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EXPERT COMMENT
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 7-9

Clinical utility of mobile phone-based thermography and low-cost infrared handheld thermometry in high-risk diabetic foot


Department of Surgery, Southwestern Academic Limb Salvage Alliance, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA

Date of Web Publication8-Mar-2019

Correspondence Address:
Mr. David G Armstrong
Department of Surgery, Southwestern Academic Limb Salvage Alliance, Keck School of Medicine of University of Southern California, Los Angeles, CA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_7_19

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  Abstract 


Literature is replete with robust studies documenting the potential clinical utility and net protective effect of the use of temperature assessment/inflammometry in high-risk diabetic foot. We present a mobile phone-based device (FLIR One Personal Thermal Imager, FLIR, Inc., Wilsonville, OR, USA) and a stand-alone handheld device (Nubee, Duarte California, USA) to provide simple, quantifiable images to assist in rapid clinical visualization. Therefore, the purpose of this manuscript was to highlight the potential day-to-day application of these tools.

Keywords: Infrared thermometry, mobile based, thermography


How to cite this article:
Boguski R, Khan T, Woelfel S, D'Huyvetter K, Armstrong AA, Armstrong DG. Clinical utility of mobile phone-based thermography and low-cost infrared handheld thermometry in high-risk diabetic foot. Indian J Vasc Endovasc Surg 2019;6:7-9

How to cite this URL:
Boguski R, Khan T, Woelfel S, D'Huyvetter K, Armstrong AA, Armstrong DG. Clinical utility of mobile phone-based thermography and low-cost infrared handheld thermometry in high-risk diabetic foot. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Mar 25];6:7-9. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/7/253742




  Introduction Top


Inflammation is characterized by pain, loss of function, swelling, redness, and heat.[1],[2] Many of these signs and symptoms are masked or blunted in a person with diabetes or made difficult to detect by differences in skin texture or color. Of these signs, temperature is the only one that is readily quantifiable.[3] For more than a generation, our team and others have utilized thermometry and thermography to better quantify and image sites of inflammation both in the clinic and, perhaps more importantly, in the home setting.[4],[5],[6],[7] Literature is replete with robust studies, reviews, and meta-analyses documenting the potential clinical utility and net protective effect of the use of this modality in high-risk diabetic foot;[8],[9] however, many devices have been too expensive or impractical for day-to-day use. Over the past several years, our group and others have begun using a consumer electronic mobile phone-based technology to capture real-time images in clinic.[10],[11] We are unaware of many studies in the literature that have documented the day-to-day use to provide simple quantifiable images to assist in rapid clinical visualization. Therefore, the purpose of this manuscript was to highlight such a potential tool.


  Case Reports Top


Case 1

A 67-year-old male with a 25-year history of diabetes mellitus, Stage 4 chronic kidney disease, coronary artery disease, and peripheral artery disease presented to the emergency department following a fall from a height of 10 feet, causing fractures to multiple ribs, sternum, and nasal septum. He underwent reconstructive surgery by the trauma team immediately following the accident. As the patient was previously seen for the treatment of Charcot arthropathy in the distant past, podiatric surgery was also consulted. The thermograph showing acute inflammation at the site of the medial cuneiform should be noted. This corresponded to acute Charcot arthropathy with the overlying osteomyelitis [Figure 1].
Figure 1: (a and b) In these images of Charcot arthropathy, note inflammation focused at the site of previous tissue loss and medial Charcot collapse plantarly and over the entire dorsal aspect of the foot seen clinically and confirmed with FLIR image

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Case 2

A 63-year-old native American woman with a 20-year history of diabetes mellitus and 1 year status postrenal transplant was transported from a rural hospital with a 2-day history of diffuse 2nd toe pain with the overlying myalgia and malaise. While she showed no clinical evidence of retained purulence and no constitutional or laboratory findings of infection, subtle signs of a plantar abscess (not appreciable visibly or by palpation) as well as clearly, clinically, and visibly observable dorsal signs of inflammation were noted [Figure 2].
Figure 2: (a-e) This visualization identifies a paradoxical minor decrease in temperature over the center of abscess of the second ray. This is likely secondary to fluid collection but accentuated proximally and distally in the sulcus of metatarsal phalangeal joint. Note the pull-down visual/infrared overlay (c) and red/white filter identifying hotspots only (d)

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Case 3

A 63-year-old woman had presented to the clinic with a past history of diabetes mellitus, venous insufficiency, gout for unilateral foot, and ankle swelling. In the presence of deformity, a diagnosis for Charcot arthropathy was confirmed clinically with the use of thermography. There was a noted temperature gradient difference of 9°F [Figure 3].
Figure 3: (a and b) Note the difference in temperature between the lower extremities revealed upon thermographic examination of a diabetic patient who presented with unilateral swelling and gross ankle deformity

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Case 4

A 68-year-old woman presented to the clinic with pain under her hallux nail following excision of the nail. Clinical examination revealed a small amount of tissue loss at the site. A large reduction of temperature (7.8°F) was revealed on thermographic examination from the hallux distally as compared to its base, revealing likely peripheral arterial disease [Figure 4].
Figure 4: (a and b) Clinical images demonstrating an area of tissue loss distal to the hallux nail, with thermographic correlation revealing a reduction in temperature, likely due to peripheral arterial disease

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  Discussion Top


We briefly present this technology as an additional tool to aid physicians, surgeons, therapists, or nurses in identifying and quantifying inflammation in high-risk diabetic foot. Its use has also been proposed for the evaluation of limb ischemia.[12] This technology has the potential to identify cold spots, which may be associated with focal or regional ischemia concomitant with diabetes. Thermometry has been used in a variety of form factors over the past generation for many different applications.[8],[9],[10],[11] However, the large majority of these applications are often complex, large in size, or require special setup. Tools that blur the line between consumer electronics and medical devices might become more useful than very expensive, more accurate instruments. Simply put, the ideal device is the one that is readily at hand.

We present two different handheld devices in our clinic. One of these is an iPhone-connected technology and the other is a purpose-built thermometer. The former allows for rapid assessment of inflammation over a wide surface area. It also provides a literal picture of symmetry that can be interpreted efficiently both at the time of patient care and over time. The latter device measures point by point. It is rather inexpensive ($15USD) but requires manual mapping by clinic staff [Figure 5].
Figure 5: Thermometry map for use in the clinic

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We believe that practical applications like this will become increasingly important both for home use and routine follow-up.[9],[13],[14] Tools that can be easily utilized for repeat measures may ultimately become effective at the front line of management of patients with active diabetic foot disease and those in diabetic foot remission as well as in the context of peripheral arterial disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bharara M, Schoess J, Armstrong DG. Coming events cast their shadows before: Detecting inflammation in the acute diabetic foot and the foot in remission. Diabetes Metab Res Rev 2012;28 Suppl 1:15-20.  Back to cited text no. 1
    
2.
Murff RT, Armstrong DG, Lanctot D, Lavery LA, Athanasiou KA. How effective is manual palpation in detecting subtle temperature differences? Clin Podiatr Med Surg 1998;15:151-4.  Back to cited text no. 2
    
3.
Lavery LA, Peters EJ, Armstrong DG. What are the most effective interventions in preventing diabetic foot ulcers? Int Wound J 2008;5:425-33.  Back to cited text no. 3
    
4.
Armstrong DG, Holtz-Neiderer K, Wendel C, Mohler MJ, Kimbriel HR, Lavery LA, et al. Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med 2007;120:1042-6.  Back to cited text no. 4
    
5.
Arad Y, Fonseca V, Peters A, Vinik A. Beyond the monofilament for the insensate diabetic foot: A systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes. Diabetes Care 2011;34:1041-6.  Back to cited text no. 5
    
6.
Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 2016;32 Suppl 1:16-24.  Back to cited text no. 6
    
7.
van Netten JJ, Price PE, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. Prevention of foot ulcers in the at-risk patient with diabetes: A systematic review. Diabetes Metab Res Rev 2016;32 Suppl 1:84-98.  Back to cited text no. 7
    
8.
Houghton VJ, Bower VM, Chant DC. Is an increase in skin temperature predictive of neuropathic foot ulceration in people with diabetes? A systematic review and meta-analysis. J Foot Ankle Res 2013;6:31.  Back to cited text no. 8
    
9.
Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017;376:2367-75.  Back to cited text no. 9
    
10.
Kanazawa T, Nakagami G, Goto T, Noguchi H, Oe M, Miyagaki T, et al. Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study. J Wound Care 2016;25:177-80, 182.  Back to cited text no. 10
    
11.
Xue EY, Chandler LK, Viviano SL, Keith JD. Use of FLIR ONE smartphone thermography in burn wound assessment. Ann Plast Surg 2018;80:S236-8.  Back to cited text no. 11
    
12.
Theuma F, Cassar K. The use of smartphone-attached thermography camera in diagnosis of acute lower limb ischemia. J Vasc Surg 2018;67:1297.  Back to cited text no. 12
    
13.
Armstrong DG. The big picture: lower extremity complications of diabetes. Diabetic Foot J 2015;18:1-2. Available from: http://www.diabetesonthenet.com/journal-content/view/the-big-picture-lower-extremity-complications-of-diabetes. [Last accessed on 2015 Oct 30].  Back to cited text no. 13
    
14.
Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT, et al. Long-term prognosis of diabetic foot patients and their limbs: Amputation and death over the course of a decade. Diabetes Care 2012;35:2021-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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