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Is there any evidence out there, regarding HBA1c levels and how they effect wound healing? Do high HBA1c levels have a dramatic negative effect on wound healing? Your opinions please?
As far as I can recall there is no evidence on HBA1c wound healing - meaning I don't think anyone has really looked at it.
There is some prospetive data linking HBA1c levels to the risk for developing an ulcer ...
It would make intuitive sense that there could be a link between HBA1c and wound healing because:
1) High levels mean there is a less than optimum physiological state, which would make sense that this is probably not conducive to optimal wound healing (ie the high HBAlc is probably associated with "ill health", which is not good)
2) High HBA1c may also indicate that there are poor self care behaviours in monitoring of blood glucose levels --- these inadequate behaiours may also be reflected in the poor self management with ulcers/wound healing.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Hi AA Lang,
I don't know where you are at with this but a starting point (possibly for others reading this?) could be,
1. Goto Google:- HBA1c.
2. Goto Google:- HBA1c wound healing.
Google lists definitions and comment ad infinitum! On HBA1c wound healing there is an abstract of a paper,
Abstract:2 by M.Berdal, S.N. Zykova, R.Seljelid, T.G.Jensosen. University of Troms, Norway.
Some of their findings are,
1. Diabetic wounds (Healing delay) partly by way of altered cellular mechanisms in the healing wound.
2. Macrophages infiltrate the wound and take part in the inflammatory response by producing cytokines.
3. Their conclusions: Macrophage function.......is impaired in diabetes. ...... topic applications of BDP improve wound healing ........ diabetic mice, despite moderate hyperglycemia.
I'm not to sure of this papers date or origin other than what is stated re. authors and Uni.
Regards.
Colin.
P.S. I wonder whether this could have any bearing on why structural change takes place in the wall of an established corn?
Last edited by C Bain : 18th March 2005 at 12:22 PM.
1. Diabetic wounds (Healing delay) partly by way of altered cellular mechanisms in the healing wound.
2. Macrophages infiltrate the wound and take part in the inflammatory response by producing cytokines.
3. Their conclusions: Macrophage function.......is impaired in diabetes. ...... topic applications of BDP improve wound healing ........ diabetic mice, despite moderate hyperglycemia.
We have to be careful jumping to those sorts of conclusions. There is plenty of cross-sectional evidence linking HBA1c and other measure of glucose levels to phyisological and structural alterations in diabetes (eg impaired macrophage function; delayed chemotactic responses; glycation of proteins; altered microciculatory blood flow control; impaired infiltration of antibiotics in to DM wounds; hemorheological abnormalties etc etc) ---- all of these have the potential to alter wound healing (and probably do) -- I am just not aware of any evidence that does directly links HBA1c levels (probably via those mechanisms) to impaired wound healing (...though it probably does).
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
We have to be careful jumping to those sorts of conclusions. There is plenty of cross-sectional evidence linking HBA1c and other measure of glucose levels to phyisological and structural alterations in diabetes (eg impaired macrophage function; delayed chemotactic responses; glycation of proteins; altered microciculatory blood flow control; impaired infiltration of antibiotics in to DM wounds; hemorheological abnormalties etc etc) ---- all of these have the potential to alter wound healing (and probably do) -- I am just not aware of any evidence that does directly links HBA1c levels (probably via those mechanisms) to impaired wound healing (...though it probably does).
Hi Craig,
I like what I see in the Abstract, however, your quote has picked up on a possible weakness in their science. I would like to believe that their work is spot on! My only concern is that it does not appear to be referenced as a published piece of research demanding a successful repeat (This is only an abstract referred to of course, the full paper may well be published?).
I wish them well and hope to hear Troms Uni. is successful in this, but until then I would say their conclusions are food for thought anyway! The information on this subject seems like a Forest, probably prompting the original posting!
I will check on my archives in the Wound Journal that I subscribe to, You never know there might be some research there regarding this barrier to healing if thats what it is?!?
Regards,
Colin.
Last edited by C Bain : 18th March 2005 at 03:23 PM.
Payne CB: Publication of Abstracts Presented at Diabetes Meetings. Diabetes Care 22(2)362 1999
In that I went through the abstract books from the national Diabetes conferences in the UK, Europe, USA & Australia from 2 (or was it 3?) years previously and then did extensive searches for authors and titles etc to see how many actually got published.... it was less than 30% (which is found in other disciplines as well). This means that:
1. Authors were lazy (I am guilty of that)
2. The methodological aspects etc meant it was not good enough for publication on subsequent peer review (I am guilty of that too)
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
As you have pointed out above, Craig regarding 1999, it seems to be the last enthusiastic examination of HBA1c by the 'Journal of Wound Care' Vol.9,No4,April 2000, too, where they were waiting at that time for B.I. Rosenblum & T.E.Lyons to publish et al. 'Evaluation of a human skin equivalent for the treatment of diabetic foot ulcers in a prospective, randomized, clinical trial.' Wounds 1999;11:4, 79-86. (To publish?).
N.B.:- When I read something in a journal/text book/paper, I have been trained to look at the person writing it! (Qualifications, background, etc.), and look upon what has been said hopefully based on good research!
In the case of 'Abstract 2' quoted in my posting above I felt (yes felt) in tune with the group of scientists putting their names to it! S.N. Zykova' name when put into Google search engine shows he/she is publishing and part of a team looking into HBA1c in a solid way at Tromso! Therefore, I feel safe in quoting their findings until something else appears in the enlightenment of research to show me otherwise! (Tell me where I'm wrong?).
Impaired collagen syntheses - fibroblast dysfunction and cytokines are also being explored in 'www.journalofwoundcare.com'. The Journal of Wound Care is a monthly at £45 yearly or £11.25 quarterly. A journal designed to share information on wound healing by mainly Senior nurses in the UK. (I strongly suspect that this is where the reservoir of the new Super-nurses are going to come from?!).
Papers in the February issue include high quality photographs and are listed amongst others under,
1. Effects of diabetics mellitus on healing.
2. Pressure ulcer aetiology.
3. Contributing factors to pressure ulcer development.
HBA1c seems to have been passed over as a subject since the last article in 1999/2000 issue of this journal as I think predicted by you!
The people in Tromso Uni. seem to be continuing in their research, however!!!
Regards,
Colin.
P.S. When I first started studies in Electrical Science in the early fifties, our textbooks showed electricity flowing from positive to negative, (Trust me I'm a scientist they said!!). I suppose it was because everything else in the then common understanding like water/gas/hydraulics all did it you know!
Halfway through my second year someone in Government decided to declassify nuclear physics (the fool!). The picture of lots of little Electrons happily jumping from atom to atom along the wire, (I bet that made them dizzy!), in the other direction from negative to positive??? The core and first principle of electrical engineering - WRONG!!! (Not even a sorry chaps from the scientific lot?). Yes I nearly allowed myself to forget where 'Abstract 2 was coming from when I quoted it. Thank you Craig! But I still like it anyway. It seems to fit in with my common understanding for the moment?
P.P.S. Better stop here but I wonder what you think of this one, Craig.,
The brain washing of 'Cause and Effect of Pure Science? No not 'cause and effect' but CAUSE AND CONSEQUENCES of Applied Science?
In HBA1c we as you have pointed out can have a number of CONSEQUENCES to a CAUSE, around a WOUND?!? Does this allow the Tromso Team a set of consequences in their conclusion even if they cannot be considered as final?
Last edited by C Bain : 22nd March 2005 at 05:25 PM.
Effect of glycaemic control on apoptosis in diabetic wounds
From latest Journal of Wound Care: Effect of glycaemic control on apoptosis in diabetic wounds
Quote:
OBJECTIVE: To study the effect of glycaemic control on apoptosis in chronic ulcers in diabetic patients and the differential roles of insulin and oral hypoglycaemic agents (OHAs).
METHOD: Ten non-diabetic (group I) and 20 diabetic patients (groups II and III), with a wound of more than four weeks' duration, who were attending the wound clinic at University Hospital, Varanasi, India were recruited. The 10 patients in group 11 received insulin and the 10 in group III an oral hypoglycaemic agent; all had diabetic foot ulcers. Wound biopsy and other routine investigations were performed. Both DNA fragmentation and morphological changes under light microscopy (apoptotic index) were used as determinants of apoptosis. Different variables, including fasting and post-prandial blood sugar, serum low-density lipoprotein (LDL) and markers of microangiopathy, such as proteinuria and diabetic retinopathy, were compared with apoptosis.
RESULTS: DNA fragmentation in groups I, II and III was 40.00 +/- 2.97, 45.26 +/- 3.21 and 60.8 +/- 3.13 respectively (p < 0.01). Near linear correlation was observed with blood sugar level, particularly post-prandial blood sugar (p < 0.05) and DNA fragmentation. DNA fragmentation was significantly correlated with serum LDL and proteinuria, and it was much greater in the OHA group than in the insulin group (p < 0.05). Similarly, in the diabetic patients with background retinopathy the DNA fragmentation was 46.50 +/- 3.42 (n=3) in the insulin group and 66.70 +/- 6.48 (n=4) in the OHA group (p < 0.05).
CONCLUSION: There is a significant increase in apoptosis in diabetic wounds with poorly controlled blood sugar and microangiopathy. This increase was greater in patients on OHAs than those on insulin, and it contributes to delayed wound healing. Morphological markers do not appear to be a reliable index of apoptosis in the diabetic wound.
This is interesting, as they set out with all the good intentions, but look what happened:
Quote:
Diabetic Medicine
Volume 22 Issue 8 Page 1060 - August 2005
doi:10.1111/j.1464-5491.2005.01606.x
Does close glycaemic control promote healing in diabetic foot ulcers? Report of a feasibility study I. Idris, F. Game and W. Jeffcoate
Aim To undertake a pilot study to determine the feasibility of a definitive trial of the effect of close glycaemic control on healing of foot ulcers in diabetes.
Methods All patients attending a dedicated multidisciplinary clinic for the management of established ulcers over a 20-week period were systematically screened for inclusion in a randomised, single-blinded study.
Findings Two hundred individuals with foot ulcers attended the clinic during the recruitment period, but only nine met the predefined inclusion and exclusion criteria. One of these was withdrawn because of an adverse event immediately before recruitment, two proved incapable of administering insulin injections and were withdrawn prior to randomization. Four withheld consent, and one was advised to withhold consent by his community nurse. One was randomised and completed the 3-month study. The study was abandoned at 20 weeks when it was decided that it would be unlikely that a sufficient number of suitable patients would ever be recruited, and that it would therefore be unethical to approach further subjects.
Conclusions It was concluded that although evidence is required to guide future practice in this field, the study design chosen was not feasible.
Not that this is related to wound healing,but I am pleased that someoneis discussing Hb1Ac.I believe that thisis probably MORE important than glucose per se.Most of my pts with diabetic neuropathy,for instance,tend to have high Hb1Aclevels(which may be why these pts heal more slowly).
Last edited by John Spina : 28th September 2005 at 03:28 PM.
Reason: add icon
I wondered if you have seen and would be interested in this study that I have on file.
The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus The Diabetes Control and Complications Trial Research Group
ABSTRACT Background Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. Methods A total of 1441 patients with IDDM -- 726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. Results In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of =" src="/math/ge.gif" border=0 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of =" src="/math/ge.gif" border=0 300 mg per 24 hours) by 54 percent (95 percent confidence interval, 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia.
This study concludes that intensive and well controled treatment of Insulin dependent diabetes reduced the risk of complications and pathology in diabetic patients. So if HbA1c shows the glucose levels over time wouldn't then well controled levels = good HbA1c results which would = less diabetic pathlogy?
One of the real chinks in the Armour of medical procedures in wound prevention is the inability to have a good safe indicator of the immanent break down of tissue and blood supply. Just maybe the loss of quality blood delivered to tissues is the main causes of necrobiosis or necrosis? Could it be caused by an imbalance in the HBA1c levels perhaps or leading to the discovery of some other indicator or practical cure all? Loss of the element of bloods food-supply come fertilizer perhaps? May be HBA1c and even more unorthodox methods are needed to be developed, even if most of them are dust-binned early rather than latter in their development?
An example of the most practical one which appears to work is the surgical stocking on the leg as a preventative measure. Problem is I had a deaf-mute patient yesterday who was not amused with the daily 30 minute wrestling match with the stockings and my recorded delivery with the written treatise on why he must!
I wonder if some of our readers might be interested in a simple explained reason why the stocking is such a good way of preventing tissue damage and would HBA1c if successful make the stocking redundant perhaps, someone?
So far in my experience of them,
1. One fractured Femur! Fell over whilst attempting same! No good telling a late eighties year old to sit down when trying with the stockings after eighty odd years of successful stocking putting on?
2. One threatened assault on a nurses integrity before she was thrown out of the house,(Hypothetically speaking of course), with a with-drawl of treatment consent as a result of the patients inability to put them on! It might of course have had something to do with the fact that the patient had had a severe stroke, lived alone and had the use of one arm. But nursing staff are so overworked that they were intent on getting his home-help who was not insured to do dressing and was also subsequently thrown out of the house after the nurse.
3. Numerous occasions when the patient just point blank refused to attempt to put them on after the first, second, third attempt! One of the commonest causes of high blood pressure in the elderly perhaps?
Possibly a hidden problem in the UK. at this time, despite the available use of applicators that work but cost money and do not appear to be prescribed by NHS. sources with the stockings? The tissue support stocking appears to be successfully when in place!
A medical antidote to the problem would be a much more practical and economical one than having a nurse spending numerous work-hours on a daily basis putting on and taking off dressings and stocking?
Is there a hidden miracle cure to wound healing, somewhere? Could it be HBA1c or an equivalent that can be practically applied in the myriad of treatments taking place today in the nursing and Podiatric establishment?
Regards,
Colin. (Pursuing a dream perhaps?).
Last edited by C Bain : 29th September 2005 at 12:27 PM.
This study concludes that intensive and well controled treatment of Insulin dependent diabetes reduced the risk of complications and pathology in diabetic patients. So if HbA1c shows the glucose levels over time wouldn't then well controled levels = good HbA1c results which would = less diabetic pathlogy?
There is no doubt that DCCT trial in type 1 and the UKPDS in type 2 definitively showed the value of good glycaemic control in the reduction/prevention of DM complications. As for less DM pathology .... given that the population is aging and DM is becoming more prevalant (ie obesity is the numero uno risk factor) ... the individual incidence of complications may well decrease, BUT the population prevelance will go through the roof.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
all Great stuff and the papers are worth reading.
But we should all know about the dcct it has been published for some time and produced some excellent results which have been included into the Nat Service Framework for Diabetes in the UK. also another study that you should be aware of is the UKPDS (UK Prospective Diabetes Study) conducted by Oxford Uni Med School and Oxford Dept of Encrinology and Diabetes. This study may have more relevance as it looked at complications and Diabetic control in type II (non insulin dependent diabtic patients) over a period of 20 years. data was collected on a multi centre basis, and this was published in the mid 1990s. (i was working in the Diabetic Foot Clinic in Oxford at the time) the results were absolutely conclusive. Diabetic control has a major effect on the healing rate of Diabetic Foot Ulcers. Other authors have published similar result and any search on the web will provide plenty of light reading on the subject.
With regard to HBA1C this is also called glycated Haemoglobin and is a measure in % terms of the amount of Haemoglobin bonded to glucose. (haemoglobin bonds to glucose in preference to Oxygen and the bond is permanent for the lifespan of the RBC). Because the lifespan of an RBC is approx 90 days this measure gives an average measure of the amount of glucose in the blood stream over that period. It is regarded by all Endocrinologists and Diabetologists in the UK as the prefered measure of overall diabetic control. All patients attending Diabetic clinics usually have this measure done before attending the clinic so that the results are there for the clinic visit. (some clinics have the capability now to give instant HBA1C results.
AS HBA1C is a measure of blood glucose levels there is an obvious correlation with healing rates. The studies probably havent been done beacause it is accepted as read by most clinicians working in the field as there are studies that have looked at standard blood glucose measures (such as pin prick) and healing rates.
I hope that this helps a little .
Rob
DPod M BSc(Physiology& Biochemistry) PGDip (Diabetes)
Objective: To determine the frequency of minor and major amputations in diabetic patients at different Wagner s grades of severity and to correlate it with the glycaemic control. Design: Cross-sectional analytical study. Place and Duration of Study: Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, over a period of 3 years from August 1999 to August 2002.
Subjects and Methods: The study included 60 patients of diabetic foot disease, who were distributed in to six grades of severity according to the Wagner s method. Glycaemic control was determined by baseline fasting and random blood sugar and HbA1c levels. Patients were treated accordingly and followed-up. Frequencies of minor and major amputations were found and these were correlated with the glycemic control of the patients.
Results: There was no patient in grade-0, 6 (10%) patients in grade-I, 13 (21.6%) in grade-II, 14 (23.3%) in grade-III, 18 (30%) in grade-IV and 9 (15%) patients in grade-V respectively. Thirty-seven (61.6%) patients were male. The mean age of the patients was 50.88 +/- 11.06 years. In 40 (66.7%) patients, the duration of diabetes was 8 years or longer. Fiftysix (93.3%) were having NIDDM and 35 (58.3%) were smokers. Staphylococcus aureus was the most common pathogen isolated from the wound. Only 1 (16.6%) patient in grade I underwent minor amputation, while 3 (23.7%), 8 (57.14%) and 8 (44.44%) underwent minor amputation in grades II, III and IV respectively. Three (21.42%), 10 (55.55%) and all 9 (100%) underwent major amputation in grade III, IV and V respectively. Below-the-knee amputation was the most commonly performed procedure. Overall frequency of minor and major amputation were 20 (33.3%) and 22 (36.3%) respectively. Patients with poor glycaemic control had higher percentage of minor and major amputation (p-value = 0.001).
Conclusion: The frequency of minor and major amputation increases with the higher grades of diabetic foot. Poor glycaemic control is a significant risk factor for amputation in diabetic foot patients.
Ostomy Wound Management have a new full text article on: Risk Factors Associated with Healing Chronic Diabetic Foot Ulcers: The Importance of Hyperglycemia
Quote:
Diabetic foot ulcer management presents a significant challenge for wound care clinicians; numerous approaches to encourage healing in these difficult wounds have been explored. To determine risk factors related to diabetic foot ulcer time to healing and closure, a secondary analysis of data from a prospective randomized study involving 245 patients treated with a bioengineered human dermal substitute (n = 130) or control treatment (n = 115) was conducted. Analyzed variables included age, race, gender, ulcer duration, initial ulcer size, initial hemoglobin (HgbA1c), average HgbA1c, change in HgbA1c, diabetes type, average hours of weight-bearing, study ulcer infection, history of smoking or alcohol use, and laboratory values. Time to healing was significantly affected by initial ulcer size (risk ratio 0.75, confidence interval 0.59–0.96), gender (risk ratio 2.01, confidence interval 1.20–3.40), and wound infection during the study (risk ratio 2.9, confidence interval 1.45–4.22). Initial ulcer size (>2 cm2), male gender, and an episode of infection during the study were associated with an increased risk of nonclosure after 12 weeks of care (P <0.05). In patients whose HgbA1C increased during the study (n = 101), 20.7% of all wounds and 21% of dermal substitute-managed wounds (n = 105) healed; whereas, in patients whose HgbA1C levels remained stable or decreased, 26.3% of all wounds and 47% of dermal substitute-managed wounds healed (P <0.05). Female gender, small ulcer size, and the absence of infection were found to have a positive effect on healing all diabetic foot ulcers; improved glucose control had a significant effect on healing wounds managed with the dermal substitute only. This is the first diabetic foot ulcer study to find a relationship between hyperglycemia and wound healing. Further research into factors that improve healing of wounds, including diabetic foot ulcers, is warranted.
HbA1c and Peripheral Arterial Disease in Diabetes
The Atherosclerosis Risk in Communities study
Elizabeth Selvin, PHD, MPH1,2, Keattiyoat Wattanakit, MD, MPH3, Michael W. Steffes, MD, PHD4, Josef Coresh, MD, PHD1,2 and A. Richey Sharrett, MD, DRPH1
OBJECTIVE—To assess the relation between HbA1c (A1C) and incident peripheral arterial disease (PAD) in a community-based cohort of diabetic adults from the Atherosclerosis Risk in Communities (ARIC) study. A second aim was to investigate whether the association was stronger for severe, symptomatic disease compared with PAD assessed by low ankle-brachial index (ABI).
RESEARCH DESIGN AND METHODS—This was a prospective cohort study of 1,894 individuals with diabetes using ARIC visit 2 as baseline (1990–1992) with follow-up for incident PAD through 2002. We assessed the relation between A1C and incident PAD, defined by intermittent claudication, PAD-related hospitalization, or a low ABI (<0.9).
RESULTS—During a mean follow-up of 9.8 years, the crude incidence rates were 2.1 per 1,000 person-years for intermittent claudication (n = 41), 2.9 per 1,000 person-years for PAD-related hospitalization (n = 57), and 18.9 per 1,000 person-years for low ABI at visit 3 or 4 (n = 123). The relative risk (RR) (95% CI) of an incident PAD event comparing the second and third tertiles of A1C to the first, respectively, after adjustment for cardiovascular risk factors was strongest for severe, symptomatic forms of disease, e.g., PAD-related hospitalization (RR = 4.56 [1.86–11.18] for the third A1C tertile compared with the first, P trend <0.001) than for low ABI (RR = 1.64 [0.94–2.87], P trend = 0.08).
CONCLUSIONS—We found a positive, graded, and independent association between A1C and PAD risk in diabetic adults. This association was stronger for clinical (symptomatic) PAD, whose manifestations may be related to microvascular insufficiency, than for low ABI. Our results suggest that efforts to improve glycemic control in persons with diabetes may substantially reduce the risk of PAD.
__________________ Stephen Tucker Eastern Health
Podiatry Manager
Interesting topic. I am part of a wound center in Florida. Studies are important but practical experience tells all. My experience has been that those patients that have poor glycemic control can heal at a similar rate to others, however, I have seen a much greater recurrence of wounds and a higher infection rate in these patients with complications resulting in hospitalization.
This is an old thread, but I just posted this study: Mortality and diabetes related amputations that found no relationship between glucose control and mortality following amputation.
Hi
I found a paper by Jelinek and Driver in podiatry today which has a section on wound healing in relation to hyperglycemia.
it states:
"Hyperglycemia results in leukocyte dysfunction and suppression of lymphocytes, high blood pressure, and impaired endothelial function. "
Heres the reference:
Jelinek, A and Driver V. (2006). Current Concept in Managing the Wound
Microenvironment. Podiatry Today. 19 (9): 44-57
The data (unpublished as yet) we have at Ayrshire and Arran is that every patient who has diabetic foot disease has a h/o a long episode of HbA1c results > 9.0
By a long episode I mean more than 3 years where there results were mostly above 9. In fact most were in double figures.
We haven't checked if every patient who has consistently high HbA1c results also has diabetic foot disease. Experience says that probably will be the case if the patient survives other diabetic complications.
The relationship between hemoglobin A(1c) values and healing time for lower extremity ulcers in individuals with diabetes.
Markuson M, Hanson D, Anderson J, Langemo D, Hunter S, Thompson P, Paulson R, Rustvang D. Adv Skin Wound Care. 2009 Aug;22(8):365-72.
Quote:
PROBLEM: The diabetic population is at an increased risk, up to 15% over a lifetime, to develop leg and foot ulcers due to such factors as neuropathy, ischemia, and infection. The tight control of glucose levels as possible is necessary to prevent the diabetic complications by preventing microvascular changes that predispose the patient to neuropathy, ischemia, and infection. Although it is clear from the literature review that tight glucose control prevents complications, the relationship between HgbA1c values and healing times of ulcers is less well defined. This study explored the relationship between HgbA1c values and healing times of leg and foot ulcers. THEORETICAL/CONCEPTUAL FRAMEWORK: The theoretical framework used was Orem's self-care deficit theory of nursing, which focuses on self-care of patients and nursing intervention if self-care is inadequate. SUBJECTS: Forty-one male and 22 female patients having either type 1 or type 2 diabetes were considered in this study. Of these 63 patients, 9 had type 1 and 54 had type 2 diabetes. Ages ranged from 33 to 94 years (mean, 67.7 years [SD, 14.98 years]). Weight ranged from 122 to 402 lb (mean, 221.84 lb [SD, 58.79 lb]). METHODOLOGY: As part of a larger study, a retrospective chart review was performed on 63 patients with diabetes served by a Midwestern outpatient wound care clinic from July 2001 to July 2004. Approval for this study was granted through the local institutional review board. No data collected required the consent of the individual or included any identifying data, thus protecting the privacy of the individuals whose charts were reviewed. A tool was developed by the researchers through literature review to gather needed information. The data collection tool included demographics, medical diagnoses, wound size at presentation, and most recent wound size, as well as the HgbA1c results closest to admission and closest to time of wound closure. Statistics were generated using the SPSS program. RESULTS: Of the 63 ulcers, 36 healed, 26 did not heal, and it was not possible to determine if healing occurred for 1 ulcer. Admission HgbA1c values ranged from 4.5 to 15.4 (mean, 8.05 [SD, 2.29]). HgbA1c values closest to ulcer closure ranged from 5.3 to 12.3 (mean, 7.68 [SD, 1.81]). It was found that patients with higher HgbA1c levels did experience wound healing, but in a significantly longer period than those with lower HgbA1c. Individuals with type 1 diabetes had a higher healing rate (77.8%) than individuals with type 2 diabetes (53.7%), whereas 40% of all closed ulcers reopened. A significant correlation was also noted between a history of smoking and increased HgbA1c levels. IMPLICATIONS: Healing times were decreased in those individuals who had lower HgbA1c values. Decreased healing times result in lower cost for the patient, decreased chance of infection due to lack of portal of entry, and increased quality of life. Patient education may increase self-care practices in the diabetic population regarding better glucose control.
HBA1c and wound healing
Effect of glycaemic control on apoptosis in diabetic wounds
Linear Mode
