Does Cognitive Dysfunction Impact Diabetic Foot Ulcer Outcomes?

By Christopher Girgis, DPM

The prevalence of cognitive dysfunction in patients with diabetes can complicate their adherence to self-care behaviors, but there is little understanding about how cognitive dysfunction may impact outcomes. Our recent abstract presented at the Symposium on Advanced Wound Care (SAWC) Fall evaluated the effect of cognitive dysfunction on outcomes in individuals with diabetic foot ulcers.¹

Our 6-year retrospective study focused on 56 patients with ulcer and cognitive dysfunction (mean age 71.9 years and 75% male) and 68 patients with ulcer without cognitive dysfunction (mean age 56 years and 76% male).¹ At 6 months, 32% (18) of patients with ulcers and cognitive dysfunction were healed compared to 72% (49) of patients with ulcers without cognitive dysfunction. The study also found 17.8% (10) of patients with ulcers and cognitive dysfunction versus 5.9% (4) patients with ulcers without cognitive dysfunction underwent higher level amputations, and 57.1% (32) of patients with ulcers and cognitive dysfunction versus 33.8% (23) of patients with ulcers without cognitive dysfunction required at least one foot-related admission.

Our study concluded that individuals with a diabetic foot ulcer and cognitive dysfunction are at elevated risk of major amputation, hospitalization, and suffer from non-healing more often than those without cognitive dysfunction at 6 months after diagnosis.¹

Cognitive function is crucial for diabetes self-management but in the diabetic foot literature, there’s limited evidence to support this, although when you think about it, I can’t think of a larger and more difficult self-care behavior than managing a foot ulceration. However, there have not been many studies to evaluate that.

I have seen this phenomenon in my own practice, and that is a major reason why I am very committed to this work. In my experience with patients who have diabetic foot ulcerations, it’s relatively common to encounter individuals who show signs of cognitive impairment, which may affect their ability to follow through on what I’m recommending for them to do. However, a lot of these patients go without a formal diagnosis, so it’s challenging to then address this effectively.

This raises important questions. If these patients do perform poorly with their wound care and have poor outcomes, how can we best screen cognitive impairment? What additional support can we offer to these patients to help them improve their outcomes?

DPMs can do a number of things to help decrease the risk of complications in this patient population. If we have any concern about a patient’s cognitive status, we should not just brush it away. At the very least, we should begin with a conversation with the primary care provider to determine if additional evaluations or referrals like a referral to neurology, if you’re noticing significant changes over a specific period of time, would be necessary. DPMs can also involve a caregiver or consulting social work to see if there’s additional support we can offer these patients such as case management or home health services.

Finally, tailor your educational modalities and patient follow-ups to keep a closer eye on patients and a closer follow-up so you can more specifically help and offer these patients increased support.

I think there’s a lot of opportunities for future prospective work in this area as it relates to how we can best screen this patient population in the podiatry clinic and what evidence-based algorithms can we apply and deploy for these patients to ultimately improve outcomes.

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Dr. Girgis is a Clinical Assistant Professor and podiatrist at the University of Michigan.

Reference
1.    Girgis C, Behme S, Holmes C, O’Dell B, et al. Does cognitive dysfunction impact diabetic foot ulcer outcomes? Presented at Symposium on Advanced Wound Care (SAWC) Fall, Las Vegas, NV, 2024.

Educating Patients With Diabetes on Their Podiatric Medical Care

By Rebecca E. Cohen, MPH

Diabetes is a chronic disease that continues to increase in prevalence globally. Patients with diabetes can develop foot-related issues, including infections, ulcerations, and gangrene, which can result in amputation and even death. Despite the well-known impact that early intervention in podiatric medical care can have on the outcome for patients with diabetes, it remains unclear why there is not more of a clinical emphasis on the importance of early podiatric referral for not only patients with diabetes but also patients with prediabetes. The importance of podiatric medical care for the prevention of adverse outcomes and on proper diabetic foot care is a public health issue that can truly improve health outcomes for patients.

Our survey, presented as an abstract at the Symposium on Advanced Wound Care (SAWC) Fall, included responses by 51 medical professionals: 33 were in podiatry, 14 were in internal medicine/primary care, and 4 were in endocrinology.¹ Twenty-eight of 51 respondents said patients with diabetes should be referred to podiatry for a diabetic foot check, although the timeline for referral after diagnosis of prediabetes varied. Thirty-four said patients with prediabetes should have a diabetic foot check once a year. Forty-one respondents said once diagnosed with diabetes, patients should be referred to podiatry for routine diabetic foot checks and 36 said even if a patient with diabetes is asymptomatic for podiatric symptoms, they should still be referred to podiatry.

Thirty-two respondents answered that it is better to educate patients immediately at an initial visit about all possible complications associated with prediabetes/diabetes as compared to slowly educating patients over time.¹ The majority of respondents said the best way to educate patients about healthcare included verbal discussions and 24 said they use the teach-back method to confirm patient understanding. In the teach-back method, physicians have the patient explain back to the healthcare provider what the provider previously taught them regarding their health and treatment plan. It allows healthcare providers to identify any potential misunderstandings and correct the important information being shared with the patient about their diagnosis and health plans.

Future research on this topic can lead to the development of standardized clinical care protocols for the timing of prediabetes and diabetes diagnosis as well as the referral timeline for podiatric medical care in order to encourage health promotion and disease prevention of diabetes. Each patient’s situation is unique, but we should identify patients with diabetes should early and refer them to podiatric medical professionals for an initial visit to pause the progression of their disease and decrease the possibility of adverse outcomes later.

Additionally, by effectively communicating with patients and educating them about their potential complications associated with uncontrolled diabetes, many patients can learn how to properly manage their diabetes diagnosis and have improved outcomes for their health and overall well-being.
 
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Rebecca E. Cohen, MPH, is a current fourth-year podiatric medical school student at New York College of Podiatric Medicine.

Reference
1.    Cohen RE, Markinson BC, Iorio AR. Diabetic education and initiation of podiatric medical care: A survey of podiatrists, endocrinologists, and internal medicine primary care professionals. Presented at Symposium on Advanced Wound Care (SAWC) Fall, Las Vegas, NV, 2024. 

How an Innovative Treatment for Acute Traumatic Wounds Helped a Ukrainian Combat Soldier

By Rostylav Bublii, MD

Ukrainian health facilities are overwhelmed with a staggering influx of seriously wounded soldiers on a daily basis. With over 30,000 new injuries per month and over 500,000 casualties to date, the demand for effective wound management is urgent. Our study, presented at SAWC Fall, evaluates the efficacy of a commercially available, shelf-stable, extended-wear transforming powder dressing (TPD) in a Ukrainian combat hospital for treatment of acute, traumatic wounds.¹  

A 34-year-old male sustained a combat injury from a shrapnel embedded deep into the upper anterior thigh near the groin.¹ His hospital course was complicated by hematoma and necrotic tissue, which was excised on day 2 after injury, resulting in a 5x2x2 cm contaminated wound that surgeons treated with TPD.  

TPD aggregates upon hydration with fluids to form an extended wear (up to 30 days) moist, oxygen-permeable barrier that helps to cover and protect the wound from contamination while facilitating the flow of excess exudate through vapor transpiration. TPD can be topped off as required and secured with simple secondary dressings in areas of high exudation or friction. As the wound heals, TPD dries and flakes off.

The soldier experienced no pain after TPD application, and required no oral pain medications.¹ He returned to duty within one week, 50% sooner than the anticipated 15 days. The wound healed in 24 days with no primary dressing changes and only 2 additional top-offs of TPD, an average of once every 8 days instead of twice daily.

I used Altrazeal (Altrazeal Life Sciences) for treating wounded military for a few reasons. This TPD is very quick. You just need a little bit of water and it can cover the damaged skin and prevent contamination with microbes. It’s very helpful in a field hospital where you don’t have a lot of resources. This product accelerates the patient’s discharge home.

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Rostylav Bublii, MD, practices at City Clinical Hospital in Dnipro, Ukraine.

Reference
1. Bublii R, St. John SR, Samotowka M. New treatment option for acute traumatic wounds resulted in reduced pain, length of stay, and frequency of dressing changes: a case study from a Ukrainian combat hospital. Presented at Symposium on Advanced Wound Care (SAWC) Fall, Las Vegas, NV, 2024.

Correcting Deformity in a Complex Wound Care Patient With Multi-Plane Ex Fix

By Rimvydas A. Statkus, DPM, FACFAS

A combination of surgical intervention, external fixation, cellular- and tissue-based products (CTPs), and other advanced modalities is often required for patients with complex medical conditions for successful limb salvage. Our case report, presented at SAWC Fall, exemplifies that one needs to consider a complete clinical picture for long-term limb salvage.¹

The complicated 54-year-old patient in our case report had multiple comorbidities, significant varus deformity, a complex wound, and was at high risk for amputation of the affected limb.¹ We applied a hexapod multiplane external fixator for progressive deformity correction and adjusted the struts 3 times per day. The patient also had a fish skin graft after extensive wound debridement and preparation, initially with a micronized graft for the deep soft tissue void and then with a sheet graft overlaying the rest of the wound surface.

Rectus alignment of the left foot and ankle occurred after 4 weeks and then maintained in place for another two weeks with the external fixator before the removal.¹ Advanced adjunct therapies (fish skin graft) in combination with conventional wound therapy including weekly wound debridement achieved complete healing. The patient remains healed.

For patients with multiple comorbidities, multidisciplinary input definitely goes a long way. In these complex patients there are so many variables that we need to control. We had our pedorthotists get involved with this patient. In terms of offloading modalities, this was a multi-step process because if you don’t address all avenues and aspects of it, then you’re doomed to fail. We had infectious disease throughout when the patient had bone infection present previously. We had multiple bone biopsies to clear that part of it before we staged the next part of the procedure.

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Dr. Statkus practices at Northern Illinois Foot and Ankle Specialists. He is board certified by the American Board of Foot and Ankle Surgery.

Reference
1.    Statkus R, McEneaney PA, Bichler JJ, Lovato P. Multi-plane external fixator for  deformity correction and application of skin substitute for complex lower extremity wound healing and limb salvage: case report. Presented at Symposium on Advanced Wound Care (SAWC) Fall, Las Vegas, NV, 2024.