From the ACP Diabetes Care Guide

This illustrated worksheet enables you to record the results of filament tests for 10 visits.

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This interactive tutorial demonstrates the proper use of a 10g monofilament to perform a foot sensory examination.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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Short patient survey about current patient practices regarding the care of their feet.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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Use this copier-ready master to create your own stickers to place on the medical record. This master is designed to be reproduced on brightly colored 1" x 2-5/8" labels from Avery.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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Pocket-size reminder card of the essential elements for performing a diabetic foot examination with monofilament.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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This single page contains a Statement of Certifying Patient for Therapeutic Footwear and a Prescription Form for Therapeutic Footwear.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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From the ACP Diabetes Care Guide

Persons with diabetes are at increased risk for macrovascular disease; microvascular disease, including retinopathy and nephropathy; peripheral and autonomic neuropathies; and lower extremity disease.

• Diabetic retinopathy is the leading cause of noncongenital blindness among adults.
• Diabetes is the most common cause of endstage kidney disease in the United States, especially among Native American, Hispanic, and African American persons. One quarter to one third of patients with type 1 or type 2 diabetes develop some degree of nephropathy.
• Diabetes doubles the risk for cardiovascular disease in men and triples it in women (data from the Multiple Risk Factor Intervention Trial [MRFIT]).
• Patients with diabetes are several-fold more likely to have peripheral arterial disease than patients without diabetes.
• Peripheral arterial disease and foot ulcers in patients with diabetes account for two thirds of all nontraumatic amputations performed in the United States.

Screening for and prevention of these complications are fundamental to the care of patients with diabetes and are important components of quality of care initiatives for diabetes.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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This PowerPoint presentation provides information on prevention of diabetic foot ulcers and lower extremity amputation with many clinical photographs and practical management tips.

"...the enormity of the global burden of diabetic foot disease...this much neglected, but potentially devastating, complication of a disease that is reaching epidemic proportions...Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday..."

- Lancet. 2005;366:1674

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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The Semmes-Weinstein 5.07 monofilament exerts 10 grams of force when bowed into a C-shape against the skin for one second. Patients who cannot reliably detect application of the 10-g monofilament to designated sites on the plantar surface of their feet are considered to have lost protective sensation. That is to say, these patients cannot reliably feel discomfort on their feet and take appropriate avoidance action to prevent tissue damage. This loss of protective sensation is not equivalent to the total absence of sensation.

Patients with diabetes who have lost protective sensation as measured by standardized testing with the 10-g monofilament are at significantly increased risk to develop a foot ulcer that can lead to subsequent lower extremity amputation. Patients who have lost protective sensation are candidates for regular podiatric care, intensive foot care education, visual inspection of the feet at every office visit, and in some cases, therapeutic footwear.

This document contains additional information, images, diagrams and suggested techniques for using the 10-g monofilament and for using the 128-Hz tuning fork.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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A list of organizations that have 10g monofilaments available.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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The nurse or medical assistant plays a key role in the prevention of serious foot problems in persons with diabetes. Team care can significantly reduce the occurrence of diabetic foot ulcer and amputation. There are two essential components to this team care:

• Annual, Comprehensive Foot History and Examination to Identify High-Risk Patients
• Intensive Intervention in High-Risk Patients to Prevent Foot Ulcer

This document contains a concise description of various roles that office staff can assume in providing team care for patients with diabetes and risk for diabetic foot ulceration.

NOTE: This content was excerpted from the ACP Clinical Skills Module, Diabetic Foot Ulcers.

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This DVD and CD-ROM-based teaching module includes everything necessary to prepare and present a workshop that will teach participants how to efficiently screen persons with diabetes for the major risk factors for diabetic foot ulcers.

Participants will learn how to provide effective interventions in the office setting to prevent foot ulcer and subsequent amputation.

Included in the workshop are an annotated reference list, a diabetes foot care patient questionnaire, forms to record the foot examination, education tools for office staff and patients, instructions for use of the 10-gram monofilament and 128-Hz tuning fork, and resources to obtain 10-g monofilaments.

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Discuss how to efficiently screen persons with diabetes for the major risk factors for diabetic foot ulcers.

Discuss how to provide effective interventions in the office setting to prevent foot ulceration in diabetic persons at high risk.

Discuss how to optimally assess and triage diabetic persons with a new foot ulcer in the office setting.

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Describe four common injuries seen with the diabetic foot.

Describe the wound color classification: RYB (red, yellow, and black wound).

Describe four components of wound bed preparation.

Describe moist wound healing and advanced wound care dressings used in management of the neuropathic foot.

Discuss off-loading options for management of the foot ulcer.

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Careful examination of the feet is an important part of the diabetic assessment because patients with diabetes frequently have peripheral vascular disease and peripheral neuropathy. Both these conditions, especially when they coexist, place the diabetic foot at extreme risk for ulceration, infection, and ultimately, possible amputation.

The clinical evaluation begins with inquiry regarding the presence of symptoms that suggest vascular insufficiency, such as cold feet, claudication, and leg fatigue on ambulation. The recognition of symptoms may be challenging in older, sedentary patients who may have other conditions that impair mobility.

The physical assessment includes gross inspection for deformities of the arch, toes, and nails. The overlying skin should be evaluated for the presence of dryness and fungal infection, which may both precipitate loss of normal defense mechanisms and bacterial infection.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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Question
How accurate is magnetic resonance imaging (MRI) for diagnosing foot osteomyelitis?

Conclusion
Magnetic resonance imaging has good diagnostic performance for foot osteomyelitis.

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Question
In healthy or immunosuppressed persons, what is the diagnostic accuracy of commercially available interferon-γ release assays (IGRAs) for diagnosing latent tuberculosis (TB)?

Conclusion
Commercial interferon-γ release assays have high specificity but less than optimal sensitivity for detecting latent tuberculosis in healthy or immunosuppressed persons.

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Question
In patients with type 2 diabetes, does pioglitazone reduce cardiovascular events, other adverse events, and mortality or improve health-related quality of life?

Conclusions
Based on 1 randomized trial, pioglitazone does not reduce risk for mortality or cardiovascular events in patients with type 2 diabetes. Some evidence exists that pioglitazone increases risk for such adverse events as weight gain, decrease in hemoglobin level, and edema.

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Question
In patients with type 2 diabetes and microalbuminuria, is a targeted intensive multifactorial intervention more effective than conventional treatment?

Conclusion
In patients with type 2 diabetes and microalbuminuria, a targeted, long-term, intensified, multifactorial intervention using behavioral modification and polypharmacologic therapy was more effective than conventional treatment for reducing cardiovascular and microvascular events.

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Question
In patients with diabetic foot ulcer, what is the effectiveness of different debridement methods?

Conclusion
In patients with diabetic foot ulcer, debridement using hydrogel seems to be more effective than standard wound care for wound healing and is associated with fewer complications.

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Question
Are systemic and topical antimicrobial agents effective for healing chronic wounds (venous leg ulcers, pressure ulcers, diabetic foot ulcers, and pilonidal sinuses)?

Conclusion
Healing of chronic wounds is improved by some topical antimicrobial agents, but few systemic agents show improvements.

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Question
Does aggressive edema reduction with a foot-level mechanical compression device improve healing of foot infection in patients with diabetes mellitus?

Conclusion
A foot-level mechanical compression device reduced edema and improved healing of foot ulcers in patients with diabetes mellitus.

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