Patients affected by Diabetes Mellitus have reduced tactile sensitivity and atrophy of the small muscles in the foot, resulting in high-pressure points that may remain unnoticed. The increased pressure can cause micro-trauma leading to wounds. Because of the Diabetes Mellitus, DFUs do not heal easily. Up to 25% of them will develop diabetic foot ulcers (DFU), and 25% of DFUs that do not heal ultimately result in amputation. This Master Thesis will describe and gather results of a newly acquired large international collaborative EU project (EIT Health 2020-2022) between three universities and three companies across Europe. This collaborative group will be the first to tackle the Diabetic Foot Ulcers problem preventatively with an innovative shoe concept, with seven different apex settings, which can be easily modified to avoid ulcerations in different areas of the foot. As an initial pilot, this master thesis project focuses on the analysis of the plantar pressure distribution by using the innovative shoes DR Comfort based on the adjustable rocker profiles, used as a prototype for the prevention of the Diabetic Foot Ulcer (DFU) formation in patients affected by Diabetes. This project captures the motion data of healthy people with different shoe soles while walking at different levels of speed and assess the values of the peak plantar pressure, with the use of the Pedar-X, a measuring system device for the in-shoe plantar pressure. The evaluation of the adjustable rocker profiles is made through the calculation and analysis of the significant differences and p-values in peak plantar pressure, as well as the analysis of the Mean Plantar Pressure (MMP). The results of this study show a reduction (although not pronounced) of the areas that are more affected by DFU. This study cannot be generalized to diabetic patients since ethical approval has not yet been received. / Patienter med DM har minskad taktil känslighet och atrofi i de små musklerna i foten, vilket resulterar i högatryckpunkter som kan för bli obemärkta. Det ökade trycket kan orsaka mikrotrauma som leder till sår. På grund av Diabetes Mellitus, läker inte DFU lätt. Upp till 25% av dem kommer att utveckla diabetiska fotsår (DFU), och 25% av DFU: er som inte läker leder slutligen till amputation. Detta examensarbete kommer att beskriva och samla resultat från ett nyförvärvat stort internationellt EU-projekt (EIT Health 2020-2022) mellan tre universitet och tre företag i hela Europa. Denna samarbetsgrupp kommer att vara den första att förebygga problemet med diabetiska fotsår med ett innovativt skokoncept diabetiska fotsår med ett innovativt skokoncept. De kommer utföras med sju olika inställningar som lätt kan modifieras för att undvika sår på olika områden i foten. Som en första pilot fokuserar detta examensarbete på analys av plantartryckfördelning genom att använda de innovativa DR Comfort-skorna baserade på de justerbara ”rocker”-profilerna, som används som en prototyp för att förebygga bildningen av Diabetic Foot Ulcer (DFU) hos patienter som drabbats av Diabetes. Den här avhandlingen fångar rörelsen hos friska personer med olika skosulor medan de går i olika hastighet och analyserar värdena för det maximala plantartrycket med användning av pedar-x. Pedar-x är en mätanordning för plantorns tryck i skon. Utvärderingen av de justerbara ”rocker”-profilerna gjordes genom beräkning och analys av de signifikanta skillnaderna i top plantartrycket samt analysen av plantartryckets maximala medelvärde (MMP). Resultaten av denna studie visar en minskning (även om den inte betydlig) av de områden som mest drabbats av DFU. Denna studie kan inte generaliseras till diabetespatienter eftersom etiskt godkännande ännu saknas.

Bakgrund: Studier visar att framtiden för vården är personcentrerad och sjuksköterskor bör möta människor i ett hälsoorienterat perspektiv. Egenvårdsråd bör anpassas efter personen med diabetessjukdom och sjuksköterskan skall ta hänsyn till skillnader i synen på hälsa och sjukdom. Syfte: Syftet med studien var att beskriva sjuksköterskors erfarenheter av preventiva åtgärder för att minska risken för fotsår hos personer med diabetes mellitus typ II. Metod: Kvalitativ intervjustudie där tio halvstrukturerade intervjuer genomfördes. Materialet transkriberades och analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Resultaten presenteras i två kategorier: förväntningar på sjuksköterskan och stöd till personen med diabetes. Förväntningar på sjuksköterskorna var att eftersträva att se personen bakom diabetessjukdomen och att fokusera på det mätbara. De skall eftersträva att möta individen där den befinner sig och eftersträva goda relationer. Det är genom goda relationer som egenvårdsråden lättare kan implementeras och fotsår förhindras, detta presenteras i subkategorin egenvårdsråd, som ligger under kategorin stöd till personer med diabetes. Detta för att minska lidande för individen samt undvika höga samhällskostnader. Sjuksköterskor har goda avsikter med sin omvårdnad och undervisning. Sjuksköterskorna såg fördel i motiverande gruppundervisning för att nå ut till flera personer samtidigt och erbjuda dem möjlighet att utbyta erfarenheter. Sjuksköterskorna upplevde att de hade instanser att vända sig till och kontakter med samarbetspartners är en självklarhet inom diabetesvården idag. Slutsats: Resultaten av denna studie visar att sjuksköterskor i primärvården kan förebygga fotsår genom att leva upp till förväntningar som finns på dem och att se personen bakom diabetessjukdomen genom att erbjuda sin breda kompetens, motiverande gruppundervisning, egenvårdsråd och kontakt med samarbetspartners. / Background: Studies show that the future of health care is person-centeredness and nurses should meet people in a health-oriented perspective. Self-care should be adapted to the person with diabetes and nurses should take differences in views regarding health and disease into account. Aim: The aim of this study was to describe nurses' experiences of preventive measures to reduce the risk of foot ulcers in people with diabetes mellitus type II. Method: Ten qualitative semi-structured interviews were conducted. The material was transcribed and analyzed using qualitative content analysis. Results: The results are presented in two categories: expectations on the nurse and support to the person with diabetes. Expectations of the nurses was to strive to see the person behind diabetes and to focus on the measurable. They must strive to meet the individual where it is located and strive for good relationships. It is through good relationships that self-care advice can be more easily implemented and foot ulcers prevented, this is presented in the subcategory self-care, which is located below main category support to person with diabetes. This is to reduce suffering for the individuals and avoid high costs for the society. Nurses had good intentions with their care and teaching. The nurses saw advantage in motivating groups by reaching out to several people at the same time and offer them the opportunity to exchange experiences. Nurses felt that they had the ability to turn to instances and contacts with partners is obvious in diabetes care today. Conclusion: The results of this study show that nurses in primary care can help prevent foot ulcers through living up to the expectations placed on them by seeing the person behind diabetes and to offer its wide expertise, motivation work, self-care and cooperation with partners.

Submitted by Maicon Juliano Schmidt (maicons) on 2015-07-08T13:58:29Z No. of bitstreams: 1 Daiana Barbosa da Silva.pdf: 1016873 bytes, checksum: 301ddcfd8b2a8dd9ecbf88294fdf3511 (MD5) / Made available in DSpace on 2015-07-08T13:58:29Z (GMT). No. of bitstreams: 1 Daiana Barbosa da Silva.pdf: 1016873 bytes, checksum: 301ddcfd8b2a8dd9ecbf88294fdf3511 (MD5) Previous issue date: 2014-03-28 / Nenhuma / A úlcera de perna é considerada uma síndrome que se caracteriza pela perda irregular ou circunscrita do tegumento, que pode atingir o tecido subcutâneo e outros tecidos subjacentes, acomete as extremidades dos membros inferiores e pode ser desencadeada por diversos fatores. É identificada como ferida crônica, considerando o longo período de duração entre o tempo de abertura e a cicatrização da ferida, além de muita recorrência em um curto espaço de tempo. OBJETIVO: Verificar o método mais eficaz de avaliação sistematizada de úlceras de membros inferiores. MATERIAL E MÉTODO: Revisão sistemática da literatura nas bases de dados indexados Crochrane, Medline/Pubmed, Lilacs e MedCarib, utilizando os descritores úlcera, úlcera de perna, úlcera de pé, protocolos, cuidados de enfermagem e diagnóstico. A elaboração do protocolo seguiu os critérios do Manual Operacional de Diretrizes Clínicas/Protocolos Assistenciais da Gerência de Ensino e Pesquisa do Grupo Hospitalar Conceição (GEP-GHC, 2008) e da Metodología para la elaboración de guías de atención y protocolos (GÓMEZ, 2007). Para a análise dos resultados utilizou-se a estratégia de hierarquização dos níveis de evidência do sistema de classificação do Oxford Center for Evidence Based Medicine e a classificação do Grading of Recommendations Assessment, Development and Evaluation (MECHANICK et al., 2010; DEL MAR; SALISBURY; GLASZIOU, 2010). RESULTADOS: Foram encontrados 74 artigos na Biblioteca Crochrane, 174 na base de dados Medline/Pubmed, 31 na Lilacs e 7 na MedCarib. Após a aplicação dos critérios de inclusão e exclusão, além dos filtros de busca, restaram 179 artigos. Artigos em duplicidade ou sem disponibilidade de texto na integra foram excluídos, e também após a leitura de títulos e resumos, restando apenas 14. O guia prático de atendimento do enfermeiro na avaliação clínica de pacientes com úlceras de membros inferiores divide-se em transcendência e vulnerabilidade, magnitude, objetivo, diagnóstico: classificação de úlceras, tipos, avaliação da úlcera e perilesional. CONCLUSÃO: A elaboração do guia de prática clínica envolveu o detalhamento do processo de avaliação de úlceras de membros inferiores, buscando reunir as melhores práticas e evidências científicas encontradas na literatura. / A leg ulcer is considered a syndrome that is characterized by irregular or circumscribed loss of the integument, which may reach the subcutaneous tissue and other underlying tissues, commonly affects the lower extremities and can be triggered by many factors. Leg ulcers are identified as chronic wounds, considering the long duration of time between the opening and wound healing, plus plenty of recurrence in a short time. AIM: to determine the most effective method of systematic assessment of lower limb ulcers. MATERIAL AND METHODS: A systematic literature review on the basis of data indexed Crochrane, Medline/Pubmed, Lilacs and MedCarib, using the descriptors ulcers, leg ulcers, foot ulcer, protocols , nursing care and diagnosis. The preparation protocol followed the criteria of (GEP- GHC, 2008) Operating Manual of Clinical Guidelines/Protocols Relief of Management Education and Research Hospital Group Conception and Methodology of guides for it Elaboración of atencion y protocols (GOMEZ, 2007). For the analysis of the results was used for the ranking of levels of evidence classification of the Oxford Centre for Evidence Based Medicine and the Classification of the Grading of Recommendations Assessment, Development and Evaluation system strategy. (MECHANICK et al., 2010; DEL MAR; SALISBURY, GLASZIOU, 2010). RESULTS: There were 74 Crochrane Library, 174 in Medline / Pubmed, Lilacs in articles 31 and 7 in MedCarib data. After applying the inclusion and exclusion criteria, in addition to the search filter, 179 articles remained. Articles in duplicate, without the availability of full text, were excluded, as well as after reading the titles and abstracts, leaving only 14 items. The practical guide to the care of the nurses in the clinical assessment of patients with leg ulcers divided into transcendence and vulnerability, magnitude, objective diagnosis: classification of ulcers types of ulcer assessment and perilesional. CONCLUSION: This clinical practice guide involved the detailing of the lower extremity ulcers rating process, seeking to bring together the best practices and scientific evidence in the literature.

For this project, we use a modified version of a previously developed mathematical model, which describes the relationships among matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), and extracellular matrix (ECM). Our ultimate goal is to quantify and understand differences in parameter estimates between patients in order to predict future responses and individualize treatment for each patient. By analyzing parameter confidence intervals and confidence and prediction intervals for the state variables, we develop a parameter space reduction algorithm that results in better future response predictions for each individual patient. Moreover, use of another subset selection method, namely Structured Covariance Analysis, that considers identifiability of parameters, has been included in this work. Furthermore, to estimate parameters more efficiently and accurately, the standard error (SE- )optimal design method is employed, which calculates optimal observation times for clinical data to be collected. Finally, by combining different parameter subset selection methods and an optimal design problem, different cases for both finding optimal time points and intervals have been investigated.

Bakgrund: Diabetes mellitus är en kronisk sjukdom som ökar över hela världen. De drabbade individerna får diabetesrelaterade komplikationer som uppkommer vid sjukdomen, bland annat fotkomplikationer såsom fotsår som är vanligt förekommande. Komplikationerna leder till stort lidande för personen. Förutom att det leder till lidande för personen så medför det stora kostnader för hälso- och sjukvården. Uppkomst av fotsår kan motverkas och förhindras genom kunskap och utbildning. Syfte: Författarna vill i denna litteraturstudie belysa diabetespatienters behov av kunskap och undervisning gällande primär prevention av fotsår. Metod: Studien har utförts som en kvalitativ litteraturstudie där tio vetenskapliga artiklar har inkluderats. Artiklarna söktes via de två databaserna PubMed och CINAHL. De inkluderande artiklarna var med kvalitativ ansats. Resultatet av artiklarna bearbetades, analyserades, kvalitetsgranskades och sammanställdes. Resultat: Resultatet framfördes genom två huvudkategorier som är egenvårdsåtgärder och patientutbildning. Genom egenvård är patienterna delaktiga i sin vårdplan. Informationen av egenvårdsåtgärder ska inkluderas i första informationsmötet med patienten. I patientutbildning ges den information och rådgivningen som behövs för att patienten ska kunna hantera sin sjukdom. Dessutom leder patientutbildning till motivation och bättre hälsofrämjande vanor. Konklusion: För att fotsår ska undvikas bör patienten ha kunskaper om vilka komplikationer diabetes kan orsaka. Genom att ha en tydlig bild om hur komplikationerna förhindras leder det till förbättrad omhändertagandet av fötterna. Kommunikationen mellan patienten och vårdpersonalen är en avgörande faktor för hur väl informationen nås fram. / Background: Diabetes mellitus is a chronic disease that is on the rise worldwide. The affected individuals get diabetes-related complications that arise from the disease, including foot complications that are common. The complications lead to great suffering for the person. In addition to suffering for people, it also entails huge costs for health care. The onset of foot ulcers can be counteracted and prevented through knowledge and education. Purpose: In this literature study, the authors want to shed light on diabetic patients' need for knowledge and education regarding the primary prevention of foot ulcers. Method: The study was conducted as a qualitative literature study where ten scientific articles have been included. The articles were searched through the two databases PubMed and CINAHL. The included articles were with a qualitative approach. In the background, both qualitative and quantitative articles were included. Only qualitative articles were included in the results. The results of the articles were processed, reviewed and compiled. Results: The results were presented through two main categories, which are self-care measures and patient education. Through self-care, patients are involved in their care plan. The information of self-care measures must be included in the first information meeting with the patient. In patient education, the information and advice need to enable the patient to manage that their illness is provided. In addition, patient education leads to motivation and better health-promoting habits. Conclusion: To avoid foot ulcers, the patient should have knowledge of what complications diabetes can cause. By having a clear picture of how the complications are prevented, it leads to improved care of the feet. The communication between the patient and the care staff is a decisive factor in how well the information is obtained.

Bakgrund: Diabetes drabbar allt fler människor och utgör ett hot mot folkhälsan. Följdsjukdomar som fotkomplikationer är vanliga. Fotsår resulterar i sänkt livskvalitet för personen som drabbas och ger ökade samhällskostnader. Regelbunden fotundersökning förebygger fotsår och utgör en rekommenderad intervention. Trots existerande riktlinjer är det skillnader i genomförandet av fotundersökningen vilket skapar ojämlik vård. I ett projekt har ett formulär baserat på riktlinjerna för fotundersökning utarbetats med syfte att underlätta och säkerställa en årlig fotundersökning med grund i evidens. Syfte: Att utvärdera vårdpersonals erfarenheter av att arbeta enligt ett formulär för strukturerad fotundersökning hos patienter med diabetes. Metod: Kvalitativ innehållsanalys utifrån Graneheim och Lundman. Studien är en del av ett projekt ” Optimerat omhändertagande av personer med diabetes och fotkomplikation” med Västra Götalandsregionen som forskningshuvudman. Semistrukturerade intervjuer genomför dessom fokusgruppintervjuer samt som enskilda intervjuer. Totalt inkluderades åtta informanter av olika yrkestillhörighet vilka intervjuades angående sina erfarenheter av formuläret i kliniskpraxis. Resultat: Formuläret underlättade arbetet vid fotundersökningen genom ökad tydlighet, struktur och överblick. Formuläret kunde bidra till att likrikta fotundersökningen eftersom skillnader i arbetssätt synliggjordes. Vid fotsår upplevdes riskkategorierna som motsägelsefulla. Osäkerhet framkom angående definitioner av exempelvis förhårdnader och svårläkta sår. Förhoppningarna var att ett införande i digitalt journalsystem skulle underlätta dokumentationen och synliggöra fotundersökningen, med ökad tillgänglighet för alla berörda. Slutsats: Formuläret fungerar väl som stöd och beslutsunderlag i det preventiva arbetet med fotundersökningen och kan komma att bidra till likriktning av fotundersökningen enligt gällanderiktlinjer och därmed bidra till en säkrare och mer jämlik vård. / Background: Diabetes is a growing threat to public health. Secondary diseases like footcomplications are common. Foot ulcers affect individual’s quality of life and are a great cost to society. Regular foot examination prevents foot ulcers and is a recommended intervention. Despite existing guidelines there are differences in the execution of the foot exam which causes care inequality. A structured foot exam form based on the guidelines was developed in a project. The aim was to facilitate the foot exam and contribute to a uniform execution. Aim: To assess health care workers experiences of working with a structured foot exam form for patients with diabetes Method: Qualitative content analysis based on Graneheim and Lundman. The study is part of a larger project entitled “Optimized care of persons with diabetes and foot complications” with Västra Götalands region as responsible authority. Semi structured interviews were held in a focus group and individually with eight informants of different professions who were interviewed regarding their experiences of working with the form in clinical practice. Results: Experiences of working with the form were that it simplified the foot exam by giving itan overview and clear structure. Using the form made apparent differences in work routines between individuals. It was believed that by implementing the form routinely that it would contribute to a more uniform execution. When the patient had foot ulcers the risk categories were perceived as contradictory. There was an uncertainty about the definition of for example chronic ulcers and callosities. The hope was that the future digital format would simplify documentation and elucidate the foot exam as well as contribute to accessibility for all concerned. Conclusion: The foot exam form works well as a support during the preventative foot exam, gives a basis for decision making and could contribute to a uniform, safer foot exam with more care equality that is consistent with the current guidelines.

37.3 million Americans (11.2% of the US population) currently have Type 2 diabetes mellitus (T2DM) with over 1.5 million new cases being diagnosed each year. The multifactorial etiology of the patient having neuropathy, overweight/obesity, foot deformities, ischemia, and infection leads to a condition called diabetic foot ulcer (DFU). One in six patients with a DFU will require amputation with infected DFUs have a 155-fold increased risk of amputation. Staphylococcus aureus is the most common bacteria isolated from severe DFU infections that require amputation. Interestingly, diabetics are more heavily colonized with S. aureus compared to non-diabetics suggesting a unique advantageous adaptation to diabetes. The specifics of the underlying molecular mechanisms and triggers by which S. aureus adapts and thrives in the T2DM patient that increase its pathogenicity and colonization compared to non-diabetics with skin ulcer infections are not fully elucidated. Thus, our studies aimed to identify the key virulence components in the pathogenesis of S. aureus infected DFUs and using that information to develop therapeutics aimed at disrupting these components to increase the success rate of conservative treatment and prevent non-traumatic lower extremity amputations in T2DM patients. Our studies found that several different elevated sugars in T2DM patients can trigger virulence factor production in S. aureus. We also found by comparing several different clinical DFU S. aureus isolates that there are clear differences in the ability of each isolate to cause necrotic infections. And lastly, we identified a possible therapeutic, the amino acid L-arginine, that can help prevent/treat S. aureus infections in the Tallyho diabetic mouse model. In conclusion, we have increased the understanding of the pathogenesis of S. aureus infected DFU and have proposed a possible therapeutic to add to the conservative treatment regimen.