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Edward J Boyko - One of the best experts on this subject based on the ideXlab platform.
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the independent contribution of diabetic Foot Ulcer on lower extremity amputation and mortality risk
Journal of Diabetes and Its Complications, 2014Co-Authors: Edward J Boyko, Matilde Monteirosoares, Daniela Martinsmendes, Manuela Ribeiro, Pedro Barata, Jorge Lima, Raquel SoaresAbstract:Abstract Aims To estimate 3-year risk for diabetic Foot Ulcer (DFU), lower extremity amputation (LEA) and death; determine predictive variables and assess derived models accuracy. Material and Methods Retrospective cohort study including all subjects with diabetes enrolled in our diabetic Foot outpatient clinic from beginning 2002 until middle 2010. Data were collected from clinical records. Results 644 subjects with mean age of 65.1 (±11.2) and diabetes duration of 16.1 (±10.8) years. Cumulative incidence was 26.6% for DFU, 5.8% for LEA and 14.0% for death. In multivariate analysis, physical impairment, peripheral arterial disease complication history, complication count and previous DFU were associated with DFU; complication count, Foot pulses and previous DFU with LEA and age, complication count and previous DFU with death. Predictive models' areas under the ROC curves ranged from 0.80 to 0.83. A simplified model including previous DFU and complication count presented high accuracy. Previous DFU was associated with all outcomes, even when adjusted for complication count, in addition to more complex models. Conclusions DFU seems more than a marker of complication status, having independent impact on LEA and mortality risk. Proposed models may be applicable in healthcare settings to identify patients at higher risk of DFU, LEA and death.
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diabetic Foot Ulcer incidence in relation to plantar pressure magnitude and measurement location
Journal of Diabetes and Its Complications, 2013Co-Authors: William R Ledoux, Jessie H Ahroni, Victoria Cohen, Jane B Shofer, Matthew S Cowley, Edward J BoykoAbstract:Abstract Aims We prospectively examined the relationship between site-specific peak plantar pressure (PPP) and Ulcer risk. Researchers have previously reported associations between diabetic Foot Ulcer and elevated plantar Foot pressure, but the effect of location-specific pressures has not been studied. Methods Diabetic subjects (n = 591) were enrolled from a single VA hospital. Five measurements of in-shoe plantar pressure were collected using F-Scan. Pressures were measured at 8 areas: heel, lateral midFoot, medial midFoot, first metatarsal, second through fourth metatarsal, fifth metatarsal, hallux, and other toes. The relationship between incident plantar Foot Ulcer and PPP or pressure–time integral (PTI) was assessed using Cox regression. Results During follow-up (2.4 years), 47 subjects developed plantar Ulcers (10 heel, 12 metatarsal, 19 hallux, 6 other). Overall mean PPP was higher for Ulcer subjects (219 vs. 194 kPa), but the relationship differed by site (the metatarsals with Ulcers had higher pressure, while the opposite was true for the hallux and heel). A statistical analysis was not performed on the means, but hazard ratios from a Cox survival analysis were nonsignificant for PPP across all sites and when adjusted for location. However, when the metatarsals were considered separately, higher baseline PPP was significantly associated with greater Ulcer risk; at other sites, this relationship was nonsignificant. Hazard ratios for all PTI data were nonsignificant. Conclusions Location must be considered when assessing the relationship between PPP and plantar Ulceration.
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prediction of diabetic Foot Ulcer occurrence using commonly available clinical information the seattle diabetic Foot study
Diabetes Care, 2006Co-Authors: Edward J Boyko, Jessie H Ahroni, Victoria Cohen, Karin M Nelson, Patrick J HeagertyAbstract:OBJECTIVE —The ability of readily available clinical information to predict the occurrence of diabetic Foot Ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic Foot Ulcer occurrence. RESEARCH DESIGN AND METHODS —We followed 1,285 diabetic veterans without Foot Ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify Foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA 1c (A1C); visual acuity; history of laser photocoagulation treatment, Foot Ulcer, and amputation; Foot shape; claudication; Foot insensitivity to the 10-g monofilament; Foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first Foot Ulcer occurrence after the baseline examination. RESULTS —At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 Foot Ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors ( P ≤ 0.05) of Foot Ulcer in the final model (hazard ratio, 95% CI) included A1C (1.10, 1.06–1.15), impaired vision (1.48, 1.00–2.18), prior Foot Ulcer (2.18, 1.61–2.95), prior amputation (2.57, 1.60–4.12), monofilament insensitivity (2.03, 1.50–2.76), tinea pedis (0.73, 0.54–0.98), and onychomycosis (1.58, 1.16–2.16). Area under the receiver operating characteristic curve was 0.81 at 1 year and 0.76 at 5 years. CONCLUSIONS —Readily available clinical information has substantial predictive power for the development of diabetic Foot Ulcer and may help in accurately targeting persons at high risk of this outcome for preventive interventions.
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a prospective study of risk factors for diabetic Foot Ulcer the seattle diabetic Foot study
Diabetes Care, 1999Co-Authors: Edward J Boyko, Jessie H Ahroni, Denise R Davignon, Victoria L Stensel, Ruby C Forsberg, Douglas G SmithAbstract:OBJECTIVE: Little prospective research exists on risk factors for diabetic Foot Ulcer that considers the independent effects of multiple potential etiologic agents. We prospectively studied the effects of diabetes characteristics, Foot deformity, behavioral factors, and neurovascular function on Foot Ulcer risk among 749 diabetic veterans with 1,483 lower limbs. RESEARCH DESIGN AND METHODS: Eligible subjects included all diabetic enrollees of a general internal medicine clinic without Foot Ulcer, of whom 83% agreed to participate. Baseline assessment included history and lower-limb physical examination, tests for sensory and autonomic neuropathy, and measurements of macro- and microvascular perfusion in the Foot. Subjects were followed for the occurrence of a full thickness skin defect on the Foot that took > 14 days to heal, with a mean follow-up of 3.7 years. RESULTS: Using stepwise Cox regression analysis, the following factors were independently related to Foot Ulcer risk: Foot insensitivity to the 5.07 monofilament (relative risk [95% CI]) 2.2 (1.5-3.1), past history of amputation 2.8 (1.8-4.3) or Foot Ulcer 1.6 (1.2-2.3), insulin use 1.6 (1.1-2.2), Charcot deformity 3.5 (1.2-9.9), 15 mmHg higher dorsal Foot transcutaneous PO2 0.8 (0.7-0.9), 20 kg higher body weight 1.2 (1.1-1.4), 0.3 higher ankle-arm index 0.8 (0.7-1.0), poor vision 1.9 (1.4-2.6), and 13 mmHg orthostatic blood pressure fall 1.2 (1.1-1.5). Higher Ulcer risk was associated with hammer/claw toe deformity and history of laser photocoagulation in certain subgroups. Unrelated to Foot Ulcer risk in multivariate models were diabetes duration and type, race, smoking status, diabetes education, joint mobility, hallux blood pressure, and other Foot deformities. CONCLUSIONS: Certain Foot deformities, reduced skin oxygenation and Foot perfusion, poor vision, greater body mass, and both sensory and autonomic neuropathy independently influence Foot Ulcer risk, thereby providing support for a multifactorial etiology for diabetic Foot Ulceration.
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increased mortality associated with diabetic Foot Ulcer
Diabetic Medicine, 1996Co-Authors: Edward J Boyko, Jessie H Ahroni, Douglas G Smith, Denise R DavignonAbstract:: The objective of this study was to evaluate the relationship between Foot Ulceration and short-term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow-up was 691.8 days (+/-SD 339.9, range 28-1436 days). Subjects who died during follow-up (n = 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p = 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed Foot Ulcer (n = 88) compared to those who did not. The risk of death for those with Foot Ulcer was 12.1 per 100 person-years of follow-up compared to 5.1 in those without Foot Ulcer. Cox regression analysis demonstrated a greater than two-fold increased risk of death in Ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle-arm index was significantly related to lower mortality risk, independent of Foot Ulcer occurrence. We conclude that Foot Ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.
Frans Nollet - One of the best experts on this subject based on the ideXlab platform.
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risk factors for plantar Foot Ulcer recurrence in neuropathic diabetic patients
Diabetes Care, 2014Co-Authors: Roelof Waaijman, Mark L J Arts, Mirjam De Haart, Daniel Wever, Anke Verlouw, Frans NolletAbstract:OBJECTIVE Recurrence of plantar Foot Ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for Ulcer recurrence and to establish targets for Ulcer prevention. RESEARCH DESIGN AND METHODS As part of a Footwear trial, 171 neuropathic diabetic patients with a recently healed plantar Foot Ulcer and custom-made Footwear were followed for 18 months or until Ulceration. Demographic data, disease-related parameters, presence of minor lesions, bareFoot and in-shoe plantar peak pressures, Footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar Foot Ulcer recurrence. RESULTS A total of 71 patients had a recurrent Ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98–27.57]), day-to-day variation in stride count (0.93 [0.89–0.99]), and cumulative duration of past Foot Ulcers (1.03 [1.00–1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01–23.96]), in-shoe peak pressure 80% (0.43 [0.20–0.94]), bareFoot peak pressure (1.11 [1.00–1.22]), and day-to-day variation in stride count (0.91 [0.86–0.96]). CONCLUSIONS The presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading Footwear was a strong protector against Ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic Foot screening and Ulcer prevention.
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effect of custom made Footwear on Foot Ulcer recurrence in diabetes a multicenter randomized controlled trial
Diabetes Care, 2013Co-Authors: Roelof Waaijman, Mark L J Arts, Mirjam De Haart, Tessa Buschwestbroek, Jeff G Van Baal, Frans NolletAbstract:OBJECTIVE Custom-made Footwear is the treatment of choice to prevent Foot Ulcer recurrence in diabetes. This Footwear primarily aims to offload plantar regions at high Ulcer risk. However, Ulcer recurrence rates are high. We assessed the effect of offloading-improved custom-made Footwear and the role of Footwear adherence on plantar Foot Ulcer recurrence. RESEARCH DESIGN AND METHODS We randomly assigned 171 neuropathic diabetic patients with a recently healed plantar Foot Ulcer to custom-made Footwear with improved and subsequently preserved offloading (∼20% peak pressure relief by modifying the Footwear) or to usual care (i.e., nonimproved custom-made Footwear). Primary outcome was plantar Foot Ulcer recurrence in 18 months. Secondary outcome was Ulcer recurrence in patients with an objectively measured adherence of ≥80% of steps taken. RESULTS On the basis of intention-to-treat, 33 of 85 patients (38.8%) with improved Footwear and 38 of 86 patients (44.2%) with usual care had a recurrent Ulcer (relative risk −11%, odds ratio 0.80 [95% CI 0.44–1.47], P = 0.48). Ulcer-free survival curves were not significantly different between groups ( P = 0.40). In the 79 patients (46% of total group) with high adherence, 9 of 35 (25.7%) with improved Footwear and 21 of 44 (47.8%) with usual care had a recurrent Ulcer (relative risk −46%, odds ratio 0.38 [0.15–0.99], P = 0.045). CONCLUSIONS Offloading-improved custom-made Footwear does not significantly reduce the incidence of plantar Foot Ulcer recurrence in diabetes compared with custom-made Footwear that does not undergo such improvement, unless it is worn as recommended.
Douglas G Smith - One of the best experts on this subject based on the ideXlab platform.
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incidence of falls risk factors for falls and fall related fractures in individuals with diabetes and a prior Foot Ulcer
Diabetes Care, 2002Co-Authors: Carolyn Wallace, Douglas G Smith, Gayle E Reiber, Joseph Lemaster, Katrina Sullivan, Shane Hayes, Christy VathAbstract:OBJECTIVE —To describe the incidence of falls, risk factors for falls, and the frequency of fall-related fractures in a cohort of individuals with diabetes and a prior Foot Ulcer. RESEARCH DESIGN AND METHODS —A total of 400 individuals with diabetes and a prior Foot Ulcer were recruited from two western Washington State health care organizations and followed prospectively for 2 years. Diabetes, demographic, and health information was collected at baseline, 1 year, and 2 years. Data on falls were collected at baseline, 4 weeks, and every 17 weeks thereafter. Medical records were abstracted to confirm fall-related morbidity. RESULTS —The average age of the study population was 62 years, with 77% male and 23% female. Approximately 32% had fixed Foot deformities, 58% had insensate feet, and 76% had comorbid conditions. Of the participants, 252 (64%) reported at least one fall during the 2-year study period. The overall incidence of falls in this cohort was 1.25 falls/person-year (95% CI 1.17–1.33). For the 164 participants (41%) who reported two or more falls, a BMI ≥30 kg/m 2 , the presence of one or more comorbid conditions, and insensate feet increased the risk. Two or more falls of any type were associated with a higher fracture risk. Although women were not at significantly greater risk for falls than men, their fracture incidence was 3.6 times higher. CONCLUSIONS —Falls are very common in individuals with diabetes and prior Foot Ulcers. A small percentage of falls resulted in fractures. The risk of a fall-related fracture was significantly higher in women than in men. Increased attention to falls and fall prevention is indicated for diabetes care providers.
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a prospective study of risk factors for diabetic Foot Ulcer the seattle diabetic Foot study
Diabetes Care, 1999Co-Authors: Edward J Boyko, Jessie H Ahroni, Denise R Davignon, Victoria L Stensel, Ruby C Forsberg, Douglas G SmithAbstract:OBJECTIVE: Little prospective research exists on risk factors for diabetic Foot Ulcer that considers the independent effects of multiple potential etiologic agents. We prospectively studied the effects of diabetes characteristics, Foot deformity, behavioral factors, and neurovascular function on Foot Ulcer risk among 749 diabetic veterans with 1,483 lower limbs. RESEARCH DESIGN AND METHODS: Eligible subjects included all diabetic enrollees of a general internal medicine clinic without Foot Ulcer, of whom 83% agreed to participate. Baseline assessment included history and lower-limb physical examination, tests for sensory and autonomic neuropathy, and measurements of macro- and microvascular perfusion in the Foot. Subjects were followed for the occurrence of a full thickness skin defect on the Foot that took > 14 days to heal, with a mean follow-up of 3.7 years. RESULTS: Using stepwise Cox regression analysis, the following factors were independently related to Foot Ulcer risk: Foot insensitivity to the 5.07 monofilament (relative risk [95% CI]) 2.2 (1.5-3.1), past history of amputation 2.8 (1.8-4.3) or Foot Ulcer 1.6 (1.2-2.3), insulin use 1.6 (1.1-2.2), Charcot deformity 3.5 (1.2-9.9), 15 mmHg higher dorsal Foot transcutaneous PO2 0.8 (0.7-0.9), 20 kg higher body weight 1.2 (1.1-1.4), 0.3 higher ankle-arm index 0.8 (0.7-1.0), poor vision 1.9 (1.4-2.6), and 13 mmHg orthostatic blood pressure fall 1.2 (1.1-1.5). Higher Ulcer risk was associated with hammer/claw toe deformity and history of laser photocoagulation in certain subgroups. Unrelated to Foot Ulcer risk in multivariate models were diabetes duration and type, race, smoking status, diabetes education, joint mobility, hallux blood pressure, and other Foot deformities. CONCLUSIONS: Certain Foot deformities, reduced skin oxygenation and Foot perfusion, poor vision, greater body mass, and both sensory and autonomic neuropathy independently influence Foot Ulcer risk, thereby providing support for a multifactorial etiology for diabetic Foot Ulceration.
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increased mortality associated with diabetic Foot Ulcer
Diabetic Medicine, 1996Co-Authors: Edward J Boyko, Jessie H Ahroni, Douglas G Smith, Denise R DavignonAbstract:: The objective of this study was to evaluate the relationship between Foot Ulceration and short-term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow-up was 691.8 days (+/-SD 339.9, range 28-1436 days). Subjects who died during follow-up (n = 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p = 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed Foot Ulcer (n = 88) compared to those who did not. The risk of death for those with Foot Ulcer was 12.1 per 100 person-years of follow-up compared to 5.1 in those without Foot Ulcer. Cox regression analysis demonstrated a greater than two-fold increased risk of death in Ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle-arm index was significantly related to lower mortality risk, independent of Foot Ulcer occurrence. We conclude that Foot Ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.
E Chantelau - One of the best experts on this subject based on the ideXlab platform.
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effectiveness of a new brand of stock diabetic shoes to protect against diabetic Foot Ulcer relapse a prospective cohort study
Diabetic Medicine, 2003Co-Authors: K. Busch, E ChantelauAbstract:Aims Diabetic patients with podopathy (diabetic Foot syndrome) may need protective Footwear, be it customized or industrially produced stock ‘diabetic’ shoes (SDS). The effectiveness of each type of ‘diabetic’ shoe needs to be proven clinically, e.g. in terms of prevention of Foot Ulceration. The following study assesses a new German SDS, the LucRo® shoe, which consists of rocker-shaped walking sole, a standardized shock absorption insole, and soft uppers without stiff toe-caps. The LucRo® SDS has been registered as a Medicinal Product according to the European Community Guideline 93/42/EC. Patients and methods A total of 92 high-risk diabetic patients (mean age 63 years, duration of diabetes 13 years) with healed Foot Ulcer were recruited prospectively over 31 months; 87 patients suffered from polyneuropathy, 24 patients had peripheral ischaemic vessel disease. One group of patients (n = 60) received the LucRo® SDS and wore them, while the remaining patients (n = 32) did not receive the SDS and were forced to use their normal Footwear. This allocation reflects the haphazard reimbursement policies of the individual patients’ health insurance, and is in accordance with the current German legislation. The patients were followed up for up to 42 months until the first Foot Ulcer relapse, or the end of the study. Results There were no differences between the groups concerning age, sex, type and duration of diabetes, prevalence of polyneuropathy and peripheral ischaemic vessel disease, frequency of Foot care and mortality rate. The first year annual rate of Foot Ulcer relapse was significantly different between the groups: 60% without SDS vs. 15% with SDS. The overall cumulative Ulcer-free survival was significantly greater with SDS (P < 0.0001, log rank test). Conclusion The LucRo® stock ‘diabetic’ shoe appears effective in the prevention of Foot re-Ulceration in high-risk patients with diabetic podopathy.
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Effectiveness of a new brand of stock 'diabetic' shoes to protect against diabetic Foot Ulcer relapse. A prospective cohort study
Diabetic Medicine, 2003Co-Authors: K. Busch, E ChantelauAbstract:AIMS: Diabetic patients with podopathy (diabetic Foot syndrome) may need protective Footwear, be it customized or industrially produced stock 'diabetic' shoes (SDS). The effectiveness of each type of 'diabetic' shoe needs to be proven clinically, e.g. in terms of prevention of Foot Ulceration. The following study assesses a new German SDS, the LucRo shoe, which consists of rocker-shaped walking sole, a standardized shock absorption insole, and soft uppers without stiff toe-caps. The LucRo SDS has been registered as a Medicinal Product according to the European Community Guideline 93/42/EC. PATIENTS AND METHODS: A total of 92 high-risk diabetic patients (mean age 63 years, duration of diabetes 13 years) with healed Foot Ulcer were recruited prospectively over 31 months; 87 patients suffered from polyneuropathy, 24 patients had peripheral ischaemic vessel disease. One group of patients (n = 60) received the LucRo SDS and wore them, while the remaining patients (n = 32) did not receive the SDS and were forced to use their normal Footwear. This allocation reflects the haphazard reimbursement policies of the individual patients' health insurance, and is in accordance with the current German legislation. The patients were followed up for up to 42 months until the first Foot Ulcer relapse, or the end of the study. RESULTS: There were no differences between the groups concerning age, sex, type and duration of diabetes, prevalence of polyneuropathy and peripheral ischaemic vessel disease, frequency of Foot care and mortality rate. The first year annual rate of Foot Ulcer relapse was significantly different between the groups: 60% without SDS vs. 15% with SDS. The overall cumulative Ulcer-free survival was significantly greater with SDS (P < 0.0001, log rank test). CONCLUSION: The LucRo stock 'diabetic' shoe appears effective in the prevention of Foot re-Ulceration in high-risk patients with diabetic podopathy.
Jessie H Ahroni - One of the best experts on this subject based on the ideXlab platform.
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diabetic Foot Ulcer incidence in relation to plantar pressure magnitude and measurement location
Journal of Diabetes and Its Complications, 2013Co-Authors: William R Ledoux, Jessie H Ahroni, Victoria Cohen, Jane B Shofer, Matthew S Cowley, Edward J BoykoAbstract:Abstract Aims We prospectively examined the relationship between site-specific peak plantar pressure (PPP) and Ulcer risk. Researchers have previously reported associations between diabetic Foot Ulcer and elevated plantar Foot pressure, but the effect of location-specific pressures has not been studied. Methods Diabetic subjects (n = 591) were enrolled from a single VA hospital. Five measurements of in-shoe plantar pressure were collected using F-Scan. Pressures were measured at 8 areas: heel, lateral midFoot, medial midFoot, first metatarsal, second through fourth metatarsal, fifth metatarsal, hallux, and other toes. The relationship between incident plantar Foot Ulcer and PPP or pressure–time integral (PTI) was assessed using Cox regression. Results During follow-up (2.4 years), 47 subjects developed plantar Ulcers (10 heel, 12 metatarsal, 19 hallux, 6 other). Overall mean PPP was higher for Ulcer subjects (219 vs. 194 kPa), but the relationship differed by site (the metatarsals with Ulcers had higher pressure, while the opposite was true for the hallux and heel). A statistical analysis was not performed on the means, but hazard ratios from a Cox survival analysis were nonsignificant for PPP across all sites and when adjusted for location. However, when the metatarsals were considered separately, higher baseline PPP was significantly associated with greater Ulcer risk; at other sites, this relationship was nonsignificant. Hazard ratios for all PTI data were nonsignificant. Conclusions Location must be considered when assessing the relationship between PPP and plantar Ulceration.
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prediction of diabetic Foot Ulcer occurrence using commonly available clinical information the seattle diabetic Foot study
Diabetes Care, 2006Co-Authors: Edward J Boyko, Jessie H Ahroni, Victoria Cohen, Karin M Nelson, Patrick J HeagertyAbstract:OBJECTIVE —The ability of readily available clinical information to predict the occurrence of diabetic Foot Ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic Foot Ulcer occurrence. RESEARCH DESIGN AND METHODS —We followed 1,285 diabetic veterans without Foot Ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify Foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA 1c (A1C); visual acuity; history of laser photocoagulation treatment, Foot Ulcer, and amputation; Foot shape; claudication; Foot insensitivity to the 10-g monofilament; Foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first Foot Ulcer occurrence after the baseline examination. RESULTS —At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 Foot Ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors ( P ≤ 0.05) of Foot Ulcer in the final model (hazard ratio, 95% CI) included A1C (1.10, 1.06–1.15), impaired vision (1.48, 1.00–2.18), prior Foot Ulcer (2.18, 1.61–2.95), prior amputation (2.57, 1.60–4.12), monofilament insensitivity (2.03, 1.50–2.76), tinea pedis (0.73, 0.54–0.98), and onychomycosis (1.58, 1.16–2.16). Area under the receiver operating characteristic curve was 0.81 at 1 year and 0.76 at 5 years. CONCLUSIONS —Readily available clinical information has substantial predictive power for the development of diabetic Foot Ulcer and may help in accurately targeting persons at high risk of this outcome for preventive interventions.
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a prospective study of risk factors for diabetic Foot Ulcer the seattle diabetic Foot study
Diabetes Care, 1999Co-Authors: Edward J Boyko, Jessie H Ahroni, Denise R Davignon, Victoria L Stensel, Ruby C Forsberg, Douglas G SmithAbstract:OBJECTIVE: Little prospective research exists on risk factors for diabetic Foot Ulcer that considers the independent effects of multiple potential etiologic agents. We prospectively studied the effects of diabetes characteristics, Foot deformity, behavioral factors, and neurovascular function on Foot Ulcer risk among 749 diabetic veterans with 1,483 lower limbs. RESEARCH DESIGN AND METHODS: Eligible subjects included all diabetic enrollees of a general internal medicine clinic without Foot Ulcer, of whom 83% agreed to participate. Baseline assessment included history and lower-limb physical examination, tests for sensory and autonomic neuropathy, and measurements of macro- and microvascular perfusion in the Foot. Subjects were followed for the occurrence of a full thickness skin defect on the Foot that took > 14 days to heal, with a mean follow-up of 3.7 years. RESULTS: Using stepwise Cox regression analysis, the following factors were independently related to Foot Ulcer risk: Foot insensitivity to the 5.07 monofilament (relative risk [95% CI]) 2.2 (1.5-3.1), past history of amputation 2.8 (1.8-4.3) or Foot Ulcer 1.6 (1.2-2.3), insulin use 1.6 (1.1-2.2), Charcot deformity 3.5 (1.2-9.9), 15 mmHg higher dorsal Foot transcutaneous PO2 0.8 (0.7-0.9), 20 kg higher body weight 1.2 (1.1-1.4), 0.3 higher ankle-arm index 0.8 (0.7-1.0), poor vision 1.9 (1.4-2.6), and 13 mmHg orthostatic blood pressure fall 1.2 (1.1-1.5). Higher Ulcer risk was associated with hammer/claw toe deformity and history of laser photocoagulation in certain subgroups. Unrelated to Foot Ulcer risk in multivariate models were diabetes duration and type, race, smoking status, diabetes education, joint mobility, hallux blood pressure, and other Foot deformities. CONCLUSIONS: Certain Foot deformities, reduced skin oxygenation and Foot perfusion, poor vision, greater body mass, and both sensory and autonomic neuropathy independently influence Foot Ulcer risk, thereby providing support for a multifactorial etiology for diabetic Foot Ulceration.
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increased mortality associated with diabetic Foot Ulcer
Diabetic Medicine, 1996Co-Authors: Edward J Boyko, Jessie H Ahroni, Douglas G Smith, Denise R DavignonAbstract:: The objective of this study was to evaluate the relationship between Foot Ulceration and short-term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow-up was 691.8 days (+/-SD 339.9, range 28-1436 days). Subjects who died during follow-up (n = 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p = 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed Foot Ulcer (n = 88) compared to those who did not. The risk of death for those with Foot Ulcer was 12.1 per 100 person-years of follow-up compared to 5.1 in those without Foot Ulcer. Cox regression analysis demonstrated a greater than two-fold increased risk of death in Ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle-arm index was significantly related to lower mortality risk, independent of Foot Ulcer occurrence. We conclude that Foot Ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.