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New research indicates that kids with Type 2 diabetes are at a higher risk of developing kidney and heart disease as adults. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) has sponsored the nationwide research to find the best ways to treat the disease. Jane Lynch, MD, professor of pediatric endocrinology in the School of Medicine at The University of Texas Health Science Center at San Antonio, led the investigation, which followed 699 children and young people for two to six years.
Scientists observed that more than a third of the study subjects required medication for hypertension or kidney disease about four years after they had joined the study. Diabetes is a chronic disease which will be well controlled by maintaining a balanced diabetic diet. Moreover, intake of fibre made fruits helps in maintaining cholesterol level that in turn normalizes the metabolic rate of the body. Fruits like cherry, papaya and pineapple are equipped with a moderate level of sugar concentration.
Making awareness about disease and favourable fruits helps to a nice extend in controlling diabetes.
Diabetics are advised to consume 1 tsp of this jamun seed powder in empty stomach early morning.
The statements on this web site have not been evaluated by the Food and Drug Administration. Researchers from China and the US (Pre-Clinical College, Nanjing University of Chinese Medicine, China, and the Departments of Surgery, of Obstetrics and Gynecology and of Internal Medicine, at the James H. This research, published in Experimental and Therapeutic Medicine shows positive effects for an aqueous extract of Heal-All in the treatment of diabetes.
Science, Technology and Medicine open access publisher.Publish, read and share novel research. Diabetic Foot Ulcers — Treatment and PreventionJarrod Shapiro1, Diane Koshimune1 and Rebecca Moellmer1[1] Western University of Health Sciences, College of Podiatric Medicine, Pomona, California, USA1. Even doctors like me don’t always look forward to our routine physicals, but they are truly one of the best ways to safeguard our health. Since the doctor has many routine questions he or she must ask, come prepared so you can speed through questions that aren’t as relevant to you and spend more time on your specific concerns. Bring an up-to-date list of your medications, including their names, doses, how often you take them, and what time you take them. The doctor will begin with a medical history, which includes questions about any present concerns, past medical history, medications, family health history, questions about your life at home and work and sexual health.
Doctors are trained to ask a variety of questions that may feel very personal, because they are often relevant to your overall health.
These are very routine questions that doctors generally ask all their patients, so do not feel that you are being singled out.
The length of routine physicals varies widely based on your specific health, whether your doctor knows you well, what tests or procedures are necessary and your doctor’s personal style.
How often you need a full physical depends on your health and what your doctor recommends – always ask your doctor when you should schedule your next physical. Is it relevant for an employer physical questionnaire to ask if your family members are currently in good health?
Our biology has been shaped by evolution to enable us to stay fit and active all our lives. Here is the best site I have found so far that talks in depth about the ideal diet and the science behind it all.
This chart shows the shift in the nature of disability in America since the early 1960’s. As the job world shrinks, millions are left out of society and so we see the disability grow. Just as we are starting to learn about why real food is more than simple nutrition – so we are starting to see breast milk as being more than a meal too.
But even as grown-ups, we have never known exactly what’s in that milk—or, as strange as it may sound, what the point of it is.
But first, a disclaimer—because conversations about lactation always seem to require disclaimers, especially if you happen to be someone who will never ever lactate. Here’s how complicated: Some human milk oligosaccharides—simple sugar carbohydrates—were recently discovered to be indigestible by infants. We think of milk as a static commodity, maybe because the milk we buy in the grocery store always looks the same. For example, she notes, in humans skin-to-skin contact appears to trigger signals that are sent through the milk.
The new awareness of this sort of signaling is why there’s been a paradigm shift in the study of milk. Almost 150 years after the first infant formula, the splendidly named Liebig’s Soluble Food for Babies, was proclaimed to be “virtually identical” to human milk, we now know how much we don’t know about milk. Nicholas Day’s book on the science and history of infancy, Baby Meets World, will be published in April. It has been known for more than 30 years that children who continue at least partial breast feedings until age 3 have lower incidences of most all infectious diseases as well as asthma, allergies, and eczema. This is why you cannot afford to use the health system – EVEN if it did make you well. We are close now to a strong agreement that the epidemic of chronic illness is diet related and that sugar and fructose is at the heart of it.
This chart showing sugar consumption is I think the smoking gun for looking at the role of sugar and now fructose in the epidemic of chronic illness. Sugar consumption continued to increase in the 1900s, with an overall doubling in the United States and the United Kingdom between 1900 and 1967 (34). There are some striking epidemiologic associations between sugar intake and the epidemic of cardiorenal disease. The researchers concluded that erectile dysfunction does not cause heart disease but may be an early indicator of the problems that lead to it, such as a build-up of plaque in the arteries. As Europeans moved from hunting and gathering to farming and agriculture, these oral communities changed from healthy, diverse ones into those that we’d typically associate with disease. Our mouths are now a gentrified shadow of their former selves. And as Carl Zimmer described earlier this week, ecosystems with an impoverished web of species are more vulnerable to parasites. Avoiding a serious case of influenza is not about vaccination but more about maintaining a healthy, well functioning immune system.
Optimize Your Gut Flora. This may be the single most important strategy you can implement as the bacteria in your gut have enormous control of your immune response. Ideally, you’ll want to get all your vitamin D from sun exposure or a safe tanning bed, but as a last resort you can take an oral vitamin D3 supplement. Avoid Sugar and Processed Foods. Sugar impairs the quality of your immune response almost immediately, and as you likely know, a healthy immune system is one of the most important keys to fighting off viruses and other illness. Have Effective Tools to Address Stress. We all face some stress every day, but if stress becomes overwhelming then your body will be less able to fight off the flu and other illness. Get Regular Exercise. When you exercise, you increase your circulation and your blood flow throughout your body.
Take a High-Quality Source of Animal-Based Omega-3 Fats. Increase your intake of healthy and essential fats like the omega-3 found in krill oil, which is crucial for maintaining health. Wash Your Hands. Washing your hands will decrease your likelihood of spreading a virus to your nose, mouth or other people. Tried and True Hygiene Measures. In addition to washing your hands regularly, cover your mouth and nose when you cough or sneeze.
Fungal diseases are caused by fungi, which are found in the environment, such as on plants, and in water, air, and soil. Either topical or systemic antifungals may be prescribed depending on the type and location of fungal infection. Since sometimes fungal infections can lead to complications that are life-threatening, it is always advisable to consult a doctor for your fungal infection, especially if it is systemic and severe. Depending on the infection, you may need to apply 105-100% solution to the skin twice daily for one to few months. The extract of the bark of Cinnamomum cassia contains cinnamaldehyde, which has antibacterial and antifungal properties. The program, called Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY), recently reported that children who develop type 2 diabetes are at high risk to develop heart, kidney and eye problems faster and at a higher rate than people who acquire type 2 diabetes as adults. Ranging in age from 10 to 17, participants in the TODAY study were overweight or obese and were diagnosed as having type 2 diabetes within two years of their enrollment, which was between 2004 and 2009.
It is healthier to prefer fresh fruits different than dry fruits for most utilization of food intake.
Grape fruit returning underneath citrus fruit family is yet another favourable fruit serving to for maintaining controlled blood glucose level. Products and information provided on this site are not intended to diagnose, treat, cure or prevent any disease. Quillen College of Medicine, East Tennessee State University, Tennessee) have looked at the medicinal effects of a herb that has been widely used for centuries in the treatment of fevers, diarrhoea, sore mouth and throat, internal bleeding, and weaknesses of the liver and heart. DFU with ischemic appearance demonstrating a yellow, fibrotic base and lack of healthy red granulation tissue. Diabetic neuropathic plantar foot ulceration underlying tibial sesamoid bone with involved hallux valgus deformity.
Acute Charcot ankle (6 weeks old) in a patient with peripheral arterial disease after sustaining a nondisplaced fibular fracture initially treated with cast immobilization. Use my personal tips to be proactive about your health and get the most out of your next visit.
Primary care professionals, including general internal medicine physicians, pediatricians and family physicians, as well as some nurse practitioners and physician assistants provide the vast majority of routine physicals.
Ask if your doctor’s office accepts your insurance and be clear on how much you will need to pay personally for the visit. Order them from most to least important – even if you don’t have time to get to them all, the most important ones will be addressed and you can schedule a follow-up for the remaining issues. Your doctor will want to know if your parents, siblings and children are still living and if they have any health problems (especially heart disease, high blood pressure, high cholesterol or cancer).
They may also conduct what is called a review of systems, when they list many specific symptoms to see if you have recently had any of them. Do not be surprised if your doctor asks you about your smoking history, alcohol use or drug use.
If you feel uncomfortable with a question, tell your doctor and he or she may be able to explain why they are asking and reassure you that you do not need to say anything you are not comfortable sharing. Will I be getting progressively more frail or will I be healthy, active and a contributor until my end? We can prevent the modern illnesses such as heart disease, cancer, strokes, type 2 diabetes and dementia. Raising human children to full adulthood is such a lengthy process that we have to be like this. It shows itself in a physical way, but its roots are in stress that comes from not having enough control. It also sets the baby’s immune system and gut flora and may do many other things too. For decades, milk was thought of strictly in terms of nutrients, which makes sense—milk is how a mother feeds her baby, after all. Scientists have gone from seeing it only as food to seeing it far more expansively—as a highly sensitive variable that plays a wide range of developmental roles.
Instead of comparing breast milk and formula, we should accept how little we actually know about breast milk. As we say, optimal digestive health is the foundation upon which total body health is built. Since that is not likely to happen with the Western lifestyle, starting an infant on probiotics, fish oil, and vitamin D may help prevent this microbial shift, but I still think food and stress are primary shifters of the microbiome. It goes into depth on the process by which sugar and then fructose affects us and some people more than others.
In addition, recent studies showing that a low-carbohydrate, high-fat diet has no adverse cardiovascular effects (40, 41) suggest that it is time to revisit the causes of the cardiorenal disease epidemic. For example, obesity was initially seen primarily in the wealthy, who would have been the only ones able to afford sugar.
The world’s largest study to examine links between erectile dysfunction and heart disease found even minor erection difficulties in healthy fit men, can be an indicator of future heart risks. They’re just some of the trillions of microbes that share our body, and that are as much a part of us as our own flesh and blood. The advent of processed flour and sugar during the Industrial Revolution made things even worse. By following these simple guidelines, you can help keep your immune system in optimal working order so that you’re far less likely to acquire the infection to begin with or, if you do get sick with the flu, you are better prepared to move through it without complications and soon return to good health.
The best way to improve your beneficial bacteria ratio is avoid sugars as they will feed the pathogenic bacteria.
Be sure to check out my article Guide to a Good Night’s Sleep for some great tips to help you get quality rest.
If you feel that stress is taking a toll on your health, consider using an energy psychology tool such as the Emotional Freedom Technique, which is remarkably effective in relieving stress associated with all kinds of events, from work to family to trauma.
The components of your immune system are also better circulated, which means your immune system has a better chance of finding an illness before it spreads. It is also vitally important to avoid damaged omega-6 oils that are trans fats and in processed foods as it will seriously damage your immune response. Be sure you don’t use antibacterial soap for this – antibacterial soaps are completely unnecessary, and they cause far more harm than good.
If possible, avoid close contact with those, who are sick and, if you are sick, avoid close contact with those who are well. The best place to get plenty of rest and recover from illness that is not life-threatening is usually in the comfort of your own home. Some also live on skin, mucous membranes, and our intestinal tract.You are at greater risk for a fungal infection if you are taking antibiotics or your immune system is weak. Others susceptible to these infections are the very young and the very old people and those with diabetes.Symptoms depend on the type and location of fungal infection.
It might be better to use the following herbal remedies as adjunctive therapy to any antifungal medications that you may be taking. It is best avoided by people with heart disease, hypertension, liver or kidney disease, and pregnant and breastfeeding women. It is effective against thrush, candidiasis, and skin and nail fungal infections because it contains the antifungal chemical called juglone.
The extracts of flowers and seeds of Echinacea angustifolia contain several chemicals that help in fighting fungal infection by boosting the immune system. Nutritionists prefer core portion or inner portion of jambul fruits for controlling diabetes. Note the characteristic red, granular base and hyperkeratotic rim under an area of increased pressure as well as the contralateral foot with prior amputation of the 3rd, 4th, and 5th rays.

Complicated diabetic wound after guillotine-type trans-metatarsal amputation treated with split thickness skin graft. Globally, diabetes mellitus has grown to pandemic proportions, affecting 194 million people worldwide and is expected to increase in prevalence to 344 million by the year 2030 [1].
Internal medicine physicians primarily treat adults, pediatricians only treat children and family medicine doctors treat people of all ages. Ask what services your doctor can provide – some general practitioners can also provide pelvic exams and Pap smears, potentially saving you an extra doctor’s visit. Be open and honest with your questions – there is no question too embarrassing to bring up.
To help you remember all of the specifics, keep a document of your family’s medical issues up to date and bring it with you to the appointment. Expect a head to toe physical exam, which may or may not include a pelvic and breast exam or a rectal exam, depending on your gender, age and whether you have another provider who performs those for you. A routine sexual history should be taken at every physical, and may include questions about whether you are sexually active, numbers of sexual partners, sexual orientation, exposure to sexually transmitted diseases and birth control and safe sex practices. Your doctor will always keep what you tell him or her confidential, unless you give permission for him or her to share information with others or if he or she believes you may harm yourself or someone else. I se a trend where many are now taking making a living into their own hands and are starting a life as networked artisans. Hundreds of years before halfway-decent formula, infants were fed gruesome substitutes for breast milk (mushed bread and beer, say)—and although many more died than those who were nursed, many also survived.
And the scientists who study it are a lot like almost any parent gazing down at their sucking child: They too are full of wonder. Whereas sugar intake continues to be marked in the industrialized nations, it is in the developing countries that the greatest increase in the rates of sugar consumption has been observed (35 ). In 2002, Havel’s group (37) made the case that the fructose content of sugar may be the critical component associated with the risks of obesity and heart disease. Also, the first documentation of hypertension, diabetes, and obesity occurred in the very countries (England, France, and Germany) where sugar first became available to the public. If you eat a narrow highly processed food diet, it will be a bad one. We eat food that promotes bad bacteria and we use chemicals that kill any good bacteria. The narrow range of microbes in industrialised gobs are more vulnerable to invasions by species that cause disease, cavities, and other dental problems.  “As an ecosystem, it has lost resilience,” says Cooper. The future of Health Care will be not a fix after we are ill but taking care so that we have the best immune system possible.
Additionally, processed foods and most grains should be limited and replacing with healthy fats like coconut oil, avocados, olives, olive oil, butter, eggs and nuts.
Be sure to take vitamin K2 if you are taking high dose oral vitamin D as it has a powerful synergy and will help prevent any D toxicity. Be aware that sugar (typically in the form of high fructose corn syrup) is present in foods you may not suspect, like ketchup and fruit juice.
When strong antibiotics are taken for a long time, they can disturb the delicate balance of the microorganisms within the body, resulting in fungal overgrowth. It can be used to treat candidiasis, thrush, ringworm, athlete’s foot, fungal nail infections, and jock itch. Always keep checking blood glucose level after food with the help of continuous blood glucose monitoring. Clinical presentation and initial evaluationAs in all medical conditions the initial evaluation of a patient with a diabetic foot ulcer begins with a detailed history. Ask if you will need routine blood work so you know if you should fast or hold off on taking certain medications before coming. Your doctor may also ask you questions about whether you feel safe at home or in a current relationship, or whether you have ever been physically or emotionally abused. My wife was, in a sense, nursing another species altogether, a species that had been evolutionarily selected to protect her child. All who are in health care should too – for  we have to acknowledge that, until now, we must have been wrong. By the early 1970s, an additional sweetener, high-fructose corn syrup (HFCS), was introduced in the United States, which had certain advantages over table sugar with relation to shelf life and cost. Sucrose is a disaccharide consisting of 50% fructose and 50% glucose, and HFCS is also a mixture of free fructose and glucose of approximately the same proportion (55:45).
The rise in sugar intake in the United Kingdom and the United States (Figure 1?) also correlates with the rise in obesity rates observed in these countries. Once you change your diet than regular use of fermented foods can radically optimize the function of your immune response. If you are healthy then sugar can be consumed but the LAST thing you should be eating when you are sick is sugar.
However, it would be wise to radically reduce the intensity of your workouts while you are sick.
Others may be severe, such as bloodstream infection or fungal pneumonia, leading to complications like meningitis and even death. Fruits like cherries are blessed with a wealthy concentration of anthocyanin promoting low blood sugar level.
The onset of a DFU often precipitates a complex chain of events that may lead to limb loss. The doctor may also order blood work or vaccines based on what is recommended for your age, gender and specific health history. Is it that she also has a low-grade infection that she’s just not symptomatic for and so her body’s doing that?
This sweetener, the composition of which is similar to that of sucrose, is used extensively to sweeten soft drinks, fruit punches, pastries, and processed foods. Furthermore, the later introduction of sugar to developing countries also correlates with the later rise in their rates of obesity and heart disease. Some of those in the mouth are involved in repairing damage to teeth and barring the way to more dangerous germs. In several ayurvedic treatments, jamun seed powder mixed with water is given to diabetic patients in specific intervals of time.
Make sure to buy fruits with low sugar concentration thus as to regulate blood sugar level.
The long-term outcome for a diabetic patient after a major limb amputation is grave, with 50% of these patients deceased at 5 years [3]. On physical examination one may appreciate the classic appearance of the diabetic plantar foot ulcer (Figure 1). The difficulty with diabetic patients is their lack of systemic response due to immunopathy, where leukocytosis may be absent.
The combination of table sugar and HFCS has resulted in an additional 30% increase in overall sweetener intake over the past 40 y, mostly in soft drinks. A series of epidemiologic studies linked the ingestion of soft drinks to obesity, hypertension, and diabetes (42, 43) and the consumption of fruit juice and fruit punch to obesity in children (44, 45). Jamun seed is a made supply of vitamins, calcium and potassium and its seed powder boosts the performance of pancreas. In the United States public discussion and much research money goes to the investigation and treatment of breast and prostate cancers.
This is most commonly a partial or full thickness wound underlying a bony prominence or area of deformity.
However, in a subset of patients elevation of white blood cells (WBC) may be found at initial presentation.
Although these epidemiologic associations suggest a potential causal role, are there any direct experimental data to show that sucrose or fructose can induce obesity or hypertension?
As per the studies created on diabetic patients, health practitioners like as well as additional amount of fibre made fruits in their diet. However, when the 5 year mortality percentages are analyzed, a diabetic neuropathic ulcer has a worse survival rate than each of these cancers. When chronic low grade elevated plantar pressures are present the skin forms reactive hypertrophic tissue, indicated by hyperkeratotic callus, the tell-tale sign of the neuropathic ulcer.
Recent studies have shown that C-reactive protein (CRP) is the most sensitive and specific lab test to distinguish between grade 2 and grade 1 ulcers [71].Plain radiographs can provide useful information in the presence of a diabetic foot ulcer when there is suspected soft tissue emphysema.
These fruits with low sugar concentration helps in controlling blood sugar level to a maximum extend. The wound should be examined for size, undermining (in which the edges of the wound overlap the base), general appearance, and the probe to bone test should be performed. Advanced imaging techniques such as magnetic resonance imaging (MRI) can provide information regarding the extent of tissue and bone involvement [58, 61, 63, 69]. In fact having a neuropathic ulcer or prior amputation has the same poor survival rate as colon cancer [4]. Note the characteristic red, granular base and hyperkeratotic rim under an area of increased pressure as well as the contralateral foot with prior amputation of the 3rd, 4th, and 5th rays.During this test the examiner uses a sterile metal probe (often the blunt end of a cotton swab is used) to gently but firmly push into the base of the wound. TreatmentThe consensus from multiple studies and practice guidelines is to utilize a multi-disciplinary approach, including providers from primary care, endocrinology (diabetologist), podiatry, vascular surgery, plastic surgery, infectious disease, microbiology, wound specialty nursing, physical therapy, orthotist and prosthetists [43, 58, 59, 61, 63, 69, 72, 73]. It is unknown if the lower extremity complications themselves lead to greater mortality, but it may be assumed that complications such as a foot ulcer are indicators of more significant diabetic disease with its well-known increased risk of cardiovascular complications.This chapter will focus on key concepts related to prevention and treatment of diabetic foot ulcers and their complications. The examiner then determines the depth to which the probe may go, whether to subcutaneous, capsular, or bone layers. However, there is no evidence-based consensus on specific treatment algorithms for soft tissue infections. If the probe is able to touch bone this is considered a positive probe to bone test and is highly predictive of osteomyelitis. Unfortunately any attempt at making such a consensus based on existing data is challenged by inconsistent definitions of infection, improvement and cure, and patient to patient variability.
A rational approach to the evaluation and treatment of diabetic foot ulcers will be discussed, utilizing the most current research.2. Therapy is typically guided by knowledge of likely pathogens, based on history and clinical presentation and spectrum of available antibiotics that can reliably provide coverage [58]. Pathogenesis of the diabetic foot ulcerThe diabetic foot ulcer is a complex multifactorial entity with a well-known etiologic pathway. In patients with severe infection and a higher likelihood of osteomyelitis, this test has a positive predictive value of 89% [15].
Patients who have a Grade 2 non-limb threatening infection should be treated on an outpatient basis, covering for gram-positive cocci, and reassessed in 48-72 hours.
If the infection has not improved the patient should be admitted for parenteral antibiotics and possible incision and drainage. Brand discussed the concept of “tenderizing” the foot [7] in which peripheral neuropathy leads to a loss of function of two types of mechanoreceptors in the skin, responsible for delivering nociceptive signals. Patients with grade 3-4 infections that are considered limb- or life- threatening should be admitted for parenteral antibiotics and incision and drainage.
High threshold mechano-receptors, carried via A-delta fibers, normally become sensitized to increased repetitive pressures on healthy tissues.
In this situation the inability to palpate bone with the probe indicates a low likelihood of osteomyelitis.A thorough physical examination should also include an evaluation of arterial outflow and the presence of peripheral arterial disease (PAD).
Caution should be exercised as approximately half of the patients in this category will not mount an immune response. This sensitization lowers the pain threshold in the patient with normal sensation, carried by polymodal nociceptors, leading to altered behaviors which reduce pain and subsequent damage. Therapy should be broad spectrum, including coverage for gram negative rods and anaerobes [59] in addition to gram positive cocci.
In the neuropathic patient this sensitization system is absent, allowing tissue damage to occur without any pain response with the subsequent diabetic foot ulcer.Diabetic peripheral neuropathy also causes motor and autonomic dysfunction.
The absence or diminution of a peripheral pulse (specifically the dorsalis pedis or posterior tibial) has a sensitivity between 63% and 95% and a specificity between 73% and 99% for peripheral arterial disease [17-19]. A familiarity with antibiotics available in specific hospital formularies and profiles of microbial resistance patterns (via antibiogram) will improve targeted therapies. It was previously thought that parenteral antibiotics were necessary initially for all severe infections. As the intrinsic pedal musculature becomes poorly functional muscular imbalances occur causing deformity. However studying the high serum concentrations achieved with oral forms of some antibiotics such as Linezolid and trimethoprim-sulfamethoxazole, for example, suggest that intravenous administrations may not always be necessary [58]. This deformity allows for focal areas of increased pressure, becoming risk areas for ulceration. Autonomic neuropathy contributes via sudomotor dysfunction causing loss of sweat glands as well as loss of nutritive supply with subsequent dry skin that breaks down easily [5]. Trophic changes of the skin may include atrophic, shiny appearance with loss of hair, coolness to touch, cyanosis, and thickened nails. Mild infections warrant a short course of 1-2 weeks, while moderate to severe infections can require up to 2-4 weeks of targeted therapy.
An ill-fitting pair of shoes may be all that was required for the shear forces to lead to an ulceration of a patient’s foot who has diminished sensation.If skin breakdown and wound formation occurs by a combination of high pressures in the insensate foot then wound chronicity is upheld by altered and inappropriately functioning biochemical pathways and chemical mediators. Trophic changes generally have a lower sensitivity and specificity for PAD [17].In the diabetic patient with a neuropathic foot ulcer and concomitant PAD the wound appearance may be slightly different. Inflammatory markers such as CRP and erythrocyte sedimentation rate (ESR) are used to define duration of therapy [58]. Various cytokines and matrix proteins have been implicated in the process of delayed wound healing.
In some situations the wound will look similar to the well vascularized ulcer with the exception of a more pale or light pink appearance to the wound base instead of a red, granular appearance.
One of these mediators that has received much emphasis over the recent past is matrix metalloproteinase 8 (MMP-8), which is the primary collagenase in normal wounds [9]. In more advanced neuroischemic wounds the appearance will be markedly different with a fibrous yellow appearance and an often irregular, sometimes punched out-appearing, shape (Figure 2). In chronic wounds MMP-8 is upregulated due to reduction of its regulating enzyme TIMP-1 (tissue inhibitor of metalloproteinase 1). Although ertapenem did not provide specific coverage for Pseudomonas or Enterococcus species, at the end of the therapy period the success rate for both groups of patients was similar. This overexpression of MMP-8 causes enzymatic destruction of the wound extracellular matrix, thus retarding wound healing. In the majority of patients an examination of the biomechanical contribution will reveal the cause of the ulcer.
This raises the question of whether certain bacteria such as Pseudomonas and Enterococcus require antibiotic coverage.
The diabetic foot ulcer may also be lacking growth factors such as platelet-derived growth factor (PDGF) and tumor growth factor beta (TGF-?) which stimulate fibroblast proliferation and synthesis and act as chemoattractants for neutrophils, smooth muscle cells, and macrophages [10] in the healthy wound.
These organisms are colonizers and become primary pathogens in very specific instances, acting as opportunistic pathogens. In order to prevent further propagation of multi-drug resistant organisms, practitioners should choose antibiotics with slightly narrower coverage [58, 60, 74].Occasionally soft tissue infections accompanied by abscess, substantial necrosis or necrotizing fasciitis require surgical debridement in addition to broad spectrum, followed by targeted, antibiotic therapy.
Overall appearance of the foot should be appreciated, followed by a detailed examination of specific deformities, including joint position, range of motion, and rigidity versus flexibility (Figure 3). Risk factorsSeveral clinical causal pathways have been researched, allowing the clinician to grade the primary risk factors associated with the onset of DFUs.
For moderate to severe diabetic foot infections, surgical intervention is often the key to limb salvage [69].

Lavery et al, described an update to the clinical staging method previously proposed by the International Working Group for the Diabetic Foot [11, 12]. For example, lack of motion of the great toe joint (hallux limitus) often leads to a compensatory increased motion at the hallux interphalangeal joint. The incision should be centered on the abscess and extended proximally until there is no evidence of infection.
Table 1 demonstrates increasing trend of ulceration, infection, and amputation, with an extremely high risk of hospitalization with increasing stage.
This compensation increases plantar pressures at the joint with a subsequent DFU (Figure 4).
Non-viable tissues can be debrided, and exposed tendons and bone can be removed in preparation for eventual closure [72].
There are three methods for wound closure: primary, delayed primary and closure by secondary intention. Plantar pressures have been shown to be increased three fold in diabetic patients with ankle equinus when compared with those without [21]. Primary closure can be achieved when the surgeon is confident the necrotic tissue and infection has been removed using a combination of sharp debridement and lavage. The monofilament is constructed to produce a standard 10 grams of force when bent and has been found to accurately predict the presence of ulceration [13].
The relationship between callus and ulceration was confirmed by Murray and colleagues who found a relative risk of 11.0 for an ulcer developing under an area of callus [22].
However, in cases of severe infection or when there is suspicion for additional drainage to be encountered, a wound may be left open initially then closed several days later when it is free of any signs of infection –delayed primary closure. As such, the relationship between ankle equinus, increased plantar pressures, and DFU is well established. Finally, for those wounds with significant undermining or other potential complicating factors, closure by secondary intention may be undertaken in which a wound is left open and allowed to granulate or contract, often with the help of advanced modalities such as NPWT, split thickness skin grafting or other synthetic graft materials [59, 72]. If the patient is unable to feel 4 of 10 sites, he is diagnosed with peripheral neuropathy.
Upon completion of the physical examination, laboratory and imaging methods may be employed in certain circumstances to better appreciate the underlying anatomy and will be discussed below.A simple, rapid examination of the foot takes no more than one to two minutes.
From a clinical standpoint a significant sign of impending ulceration is the preulcerative callus. When superficial infections are encountered physicians should aggressively treat them to prevent progression and involvement of deeper or wider margins of tissue. This is seen as hyperkeratotic tissue with visible hemorrhage within the epidermal or dermal skin layers. Some infections warrant early surgical debridement, which can reduce morbidity and cost [63].
Treatment of diabetic foot ulcerations can be intimidating and complex without a basic understanding of the treatment options available and a thorough evaluation of the ulcer’s characteristics. When amputations are considered, they should be performed as far distal as possible as there are higher energy expenditures and disturbance to quality of life with proximal amputations.
Current literature suggests that, if the initial treatment plan does not reduce the size of the ulcer by 50% in four weeks that the course of treatment should be re-assessed [23-26]. In paraplegic and quadriplegic patients or other patients who are otherwise non-ambulatory, surgical planning should take into account the future risk of complications such as decubitus or neuropathic ulcerations, contractures or infection [59].
Essential components of any initial or re-evaluated treatment plan should consist of debridement, moist wound healing environment, offloading and infection control [27]. Conservative options are typically employed initially [28] but if progress stalls, surgical components to the treatment plan may help to decrease time to healing or even promote healing. Characteristics of the diabetic foot ulcer are important to consider because they directly influence what treatment modalities are used.
OsteomyelitisOccasionally, soft tissue infections can be severe and deep, involving underlying bony structures.
Evaluation of the diabetic foot ulcer’s location, size and depth, tissue type, presence or absence of drainage, length of time the ulcer has been present, vascular supply, and any pathomechanics present are all important variables when formulating the treatment plan.
When there is a break in the soft tissue, and the infective organisms have entered the bone directly, this is referred to as contiguous or direct extension osteomyelitis [15, 61, 75]. DebridementThe type of tissue found within the diabetic foot ulceration is an important treatment consideration. Other types of osteomyelitis include hematogenous osteomyelitis which is seen in prepubescent children and in elderly patients in which spread occurs through the blood [75]. When yellow fibrotic tissue or dusky necrosis is noted, steps must be taken to covert the diabetic ulcer base to a beefy, red, healthy granular tissue. Surgical debridement of avascular tissue may improve rates of ulcer closure by removing the tissue that had served as a foreign body.
PathogenesisInfections in the bone are initiated by adhesion of bacteria in the acute osteitis phase followed by firm attachment, which is the chronic phase. Several types of debridement are commonly employed today but there is no scientific evidence suggesting that one type is superior to another [29, 30] only that diabetic foot ulcers receiving a regular debridement are found to heal faster [30].
The adhesions are formed through a polysaccharide capsule that links strongly to the bone matrix. Debridement is a necessary step that prepares the wound bed to promote healing [30] and is helpful when converting a chronic wound to an acute ulcer [25]. Sharp debridement is considered the gold standard [30, 31] and can be performed at the bedside or in the operating room [32].
Enzymatic debridement, such as collagenase for fibrotic tissue is a good option when the risk of debriding small quantities of healthy tissue is not acceptable or if the patient experiences pain with sharp debridement.
Hydrosurgical debridement, as with Versajet® (Smith and Nephew corporation), demonstrates no statistically significant reduction in bacterial contamination [33] and was found only to decrease the duration of time spent debriding the ulcer [31]. In reaction to the bacterial antigens, the body will also produce interleukin-1 (IL-1) and tumor necrosis factor-? (TNF-?) which result in an increase in osteoclast-mediated osteolysis [60, 62].As mentioned above, emergence of drug resistant organisms is a large problem facing healthcare providers today. Biologic debridement, using medically sterilized Lucilia sericata larvae, aims to rid the ulcer of necrotic tissue and pathogens [30, 34].
It has been shown that gradual exposure of antibiotics through the biofilm layers can result in resistance as the organisms are able to tolerate 10-1000 times higher levels of antimicrobial agents in comparison to the minimum inhibitory concentration. However, maggot therapy has not demonstrated improvement of healing rate or reduction of bacterial load as compared with hydrogel [29, 30]. Applying hydrogel or hydrocolloid dressings introduces moisture, and if placed under occlusion, serves as a form of autolytic debridement that allows the body’s own enzymes to liquefy necrotic tissue. Hydrogel, additionally, has been found to increase the rate of healing as compared with plain gauze [29].
Mechanical debridement, also known as “non-selective debridement” is performed by applying saline moistened gauze to the ulcer and allowing it to dry before the dressing is periodically changed. The removal of the gauze mechanically removes both healthy and unhealthy tissue and is no longer considered the best dressing for diabetic foot ulcers [26].The size and depth of the diabetic foot ulcer are important factors to evaluate because a deep ulcer may have avascular tissue such as tendon exposed. Instead of allowing the avascular tissues to desiccate and require debridement, potentially losing long-term function in the foot, immediate use of a negative pressure wound therapy (NPWT) system has been shown to increase volume of granulation tissue within the ulcer [29, 35, 36] which may possibly preserve that structure. NPWT has also been shown to significantly improve the rate of wound closure as compared to simple saline gauze dressings [26, 29, 37] and NPWT has demonstrated a reduced amputation incidence [26] and decreased hospital stay [38]. Ultrasound, lasers, electrical and electromagnetic therapies have been evaluated in laboratory research but there is insufficient evidence to suggest these have any effect on diabetic foot ulceration healing times [29]. Clinical evaluationThorough history of patients who present with suspected osteomyelitis should be performed in addition to a thorough physical exam as previously discussed.
Moist wound healing environmentThe presence or absence of drainage helps to determine what type of adjunct dressing the diabetic foot ulcer may require. Lab evaluationComplete blood count is of limited usefulness in diagnosing osteomyelitis as leukocytosis is infrequent [62, 75]. By converting a chronic diabetic foot ulcer to an acute wound and maintaining a moist wound bed, the inflammation, infection and exudate are controlled while increasing epithelial advancement [25, 34]. This prevents retardation of cellular proliferation and angiogenesis by eliminating the excessive levels of matrix metalloproteinase’s, growth factors and cytokines [34] present in the chronic wound. Unlike in metastatic or metabolic bone diseases, the serum calcium, phosphate and alkaline phosphatase all remain normal [75].
If excessive drainage is present an absorbent dressing should be used, such as a calcium alginate or another absorbent fiber. Microbiologic evaluationSimilar to the evaluation of infections, surface wound swabs are unreliable for identification of infecting organisms [58, 63, 75]. Other dressing components have been found to increase healing in small studies such as the use of topical and oral ?-glucan [39]. Specimens of deep tissue obtained from areas adjacent to bone in question can also grow different bacterial isolates [62, 63]. In another study, comparison of various dressing options demonstrated no statistical difference in ulcer healing but did note that the basic wound contact dressing, was more cost-effective in healing diabetic foot ulcers than a fibrous hydrocolloid dressing [40].If the diabetic foot ulcer has been present for 30-90 days [35] it is considered chronic.
Chronicity may dictate whether or not to use bioengineered products that deliver fibroblasts superficially, such as Dermagraft® (Advanced Tissue Sciences), Apligraf (Organogenesis) or healthy doses of growth factors, such as platelet rich protein gel delivered superficially. Both, Dermagraft® and Apligraf®, used with effective offloading, have demonstrated decreased healing time [41, 42] and several studies suggest that utilization of near-physiological concentration of platelet rich protein gel on recalcitrant or chronic wounds demonstrate a rapid and consistent healing [32, 34, 35, 43] and is cost-effective [42]. A smaller study suggests that injected, rather than topical, epidermal growth factor at the lesion’s base may result in improved healing [44] due to elimination of high levels of proteases that reduce levels of growth factors needed for healing [34]. OffloadingThe location of the diabetic foot ulcer is commonly found overlying a bony prominence [25, 34] or involving a deformity (Figure 5).
Total contact casting (TCC) (Figure6A ), is considered the best method of offloading as compared to a removable walking cast [27]. When these conservative means for offloading are ineffective, surgical resection of the underlying bony prominence, termed internal off-weighting, is an option [25]. This surgical treatment may entail bony procedures such as an exostectomy, condylectomy, arthroplasty [25, 36], metatarsal osteotomy [28] or arthrodesis [28]. Additionally, tendon transfers to rebalance the foot and amputation may also be applied as indicated (Figure 7).Surgical procedures should be chosen and performed by those with expertise in surgical reconstruction of the diabetic foot and ankle. Pathomechanics of the patient’s foot, such as gastrocnemius-soleus equinus or a taut plantar fascial ligament both leading to plantar forefoot ulcerations, may necessitate conservative offloading measures as previously mentioned. However, if the offloading attempts are ineffective, a surgical release (plantar fascial ligament resection [28, 46, 47]) or surgical lengthening (tendo-achilles lengthening [25, 28, 46, 48]) of the contracture may allow the forefoot to be more flexible when met with ground reactive forces thus healing the diabetic plantar foot ulcer [49].
Mueller et al’s randomized clinical trial found that patients treated with a tendo-achilles lengthening and a TCC were 12% more likely to heal a plantar foot ulcer than with a TCC alone.
Additional methodsVarious types of skin grafts and flaps may assist with closure of the ulceration (Figure 8) as healing an ulcer by means of secondary intention represents a major burden to patients, health care professionals and the health care system [50].
Bioengineered skin grafts and split-thickness skin grafts do not show statistically significant success in healing diabetic foot ulcers [29] despite small studies suggesting grafts improve rates of healing and decreased evidence of amputations [51, 52]. Local muscle flaps have also been found to be successful in closing complicated diabetic foot wounds and are far superior as compared to the survival rates of amputees [53].
Despite an increased complication rate, pedicled flaps were found to have comparable limb salvage success as compared with free flaps [53]. Successful healing.Hyperbaric oxygen (HBO) therapy systemically has been found to decrease the rate of major amputations [29] but not in the rate of minor amputations [54]. When a conservative treatment plan is found to improve the ulcer but does not heal it, utilizing HBO therapy may help to increase the partial pressure of oxygenation to tissues and help heal the wound [54, 55]. A study has demonstrated that the use of HBO facilitates wound closure when there is a change in transcutaneous oxygen measurements of ? 10 torr [56]. Topical hyperbaric oxygen therapy has not been found to decrease the rate of major amputations [29] and cannot be recommended for use in diabetic foot ulcers at this time.
When various treatment modalities are not successful, if possible, a limb salvage attempt is advised. External fixation is an additional option, boasting skeletal stability, easy access for soft tissue management, and assisting with plastic surgery wound closure techniques [36, 57]. If external fixation is not available or possible, there are many levels of amputations to consider [36]. While a trans-tibial amputation has the same long-term survivorship as some mid and rearfoot amputations (Symes, Lisfranc, calcanectomy or Chopart’s) a partial foot amputation allows higher ambulatory levels and longer durability with less morbidity and mortality than trans-tibial amputations [51].
Allowing the patient to have a good quality of life, maintain as much function as possible and increase ease of prosthetic use following the amputation are important advantages to consider.5.
InfectionOne of the earliest complications of diabetic foot ulcerations is infection [58] and if not treated adequately, may require amputation. This of particular concern because the 3 year survival rate following a lower limb amputation is 50%, decreasing to only 40% after 5 years [59].All skin surfaces, and thus all wounds, have a certain level of bacteria on the surface at baseline, referred to as surface contaminants, defined as bacteria which are present but do not multiply.
Whether the bacteria are able to surmount a response from the host immune system will dictate whether there is an infection. Some believe that observing 105 bacteria per 1 gram of tissue is the threshold between a colonizer and an established infection. However, depending on the bacterial species or strain, an infection can result with far fewer than the 105 bacteria per 1 gram of tissue.
Take for example ?-hemolytic streptococci, which produce enzymes that promote tissue invasion and cause progressive infections without the same bacterial burden as other organisms [58, 60-62].Risk factors for infection include a non-healing ulcer, advanced age, male sex, black race and a history of smoking in addition to sensory and autonomic neuropathy [63]. Diabetic foot infections are difficult to manage due to the associated comorbidities affecting the patient such as neuropathy, peripheral vascular disease, immunopathy and nephropathy [59].
Organisms such as methicillin resistant strains of Staphylococcus aureus, among others, pose a challenge to healthcare providers. Several factors such as prolonged hospital stays, exposure to surfaces and personnel who may have come into contact with resistant strains, and prolonged or prior antibiotic treatment can result in infections with these organisms. Many patients with chronic ulcerations have a history of recurrent ulcerations and infections that place them at high risk for infection with resistant organisms [65]. Poor glycemic control has been connected to impairment in leukocyte phagocytosis and chemotaxis, which increase the risk for infection. Clinical findingsPatients with infections typically present with erythema, edema, purulent drainage, malodor, calor, induration, lymphangitis, soft tissue edema and occasionally gangrene or necrotic tissue (Figure 9).
Patients also complain of recalcitrant hyperglycemia and other constitutional symptoms such as fevers, malaise and chills, sometimes referred to as the ‘diabetic flu’, which should raise suspicion for a deep infection [59, 61, 68]..
Superficial infections typically show no signs of systemic toxicity and glycemic levels remain unaffected. Deep foot infections, in contrast, result in contiguous spread of erythema and edema with accompanying constitutional symptoms such as fever, chills, malaise, and occasionally blood glucose elevations.
DiagnosisIdentification of infecting organisms for diabetic foot wounds is of great interest, particularly when considering antibiotic therapies. Depending on the chronicity of the wound there can be a slight difference in the organisms that can be isolated from a wound culture. Acute wounds typically grow gram positive cocci while chronic wounds are polymicrobial, with a mixture of gram positive cocci, gram negative bacilli and anaerobic organisms (Table 2) [58, 69, 70]. Those patients who have been previously hospitalized or have had prolonged antibiotic therapy can have an altered profile of organisms. Patients who have not been on any recent antibiotics typically grow gram positive organisms with a greater likelihood of gram negative organisms and organisms that are resistant to antibiotics [65].
Instead, deep tissue specimens should be taken from the wound after a sharp debridement either with a scalpel or curette. Alternatively, in the presence of an abscess, aspiration of the abscess can provide more accurate information regarding the infecting organisms [58, 61, 63, 64].

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