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The Diabetic Foot Ulcer: Management and Prevention Strategies in Primary Care
CME-CE Certified Activity Sponsored by the
University o f M edicine & D entistry of New Jersey (UMD NJ)–
Center for Continuing and Outreach Education
Release Da te: July 2004 • Expiration D ate: June 30, 2005
This activity is supported b y a n unrestricted educationa l grant from No vo N ordisk.
Introduction:
The purpose of this activity is to educate health care providers on the management and prevention of
diabetic foot ulcer.
Target Audi ence:
This activity is designed for primary care practitioners, nurses, and pharmacists.
Learni ng O bjecti ves:
Upon compl etion of this activi ty, part icipants should be able to:• Discuss the causes and risk factors of foot ulcer in diabetic patients• Determine the severity of foot ulcer in a particular patient• List a pplication o f a ppropriate treatment• D escribe measures to prevent occurrence of foo t ulcer
M ethod of I nstruction:
Participants should read the learning objectives and review the activity in its entirety. After reviewing the
ma teria l, complete the post-test/self-assessment test consisting of a series of mult iple-choice questions.
Upon completing this activity as designed and achieving a passing score of 70% or more on the post-test,
part icipants w ill receive a CM E-CE credit letter aw arding AMA/PR A category 1 credit, nursing continuing ed-
ucation credit, pharmacy continuing education credit, and the test answer key four (4) to six (6) weeks after re-
ceipt of the post-test, registration, and evaluation materials.
Estimated time to complete this activity as designed is 1.0 hour.Physician Accreditat ion :
UMDNJ–Center for Continuing and Outreach Education is accredited by the Accreditation Council for
C ontinuing Medical Education to provide continuing medical education fo r physicians.
UMDNJ–Center for Continuing and Outreach Education designates this educational activity for a maximum
of 1.0 category 1 credit tow ard the AM A Physician’s Recognition Aw ard . Each physician should claim o nly
tho se credits tha t he/she actua lly spent in the act ivity.
The activity w as prepared in a ccordance with the AC CM E Essentials.
Nu rsing Accredit ation:
UMDNJ–Center for Continuing and Outreach Education is an approved provider of continuing education
by the New Jersey Sta te Nurses Associat ion (NJ SNA), P rovider N umber P173-9/2003-2006. Pro vider Approval
is valid through June 30, 2005. NJSNA is accredited by the ANCC Commission on Accreditation. This activity
is approved fo r 1.0 contact hours.Provider approved by the Ca lifornia Boa rd of Registered N ursing, Provider Number CEP 13780 for 1.0
contact hours.
Pharmacy Accreditat ion :
UM D NJ is accredited by the American C ouncil on Pharma ceutical Education as a provider of
continuing pharmaceutical education. This course 374-000-04-017-H01 qualifies for 1.0 contact hour
(0.100 CEU) of continuing pharmacy credit, which will be awarded via mail within four (4) to
six (6) w eeks after successful completion of the progra m. Release Da te: July 2004 • Expira tion
D ate: June 30, 2005.
This activity was reviewed for relevance, accuracy of content, balance of presentation, and time required for
participation by Azeez Farooki, M D ; Anne M arie Van H oven, MD ; M s. Lorna Austin, C PhT; M s. Jennifer
Nishioka, RPh; Ms. Helene Mitzi Dolese, RN, CIM; Joanne Librie, RN; and Irina Lipets, RN, BSN.
Figure 2—Role of sorbitol in diabetic microvascular disease. Adapt ed from Frank RN.
On the pathogenesis of diabetic retinopathy. A 1990 update. Ophthalmology. 1991;98:586-593.
GlucoseFructose
NAD = n icotina mide ad enine dinucleotide; NADH = the reduced fo rm of nicoti-na mide ad enine dinucleotide; NADP = nicotina mide ad enine dinucleotide ph os-pha te; NADPH = the reduced fo rm of nicotina mide ade nine dinucleotide phosphat e.
NADPH NADP NAD NADH
Sorbitol
Osmoticeffects
Other?Decreasedcell myoinositol
Aldose reductase Sorbitol dehydrogenase
I n persons with diabetic neuropathy,
the small intrinsic muscles of the foot
atrophy as a result of demyelinizationin distal motor nerves.
References1. Centers for Disease Control and Preven-tion. National diabetes fact sheet: generalinformation and national estimates on dia-betes in the United Sta tes, 2003. Rev ed. At-lanta, Ga: U.S. Department of Health andHuman Services, Centers for Disease Con-trol and Prevention, 2004.2. http://www.diabetes.org/info/diabetesinfo. jsp.3. G ordo is A, Scuffham P, Shearer A, et al.
The health care costs of diabetic peripheralneuropathy in the U.S. D iabetes Care .2003;26:1790-1795.4. G reene DA, La ttimer SA, Sima AA. Sor-bitol, phosphoinositides, and sodium-potas-sium-ATPa se in the pa thog enesis of diab eticcomplications. N Engl J M ed. 1987;316:599-606.5. Kador PF, Kinoshita JH. Role of aldosereductase in the development of diabetes-associated complications. Am J M ed. 1985;79(suppl 5A):8-12.6. G reene DA, La ttimer SA. Action ofsorbinil in diabetic peripheral nerve. Rela-tionship of polyol (sorbitol) pathw ay inhibi-tion to a myoinositol-mediated defect in
sodium-potassium ATPase activity. D iabetes.1984;33:712-716.7. Vlassara H. Protein glycation in the kid-ney: role in diabetes and aging. Kidney Int.1996;49:1795-1804.8. Brow nlee M. Lilly Lecture 1993. G lyca-tion and diabetic complications. D iabetes.1994;43:836-841.9. Inoguchi T, Ba ttan R, H andler E, et al.Preferential elevation of protein kinase Cisoform βII and diacylglycerol levels in theaorta and heart of diabetic rats: differentialreversibility to glycemic control by islet celltransplantation. Proc N atl A cad Sci U S A.1992;89:11059-11063.10. Wolf BA, Williamson JR, Eamon RA, et
al. D iacylglycerol a ccumulation and microvas-cular abnormalities induced by elevated glu-cose levels. J Cli n Invest. 1991;87:31-38.11. Sumpio BE. Foot ulcers. N Engl J M ed.
2000;343:787-793.12. Boulton AJM. The pathogenesis of dia-betic foot problems: an overview. D iabet M ed . 1996;13(suppl 1):S12-S16.13. Collier JH, Brodbeck CA. Assessing thediabetic foot: plantar callus and pressuresensation. D iabetes Educ. 1993;19:503-508.14. Stess RM, Jensen SR, Mirmiran R. Therole of dynamic plantar pressures in diabeticfoo t ulcers. D iabetes Care. 1997;20:855-858.15. Bornmyr S, Svensson H, Lilja B, et al.Cutaneous vasomotor responses in youngtype I diabetic patients. J D iabetes Compli - cations. 1997;11:21-26.16. Purewa l TS, Go ss DE, Wat kins PJ, et al.Lower limb venous pressure in diabetic neu-ropathy. D iabetes Care. 1995;18:377-381.17. Uccioli L, Ma ncini L, G iordano A, et al.Lower limb arterio-venous shunts, auto-
nomic neuropathy and diabetic foot. Dia- betes Res Cl in Pr act. 1992;16:123-130.18. Spallone V, Uccioli L, M enzinger G .Diabetic autonomic neuropathy. D iabetes M etab Rev. 1995;11:227-257.19.Singer AJ, Clark RAF. Cutaneous wound
healing. N Engl J M ed. 1999;341:738-746.20. Kamal K, Powell RJ, Sumpio BE. Thepathobiology of diabetes mellitus: implica-tions for surgeons. J Am Co ll Surg. 1996;183:271-289.21. Brower AC, Allman RM. Pathogenesisof the neurotrophic joint: neurotraumaticvs. neurovascular. Radiology. 1981;139:349-354.22. Witte M B, Ba rbul A. G eneral principlesof wound healing. Surg Clin N orth Am .1997;77:509-528.23. Joshi N, Caputo M, Weitekamp MR,et al. Infections in patients with diabetesmellitus. N Engl J M ed. 1999;341:1906-1912.24. Joseph WS, LeFrock JL. The pat hogene-sis of diabetic foot infections—immuno-pathy, angiopathy, and neuropathy. J Foot Surg. 1987;26(suppl):S7-S11.25.Wieman TJ, Smiell JM, Su Y. Efficacy andsafety of a topical gel formulation of recom-binant human platelet-derived growth factor-
BB (becaplermin) in patients w ith chronicneuropathic diabetic ulcers. A phase III ran-domized placebo-controlled double-blindstudy. D iabetes Care . 1998;21:822-827.26. Smith J. Debridement of diabetic footulcers. Cochrane Database Syst Rev . 2002;
(4):CD003556.27. Stoddard SR, Sherman RA, Mason BE,et al. Maggot debridement therapy. An alter-native treatment for nonhealing ulcers. J Am Podiatr M ed Assoc . 1995;85:218-221.28. Hollingshead TS. Pathophysiology andtreatment of diabetic foot ulcer. Clin Podia- tr M ed Surg. 1991;8:843-855.29. Joseph WS. Treatment o f low er extremi-ty infections in diabetics. D rugs. 1991;42:984-996.30. Lipsky BA, Itani K, Norden C. LinezolidDiabetic Foot Infections Study Group.Treating foot infections in diabetic patients:a randomized, multicenter, open-label trialof linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate. Clin Infect Dis .2004;38:17-24.31. Kapor-Drezgic J, Zhou X , Ba bazono T,et al. Eff ect of high glucose on mesangial cellprotein kinase C-σ and -ε is polyol pathway-dependent. J Am Soc N ephrol . 1999;10:1193-1203.
32. National Diabetes Education Program.ht tp://ndep.nih.gov.33. Ma yfield JA, Reiber GE, Sand ers LJ, etal. American Diabetes Association. Positionstatement. Preventive foot care in diabetes.D iabetes Care . 2004;27(suppl 1):S63-S64.
CM E-CE Questions for The D iabe tic Foot Ulcer
1. During a routine examination, it is determined
that Mr Smith, a patient w ith long-standing diabetes,
has developed a foot ulcer. It is a 1-cm shallow ulcer
on the plantar aspect of the foot under the firstmetatarsal head. There appears to be a clean base
with 1.5 cm of surrounding cellulitis. Which of the
following is NOT an appropriate initial choice of
mana gement fo r this patient?
a. cephalexin
b. clindamycin
c. linezolid
d. mupirocin topical
e. amoxicillin/clavulanate
2. Ms Johnson is a 52-year-old female diagnosed
with type 2 diabetes 7 years ago. She notes that she
has ha d va riable control over her diabetes in the past,
although her hemoglobin A1c has been excellent for
the past 4 years. Which of the follow ing would clas-
sify this patient as “ high risk” for development of a
diabetic foot ulcer?
a. absence of palpable pedal pulses
b. abnorma lities of sensation via t he Semmes-
Weinstein monofilament test
c. presence of musculoskeleta l foot deformities
d. previous history of foot ulcers
e. all of the above
3. The patient in question 2 is determined to have
“ low-risk” feet by your history and physical exami-
nation. In the absence of other complaints, the most
appropriate management o f this pat ient is:a. arterial evaluat ion via the ankle-brachial index
b. proper education of the patient regarding ap-
propriate footwear, daily foot inspection, ap-
propriate nail care, and foot hygiene
c. thorough annual foot examination
d. all of the above
e. b and c only
4. Of the 18.2 million patients in the United States
with diabetes mellitus, what percentage exhibit signs
or symptoms of peripheral neuropathy?
a. 5%
b. 15%
c. 30%
d. 45%
e. greater than 50%
5. Severe or limb-threatening diabetic foot ulcers are
University of Medicine & Dentistry of New JerseyCenter for Continuing and Outreach Education
The Diabetic Foot Ulcer: Management and Prevention Strategies in Primary Care
REGISTRATION FORMThere is no charge for this CME-CE activity.
In order to o bta in credit, pa rticipants a re req uired to :
(1) Read the learning objectives, review the activity, and complete the self-assessment q uiz.
(2) Co mplete this registrat ion form and the activity evaluation form on the follow ing page, and record your
test answers in the box below.
(3) Send the registrat ion and evaluation forms to:
UMDNJ-Center for Continuing and Outreach Education
via ma il: PO Box 1709, New a rk, NJ 07101-1709
via fax: 973-972-7128
(4) Retain a copy of yo ur test a nswers. Your answ er sheet will be graded and if a passing score of 70% or
more is achieved, a C M E-C E credit letter aw arding AMA/PR A category 1 credit, nursing continuing edu-
cation credit, pharmacy continuing educat ion credit, a nd the test a nswer key w ill be mailed to you w ithinfour (4) to six (6) weeks. Individuals who fail to attain a passing score will be notified and offered the op-
portunity to complete the activity aga in.
SELF-ASSESSMENT TEST
Circle the best answer for each question on pages 10-11.
1. A B C D E 6. A B C D E
2. A B C D E 7. A B C D E
3. A B C D E 8. A B C D E
4. A B C D E 9. A B C D E
5. A B C D E 10. A B C D E
REGISTRATION
First Na me M.I. Last Na me Degree
D aytime Phone Evening Phone
Fax E-mail
Preferred Mailing Address ■ Home ■ Business
City State Zip Code
Affiliation, Specialty
I attest that I have completed the acti vit y “ The D iabeti c Foot Ul cer: M anagement and Prevent ion Str ategies in
Primary Care” as designed and I am claiming 1.0 AM A/PRA category 1 credit .
Signature Date
Credit for this activity is available until June 30, 2005.
UMDNJ–Center for Continuing and Outreach Education
University of Medicine & Dentistry of New JerseyCenter for Continuing and Outreach Education
The Diabetic Foot Ulcer: Management and Prevention Strategies in Primary Care
ACTIVITY EVALUATION FORM
The planning and execution of useful and educationally sound continuing education activities are guided inlarge part b y input from pa rticipant s. To assist us in evalua ting the effectiveness of this act ivity and to ma ke rec-
ommendations for future educational offerings, please take a few moments to complete this evaluation form.
Your response will help ensure that future programs are informative and meet the educational needs of all par-
ticipants. Please note: CE credit letters and long-term credit retention information will only be issued upon re-ceipt of this completed evaluation form.Thank you for your cooperation!
Strongly StronglyPROGRAM OBJECTIVES: H aving completed this activity, a re you better able to: Agree Disagree
• D iscuss the causes and risk factors of foot ulcer in diabetic patients 5 4 3 2 1
• D etermine the severity of foot ulcer in a particula r pa tient 5 4 3 2 1
• List applica tion of appropria te treatment 5 4 3 2 1
• D escribe measures to prevent occurrence of foot ulcer 5 4 3 2 1