thesis in ulcer

Rethinking the history of peptic ulcer disease and its relevance for network epistemology

• Original Paper
• Open access
• Published: 04 November 2021
• Volume 43 , article number  113 , ( 2021 )

Cite this article

You have full access to this open access article

• Bartosz Michał Radomski 1 ,
• Dunja Šešelja   ORCID: orcid.org/0000-0001-5679-5787 2 &
• Kim Naumann 3  

6438 Accesses

7 Citations

4 Altmetric

Explore all metrics

The history of the research on peptic ulcer disease (PUD) is characterized by a premature abandonment of the bacterial hypothesis, which subsequently had its comeback, leading to the discovery of Helicobacter pylori—the major cause of the disease. In this paper we examine the received view on this case, according to which the primary reason for the abandonment of the bacterial hypothesis in the mid-twentieth century was a large-scale study by a prominent gastroenterologist Palmer, which suggested no bacteria could be found in the human stomach. To this end, we employ the method of digital textual analysis and study the literature on the etiology of PUD published in the decade prior to Palmer’s article. Our findings suggest that the bacterial hypothesis had already been abandoned before the publication of Palmer’s paper, which challenges the widely held view that his study played a crucial role in the development of this episode. In view of this result, we argue that the PUD case does not illustrate harmful effects of a high degree of information flow, as it has frequently been claimed in the literature on network epistemology. Moreover, we argue that alternative examples of harmful effects of a high degree of information flow may be hard to find in the history of science.

Similar content being viewed by others

Commentary on Kate E. Lynch, Emily C. Parke, and Maureen A. O’Malley: ‘How Causal are Microbiomes? A Comparison with the Helicobacter pylori Explanation of Ulcers’

Big Data and Network Analysis: A Promising Integration for Decision-Making

Digital Epidemiology

Avoid common mistakes on your manuscript.

1 Introduction

The early 20th century research on peptic ulcer disease (PUD) is often mentioned as an example of scientific inquiry ‘gone wrong’ (e.g. Thagard, 2000 ; Gilbert, 2000 ; Solomon, 2001 ; Zollman, 2010 ; Wray, 2010 ; Miller, 2013 ; Šešelja & Straßer, 2014 ; O’Connor, 2020). As most accounts of this case report, from the 19th century on there were two major rivaling hypotheses of the disease: the acidity hypothesis, according to which the disease is caused by an excessive acidity of the stomach, and the bacterial hypothesis, which stipulated bacteria as the primary cause of the disease. In the mid-20th century the bacterial hypothesis was abandoned, and the research on PUD proceeded along the lines of the acidity research program. The latter focused on the study of various treatments aimed at achieving a chemical balance in the stomach, from antacid medications to surgical procedures, rather than on the identification of bacteria and their eradication. For three decades the research on PUD was based on a worse of the two hypotheses. It was only in the 1980s that Robin Warren and Barry Marshall discovered Helicobacter pylori, a bacterium which turned out to be the major cause of PUD. This discovery, for which Warren and Marshall received a Nobel Prize in Physiology or Medicine, led to the revival of the bacterial research program.

According to the received view on the history of this episode (originating primarily in Warren and Marshall, 1983 ; Marshall, 2002 ), Footnote 1 the main reason for the abandonment of the bacterial hypothesis was a large-scale study by a prominent gastroenterologist, Palmer ( 1954 ). Palmer examined 1,180 subjects, fifth of whom were healthy individuals, while the remainder of the group were patients with gastrointestinal complaints. The study showed no presence of bacteria in the gastric mucosa of the subjects. As scientists Fukuda et al. ( 2002 ), reflecting on the history of this case, write:

[T]he hypothesis that PUD was caused by bacteria in the mucosa of the human stomach was rejected in 1954 by the major authority in American gastroenterology, [Palmer, 1954] despite consistent information in the preceding 50 years of bacteria that adhered to the gastric musosa \(\dots\) His words ensured that the development of bacteriology in gastroenterology would be closed to the world as if frozen in ice. (p. 17) His study established the dogma that bacteria could not live in the human stomach, and as a result, investigation of gastric bacteria attracted little attention for the next 20 years. (p. 20)

Nowadays we know that Palmer’s study was deeply misleading as it was based on a method unsuitable for detecting spiral bacteria (see Fukuda et al., 2002 ). As a result, this historical episode has become one of the central examples of an inquiry in which everything was done by the book in the sense that each individual scientist had good reasons to abandon the bacterial hypothesis, and yet, the scientific community on the whole was sidetracked towards a false theory for a long period of time (Zollman, 2010 ; Kummerfeld and Zollman, 2016 ; O’Connor, 2020). As such, the PUD case appears to be a nice example of the individual and group rationality coming apart in the sense that rational choices by individual scientists do not sum up to an optimal inquiry at the level of the given community. It also appears to be illustrative of how a wide dissemination of erroneous findings can sidetrack the entire scientific community.

However, such an interpretation of the events leaves some questions open. For instance, if Palmer’s study was that influential, how come nobody in the scientific community noticed potential problems with it? After all, warnings about the unsuitability of the method of staining used in Palmer’s study had previously been pointed out by Freedberg and Barron ( 1940 ), whom Palmer even cited in his paper. This is all the more surprising if we agree with Šešelja and Straßer ( 2014 ) that the bacterial research program (in spite of Palmer’s findings) had promising lines of inquiry in the 1950s, when it was largely abandoned. What is more, the alleged impact of Palmer’s study has never been corroborated by adequate historical evidence. Nor has the widely adopted view of the popularity of the bacterial hypothesis prior to Palmer’s publication ever received a proper evidential support.

In this paper we aim to advance this debate by conducting a critical examination of the received view on PUD, according to which, the main reason for the abandonment of the bacterial hypothesis was Palmer’s study. If the received narrative is correct, the abandonment of the bacterial hypothesis can be ascribed, for instance, to Palmer’s influence, which swayed the entire medical community. As Zollman ( 2010 ) writes: “It was the widespread acceptance of Palmer’s result which led to the premature abandonment of the diversity in scientific effort present a few years earlier.” (p. 21).

However, claims about Palmer’s influence are often asserted without considering the state of the research landscape prior to 1954. Our aim is therefore to examine whether the bacterial hypothesis of PUD had been largely abandoned already before Palmer’s publication. In order to uncover the details of this episode, we have used the method of digital textual analysis applied to the corpus of the English-language literature on PUD published in the decade prior to Palmer’s study. The reason why this point is especially interesting is that, if confirmed, it would have important repercussions for philosophical discussions of this episode.

First of all, the relevance of Palmer’s study would be significantly reduced: even if his claims had discouraged some scientists from pursuing the bacterial hypothesis, they’d be the final nail in the coffin of an already dying theory, rather than the main cause of its abandonment.

Second, explaining the PUD episode in terms of a wide dissemination of Palmer’s results would be undermined. As a result, this case would fail to serve as an example of how a high degree of information flow among scientists can lead to inefficient inquiry. While this point originates in Zollman’s work on network epistemology, it has become widely adopted across the philosophical literature, beyond discussions on formal models of science (e.g. Wray, 2010 ; Douven & Kelp, 2011 ; Nunn, 2012 ; Vickers, 2020 ; Peters, 2020 ; Killin & Pain, 2021 ). Since examples of harmful effects of a dense communication flow are hard to find, PUD has been particularly valuable as an illustration of this phenomenon. Hence, if our hypothesis is confirmed, philosophers need to find other suitable historical case studies in order to illustrate such a socio-epistemic mechanism. But as we shall argue in Sect.  4 , this may be challenging.

Finally, if it turns out that there was hardly any research on the bacterial theory already in the 1940s, then the above question—why was the bacterial hypothesis abandoned in the 1950s?—wouldn’t be puzzling anymore. Instead, we would be confronted with different questions, raised by alternative possible histories of this case. One such possibility is that the bacterial hypothesis used to be popular at the end of the nineteenth century, after which it went through a gradual decline. Another option is that its decline wasn’t gradual, but abrupt and triggered at some point between the end of the nineteenth century and early 1940s. Finally, it is also possible that the bacterial theory had not been popular at any point in the first half of the twentieth century, but had always been a fringe research line. While previous historical discussions of this case had been based solely on a qualitative analysis, new quantitative methods, based on digital tools, could be fruitfully used to acquire new evidence and reveal which of the above scenarios is best corroborated. As we will argue, such new scenarios come with specific philosophical puzzles, which have so far not been considered.

Here is how we will proceed. In Sect.  2 we give a historical overview of this case-study focusing on the question, which factors might have contributed to the abandonment of the bacterial research program. In Sect.  3 we introduce the method of digital textual analysis, which we use to examine the historical claim that the bacterial research program was largely abandoned prior to the publication of Palmer’s study. In Sect.  4 we examine the consequences of our results for philosophical discussions of this episode, with a special focus on the literature in network epistemology. Section  5 concludes the paper.

2 Etiological theories of PUD

In this section we provide a historical overview of the English-language research on PUD in the first half of the twentieth century, focusing on the question as for which factors, besides Palmer’s paper, could have indirectly contributed to the abandonment of the bacterial hypothesis of PUD. To this end, we will primarily rely on secondary sources from history of medicine Footnote 2 and first-hand testimonies from gastroenterologists who were working on PUD during the period of our interest, in Britain (Christie and Tansey, 2002 ) and worldwide (Warren, 2005 ). These primary sources give an insight into personal factors that led researchers away from the correct hypothesis.

Before turning to factors that are relevant in considering the downfall of the bacterial research program (or the ‘germ theory of PUD’), we give a brief overview of different etiological theories of this disease researched in the first half of the twentieth century.

2.1 Theoretical diversity

According to the received view that we engage with (Kidd and Modlin, 1998 ; Zollman, 2010 ; Pollock, 2014 ), two influential hypotheses of what causes PUD developed early on: on the one hand, the so-called acidity hypothesis, according to which the ulcer is caused by gastric juice corroding the stomach, and on the other hand, the bacterial hypothesis, which postulated bacteria as the cause of the disease. Eventually, the story goes, the latter strand of research was brought down by the paper by Palmer ( 1954 ) thus “setting back gastric bacterial research by a further 30 years” (Kidd and Modlin, 1998 , p. 10). Our aim in this section is to show that, contrary to the commonly told story, the question of what causes PUD rarely took shape of a simple choice between the bacterial and the acidity theory.

While the research on PUD draws its origins from the late 16th century, modern gastroenterological study of the disease started in the 19th century. Moving on to the first half of the twentieth century, it is easy to notice a range of insufficiently corroborated etiological theories forming this research landscape (Miller, 2010 , p. 105). For instance, Pollock ( 2014 , Chapter 3) distinguishes eight different factors that were at some point considered important in the genesis of peptic ulcers. These include not only germs and the acid, but also factors related to anatomical pathologies, inborn predispositions (such as e.g. an “ulcer personality type”, see also (Miller, 2010 , p. 102)), or psychological factors, such as stress (see also Jones, 2012 , p. 13). What is more, gastroenterology was slow to develop as a specialized field, partly because there was no general agreement among surgeons and physicians on how to best treat digestive diseases (Miller, 2010 , p. 105). Notably, however, the treatment of PUD–whether pharmacological or surgical—was mainly focused on reducing the acidity in the stomach (Miller, 2010 , p. 105).

The research in the 1940s and the 1950s witnessed an increasing focus on the role of physiological and psychological factors on the development of PUD. The Lancet editorial from the end of the 1940s nicely illustrates this point: it posits that theories of peptic ulceration inevitably center around two possibilities: heightened erosive potency of gastric contents, or lowered anti-acid resistance (“Ætiology of Peptic Ulcer. Editorial”, 1949 , p. 997). At the similar time, a number of editorials from The American Journal of Digestive Diseases Footnote 3 emphasized in turn the psychological causes of PUD, such as anxiety and stress. The appearance of an ulcer was considered to indicate a reduced capability of the body to prevent ulcers, rather than a result of increased external ulcerogenic factors (such as bacteria).

Altogether, the research on PUD shifted away from a mono-causal and towards multi-causal approaches, and away from acidity as the sole etiological factor and towards the overall physiological balance in the stomach, including the failure of its anti-ulcer mechanism (Connell, 1949 ). This reflects the overall trend in medicine at the time. While in the beginning of the 20th century the medical research was largely driven by a mono-causal perspective, closely related to the germ paradigm of disease (originating in the works of Koch and Pasteur), the situation started to change around the 1950s with the emergence of the chronic disease epidemiology (Carter, 2003 ; Šešelja & Straßer, 2014 ). In case of the research on PUD, the multi-causal perspective was already present prior to Palmer’s study.

Some of the earliest indications that the idea of multiple causes was on the table comes from J. Shelton Horsley who commented that an ulcer may be produced by a combination of three factors: hyperacidity, toxic influences (possibly bacterial in nature), and the neurogenic (psychological) factors (Dragstedt, 1935 , p. 579). After WWII, the popularity of multi-causal theories increased. For instance, according to Kirsner and Palmer, ( 1952 , p. 615), “acid is indispensable” as a factor but “apparently not the only one”. In a similar vein, Sullivan and McKell, ( 1950 , p. 14–20) introduced a ‘Theory of Multiple Etiology’, taking a form of a simple mathematical ratio, where the ulcer was a result of imbalance in the ratio of the sum of contributing factors, e.g. personality, precipitating emotional situations, genetic factors, etc., and the overall resistance to ulcers. Relatively strong ulcer-inducing factors, or relatively weak resistance, could both lead to ulceration. Footnote 4 Remarkably, while the presence of acid was deemed essential, the bacteria were not mentioned by Sullivan and McKell. Taken together, the multi-causal approach meant that the etiological search space was more nuanced and complex than a simple choice between an acid theory and a germ theory.

However, the possibility that PUD was considered at the time as a multi-factorial disease is not discussed in the received view literature (e.g., Kidd & Modlin, 1998 ; Zollman, 2010 ). Even Pollock ( 2014 ), who discusses multiple etiological theories, portrays them as if they were pursued one at a time and treated as mono-causal accounts intended to be both sufficient and exhaustive. Thus, the evidence we provide above invites to reconsider the PUD case as that of scientists confronted not with a binary choice but with having to weight multiple factors in terms of their importance, perhaps in a way that the aforementioned theory of Sullivan and McKell from 1950 would suggest.

2.2 Factors that played a role in the demise of the bacterial hypothesis

We now take a closer look at different issues, beside Palmer’s study, which could be explanatory of why the bacterial research program lost its popularity in the mid-twentieth century.

The role of hyperacidity As mentioned above, despite prolific arguments and the lack of agreement about the role of acid in ulceration, the acid theory seemed at the time to be the most fruitful hypothesis in terms of possible treatment (Christie & Tansey, 2002 , p. 20). Therefore, the primary focus for treatment centered on regulating gastric secretion, which was reflected in a widely popular dictum: ‘no acid, no ulcer’, coined by Karl Schwarz in 1910 (Bralow et al., 1950 ).

The significance of acid as an etiological factor was in big part due to the work of Dragstedt (e.g. 1935 ) who demonstrated that a high degree of acidity in the stomach was alone capable of causing ulcers. This immediately led some scientists to consider hyper-acidity as the most immediate cause of ulcer (e.g. Rowland, 1937 ). As Pollock ( 2014 , p. 93) comments, despite the lack of unanimity in the community, hyper-acidity became the main working hypothesis and the efforts towards an effective treatment were largely based on this assumption.

Vagotomy Another factor that played an important role in the decline of the bacterial research program is the success of a surgical procedure known as vagotomy. In order to treat ulcers, Dragstedt and Owens ( 1943 ) introduced a surgical method of cutting the vagus nerve, responsible for the acid secretion. Dragstedt established the viability of this procedure through a series of papers (Dragstedt, 1945 ; Dragstedt & Schafer, 1945 ; Dragstedt et al., 1947 , 1949 ). Vagotomy appeared to work and until late 1970s it remained the most effective and reliable treatment for the condition, with comparatively fewest side-effects (Hobsley, 1994 ). Footnote 5

Problems in early bacteriological research Since the introduction of Koch’s principles Footnote 6 the major challenge for bacteriological theories was finding and identifying the disease-causing organism. Even though bacteria isolated from stomach ulcers were microscopically identified as early as in 1875, it was not clear which of them could play a part in the genesis of ulcers (Pollock, 2014 , p. 85). Moreover, their reported frequency of occurrence in ulcerated stomachs was considerably lower than in other animals (Warren, 2005 , p. 19). In the early 20th century Turck ( 1907 , 1908 ) examined the link between Bacillus coli and PUD, but his findings were not successfully reproduced (Kidd & Modlin, 1998 , p. 8). Soon thereafter, another researcher, Edward Rosenow, hypothesized that a different strand, Streptococci, was “commonly the original cause” of PUD (Rosenow & Sanford, 1915 , p. 226) and attempted to induce ulcers with the aid of bacteria. Rosenow’s findings were influential and well-known (Pollock, 2014 , p. 86) but later researchers again could not replicate the results using Rosenow’s technique (as reported in Ivy et al., 1950 , p. 271). Thus, we can see that the initial studies, despite being based on the germ theory, posited wrong candidate microbes as etiological agents and as a result were not successfully replicated.

What’s more, while Rosenow believed in the etiological role of bacteria in ulceration, he held that it was the bacteria in and around the mouth and away from the abdomen that were to blame. In short, he looked for PUD-related bacteria outside of the stomach. This view was a particular expression of a “focal infection” theory, which posited that local sepsis in the teeth, tonsils, or sinuses, allowed a blood-borne spread of bacteria or toxins to other bodily areas, causing various diseases (Pollock, 2014 , p. 89–98). As a treatment, Rosenow advised the surgical removal of the “loci of infection” (Rosenow, 1916 , p. 359). However, the focal infection theory kept on drawing increasing criticism. It soon became evident that it is both life-threatening and practically impossible to try to remove all the loci of infection, and that one can have focal sepsis and still lead a perfectly healthy life (Pollock, 2014 , p. 92). Eventually, by 1940 Rosenow’s theory was flatly rejected by Grossman ( 1940 ). Because of a misconceived mechanism for infection and unviable treatment, this strand of bacterial research faded away well before Palmer’s study.

Altogether, the significance of microbes in the stomach was not appreciated (Pollock, 2014 , p. 89). Contemporary researchers regarded bacterial presence as “accidental” or at best secondary, following the ulceration but not causing it (Dragstedt, 1917 ; Smithies, 1935 ; Hinton, 1936 ; Winkelstein, 1936 ; Henry, 1942 ). This pattern continued outside of the US, as the presence of bacteria in the stomach kept being reported after the war (Barber and Franklin, 1946 ; Cregan et al., 1953 ) and even after Palmer’s paper (Bishop and Anderson, 1960 ; Franklin and Skoryna, 1966 ). Nevertheless, in each case the researchers did not assign any etiological role to the found microorganisms and maintained their beliefs that healthy stomachs are sterile.

An exception was the research by Freedberg and Barron ( 1940 ), who identified spiral bacteria in patients suffering from PUD. However, their study was small in scale and the results inconclusive. While their findings (subsequently cited by Palmer) provided some argumentative support to the bacterial research program, hardly anyone engaged in its pursuit. Footnote 7

Psychogenic Factors Finally, the idea that gastric problems were in some way related to mental activity was a dominant theme in the North American and British literature on indigestion for centuries (Miller, 2010 , footnote 30). This conjecture had a fertile ground to grow at the beginning of the 19th century, which marked the shift in medicinal practice towards a holistic approach, taking into account not only physical symptoms, but also the psyche, emotions and social environment of a patient (Spiro, 1998 , p. 645; Miller, 2011 , Ch. 5). The role of psychogenic factors was further corroborated by emerging physiological evidence linking brain malfunction and stomach disturbances (Miller, 2010 , p. 101).

Another important development during this time was the rise in influence of Franz Alexander who in 1934 offered a psychogenic hypothesis of ulcer (Spiro, 1998 , p. 645; Miller, 2010 , p. 101). According to Alexander ( 1934 ), ulcer was developed as the result of suppressed subconscious tendencies, such as a desire to be fed, which in turn would trigger a negative somatic response leading to a disease. Furthermore, Robinson ( 1935 ) argued that PUD was found only among slender people of white race who as a result of their body type were supposed to have a disposition for mental instability, thus being at risk of developing ulcer. Inspired by these ideas, Davies and Wilson ( 1937 ) proposed the existence of an “ulcer type” of a person. Their work became highly influential and started a quest to define the “peptic ulcer personality” (Miller, 2011 , p. 111–113). As Davey Smith ( 2005 ) argues, it was the belief in the ulcer-inducing power of stress that shifted the attention away from bacteriological research:

[T]he stress model served to block people from building on this [bacterial theory] and moving towards an answer ... Things may appear clear with hindsight, but people really were directed away from a treatment for peptic ulcers that worked—antibiotics—to ones that did not.

Coincidentally, the outbreak of WWII also boosted the influence of the psychogenic theory (Christie and Tansey, 2002 , p. i). The incidence of peptic ulcer grew at an unprecedented rate, especially among troops internationally, and stomach disorders quickly became a major health complaint (Miller, 2010 , p. 97). The war and the ulcers were associated so strongly that already early into the war, British practitioners began calling PUD a ‘military dyspepsia’ or a ‘war ulcer’. This novel rate of increase in ulcers was a new phenomenon and defied any logic in medical thinking. First, it contrasted with WWI, during which abdominal problems went relatively unnoticed (Miller, 2010 , p. 97). Secondly, on the Eastern Front, few soldiers on the front-line developed ulcers, as opposed to those further back in the supply line (Miller, 2010 , p. 97). Some researchers associated peptic ulcers with poor nutrition in the war-zone (Hoelzel, 1943 ; Steele 1944 ), but even as diet improved, the rate of occurrence kept increasing, reaching its peak in the mid-1950s (Jones, 2012 , p. 1). As a result, in these post-Freudian days of the 1950s the psychosomatic factors, especially stress, in combination with ‘ulcer type personality’, were widely thought to be the main cause of the ulcer (Christie & Tansey, 2002 , p. i). Looking for a connection between the army service and PUD continued in the US after the war and became a focus of several studies (Garbat, 1946 ; Halsted & Weinberg, 1946 ; Barrett, 1953 ; Palmer & Sullivan, 1952 ).

In this section we have provided an overview of developments other than Palmer’s paper, which contributed to the demise of the bacterial theory of the PUD etiology. This summary aimed to be primarily descriptive (rather than normative): while we presented a number of potentially relevant factors in the abandonment of the bacterial theory, we did not evaluate whether such a neglect was epistemically warranted (we will come back to this point in Sect.  4 ). Moreover, we do not claim we have established a definite answer as to what put the germ theory to a pause. However, we hope to have shown that there was a variety of factors that worked against it. In the next section, we will put forward a thesis that by the time Palmer’s infamous study was published, the germ theory had already been marginalized and cast aside by the overwhelming majority of scientists.

3 The status of bacterial research program prior to Palmer’s study: digital textual analysis

In this section we examine the following historical question: to what extent was the bacterial hypothesis of PUD pursued prior to the publication of Palmer’s 1954 study? By answering this question we will be in a better position to judge the significance of Palmer’s result on the abandonment of the bacterial hypothesis.

The motivation for asking this question comes from a few separate considerations. First, as we have seen in the previous section, towards the 1950s, the overall research climate was not very forthcoming to the bacterial hypothesis. Second, assuming that the bacterial research program was active in the early 1950s, it is surprising that nobody noticed the methodological error underlying Palmer’s results. Finally, looking at the articles on the etiology of PUD published in the early 1950s, one can easily encounter articles that do not even mention bacteria as a potentially relevant factor (as noted by Šešelja and Straßer ( 2014 )). Nevertheless, these indicators are insufficient evidential basis for answering the above query, whether Palmer’s paper was indeed a game-changer to PUD researchers. To approach the issue more systematically we turn to digital textual analysis of the relevant literature.

3.1 Methodology

To address the above line of historical inquiry, we have performed a digital textual analysis of a selection of English language articles published in the period from 1943-1953 Footnote 8 . More precisely, we have selected articles in PubMED database that have a MeSH Major Topic “Peptic Ulcer” and a a MeSH Qualifier “etiology”. Footnote 9 Together, the Major Topic and the Qualifier yield a combined search term “Peptic Ulcer/etiology”, which we assumed to be sufficient for picking out the articles that are most likely to feature any significant research on bacteria as an etiological factor in PUD. Our complete search command was:

Our search resulted in 186 hits, but actually consisted of 184 unique and complete papers, out of which we have managed to access 163 manuscripts. One of the papers was mistagged and was therefore removed from the bibliography. Footnote 10 It is also worth mentioning that MeSH terms are either assigned to articles by human reviewers or automatically using natural language processing methods. In our case 80 out of 186 positions have been indexed automatically (without human supervision), making it not implausible that some “germ theory” articles were omitted.

To better understand this output, we will now elaborate on the status of PUD articles in the PubMed database in this time period.

For the period 1943–1953, PubMed lists 172,719 articles belonging to “Diseases Category”. Roughly 10.7% of these (18,477) are articles concerning “Digestive System Diseases”. In comparison, the “Infections” Major Term yields 45,221 articles (26.1%) and “Nervous System Diseases” yields 23,213 articles (13.4%). Within the “Digestive System Diseases”, PUD articles comprise roughly 14% (2579/18,477) making it roughly 1.5% (2659/172,719) of the more encompassing “Diseases Category”. Thus, PUD research appears to be a considerable area of study in this time period. Our selection of manuscripts is narrowed down to those that revolve around PUD’s etiology. Out of these, a substantial amount of articles comes from well-known specialised gastroenterological journals. For instance, there are 16 (out of 184) publications from Gastroenterology —American Gastroenterology Association’s (AGA) flagship journal and 12 from the American Journal of Digestive Diseases —also once the AGA’s flagship journal. Over a dozen of articles comes from non-specialised but equally well-renowned medical journals. For instance, 8 from the Journal of American Medical Association , 4 from The New England Journal of Medicine, 8 articles from the British Medical Journal , and 3, resp. 2 articles from the British journals The Practitioner and Lancet . Overall, our search results are representative exclusively of the English-language publishing in the period 1943–1953 given that they consist mostly of publications from the US (132 out of 184) with the rest of the articles in English from Europe and Southern Asia.

All the manuscripts have been digitally processed via the Optical Character Recognition software (OCR). Footnote 11 To determine the presence of the bacterial research program in this body of manuscripts, we have examined the of occurrences of the following strings: ‘bacter’ and ‘spiroch’ (thereby identifying all the words that include the given string, such as bacteria/spirochetes. Footnote 12 ) To digitally analyze the text in this way we have used pdfgrep , an open source Linux command line tool for searching text in PDF files (see https://pdfgrep.org/ , accessed on July 1, 2021). More precisely, we have used the following command: pdfgrep -R -c “string” , which displays the number of instances of the given string in each file within the given folder. For each occurrence of the string, we have first-hand examined the context in which the string appears in order to determine whether the term is related to the bacterial hypothesis of PUD. In addition, for the sake of comparison, we have searched for the number of occurrences of the strings related to keywords of the acidity hypothesis, such as ‘acid’.

3.2 Results

Among the analyzed manuscripts, we have found hardly any occurrence of the string ‘bacter’, and no occurrence of the string ’spiroch’. Out of 162 analyzed papers, only four mention bacteria as a possible cause of PUD. Out of these four papers, only one mentions bacteria in a more detailed context (Barber & Franklin, 1946 ), while the remaining three list it as one of numerous possible etiological factors (see Table  1 ). In contrast, string ‘acid’ appears in 145 of the analyzed manuscripts.

The average occurrence of string ‘bacter’ in the whole set of examined articles is 0.41 times per article, while the average occurrence of string ‘acid’ is 14.58 times per article. Footnote 13 Such a low average of bacteria-related strings, coupled with roughly a 30-fold disparity in the frequency of occurrence, is indicative of a largely abandoned status of the germ research program.

3.3 Discussion

These results suggest that the bacterial hypothesis was indeed largely abandoned already before the publication of Palmer’s study, at least in the gastroenterological journal literature in English language.

We have further corroborated these findings by conducting an additional search in PubMed. Instead of focusing our search on the above mentioned corpus of articles that include the “Peptic ulcer/etiology” qualifier, we have searched PubMed for the same time period as well as the following decade based on ‘text words’, Footnote 14 displayed in Table  2 . The search command in this case had the following format:

where string stands for the additional search term listed in Table  2 . Footnote 15

The number of hits for the acidity research program (‘acid*’, ‘vagus’, ‘vagotomy’) is again much higher than the number of hits for the bacterial research program. Moreover, the majority of the 10 articles resulting from the search for ‘bacter*’ do not belong to the bacterial research program (e.g. some are related to infections following a perforated ulcer, bacterial diseases that are complicated by the appearance of peptic ulcers, or the reduction of acidity in the stomach via substances of bacterial origin.) We list the number of hits for ‘peptic ulcer’ alone mainly to show the overall number of papers in this research area at the time (for the comparison with other articles in PubMed on digestive diseases see Sect.  3.1 ).

It is also worth mentioning that the number of articles on peptic ulcer available in the database rapidly increases towards the 1950s: out of 2659 hits for ‘peptic ulcer’ more than half are from 1950–1953. This is due to a more general trend in the PubMed database, which includes less than 10,000 articles published 1943–1944, compared to 250,000 in 1945–1949, and ca. 400,000 in 1950–1953. Footnote 16

Finally, let us indicate some limitations of our study. First, one may wonder why we haven’t used citation analysis to examine the extent to which Palmer’s results had been cited at the time. The main reason for this is that the bibliometric data for the period between 1950-1970 is rather sparse. Hence, obtaining reliable information on how many scientists cited Palmer’s paper proved difficult.

Second, our study focused on a specific corpus of the relevant literature in gastroenterology, that is, English language literature on peptic ulcer indexed in PubMed in the period 1943-1953. Future studies may be extended to non-English language sources and further databases and archives. Moreover, looking into other historical sources may bring additional valuable insights into this episode. For instance, it would be interesting to examine funding applications at this time period and check whether those based on the bacterial hypothesis were submitted at the time, whether they were successful, etc.

4 What can philosophers learn from this case-study?

As mentioned in the previous section, our results provide evidence for the claim that bacterial research program was largely abandoned already before 1954, the year when Palmer published his paper. Hence, it is not surprising that the bacterial hypothesis wasn’t investigated after Palmer’s publication: its pursuit had already been inactive for a whole decade. This is also why it is unlikely that the bacterial program was dropped because of Palmer’s study. If anything, the latter may have just assured scientists that the contemporary research community did not miss much by abandoning this line of inquiry.

However, the above conclusion opens a new set of problems and questions. In this section we list some of them, hoping to restart discussion on this historical episode and its role in the philosophical literature.

4.1 Lessons for network epistemology

We first consider the implications of our results for previous employments of this case study in philosophical discussions. Our findings suggest that the given historical narrative, commonly used by philosophers, is unfounded. In particular, the claim alleging Palmer’s role in the premature loss of bacterial hypothesis seems insufficiently supported by historical evidence. However, it is precisely due to Palmer’s role that the PUD case has become one of the most common examples of the tension between the individual and group rationality used by philosophers of science. In particular, as mentioned in Sect.  1 , PUD has been a central case study in the literature on network epistemology, illustrating how erroneous results obtained by one scientist can spread throughout the given scientific community, swaying it to a wrong theory. For instance, according to Zollman ( 2010 ):

In hindsight, Palmer’s study was too influential. Had it not been as widely read or been as convincing to so many people, perhaps the bacterial theory would have won out sooner. It was the widespread acceptance of Palmer’s result which led to the premature abandonment of the diversity in scientific effort present a few years earlier. (p. 21)

More recently, in reference to Zollman’s work O’Connor and Weatherall ( 2020 ) write:

Palmer’s findings were misleading. But they were so influential, that an entire generation of scientists turned away from the bacterial theory of ulcers and focused on treatments for stomach acid. (p. 40)

Our results reveal that such a narrative, rooted in Warren and Marshall’s interpretation of this historical episode, may not be accurate after all. If our findings are correct, the bacterial hypothesis had been largely abandoned already before Palmer’s study, in which case this episode cannot be used as an example of a scenario in which a quick spread of misleading information sidetracks the entire research community. Footnote 17

But why should network epistemologists care about this? After all, they could simply use a different example to illustrate the same point. The problem is, however, that such examples may be rather hard to find. To see why this is the case, note that episodes illustrating the above claim that a high degree of interaction among scientists may lead to a premature abandonment of a fruitful scientific theory, have to satisfy two criteria: a) they should include a scenario in which the given scientific community initially pursues, but then abandons a hypothesis, which is in fact superior to its alternatives; b) such an abandonment should be primarily based on a wide-spread information flow of misleading results (rather than some other factors, such as dogamtism, various kinds of biases, etc.). Altogether, such cases would illustrate that a high degree of interaction among scientists can trigger a premature reduction in ‘exploration’ of different hypotheses, which is replaced by ‘exploitation’ of one of the sub-optimal ones.

Looking at the episodes of prematurely abandoned or ignored hypotheses (criterion a), such cases are already quite rare (the most prominent examples include Mendelian genetics, Wegener’s hypothesis of continental drift and the bacterial hypothesis of PUD). The main reason for this is that in most cases of a premature hypothesis rejection, the given scientific community remains split on the given issue, which then results in a scientific controversy rather than a widely adopted rejection of what is, in fact, a superior theory. Out of the above examples, only PUD has so far appeared to be a suitable case satisfying condition b) as an episode in which the abandonment occurred due to a wide dissemination of misleading results (rather than due to, for instance, dogmatic views of the involved scientists). But if, as we argue, this case does not fit the bill, we are left to wonder what other historical episode could be used as a replacement. After all, any suitable case would have to be such that a high degree of interaction, rather than some other factors, is causally relevant for the development of the given episode. Footnote 18 The upshot is that the PUD case has seemed to be the only suitable candidate of this particular phenomenon modelled in the network epistemological literature, but the novel evidence we provide suggests it cannot play this role.

But couldn’t we still use the received narrative on PUD as a plausible historical scenario (even if inaccurate)? The problem with this idea is that the received narrative is not that plausible. If we assume that Palmer’s erroneous study was widely shared across the scientific community, it seems unlikely that nobody noticed a problem with it. In other words: a wide dissemination of erroneous results doesn’t simply increase the chance of a wide adoption of the given idea, but also of its critical assessment. Footnote 19 It is also unlikely that Palmer’s results would trigger an outright rejection of the bacterial hypothesis, as maintained by the received view, rather than a controversy (which would preserve a theoretical diversity), as it usually happens in such cases.

Nevertheless, using highly idealized models to explain concrete historical episodes is not their only epistemic function. They can also have an exploratory function by providing a proof of possibility of a certain theoretical phenomenon or novel hypotheses about socio-epistemic mechanisms that underlie scientific inquiry (Šešelja, 2021 ). Even if we fail to empirically observe a causal mechanism that has been identified via an idealized model, this alone does not mean the given mechanism is philosophically uninteresting or irrelevant. On the one hand, the mechanism could remain empirically undetected for various reasons, including the possibility that some other empirical factors are typically more dominant, or that the phenomenon in question occurs only under very specific empirical conditions. On the other hand, the given mechanism could be theoretically relevant and explanatory of theoretical phenomena (such as scientific rationality taken in abstracto ). In both cases the model could be motivated by a stylized scenario rather than a concrete historical one. However, this also means that the simulation cannot be considered validated in view of concrete historical episodes and arguably does not result from a properly integrated history and philosophy of science. Consequently, results of such simulations need to be taken with caution when drawing inferences about actual scientific inquiry. An argument that a certain phenomenon could be epistemically harmful because it has proved to be so in the past (where the model explains how and why), hasn’t been established.

Our study thus supports the claim that the results of the above mentioned network epistemological studies still need to be treated as exploratory. In particular, how significant the threat of a high degree of information flow among scientists is (e.g. for the purposes of science policy) remains an open question. While it may turn out that such a threat is indeed relevant under specific conditions of inquiry, which exact conditions these are (when interpreted in terms of actual scientific practice) has remained largely underspecified in the literature. Footnote 20 From a more general point of view, our study provides support to recent calls for a modest treatment of results obtained by highly idealized agent-based models of scientific inquiry unless they have been empirically validated (Martini & Fernández Pinto, 2017 ; Frey & Šešelja, 2018 ; Thicke, 2020 ; Šešelja et al. 2020 ; Šešelja, 2021 ; for a somewhat different viewpoint see Mayo-Wilson & Zollman, 2021 ).

4.2 Some open questions

As mentioned above, it was previously argued that the bacterial theory of PUD was worthy of pursuit in the 1950s, even after the publication of Palmer’s results (Šešelja & Straßer, 2014 ). As the authors point out, the bacterial research program not only had open lines of inquiry, but for each of the major objections directed against it (some of which have been elaborated in Sect.  2 ), there were clear methodological responses available at the time. Beside the objection coming from Palmer’s study, Šešelja and Straßer also examine the objection that the bacteria could not survive in the acid environment of the stomach, as well as the objections coming from the successes of the acidity research line. For instance, in response to Palmer’s results the research community had a counterargument coming from a study by Freedberg and Barron ( 1940 ), which emphasized the importance of using silver staining technique for detecting bacteria rather than hematoxylin-eosin stain, used by Palmer (see Footnote 7).

If we agree with this assessment, then the results presented in the current paper raise a number questions, both of historical and socio-epistemic nature. First of all, how come that a program which was worthy of pursuit in view of the arguments available at the time failed to be actually pursued? Was this just a result of an unfortunate division of labor, resulting from factors discussed in Sect.  2 , or were some additional factors at play? This is particularly interesting in view of the claim by Fukuda et al. ( 2002 ) that prior to Palmer’s work there had been a consistent line of research on the bacterial origin of PUD throughout the first half of the twentieth century (see the quote in Sect.  1 ). Footnote 21 Together with our findings, this would indicate that the bacterial research program declined over this time period. Such a course of events is interesting not only for discussions on the division of cognitive labor, but also for the problem of epistemic responsibility. For instance, we could ask: should anyone be held accountable for the abandonment of the bacterial research program? Answering this question is at the heart of contemporary discussions on collective epistemic responsibility and normative accounts of accountability of scientists as (unorganized) collectives (see e.g. Fleisher & Šešelja, 2021 ). Moreover, this problem is closely related to discussions on scientific pluralism as well (e.g. Longino, 2002 ; Chang, 2012 ) since the PUD case illustrates potential dangers of losing a fruitful line of inquiry.

Finally, the status of the bacterial hypothesis in non-English speaking literature is another open question worthy of further investigation, which may shed additional light on the overall dynamics of the medical community at the time.

5 Conclusion

In this paper we have re-examined the history of the research on PUD, and the role of Palmer’s infamous study, which has long been considered to have played a central role in convincing other scientists that bacteria cannot be an etiological factor in this disease. To this end, we have used digital tools to systematically analyze a scope of journal articles published in English language in the decade before Palmer’s publication. Our results suggest that there had been hardly any active pursuit of the bacterial hypothesis already before Palmer’s publication. This indicates that the impact of a single influential figure on the whole research program is perhaps overestimated in the received view.

Even for those who would rather proceed with caution and who consider our results as just a piece of the puzzle requiring further investigation, our study should at least make them pause. The obtained results indicate that, at the minimum, we need to re-examine the received narrative before we take it to be an accurate historical presentation of the PUD episode. This is all the more important given the lack of historical evidence corroborating the alleged role of Palmer’s work in the history of PUD, as well as the lack of attempts at using quantitative tools for systematic digital analysis of the literature on PUD published throughout the first half of the twentieth century.

We will close by highlighting the methodological relevance of our study. The availability of digital tools makes re-examinations of historical episodes discussed by philosophers of science timely and relevant. In addition to the method of textual analysis employed in this paper, other types of related methods may be even more suitable for similar investigations. In particular, citation analysis in view of bibliometric data may provide insights into social networks characteristic of the scientific community at the time. Footnote 22 As we have mentioned, the reason we have turned to textual analysis rather than to the citation analysis is that the bibliometric data for this time period is rather sparse. Hence, obtaining reliable data (e.g. on how many scientists cited Palmer’s paper) proved difficult. However, for more recent case-studies, bibliometric data may be a valuable additional evidence.

See also Kidd and Modlin ( 1998 ), Fukuda et al. ( 2002 ), Warren ( 2005 , p. 18).

Sources include: two articles on the history of abdominal illness in Britain during WWII by professional historians of medicine (Miller, 2010 ; Jones, 2012 ); an MD thesis in the history of medicine by Pollock ( 2014 ), which comprises a chapter on the history of etiological theories until 1960s; a historical overview of ‘germ theory’ research until Palmer’s paper (Kidd and Modlin, 1998 ); a critique of the biopsychosocial model with PUD as a case study (Davey Smith, 2005 ). The authors of the last two publications are medical practitioners and were included to represent two different interpretations of factors leading to the abandonment of the ‘germ theory’. Moreover, we have included a more recent case study on this topic, written in the field of integrated history and philosophy of science (Šešelja and Straßer, 2014 ).

For example Cornell et al. ( 1944 ), “Editorial” ( 1954b ), “Editorial” ( 1954a ), and “Peptic ulcer and “ordinary” anxiety” ( 1950 ).

Sullivan and McKell summed their theory in the following formula: \(u = \dfrac{a+b+c+d+x}{r}\) , where u = ulcer, a = constitutional and genetic factors, b = personality, c = precipitating emotional situations, d = physical injury, x = unique factors, r = resistance.

This is not to say that vagotomy was harmless: it still had a significant mortality rate. For example, Edwards et al. ( 1963 ) report the operative mortality rate of 2.7 % (see also Šešelja and Straßer, 2014 , p. 437).

In the second half of the 19th century Koch presented a set of postulates for accepting the etiological role of bacteria: (1) The organism must be shown to be constantly present in characteristic form and arrangement in the diseased tissue; (2) the organism must be isolated and grown in pure culture; (3) the cultured organism must be shown to initiate and reproduce the disease when reinoculated into a healthy body; (4) the organism must be re-isolated from the experimentally infected organism (Thagard, 2000 , p. 59).

A particularly interesting aspect of Freedberg and Barron’s study is that they explicitly advise against the employment of hematoxylin-eosin staining technique (later on used by Palmer) for the identification of bacteria, since in contrast to silver staining (subsequently used by Warren and Marshall), it did not reveal the spiral bacteria. Note also that while Palmer cites their paper he does not comment on Freedberg and Barron’s warnings concerning the staining techniques (see also Šešelja & Straßer, 2014 , Sect. 5).

The textual analysis did not consider books published during this period. These resources could be included in futures studies.

Medical Subject Headings (MeSH) Major Topic terms are assigned to articles by the U.S. National Library of Medicine. The MeSH Major Topics classify articles in terms of a disease, a type of an injury, or a pathological condition that a medical article focuses on, and they are usually obtained from the title and/or statement of purpose (see https://www.nlm.nih.gov/bsd/disted/meshtutorial/principlesofmedlinesubjectindexing/majortopics/ accessed on July 14, 2019). MeSH Qualifiers allow to bring together citations focusing on a particular aspect of a subject (which usually is a particular disease). The “etiology” Qualifier is “used with diseases for causative agents including microorganisms and includes environmental and social factors and personal habits as contributing factors”. The above qualifier includes, among others, the “pathogenesis” (see https://www.nlm.nih.gov/mesh/qualifiers_scopenotes.html ) and the “microbiology” Qualifiers (see https://www.nlm.nih.gov/mesh/subhierarchy.html ).

The mistagged paper, unrelated to PUD, is Twiss and Carter ( 1952 ). A paper by Monro ( 1945 ) was published twice, while a paper by Chattopadhyaya ( 1951 ) was split in two. The main reason we couldn’t retrieve all the articles is that they are not available in libraries across Germany, which means that obtaining them would be significantly more costly.

More precisely, we used OCRmyPDF software based on Tesseract, an open source OCR engine, see https://ocrmypdf.readthedocs.io/en/latest/index.html . Our results are based on the 4.1.0 release of Tesseract, see https://github.com/tesseract-ocr (both links accessed on July 1, 2021).

Spirochetes are spiral bacteria discussed by Palmer and others (e.g. by Freedberg and Barron, see Sect.  2 ) in the context of PUD.

We have further validated these results by examining the occurrences of related terms, such as “microbe” and “germ”, which were very scarce and in no instance related to the etiological role in PUD. As a basic test we checked the occurrences of the string “ulcer” which indeed appeared in 100% of the articles.

Text words search includes “all words and numbers in the title, abstract, other abstract, MeSH terms, MeSH Subheadings, Publication Types, Substance Names, Personal Name as Subject, Corporate Author, Secondary Source, Comment/Correction Notes, and Other Terms \(\dots\) ” ( https://pubmed.ncbi.nlm.nih.gov/help/#tw , accessed on July 1, 2021).

In order to stay sufficiently broad in our search we included each decade plus an additional year.

This disparity could be due to multiple reasons: from the increase in the number of post-war publications to a higher coverage by the relevant indexes to medical periodical literature, which were for this time period selective (see https://www.nlm.nih.gov/databases/databases_oldmedline.html , accessed on July 1, 2021).

We are not suggesting that the scientific community at the time was not tightly connected, but rather, that factors other than the connectedness of the community and the structure of its information flow may be more explanatory of the loss of the bacterial hypothesis.

This may be challenging: for example, in case of the continental drift debate, biased outlooks of North American scientists played an important role in their rejection of Wegener’s hypothesis of continental drift, see Oreskes ( 1999 ), Šešelja & Weber ( 2012 ).

Think of Wakefield’s fraudulent study aiming to show an association between the measles-mumps-rubella vaccine and autism, which received primarily critical response from the scientific community (see e.g. Suelzer et al., 2019 ).

For some attempts at specifying such conditions by means of robustness analysis see Rosenstock et al. ( 2017 ), Frey and Šešelja ( 2020 ).

While their claim is based on 15 studies related to the bacterial hypothesis of PUD conducted between 1875 and 1940 (Fukuda et al. 2002 , p. 18), it would be interesting to apply digital textual analysis to this time period as well and reexamine whether this was indeed the case, or whether the bacterial research program had been rather fringe all along.

For examples of using social network analysis in the context of integrated history and philosophy of science see Claveau and Herfeld ( 2018 ), Herfeld and Doehne ( 2018 ). For a more general discussion on digital approaches to philosophy of science see Pence and Ramsey ( 2018 ).

“Ætiology of Peptic Ulcer. Editorial” (1949). In The Lancet 254, 6587, pp. 997–998.

Alexander, F. (1934). The influence of psychologic factors upon gastro-intestinal disturbances: A symposium. The Psychoanalytic Quarterly, 3 (4), 501–539.

Article   Google Scholar  

Anonymous (1950). Peptic ulcer and “ordinary” anxiety. The American Journal of Digestive Diseases 17 (8), 289.

Anonymous (1954a). Editorial The American Journal of Digestive Diseases , 21 (8), 240.

Anonymous (1954b). Editorial The American Journal of Digestive Diseases, 21 (5), 145.

Arends, N. W. (1951). Symposium on peptic ulcer anatomy and pathologic physiology. The Journal of the American Osteopathic Association, 51 (2), 112–114.

Google Scholar  

Barber, M., & Franklin, R. H. (1946). Bacteriology of stomach and duodenum in cases of peptic ulcer and gastric carcinoma. British Medical Journal, 1 (4459), 951–953.

Barrett, A. A. (1953). Duodenal ulcer in military personnel: A social service study of 40 cases. United States Armed Forces Medical Journal, 4 (12), 1693–1702.

Bishop, R. F., & Anderson, C. M. (1960). The bacterial flora of the stomach and small intestine in children with intestinal obstruction. Archives of Disease in Childhood, 35 (183), 487–491.

Bralow, S. P., Spellberg, M. A., Kroll, H., & Necheles, H. (1950). Peptic ulcer in man. Part I. The ulcer problem. The American Journal of Digestive Diseases, 17 (2), 41–45.

Carter, K. C. (2003). The rise of causal concepts of disease: Case histories . Ashgate Publishing, Ltd.

Herfeld, C., & Doehne, M. (2018). Five reasons for the use of network analysis in the history of economics. Journal of Economic Methodology, 25 (4), 311–328.

Chang, H. (2012). Is water H2O? Evidence, pluralism and realism . Springer.

Chattopadhyaya, S. N., et al. (1951). Some observations on dietetic factors in relation to the incidence of chronic simple peptic ulcer in India. Calcutta Medical Journal, 48, 215–266.

Christie, D. A., & Tansey, E. M. (eds). (2002). Peptic ulcer: Rise and fall. Vol. 14. Wellcome Witnesses to Twentieth Century Medicine. London: Wellcome Trust Centre for the History of Medicine at UCL.

Claveau, F., & Herfeld, C. S. (2018). Social network analysis: A complementary method of discovery for the history of economics. In E. Roy Weintraub and Till Düppe (Eds.) A contemporary historiography of economics (25 pp.). Oxon.

Connell, G. (1949). Trends in diagnosis, etiology and treatment of duodenal ulcer. The American Journal of Digestive Diseases, 16 (2), 55–63.

Cornell, B., Lust, F., & Wyatt, J. (1944). Editorial. The American Journal of Digestive Diseases, 11 (1), 20–23.

Cregan, J., Dunlop, E. E., & Hayward, N. (1953). Bacterial content of human small intestine in disease of the stomach. British Medical Journal, 2 (4848), 1248–1251.

Davey Smith, G. (2005). The biopsychosocial approach: A note of caution. In Peter White (Ed.), Biopsychosocial medicine: An integrated approach to understanding illness (pp. 77–102). Oxford University Press.

Davies, D. T., & Wilson, A. T. M. (1937). Observations on the life-history of chronic peptic ulcer. The Lancet, 230 (5963), 1353–1360.

Douven, I., & Kelp, C. (2011). Truth approximation, social epistemology, and opinion dynamics. Erkenntnis, 75 (2), 271–283.

Dragstedt, L. R. (1917). Contributions to the physiology of the stomach: Xxxviii. Gastric juice in duodenal and gastric ulcers. Journal of the American Medical Association LXVIII, 5, 330–333.

Dragstedt, L. R. (1935). Some physiologic principles involved in the surgical treatment of gastric and duodenal ulcer. Annals of Surgery, 102 (4), 563–580.

Dragstedt, L. R. (1945). Vagotomy for gastroduodenal ulcer. Annals of Surgery, 122 (6), 973–989.

Dragstedt, L. R., Camp, E. H., & Fritz, J. M. (1949). Recurrence of gastric ulcer after complete vagotomy. Annals of Surgery, 130 (4), 843–854.

Dragstedt, L. R., & Owens, F. M. (1943). Supra-diaphragmatic section of the Vagus nerves in treatment of duodenal ulcer. Proceedings of the Society for Experimental Biology and Medicine, 53 (2), 152–154.

Dragstedt, L. R., & Schafer, P. W. (1945). Removal of the vagus innervation of the stomach in gastroduodenal ulcer. Surgery, 17 (5), 742–749.

Dragstedt, L. R., Harper, P., Tovee, B., & Woodward, E. (1947). Section of the Vagus nerves to the stomach in the treatment of peptic ulcer: Complications and end results after four years. Annals of Surgery, 126 (5), 687–699.

Edwards, L. W., Edwards, W. H., Sawyers, J. L., Gobbel Jr, W. G., Lynwood Herrington Jr, J., & William Scott Jr, H. (1963). The surgical treatment of duodenal ulcer by vagotomy and antral resection. The American Journal of Surgery, 105 (3), 352–360.

Fleisher, W., & Šešelja, D. (2021). Responsibility for collective epistemic harms (Forthcoming).

Franklin, M. A., & Skoryna, S. C. (1966). Studies on natural gastric flora: I. Bacterial Flora of fasting human subjects. Canadian Medical Association Journal, 95 (26), 1349–1355.

Freedberg, A. S., & Barron, L. E. (1940). The presence of spirochetes in human gastric mucosa. American Journal of Digestive Diseases, 7 (10), 443–445.

Frey, D., & Šešelja, D. (2018). What is the epistemic function of highly idealized agent-based models of scientific inquiry? Philosophy of the Social Sciences , 48 (4), 407–433. https://doi.org/10.1177/0048393118767085 .

Frey, D., & Šešelja, D. (2020). Robustness and idealization in agent-based models of scientific interaction. The British Journal for the Philosophy of Science, 71 (4), 1411-1437.

Fukuda, Y., Shimoyama, T., Shimoyama, T., & Marshall, B. J. (2002). Kasai, Kobayashi and Koch’s postulates in the history of Helicobacter pylori. In B. J. Marshall (Ed.), Helicobacter pioneers: Firsthand accounts from the scientists who discovered helicobacters, 1892–1982 (pp. 15–24). Blackwell.

Garbat, A. L. (1946). Problems of peptic ulcer in the armed forces and in the returned soldiers. New York State Journal of Medicine, 46, 894–901.

Gilbert, M. (2000). Sociality and responsibility: New essays in plural subject theory . Rowman & Littlefield.

Grossman, L. I. (1940). Root canal therapy, English . Philadelphia: Lea & Febiger.

Halsted, J. A., & Weinberg, H. (1946). Peptic ulcer among soldiers in the Mediterranean theater of operations. The New England Journal of Medicine, 234, 313–320.

Henry, C. M. (1942). Peritoneal fluid and gastric contents in cases of perforated peptic ulcer. Archives of Surgery 45 (4), 564–570. eprint: /data/journals/surg/14484/archsurg\_45\_4\_007.pdf.

Hinton, J. W. (1936). A review of 746 gastric and duodenal ulcers. The American Journal of Digestive Diseases, 3 (1), 59–62.

Hobsley, M. (1994). Dragstedt, gastric acid and duodenal ulcer. The Yale Journal of Biology and Medicine, 67 (3–4), 173–180.

Hoelzel, F. (1943). Nutritional versus psychic factors in peptic ulcer. The American Journal of Digestive Diseases, 10 (6), 239–240.

Ivy, A. C., Grossman, M. I., & Bachrach, W. H. (1950). Peptic Ulcer . Philadelphia.

Jones, E. (2012). The gut war: Functional somatic disorders in the UK during the Second World War. History of the human sciences, 25 (5), 30–48.

Kidd, M., & Modlin, I. M. (1998). A century of Helicobacter pylori. Digestion, 59 (203), 1–15.

Killin, A., & Pain, R. (2021). Cognitive archaeology and the minimum necessary competence problem. Biological Theory . https://doi.org/10.1007/s13752-021-00378-7 .

Kirsner, J. B., & Palmer, W. L. (1952). Seminars on gastrointestinal physiology: The problems of peptic ulcer. American Journal of Medicine, 13 (5), 615–639.

Kummerfeld, E., & Zollman, K. (2016). Conservatism and the scientific state of nature. The British Journal for the Philosophy of Science, 67 (4), 1057–1076.

Longino, H. (2002). The fate of knowledge . Princeton University Press.

Book   Google Scholar  

Lust, F. J. (1952). Konjetzny’s theory of the development of gastroduodenal ulcer. The American Journal of Digestive Diseases, 19 (6), 194.

Marshall, B. J. (2002). Helicobacter pioneers: Firsthand accounts from the scientists who discovered helicobacters, 1892–1982 . Blackwell.

Martini, C., & Fernández Pinto, M. (2017). Modeling the social organization of science. European Journal for Philosophy of Science , 7 , 221–238.

Mayo-Wilson, C., & Zollman, K. J. S. (2021). The computational philosophy: Simulation as a core philosophical method. Synthese . https://doi.org/10.1007/s11229-020-02950-3 .

Mears, F. B. (1953). Autopsy survey of peptic ulcer associated with other disease: A review of related etiological factors concerned. Surgery, 34 (4), 640–654.

Miller, B. (2013). When is consensus knowledge based? Distinguishing shared knowledge from mere agreement. Synthese, 190 (7), 1293–1316.

Miller, I. (2010). The mind and stomach at war: Stress and abdominal illness in Britain c.1939–1945. Medical History, 54 (1), 95–110.

Miller, I. (2011). A modern history of the stomach: Gastric illness, medicine, and British Society, 1800–1950 . Studies for the Society for the Social History of Medicine no. 4. London ; Brookfield, VT: Pickering & Chatto.

Monro, A. K. (1945). The complications of gastric and duodenal ulcer. Postgraduate Medical Journal, 21 (237), 228.

Nunn, R. (2012). Many-models medicine: Diversity as the best medicine. Journal of Evaluation in Clinical Practice, 18 (5), 974–978.

O’Connor, C., & Weatherall, J. O. (2020). False beliefs and the social structure of science: Some models and case studies. In D. M. Allen & J. W. Howell (Eds.), Groupthink in science: Greed, pathological altruism, ideology, competition, and culture (pp. 37–48). Springer.

Oreskes, N. (1999). The rejection of continental drift: Theory and method in American Earth Science . New York, Oxford: Oxford University Press.

Palmer, E. D. (1954). Investigation of the gastric mucosa spirochetes of the human. Gastroenterology, 27 (2), 218–220.

Palmer, E. D., & Sullivan, B. H. (1952). Duodenal ulcer in military personnel; studies on military effectiveness of the ulcer patient: 1. The problem. United States Armed Forces medical journal, 3 (3), 455–459.

Pence, C. H., & Ramsey, G. (2018). How to do digital philosophy of science. Philosophy of Science, 85 (5), 930–941.

Peters, U. (2020). Illegitimate values, confirmation bias, and mandevillian cognition in science. The British Journal for the Philosophy of Science .

Pollock, A. C. (2014). From dyspepsia to Helicobacter: A history of peptic ulcer disease . MD thesis. University of Glasgow.

Robinson, S. C. (1935). On the etiology of peptic ulcer. The American Journal of Digestive Diseases, 2 (6), 333–343.

Rosenow, E. C. (1916). The Causation of gastric and duodenal ulcer by streptococci: Plates 5 to 14. The Journal of Infectious Diseases, 19 (3), 333–384.

Rosenow, E. C., & Sanford, A. H. (1915). The bacteriology of ulcer of the stomach and duodenum in man. The Journal of Infectious Diseases, 17 (1), 219–226.

Rosenstock, S., O’Connor, C., & Bruner, J. (2017). In epistemic networks, is less really more? Philosophy of Science , 84 (2), 234–252.

Rowland, V. (1937). The etiology of peptic ulcer. The American Journal of Digestive Diseases, 4 (11), 760–762.

Schwarz, K. (1910). Ueber penetrierende Magen- und Jejunalgeschwuere. Beitrage zur klinischen Chirurgie, 67, 86–128.

Šešelja, D. (2021). Exploring scientific inquiry via agent-based modeling. Perspectives on Science, 29 (4).

Šešelja, D., & Straßer, C. (2014). Heuristic reevaluation of the bacterial hypothesis of peptic ulcer disease in the 1950s. Acta Biotheoretica, 62, 429–454.

Šešelja, W., Weber E. (2012). Rationality and irrationality in the history of continental drift: Was the hypothesis of continental drift worthy of pursuit? Studies in History and Philosophy of Science Part A , 43 (1), 147–159. https://doi.org/10.1016/j.shpsa.2011.11.005 .

Šešelja, D., Straßer, C., & Borg, A. (2020). Formal models of scientific inquiry in a social context: An introduction. Journal for General Philosophy of Science , 51(2), 211-217. https://doi.org/10.1007/s10838-020-09502-w .

Smithies, F. (1935). On an adequate conception of the etiology and the significance of peptic ulcer (gastric and duodenal). The American Journal of Digestive Diseases, 2 (7), 437–440.

Solomon, M. (2001). Social empiricism . MIT Press.

Spiro, H. M. (1998). Peptic ulcer: Moynihan’s or Marshall’s disease? The Lancet, 352 (9128), 645–646.

Steele, E. (1944). Peptic ulcer-suggesting malnutrition as the etiology. The American Journal of Digestive Diseases, 11 (4), 119–122.

Suelzer, E. M., Deal, J., Hanus, K. L., Ruggeri, B., Sieracki, R., & Witkowski, E. (2019). Assessment of citations of the retracted article by Wakefield et al with fraudulent claims of an association between vaccination and autism. JAMA Network Open 2 (1), e1915552–e1915552. https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2755486/suelzer_2019_oi_190588.pdf .

Sullivan, A. J., & McKell, T. E. (1950). Personality in peptic ulcer . Oxford, England: C. C. Thomas, pp. x, 100–x, 100.

Thagard, P. (2000). How scientists explain disease . Princeton University Press.

Thicke, M. (2020). Evaluating formal models of science. J Gen Philos Sci , 51 , 315–335.

Turck, F. B. (1907). Further observations on the etiology and pathology of peptic ulcer. British Medical Journal, 1 (2416), 922–926.

Turck, F. B. (1908). Experimental studies on round ulcer of the stomach and duodenum. The Journal of Medical Research, 17 (4), 365-378.

Twiss, J. R., & Carter, R. F. (1952). The relationship of biliary tract disorders to diabetes mellitus. The American Journal of the Medical Sciences, 224 (3), 263–273.

Vickers, P. (2020). Expecting the unexpected in the search for extraterrestrial life. International Journal of Astrobiology, 19 (6), 482–491.

Warren, R. (2005). Discovery of H. Pylori in Perth, WA. In Barry J. Marshall. (Ed.), Helicobacter pioneers: Firsthand accounts from the scientists who discovered helicobacters, 1892–1982 (pp. 151–163). Blackwell.

Warren, R. J., & Marshall, B. J. (1983). Unidentified curved bacilli on gastric epithelium in active chronic gastritis. The Lancet, 321 (8336), 1273–1275.

Winkelstein, A. (1936). The etiology and therapy of ulcerative colitis. The American Journal of Digestive Diseases, 3 (11), 839–844.

Wray, K. B. (2010). Introduction: Collective knowledge and science. Episteme, 7 (3), 181–184.

Zollman, K. (2010). The epistemic benefit of transient diversity. Erkenntnis, 72 (1), 17–35.

Download references

Acknowledgements

We are grateful to two anonymous reviewers for valuable comments, which helped to improve this paper. We also wish to thank the RTG “Situated Cognition”, the work group led by Tobias Schlicht at Ruhr University Bochum, Philosophy & Ethics Group at TU Eindhoven, and Christian Straßer for valuable comments on an earlier draft of this paper. The research for this paper was partially funded by the Munich Center for Mathematical Philosophy (MCMP) at LMU Munich and the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), Research Grant HA 3000/9-1; Project number 426833574 (DFG Research Network on Simulations of Scientific Inquiry) and GRK-2185/1, META 2.3 (DFG Research Training Group “Situated Cognition”).

Author information

Authors and affiliations.

Institute for Philosophy II, Ruhr University Bochum, Bochum, Germany

Bartosz Michał Radomski

Philosophy and Ethics Group, TU Eindhoven, Eindhoven, The Netherlands

Dunja Šešelja

Munich Center for Mathematical Philosophy, LMU Munich, Munich, Germany

Kim Naumann

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Dunja Šešelja .

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Radomski, B.M., Šešelja, D. & Naumann, K. Rethinking the history of peptic ulcer disease and its relevance for network epistemology. HPLS 43 , 113 (2021). https://doi.org/10.1007/s40656-021-00466-8

Download citation

Received : 31 January 2021

Accepted : 16 September 2021

Published : 04 November 2021

DOI : https://doi.org/10.1007/s40656-021-00466-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Peptic ulcer disease
• Eddy Palmer
• Digital textual analysis
• Network epistemology
• Find a journal
• Publish with us
• Track your research

Peptic Ulcer Disease

• In book: Management of Digestive Disorders [Working Title]

• Xiamen University

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

• K. I. Matazu
• I. H. Kankia
• H. K. Matazu
• N Schmied Arch Pharmacol
• Mohamed H. Aly
• Aya K. Said
• Aya M. Farghaly
• Maha E. Wally

• Zaffar Hussain

• ALIMENT PHARM THER

• Ashwak M. F. Abu-Taleb
• Randa S. Abdelattef

• Ahmed M. El-Gebaly
• AM J GASTROENTEROL

• Brian E. Lacy
• Christopher N. Andrews
• Nimish Vakil

• Kin Tong Chung

• P Malfertheiner

• Emad El-Omar

• GASTROENTEROLOGY

• Gordon V. Ohning

• Steven F. Moss
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

• Research article
• Open access
• Published: 20 March 2020

Diabetic foot care: knowledge and practice

• Aydin Pourkazemi 1 ,
• Atefeh Ghanbari   ORCID: orcid.org/0000-0002-7949-5717 2 ,
• Monireh Khojamli 1 ,
• Heydarali Balo 1 ,
• Hossein Hemmati 1 ,
• Zakiyeh Jafaryparvar 1 &
• Behrang Motamed 3  

BMC Endocrine Disorders volume  20 , Article number:  40 ( 2020 ) Cite this article

38k Accesses

58 Citations

1 Altmetric

Metrics details

Diabetic foot ulcers (DFUs) are common problems in diabetes. One of the most important factors affecting the quality of diabetes care is knowledge and practice. The current study aimed at determining the knowledge and practice of patients with diabetes regarding the prevention and care of DFUs.

The current analytical, cross sectional study was conducted in Guilan Province (north of Iran) on 375 patients registered in the medical records as type 2 diabetes mellitus. Demographic characteristics, knowledge, and practice of participants were recorded in a questionnaire during face-to-face interviews conducted by the researcher. Descriptive and inferential statistics were performed using SPSS version18.

The mean score of knowledge was 8.63 ± 2.5 out of 15, indicating that the majority of participants had a poor knowledge (84.8%). The mean practice score was 7.6 ± 2.5 out of 15, indicating that a half of them had poor performance (49.6%). There was a significant and direct correlation between knowledge and practice. Knowledge level, place of residence, marital status, and history of admission due to diabetic foot were predictors of practice score.

Conclusions

According to the low level of knowledge and practice in patients with diabetes regarding the prevention and care of DFUs, and considering the significant relationship of some demographics of patients with knowledge and practice scores, a targeted educational program is needed to promote knowledge of patients with diabetes.

Peer Review reports

What is already known about this subject?

Diabetes accounted for 1.3 million deaths (2.4% of all death). The prevalence of diabetes varies among countries in Eastern Mediterranean Region (EMR).

Prevalence of diabetes mellitus in Iran ranged 20 to 30% in different provinces with higher frequency among females from 1990 to 2013.

Among people living with diabetes mellitus, 20% are at risk for foot ulceration as a result of neuropathy.

Diabetic foot ulcers (DFUs) are one of most common diabetes complications with 0–4% prevalence.

Good knowledge and practice regarding DFU reduces the risk of diabetic foot complications and ultimately amputation.

What are the new findings?

- In the current study, 84.8% of the participants had poor knowledge and only 8.8% had good practice. There was a direct and significant correlation between knowledge and practice.

The lowest knowledge scores belonged to the use of talcum powder or other powders and not using lotions between the toes.

The strongest variables related to practice were knowledge, place of residence, marital status, and history of admission due to diabetic foot, indicating that these four variables were the predictors of practice score.

How might this impact on clinical practice in the foreseeable future?

Patients’ knowledge about foot ulcer prevention should be promoted based on guidelines both in community and hospitals.

Adherence to guidelines prevents DFU; targeted interventions directed toward patients/health care providers can lead to reduced DFU complications.

Diabetes mellitus is a group of common metabolic disease characterized by hyperglycemia. Due to multiple and prolonged complications, diabetes affects almost all systems of the body [ 1 ]. Diabetes caused 1.3 million deaths (2.4% of all death) and 56 million disability adjusted life years (DALYs) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 in 1990 to 883.5 per 100,000 populations in 2013. Total DALYs from diabetes increased by 148.6% during 1990–2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8 and 53.9%, respectively [ 2 ]. The prevalence of diabetes varies among countries in EMR. In Saudi Arabia, the prevalence of diabetes was reported 13.4% Saudis aged 15 years or older [ 3 ] and in Pakistan 12.1% for males and 9.8% for females aged ≥25 years [ 2 ]. A systematic review on the prevalence of type 2 diabetes in Iran showed a range of 3 to 20% in different provinces [ 4 ].

Of people living with diabetes, 20% are at high risk of foot ulceration as a result of neuropathy [ 5 ]. Diabetic foot ulcers (DFU S ) comprise 12–15% of total estimated cost of diabetes in the developed countries, increasing to 40% in the developing countries [ 6 ]. DFUs are one of the most common diabetes complications with 4 to 10% prevalence in the affected population [ 7 ]. The overall incidence of DFU is 5.8–6.0% in some particular diabetic in the U. S, while it is 2.1–2.2% in smaller populations in Europe [ 8 ]. Treating foot ulcers can be expensive and it is evident that about 49–85% of all DFU S can be prevented by raising awareness and taking proper measures [ 7 ]..

Among the complications of diabetes, DFU S affects the patient’s quality of life in case of amputation. However, it is possible to prevent amputation using educational and care strategies [ 9 ]. Data show that 25% of patients with diabetes develop a foot ulcer in their lifetime and that the cost of treating a DFU S is more than twice that of any other chronic ulcer [ 10 ]. Diabetic foot amputation remains an unpleasant impact on patients’ life more than other complications [ 11 , 12 ]. Delays in referral of serious foot problems are of particular concern [ 5 ]. Ndosi et al., reported that 15.1% of patients died within the year of presentation, the ulcer had healed in 45.5%, but recurred in (9.6%). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06) [ 13 ].

Understanding the level of knowledge and practice in patients with diabetes is important in planning for the better control of diabetes and its complications. A study by Ahmad and Ahmad on 124 patients with diabetes in North India reported that 60.5 and 79.0% got lower scores in knowledge and practice toward diabetes, respectively [ 14 ]. Jackson IL et al., reported that 79.5% of patients with diabetes in Nigeria had more than 70% of overall knowledge about self-care [ 15 ]. The results of a study in Malaysia showed that the most patients (58%) had poor knowledge and 61.8% of them had poor practice of foot care [ 16 ].

Among diabetes complications, the foot ulcers are considered as the most preventable ones. Risk factors of DFU S are correlated with poor practices and knowledge. Good knowledge and practice toward diabetic foot care reduces the risk of diabetic foot complications and ultimately amputation [ 7 ]. According to American Diabetes Association, annual assessments of knowledge, skills and behaviors are necessary for patients with diabetes [ 15 ].. The current study was conducted to assess patients’ knowledge and practice toward diabetic foot care. No similar study is conducted in Rasht City (the capital of Guilan Province, Northern Iran) thus far; therefore, the present study aimed at evaluating the level of practice and knowledge toward foot care in patients with type 2 diabetes mellitus. Health system can prevent DFU and amputation by applying a strategy to raise knowledge in patients.

Study design and subjects

The current analytical, cross sectional study was conducted at a clinic in Razi Hospital, affiliated to Guilan University of Medical Sciences, which is the only endocrine disease referral center across the province. Data were gathered from May to July 2017 and the subjects were selected by consecutive sampling. To Diagnostic and classify the patients, the American Diabetic Association, the diagnostic criteria were utilized [ 17 ]. Patients with diabetes receive care, education, treatment, and other services at this center. The center also delivers healthcare services to outpatients and inpatients, as well as routine training. The research project was approved by the Deputy of Research, Guilan University of Medical Sciences. Participation in the study was voluntarily and the subjects were informed about their right to withdraw from the study at any stage. The participant’s privacy was respected, and data were kept confidential and utilized for study purposes only. Participants were asked to read and sign an informed consent form. Inclusion criteria were: receiving the diagnosis of type 2 diabetes mellitus, age 18 years or above, taking anti-diabetic medications for at least 1 month prior to the study, having clinical records at the center, and willing to participate in the study. The exclusion criteria were: critically ill patients with diabetes, pregnant or newly diagnosed (less than 1 month) patients, receiving any other treatment or therapy, and having major psychiatric problems. A structured datasheet was used to collect demographic and clinical information of the patients using paper-based and digital records archives. Some information was also collected by a medical student through face-to-face interviews. A paper-based questionnaire was distributed among both outpatients and inpatients. Wagner DFU classification system was used to classify the patients based on ulcers. In this hospital, we assessed peripheral neuropathy, retinopathy and peripheral vascular disease (PVD), respectively by using monofilament testing, optometrist or ophthalmologist reports and the clinical diagnosis documented by the surgeon or, if available, images taken through arterial Doppler or angiography. Macro vascular disease was defined as any macro vascular complications other than PVD including prior myocardial infarction, angioplasty, coronary artery bypass grafting, ischemic heart disease, or stroke [ 18 ].

In the current study, having one or two more complications was considered a positive condition. The sample size was determined 375 considering 95% confidence interval with d = 0.05 and P  = 0.58. A total of 375 out of 395 distributed questionnaires were completed and returned; the response rate was 94.4%.

A three-section questionnaire was used in the current study. First section included demographic characteristics such as age, gender, and duration of diabetes mellitus, place of residence, occupation, and level of education, marital status, and body mass index. Second part consisted of 15 questions about knowledge scored based on nominal (yes/no/I don’t know) scale, and third part with 15 questions focusing on practice was scored based on “yes/no” scale. The questionnaire was used to measure the level of knowledge and practice of subjects toward diabetic foot care. Patients’ demographic data were collected to analyze factors associated with knowledge and practice toward diabetic foot care. Each correct answer was given 1 point; however, wrong answers or choosing “I don’t know” option was given 0 point. The total score for each part ranged 0 to 15. Good or poor level of knowledge was determined based on the 75% of the maximum score of the questionnaire; therefore, the scores higher than 11.25 were considered good and those lower than 11.25 were considered poor. Examples of the questions included “Do you care about your diabetes?”; “Do you wash your feet every day?”; “Do you check the water temperature before using it?” and “Do you dry your feet after washing?”

The questionnaire was translated into the Persian language. Following the translations conducted by an Iranian professor of English literature, a native bilingual English speaker translated it back into English. Content validity was determined by gathering the views of 15 medical and nursing professionals after reviewing the questionnaire. Content validity ratio (CVR) and content validity index (CVI) of the questionnaire were assessed. Mean scores of CVI and CVR were higher than 0.80. Cronbach’s α coefficients were computed to evaluate reliability of knowledge and practice, which were 0.80 and 0.85, respectively.

Statistical analysis

After collecting data, descriptive statistics (frequency, mean, and standard deviation) were employed to summarize patients’ socio-demographic data and Chi-square test to investigate association between predictors (factors) and knowledge and practice level. In order to assess the differences between groups, the Wilcoxon, Mann-Whitney, and Kruskal-Willis tests were used for continuous variables. Factors related to knowledge and practice was estimated by multiple regressions. In this research, wrong answers and “I don’t know” merged as poor awareness. In order to assess the relationship between individual variables with knowledge and practice, we had to integrate these two items in order to have a better analysis. Variables with a P -value of < 0.1 were included in the multi-variate models. P -value < 0.05 was considered as the level of significance. All analyses were performed using SPSS version 18.

The mean (± SD) age of the 375 participants was 55.4 (±12.9) years, and 56.4% were female. Majority of patients had diabetes for less than 10 years (54.1%), were female (56.5%), urban residents (62.1%), illiterate or had elementary education (73.1%), did not have normal BMI (69.8%), and (10.6%) patients had 2 and more complications (Table  1 ). In terms of knowledge, only 57 participants (15.2%) had good knowledge, most of them (84.8%) had poor knowledge, and the mean score of patients’ knowledge was 8.63 ± 2.65. The highest percentage of correct answers was found with the knowledge about “The need for meeting or consulting a physician, if there were signs of wounding” (88.8%), followed by “Not walking without shoes” (83.5%) and “Washing and changing socks” (9.81%). The lowest knowledge was about “The use of talcum powder or other powders between the toes” (3.5%), followed by “Not using lotion between the toes” (22.24%), and “The proper method of trimming the toenails” (23.2%).

In terms of practice, only 33 patients (8.8%) had a good practice; most of them (91.2%) had a poor practice (Table  2 ), and the mean score of patients’ practice was 7.6 (± 2.5). The participants reported their best practice toward “Importance of diabetes control” (80.5%), followed by “Meeting or consulting a physician, in case of signs of DFU” (79.2%). The poorest practice was toward “The use of talcum powder between the toes” (2.7%), followed by “Proper method of trimming the toenails” (25.9%), and “Keeping the foot skin soft” (30.9%).

There was a direct and significant correlation between knowledge and practice ( P  < 0.0001, r < 0.8) (Fig.  1 ). There was a significant relationship between knowledge score and gender, duration of diabetes, occupation, level of education, place of residence, having DFU, hospital stay history, and amputation history.

Correlation Between Khowledge and Practice

The study results showed that patients with more than 10 years history of diabetes, history of DFU, history of hospital stay or experience of lower limb amputation due to DFU, female gender, and the ones with complications had higher knowledge ( P  < 0.05).

There was a significant correlation between practice score and gender, duration of diabetes, occupation, level of education, and place of residence (P < 0.05) (Table  3 ).

Also, based on multiple regression, the strongest variables related to practice were knowledge score ( P  < 0.0001), place of residence ( P  < 0.03), marital status ( P  = 0.008), and DFU ( P  = 0.02), indicating that these four variables were the predictors of foot care practices in the current study (Table  4 ).

In the current study, majority of patients with diabetes had lower levels of education. Studies report that level of knowledge depends on the level of education [ 14 , 19 ]. Understanding this variable is highly important in designing strategies to prevent diabetes.

In the current study, most patients had lower scores of knowledge and practice toward foot care, and the mean practice score was lower than the mean knowledge score, which was similar to the findings of Muhammad-Lutfi’s and Kim’s studies [ 16 , 20 ]. A study conducted on patients with diabetes in Western Nepal reported poor KAP (knowledge, attitude and practices) score; they indicated that the plausible factors could be lack of knowledge, lack of information, and literacy level of the studied population [ 21 ]. Another study on young Saudi females with diabetes also reported poor KAP scores [ 19 ]. Some studies reported that patients with diabetes had good level of knowledge about diabetes [ 7 , 16 , 22 , 23 ]. The differences in knowledge about foot care among patients with diabetes across the studies could be due to different trainings on diabetes care provided by the health care professionals in different settings [ 23 ] and also the literacy level of the studied subjects.

Several studies reported poor foot care practices among patients with diabetes. Kheir et al., reported poor practices toward regular inspection of feet among patients in Qatar [ 24 ]. Hamidah et al., from Malaysia observed that 28.4% of patients newly diagnosed with diabetes practiced good habits towards foot care [ 25 ]. Desalu et al., from Nigeria observed that only 10.2% of patients with diabetes had good foot care practices [ 26 ]. It was difficult to compare the results of the current study with those of other studies since the nature of the study populations and the applied measurements were different.

In the current study, there was a direct and significant correlation between knowledge and practice scores; therefore, with an increase in the knowledge score, the practice score also increased. Other studies also showed that patients who receive trainings on foot care checked their feet regularly [ 20 ]. Patients who are advised to take care of their feet and the ones whose feet are regularly checked by physicians have better practices toward foot care [ 27 ].

In the current study, the lowest knowledge scores were regarding the application of talcum powder or other powders and not using lotions between the toes, and the proper way of trimming the toenails; while the lowest practice scores were related to the application of talcum powder between the toes, the proper way of trimming the toenails; keeping the foot skin soft, and avoid dryness.

It should also be noted that due to wet climate in the North of Iran, use of lotion between the toes is not common. Nevertheless, it also needs training. Patients with diabetes need to keep between their toes dry using talcum powder and avoid the application of lotion since it is important as a hygienic measure for feet in preventing fungal infection [ 28 ]. Patients should also use skin moisturizers daily to keep the skin of their feet soft and should trim their toenails straight across (not rounded) to prevent damage to their toes [ 29 ].

In the current study, gender, duration of disease, occupation, place of residence, level of education, having DFU, and a history of hospitalization, amputation, and complication had significant relationships with knowledge. Also, gender, duration of disease, place of residence, occupation, and level of education had significant relationships with practice. It was found that knowledge level was higher in females, patients with a diabetes history of more than 10 years, and the ones underwent amputation due to DFU compared to the others; in addition, females, patients with a diabetes history of more than 10 years, and urban residents had better performance. The current study results showed that males were usually reluctant to disclose their health problems and seek professional care. Also, males presented greater deficit in self-care compared to females [ 30 ].

In the study by Muhammad-Lotfi, age, gender, level of education, and duration of diabetes had no significant relationship with knowledge and practice. This finding was in agreement with that of the current study [ 16 ], but another study indicated a significant relationship between the level of education and knowledge [ 31 ].

People with higher education are expected to be more likely to read and receive information about their illness and foot care and understand the information provided by medical staff in health care settings.

But in the current study, there was no significant relationship between the level of education and knowledge or practice, which could be due to the poor and inadequate resources of information about diabetes at the community level, since both educated and uneducated groups had inadequate information. It may also be due to the fact that in spite of possessing knowledge, due to the lack of time, heavy work load, and lack of adequate insurance coverage, patients could not take good care of their feet in practice, which requires more studies to root out the causes.

Nevertheless, the attitude of patients toward self-care in addition to sufficient knowledge was not studied in the current study. As observed in the present study, patients with a history of DFU or hospital stay, and even amputation and complication had higher knowledge level. It could be due to the fact that while completing the questionnaire, the current knowledge level of the subjects was questioned, which indicated that training medical centers can raise the level of knowledge in patients with DFU. In many Iranian state hospitals, diabetic training programs are not well organized, and the existing programs are weak. It is believed that knowledge about diabetes in the general population as well as patients with diabetes in Iran is not enough and there is a dire need for a good program for diabetes [ 32 ].

The collected data indicated that patients with diabetes had poor practice and knowledge about foot care. This is basically due to lack of proper communication between patients and medical team and inadequate education. Based on nurses’ opinion, recommendations and guidelines play an effective role in prevention, treatment, and reduction of complication among patients with DFU. Therefore, adaptation, implementation, and evaluation of the educational programs were recommended [ 33 ].

Thus, patients should be trained for foot ulcer prevention based on clinical practice guidelines for diabetes mellitus both in the community and hospitals. The results of the current study encouraged a positive outlook: A diabetes educator should give necessary advices to patients during every visit, in order to improve their perception about disease, diet, and lifestyle changes and help them control their glycemic level and overcome the complications of diabetes.

According to the principle of “prevention is better than cure” and considering the predictive factors in the current study including poor knowledge, urban residency, being single, and lack of DFU, more attention should be paid to patients possessing risk factors .

Knowledge and practice toward foot care were poor in most patients with diabetes. There was a significant relationship between some demographic characteristics of patients and knowledge and practice toward foot care. The level of knowledge, place of residence, marital status, and history of hospital stay due to DFU were the predictors of practice in patients with diabetes.

The strength of the current study was that it was the first, study to discuss this important issue in Guilan Province. The study also had some limitations; first, since the work had a cross sectional design, the direction of relationships and causal relationships cannot be determined. Second, the result of the study should be interpreted with caution, since they were obtained from a single center; a clinic-based study. Hospital-based studies cannot provide a true picture of knowledge and practice in the community. The current study sample did not represent the whole Iranian population consisting of several ethnicities. In this research, responses of the wrong answers and “I don’t know” have been grouped together, in order to achieve better analysis. Perhaps with increasing sample size, we could solve this problem in future studies.

Adequate knowledge and good practices are important to effectively control diabetes mellitus. Patients require continuous support of family members and community in order to modify their lifestyle and behaviors and make sustainable changes in order to better control their diabetes disease. Also, education about diabetes mellitus and its risk factors should be provided through mass media in order to effectively control it in the community.

Availability of data and materials

The datasets used and /or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Content validity index

Content validity ratio

Diabetic foot ulcers

Eastern Mediterranean Region

World health organization

Janmohammadi N, Moazzezi Z, Ghobadi P, et al. Evaluation of the risk factors of diabetic foot ulcer and its treatment in diabetic patients, Babol, North of Iran. Iranian J Endocrinol Metab. 2010;11(2):121–5. https://doi.org/10.1155/2018/7631659 .

Article   Google Scholar  

Moradi-Lakeh M, Forouzanfar MH, El Bcheraoui C, et al. High fasting plasma glucose, diabetes, and its risk factors in the eastern mediterranean region, 1990–2013: findings From the Global Burden of Disease Study 2013. Diabetes Care. 2017;40(1):22–9. https://doi.org/10.2337/dc16-1075 Epub 2016 Oct 26.

Article   PubMed   Google Scholar  

Bcheraoui C, Basulaiman M, Tuffaha M, et al. Status of the diabetes epidemic in the kingdom of Saudi Arabia, 2013. Int J Public Health. 2014;59:1011–21.

Haghdoost AA, Rezazadeh-Kermani M, Sadghirad B, Baradaran HR. Prevalence of type 2 diabetes in the Islamic Republic of Iran: systematic review and meta-analysis. East Mediterr Health J. 2009;15:591–9.

Article   CAS   Google Scholar  

Paisey R, Abbott A, Levenson R, et al. Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the south-west of England. Diabet Med. 2018;35(1):53–62. https://doi.org/10.1111/dme.13512 Epub 2017 Oct 11.

Article   CAS   PubMed   Google Scholar  

Solan YM, Kheir HM, Mahfouz MS, et al. Diabetic Foot Care: Knowledge and Practice. J Endocrinol Metab. 2017;6(6):172–7. https://doi.org/10.14740/jem388e .

Haq NU, Durrani P, Nasim A, et al. Assessment of Knowledge and Practice of Diabetes Mellitus Patients Regarding Foot Care in Tertiary Care Hospitals in Quetta, Pakistan. Specialty J Med Res Health Sci. 2017;2(4):35–43.

Google Scholar  

Jeffcoate WJ, Boyko EJ, Vileikyte L, et al. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care. 2018;41:645–52. https://doi.org/10.2337/dc17-1836 .

Morey-Vargas OL, Smith SA. Be Smart: Strategies for foot care and prevention of foot complications in patients with diabetes. Prosthet Orthot Int. 2015;39(1):48–60.

Hurlow JL, Hamphreys GI, Bowling FL, et al. Diabetic foot infection: a critical complication. Int Wound J. 2018:1–8. https://doi.org/10.1177/0309364614535622 .

Clarke P, Gray A, Holman R. Estimating utility values for health states of type 2 diabetic patients using the EQ-5D (UKPDS 62). Med Decis Mak. 2002;22(4):340–9. https://doi.org/10.1177/0272989X0202200412 .

Laiteerapong N, Karter AJ, Liu JY, et al. Correlates of quality of life in older adults with diabetes. Diabetes Care. 2011;34(8):1749–53. https://doi.org/10.2337/dc10-2424 Epub 2011 Jun 2.

Article   PubMed   PubMed Central   Google Scholar  

Ndosi M, Wright-Hughes A, Brown S, et al. Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study. Diabet Med. 2018;35(1):78–88. https://doi.org/10.1111/dme.13537 Epub 2017 Nov 20.

Ahmad S, Ahmad MT. Assessment of knowledge, attitude and practice among diabetic patients attending a health care facility in North India. Indian J Basic Appl Med Res. 2015;4(3):501–9.

Jackson IL, Adibe MO, Okonta MJ, et al. Knowledge of self-care among type 2 diabetes patients in two states of Nigeria. Pharmacy Pract. 2014;12(3) PMID:25243026,PMCID:PMC4161403.

Muhammad-Lutfi A, Zaraihah M, Anuar-Ramdhan I. Knowledge and practice of diabetic foot care in an in-patient setting at a tertiary medical center. Malays Orthop J. 2014;8(3):22. https://doi.org/10.5704/MOJ.1411.005 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

American Diabetes Association. Classification and diagnosis of diabetes: standards of medical Care in Diabetes 2019. Diabetes Care. 2019;42(Suppl. 1):S13–28. https://doi.org/10.2337/dc19-S002 .

Jeyaraman K, Berhane T, Hamilton M, et al. Mortality in patients with diabetic foot ulcer: A retrospective study of 513 cases from a single Centre in the Northern Territory of Australia. BMC Endocr Disord. 2019;19:1. https://doi.org/10.1186/s12902-018-0327-2 .

Saadia Z, Rushdi S, Alsheha M, et al. A study of knowledge attitude and practices of Saudi women towards diabetes mellitus. A (KAP) study in Al-Qassim region. Internet J Health. 2010;11(2). https://doi.org/10.4236/jdm.2015.52014 .

Kim A, Hongsranagon P. Preventive behaviors regarding foot ulcers in diabetes type II patients at BMA health center no. 48, Bangkok, Thailand. J Health Res. 2008;22(suppl):21–8.

Gautam A, Bhatta DN, Aryal UR. Diabetes related health knowledge, attitude and practice among diabetic patients in Nepal. BMC Endocr Disord. 2015;15(1):25. https://doi.org/10.1186/s12902-015-0021-6 .

Saleh F, Mumu SJ, Ara F, et al. Knowledge and self-care practices regarding diabetes among newly diagnosed type 2 diabetics in Bangladesh: a cross-sectional study. BMC Public Health. 2012;12(1):1112. https://doi.org/10.1186/1471-2458-12-1112 .

Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. J Ayub Med Coll Abbottabad. 2010;22(3):128–31 PMID: 22338437.

PubMed   Google Scholar  

Kheir N, Greer W, Yousif A, et al. Knowledge, attitude and practices of Qatari patients with type 2 diabetes mellitus. Int J Pharm Prac. 2011;19(3):185–91. https://doi.org/10.1111/j.2042-7174.2011.00118.x .

Hamidah H, Santhna L, Ruth RP, et al. Foot care strategy for the newly diagnosed DM Type 2 patients with low educational and socio-economic background: a step towards future. Clin Ter. 2012;163(6):473–8.

CAS   PubMed   Google Scholar  

Desalu O, Salawu F, Jimoh A, et al. Diabetic foot care: self-reported knowledge and practice among patients attending three tertiary hospital in Nigeria. Ghana Med J. 2011;45(2):60–5 PMID: 21857723.

Bell RA, Arcury TA, Snively BM, et al. Diabetes foot self-care practices in a rural, triethnic population. Diabetes Educ. 2005;31(1):75–83. https://doi.org/10.1177/0145721704272859 .

Aalami HB, Aalami HA, Siavashi B. Diabetic foot ulcer management review of literature. Iran J Surgery. 2009;16(4):1–7. https://doi.org/10.17795/jssc23312 .

Hasnain S, Sheikh NH. Knowledge and practices regarding foot care in diabetic patients visiting diabetic clinic in Jinnah hospital, Lahore. J Pak Med Assoc. 2009;59(10):687 PMID: 19813683.

Rossaneis MA, Haddad MD, Mathias T, et al. Differences in foot self-care and lifestyle between men and women with diabetes mellitus. Rev Lat Am Enfermagem. 2016;24:e2761. https://doi.org/10.1590/1518-8345.1203.2761 .

Chiwanga FS, Njelekela MA. Diabetic foot: prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania–a cross-sectional study. J Foot Ankle Res. 2015;8(1):20. https://doi.org/10.1186/s13047-015-0080-y .

Delavari A, Alikhani S, Nili S, et al. Quality of care of diabetes mellitus type II patients in Iran. AIM . 2009;12(5):492–5 PMID: 19722773.

Ghanbari A, Rahmatpour P,Jafaraghaee et al .Quality assessment of Diabetic Foot ulcer clinical practice guildeline. J Evid Based Med .2018; 11(3):200–207. doi: https://doi.org/10.1111/jebm.12304 .

Download references

Acknowledgements

The authors wish to thank all the individuals who helped throughout the study, especially Razi Clinical Research Development Center.

The study was funded by the Deputy for Research; Guilan University of Medical Sciences. The funder had no role in the study design, data analysis and interpretation, and writing of the manuscript.

Author information

Authors and affiliations.

Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran

Aydin Pourkazemi, Monireh Khojamli, Heydarali Balo, Hossein Hemmati & Zakiyeh Jafaryparvar

Social Determinants of Health Research center, nursing and midwifery school, Guilan University of medical sciences, Rasht, Iran

Atefeh Ghanbari

Department of internal medicine , Razi Hospital ,School of Medicine, Guilan university of Medical Sciences, Rasht, Iran

Behrang Motamed

You can also search for this author in PubMed   Google Scholar

Contributions

PA, KM, and GA: the study design; PA,KM and MB: data collection; PA, KM, GA, HH, and BH: data analysis; PA, GA, KM, BH, HH, MB and JZ: data interpretation and drafting of the manuscript. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Atefeh Ghanbari .

Ethics declarations

Ethics approval and consent to participate.

Written informed consent was obtained from participations and verbal consent from illiterate participants following a detailed explanation of the study objectives. The study was conducted in accordance with the ethical principles and its protocol was approved by the Ethics Committee of Guilan University of Medical Sciences (ethical code: IR.GUMS.REC.1396.8).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Pourkazemi, A., Ghanbari, A., Khojamli, M. et al. Diabetic foot care: knowledge and practice. BMC Endocr Disord 20 , 40 (2020). https://doi.org/10.1186/s12902-020-0512-y

Download citation

Received : 07 January 2019

Accepted : 25 February 2020

Published : 20 March 2020

DOI : https://doi.org/10.1186/s12902-020-0512-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Diabetic foot
• Diabetes mellitus

BMC Endocrine Disorders

ISSN: 1472-6823

• General enquiries: [email protected]

‘SNL’ Alum Laraine Newman Says ‘I Can Feel an Ulcer Developing’ Over ‘The Bear’ Being a Comedy at the Emmys: ‘It’s Not Even a Dark Comedy’

By Zack Sharf

Digital News Director

• ‘Agatha All Along’ First Reactions: Kathryn Hahn’s Marvel Return Hailed as ‘Bewitching,’ ‘Deliciously Devious’ and ‘Bats— Crazy in All the Right Kinds of Ways’ 8 hours ago
• Donald Glover Says ‘Star Wars’ Is ‘Way Too Serious’ Sometimes and Hopes a Lando Movie Brings Fun Back: ‘We Have a Responsibility to Have Enjoyment’ 15 hours ago
• Hillary Clinton Slams Elon Musk’s Offer to Give Taylor Swift a Child as ‘Rotten and Creepy’: It’s ‘Kind of Another Way of Saying Rape’ 16 hours ago

Original “Saturday Night Live” cast member Laraine Newman railed against “ The Bear ” on Emmys night, where the FX series set a new record for most comedy wins in a single year with 11 trophies for its second season. The previous record holder was the first season of “The Bear” with 10 wins. Newman, who was on “SNL” for five years (and who is also the mother of “ Hacks ” star Hannah Einbinder), called out the show for supposed category fraud.

Related Stories

4D Movie Tech Lacks Consumer Awareness: Survey

Jeremy Clarkson, Richard Hammond and James May Get Sentimental in Trailer for 'The Grand Tour' Finale

Popular on variety.

Hannah Einbinder lost the Emmy for outstanding supporting actor in a comedy series to “The Bear’s” Liza Colón-Zayas. It was Einbinder’s third nomination for “Hacks,” which ended up prevailing over “The Bear” to win outstanding comedy series in what many pundits believed to be the biggest upset of the Emmys. “Hacks” leading lady Jean Smart also took home the lead actress prize over “The Bear’s” Ayo Edebiri, while “The Bear” stars Jeremy Allen White and Ebon Moss-Bachrach won their own acting Emmys for lead actor and supporting actor, respectively.

The debate over whether “The Bear” is a comedy or a drama intensified after the show’s second season dominated the Emmy nominations. The season earned acclaim largely for its dramatic episodes, including an intense family flashback episode (“Fishes”) that won Jamie Lee Curtis an Emmy for outstanding guest actress in a comedy series for playing a mother with bipolar disorder.

Emmy hosts Dan and Eugene Levy even made fun of the ongoing debate about “The Bear” during their monologue , saying: “‘The Bear’ is nominated for 23 Emmys tonight, making it the most-nominated comedy in history,. Now, I love the show, and I know some of you will be expecting us to make a joke about whether ‘The Bear’ is really a comedy — but in the true spirit of ‘The Bear,’ we will not be making any jokes.”

Every time I think about The Bear being in the comedy category for the Emmys I can feel an ulcer developing. — Laraine Newman (@larainenewman) September 15, 2024

I think the Bear is a great show but IMHO it’s not a comedy- not even a dark comedy. — Laraine Newman (@larainenewman) September 16, 2024

More from Variety

‘Ahsoka’: Rosario Dawson on How Costume Designer Shawna Trpcic Honored the ‘Star Wars’ Aesthetic  

How Much Should AI Giants Pay Hollywood? What Insiders Say Has Stalled Any Licensing Deals

From Barbra Streisand’s Auschwitz Ode to Maya Rudolph’s Motherly Rap, Here’s This Year’s Wildest Emmys Category  

Jon Hamm on How He Tapped Into ‘The Morning Show’ and ‘Fargo’ Roles Simultaneously and the Rise of the Elon Musk Character

Venu Legal Fight Is About More Than FuboTV: What’s at Stake for the Entire Industry

Married Duo Carrie Coon and Tracy Letts on Landing Emmy Noms Together for ‘Gilded Age’ and ‘Winning Time’ 

More from our brands, sean combs arrested after grand jury indictment.

Artist JR Just Designed a New Suite for the Venice Simplon-Orient-Express

Coffey Talk: Ares Sports Chiefs Affolter, Miller on NFL Investing

The Best Loofahs and Body Scrubbers, According to Dermatologists

Anna Delvey Seeks ‘On-Air Correction’ From The View Over Remarks About Her Controversial DWTS Casting: ‘Get Your Facts Straight’

site categories

Tim davie confirms huw edwards will never work for bbc again & says he wants his legacy to be moving “beyond” these crises, breaking news.

• ‘SNL’ Alum Laraine Newman, ‘Hacks’ Star Hannah Einbinder’s Mom, Slams Inclusion Of ‘The Bear’ In Comedy Category: “I Can Feel An Ulcer Developing”

By Natalie Oganesyan

Natalie Oganesyan

More stories by natalile.

• Donald Glover Wants ‘Star Wars’ To Be “Fun” Through ‘Lando’ Film
• ‘Hamilton’ Broadway Cast Updates ‘The Election Of 1800’ For National Voter Registration Day

Saturday Night Live alumna Laraine Newman , and mother to Hacks star Hannah Einbinder , slammed the inclusion of The Bear in the Emmys comedy category ahead of last night’s ceremony in since-deleted posts made on X.

Related Stories

Casey Bloys On 'Hacks' Surprise Comedy Series Emmy Win & Category Debate; 'White Lotus', 'The Last Of Us', 'Euphoria' & 'Harry Potter' Updates

FX Boss John Landgraf Talks Of "Thrilling" Emmy Night For 'Shōgun' & 'The Bear' & Dishes On Future Seasons Following Disney's Record-Breaking Night

Watch on deadline.

“I think the Bear is a great show but IMHO it’s not a comedy- not even a dark comedy,” Newman said .

She added, in response to a commenter, “I know. I took it down. Not my best moment,” in reference to her previous posts. Doubling down, she told another, “I regret that post and I think the actress who won is wonderful in that role. But the other people in the various categories that lost to The Bear, In my opinion, we’re robbed.” Liza Colón-Zayas won the Emmy for Outstanding Supporting Actress in a Comedy Series, a category she was nominated in against Carol Burnett ( Palm Royale ), Meryl Streep ( Only Murders in the Building ), Abbott Elementary ‘s Sheryl Lee Ralph and Janelle James, as well as Einbinder.

Must Read Stories

Gadd inks netflix deal; sarandos on ‘baby reindeer’; bbc on huw edwards.

HBO’s Casey Bloys On ‘Hacks’ Surprise Emmy Win, ‘Harry Potter’ Series & More

‘maxton hall’ future teased; amazon, constantin execs talk market, james cameron buys ‘ghosts of hiroshima’ book; pic is his next project post-‘avatar’, read more about:, subscribe to deadline.

Get our Breaking News Alerts and Keep your inbox happy.

Deadline is a part of Penske Media Corporation. © 2024 Deadline Hollywood, LLC. All Rights Reserved.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

The PMC website is updating on October 15, 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int Wound J
• v.20(6); 2023 Aug
• PMC10332999

Summary of best evidence for prevention and control of pressure ulcer on support surfaces

Lijun huang.

1 School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou China

Yimin Huang

Xiaoting lu, associated data.

The data that support the findings of this study are openly available in [figshare”] at http://doi.org [doi], reference number [reference number].

The aim of this study was to summarise the best evidence for the prevention and control of pressure ulcer at the support surface based on the site and stage of the pressure ulcer in order to reduce the incidence of pressure ulcer and improve the quality of care. In accordance with the top‐down principle of the 6 S model of evidence‐based resources, evidence from domestic and international databases and websites on the prevention and control of pressure ulcer on support surfaces, including randomised controlled trials, systematic reviews, evidence‐based guidelines, and evidence summaries, was systematically searched for the period from January 2000 to July 2022. Evidence grading based on the Joanna Briggs Institute Evidence‐Based Health Care Centre Evidence Pre‐grading System (2014 version), Australia. The outcomes mainly embraced 12 papers, including three randomised controlled trials, three systematic reviews, three evidence‐based guidelines, and three evidence summaries. The best evidence summarised included a total of 19 recommendations in three areas: type of support surface selection assessment, use of support surfaces, and team management and quality control.

1. INTRODUCTION

A pressure ulcer is a localised injury caused by continuous pressure on the skin and/or subcutaneous soft tissues, usually located at a bony prominence, or involving a medical device or other instrument. 1 Pressure redistribution is important in pressure ulcer prevention and control strategies, which include the use of support surfaces and postural management. Nursing staff have standardised and comprehensive care practices for postural management, but lack sufficient attention to support surfaces. Support surfaces include specially‐designed beds, mattresses, mattress overlays and cushions that are used to protect vulnerable parts of the body and distribute the surface pressure more evenly. 2 The results of the pressure ulcer prevention measures statistics show that only 61.81% of patients at risk of pressure ulcer use support surfaces, and mostly electric pressure inflatable mattresses, 3 the use rate is low and the appropriate support surface is not selected according to the stage of pressure ulcer or the site of occurrence. Currently, there is no separate summary and classification of support surfaces, and the evidence is scattered and lacks guidance from studies with high levels of evidence, 4 which weakens the overall prevention and control of pressure ulcer. Therefore, in this study, we systematically searched the literature related to the prevention and control of pressure ulcer with brace surfaces at home and abroad, evaluated, synthesised, and summarised the evidence using evidence‐based methods, classified the sites and stages of pressure ulcer occurrence, and finally formed a comprehensive evidence on the selection, use and management of brace surfaces in order to provide an evidence‐based basis for clinical practice.

2. MATERIALS AND METHODS

2.1. search strategy.

This study was searched in the following databases, Cochrane Library, Embase, PubMed, Wanfang, CNKI and China Biomedical Literature Database. The English search terms included “pressure ulcer/pressure ulcer/pressure sore/decubitus ulcer/bed sore/pressure sore” and “pressure relieving device/support surfaces/beds/mattress” and Chinese search terms include “pressure ulcer/pressure ulcer/pressure sore/pressure ulcer” and “support surfaces/airbeds/pressure‐relieving mattresses/gel mattresses/pressure‐relieving devices/support tools”. The comprehensive database was searched using a combination of subject terms and free words. The search time frame is from 2000 to 2022.

2.2. Criteria for considering studies

The inclusion criteria included: (a) study subjects were patients with pressure injuries using support surfaces or at‐risk groups; (b) intervention: use of support surfaces based on routine pressure ulcer care; (c) outcome indicators: 1 or more of pressure ulcer incidence and Branden score; (d) balanced consistency across studies, comparable baseline data between intervention and control groups; (e) study type. Randomised controlled trials, evidence‐based guidelines, systematic reviews, evidence summaries, expert consensus. Exclusion criteria: (a) literature types were guideline interpretations and plans; (b) repeatedly published or updated articles; (c) literature with incomplete information or inaccessible full text; (d) studies that failed the literature quality assessment.

2.3. Studies selection, data extraction, and quality assessment

Two authors (Lijun Huang, Yuan Liao) scanned the titles and abstracts of all records identified through the search strategy independently. The full text of potentially relevant articles was obtained and assessed independently by two authors (Lijun Huang, Yuan Liao) in accordance with inclusion and exclusion criteria. Any differences of opinion were resolved through discussion with a senior author (Yimin Huang) Data were collected using a standardised form to include first author, publication year, baseline characteristics of participants, sample sizes, type of support surfaces, type of intervention, details of comparison, and incidence of pressure ulcer. Two authors (Lijun Huang, Yimin Huang) independently assessed the risk of bias using the UK's 2017 updated clinical guidelines research and evaluation system (Appraisal of Guidelines for Research and Evaluation II,AGREE II), 5 the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2). Systematic evaluations were performed using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2). 6 Randomised controlled trials were evaluated using the evaluation criteria of the Australian JBI Centre for Evidence‐Based Health Care (2016). 7 The extracted evidence was evaluated in this study using the Johns Hopkins Centre for Evidence‐Based Care evidence grading system, 8 Under the guidance of FAMA structure, combined with the JBI recommendation strength grading principle of the evidence, the research team determined the strength of the evidence recommendation, that is, A‐level recommendation (strong recommendation) and B‐level recommendation (weak recommendation).

3.1. General characteristics of the included literature

A total of 635 publications were included, and after excluding duplicates and those that did not meet the requirements after reading the title, abstract, and full text, a total of 12 publications were finally included, including three randomised controlled trials, three systematic reviews, three evidence‐based guidelines, and three best evidence summaries. The basic characteristics of the included literature are shown in Table  1 .

Basic characteristics of the included literature.

3.2. Evaluation results of the quality of the included literature

3.2.1. quality evaluation results of the guidelines.

Three guidelines were included in this study with high inter‐rater agreement, and the results of the standardised scores for each domain and the overall quality evaluation of the guidelines are shown in Table  2 .

Results of the quality evaluation of the guidelines.

3.2.2. Results of the quality evaluation of the systematic review

Three systematic reviews were included in this study, one from the Wanfang database and two from the cochrane database. Sun Xin et al. 12 For the study of Sun Xin et al. in the study, entry 2 “Whether the study method of the systematic evaluation was determined before the implementation of the systematic evaluation. Were inconsistencies with the study protocol explained?”, entry 7 “Did the authors of the systematic evaluation provide a list of excluded literature and the reasons for their exclusion?”, entry 10 “Do the authors of the systematic evaluation report the sources of funding for the inclusion of individual studies?”, entry 16 “Do the systematic evaluation authors report all sources of potential conflicts of interest, including any grants received for the production of the systematic evaluation?” Evaluated as no, entry 4 “Did the systematic evaluation authors use a comprehensive search strategy?”, entry 8 “Did the systematic evaluation authors describe the included studies in detail?”, and entry 9 “Did the systematic evaluation authors use appropriate tools to assess the risk of bias for each included study?” The results were partially yes and yes for all other entries; McInnes, E et al. 13 For the study by McInnes, E et al., entry 2 “Were study methods determined prior to systematic evaluation? Are inconsistencies in protocols explained?” and entry 10 “Do the authors of the systematic evaluation report the source of funding for each study included?” The evaluation result was no, while all other entries were yes; ShiC et al. 14 studies, all entries were evaluated as yes. The study design was relatively complete, and the overall quality was moderate, and was included after discussion by the study team.

3.2.3. Quality evaluation results of the evidence summary

Three evidence summaries from CINAHL and Wanfang, which followed the evidence development process and criteria and met the inclusion criteria for this study, were included in this study.

3.2.4. Quality evaluation of randomised controlled trials

A total of three randomised controlled trials were included in this study. Among them, the study by Qu et al. 9 the evaluation result was no, entry 6 “Was the outcome assessor blinded?” and entry 7 “Did the groups receive the same measures other than the intervention to be validated?” All entries were evaluated as yes, except for entry 6, “Was the outcome measure blinded?” and entry 7, “Did the groups receive the same measures except for the intervention to be validated?”, which were evaluated as unclear. The study by Luo Qiaofang et al. 10 was evaluated as high quality, except for entry 5, “Was the intervention blinded?” The evaluation result was no, and entry 7 “Apart from the intervention to be validated, were the other measures received by each group the same?” The study by Bueno et al. 11 was evaluated as yes, except for entry 5, “Was the intervention blinded?”, which was evaluated as no. All entries were evaluated as yes, and the quality of the literature was high.

3.3. Evidence aggregation and generation

The researchers extracted relevant evidence from the 12 included papers to form the first draft of the evidence summary, and a total of 35 pieces of evidence were obtained. This research team combined the evidence with the same formulation, and conflicting evidence was selected with high evidence level and newer chronology. Discussions were held by two (Lijun Huang, Yuan Liao), and the final evidence summary was conducted in three areas: selection assessment of support surfaces, use of support surfaces, and team management and quality control, resulting in 19 best evidence summaries, which are shown in Table  3 . The Australian JBI evidence‐based health care centre evidence pregrading and evidence recommendation level system (2014) was used to determine the grading of included evidence.

Summary of best evidence for support surfaces to reduce and manage pressure ulcer.

3.4. Summary and analysis of best evidence

After a rigorous literature search, quality evaluation, and evidence grading, 19 pieces of evidence were finally included in this study, which were divided into three areas, of which 12 were recommended at level A and 7 at level B. The details are shown in Table  3 .

4. DISCUSSION

Through evidence extraction and integration, the evidence for support surfaces to prevent and manage stressful injuries included three major areas of support surface type selection assessment, support surface use, and team management and quality control, with a total of 19 pieces of evidence, as shown in Table  3 .

4.1. Support surface prevention and treatment of pressure ulcer has received attention, and the benefits of some support surfaces remain controversial

The treatment of pressure ulcer is complex, which not only increases patient pain and prolongs hospital stay, but also increases the consumption of medical resources. 20 Therefore, standardised, scientific and effective prevention and treatment are particularly important to reduce the incidence of pressure ulcer. In recent years, the prevention and treatment of pressure ulcer has received attention from health care professionals worldwide, and Emily Haesler 2 is one of the most authoritative guidelines currently developed by the European Pressure Ulcer Advisory Panel (EPUAP), the Pressure Injury Advisory Panel of the United States (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA), which is revised every five years, with the first edition published in The 2019 edition adopts the latest methodological theories, summarises and evaluates research evidence using an evidence‐based decision‐making framework, and enriches the evidence description section with more comprehensive and detailed recommendations and evidence discussions. In addition, the guidelines provide implementation considerations for the recommendations, making the new guidelines more scientific, readable, and actionable, and of great importance to clinical practice.

Emily Haesler 2 added to the recommendations for the use of support surfaces by adding a new section on special populations to the transport population. Patients are at a higher risk of pressure ulcer because of the prolonged restriction of movement during travel to and from clinical care settings (eg, in an ambulance or waiting in an emergency department). In addition, the incidence of pressure injury for patients with suspected cervical spine injuries who remained on a hardboard in the spine for four hours was 28.3%. 21 It is recommended that patients be transferred from the spinal rigid board or posterior board to acute care equipment as soon as possible after consultation with medical staff. Pressure ulcer may also occur in patients during transfer, which has been less studied in China and should be taken seriously by clinical practitioners.

The new guidelines make more specific recommendations for new types of support surfaces, but the strength of evidence and strength of recommendation for this part of the opinion is low and needs to be supported by more high‐quality research. The effectiveness of alternating pressure inflatable mattresses compared with other mattresses for the management of pre‐existing pressure injuries is controversial in current research, and the available evidence on these types of support surfaces is limited and conflicting. Nevertheless, this paper recommends the use of alternating pressure inflatable mattresses in patients at risk of developing pressure‐related injuries and for whom pressure repositioning is not possible versus patients with prolonged chair or wheelchair‐based pre‐existing pressure ulcer, as more quality literature (Emily Haesler, 2 Colin D 16 ) recommends the use of alternating pressure inflatable mattresses and their greater cost‐effectiveness in Adverse events (eg, falls) are uncommon. Therefore, the relative benefits of using alternating pressure inflatable mattresses for individuals at risk of pressure‐related injury need to be evaluated on a case‐by‐case clinical basis.

4.2. Different parts and stages should be selected to correspond to the support surface to facilitate the extension of the turning interval

The different support surfaces are designed to relieve pressure and are used to cushion vulnerable areas of the body and distribute surface pressure more evenly. 13 Support surfaces are mainly divided into total body support surfaces and local support surfaces. Domestic and international research on support surfaces has focused on systemic support surfaces, especially mattresses, mainly to relieve pressure in the sacrococcygeal region, the most common site of pressure ulcer. Clinically reported systemic support surfaces in China mainly include foam mattresses, gel foam mattresses, static air mattresses, water mattresses, fluctuating inflatable mattresses, and alternating pressure‐reducing mattresses. Fewer local support surfaces have been reported, mainly including cotton pillow cores, air loops, water loops, sponge pads, gel pads, celiac pads, etc. There are various forms of support surfaces, and there is a lack of high evidence‐based level of evidence guiding the selection of support surfaces by nursing staff, so the blind selection of support surfaces during nursing care may lead to problems such as over‐care or difficulty in controlling the development of pressure injury, which may affect the patient's pressure ulcer control effect. In this study, we categorised different sites and different stages of PI and compiled the recommended evidence for the corresponding support surfaces. Because there are some differences in symptoms, risks, and control measures for pressure ulcer in different stages and sites, it suggests that we should develop care plans for different sites and stages according to PI stages and sites, and select support surfaces of corresponding levels to facilitate patients’ access to targeted care interventions.

Studies have shown that 10 the support surface can prolong the turning interval without increasing the incidence of pressure ulcer. Turning is an effective method of pressure reduction to help prevent pressure ulcer, but frequent turning in clinical practice tends to increase patient discomfort, interfere with the patient's resting state, and increase nursing workload. Based on this, domestic and international scholars have turned their research focus to the support surface to find a more effective support surface to extend the turning interval for people at risk of pressure ulcer. 22 A study by Luo Qiaofang 10 showed that a static air mattress has a better pressure sore prevention effect than a conventional pressure‐reducing mattress and has some therapeutic effect on pressure ulcer. 23 Moreover, the static air mattress has moderate softness and good touch, which can effectively disperse the pressure of the mattress on the body, reduce the friction and shear force generated by the process of body position movement, and can prolong the turning interval of patients. Therefore, this study recommends the use of this support surface to extend the turning interval time, but at present, the specific turning interval time after using the support surface still needs to be decided according to the patient's disease condition and the characteristics of the support surface, and the turning interval time of patients after using a specific model of support surface can be studied in depth in future, and the turning interval time of patients in a specific place (such as ICU) after using the pressure‐reducing mattress can also be studied. 24

4.3. Enhanced assessment and support surface research in heel pressure ulcer to facilitate heel pressure ulcer prevention

Domestic and international literature. 25 It is reported that the heel is the second most prevalent site after the sacrococcygeal region, and its incidence accounts for 9.6% to 33.3% of the total incidence of pressure injuries. If the heel pressure ulcer continues to worsen, it will lead to local tissue necrosis, bone exposure, increased risk of osteomyelitis, and even amputation in severe cases, reducing the quality of life of patients and increasing the consumption of health care resources. 18 Therefore, this study included heel pressure ulcer as a special site in the prone situation. Colin D, 16 Emily Haesler, 2 and Yang Ting 18 showed that the ideal way to prevent heel pressure ulcer is to ensure that the heel does not touch the bed to avoid all pressure, that is, to keep the heel in a “floating” position. 26 This means keeping the heel “floating”. For patients with established pressure ulcer and those who are bedridden, heel support devices are recommended, but there are many different types, such as heel suspension boots, long foam pads, and their composition, materials, and performance need to be considered when choosing one. There is insufficient evidence to determine which support surface is most effective in preventing and treating heel pressure ulcer. At the same time, many scholars 27 , 28 are of the opinion that heel pressure ulcer risk assessment should not be limited to existing scale entries, but needs to consider other high‐risk factors, but there is no PI‐specific risk assessment tool for the foot among the widely used pressure ulcer assessment tools at home and abroad, and it is necessary to develop a specific tool for heel pressure ulcer risk assessment in the future.

4.4. Raising nursing staff awareness of support surfaces facilitates the reduction of pressure ulcer incidence

Foreign studies have shown that nurses' knowledge of stress injuries is still lacking. 25 The increase in the prevalence of pressure injuries is related to the lack of awareness of risk factors and inadequate protective measures among nurses. 29 For example, clinical nursing staff often use posture devices instead of support devices. When patients are at risk of pressure ulcer, nursing staff often consciously use air rings, cotton pillows, or R‐shaped turning pillows to turn them, and consider this measure as a preventive measure for pressure ulcer. However, R‐shaped pillows, although they have certain support functions, are essentially postural placement devices, so confusing the two functions is not conducive to the effective prevention of pressure ulcer. 30 The confusion between the two is not conducive to the prevention of pressure ulcer.

Therefore, hospital administrators should pay attention to the promotion of knowledge related to pressure ulcer guidelines and strengthen the study and assessment of updated guidelines by health care personnel. Also introduce current advanced support surfaces and standardise the use of support surfaces. The training of nurses should be emphasised, and centralised education and face‐to‐face lectures can be used to improve the ability to use it, skills and techniques so that the support surface can better play a role in preventing pressure injuries in the clinic. 31 Medical and nursing staff should enhance their learning, deepen their understanding of the support surface, and use the pressure ulcer assessment tool for individualised assessment. Combine with the causes of pressure ulcer in our department, early support surface intervention, and adhere to the principle of prevention in the first place. At the same time, we should master new advances in pressure ulcer assessment tools, continuously innovate new techniques and methods in clinical work, and improve the clinical use of brace surfaces. The clinical use of brace surfaces should be improved. Starting from the clinical needs, avoiding harm, continuously strengthening the development and improvement of the support surface, and fully considering the economic acceptability of patients and the principle of nursing staff saving labour to design the support surface with good safety, high comfort and practicality. 30 The support surfaces are designed with good safety, comfort, and practicality in mind.

This study summarises the current best evidence on the use of bracing surfaces in the prevention and management of pressure ulcer, with the aim of providing clinical caregivers with a reference for the selection of appropriate bracing surfaces to prevent and manage the occurrence of pressure ulcer and improve quality of life and reduce health care costs, depending on the site and stage of the pressure ulcer. However, there is a lack of high‐quality experimental studies on support surfaces. In future studies, outcomes should also be carefully selected, and adverse events should be carefully assessed and reported in studies to generate meaningful data. Similarly, patient comfort, quality of life, and cost analysis are important outcomes that are not currently clearly defined or reported. 14 Finally, with respect to potential bias, it is important that all future studies be designed to the highest possible standard of the randomised control principle. Although avoiding the risk of performance bias in support surface trials is challenging because it is difficult to blind participants and researchers, we need to adequately describe common interventions and ensure that intervention protocols accurately carry out these measures in different trial groups. In addition, the risk of detection bias can also be minimised by using digital photography and by researchers masking the support surfaces in photographs. Finally, it is recommended that the clinical translation process be evaluated in the context of different cultural backgrounds, relevant infrastructure and care settings, and that a comprehensive cost and benefit analysis be conducted to apply the evidence to the clinic and maximise patient benefit.

6. LIMITATIONS

This evidence summary only includes published studies in Chinese and English, and articles in other languages could be included to form a better evidence summary. The search for this study may lack comprehensiveness, and literature with guidelines that are more than twenty years old, pre‐updated guidelines, and consensus were excluded, which may have some bias, and this study did not include special and rare support surfaces. This study included mostly foreign literature, taking into account differences in ethnicity, perceptions, and values, as well as geographical and cultural differences in health care delivery systems. Further consideration of the clinical context is needed during the application of the evidence to develop a localised practice plan. Future clinical reviews will be conducted to assess any barriers to the application of the evidence.

FUNDING INFORMATION

Conflict of interest.

The authors declare that there is no conflict of interest.

Huang L, Yan Y, Huang Y, et al. Summary of best evidence for prevention and control of pressure ulcer on support surfaces . Int Wound J . 2023; 20 ( 6 ):2276‐2285. doi: 10.1111/iwj.14109 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Lijun Huang, Yu Yan contributed equally to this study

Contributor Information

Yu Li, Email: moc.361@125yppahuyoyoy .

Chun Li, Email: moc.qq@584269673 .

DATA AVAILABILITY STATEMENT