Sharp debridement in the management of diabetes-related foot ulcers: outcomes of a randomised study of debridement frequency, current practice of debridement and implications for frequency of treatment.

Diabetes related foot ulcers (DFU) are a leading cause of hospital admission and lower extremity amputations. DFU are optimally managed by an interdisciplinary team including podiatrists. Sharp debridement (SD) of DFU is standard care based on observational data that more frequent SD is positively associated with healing. There are no prospective studies assessing frequency of SD. Available literature relating to SD was explored in this thesis and three studies conducted; a clinician survey to determine what is current practice, a randomised trial to determine whether SD performed weekly vs second weekly results in a higher proportion of DFU healed, and a survey exploring patients’ experiences. Clinician survey respondents (n=75), mostly podiatrists, reported weekly and second weekly SD regimens were usual practice and publicly funded podiatrists debride at every visit. Those in rural/regional areas, SD DFU less often and clinicians rely on clinical features to inform SD frequency. The randomised trial recruited 122 participants from seven centres. DFU stratified by Centre and size, were randomised to weekly or second weekly SD. All received weekly standard care. Healing outcome at 12 weeks was objectively based on digital images (n=78) assessed by wound experts blinded to group allocation with 53% of weekly and 52% of second weekly debrided DFU healed (mean difference 1.8%, 95% CI -16.3 to 20). Clinician reported healing outcomes were similar. The patient survey included (n=60) participants from three clinics. Participants expressed satisfaction with SD, half reported mobility restricted their capacity to attend, and the majority used a car to travel to the appointments with family support often being required. The aetiology of DFU is multifactorial and many factors impact healing outcomes. In the context of standard care, second weekly SD has similar outcomes to weekly, with the potential to reduce the burden of care for patients and their families

The microbiome of diabetic foot ulcers and the role of biofilms

Diabetic Foot Ulcers are a common precursor to the development of infection and amputations. A breach in the protective skin barrier represents a portal of entry for invading microorganisms, where infective episodes frequently pursue. Three key areas that may augment clinical care are one. understanding what microorganisms are present in Diabetic Foot Ulcers, two. differentiating if microorganisms are planktonic microbial cells or slow growing microbial biofilms and three. treating Diabetic Foot Ulcers complicated by microorganisms with effective topical agents. As part of this thesis, 16S rDNA next generation sequencing was utilised to profile the microbiota of infected Diabetic Foot Ulcers (DFUs). Clinical / laboratory data and treatment outcomes were collected and correlated against microbiota data. Thirty-nine patients with infected DFUs were recruited over twelve-months. Shorter duration DFUs (less than six weeks) all had one dominant bacterial species (n= five of five, 100%, p <⋅001), S. aureus in three cases and S. agalactiae in two. Longer duration DFUs (≥six weeks) were diversely polymicrobial (p = .01) with an average of 63 (range 19-125) bacterial species. Severe Diabetic Foot Infections (DFIs) had complex microbiota’s and were distinctly dissimilar to less severe infections (p = .02), characterised by the presence of low frequency microorganisms. Our results confirm that short DFUs have a simpler microbiota’s consisting of pyogenic cocci but chronic DFUs have a highly polymicrobial microbiota. The duration of a DFU may be useful as a guide to directing antimicrobial therapy. Secondly, we utilised Scanning electron microscopy (SEM) and Fluorescent in situ Hybridisation (FISH) techniques to determine if DFUs were complicated by sessile, slow growing bacteria referred to as biofilms. 65 DFU specimens were obtained from subjects with infected chronic ulcers. Of the 65 DFU specimens evaluated by microscopy, all were characterized as containing biofilm (100%, p < .001). Molecular analyses of DFU specimens revealed diverse polymicrobial communities. No clinical visual cues were identified in aiding clinicians identify wound biofilm. Microscopy visualization when combined with molecular approaches, confirms biofilms are ubiquitous in DFUs and a paradigm shift of managing these complicated wounds needs to consider anti-biofilm strategies. Lastly, the effectiveness of various topical antimicrobials commonly used in woundcare were tested in two separate studies by employing in vitro models, ex vivo porcine skin explant models and in vivo human studies. In the first study, 17 participants with chronic non-healing DFUs due to suspected biofilm involvement were recruited to receive one-week application of Cadexomer Iodine ointment. Real-time qPCR was used to determine the microbial load with 11 participants exhibiting one-two Log10 reductions in microbial load after treatment, in comparison to six patients who experienced less than one log10 reduction (p =.04). Scanning electron microscopy (SEM) and/or fluorescent in situ hybridisation (FISH) confirmed the presence or absence of biofilm in all 17 participants. 16SrDNAnextgenerationsequencing provided useful insights that these wounds support complex polymicrobial communities and demonstrated that Cadexomer Iodine had a broad level of antimicrobial activity in reducing both facultative anaerobes such as Staphylococcus spp., Serratia spp., aerobes including Pseudomonas spp., and obligate anaerobes including Clostridiales family XI. In the second study, a range of topical antimicrobial wound solutions were tested under three different conditions; (in vitro) 4 % w/v melaleuca oil, polyhexamethylene biguanide, chlorhexidine, povidone iodine and hypochlorous acid were tested at short duration exposure times for 15-minutes against three-day mature biofilms of S. aureus and P. aeruginosa. (ex vivo) Hypochlorous acid was tested in a porcine skin explant model with twelve cycles of tenminute exposure, over 24 hours, against three-day mature P. aeruginosa biofilms. (in vivo) 4 % w/v Melaleuca Oil was applied for 15-minutes exposure, daily, for seven days, in ten patients with chronic non-healing Diabetic Foot Ulcers (DFUs) complicated by biofilm. In vitro assessment demonstrated variable efficacy in reducing biofilms ranging between 0.5 log10 reductions to full eradication. Repeated instillation of hypochlorous acid in a porcine model achieved less than one log10 reduction (0.77 log10, p < 0.1). Application of 4 % w/v melaleuca oil in vivo, resulted in no change to the total microbial load of DFUs complicated by biofilm (median log10 microbial load pre-treatment = 4.9 log10 versus 4.8 log10 (p = .43). In conclusion, to the best of our knowledge, the in vivo human studies testing the performances of topical antimicrobials represents the first in vivo evidence employing a range of molecular and microscopy techniques. These demonstrate the ability of Cadexomer Iodine (sustained release over 48-72 hours) to reduce the microbial load of chronic non-healing DFUs complicated by biofilm. In contrast, short durations of exposure to topical antimicrobial wound solutions commonly utilised by clinicians are ineffective against microbial biofilms, particularly when used in vivo

The Host-Microbiota Axis in Chronic Wound Healing

Chronic, non-healing skin wounds represent a substantial area of unmet clinical need, leading to debilitating morbidity and mortality in affected individuals. Due to their high prevalence and recurrence, chronic wounds pose a significant economic burden. Wound infection is a major component of healing pathology, with up to 70% of wound-associated lower limb amputations preceded by infection. Despite this, the wound microbiome remains poorly understood. Studies outlined in this thesis aimed to characterise the wound microbiome and explore the complex interactions that occur in the wound environment. Wound samples were analysed using a novel long-read nanopore sequencing-based approach that delivers quantitative species-level taxonomic identification. Clinical wound specimens were collected at both the point of lower-extremity amputation and via a pilot clinical trial evaluating extracorporeal shockwave therapy (ESWT) for wound healing. Combining microbial community composition, host tissue transcriptional (RNAseq) profiling, with clinical parameters has provided new insight into healing pathology. Specific commensal and pathogenic organisms appear mechanistically linked to healing, eliciting unique host response signatures. Patient- and site-specific shifts in microbial abundance and communitycomposition were observed in individuals with chronic wounds versus healthy skin. Transcriptional profiling (RNAseq) of the wound tissue revealed important insight into functional elements of the host-microbe interaction. Finally, ESWT was shown to confer beneficial effects on both cellular and microbial aspects of healing. High-resolution long-read sequencing offers clinically important genomic insights, including rapid wide-spectrum pathogen identification and antimicrobial resistance profiling, which are not possible using current culture-based diagnostic approaches. Thus, data presented in this thesis provides important new insight into complex host-microbe interactions within the wound microbiome, providing new and exciting future avenues for diagnostic and therapeutic approaches to wound management

The Host-Microbiota Axis in Chronic Wound Healing

Chronic, non-healing skin wounds represent a substantial area of unmet clinical need, leading to debilitating morbidity and mortality in affected individuals. Due to their high prevalence and recurrence, chronic wounds pose a significant economic burden. Wound infection is a major component of healing pathology, with up to 70% of wound-associated lower limb amputations preceded by infection. Despite this, the wound microbiome remains poorly understood. Studies outlined in this thesis aimed to characterise the wound microbiome and explore the complex interactions that occur in the wound environment. Wound samples were analysed using a novel long-read nanopore sequencing-based approach that delivers quantitative species-level taxonomic identification. Clinical wound specimens were collected at both the point of lower-extremity amputation and via a pilot clinical trial evaluating extracorporeal shockwave therapy (ESWT) for wound healing. Combining microbial community composition, host tissue transcriptional (RNAseq) profiling, with clinical parameters has provided new insight into healing pathology. Specific commensal and pathogenic organisms appear mechanistically linked to healing, eliciting unique host response signatures. Patient- and site-specific shifts in microbial abundance and community composition were observed in individuals with chronic wounds versus healthy skin. Transcriptional profiling (RNAseq) of the wound tissue revealed important insight into functional elements of the host-microbe interaction. Finally, ESWT was shown to confer beneficial effects on both cellular and microbial aspects of healing. High-resolution long-read sequencing offers clinically important genomic insights, including rapid wide-spectrum pathogen identification and antimicrobial resistance profiling, which are not possible using current culture-based diagnostic approaches. Thus, data presented in this thesis provides important new insight into complex host-microbe interactions within the wound microbiome, providing new and exciting future avenues for diagnostic and therapeutic approaches to wound management

Global Perspective on Diabetic Foot Ulcerations

Over the last decade, it is becoming increasingly clear that diabetes mellitus is a global epidemic. The influence of diabetes is most readily apparent in its manifestation in foot complications across cultures and continents. In this unique collaboration of global specialists, we examine the explosion of foot disease in locations that must quickly grapple with both mobilizing medical expertise and shaping public policy to best prevent and treat these serious complications. In other areas of the world where diabetic foot complications have unfortunately been all too common, diagnostic testing and advanced treatments have been developed in response. The bulk of this book is devoted to examining the newest developments in basic and clinical research on the diabetic foot. It is hoped that as our understanding of the pathophysiologic process expands, the devastating impact of diabetic foot complications can be minimized on a global scale

A Comparative Study to Assess the Effectiveness of Infra Red Radiation, Insulin Dressing and Metronidazole Dressing in Healing of Diabetic Ulcer Foot at MAPIMS

INTRODUCTION : Diabetes is a worldwide health problem. It may begins around twenty years of age and become more prevalent when age get advances. Diabetes has been detected more in urban population but undiagnosed diabetes is most common in the rural people. In India, one in two out of population has diabetes mellitus. Approximately ninety two million of Indian people may get diabetes in the year 2035. Diabetic foot ulcer is one of the serious complications of diabetes mellitus. Eighty four percent people get lower leg amputation because of diabetes. Peripheral arterial disease and neuropathy are the common causes for foot amputation. Statistics shows that twenty five percent diabetic people develop diabetic ulcer foot in the later stage. Fifty percent diabetic population develops infection and need hospitalization in their lifetime. One out five diabetic people is prone to get amputation. The care of chronic non healing ulcer foot is challenging for health team. There are many human studies that searching for efficient and effective treatment for diabetic ulcer foot. This study compared three different interventions towards the management of diabetic ulcer foot. Statement of the Problem : A comparative study to assess the effectiveness of Infrared Radiation, Insulin Dressing and Metronidazole dressing in healing of diabetic ulcer foot at MAPIMS OBJECTIVES : 1. To assess the pretest condition of diabetic ulcer foot among patients with Diabetes mellitus. 2. To evaluate the effectiveness of infra-red radiation application, insulin dressing and metronidazole dressing in healing of diabetic ulcer foot among patients with Diabetes mellitus. 3. To compare the effectiveness of infra-red radiation with insulin dressing and metronidazole dressing in healing of diabetic ulcer foot among patients with Diabetes mellitus. 4. To associate the effectiveness of intervention in healing of diabetic ulcer foot with the selected demographic variables. Hypotheses: H1- There will be significant improvement in healing of diabetic ulcer foot at the post test. H2- There will be significant differences between infrared radiation, insulin dressing and metronidazole dressing on healing of diabetic ulcer foot. H3 - There will be significant association of post test score on healing of diabetic ulcer foot with the selected demographic variables among diabetic foot ulcer clients. Research methodology : Quasi experimental pretest posttest design was adopted for this study and Non probability consecutive sampling technique was used to select the samples. Based on the sampling criteria totally 225 samples were selected for this study, out of this seventy five subjects were treated with infra-red radiation, seventy five treated by insulin dressing and remaining seventy five were treated metronidazole dressing. First day, three interventional group was assessed by using modified Bates Jensen’s wound assessment tool and same day treatment was started, posttest was done on seventh day and tenth day by using the tool. RESULTS : Infrared Radiation Group: The pretest and post scores of the Infra-red radiation group, that the pretest mean and standard deviation were respectively 51.5067 and 4.21828. At the post test mean and standard deviation were respectively 20.32 and 3.673. The” t” value was 68.352 it is more than table value. The results shows a high level of significance statistically at p<0.001 level. Occupation and education of the diabetic clients had significant influences in the healing of diabetic ulcer foot. Insulin Dressing Group: The pretest and Post-test score of Insulin Dressing in healing of diabetic foot ulcer that Insulin dressing pretest mean score is 50.24 and standard deviation 5.74, post mean score 24.25, standard deviation 4.02 and the ” t” value 45.27 which is greater than table value. The results shows a high level of significance statistically at p<0.001 level. Diabetic client’s Demographic variables like Age, area of residence and family history of diabetes had significant influences in the healing of diabetic ulcer foot. Metronidazole Dressing Group: The pretest and Post-test score of Metronidazole Dressing in healing of diabetic foot ulcer. It reveals that in Metronidazole dressing, pretest and posttest mean scores were respectively 50.3 and 27.06 and the standard deviation were 4.0 and 3.58 respectively and the “t” value was 52.825 which is more than table value. The result shows a high level of significance statistically at p<0.001 level. Diabetic client’s demographic variables like age and area of residence had significant influences in the healing of diabetic ulcer foot. CONCLUSION : These study results shows that all the three interventions were effective in healing of diabetic ulcer but infrared radiation was the most effective method when comparing other two interventions in the healing of diabetic ulcer foot. IMPLICATIONS : The findings of the study have several implications for medical surgical nursing, community health nursing, nursing education, nursing administration and nursing research towards the healing of diabetic ulcer. The study findings help to reduce the complications of diabetic foot ulcer and increase the granulation status of wound. Primary health nurse can plan diabetes education and develop awareness programme regarding risk factors of diabetes and diabetic foot complications. Nursing practice provides a prompt patient care. They will act as a essential role in control of diabetes and care of foot. Nurse educators basically from clinical nursing which gives them, knowledge, skills and attitude of theory. Nurse educators are responsible for teaching current trends in nursing practice in clinical setting. Nurse administrator should plan of programme and strategies about diabetes and diabetic ulcer foot

Diabetic Foot Infection and Lower Extremity Amputations : Recent trends, outcomes and prognostic factors

Diabetes on nopeasti lisääntyvä sairaus. Siitä aiheutuneet jalkaongelmat aiheuttavat potilaille elämänlaadun ja toimintakyvyn alenemista sekä sairastavuuden ja kuolleisuuden lisääntymistä. Diabetes vaurioittaa alaraajan kudoksia aiheuttaen diabeetikolle moninaisia jalkaongelmia. Diabeetikon jalka on altis toistuville haavautumisille ja infektioille, joiden seurauksena voidaan pahimmillaan joutua tekemään alaraaja-amputaatio. Amputaatio on merkittävä käännekohta diabetesta sairastavan potilaan elämässä, ja alentaa sekä fyysistä että psykososiaalista toimintakykyä ja altistaa ennenaikaiselle kuolemalle. Tämän väitöskirjan ensisijainen tavoite oli tutkia alaraaja-amputaatioiden määriä väestötasolla valtakunnallisesti ja diabetesta sairastavien osalta alueellisesti. Lisäksi tavoitteena oli tutkia potilaan ennustetta diabeettisen jalkainfektion ja amputaation jälkeen, sekä selvittää alueellisesti infektion yleisimmät aiheuttajabakteerit. Alaraaja-amputaatioiden määriä tutkittiin kolmessa eri potilasryhmässä. Ensiksi Osatyössä I verrattiin sairaalahoitoisen diabeettisen jalkainfektion Tampereen Yliopistollisessa Sairaalassa (Tays) sairastaneiden potilaiden kohortteja ennen (vuodet 2006-7, n=124) moniammatillisen haavaosaston perustamista (vuonna 2012) ja sen jälkeen (vuodet 2013-4, n=148). Sääriamputaatioiden määrä väheni merkittävästi 25.8 prosentista (n=32) vuosina 2006-7 9.5 prosenttiin (n=14) vuosina 2013-4. Toiseksi, osatyössä V tutkittiin diabetesta sairastavia potilaita, joille tehtiin alaraaja-amputaatio (n=1081) vuosina 2008-2019 Tays:ssa. Potilaiden määrä, joille tehtiin sääriamputaatio ensimmäisenä amputaationa väheni tutkimusaikana 40%, ollen 20 vuonna 2008 ja 12 vuonna 2019. Samaan aikaan havaittiin 73% nousu jalkaterän alueen amputaatioissa (41 vs. 71) ja reisiamputaatioissa (11 vs. 19) amputaatioissa. Kolmanneksi, osatyössä IV kerättiin kansallisesta hoitoilmoitusrekisteristä Suomessa tehdyt amputaatiot vuosilta 1997-2018. Sääriamputaatioiden ilmaantuvuus väheni 46.2% (13 vs. 7 per 100 000 henkilövuotta), kun taas jalkaterän alueen amputaatiot lisääntyivät 104.3% (23 vs. 47 per 100 000 henkilövuotta) ja reisiamputaatoiden ilmaantuvuudessa ei tapahtunut muutosta (16 per 100 000 henkilövuotta). Kaikkien ja ensimmäisten nilkan ala- ja yläpuolelta tehtyjen amputaatioiden suhde nousi vuoden 2008 (1.33, 95%CI 1.23-1.44 ja 1.13, 95%CI 1.03-1.24) vuoden 2018 (1.93, 95%CI 1.79-2.08 ja 1.49, 95%CI 1.36-1.62) välillä. Osatyössä IV havaittiin valtimonsisäisten pallolaajennusten määrän kasvaneen eksponentiaalisesti (14-21 kertaiseksi) vuosien 1997 ja 2018 välillä, mikä suurelta osin aiheuttaa nilkan ala- ja yläpuolelta tehtyjen amputaatioiden suhteiden nousun. Lisäksi ilman edeltävää valtimoverenkierron korjausta alaraaja- amputaatioon joutuvien potilaiden määrä väheni vuosien 2009 ja 2018 välillä. Toisaalta osatyössä I verisuonikirurgin konsultaatioiden tai valtimotoimenpiteiden määrissä ei havaittu eroa verrattaessa kahta diabeettisen jalkainfektion sairastaneiden potilaiden kohorttia. Näin ollen voidaan olettaa muiden tekijöiden (esim. moniammatillinen haavaosasto) vaikuttaneen havaittuun muutokseen amputaatiomäärissä. Osatyössä III tutkittiin hoidon tuloksia ja potilaan ennustetta sairaalahoitoa vaatineen diabeettisen jalkainfektion jälkeen. Elossa oli yhden ja viiden vuoden jälkeen 81.2% (95%CI 77.5-84.9%) ja 49.7% (95%CI 44.8-54.6%) potilaista. Nilkan yläpuolinen amputaatio oli merkittävin riskitekijä kuolemalle (HR 6.673, 95%CI 2.836-15.700). Nilkan yläpuolisen amputaation jälkeen elossa oli yhden ja viiden vuoden jälkeen 41.7% (95%CI 13.9-69.5%) ja 8.3% (95%CI 0.0-24.0%) potilaista. Ikä, alaraajaiskemia ja alentunut munuaistoiminta olivat kuoleman riskitekijöitä. Elossa oloa ilman nilkan yläpuolista amputaatiota (major amputation-free survival, MAFS) heikensivät ikä, haavaiskemia ja korkea tulehdusarvo. Verenpainetta alentava lääkitys liittyi parempaan MAFS:n. Iskeemistä infektiota sairastavilla potilailla revaskularisaatio paransi MAFS:a merkittävästi (p<0.05). Osatyössä I todettiin moniammatillisen haavaosaston toiminnan alkamisen jälkeen sairaalaan tulon ja ensimmäisen kirurgisen toimenpiteen välin lyhentyneen merkittävästi (mediaani 5 vs. 2 päivää, p<0.05). Lisäksi todettiin hoitojakson mahdollinen lyheneminen (mediaani 7 vs. 6 päivää, p=0.120). Aika sairaalaan tulosta verisuonikirurgin konsultaatioon ei merkittävästi muuttunut. Osatyössä V tutkittiin diabetesta sairastavien potilaiden selviämistä alaraaja- amputaation jälkeen. Yhden ja viiden vuoden jälkeen elossa oli 75.8% (95%CI 73.3-78.3) ja 38.3% (95%CI 34.7-41.7) potilaista. Nilkan yläpuolinen amputaatio lisäsi kuoleman riskiä, kun taas useampi amputaatio liittyi parempaan selvitymiseen. Ikä, ahtauttava ääreisvaltimotauti ja alentunut munuaistoiminta lisäsivät sekä kuoleman riskiä, että heikensivät MAFS:a. Lisäksi verepainetauti ja rasva-aineenvaihdunnan häiriö liittyivät pienempään kuolleisuuteen. Sairaalassa diabeettisen jalkainfektion vuoksi hoidettujen potilaiden bakteeriviljelylöydökset analysoitiin osatyössä III. Staphylococcus aureus (SA) oli kudosnäytteissä yleisin grampositiivinen bakteeri (34.8%, n=72) ja toiseksi yleisin oli beetahemolyyttinen streptokokki (Streptococcus haemolyticus, BHS, 18.4%, n=38). Gramnegatiivisten bakteerien (Gram negative bacilli, GNB) osuus oli 23.2% (n=48). SA ja BHS olivat yleisimmät veressä kasvaneet bakteerit (kumpikin 32.1%, n=9). GNB oli merkittävästi yleisempi iskeemisessä infektiossa (40.3% vs. 21.3%, p<0.05). Pinnallisen pumpulitikkunäyteen tarkkuus oli 91.8- 92.9% ja herkkyys oli 66.7-87.5% verrattuna syvään kudospalanäytteeseen. Yhteenvetona voidaan todeta, että alaraajan (erityisesti jalkaterän alueen) amputaatioiden kokonaismäärä on diabeetikoilla lisääntynyt. Sääriamputaatioiden määrä on vähentynyt valtakunnallisesti kaikilla potilailla ja myös diabeettisen jalkainfektion vuoksi hoidetuilla potilailla. Diabetesta sairastavan potilaan ennuste jalkainfektion ja erityisesti nilkan yläpuolisen amputaation jälkeen on edelleen heikko. Jalkaterän alueen amputaation jälkeen ennuste on parempi verrattuna nilkan yläpuoliseen amputaatioon ja jalan säästämisen tulisi olla ensisijainen tavoite aina kun se on mahdollista. Lisäksi krooninen raajaa uhkaava iskemia on vakava liitännäissairaus, jonka tehokas tunnistaminen ja hoito on tärkeää diabeettisen jalkainfektion hoidossa. Infektion aiheuttajabakteerit Tays:ssa ovat yhteneväiset valtaosan muun Euroopasta julkaistun tiedon kanssa ja näin ollen antibioottihoidossa on perusteltua noudattaa kansainvälisten hoitosuositusten ohjeistuksia.Diabetes and its complications in the lower extremity are an increasing burden that causes individual suffering for the patient and challenges and increased costs to the healthcare system in the form of high morbidity and mortality. Diabetes causes changes in lower extremity tissues, leading to the formation of diabetic foot. Diabetic foot is prone to recurrent ulceration and infections that further predispose to lower extremity amputation (LEA). LEA is a pivotal moment in the patient’s life and often leads to physical and psychosocial impairment and premature death. This dissertation aimed primarily to evaluate the rates of LEA nationally in the general population and regionally in patients with diabetes. Secondly, the dissertation aimed to investigate the outcomes of patients after diabetic foot infection (DFI) and LEA and to identify the causative pathogens of DFI. The rate of amputations was evaluated in three cohorts. First, Study I compared cohorts of patients hospitalised due to DFI before (years 2006-7, n=124) and after (years 2013-14, n=148) the initiation of a dedicated wound centre (in 2012) at Tampere University Hospital (TAUH). A significant decrease in the rate of below knee amputations (BKA) from 25.8% (n=32) in 2006-7 to 9.5% (n=14) in 2013-14 was observed. Second, patients with diabetes undergoing LEA (n=1081) between 2008-19 were evaluated in Study V. The number of BKA as index amputation (first amputation) decreased by 40% from 20 in 2008 to 12 in 2019, while a 73% increase was identified in both below ankle (BAA, from 41 to 71) and above knee (AKA, from 11 to 19) amputations. Third, data on all LEAs performed in Finland between 1997 and 2018 were obtained from the National Hospital Discharge Register in Study IV. The incidence of BKA decreased by 46.2% (from 13 to 7 per 100 000 person-years), while BAA increased by 104.3% (from 23 to 47 per 100 000 person-years) and AKA remained unchanged (16 per 100 000 person years). Crude and index minor- major ratios increased from 1.33 (95%CI 1.23-1.44) and 1.13 (95%CI 1.03-1.24) in 2008 to 1.93 (95%CI 1.79-2.08) and 1.49 (95%CI 1.36-1.62) in 2018, respectively. During the years 1997-2018, endovascular revascularisations increased exponentially (14-21 fold), which may have contributed to the increase in minor- major ratios (Study IV). In addition, the percentage of patients undergoing LEA without prior revascularisation decreased between 2009 and 2018. However, no significant difference was observed in frequencies of vascular surgeon consultations or revascularisations between the two cohorts of DFI in Study I. This indicates that other factors, such as the dedicated wound centre, have contributed to the observed outcomes. Study I evaluated the outcomes for patients hospitalised due to DFI. Overall survival (OS) after DFI during one and five years was 81.2% (95%CI 77.5-84.9%) and 49.7% (95%CI 44.8-54.6%), respectively. Major amputation was the most significant risk factor (HR 6.673, 95%CI 2.836-15.700) for OS. After major amputation, OS was 41.7% (95%CI 13.9-69.5%) after one and 8.3% (95%CI 0.0- 24.0%) after five years. Other factors reducing OS included higher age, wound ischaemia and lower glomerular filtration rate (GFR). Major amputation-free survival (MAFS) was reduced by age, wound ischaemia and higher CRP. In addition, antihypertensive medication was associated with improved MAFS. Revascularisation improved MAFS in patients with ischaemic DFI (p<0.05). (Study III) After initiation of a dedicated wound centre, the median time interval from admission to first surgical intervention reduced from 5 to 2 (p<0.05). In addition, there was indication of decreased length of hospitalisation (median 7 vs. 6, p=0.120). No significant change was observed in time interval from admission to vascular surgeon consultations. Outcome was also evaluated for patients with diabetes who underwent LEA in Study V. OS after LEA during one and five years was 75.8% (95%CI 73.3- 78.3) and 38.3% (95%CI 34.7-41.7), respectively. Higher index amputation level decreased OS, while multiple amputations associated with improved OS. Higher age, peripheral artery disease and lower GFR reduced both OS and MAFS. In addition, dyslipidaemia and hypertension were associated with improved OS. In Study II, bacterial culture data on patients hospitalised due to DFI at TAUH were analysed. In tissue cultures, Staphylococcus aureus (SA) was the most frequent gram positive cocci (34.8%, n=72), followed by streptococcus betahaemolyticus (BHS, 18.4%, n=38). The percentage of gram negative bacilli (GNB) was 23.2% (n=48). SA and BHS were the most common causative pathogens of bacteraemia (each 32.1%, n=9). GNB was significantly more frequent in ischaemic infection than in nonischaemic infection (40.3% vs. 21.3%, p<0.05). Superficial swab culture had 91.8-92.9 specificity and 66.7-87.5% sensitivity compared to tissue culture. In conclusion, the overall incidence of LEA is increasing due to the rising numbers of BAA. In contrast, the incidence of BKA seems to be decreasing. The outcome after DFI and especially major amputation is poor. BAA is associated with improved prognosis (compared to BKA and AKA) and should be preferred when feasible. In addition, chronic limb threating ischaemia is a serious comorbidity and should be swiftly diagnosed and treated in DFI. The causative pathogens in patients treated at TAUH are congruent with most of the European data that advocate selecting the antibiotic treatment of DFI according to international guidelines

A Comparative study to Assess the Effectiveness of Infra Red Radiation Insulin Dressing and Metronidazole Dressing in Healing of Diabetic Ulcer Foot at MAPIMS

Diabetes is a worldwide health problem. It may begins around twenty years of age and become more prevalent when age get advances. Diabetes has been detected more in urban population but undiagnosed diabetes is most common in the rural people. In India, one in two out of population has diabetes mellitus. Approximately ninety two million of Indian people may get diabetes in the year 2035. Diabetic foot ulcer is one of the serious complications of diabetes mellitus. Eighty four percent people get lower leg amputation because of diabetes. Peripheral arterial disease and neuropathy are the common causes for foot amputation. Statistics shows that twenty five percent diabetic people develop diabetic ulcer foot in the later stage. Fifty percent diabetic population develops infection and need hospitalization in their lifetime. One out five diabetic people is prone to get amputation. The care of chronic non healing ulcer foot is challenging for health team. There are many human studies that searching for efficient and effective treatment for diabetic ulcer foot. This study compared three different interventions towards the management of diabetic ulcer foot. STATEMENT OF THE PROBLEM: A comparative study to assess the effectiveness of Infrared Radiation, Insulin Dressing and Metronidazole dressing in healing of diabetic ulcer foot at MAPIMS OBJECTIVES: 1. To assess the pretest condition of diabetic ulcer foot among patients with Diabetes mellitus. 2. To evaluate the effectiveness of infra-red radiation application, insulin dressing and metronidazole dressing in healing of diabetic ulcer foot among patients with Diabetes mellitus. 3. To compare the effectiveness of infra-red radiation with insulin dressing and metronidazole dressing in healing of diabetic ulcer foot among patients with Diabetes mellitus. 4. To associate the effectiveness of intervention in healing of diabetic ulcer foot with the selected demographic variables. HYPOTHESES: H1- There will be significant improvement in healing of diabetic ulcer foot at the post test. H2- There will be significant differences between infrared radiation, insulin dressing and metronidazole dressing on healing of diabetic ulcer foot. H3 - There will be significant association of post test score on healing of diabetic ulcer foot with the selected demographic variables among diabetic foot ulcer clients. RESEARCH METHODOLOGY: Quasi experimental pretest posttest design was adopted for this study and Non probability consecutive sampling technique was used to select the samples. Based on the sampling criteria totally 225 samples were selected for this study, out of this seventy five subjects were treated with infra-red radiation, seventy five treated by insulin dressing and remaining seventy five were treated metronidazole dressing. First day, three interventional group was assessed by using modified Bates Jensen’s wound assessment tool and same day treatment was started, posttest was done on seventh day and tenth day by using the tool. RESULTS: Infrared Radiation Group: The pretest and post scores of the Infra-red radiation group, that the pretest mean and standard deviation were respectively 51.5067 and 4.21828. At the post test mean and standard deviation were respectively 20.32 and 3.673. The” t” value was 68.352 it is more than table value. The results shows a high level of significance statistically at p<0.001 level. Occupation and education of the diabetic clients had significant influences in the healing of diabetic ulcer foot. Insulin Dressing Group: The pretest and Post-test score of Insulin Dressing in healing of diabetic foot ulcer that Insulin dressing pretest mean score is 50.24 and standard deviation 5.74, post mean score 24.25, standard deviation 4.02 and the ” t” value 45.27 which is greater than table value. The results shows a high level of significance statistically at p<0.001 level. Diabetic client’s Demographic variables like Age, area of residence and family history of diabetes had significant influences in the healing of diabetic ulcer foot. Metronidazole Dressing Group: The pretest and Post-test score of Metronidazole Dressing in healing of diabetic foot ulcer. It reveals that in Metronidazole dressing, pretest and posttest mean scores were respectively 50.3 and 27.06 and the standard deviation were 4.0 and 3.58 respectively and the “t” value was 52.825 which is more than table value. The result shows a high level of significance statistically at p<0.001 level. Diabetic client’s demographic variables like age and area of residence had significant influences in the healing of diabetic ulcer foot. CONCLUSION: These study results shows that all the three interventions were effective in healing of diabetic ulcer but infrared radiation was the most effective method when comparing other two interventions in the healing of diabetic ulcer foot. IMPLICATIONS: The findings of the study have several implications for medical surgical nursing, community health nursing, nursing education, nursing administration and nursing research towards the healing of diabetic ulcer. The study findings help to reduce the complications of diabetic foot ulcer and increase the granulation status of wound. Primary health nurse can plan diabetes education and develop awareness programme regarding risk factors of diabetes and diabetic foot complications. Nursing practice provides a prompt patient care. They will act as a essential role in control of diabetes and care of foot. Nurse educators basically from clinical nursing which gives them, knowledge, skills and attitude of theory. Nurse educators are responsible for teaching current trends in nursing practice in clinical setting. Nurse administrator should plan of programme and strategies about diabetes and diabetic ulcer foot