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 For many years, it has been standard practice
to treat diabetic foot ulcers with a combination of any of the following:
appropriate wound dressing; offloading; antibiotics; and improving the blood
supply. The best way of offloading the foot is, however, uncertain. In
addition, whilst there are widely respected guidelines available on treating
infection, the choice of antibiotics is also hotly debated, and relies on local
sensitivities, the availability of antimicrobial agents and frequently, local
microbiologist preferences. Revascularization is dependent on local availability;
non-invasive techniques such as angioplasty are often only available in
specialist centers, meaning that many units in low-resource environments do not
have access to this procedure, let alone a vascular surgeon. Even after
effective treatment, relapse probability is 70%, which frequently leads to
amputation.

With
this background, newer aspects of the care and management of the diabetic foot
are emerging. Martha Clokie and Alice Greenway discuss the impact of newer
technologies on the identification of the organisms present in an ulcer, as
well as novel approaches to treating infections. Keith Harding and Nia Jones
also discuss newer technologies, in particular, various uses of remote sensing,
that may help in the early detection of tissue damage, thus allowing more
timely intervention to prevent ulceration developing. (Jan aw, Khan H; 2016)

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Microbiology and current diagnosis
of diabetic foot ulcers

The
diagnosis of most diabetic foot ulcers is based on the presence of clinical
signs and symptoms. Most frequently, tissue biopsy and ulcer fluid aspirates
are sent for culture based identification. Less invasive swabbing from the base
of the ulcer is also used to detect surface-associated bacteria, but does not
detect bacteria associated with deeper structures. The use of non-culture-based
molecular microbiological techniques to characterize foot infection micro biota
could significantly enhance our understanding of the composition and abundance
of the infection and guide effective antimicrobial selection. These techniques
have the advantage over culture-based approaches because they are not dependent
on the cultivability of the bacteria. This is particularly pertinent for
diabetic foot ulcers, which are typically colonized by anaerobes that are
notoriously difficult to isolate.  (Jan
aw, Khan H; 2016)

 

Bacteriophages

The
diagnosis of the infection with deep tissue swabs, selection of the wrong
antibiotic can lead to chronic ‘superbug’ infections. Bacteriophages One of the
key problems associated with diabetes is peripheral vascular disease and wound ischemia.
Poor antibiotic penetration into tissues because of a lack of blood flow is
another reason why antibiotics are so unsuccessful. Both the lack of effective
penetration of antibiotics, and problems with antibiotic resistance mean that
novel approaches to treating infection are needed. One promising alternative to
standard antibiotics is the use of bacteriophages, or phages, which are viruses
that target and kill bacteria. (Clokie1, A. L. Greenway, 2017)

Remote sensing in the assessment of
diabetic foot disease

It
is generally accepted that early diagnosis of risk factors associated with
diabetic foot ulcers is a prerequisite for maintenance of lower limb health. In
comparison to current clinical assessment methods, the evolution of innovative
technologies provides new opportunities for remotely detecting and monitoring
diabetic neuropathy and angiopathy earlier in the disease progression.

 Measuring skin temperature is considered one
of the most reliable indicators of cutaneous perfusion, and evidence suggests
that infrared thermo graphic monitoring may be an effective method of
predicting tissue viability complications in the diabetic foot. Dermal
thermography is currently used in routine clinical practice to detect
temperature differences between the ipsilateral and contralateral foot in
Charcot neuroarthropathy, but emerging evidence suggests that this technology
could be adopted to support self-monitoring of diabetic foot disease. (Clokie1,
A. L. Greenway, 2017)

Hyper
spectral imaging is currently a laboratory-based assessment method used to
determine oxygen saturation in human tissue and to detect early
microcirculatory changes in the diabetic foot. Hyper spectral imaging
technology has also been evaluated as a tool for predicting the healing
potential of a foot ulcer with a reported sensitivity and specificity of 80%
and 74%, respectively. (Tsai FW, Tulsyan N; 2000)

Skin
perfusion pressure, in contrast to hyper spectral imaging, is a portable tool
used in routine clinical practice to diagnose small vessel disease in high-risk
populations and assess the healing potential of chronic wounds in the lower
limb. Skin perfusion pressure is not affected by diffuse vascular calcification
and was superior in the diagnosis of peripheral arterial disease in people with
diabetes when compared with ankle and toe brachial pressure indices and
transcutaneous partial pressure of oxygen (TcPO 2). The one major drawback is
that the application of these technologies is driven by the clinician and not
the person with diabetes. (Castronuovo JJ, Adera HM; 1997)

Wearable
technology is another evolving field in the monitoring and treatment of
diabetic foot disease because sensory and motor complications associated with
peripheral neuropathy often result in altered proprioception and ataxic gait
patterns. Human exoskeleton robots are in early development, but some of these
devices have remote body sensors which consist of shoe-embedded force sensors
and walking canes to aid with gait difficulties and alert people to the risk of
falls when standing from a sitting position (Iqbal MH, Aydin A; 2016). One
simple and inexpensive method of adopting wearable technology into practice
would be to encourage patients to wear pedometers to monitor their physical
activity levels and visually inspect their feet daily for evidence of tissue
trauma. This intervention would enable the person to recognize when they need
to limit their activity levels and seek advice from their podiatrist. Pulse
Flow DFTM is an offloading device which has taken the concept of monitoring
physical activity to another level. It has built-in monitoring software that
enables the clinician to capture data on the use of the offloading device.
Previous work has suggested that people with ulceration may be more active than
they admit to their treating clinician (Armstrong DG, Lavery LA; 2003)

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