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Diabetic foot ulcers (DFU) are responsible for more hospitalizations than any other complication of diabetes, and the biggest cause of amputation. Of the 26 million people in the US, and some 3.8 million in the UK diagnosed with diabetes, as many as 25% may experience a DFU in their lifetime. 
 
People living with diabetes are at risk of nerve damage (neuropathy), and problems with the blood supply to their feet (ischaemia). Nerve damage results in a reduced ability to feel pain, and therefore injuries often go un-noticed. Ischaemia can slow down wound healing. Both ischaemia and neuropathy can lead to DFUs. Infections in DFUs can lead to amputation.
 
The burden of DFUs
DFUs impose a substantial burden on public and private payers, doubling care costs per patient compared with diabetic patients without foot ulcers. In the US, ulcer care adds around US$9 to US$13 billion to the direct yearly costs associated with diabetes, and in the UK, around £650 million is spent on DFUs and amputations each year.
 
The five-year recurrence rates of DFUs are as high as 70%. People with diabetes with one lower limb amputation have a 50% risk of developing a serious ulcer in the second limb within two years. People with diabetes have a 50% mortality rate in the five years following an initial amputation. These numbers have not changed much in the past 30 years, despite significant advances in the medical and surgical therapies for people with diabetes.
  
Poorly understood pathology
The exact mechanism by which diabetes impairs wound healing is not fully understood, and as a result, the management of DFUs is challenging, and has been a neglected area of healthcare research and planning. Current clinical practice is based more on opinion than scientific fact.
 
According to Hisham Rashid, a consultant vascular surgeon at Kings College Hospital, London who specializes in the surgical therapy for DFUs,  "Because the pathological processes of DFUs are complex, they tend to be poorly understood, and communication between the many specialties involved can be disjointed and insensitive to the needs of patients. One of the biggest recent improvements in foot care has been the close liaison of different specialties in multidisciplinary foot clinics."
Advances in therapeutics
Surgeons have tended to use free tissue transfer, as the treatment of choice for complex DFUs, but the length and intricacies of these procedures is contraindicated, and can lead to complications. This has led surgeons to turn to bioengineered alternative tissue in the reconstruction of these complex wounds.

One new bioengineered tissue for DFUs is an advanced bilayer skin replacement system designed to provide immediate wound closure, and permanent regeneration of the dermis. The product, Integra Dermal Regeneration Template, recently completed a clinical study, and an initial review suggests that the study has achieved its primary goal, which is complete wound closure at 16 weeks.

Takeaways
It's possible to reduce DFUs and consequent amputation rates by as much as 49 to 85%. This can be achieved through a care strategy, which combines prevention, close monitoring and education. According to Rashid, "Health professionals have an important role to play in enhancing the education for people living with diabetes in order to propel them towards self-management, and slow the onset of complications such as DFUs."
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It's a travesty!

Health professionals don't effectively use mHealth strategies to proactively engage and support people living with diabetes. This failure destroys the lives of millions and unnecessarily increases healthcare costs by billions. This is a travesty.

Health information online
In the UK and US the majority of people living with diabetes and pre-diabetes have smartphones, which they use on a daily basis to send and receive information, purchase goods, bank, educate and socialize. Notwithstanding, 80% of health professionals still provide information for the management of diabetes in paper pamphlets, and the majority of diabetes care information on websites is digitalised paper pamphlets. Such communications strategies, cost millions, and fail to slow the progression of the condition.

Epidemic
Here's evidence, which suggests that current healthcare communications strategies are failing. Recent UK data released by the NHS show that people diagnosed with diabetes has increased significantly over the past decade. Today, 6% of UK adults are registered as diabetic, and an estimated 0.85 million people have diabetes without knowing it. In 2013 there were 163,000 new diagnoses: the biggest annual increase since 2008.

A 2014 study reported in the British Medical Journal revealed that the prevalence of pre-diabetes in England has tripled in eight years, from 11.6% in 2003 to 35.3% in 2011, which puts immense pressure on NHS finances. It's projected that by 2025, five million people will have diabetes in the UK.

The situation in the US is similar. Results of a 2014 study published in the Journal of the American Medical Association, show that there was a significant increase in diabetes between 2001 and 2009, and warns of a growing epidemic that could strain the American health-care system.
 
Diabetes UK report
Governments and charities are good at describing the burden of diabetes, but poor at introducing and promoting effective mHealth strategies to reduce the burden. In a 2014 Diabetes UK report, Barbara Young, the charity's CEO says, "The NHS is spending an eye watering amount on diabetes (£10 billion annually), but the money isn't being used effectively." Those who are diagnosed late or don't receive timely care can suffer complications such as kidney and nerve damage, which costs the NHS billions.

The Report emphasises the importance of better education on how to manage diabetes, and stresses that a staggering 80% of the £10 billion the NHS spends on diabetes goes on treating complications, which may have been prevented if patients had received more effective information about the condition.

If nothing changes, the Report suggests, by 2035 diabetes will cost the NHS £17billion a year, and thousands of diabetics will suffer unnecessary complications.

Online managed care systems
Where's the leadership to help change the situation?  There's evidence to suggest that when mHealth strategies are used in the management of diabetes, they slow the progression of the condition, propel self-management, and significantly reduce the costs of care.

For example, Professor Shahid Ali, a UK practicing GP and Head of Digital Health, University of Salford, has developed and implemented a mHealth system, which enhances the quality of diabetes care, while substantially reducing costs and increasing the efficiency of health professionals. 
 
In the US, Welldoc a successful technology company, founded in 2005 by an endocrinologist, provides  a mHealth solution for people living with diabetes, which coordinates diabetes care, propels self-management and achieves long-term adherence.
 
Professor Gordon Moore from Harvard University Medical School has developed a managed care system that embeds the clinical, behavioural and motivational aspects of diabetes care into any handheld device. It's like, Moore says, "having your doctor in your pocket".
 
Notwithstanding, governments and agencies responsible for enhancing the quality of care for people living with diabetes are failing to bring such tried-and-tested mHealth solutions to their attention.
 
Takeaways
According to Diabetes UK's, we, "know what needs to happen":
  • "More focus on ensuring that people know about diabetes
  • Provision and promotion of effective self-management
  • Integrated care planned around the needs of the individual
  • Effective promotion of lifestyle change."
But, how many more people living with diabetes have to endue unnecessary progression of their condition, and devastating complications, which cost health systems billions, before health professionals abandon their costly and ineffective communications systems and embrace cheaper and more effective mHealth strategies?  
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Islet cell transplantation is a therapy for people with Type1 diabetes. Islet cells are harvested from donors' pancreases, purified, processed and infused into a patient’s liver. Once transplanted the islets begin to produce insulin, and actively start regulating your blood glucose level.

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Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body can’t effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Raised blood sugar (hyperglycaemia) is a common effect of uncontrolled diabetes. Over time uncontrolled diabetes leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

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Diabetes is a complex, chronic illness, which requires continuous medical care and risk reduction strategies over and above glycemic control. Education and on-going patient self-management and support are critical to preventing complications and reducing the risk of long-term acute complications.

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