening and treatment program for "diabetic" foot ulcers that is more than 90% effective in healing plantar ulcers.