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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIn an attempt to lower current rates of amputation due to diabetic foot ulcers, the foot care interest group of the American Diabetes Association has published updated management guidelines. This article reviews these literature-based recommendations.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eendocrinology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eprevention \u0026amp; screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ediabetes mellitus\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003EIn an attempt to lower current rates of amputation due to diabetic foot ulcers, the foot care interest group of the American Diabetes Association has published updated management guidelines. Andrew Boulton, MD, FRCP, Manchester Diabetes Center, Manchester, UK, and a co-chair of the Comprehensive Diabetic Foot Exam (CDFE) task force, reviewed these literature-based recommendations.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003E\u201cTo talk about prevention, we need to talk about causality,\u201d began Dr. Boulton, \u201cand 80% of all amputations are preceded by foot ulcers.\u201d Of the preconditions for this type of wound, neuropathy is the most salient component. However, for an ulcer to form, a triad of conditions is commonly present: neuropathy, deformity, and trauma (Reiber et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 1999).\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIdentifying the At-Risk Foot\u003C\/h2\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe most prevalent risk factors that were identified by the CDFE include neuropathy, peripheral vascular disease, prior ulceration, foot deformity, and prior amputation. A new and profound addition to this list is end-stage renal disease; recent data suggest that up to 40% of dialysis patients have past or current ulceration (Game et al. \u003Cem\u003ENephrol Dial Transplant\u003C\/em\u003E 2006).\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EA careful general exam, including patient history, will reveal the majority of the aforementioned risks, though neuropathy remains a primary concern, because it may not be readily detected or even be a noticeable cause of concern to the patient. The recommended techniques for the detection of neuropathy are the use of monofilaments (MFs), vibration, pin prick, ankle reflexes, and quantitative sensory testing (eg, biothesiometer).\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EMFs are the most widely used diagnostic tool and have a proven track record but also have several drawbacks: the issue of accuracy if the MFs buckles at 10 g, an uncertainty about how many sites to test, and the time-consuming nature of the procedure.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ECDFE recommendations for neuropathy assessment (or loss of sensory protection; LOPS) are as follows:\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003E10 g monofilament tested at 4 sites (MTH 1, 3, and 5 and hallux plantar)\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EIn conjunction with one of the following:\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-10\u0022\u003E128 Hz tuning fork vibration (hallux)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-11\u0022\u003Epin prick sensation (dorsal hallux)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-12\u0022\u003Eankle reflexes\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n               \u003Cp id=\u0022p-13\u0022\u003Evibration perception threshold\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe foot should then be assessed for healthy vasculature (peripheral artery disease; PAD), and if any pulse is absent, further investigation with an ankle brachial index is warranted.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EFollow-up based on stratified risk is recommended:\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11278\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11278\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11278\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EFinally, Dr. Boulton highlighted several recent studies that have investigated inflammation as a precursor to ulceration and heat as a signature of the presence of inflammation (Lavery et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2007; Armstrong et al. \u003Cem\u003EAm J Med\u003C\/em\u003E 2007). These investigations show that an increase in foot temperature correlates to more than a 3-fold increase in the risk of ulceration. Several instruments are now available that can be used by the patient for self-monitoring of foot temperature, including the handheld TempTouch\u00ae and TempStat, a liquid crystal pad that the patient stands on.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/7\/27.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmcbd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmcbd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}