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HBA1c and wound healing

Discussion in 'Diabetic Foot & Wound Management' started by AALang, Mar 18, 2005.

  1. AALang

    AALang Member


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    Is there any evidence out there, regarding HBA1c levels and how they effect wound healing? Do high HBA1c levels have a dramatic negative effect on wound healing? Your opinions please?
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    As far as I can recall there is no evidence on HBA1c wound healing - meaning I don't think anyone has really looked at it.

    There is some prospetive data linking HBA1c levels to the risk for developing an ulcer ...

    It would make intuitive sense that there could be a link between HBA1c and wound healing because:
    1) High levels mean there is a less than optimum physiological state, which would make sense that this is probably not conducive to optimal wound healing (ie the high HBAlc is probably associated with "ill health", which is not good)
    2) High HBA1c may also indicate that there are poor self care behaviours in monitoring of blood glucose levels --- these inadequate behaiours may also be reflected in the poor self management with ulcers/wound healing.
     
  3. C Bain

    C Bain Active Member

    HBA1c.

    Hi AA Lang,
    I don't know where you are at with this but a starting point (possibly for others reading this?) could be,
    1. Goto Google:- HBA1c.
    2. Goto Google:- HBA1c wound healing.

    Google lists definitions and comment ad infinitum! On HBA1c wound healing there is an abstract of a paper,
    Abstract:2 by M.Berdal, S.N. Zykova, R.Seljelid, T.G.Jensosen. University of Troms, Norway.
    Some of their findings are,
    1. Diabetic wounds (Healing delay) partly by way of altered cellular mechanisms in the healing wound.
    2. Macrophages infiltrate the wound and take part in the inflammatory response by producing cytokines.
    3. Their conclusions: Macrophage function.......is impaired in diabetes. ...... topic applications of BDP improve wound healing ........ diabetic mice, despite moderate hyperglycemia.

    I'm not to sure of this papers date or origin other than what is stated re. authors and Uni.

    Regards.

    Colin.

    P.S. I wonder whether this could have any bearing on why structural change takes place in the wall of an established corn?
     
    Last edited: Mar 18, 2005
  4. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    We have to be careful jumping to those sorts of conclusions. There is plenty of cross-sectional evidence linking HBA1c and other measure of glucose levels to phyisological and structural alterations in diabetes (eg impaired macrophage function; delayed chemotactic responses; glycation of proteins; altered microciculatory blood flow control; impaired infiltration of antibiotics in to DM wounds; hemorheological abnormalties etc etc) ---- all of these have the potential to alter wound healing (and probably do) -- I am just not aware of any evidence that does directly links HBA1c levels (probably via those mechanisms) to impaired wound healing (...though it probably does).
     
  5. C Bain

    C Bain Active Member

    Hi Craig,

    I like what I see in the Abstract, however, your quote has picked up on a possible weakness in their science. I would like to believe that their work is spot on! My only concern is that it does not appear to be referenced as a published piece of research demanding a successful repeat (This is only an abstract referred to of course, the full paper may well be published?).

    I wish them well and hope to hear Troms Uni. is successful in this, but until then I would say their conclusions are food for thought anyway! The information on this subject seems like a Forest, probably prompting the original posting!

    I will check on my archives in the Wound Journal that I subscribe to, You never know there might be some research there regarding this barrier to healing if thats what it is?!?

    Regards,

    Colin.
     
    Last edited: Mar 18, 2005
  6. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    I published a "paper" as a Letter to the Editor :
    In that I went through the abstract books from the national Diabetes conferences in the UK, Europe, USA & Australia from 2 (or was it 3?) years previously and then did extensive searches for authors and titles etc to see how many actually got published.... it was less than 30% (which is found in other disciplines as well). This means that:
    1. Authors were lazy (I am guilty of that)
    2. The methodological aspects etc meant it was not good enough for publication on subsequent peer review (I am guilty of that too)
     
  7. C Bain

    C Bain Active Member

    HBA1c

    Hi Craig,

    Nice to speak with a honest scientist!

    Regards,

    Colin.
     
  8. C Bain

    C Bain Active Member

    HBA1c

    Hi Craig,

    As you have pointed out above, Craig regarding 1999, it seems to be the last enthusiastic examination of HBA1c by the 'Journal of Wound Care' Vol.9,No4,April 2000, too, where they were waiting at that time for B.I. Rosenblum & T.E.Lyons to publish et al. 'Evaluation of a human skin equivalent for the treatment of diabetic foot ulcers in a prospective, randomized, clinical trial.' Wounds 1999;11:4, 79-86. (To publish?).

    N.B.:- When I read something in a journal/text book/paper, I have been trained to look at the person writing it! (Qualifications, background, etc.), and look upon what has been said hopefully based on good research!

    In the case of 'Abstract 2' quoted in my posting above I felt (yes felt) in tune with the group of scientists putting their names to it! S.N. Zykova' name when put into Google search engine shows he/she is publishing and part of a team looking into HBA1c in a solid way at Tromso! Therefore, I feel safe in quoting their findings until something else appears in the enlightenment of research to show me otherwise! (Tell me where I'm wrong?).

    Impaired collagen syntheses - fibroblast dysfunction and cytokines are also being explored in 'www.journalofwoundcare.com'. The Journal of Wound Care is a monthly at £45 yearly or £11.25 quarterly. A journal designed to share information on wound healing by mainly Senior nurses in the UK. (I strongly suspect that this is where the reservoir of the new Super-nurses are going to come from?!).

    Papers in the February issue include high quality photographs and are listed amongst others under,

    1. Effects of diabetics mellitus on healing.
    2. Pressure ulcer aetiology.
    3. Contributing factors to pressure ulcer development.

    HBA1c seems to have been passed over as a subject since the last article in 1999/2000 issue of this journal as I think predicted by you!

    The people in Tromso Uni. seem to be continuing in their research, however!!!

    Regards,

    Colin.

    P.S. When I first started studies in Electrical Science in the early fifties, our textbooks showed electricity flowing from positive to negative, (Trust me I'm a scientist they said!!). I suppose it was because everything else in the then common understanding like water/gas/hydraulics all did it you know!

    Halfway through my second year someone in Government decided to declassify nuclear physics (the fool!). The picture of lots of little Electrons happily jumping from atom to atom along the wire, (I bet that made them dizzy!), in the other direction from negative to positive??? The core and first principle of electrical engineering - WRONG!!! (Not even a sorry chaps from the scientific lot?). Yes I nearly allowed myself to forget where 'Abstract 2 was coming from when I quoted it. Thank you Craig! But I still like it anyway. It seems to fit in with my common understanding for the moment?

    P.P.S. Better stop here but I wonder what you think of this one, Craig.,

    The brain washing of 'Cause and Effect of Pure Science? No not 'cause and effect' but CAUSE AND CONSEQUENCES of Applied Science?

    In HBA1c we as you have pointed out can have a number of CONSEQUENCES to a CAUSE, around a WOUND?!? Does this allow the Tromso Team a set of consequences in their conclusion even if they cannot be considered as final?
     
    Last edited: Mar 23, 2005
  9. Admin2

    Admin2 Administrator Staff Member

    Effect of glycaemic control on apoptosis in diabetic wounds

    From latest
    Journal of Wound Care:
    Effect of glycaemic control on apoptosis in diabetic wounds
     
  10. admin

    admin Administrator Staff Member

    This is interesting, as they set out with all the good intentions, but look what happened:

     
  11. John Spina

    John Spina Active Member

    Not that this is related to wound healing,but I am pleased that someoneis discussing Hb1Ac.I believe that thisis probably MORE important than glucose per se.Most of my pts with diabetic neuropathy,for instance,tend to have high Hb1Aclevels(which may be why these pts heal more slowly).
     
    Last edited: Sep 29, 2005
  12. David Smith

    David Smith Well-Known Member

    Dear A A Lang et al

    I wondered if you have seen and would be interested in this study that I have on file.

    The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus
    The Diabetes Control and Complications Trial Research Group

    ABSTRACT

    Background Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications.
    Methods A total of 1441 patients with IDDM -- 726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly.
    Results In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of =" src="/math/ge.gif" border=0 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of =" src="/math/ge.gif" border=0 300 mg per 24 hours) by 54 percent (95 percent confidence interval, 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia.

    This study concludes that intensive and well controled treatment of Insulin dependent diabetes reduced the risk of complications and pathology in diabetic patients. So if HbA1c shows the glucose levels over time wouldn't then well controled levels = good HbA1c results which would = less diabetic pathlogy?

    Just askin, Cheers Dave Smith
     
  13. C Bain

    C Bain Active Member

    HBA1c!

    Hi All,

    One of the real chinks in the Armour of medical procedures in wound prevention is the inability to have a good safe indicator of the immanent break down of tissue and blood supply. Just maybe the loss of quality blood delivered to tissues is the main causes of necrobiosis or necrosis? Could it be caused by an imbalance in the HBA1c levels perhaps or leading to the discovery of some other indicator or practical cure all? Loss of the element of bloods food-supply come fertilizer perhaps? May be HBA1c and even more unorthodox methods are needed to be developed, even if most of them are dust-binned early rather than latter in their development?


    An example of the most practical one which appears to work is the surgical stocking on the leg as a preventative measure. Problem is I had a deaf-mute patient yesterday who was not amused with the daily 30 minute wrestling match with the stockings and my recorded delivery with the written treatise on why he must!

    I wonder if some of our readers might be interested in a simple explained reason why the stocking is such a good way of preventing tissue damage and would HBA1c if successful make the stocking redundant perhaps, someone?

    So far in my experience of them,

    1. One fractured Femur! Fell over whilst attempting same! No good telling a late eighties year old to sit down when trying with the stockings after eighty odd years of successful stocking putting on?

    2. One threatened assault on a nurses integrity before she was thrown out of the house,(Hypothetically speaking of course), with a with-drawl of treatment consent as a result of the patients inability to put them on! It might of course have had something to do with the fact that the patient had had a severe stroke, lived alone and had the use of one arm. But nursing staff are so overworked that they were intent on getting his home-help who was not insured to do dressing and was also subsequently thrown out of the house after the nurse.

    3. Numerous occasions when the patient just point blank refused to attempt to put them on after the first, second, third attempt! One of the commonest causes of high blood pressure in the elderly perhaps?


    Possibly a hidden problem in the UK. at this time, despite the available use of applicators that work but cost money and do not appear to be prescribed by NHS. sources with the stockings? The tissue support stocking appears to be successfully when in place!

    A medical antidote to the problem would be a much more practical and economical one than having a nurse spending numerous work-hours on a daily basis putting on and taking off dressings and stocking?

    Is there a hidden miracle cure to wound healing, somewhere? Could it be HBA1c or an equivalent that can be practically applied in the myriad of treatments taking place today in the nursing and Podiatric establishment?

    Regards,

    Colin. (Pursuing a dream perhaps?).
     
    Last edited: Sep 29, 2005
  14. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    There is no doubt that DCCT trial in type 1 and the UKPDS in type 2 definitively showed the value of good glycaemic control in the reduction/prevention of DM complications. As for less DM pathology .... given that the population is aging and DM is becoming more prevalant (ie obesity is the numero uno risk factor) ... the individual incidence of complications may well decrease, BUT the population prevelance will go through the roof.
     
  15. robby

    robby Active Member

    all Great stuff and the papers are worth reading.
    But we should all know about the dcct it has been published for some time and produced some excellent results which have been included into the Nat Service Framework for Diabetes in the UK. also another study that you should be aware of is the UKPDS (UK Prospective Diabetes Study) conducted by Oxford Uni Med School and Oxford Dept of Encrinology and Diabetes. This study may have more relevance as it looked at complications and Diabetic control in type II (non insulin dependent diabtic patients) over a period of 20 years. data was collected on a multi centre basis, and this was published in the mid 1990s. (i was working in the Diabetic Foot Clinic in Oxford at the time) the results were absolutely conclusive. Diabetic control has a major effect on the healing rate of Diabetic Foot Ulcers. Other authors have published similar result and any search on the web will provide plenty of light reading on the subject.

    With regard to HBA1C this is also called glycated Haemoglobin and is a measure in % terms of the amount of Haemoglobin bonded to glucose. (haemoglobin bonds to glucose in preference to Oxygen and the bond is permanent for the lifespan of the RBC). Because the lifespan of an RBC is approx 90 days this measure gives an average measure of the amount of glucose in the blood stream over that period. It is regarded by all Endocrinologists and Diabetologists in the UK as the prefered measure of overall diabetic control. All patients attending Diabetic clinics usually have this measure done before attending the clinic so that the results are there for the clinic visit. (some clinics have the capability now to give instant HBA1C results.
    AS HBA1C is a measure of blood glucose levels there is an obvious correlation with healing rates. The studies probably havent been done beacause it is accepted as read by most clinicians working in the field as there are studies that have looked at standard blood glucose measures (such as pin prick) and healing rates.

    I hope that this helps a little .

    Rob

    DPod M BSc(Physiology& Biochemistry) PGDip (Diabetes)
     
  16. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Frequency of lower extremity amputation in diabetics with reference to glycemic control and wagner s grades.
    J Coll Physicians Surg Pak. 2006 Feb;16(2):124-7.
     
  17. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Wound healing

    Ostomy Wound Management have a new full text article on:
    Risk Factors Associated with Healing Chronic Diabetic Foot Ulcers: The Importance of Hyperglycemia
    Full article.
     
  18. Tuckersm

    Tuckersm Well-Known Member

    HbA1c and Peripheral Arterial Disease in Diabetes

    New Article in Diabetes care

    http://care.diabetesjournals.org/cgi/content/abstract/29/4/877?etoc

     
  19. drmkatz

    drmkatz Member

    Interesting topic. I am part of a wound center in Florida. Studies are important but practical experience tells all. My experience has been that those patients that have poor glycemic control can heal at a similar rate to others, however, I have seen a much greater recurrence of wounds and a higher infection rate in these patients with complications resulting in hospitalization.

    There is no doubt that HbA1c is important.

    Marc Katz, DPM
    Tampa, FL
    http://www.thetampapodiatrist.com
    drmkatz@yahoo.com
     
  20. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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  21. Cavoriaz

    Cavoriaz Member

    Hi
    I found a paper by Jelinek and Driver in podiatry today which has a section on wound healing in relation to hyperglycemia.
    it states:
    "Hyperglycemia results in leukocyte dysfunction and suppression of lymphocytes, high blood pressure, and impaired endothelial function. "
    Heres the reference:
    Jelinek, A and Driver V. (2006). Current Concept in Managing the Wound
    Microenvironment. Podiatry Today. 19 (9): 44-57

    Hope this is helpful.
     
  22. johnmccall

    johnmccall Active Member

    Hi Allan (and everyone),

    The data (unpublished as yet) we have at Ayrshire and Arran is that every patient who has diabetic foot disease has a h/o a long episode of HbA1c results > 9.0
    By a long episode I mean more than 3 years where there results were mostly above 9. In fact most were in double figures.
    We haven't checked if every patient who has consistently high HbA1c results also has diabetic foot disease. Experience says that probably will be the case if the patient survives other diabetic complications.
     
  23. AALang

    AALang Member

    Sounds a like a very interesting study. Which journal are you hoping to get it published in?
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The relationship between hemoglobin A(1c) values and healing time for lower extremity ulcers in individuals with diabetes.
    Markuson M, Hanson D, Anderson J, Langemo D, Hunter S, Thompson P, Paulson R, Rustvang D.
    Adv Skin Wound Care. 2009 Aug;22(8):365-72.
     
  25. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Association between glycated haemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus-review and meta-analysis.
    Adler AI, Erqou S, Lima TA, Robinson AH.
    Diabetologia. 2010 Feb 3. [Epub ahead of print]
     
  26. NewsBot

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    Articles:
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    Hemoglobin A1c Predicts Healing Rate in Diabetic Wounds
    Andrea L Christman, Elizabeth Selvin, David J Margolis, Gerald S Lazarus and Luis A Garza
    Journal of Investigative Dermatology 131, 2121-2127 (October 2011)
     
  27. NewsBot

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    Importance of Sustained Glycemic Control During Wound Healing
    Emily Cook, et al
    From the APHA Conference Tuesday, October 30, 2012 : 2:50 PM
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    From the 2012 ADA Mtg:
    HbA1c and Long-Term Mortality in Patients with Diabetic Foot Ulcer
    MAGNUS LÖNDAHL, KATARINA FAGHER, ANDERS L. NILSSON
     
  29. NewsBot

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    Effect of the Blood HbA1c Level on Surgical Treatment Outcomes of Diabetics with Ankle Fractures
    Jiayong Liu MD, Todd Ludwig MS, Nabil A. Ebraheim
    Orthopaedic Surgery; Volume 5, Issue 3, pages 203–208, August 2013
     
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    The Impact of Glycosylated Hemoglobin and Diabetes Mellitus on Postoperative Wound Healing Complications and Infection Following Foot and Ankle Surgery.
    Jon Humphers, Naohiro Shibuya, Benjamin L. Fluhman, and Daniel Jupiter
    Journal of the American Podiatric Medical Association In-Press.
     
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    HbA1c and Lower Extremity Amputation Risk in Patients With Diabetes
    A Meta-Analysis

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    International Journal of Lower Extremity Wounds June 2015 vol. 14 no. 2 168-177
     
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    THE IMPACT OF POOR GLUCOSE CONTROL ON OUTCOMES OF TREATMENT

    Tina Lefrancois
    Master of Science Thesis ; Dalhousie University 2015 (full text)
     
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    Fernando ME, Seneviratne RM, Tan YM, Lazzarini PA, Sangla KS, Cunningham M, Buttner PG, Golledge J.
    Cochrane Database Syst Rev. 2016 Jan 13;1:CD010764
     
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    HbA1c and Lower Extremity Amputation Risk in Patients With Diabetes: A Meta-Analysis.
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