Associations of foot ulceration with quality of life and psychosocial determinants among patients with diabetes; a case-control study.

BACKGROUND: Patients with diabetic foot ulcers may have a lower quality of life. The objective was to compare the quality of life and its psychosocial determinants among patients with and without diabetic foot ulcers. METHODS: A case-control study was conducted in 2017 among patients with (cases) and without (controls) diabetic foot ulcers. The study tools included the World Health Organization's Quality of Life scale (WHOQOL-BREF), the Hospital Anxiety and Depression (HAD) scale for anxiety and depression, the Patient Health Questionnaire Physical Symptoms (PHQ-15) for the severity of somatic symptoms, and the Summary of Diabetes Self-Care Activities (SDSCA) measure for self-management. RESULTS: A total of 209 patients (45 cases and 164 controls) were included. The average age was 56.2 ± 11.7 years, and 55.5% were female. The average scores of WHOQOL-BREF, PHQ-15, and SDSCA were 74.4% ± 12.1% and 8.1 ± 6.1, and 30.4 ± 21.8, respectively. The prevalence of anxiety and depression were 19.6 and 24.9%, respectively. SDSCA was the only psychosocial determinants higher in cases than controls (mean difference = 15.0, 95% CI = -8.0-22.0). The correlation coefficients of WHOQOL-BREF scores with anxiety, depression, and PHQ-15 scores in all patients were - 0.559 (p < 0.001), - 0.582 (p < 0.001), and - 0.532 (p < 0.001), respectively, with similar numbers in both groups. In multivariate analysis, only the association between quality of life and depression was maintained. CONCLUSION: Quality of life and psychosocial determinants with the exception of self-management were not associated with diabetic foot ulcers. Depressive symptoms were independent determinant of poor quality of life, irrespective of the status of diabetic foot ulcers.

Health-related quality of life among adults living with diabetic foot ulcers: a meta-analysis.

PURPOSE: To undertake a systematic review of the literature to investigate the HRQOL among adults living with DFUs. METHODS: A systematic search of the medical and nursing/health content databases including MEDLINE, CINAHL, and PsycINFO was conducted up to November 2018. The methodological quality of each study was assessed independently by all authors using the Joanna Briggs Institute checklist. Data analysis was conducted using the Comprehensive Meta-analysis software. All analyses were performed using random-effects models and heterogeneity was quantified. RESULTS: A total of 12 studies were included in the review. Overall, the HRQOL of participants in the studies was poor on four of eight subscales in the SF-36: physical functioning (mean = 42.75, SE 1.5); role physical (mean = 20.61, SE 3.4); general health (mean = 39.52, SE 1.7); and vitality (mean = 45.73, SE 2.8). In addition, presence of pain, high levels of C-reactive protein (> 10 mg/L), ulcer size > 5 cm2, Ankle Brachial Index < 0.9, high glycosylated haemoglobin and body mass index > 25 kg/m2 were associated with poorer HRQOL in people with DFUs. CONCLUSIONS: This review has provided evidence indicating that people with DFUs have a significantly lower HRQOL. Evidence-based interventions to improve the HRQOL in this group of people is needed.

Validity and feasibility of the wound-QoL questionnaire on health-related quality of life in chronic wounds.

Chronic wounds have a major socioeconomic impact due to their frequency, chronicity, and societal costs. Patients experience substantial quality of life (QoL) impairments. The use of questionnaires for a continuous assessment of QoL and resulting interventions to improve the situation of the individual are an important cornerstone of a guideline-based wound care. The aim of this study was to investigate the validity of the Wound-QoL questionnaire. Patients with chronic wounds from two different centers were included in the prospective study. All patients completed the Wound-QoL and two other QoL questionnaires (European Quality of Life-5 Dimensions, EQ-5D, and Freiburg Life Quality Assessment for wounds, FLQA-wk) at baseline and at two more time points (4 and 8 weeks, respectively). Wound status was defined with an anchor question. Two hundred and twenty-seven patients (48.5% women) participated in the study. Mean age was 66.9 years (range 17-96, median 69.5). Indications were venous leg ulcers (40.1%), pyoderma gangraenosum (14.1%), diabetic or ischemic foot ulcers (5.3%), pressure ulcers (2.6%), and other etiologies (30.0%). The Wound-QoL showed good internal consistency, with high Cronbach's alpha in all the subscales and in the global scale in all time points (>0.8). Convergent validity was satisfactory since there were significantly (p ≤ 0.001) good correlations with the EQ-5D (range = 0.5-0.7) and FLQA-wk global score (r > 0.8) at every time point. Responsiveness was high, too. The Wound-QoL is a simple, valid tool for the longitudinal assessment of QoL in patients with chronic wounds. This questionnaire is suitable for use in clinical trials, quality of care studies and clinical routine.

Quality of life in patients with diabetic foot ulcer in Visegrad countries.

AIMS AND OBJECTIVES: To identify the quality of life of patients with diabetic foot ulcers in the Visegrad countries. BACKGROUND: The diabetics with foot ulcers are principally evaluated on the basis of physical parameters, but this does not always reveal much about the patient's experience of life with ulceration. DESIGN: The cross-sectional study. METHODS: The standardised generic questionnaire World Health Organization Quality of Life-BREF was used. The sample was made up of 525 participants and the calculations were performed using the IBM spss statistical program. RESULTS: The significant negative correlations between demographic data such as age, duration of diabetes mellitus, duration of diabetic ulceration treatment and a lower level of quality of life were found across the sample. The statistically significant differences according to clinical characteristics such as Wagner classification, frequency of foot ulcers, present peripheral vascular disease and pain in terms of quality of life were also revealed. Significant differences of quality of life among Visegrad countries were revealed: Hungary's participants had a worse quality of life than others, while Slovak participants expressed lower satisfaction with their health than Czech. CONCLUSIONS: Socio-demographic factors and clinical characteristics influence the quality of life of patients with diabetic foot ulcer. Significant differences between patients of Visegrad countries were found in all domains of quality of life: physical, psychological, social and environmental. RELEVANCE TO CLINICAL PRACTICE: The quality of life of patients with diabetic foot ulcer reflects the conditions and healthcare system in each of the Visegrad countries. We have to respect socio-demographic factors and clinical characteristics in nursing care. This could have an impact on managing patient care not only with regard to their diabetic foot ulcer but also with regard to the patient as a personality with their own problems in relation to physical, psychosocial and environmental conditions.

Health beliefs surrounding leprosy induced foot ulceration; an exploratory qualitative study from South Nepal.

UNLABELLED: Leprosy is a complex and multi-faceted disease responsible for significant disability in several endemic countries. Physical impairments caused by leprosy are often amplified by local sociocultural phenomena in many parts of the world. In Nepal, sociocultural phenomena such as stigmatisation and health beliefs affecting treatment compliance and health seeking behaviours are known to play an important role in the acquisition of disability. Foot-ulceration is reported to be a common sequelae of leprosy, however, presently little research has been published investigating the potential influence of patient beliefs on management of foot ulceration in leprosy affected persons. OBJECTIVE: In light of this we conducted an exploratory qualitative study to investigate the health beliefs held by patients with foot ulceration at a Leprosy hospital in Nepal. METHODS: A mixture of open-ended interviews (n = 21), three focus groups and a series of field observations were used to explore the explanatory models of foot ulceration thought to be used by leprosy affected people to understand and explain this specific comorbidity. RESULTS: Our findings indicated that a wide range of health beliefs were present in our sample, many of which lie outside of the biomedical understanding of illness. This included a range of non-biomedical beliefs regarding wounds and widespread application of the traditional 'hot-cold' model of illness used to explain foot ulceration. DISCUSSION: The findings of this study appear to suggest many beliefs held by leprosy affected persons concerning foot ulceration are highly complex, with some expressed beliefs potentially having a negative impact on self-management of ulceration.

Midfoot Charcot Neuroarthropathy in Patients With Diabetes: The Impact of Foot Ulceration on Self-Reported Quality of Life.

INTRODUCTION: Charcot neuroarthropathy (CN) and diabetic foot ulceration (DFU) are serious complications of diabetes mellitus (DM) that can result in infection, hospitalization, amputation, and have been shown to negatively affect quality of life (QOL). To the best of our knowledge, there are no studies in the literature that have specifically compared QOL in patients with diabetic CN without DFU to a group of patients with diabetic CN and concurrent DFU. The aim of this study was to compare self-reported assessments of QOL in patients with CN to a group of patients with CN and concomitant midfoot ulceration. MATERIALS AND METHODS: We compared a group of 35 diabetic patients with midfoot CN and no ulcer to a group of 22 diabetic patients with midfoot CN and concurrent DFU. Self-reported outcome was assessed using the Medical Outcome Study Short Form 36 (SF-36) health survey and Foot and Ankle Ability Measure (FAAM). RESULTS: No significant differences were found when comparing the 2 groups utilizing the SF-36 and FAAM with the exception that CN patients without foot ulcers had lower mean scores on the Bodily Pain Subscale. Both groups demonstrated negative impact on physical QOL and lower extremity function to a greater degree than mental QOL. CONCLUSION: The presence of ulceration does not appear to significantly impact QOL in patients with CN when compared to patients with CN without ulceration. LEVELS OF EVIDENCE: Prognostic, Level III: Case control.

The ghost of Nora Batty: A qualitative exploration of the impact of footwear, bandaging and hosiery interventions in chronic wound care.

OBJECTIVE: To explore the impact of footwear, bandaging and hosiery interventions in the everyday lives of women and men undergoing treatment for chronic, complex wounds in a city in England, UK. METHODS: This study draws on data generated in semi-structured interviews with patients exploring outcomes and impacts of undergoing treatment for leg and foot ulcers undertaken as part of a UK National Institute for Health Research funded study. Footwear, bandaging and hosiery are explored here as aspects of material culture, not only in functional terms as a treatment supporting or hindering healing but also as part of the means by which people receiving treatment for two of the most common complex, chronic wounds, leg ulcers and foot ulcers, negotiate and understand their embodied selves in everyday life. FINDINGS: Physical and social discomfort associated with interventions can lead to ambivalence about effectiveness. Not being able to dress appropriately impacts on the ability of people to feel comfortable and take part in special occasions and everyday events. In this context, the removal of bandaging or refusal to wear support hosiery which may be viewed as 'non-compliance' by a health professional may feel like a strategy of self-care or self-preservation from a patient perspective. DISCUSSION: The study of material culture explores how inanimate objects work and how they are worked with in carrying out social functions, regulating social relations and giving symbolic meaning to human activity. The interviews show some of the ways in which footwear, hosiery and bandaging play a role in controlling the boundaries between the private (wounded and potentially socially unacceptable smelly, leaky, embodied), self and the public presentation of self.

Experiences of healthcare provision for foot ulceration occurring in people with rheumatoid arthritis.

BACKGROUND: Participants with rheumatoid arthritis (RA) report that foot ulceration has an impact on their health-related quality of life (HRQL) across physical, social and psychological domains. What is not known is how experiences of healthcare provision influence HRQL. The present study set out to map the patent journey while integrating the impact on HRQL. METHODS: A purposive sample of RA patients with open foot ulceration was recruited from podiatry clinics in West Yorkshire (UK) between May 2008 and June 2009. Patients with diabetes were excluded (the impact of foot ulceration in this group is well established). In-depth interviews were taped and transcribed. A framework approach to data management was used to facilitate a case- and theme-based analysis. RESULTS: Twenty-three RA patients (18 female, five male; aged 45-88 years) participated. Two themes and five sub-themes were identified. The patient journey theme comprised the following sub-themes: access to care; knowledge acquisition; care pathways and continuity of care. Patient-professional relationships comprised the sub-themes: therapeutic patient-professional relationships and task-orientated care. The journey took a highly variable course that was influenced by patient-specific factors (past experience of ulceration; symptomology; knowledge and self-efficacy); service-specific factors (access to care and care pathways) and professional-specific factors (knowing and trusting someone; holism). CONCLUSIONS: The present study highlights the need for clearer care pathways for patients affected by foot ulceration improved patient education and better coordination of care.

Cognitive function is not associated with recurrent foot ulcers in patients with diabetes and neuropathy.

OBJECTIVE: To study whether there is an association between cognitive impairment and the relapse rate of foot ulcers in diabetic patients and those with previous foot ulcers. RESEARCH DESIGN AND METHODS: This single-center prospective study assessed the association of cognitive function and risk for ulcer relapse in 59 patients with diabetes (mean age 65.1 years, diabetes duration 16.5 years, and A1C 7.4%), peripheral neuropathy, and a history of foot ulceration. Premorbid and current cognitive functions were measured (multiple-choice vocabulary test [Lehrl], number-symbol test, mosaic test [HAWIE-R], and trail-making tests A and B [Reitan]). Prevalence of depression was evaluated retrospectively (diagnoses in patient files or use of antidepressive medication). Patients were re-examined after 1 year. RESULTS: Three patients (5%) died during follow-up (one of sepsis and two of heart problems). The remaining 56 patients (48%) developed 27 new foot ulcerations (78% superficial ulcerations [Wagner stage 1]). Characteristics of patients with and without ulcer relapse were not different. In a binary logistic regression analysis, cognitive function is not predictive of foot reulceration. CONCLUSIONS: Cognitive function is not an important determinant of foot reulceration.

A holistic approach to the management of a neuropathic plantar ulcer.

While pressure relief is a vital component of the treatment of neuropathic plantar foot ulcers, many patients are reluctant to wear offloading devices. Healing is more likely to occur if the patient is happy with its appearance and comfort.

The foot in perspective.

The diabetic foot constitutes a tremendous challenge for patients, caregivers and the health care system. The International Consensus Document of 1999 was a milestone in the recognition of the importance and consequences of the diabetic foot. Since then, many original papers have been published in this area. Large cohort studies have given us a deeper understanding regarding factors related to the outcome of diabetic foot ulcers: according to these studies, the severity of diabetic foot ulcers is greater than previously reported. More than 50% of individuals' foot ulcers have signs of infection at admission, and one-third have signs of both peripheral artery disease (PAD) and infection. The co-morbidities increase significantly with increasing severity of the foot disease. However, the trend in all these studies is a successive improvement in healing rate (50-60% at 20 weeks follow-up, > 75% at 1 year). It is important to differentiate between neuropathic and neuro-ischaemic ulcers with regard to factors related to outcome and co-morbidities.Recent research has emphasized the importance of psychological factors in the development and outcome of diabetic foot ulcers. Studies have shown that perceptions of the individual's own risks based on symptoms, and their own beliefs in the efficacy of self-care, can affect foot-care practice.The importance and influence of the health care organization and reimbursement should not be underestimated, both in the prevention and management of diabetic foot lesions. The diabetic foot should be considered a lifelong condition, as having had one ulcer dramatically increases the risk of developing a new ulcer. In an individual with diabetes and a foot ulcer, the ulcer should be considered as a sign of multi-organ disease, and a holistic approach to both management and prevention is recommended.

A comparison of the health-related quality of life in patients with diabetic foot ulcers, with a diabetes group and a nondiabetes group from the general population.

OBJECTIVE: The aim of this study was to describe health-related quality-of-life (HRQL) in patients with diabetic foot ulcers by comparing their HRQL with that of a sample from the general population without diabetes (general population) and a subgroup with diabetes (diabetes population), and to examine the differences between groups by sociodemographic characteristics and lifestyle factors. DESIGN AND METHODS: A cross-sectional study was made of 127 adults with current diabetic foot ulcer, recruited from six hospital outpatient clinics, a control sample categorized as a diabetes population (n = 221) from the Norwegian Survey of Level of Living, and a sample from the general population (n = 5903). Data on sociodemographic characteristics (sex, age, cohabitation, education and employment) and lifestyle (body mass index [BMI] and smoking status) and HRQL (SF-36) were obtained. RESULTS: In all the SF-36 subscales and in the two SF-36 summary scales, the patients with diabetic foot ulcer reported significantly poorer HRQL than the diabetes population. The most striking differences were for role limitation-physical (32.1 vs. 62.2, p < 0.001), physical functioning (57.5 vs. 77.3, p < 0.001) and role limitation-emotional (57.4 vs. 72.0, p < 0.001). The patients with foot ulcer had significantly lower HRQL than the general population on all scales, and in particular on role limitation-physical (32.1 vs. 74.3, p < 0.001), physical functioning (57.5 vs. 85.2, p < 0.001) and general health (50.1 vs. 74.3, p < 0.001). The most important sociodemographic characteristic that differed between the diabetic foot ulcer patients and the diabetes population was that significantly more of the foot ulcer patients were men living alone. The largest differences between the foot ulcer patients and the general population were that more of the foot ulcer patients were men, older, living alone, less well educated, and not working. The diabetic foot ulcer patients, the diabetes population and the general population differed in BMI: 28 kg/m(2) in the foot ulcer patients, 27 kg/m(2) in the diabetes population and 25 kg/m(2) in the general population. CONCLUSION: Diabetic foot ulcer patients had much worse HRQL compared with the diabetes population and the general population, especially in physical health. Foot ulcer patients were more often men living alone, and obesity was a problem in both the foot ulcer patients and the diabetes population.

Quality of life and clinical correlates in patients with diabetic foot ulcers.

OBJECTIVE: To compare the Health Related Quality of Life (HRQL) of French diabetic patients with and without foot ulcers and to determine the factors influencing disease-specific HRQL for those with foot ulcers. METHODS: 355 diabetic patients, including 239 with foot ulcers (group 1) and 116 without foot ulcers (group 2) were studied in a cross-sectional setting. Socio-demographic and clinical variables were recorded and HRQL was evaluated using a generic HRQL questionnaire (SF-36) for all subjects. For group 1, the severity of foot ulcers was assessed according to Wagner's classification, and disease-specific HRQL assessed using the Diabetes Foot Ulcer Scale (DFS). RESULTS: HRQL was found to be significantly lower (P = 0.0001) in group 1 than in group 2 for all domains of the SF-36. Independent inverse relationships were found between good HRQL in the DFS domain of Leisure and Wagner grade (OR = 0.136 [0.029-0.467]) as well as the number of foot ulcers (OR = 0.365 [0.191-0.678]). Age was significantly associated with several DFS domains including Daily Activities, Physical Health and Dependence. CONCLUSION: Our findings suggest that the number and severity of foot ulcers are associated with patient HRQL, especially in terms of leisure activity disruption and constraints due to treatment. These findings have implications for the evaluation, planning and management of patient care in diabetic foot disease.

Caminhando sem sentir: representaçöes de pessoas com hanseníase / Walking without feeling: representations for leprosy people

Este estudo explora as relações entre as representações sociais de pacientes com hanseníase sobre o seu pé anestésico e a utilização de comportamentos de autocuidado para a prevenção e cura da úlcera plantar. Os resultados revelaram percepções deste membro: "normal", "morto" e "vulnerável". As duas primeiras representações são inadequadas do ponto de vista da prevenção da úlcera plantar na medida em que não despertam em seus portadores a atitude de alerta com relação aos fatores de risco e a necessidade da prática de autocuidado. A representação do pé anestésico como membro "vulnerável" leva à preocupação com os cuidados para evitar o aparecimento ou agravamento do processo ulcerativo, porém, nota-se a existência de várias barreiras internas e externas que impedem a incorporação e execução adequadas destes comportamentos de autocuidado no cotidiano destas pessoas. Pode-se concluir que a educação em saúde, a divulgação de informações corretas sobre a doença, o processo da úlcera plantar e os comportamentos de autocuidado são imprescindíveis para a prevenção e cura da úlcera plantar. Além disso, a ajuda psicossocial destes pacientes e familiares e o relacionamento entre a equipe de saúde e os usuários são requisitos básicos para que tais barreiras sejam identificadas e superadas, levando a maior aderência ao tratamento e prática dos comportamentos de autocuidado

An approach to leg and foot ulcers: a brief overview.

Legs and feet are susceptible to ulcer formation. Three main types of lower extremity ulcers are venous, arterial, and neurotropic. Ulcer care should include treatment of the underlying cause, moist interactive healing, and quality of life (pain control). If the ulcer shows no signs of healing in 6 to 12 weeks, the wound should be biopsied, the diagnosis confirmed, and a plan of care instituted. In certain instances, biologicals may be used. A graphical representation of an approach to ulcer care, in addition to common differential diagnoses of leg ulcers, is presented.