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Provide Local Wound Care

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a. Intervention Algorithm

 

 

Intervention Algorithm Placeholder

 


b. Signs and Symptoms of Wound Infection

Diabetic Foot Ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria. However, the risk for infection in the diabetic foot is especially problematic. Reasons for heightened risk of infection in the Diabetic Foot include 2:

  • Immune compromised host
  • Poor glycemic control
  • Poor granulation and prolonged wound healing
  • More than 50% of foot infections in diabetics lack elevated WBC and erythrocyte sedimentation rate or fever
  • High colonization with staph /fungal

 

Signs and Symptoms Specific to Diabetic Foot Infection

Usual signs and symptoms of infection may be more subtle in patients with diabetes
Local Infection: NERDS (non-healing, exudate, red friable tissue, debris, smell)
Deep Infection: STONEES (size increasing, temperature increase, os – probes to bone,
new areas of breakdown, exudate, erythema, edema, smell)

• Elevated blood sugars from patient’s baseline
• Increase in pain level (new pain is a red flag in patients with altered sensation)
• Generalized malaise/fever
• Wound probes to bone (likely osteomyelitis)

 

The average cost of healing a single ulcer is $8,000, that of an infected ulcer is $17,000, and that of a major amputation is $45,000. 3 Limb-threatening diabetic foot infections are usually polymicrobial. Commonly encountered pathogens include methicillin-resistant staphylococcus aureus (MRSA), β-hemolytic streptococci, enterobacteriaceae, pseudomonas aeruginosa, and enterococci. Anaerobes, such as bacteroides, peptococcus, and peptostreptococcus, are rarely the sole pathogens but are seen in mixed infections with aerobes. Antibiotics selected to treat severe or limb-threatening infections should include coverage of gram-positive and gram-negative organisms and provide both aerobic and anaerobic coverage.4

Proper debridement is necessary to decrease the risk of infection and reduce peri-wound pressure, which can impede normal wound contraction and healing. 5678 9 10 11 12

The International Working Group has created the IWGDF Guidance on the diagnosis, and management of infection in patients with foot ulcers in diabetes. 13 The Guideline outlines assessment procedures, recommendations, treatment and rationales.

 

Classification/Diagnosis

  1. Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (Strong; Low).
  2. Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (Strong; Moderate)
 

c. Classification Systems

Table 8: Classification System and Ischemia - DFU

Classification

Key Points

Pros/Cons


References
Wagner   Assesses ulcer depth along with presence of gangrene and loss of perfusion using six grades (0-5)

 
Well Established 15

Suggest: Low adherent knitted viscose fabric Does not fully address infection and ischemia

Wagner 198116



 
University of Texas (Armstrong) Assesses ulcer depth, presence of infection and presence of signs of lower-extremity ischemia using a matrix of four grades combined with four stages
 
Well Established 17

Describes the presence of infection and ischemia better than Wagner and may help in predicting the outcome of the DFU

Lavery et al 199618

Armstrong et al 199819

PEDIS Assesses Perfusion, Extent (size), Depth (tissue loss), Infection and Sensation (neuropathy) using four grades (1-4) Developed by IWGDF

User-friendly (clear definitions, few categories) for practitioners with a lower level of experience with diabetic foot management

Lipsky et al 201220
 
SINBAD Assesses, Ischemia, Neuropathy, Bacterial infection and Depth

Uses a scoring system to help predict outcomes and enable comparisons between different settings and countries

Simplified version of the S(AD)SAD classification system 21

Includes ulcer site as data suggests this might be an important determinant of outcome.22

Ince et al 2008 23
 


Table 9: Texas Diabetic Wound Classification System24

 

Table 10 - Limb-Threatening Infection in Patients with a Diabetic Foot Ulcer 2526

SUPERFICIAL INFECTION

DEEP WOUND INFECTION

SYSTEMIC INFECTION

■ Non-healing
■  Bright red granulation tissue
■  Friable and exuberant granulation
■  New areas of breakdown  or necrosis
■  Increased exudates
■  Bridging of soft tissue  and the epithelium
■ Foul odour

 

■ Pain
■ Swelling, induration
■ Erythema (> 2 cm)
■ Wound breakdown
■  Increased size or  satellite areas
■  Undermining or tunneling
■  Probing to bone
■  Anorexia
■  Flu-like symptoms
■  Erratic glucose control

In addition to deep wound infection:
■  Fever
■  Rigour
■  Chills
■  Hypotension
■  Multi-organ failure

 

 

 

 


Deep foot infections have been identified as the immediate cause of 25 to 51% of amputations in persons with diabetes
Signs of deep wound and systemic signs of infection are potentially limb and/or life threatening. These clinical signs and symptoms require urgent medical attention.27

Lipinsky (2012) recommends that persons with new diabetic foot infections have plain radiographs to identify bony abnormalities such as bone deformity or destruction, foreign bodies or soft tissue gas. An abnormal plain radiograph finding can be helpful in the diagnosis of osteomyelitis. 2829
 


d. Management of Infection

  • Swabs for C&S not usually helpful if wound is dry; if wet then should be done using LEVINE semi-quantitative method
  • In addition to recognizing the signs and symptoms of infection in diabetic foot ulcers, it may be helpful to obtain a culture and sensitivity (C&S) using a validated method of sampling to quantify bacteria in wounds
  • Tissue biopsies are considered the gold standard but unfortunately are not practical in many settings.
  • A linear relationship between quantitative tissue biopsy and swab for C&S taken using the Levine method of sampling (see below) has been validated and is recommended for assessing any open wound
  • Swabs for C&S are important in determining the type of bacteria and the appropriate antibiotics, but are not necessary to confirm the presence or absence of infection.
  • C&S results may not reflect the presence or absence of biofilm.

Levine Method for obtaining C&S laboratory swab 30

  1. Cleanse wound thoroughly
  2. Place swab on granulation tissue
  3. Apply enough pressure to extract fluid
  4. Turn swab 360 degrees on fluid (avoid slough or debris)
  5. Place swab in transport medium

IWGDF Guidance on the diagnosis and management of foot infections in persons with diabetes 31

Diabetic foot infection must be diagnosed clinically, based on the presence of local and systemic signs and symptoms of inflammation (Strong; moderate). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme. 32

The full PEDIS system (which includes classification of other wound descriptors, such as arterial disease, neuropathy and wound size) of the IWGDF was originally developed for research purposes, but it can serve as a clinical classification as well 33. Classification of Diabetic Foot Infections (DFIs) using the full PEDIS system or the infection part of the IWGDF/IDSA DFI scheme has been shown in several prospective studies to predict the need for hospitalization or lower extremity amputation34 .

 
Table 11. Infectious Diseases Society of America and International Working Group on the Diabetic Foot Classifications of Diabetic Foot Infection
Clinical Manifestation of Infection Pedis Grade IDSA Infection Severity
No symptoms or signs of infection 1 Uninfected
Infection present, as defined by the presence of at least 2 of the following items:
  • Local swelling or induration
  • Erythema
  • Local tenderness or pain
  • Local warmth
  • Purulent discharge (thick, opaque to white or sanguineous secretion)
Local infection involving only the skin and the subcutaneous tissue (without involvement of deeper tissues and without systemic signs as described below). If erythema, must be >0.5 cm to ≤2 cm around the ulcer.
Exclude other causes of an inflammatory response of the skin (e.g. trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).
2 Mild
Local infection (as described above) with erythema > 2 cm, or involving structures deeper than skin and subcutaneous tissues (e.g. abscess, osteomyelitis, septic arthritis, fasciitis), and No systemic inflammatory response signs (as described below) 3 Moderate
Local infection (as described above) with the signs of SIRS, as manifested by ≥2 of the following:
  • Temperature >38°C or <36°C
  • Heart rate >90 beats/min
  • Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg
  • White blood cell count >12 000 or <4000 cells/μL or ≥10% immature (band) forms
4 Severe*
Abbreviations: IDSA, Infectious Diseases Society of America; PaCO2, partial pressure of arterial carbon dioxide; PEDIS, perfusion, extent/size, depth/tissue loss, infection, and sensation; SIRS, systemic inflammatory response syndrome.

Ischemia may increase the severity of any infection, and the presence of critical ischemia often makes the infection severe. Systemic infection may sometimes manifest with other clinical findings, such as hypotension, confusion, vomiting, or evidence of metabolic disturbances, such as acidosis, severe hyperglycemia, and new-onset azotemia 38 39 40


e. Signs and symptoms of Osteomyelitis

  • Based on bone culture results
  • Empiric therapy always cover S. aureus mixed infections are common
  • Parenteral for penetration initially and prolonged oral for  6 weeks
  • Oral good bioavailability fluoroquinolones and clindamycin may be adequate for most
  • If necrotic bone is removed then shorter course
Table 12: Signs and Symptoms of Osteomyelitis 41
  Mild infection Serious Infection
Present Slow progression Acute or rapid
Ulceration Involves skin only epidermis/dermis Penetrates to fascia ,muscle, bone
Cellulitis Min <2 cm Extensive distant
Local signs Slight inflammation Severe crepitus
Systemic signs None or min Fever  chills confusion leukocytoisis
Metabolic control Mild abnormal Severe hyperglycemia /acidosis
Foot vascularity Minimal impaired Absent pulses reduced ABI
Complicating features None or minimal Gangrene eschar abscesses foreign body


f. Antiseptics Guidelines

Recommendations for the use of antiseptics and antiseptic dressings

An international consensus panel studied use of silver in healable wounds. This panel recommended that silver be used for a two week period if infections is suspected and then be reassessed. It is the opinion of Dr. David Keast, a leading wound care specialist that these recommendations can be extended to the use of all antiseptics and antiseptic dressings (eg. iodine and PHMB).42

Choices for after initial two weeks using antiseptics or antiseptic dressings
Healable wounds Bacterial burden has been reduced and the wound is progressing to healing Discontinue use of antiseptics and antiseptic dressings  
Bacterial burden has been reduced and the wound is progressing but there are patient risk factors that put them at risk of re-infection Continue to use and monitor Suggest: Low adherent knitted viscose fabric impregnated with a polyethylene glycol (PEG) base containing 10% Povidone Iodine
Bacterial burden is controlled but the location of the wound is such that it is at risk of recontamination e.g. perianal, or exit sites for g-tubes etc Continue to use as an antimicrobial barrier  
No effect Discontinue and change strategy such as systemic antibiotics or a change of the topical antiseptic or better debridement. As always factors such as adequate plantar pressure redistribution in neuropathic foot ulcers or compression therapy for venous disease must be in place.  
Slough/Eschar No slough or obvious biofilm present   Suggest: Iodine gel
Slough is present Topical antiseptic to remove biofilm needed Suggest: Periodic debridement provided arterial blood supply is adequate
Maintenance or Non-healable Wounds Eschar to be kept dry No real limit to use. Use as long as required Suggest: Povidone iodine is best as an antiseptic with drying properties. Use it as long as required to keep dry
Table 13: As per Dr. Stephan Landis and Dr. David Keast (Leading Wound Care Specialists) Aug. 2015


g. Antibiotic Guidelines

Antibiotics should be prescribed using local protocols and, in complex cases, the advice of a clinical microbiologist or infectious diseases specialist. Avoid prescribing antibiotics for uninfected ulcerations. IDSA46 offers evidence-based suggestions, which can be adapted to local needs.

Table 14- Guidelines of Antibiotics for the Infected Diabetic Foot Ulcer from IDSA GUIDELINES 43

Infection Severity Probable Pathogen(s) Antibiotic Agent Comments

Mild (usually treated with oral agent(s))

 

Staphylococcus aureus(MSSA); Streptococcus spp

 

Dicloxacillin Requires QID dosing; narrow spectrum; inexpensive
    Clindamycin Usually active against community associated MRSA, but check macrolide sensitivity and consider ordering a “D-test” before using for MRSA. Inhibits protein synthesis of some bacterial toxins
    Cephalexin Requires QID dosing; inexpensive
    Levofloxacin Once-daily dosing; suboptimal against S. aureus
    Amoxicillin-clavulanate Relatively broad-spectrum oral agent that includes anaerobic coverage
  Methicillin-resistant S. aureus (MRSA) Doxycycline Active against many MRSA & some gram-negatives; uncertain against streptococcus species
    Trimethoprim/ sulfamethoxazole Active against many MRSA & some gram-negatives; uncertain against streptococci
Moderate (may be treated with oral or initial parenteral agent[s]) or severe (usually treated with parenteral agent[s]) MSSA; Streptococcus spp; Enterobacteriaceae; obligate anaerobes Levofloxacin Once-daily dosing; suboptimal against S. aureus
    Cefoxitin Second-generation cephalosporin with anaerobic coverage
    Ceftriaxone Once-daily dosing, third-generation cephalosporin
    Ampicillin-subactam Adequate if low suspicion of P. aeruginosa
    Moxifloxacin Once-daily oral dosing. Relatively broad-spectrum, including most obligate anaerobic organisms
    Ertapenem Once-daily oral dosing. Relatively broad-spectrum, including most obligate anaerobic organisms
    Tigecycline Tigecyclineb
    Levofloxacinor ciprofloxacinwith clindamycin Limited evidence supporting clindamycin for severe S. aureus infections; PO & IV formulations for both drugs
    Imipenem-cilastatin Very broad-spectrum (but not against MRSA); use only when this is required. Consider when ESBLproducing pathogens suspected
  MRSA Linezolid Expensive; increased risk of toxicities when used >2 wk
    Daptomycin Once-daily dosing. Requires serial monitoring of CPK
    Vancomycin Vancomycin MICs for MRSA are gradually increasing
  Pseudomonas aeruginosa Piperacillin-tazobactam TID/QID dosing. Useful for broadspectrum coverage. P. aeruginosais an uncommon pathogen indiabetic foot infections except in special circumstances (2)

 


h. Determining Goals for Local Treatment for Diabetic Foot Ulcers (Level A, B and C: RNAO’s Assessment and Management of Diabetic Foot Ulcers)

Healable Wounds: Have sufficient vascular supply, underlying cause can be corrected, offloaded & health can be optimized
 
Goal: Principles of wound bed preparation and moist wound healing: treat the cause, debridement, bacterial balance, exudate control, protect peri-wound skin
 
Maintenance Wounds: have healing potential, but various patient factors are compromising wound healing at this time
 
Goal: Principles of wound bed preparation and moist wound healing: treat the cause, debridement, bacterial balance, exudate control and protect peri-wound skin. Avoid higher cost advanced wound treatments until factors compromising wound healing are resolved. Focus on quality of life issues, exudate and odour management
 
Non-healable/Palliative wounds:  has no ability to heal due to untreatable causes such as terminal disease or end-of-life
 
Goal: Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues. 44

 

If healing potential is not established, aggressive debridement and moist interactive healing is not recommended.
 45 46 47 48 49


i. Utilize Product Picker from Canadian Association of Wound Care (CAWC)

Product Picker for Classification of Dressing Products Each organization may use the PDF Fillable CAWC Product Picker to list the products available within their organization (see Toolkit Item #14)

 

j. South West Regional Wound Care Program’s Dressing and Wound Cleansing Table: Healable and Non-Healable/Maintenance Wounds

 

k. Patient Education on Foot Care and Daily Assessment50

Ongoing Foot care is a vital element to promote wound healing and prevent recurrence of Diabetic Foot Ulcers
The following information is provided to clients as recommended practices:
  • Foot care -- Podiatrist or chiropodist
  • Foot wear -- protective shoes and pressure reduction
  • Daily foot assessment
  • Monofilament testing for neuropathy
  • Glycemic control
  • Prophylactic surgery
External siteSteps for Healthy Feet Checklist
External siteDiabetic Foot Ulcer Handout

Foot soaks are NOT recommended for patients with a Diabetic Foot Ulcer. There is currently no proven benefit to soaking diabetic feet, and in fact there is the potential for maceration of tissues and increased risk of infection. Use of hot water may not be recognized by the patient due to the presence of neuropathy leading to thermal tissue damage and soaking in antiseptic chemicals such as hydrogen peroxide maybe damaging to healthy granulation tissue. 53 54 55 56 57 58 59

l. Adjunctive Therapies

Consider Multi-disciplinary referrals for adjunctive therapy. Adjunctive therapy refers to additional treatment used together with the primary treatment to achieve the outcome of the primary treatment.

There are many types of adjunctive therapies for wound management.The ones contained in this resource include only those that have been verified by rigorous research standards and are included in the RNAO/CAWC best practice guidelines.
 
Electrical Stimulation Therapy (EST)

(Level B: RNAO’s Assessment and Management of Diabetic Foot Ulcer51)

  • Refers to the application of a low level electrical current to the base of a wound or peri-wound using conductive electrodes to induce cellular activity to facilitate wound healing.

Therapeutic Ultrasound (TU)

(Level A: RNAO’s Assessment and Management of Diabetic Foot Ulcer52)

  • Refers to the therapeutic application of ultrasound waves to the base of a wound or peri-wound to induce cellular activity to facilitate wound healing.


Provide Organizational Support

 
  1. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  2. International Working Group on the Diabetic Foot, "Guidance on the Prevention of Foot Ulcer in At Risk Patients with Diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  3. I. D. S. o. A. (IDSA). [Online]. Available: http://www.idsociety.org/Organ_System/#DiabeticFootInfections.
  4. I. D. S. o. A. (IDSA). [Online]. Available: http://www.idsociety.org/Organ_System/#DiabeticFootInfections.
  5. Sibbald, G; Orstead, H; Coutts, D; Keast, D., "Best Practice Recommendations for Preparing the Wound Bed," Wound Care Canada, vol. 4, no. 1, pp. 15-29, 2006.
  6. American Diabetes Society, "Preventative Foot Care in People with Diabetes," Diabetes Care, pp. S78-S79, 2003.
  7. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  8. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  9. Boulton, A; Armstron, D; Albert, S; R, Frykberg; R, Hellman; D, Kirkman; L, Lavery; J, LeMaster; J, Mills; M, Mueller; D, Sheehan; D., Wukich, "A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists," Diabetes Care, vol. 31, no. 8, p. 1679–1685, 2008.
  10. (ACDS), Australian Centre for Diabetes Strategies, "National evidence based guidelines for the management of type 2 diabetes mellitus – Draft for public consultation – 6 April 2001 for the identification & management of diabetic foot disease.," Retrieved from http://www.diabetes.net.au/PDF/evidence_based_healtcare/FootProblems.pdf, 2001.
  11. Bowker, John H. & Pfeifer, Michael , Levin and O'Neal's The Diabetic Foot 7th edition, St Louis : MOsby, 2009.
  12. Sibbald, G; Orstead, H; Coutts, D; Keast, D., "Best Practice Recommendations for Preparing the Wound Bed," Wound Care Canada, vol. 4, no. 1, pp. 15-29, 2006.
  13. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  14. J, Mayfield; G, Reiber; L, Sanders; D, Janisse, "Preventative Foot Care in People with Diabetes," Diabetes Care, vol. 21, no. 7, pp. 2161-2177, 2008.
  15. A, Boulton; L, Vileikyte; E, Boyko; M, del Aguuila; D, Smith; L, Lavery; A., Boulton, "Causal Pathways for Incident Lower Extremity Ulcers in Patients with Diabetes from Two Settings," N Engl J Med, vol. 351, no. 2, pp. 48-55, 2004.
  16. J, Mayfield; G, Reiber; L, Sanders; D, Janisse, "Preventative Foot Care in People with Diabetes," Diabetes Care, vol. 21, no. 7, pp. 2161-2177, 2008.
  17. S. E. F. R. A. &. H. S. L. Gardner, "A prospective study of the push tool in diabetic foot ulcers.," in Wound Repair and Regeneration Conference: #20100417 Conference End(var.pagings)., 2009.
  18. Shaw, J. E. & Boulton, A. J. M., "The pathogenesis of diabetic foot problems: An overview.," Diabetes,, vol. 46(Suppl 2), pp. , S58-S61., 1997.
  19. Gardner, S.E., Frantz, R.A., Bergquist, S. & Shin, C.D. (2005). , "A prospective study of the pressure ulcer scale for healing (PUSH).," The Journals of Gerontology, vol. 60, no. 1, pp. 93-97., 2005.
  20. D, Armstrong; L, Lavery; A, Vela; T, Quebedeaux; J., Fleischli, "Choosing a Practical Screening Instrument to Identify Patients at Risk for Diabetic Foot Ulceration," Arch Intern Med, vol. 158, no. 6, pp. 289-292, 2008.
  21. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  22. I. D. S. o. A. (IDSA). [Online]. Available: http://www.idsociety.org/Organ_System/#DiabeticFootInfections.
  23. [Online]. Available: http://cid.oxfordjournals.org/content/54/12/e132.full?sid=54d872f6-fe76-4e81-b7ce-0133a3fb4e96.
  24. Lipskey, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G., Amrstrong, D. G., et al., "2012 Infectious disease society of America clinical practical guideline for the diagnosis and treatment of diabetic foot infections," Clinical Infectious Diseases , vol. 54, no. 12, pp. 132-173., 2012.
  25. Embil JM, Trepman E. , "Diabetic foot infections," in Principles and Practice of Hospital Medicine., Ch, McGraw-Hill; 2012, 2012.
  26. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  27. Sibbald, G; Orstead, H; Coutts, D; Keast, D., "Best Practice Recommendations for Preparing the Wound Bed," Wound Care Canada, vol. 4, no. 1, pp. 15-29, 2006.
  28. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  29. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  30. Benjamin A. Lipsky,1 Anthony R. Berendt,2 Paul B. Cornia,3 James C. Pile,4 Edgar J. G. Peters,5 David G. Armstrong,6, "2012 Infectious Diseases Society of America," Clincial Infectious Diseases of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections, vol. 54, no. 12, pp. e132-e173, (2012).
  31. Lipskey, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G., Amrstrong, D. G., et al., "2012 Infectious disease society of America clinical practical guideline for the diagnosis and treatment of diabetic foot infections," Clinical Infectious Diseases , vol. 54, no. 12, pp. 132-173., 2012.
  32. Lipskey, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G., Amrstrong, D. G., et al., "2012 Infectious disease society of America clinical practical guideline for the diagnosis and treatment of diabetic foot infections," Clinical Infectious Diseases , vol. 54, no. 12, pp. 132-173., 2012.
  33. Ledoux, W. R., Shofer, J. B., Ahroni, J. H., Smith, D. G., Sangeorzan, B. J., & Boyko, E. J., "Biomoechanical differences among pes cavus, neutrally aligned, and pes planus feet in subjects with diabetes.," Foot and Ankle International,, vol. 24, no. 11, pp. 845-850., 2003.
  34. Peters, E; Lavery, L., "Effectiveness of the Diabetic Foot Ulceration Classification System of the International Working Group on the Diabetic Foot," Diabetes Care, vol. 24, no. 8, pp. 1442-1447, 2001.
  35. N, Singh; D, Armstrong; B., Lipsky, "Preventating Foot Ulcers in Patients with Diabetes," JAMA, vol. 193, no. 5, pp. 217-228, 2005.
  36. International Working Group on the Diabetic Foot, "Guidance on the dianosis and management of foot infection in persons with diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  37. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  38. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, "Canadian Diabetes Association 2013 Clininical Practice Guidelines Expert Committee for the Prevention & Management of Diabetes in Canada," Canadian Journal of Diabetes, p. 37 (supl. 1), 2013.
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  40. Sussman, Carrie & Bates-Jensen Barabara, Wound Care: A Collaborative Practice Manual for Health Professionals, Philadelphia, PA: Lippincott Williams&Wilkins, 2007.
  41. Bowker, John H. & Pfeifer, Michael , Levin and O'Neal's The Diabetic Foot 7th edition, St Louis : MOsby, 2009.
  42. Mueller, M; Hastings, M; P, COmmean; K, Smith; T, Pilgram; D, Robertson; J., Johnson, "Forefront Structural Predictors of Plantar Pressures During Walking in People with Diabetes and Peripheral Neuropathy," J Biomech, vol. 36, no. 2, pp. 1009-1017, 2003.
  43. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  44. American Diabetes Association, "Peripheral Arterial Disease in People with Diabetes," Diabetes Care, vol. 54, pp. 3333-3341, 2003.
  45. Bowker, John H. & Pfeifer, Michael , Levin and O'Neal's The Diabetic Foot 7th edition, St Louis : MOsby, 2009.
  46. Baranoski, S. and Ayello, E., Wound Care Essentials, New York: Lippincott, 2011.
  47. Mueller, M; Hastings, M; P, COmmean; K, Smith; T, Pilgram; D, Robertson; J., Johnson, "Forefront Structural Predictors of Plantar Pressures During Walking in People with Diabetes and Peripheral Neuropathy," J Biomech, vol. 36, no. 2, pp. 1009-1017, 2003.
  48. Canadian Association of Wound Care, "Recommendations for the Prevention and Treatment of Diabetic Foot Ulcers," CAWC, Toronto, 2006.
  49. International Working Group on the Diabetic Foot, "Prevention and management of foot problems in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  50. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  51. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.
  52. Wild, S; Rogklic, G; Green, A; Sicree, R; King, H, "Global Prevalence of Diabetes," Diabetes Care, pp. 1047-1053, 2004.
  53. American Diabetes Association, "Peripheral Arterial Disease in People with Diabetes," Diabetes Care, vol. 54, pp. 3333-3341, 2003.
  54. Bowker, John H. & Pfeifer, Michael , Levin and O'Neal's The Diabetic Foot 7th edition, St Louis : MOsby, 2009.
  55. Baranoski, S. and Ayello, E., Wound Care Essentials, New York: Lippincott, 2011.
  56. Mueller, M; Hastings, M; P, COmmean; K, Smith; T, Pilgram; D, Robertson; J., Johnson, "Forefront Structural Predictors of Plantar Pressures During Walking in People with Diabetes and Peripheral Neuropathy," J Biomech, vol. 36, no. 2, pp. 1009-1017, 2003.
  57. Canadian Association of Wound Care, "Recommendations for the Prevention and Treatment of Diabetic Foot Ulcers," CAWC, Toronto, 2006.
  58. International Working Group on the Diabetic Foot, "Prevention and management of foot problems in diabetes," International Working Group on the Diabetic Foot, Brussels, 2015.
  59. Registered Nurses Association of Ontario, "Assessment and Management of Diabetic Foot Ulcers," Registered Nurses Association of Ontario, Toronto, 2013.

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