A perda da sensibilidade decorrente da complicação crônica da neuropatia diabética periférica distal faz com que os mecanismos de proteção contra microtraumas e dor estejam ausentes, predispondo o pé diabético à ulceração, podendo evoluir para amputações do membro inferior. A presença de deformidades nos pés aumenta a sobrecarga quando associada as alterações sensoriais. O objetivo deste estudo foi investigar a influência da neuropatia diabética e da história de úlceras plantares na sensibilidade somatossensorial e na distribuição da pressão plantar durante o andar descalço entre diabéticos neuropatas com (GDU) e sem (GD) história de úlcera plantar com não diabéticos assintomáticos (GC), a fim de verificarmos se a presença de ulceração plantar na história clínica de diabéticos neuropatas, incidência de deformidades do pé e a perda sensorial influenciam no padrão dinâmico da distribuição da pressão plantar. A casuística foi composta de 44 sujeitos sendo 19 sujeitos no GC, 16 no GD e 9 no GDU. Foram avaliadas as ensibilidades tátil, térmica e a cronaxia sensitiva e realizada a avaliação inâmica da distribuição da pressão plantar durante a marcha descalça, utilizando as palmilhas do sistema PEDAR ® da Novel, em cadência auto-selecionada. A sensibilidade e as variáveis de ressão plantar foram comparadas entre os rupos em cinco áreas plantares de ambos os pés: calcanhar, meio-pé, antepé lateral, antepé medial e hálux.Os grupos foram comparados por meio dos testes Kruskal-Wallis e ANOVA one-way, adotando alfa de 5%. O tempo de diabetes e o escore do questionário que avaliava a sintomatologia dos diabéticos, não diferenciaram os grupos neuropatas em relação à gravidade da doença. O GDU apresentou maior quantidade de áreas plantares com perda sensorial para todas as modalidades testadas e maior incidência de indivíduos com valores de sensibilidades anormais. Ambos os grupos neuropatas apresentaram maior área de contato no calcanhar em relação ao GC (p=0,0063) e apenas o GDU apresentou maior área de contato no antepé medial em comparação com o GC (p=0,0384). Não houve diferença entre os grupos para os picos de pressão para todas as áreas testadas. A integral da pressão (kPa.s) apresentou diferença entre os grupos para a região do meio-pé (GC: 37,4 ± 12,8; GD: 43,4 ± 9; GDU: 69,1 ± 35,5; p=0,0001) e maiores valores para os neuropatas em relação ao GC no antepé lateral (GC: 92 ± 25,3; GD: 104,9 ± 25; GDU 108 ± 28; p=0,02) e no antepé medial (GC: 98,9 ± 22,6; GD: 113,2 ± 29,7; GDU: 128,1 ± 34,2; p=0,0029). O GDU apresentou maior carga relativa na região do meio-pé em comparação com o GC e menor carga relativa para as regiões do antepé lateral em comparação com os dois outros grupos e para o hálux em comparação com o GC. Concluiu-se que os sujeitos já ulcerados apresentam pior déficit sensorial. A presença de úlcera na história clínica não interferiu nos picos de pressão e na área de contato, mas a variável integral da pressão parece sofrer influência do déficit sensitivo, e apresentou maiores valores entre os neuropatas já ulcerados. / The loss of protective sensation due to the chronic complication of distal peripheral diabetic neuropathy makes absent the trauma and pain protection mechanisms, increasing the chances for ulceration in diabetic foot, which can evolutes to amputation of the lower limbs. The presence of foot deformities can lead to higher loading under the foot when it is associated with sensorial changes. The objective of this study was to evaluate the influence of diabetic neuropathy and history of plantar ulcers in the somatossensorial sensibility and the plantar pressure distribution during the barefoot condition between diabetic neuropathic subjects with (DNU) and without (DN) previous ulcers with non diabetic asymptomatic (CG) to investigate if the presence of plantar ulceration on clinic history of neuropathic diabetics, the incidence of foot deformities and the loss of sensation have influence in dynamic patterns of plantar pressure distribution. The casuistics was composed of 44 subjects: 19 subjects in the CG, 16 subjects in the DN and 9 subjects in the DNU. The tactile sensibility using a 10g monofilament, thermal sensibility and sensitive cronaxie were measured. The plantar pressure distribution was recorded with the subjects walking barefoot using the insoles of Pedar ® (Novel) system at a self-selected speed. The sensibility and the pressure variables were compared between groups in five regions of the feet: rear foot, midfoot, lateral forefoot, medial forefoot and hallux. The groups were compared using the Kruskal-Wallis test and ANOVA one-way, an alpha of 5% was adopted. The time of diabetes and the score on the questionnaire for diabetic symptoms were not different between the neuropathic groups. DNU showed more number of plantar areas with deficit of sensibility for all modalities measured and also showed higher incidence of subjects with abnormal values for sensibility. Both neuropathic groups showed greater contact area in rearfoot in comparison with CG (p=0,0063) and only the DNU had greater contact area under the medial forefoot in comparison with GC (p=0,0384). We found no differences for peak pressure in all areas tested. The pressure time integral (kPa.s) showed significant differences between the three groups for midfoot (CG: 37,4 ± 12,8; DN: 43,4 ± 9; DNU: 69,1 ± 35,5; p=0,0001) and higher values for the neuropathic subjects in relation to CG in the lateral forefoot (CG: 92 ± 25,3; DN: 104,9 ± 25; DNU 108 ± 28; p=0,02) and in the medial forefoot (CG: 98,9 ± 22,6; DN: 113,2 ± 29,7; DNU: 128,1 ± 34,2; p=0,0029). The DNU showed higher relative load in the midfoot in comparison with CG, lower relative load for the lateral forefoot in comparison with other groups and for the hallux in comparison only to CG. In conclusion, neuropathic subjects with prior history of plantar ulcers have worse deficit of sensibility. The presence of ulcer on the clinic history did not interfer in the peak pressure and in the contact area, but the pressure time integral seems to be influenced by the deficit of sensibility and showed higher values among the neuropathic subjects with previous history of ulcers for all plantar regions.

A perda da sensibilidade decorrente da complicação crônica da neuropatia diabética periférica distal faz com que os mecanismos de proteção contra microtraumas e dor estejam ausentes, predispondo o pé diabético à ulceração, podendo evoluir para amputações do membro inferior. A presença de deformidades nos pés aumenta a sobrecarga quando associada as alterações sensoriais. O objetivo deste estudo foi investigar a influência da neuropatia diabética e da história de úlceras plantares na sensibilidade somatossensorial e na distribuição da pressão plantar durante o andar descalço entre diabéticos neuropatas com (GDU) e sem (GD) história de úlcera plantar com não diabéticos assintomáticos (GC), a fim de verificarmos se a presença de ulceração plantar na história clínica de diabéticos neuropatas, incidência de deformidades do pé e a perda sensorial influenciam no padrão dinâmico da distribuição da pressão plantar. A casuística foi composta de 44 sujeitos sendo 19 sujeitos no GC, 16 no GD e 9 no GDU. Foram avaliadas as ensibilidades tátil, térmica e a cronaxia sensitiva e realizada a avaliação inâmica da distribuição da pressão plantar durante a marcha descalça, utilizando as palmilhas do sistema PEDAR ® da Novel, em cadência auto-selecionada. A sensibilidade e as variáveis de ressão plantar foram comparadas entre os rupos em cinco áreas plantares de ambos os pés: calcanhar, meio-pé, antepé lateral, antepé medial e hálux.Os grupos foram comparados por meio dos testes Kruskal-Wallis e ANOVA one-way, adotando alfa de 5%. O tempo de diabetes e o escore do questionário que avaliava a sintomatologia dos diabéticos, não diferenciaram os grupos neuropatas em relação à gravidade da doença. O GDU apresentou maior quantidade de áreas plantares com perda sensorial para todas as modalidades testadas e maior incidência de indivíduos com valores de sensibilidades anormais. Ambos os grupos neuropatas apresentaram maior área de contato no calcanhar em relação ao GC (p=0,0063) e apenas o GDU apresentou maior área de contato no antepé medial em comparação com o GC (p=0,0384). Não houve diferença entre os grupos para os picos de pressão para todas as áreas testadas. A integral da pressão (kPa.s) apresentou diferença entre os grupos para a região do meio-pé (GC: 37,4 ± 12,8; GD: 43,4 ± 9; GDU: 69,1 ± 35,5; p=0,0001) e maiores valores para os neuropatas em relação ao GC no antepé lateral (GC: 92 ± 25,3; GD: 104,9 ± 25; GDU 108 ± 28; p=0,02) e no antepé medial (GC: 98,9 ± 22,6; GD: 113,2 ± 29,7; GDU: 128,1 ± 34,2; p=0,0029). O GDU apresentou maior carga relativa na região do meio-pé em comparação com o GC e menor carga relativa para as regiões do antepé lateral em comparação com os dois outros grupos e para o hálux em comparação com o GC. Concluiu-se que os sujeitos já ulcerados apresentam pior déficit sensorial. A presença de úlcera na história clínica não interferiu nos picos de pressão e na área de contato, mas a variável integral da pressão parece sofrer influência do déficit sensitivo, e apresentou maiores valores entre os neuropatas já ulcerados. / The loss of protective sensation due to the chronic complication of distal peripheral diabetic neuropathy makes absent the trauma and pain protection mechanisms, increasing the chances for ulceration in diabetic foot, which can evolutes to amputation of the lower limbs. The presence of foot deformities can lead to higher loading under the foot when it is associated with sensorial changes. The objective of this study was to evaluate the influence of diabetic neuropathy and history of plantar ulcers in the somatossensorial sensibility and the plantar pressure distribution during the barefoot condition between diabetic neuropathic subjects with (DNU) and without (DN) previous ulcers with non diabetic asymptomatic (CG) to investigate if the presence of plantar ulceration on clinic history of neuropathic diabetics, the incidence of foot deformities and the loss of sensation have influence in dynamic patterns of plantar pressure distribution. The casuistics was composed of 44 subjects: 19 subjects in the CG, 16 subjects in the DN and 9 subjects in the DNU. The tactile sensibility using a 10g monofilament, thermal sensibility and sensitive cronaxie were measured. The plantar pressure distribution was recorded with the subjects walking barefoot using the insoles of Pedar ® (Novel) system at a self-selected speed. The sensibility and the pressure variables were compared between groups in five regions of the feet: rear foot, midfoot, lateral forefoot, medial forefoot and hallux. The groups were compared using the Kruskal-Wallis test and ANOVA one-way, an alpha of 5% was adopted. The time of diabetes and the score on the questionnaire for diabetic symptoms were not different between the neuropathic groups. DNU showed more number of plantar areas with deficit of sensibility for all modalities measured and also showed higher incidence of subjects with abnormal values for sensibility. Both neuropathic groups showed greater contact area in rearfoot in comparison with CG (p=0,0063) and only the DNU had greater contact area under the medial forefoot in comparison with GC (p=0,0384). We found no differences for peak pressure in all areas tested. The pressure time integral (kPa.s) showed significant differences between the three groups for midfoot (CG: 37,4 ± 12,8; DN: 43,4 ± 9; DNU: 69,1 ± 35,5; p=0,0001) and higher values for the neuropathic subjects in relation to CG in the lateral forefoot (CG: 92 ± 25,3; DN: 104,9 ± 25; DNU 108 ± 28; p=0,02) and in the medial forefoot (CG: 98,9 ± 22,6; DN: 113,2 ± 29,7; DNU: 128,1 ± 34,2; p=0,0029). The DNU showed higher relative load in the midfoot in comparison with CG, lower relative load for the lateral forefoot in comparison with other groups and for the hallux in comparison only to CG. In conclusion, neuropathic subjects with prior history of plantar ulcers have worse deficit of sensibility. The presence of ulcer on the clinic history did not interfer in the peak pressure and in the contact area, but the pressure time integral seems to be influenced by the deficit of sensibility and showed higher values among the neuropathic subjects with previous history of ulcers for all plantar regions.

For individuals with type 2 diabetes, diabetic foot ulcers represent a significant health issue and the wound care cost is quite high. Currently, clinicians and nurses mainly base their wound assessment on visual examination of wound size and the status of the wound tissue. This method is potentially inaccurate for wound assessment and requires extra clinical workload. In view of the prevalence of smartphones with high resolution digital camera, assessing wound healing by analyzing of real-time images using the significant computational power of today’s mobile devices is an attractive approach for managing foot ulcers. Alternatively, the smartphone may be used just for image capture and wireless transfer to a PC or laptop for image processing. To achieve accurate foot ulcer image assessment, we have developed and tested a novel automatic wound image analysis system which accomplishes the following conditions: 1) design of an easy-to-use image capture system which makes the image capture process comfortable for the patient and provides well-controlled image capture conditions; 2) synthesis of efficient and accurate algorithms for real-time wound boundary determination to measure the wound area size; 3) development of a quantitative method to assess the wound healing status based on a foot ulcer image sequence for a given patient and 4) design of a wound image assessment and management system that can be used both in the patient’s home and clinical environment in a tele-medicine fashion. In our work, the wound image is captured by the camera on the smartphone while the patient’s foot is held in place by an image capture box, which is specially design to aid patients in photographing ulcers occurring on the sole of their feet. The experimental results prove that our image capture system guarantees consistent illumination and a fixed distance between the foot and camera. These properties greatly reduce the complexity of the subsequent wound recognition and assessment. The most significant contribution of our work is the development of five different wound boundary determination approaches based on different computer vision algorithms. The first approach employs the level set algorithm to determine the wound boundary directly based on a manually set initial curve. The second and third approaches are the mean-shift segmentation based methods augmented by foot outline detection and analysis. These two approaches have been shown to be efficient to implement (especially on smartphones), prior-knowledge independent and able to provide reasonably accurate wound segmentation results given a set of well-tuned parameters. However, this method suffers from the lack of self-adaptivity due to the fact that it is not based on machine learning. Consequently, a two-stage Support Vector Machine (SVM) binary classifier based wound recognition approach is developed and implemented. This approach consists of three major steps 1) unsupervised super-pixel segmentation, 2) feature descriptor extraction for each super-pixel and 3) supervised classifier based wound boundary determination. The experimental results show that this approach provides promising performance (sensitivity: 73.3%, specificity: 95.6%) when dealing with foot ulcer images captured with our image capture box. In the third approach, we further relax the image capture constraints and generalize the application of our wound recognition system by applying the conditional random field (CRF) based model to solve the wound boundary determination. The key modules in this approach are the TextonBoost based potential learning at different scales and efficient CRF model inference to find the optimal labeling. Finally, the standard K-means clustering algorithm is applied to the determined wound area for color based wound tissue classification. To train the models used in the last two approaches, as well as to evaluate all three methods, we have collected about 100 wound images at the wound clinic in UMass Medical School by tracking 15 patients for a 2-year period, following an IRB approved protocol. The wound recognition results were compared with the ground truth generated by combining clinical labeling from three experienced clinicians. Specificity and sensitivity based measures indicate that the CRF based approach is the most reliable method despite its implementation complexity and computational demands. In addition, sample images of Moulage wound simulations are also used to increase the evaluation flexibility. The advantages and disadvantages of three approaches are described. Another important contribution of this work has been development of a healing score based mechanism for quantitative wound healing status assessment. The wound size and color composition measurements were converted to a score number ranging from 0-10, which indicates the healing trend based on comparisons of subsequent images to an initial foot ulcer image. By comparing the result of the healing score algorithm to the healing scores determined by experienced clinicians, we assess the clinical validity of our healing score algorithm. The level of agreement of our healing score with the three assessing clinicians was quantified by using the Kripendorff’s Alpha Coefficient (KAC). Finally, a collaborative wound image management system between the PC and smartphone was designed and successfully applied in the wound clinic for patients’ wound tracking purpose. This system is proven to be applicable in clinical environment and capable of providing interactive foot ulcer care in a telemedicine fashion.

Chronic diabetic foot ulcers, venous leg ulcers and pressure ulcers affect a large subset of the United State population yet they remain a challenge for physicians to treat. There are many different types of products on the market for the treatment of chronic wounds. Some use living cells but only two are FDA approved to heal chronic wounds. A new type of product recently garnered attention in the wound care market because it also contains living cells: hypothermically stored amniotic tissue products. Hypothermically stored amniotic tissue is unique because it maintains living cells and offers the benefits of containing signaling molecules and maintaining an intact extra cellular matrix. While there are other types of amniotic or placental tissue products in the wound care market, they are processed by dehydration or cryopreservation which limits their capacities for maintaining living cells. This thesis will explore the potential for hypothermically processed amniotic tissue products to treat chronic wounds.

Objective: This dissertation includes three projects that study care environments and apathy in dementia as well as measures of activity. Project 1 developed the Person-Environment Apathy Rating (PEAR) scale to measure environmental stimulation and apathy, and tested its psychometrics. Project 2 examined the association between care environments and apathy in persons with dementia. Project 3 tested the accuracy of ActiGraph and activPALTM activity monitors in measuring weight-bearing activities among persons with previous diabetic foot ulcers. Methods: The PEAR consists of environment (PEAR-Environment) and apathy (PEAR-Apathy) subscales. The validity and reliability of the PEAR was examined through video observation of 24 participants. Project 2 selected 40 participants with dementia in order to examine the association between apathy and environmental stimulation, ambiance, crowding, staff familiarity, and light and sound. Study procedures involved video observation and data extraction. Project 3 enrolled 31 participants to test the accuracy of ActiGraph and activPALTM in measuring number of steps taken and duration of walking, standing, sitting, and lying. Results: The PEAR-Environment subscale had significant but fair correlation with the Crowding Index (Ρ=.27, p<.01), suggesting fair validity. The PEAR-Apathy highly correlated with the Passivity in Dementia Scale (ρ=.81) and Neuropsychiatry Inventory (NPI)-Apathy subscale (ρ=.266), and moderately correlated with the NPI-Depression subscale (ρ=.46), indicating good convergent validity and moderate discriminate validity. The PEAR also demonstrated good internal consistency (Cronbach's Α= .84 -.85) and moderate to good inter-rater (Weighted Kappa=.47-.94) and intra-rater (Weighted Kappa=.47-.94) reliability. Project 2 revealed that stimulation clarity and strength were significantly associated with a low apathy level (p<.001). An increase of 1 point on stimulation clarity and strength corresponded to a decrease on apathy score of 1.3 and 1.9 points, respectively. Project 3 revealed that ActiGraph had widely varied accuracy in measuring duration of standing, walking, sitting, and lying (0-100%) and in measuring number of steps taken (43-81%). In contrast, activPALTM showed consistently high accuracy in measuring duration of standing, walking, sitting, and lying (97-100%) and in measuring number of steps of taken (91-99%). Discussion: The PEAR is a valid and reliable measure of care environment and apathy in long-term care residents with dementia. Care environments that contain clear and sufficiently strong environmental stimulation are significantly associated with lower apathy levels, providing a foundation for interventions targeting apathy. ActivPALTM is a valid tool to measure weight-bearing activity in persons with diabetes in order to examine the role of weight-bearing activity in foot ulceration. This monitor may also be useful as a supplemental measure for apathy in persons with dementia.

Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 4 uppsatser.

Tissue biopsy and swab culture are the gold standards for diagnosing tissue infection; these tests require significant time, diagnostic costs, and resources. Towards earlier and specific diagnosis of infection, a non-destructive, rapid, and mobile detection device is described to distinguish bacterial species via light scatter spectra from the surface of an infected tissue, reagent-free. Porcine skin and human cadaveric skin models of wound infection were used with a 650 nm LED and an angular photodiode array to detect bacterial infections on the tissue surface, which can easily be translated to a typical CMOS array or smartphone. Tissue samples were inoculated with Escherichia coli, Salmonella Typhimurium, or Staphylococcus aureus and backscatter was collected from 100 degrees to 170 degrees in 10 degrees increments; each bacterial species resulted in unique Mie scatter spectra. Distinct Mie scatter spectra were obtained from epidermis (intact skin model) and dermis (wound model) samples, as well as from porcine and human cadaveric skin samples. Interactions between bacterial colonies and lipid particles within dermis samples generated a characteristic Mie scatter spectrum, while the lipid itself did not contribute to such characteristic spectrum as corroborated with body lotion experiments. The designed angular photodiode array is able to immediately and non-destructively detect tissue bacterial infection and identify the species of infection within three seconds, which could greatly improve point of care diagnostics and antibiotic treatments.

Bakgrund: Forskning idag visar på bristande egenvårdsförmåga vid fotsår orsakade av diabetesneuropati. Diabetesrelaterade fotsår ökar risken för infektioner och resulterar ofta i ökad sjukhusvård och dödlighet. Sjuksköterskor spelar en central roll i att säkerställa att patienter har förmåga att utföra god egenvård och på så sätt minska risken för utveckling av fotsår och dess komplikationer. Syfte: Syftet var att identifiera faktorer som påverkar patienters egenvård vid fotsår orsakade av diabetesneuropati. Metod: Studien genomfördes som en allmän litteraturstudie med en induktiv ansats vilken baseras på tio artiklar med kvalitativ metod, två artiklar med kvantitativ metod och en med mixad metod. Artiklarnas resultat granskades och bearbetades till kategorierna: kunskapsbrist hos sjuksköterskor, kunskapsbrist hos patienter, psykiska, fysiska och sociala hinder för patienters egenvård, motivation och patientutbildning och kommunikation. Resultat: Resultatet i litteraturstudien identifierade faktorer som påverkade egenvården vid fotsår orsakade av diabetesneuropati. Bland dessa faktorer framkom en tydlig kunskapsbrist hos både sjuksköterskor och patienter när det gällde sårvård och diabetesrelaterade fotsår. Även vikten av motivation och god kommunikation mellan hälso- och sjukvården och patienter framkom. Konklusion: Genom att identifiera faktorer som påverkade patienters egenvårdsförmåga framkom det bland annat brister i patientutbildning. Praktisk vårdverksamhet behöver därför fokusera på att åtgärda utbildningsbrister för att främja god egenvård och hälsa. / Background: Research today shows a lack of self-care ability in foot ulcers caused by diabetic neuropathy. Diabetes-related foot ulcers increase the risk of infections and often lead to increased hospital care and mortality. Nurses, therefore, play a central role in ensuring that patients have ability to carry out proper self-care and reduce the risk of develop foot ulcers and their complications. Aim: The aim was to identify factors influencing patients' self-care in cases of foot ulcers caused by diabetic neuropathy. Method: The study was conducted as a general literature review with an inductive approach and is based on ten articles using qualitative methods, two articles using quantitative methods, and one using mixed methods. The results of the articles were reviewed and categorized into: lack of knowledge among nurses, lack of knowledge among patients, psychological, physical and social barriers to patient self-care, motivation and patient education and communication. Results: The results of the literature review identified factors influencing self-care in cases of foot ulcers caused by diabetic neuropathy. Among these factors, a clear lack of knowledge was evident among both nurses and patients concerning wound care and diabetes-related foot ulcers. The importance of motivation and effective communication between healthcare and patients also emerged. Conclusion: By identifying factors affecting patients' self-care ability, deficiencies in patient education, among other things, were identified. Practical healthcare practice should, therefore, focus on addressing educational gaps to promote proper self-care and health.

Bakgrund: Förekomsten av diabetes typ 2 ökar både nationellt och internationellt. Många av dessa patienter utvecklar diabeteskomplikationer i form av diabetesneuropati som är en av de vanligaste bakomliggande orsakerna till diabetesfotsår. Samarbetet kring diabetesfotsår mellan olika professioner behöver öka för att få en bättre prognos för sårläkning och således bättre livskvalitet för dessa patienter. Diabetessjuksköterskor och distriktssköterskor är involverade i vården av patienter med diabetes och diabetesfotsår men hur samarbetet mellan dessa professioner ser ut är inte klarlagt. Syfte: Syftet med denna studie är att undersöka diabetessjuksköterskans och distriktssköterskans upplevelse av samarbete vid omvårdnad av diabetesfotsår hos patienter med typ 2 diabetes samt hur ett samarbete kan förbättra vården för patienter med diabetesfotsår.   Metod:  En kvalitativ intervjustudie med deduktiv ansats valdes för att bemöta studiens syfte. Sex semi-strukturerade intervjuer genomfördes och data analyserades enligt Granheim &amp; Lundmans kvalitativa innehållsanalys. Resultat: Studien resulterade i fem olika kategorier; vikten av kommunikation, brist på rutiner, integrerat samarbete inom vården, utveckling och heterogen kompetens samt säkerhetskultur inom vården. Förbättring av samarbetet mellan diabetessjuksköterskor och distriktssköterskor kan leda till ökad kompetensen hos sjuksköterskorna samt till bättre livskvalitet för patienter med diabetesfotsår.  Slutsats: Samtliga deltagare har uttryckt vikten av ett bra samarbete och skapande av rutiner som kan leda till bättre förutsättningar för patienter med diabetesfotsår. Betydelsen av kompetensen och kunskapsutbyte var viktiga faktorer för ett välfungerande samarbete. / Background: The incidence of type 2 diabetes is increasing both nationally and internationally. Many of the patients develop diabetic complications in the form of diabetic neuropathy, which is one of the most common underlying causes of diabetic foot ulcers. Diabetes nurses and community health nurses are involved in the care of patients with diabetes and diabetic foot ulcers, but what the collaboration between these professions looks like is not clear. Objective: The purpose of this study is to investigate the diabetes nurse's and community health nurse's experience of collaboration in the care of diabetic foot ulcers in people with type 2 diabetes and how collaboration could improve care for patients with diabetic foot ulcers. Method: A qualitative interview study with an deductive approach was chosen to meet the purpose of the study. Six semi-structured interviews were conducted and the data were analyzed according to Granheim &amp; Lundman's qualitative content analysis. Results: The study results in five different categories; the importance of communication, lack of routines, integrated collaboration in healthcare, development and heterogeneous competence and safety culture in healthcare. Improving of the collaboration between different professional groups can lead to an increase in the competence of the staff and to a better quality of life for the patients with diabetic foot ulcers. Conclusion: All participants emphasized on the importance of good collaboration and the creation of routines that can lead to better conditions for patients with diabetic foot ulcers. The importance of competence and knowledge exchange were important factors for a well-functioning collaboration.

Bakgrund: Sår på nedre extremiteter är vanligt förekommande, särskilt hos äldre. De sår som inte läkt inom sex veckor räknas som svårläkta och brukar medföra stora lidanden för de drabbade samt stora samhällsekonomiska kostnader. Sårens komplexitet påverkas av bakomliggande sjukdomsfaktorer och diabetespatienter är särskilt utsatta. Kosten är grundläggande för att upprätthålla kroppens livsviktiga funktioner men trots detta används sällan nutritionsbehandling för denna typ av sår. Syfte: Att sammanställa nutritionens betydelse för sår på nedre extremiteter. Metod: En litteraturstudie baserad på 15 kvantitativa empiriska studier om nutritionens betydelse för bensår och/eller diabetiska fotsår. Huvudresultat: Samband identifierades mellan nutritionsstatus och såromfattning där sämre nutritionsstatus ledde till mer allvarliga sår och ökad amputationsrisk. Näringsbrister, framför allt av mikronäringsämnena vitamin C, D, magnesium och zink, uppdagades hos deltagarna. Deltagarnas kost bestod av hög andel kolhydrater och fett medan proteinintaget i många fall var under rekommenderade nivåer. Trots påtaglig undernäring led majoriteten av deltagarna av övervikt eller fetma. Näringstillskott, särskilt av mikronäringsämnen, påskyndade sårläkningsprocessen och gav även förbättrade värden för CRP och glykemisk kontroll. Vikten av vitamin D är speciellt framträdande. Slutsats: Nutritionen har bevisligen stor betydelse för sårutvecklingen. Därför bör patienter med svårläkta sår utredas för eventuella näringsbrister oavsett kroppsvikt. Med individanpassade kostråd och nutritionsinsatser kan patienten bättre stödjas i strävan efter sårläkning genom egenvårdsinsatser. / Background: Ulcers on lower extremities are common, especially among the elderly. Ulcers not healing in six weeks are considered chronic and lead to significant suffering for those affected and substantial socioeconomic costs. Underlying medical factors contribute to ulcer complexity and patients with diabetes are particularly exposed. Nutrition is essential for maintaining and strengthening the body's vital functions. However, nutritional therapy is not as commonly used for lower extremity ulcers as for other wounds. Objective: To compile the significance of nutrition for lower extremity ulcers. Method: A literature review based on 15 quantitative primary studies on the significance of nutrition for leg ulcers and/or diabetic foot ulcers. Main Results: Relationship between nutritional status and ulcer size was identified where poorer nutritional status led to more severe ulcers and increased risk of amputation. Nutritional deficiencies, especially micronutrients vitamin C, D, magnesium, and zinc, were found among the participants. Diets consisted of a high proportion of carbohydrates and fats, while protein intake often was below recommended levels. Most participants were overweight or obese despite apparent malnutrition. Nutritional supplements, especially of micronutrients, accelerated the ulcer healing process and improved values for C-reactive protein (CRP) and glycemic control in controlled studies. The importance of vitamin D was emphasized in this literature review. Conclusion: Nutrition plays a significant role on ulcer development. Patients with chronic ulcers should be screened for potential nutritional deficiencies, regardless of body weight. With individualized dietary advice and nutritional interventions can patients receive better support in efforts for self-care and ulcer healing.