Aim To assess the usefulness of monthly thermography and standard foot care to reduce diabetic foot ulcer recurrence. Methods People with diabetes (n = 110), neuropathy and history of >= 1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention System). Participants were randomized to intervention (active thermography + standard foot care) or control (blinded thermography + standard foot care) and were followed up monthly until ulcer recurrence or for 12 months. Foot thermograms of participants from the intervention group were assessed for hot spots (areas with temperature >= 2.2 degrees C higher than the corresponding contralateral site) and acted upon as per local standards. Results After 12 months, 62% of participants were ulcer-free in the intervention group and 56% in the control group. The odds ratios of ulcer recurrence (intervention vs control) were 0.82 (95% CI 0.38, 1.8; P = 0.62) and 0.55 (95% CI 0.21, 1.4; P = 0.22) in univariate and multivariate logistic regression analyses, respectively. The hazard ratios for the time to ulcer recurrence (intervention vs control) were 0.84 (95% CI 0.45, 1.6; P = 0.58) and 0.67 (95% CI 0.34, 1.3; P = 0.24) in univariate and multivariate Cox regression analyses, respectively. Conclusions Monthly intervention with thermal imaging did not result in a significant reduction in ulcer recurrence rate or increased ulcer-free survival in this cohort at high risk of foot ulcers. This trial has, however, informed the design of a refined study with longer follow-up and group stratification, further aiming to assess the efficacy of thermography to reduce ulcer recurrence.

Objective: People with diabetic neuropathy who have previously ulcerated are at high risk of re-ulceration. They should regularly attend podiatry clinics for surveillance and routine protective podiatric treatment. It has been suggested that inflammation prior to skin breakdown shows up as a hotspot on a thermal image even in the absence of clinical signs. The aim of this study is to quantify inter-patient and intra-patient thermal variations presented by diabetic feet at high risk of ulceration. Approach: Whole foot and spot temperatures were recorded for 96 patients who attended two successive podiatry appointments without ulceration 28 [28, 31] days apart, median [interquartile range]. This was a part of a longer study into whether thermal imaging in clinic can reduce the rate of re-ulceration. Main results: The variation in spot temperature right/left differences for single patients between visits was comparable to the variation observed between patients (0.8 [0.3, 1.5] °C compared with 0.9 [0.4, 1.7] °C). Similarly, whole foot temperature variation for a single patient between visits was comparable to the variation observed between patients (0.6 [0.2, 1.1] °C compared with 0.8 [0.2, 1.3] °C). Significance: Thresholds which depend on thermal differences from visit to visit are unlikely to have sufficient specificity to effectively target treatment designed to prevent the development of foot ulcers.

Since the advent of reliable mercury-in-glass thermometers in the latter part of the 19th century the practice of clinical thermometry was thought to be a solved issue. However with advances in technology there has, in recent decades, been a proliferation of temperature measurement methods applied to medical science. Many of these have been introduced because of the clinical benefit they confer, nevertheless, in some cases the metrological foundation and infrastructure to ensure sound measurement was not in place. This paper will focus on the standardisation activity undertaken by the UK’s National Physical Laboratory (NPL) to support reliable temperature measurement, using a number of innovative methods, in a clinical setting.

Non-contact infra-red skin thermometers (NCITs) are becoming more prevalent for use in medical diagnostics. Not only are they used as an alternative means of estimating core body temperature but also to assess the diabetic foot for signs of inflammation prior to ulceration. Previous investigations have compared the performance of NCITs in a clinical setting against other gold standard methods. However, there have been no previous investigations comparing the performance of NCITs in assessing temperature measurement capability traceable to the International Temperature Scale of 1990 (ITS-90). A metrological assessment of nine common NCITs was carried out over the temperature range of 15-45 °C using the National Physical Laboratory's blackbody reference sources to identify their accuracy, repeatability, size-of-source and distance effects. The results are concerning in that five of the NCITs fell far outside the accuracy range stated by their manufacturers as well as the medical standard to which the NCITs are supposed to adhere. Furthermore, a 6 °C step change in measurement error over the temperature range of interest for the diabetic foot was found for one NCIT. These results have implications for all clinicians using NCITs for temperature measurement and demonstrate the need for traceable calibration to ITS-90.

Thermal imaging is a useful modality for identifying preulcerative lesions (“hot spots”) in diabetic foot patients. Despite its recognised potential, at present, there is no readily available instrument for routine podiatric assessment of patients at risk. To address this need, a novel thermal imaging system was recently developed. This paper reports the reliability of this device for temperature assessment of healthy feet.

Quantitative thermal imaging has the potential of reliable temperature measurement across an entire field-ofview. This non-invasive technique has applications in aerospace, manufacturing and process control. However, robust temperature measurement on the sub-millimetre (30 mu m) length scale has yet to be demonstrated. Here, the temperature performance and size-of-source (source size) effect of a 3-5 mu m thermal imaging system have been assessed. In addition a technique of quantifying thermal imager non-uniformity is described. An uncertainty budget is constructed, which describes a measurement uncertainty of 640 mK(k = 2) for a target with a size of 10 mm. The results of this study provide a foundation for developing the capability for confident quantitative sub-millimetre thermal imaging.

Thirty participants with healthy feet were imaged in the same way on two separate occasions (an average of 4 weeks apart). Overall, feet were found to be thermally symmetric although absolute temperature could vary considerably between visits. Temperature differences at specific sites on the foot sometimes exceeded the threshold of 2.2 degrees C regarded as clinically significant when looking for evidence of inflammation prior to skin breakdown in diabetes. At least one site exceeded this threshold in nine (30%) participants (the same figure for both visits). However, when looking for significant thermal asymmetry it is important to rule out transient changes by repeated imaging and to refer to baseline images.

In this paper a description is given of the development, characterisation and first results of a thermal imaging device aimed at significantly reducing the incidence of diabetic foot ulceration (DFU). These devices will be used in three clinical centres and in two preliminary clinical trials. The first will be on healthy volunteers to set a robust baseline for the overall research aims and the second on  >100 patients at high risk of DFU. In the second phase of the project the objective is to demonstrate significant reduction in the incidence of DFU through a comparison of the results of standard care of high risk feet with standard care plus thermal imaging.

The eutectic alloys rhenium-carbon, platinum-carbon and cobalt-carbon have been proposed as reference standards for thermometry, with temperature and uncertainty values specified within the mise en pratique of the definition of the kelvin. These alloys have been investigated in a collaboration of eleven national measurement institutes and laboratories. Published results reported the point-of-inflection in the melting curve with extremely low uncertainties. However, to be considered as standards it is necessary to stipulate what phenomenon a temperature value has been ascribed to; specifically, this should be a thermodynamic state. Therefore, the data have been further evaluated and the equilibrium liquidus temperatures determined based on a consideration of limits and assuming a rectangular probability distribution. The values are: for rhenium-carbon 2747.91 +/- 0.44 K, for platinum-carbon 2011.50 +/- 0.22 K and for cobalt-carbon 1597.48 +/- 0.14 K, with uncertainties at approximately a 95% coverage probability. It is proposed that these values could be used as the basis of thermodynamic temperature measurement at high temperatures (above 1300 K).

The thermodynamic temperature of the point of inflection of the melting transition of Re-C, Pt-C and Co-C eutectics has been determined to be 2747.84 ± 0.35 K, 2011.43 ± 0.18 K and 1597.39 ± 0.13 K, respectively, and the thermodynamic temperature of the freezing transition of Cu has been determined to be 1357.80 ± 0.08 K, where the ± symbol represents 95% coverage. These results are the best consensus estimates obtained from measurements made using various spectroradiometric primary thermometry techniques by nine different national metrology institutes. The good agreement between the institutes suggests that spectroradiometric thermometry techniques are sufficiently mature (at least in those institutes) to allow the direct realization of thermodynamic temperature above 1234 K (rather than the use of a temperature scale) and that metal-carbon eutectics can be used as high-temperature fixed points for thermodynamic temperature dissemination. The results directly support the developing mise en pratique for the definition of the kelvin to include direct measurement of thermodynamic temperature.

Early identification of areas of inflammation may aid prevention of diabetic foot ulcers. A new bespoke thermal camera system has been developed to thermally image feet at risk. Hotspots (areas at least 2.2 °C hotter than the contralateral site) may indicate areas of inflammation prior to any apparent visual signs. This article describes the thermal pattern and symmetry of 103 healthy pairs of feet. 68% of participants were thermally symmetric at the 33 foot sites measured. 32% of participants had at least one hotspot, but hotspots overall only accounted for 5% of the measurements made. Refinements to the definition of hotspots are proposed when considering feet at risk of ulceration.

The number of thermal imagers being used for absolute temperature measurement in industry has increased dramatically in the past few years. Due to this it is vital that we have a greater understanding of the performance and limitations of thermal imagers for manufacturing, design and calibration purposes, in particular for applications where they are being used for quantitative temperature measurements. A metrological assessment of six thermal imagers was carried out over their full temperature range using the National Physical Laboratory (NPL) high performance standard blackbody reference sources to identify their accuracy and repeatability. The size-of-source effect, temperature drift due to warm up, image non-uniformity, effects of ambient temperature changes and distance effects were also investigated. Results show that temperature errors for five out of the six imagers fell outside of the manufacturers’ stated uncertainty at a distance of 1.0 m from the blackbody reference source. Additionally, a number of the imagers showed poor performance with regard to image non-uniformity, drift, size of source and distance effects. This has implications when the imagers are used for in situations where accurate temperature measurements or temperature differences are required.

This study forms part of the European Metrology Research Programme project implementing the New Kelvin to assign thermodynamic temperatures to a selected set of high-temperature fixed points (HTFPs), Cu, Co–C, Pt–C, and Re–C. A realistic thermal model of these HTFPs, developed in finite volume software ANSYS FLUENT, was constructed to quantify the uncertainty associated with the temperature drop across the back wall of the cell. In addition, the widely applied software package, STEEP3 was used to investigate the influence of cell emissivity. The temperature drop, \(\Delta T\), relates to the temperature difference due to the net loss of heat from the aperture of the cavity between the back wall of the cavity, viewed by the thermometer, defining the radiance temperature, and the solid–liquid interface of the alloy, defining the transition temperature of the HTFP. The actual value of \(\Delta T\) can be used either as a correction (with associated uncertainty) to thermodynamic temperature evaluations of HTFPs, or as an uncertainty contribution to the overall estimated uncertainty. In addition, the effect of a range of furnace temperature profiles on the temperature drop was calculated and found to be negligible for Cu, Co–C, and Pt–C and small only for Re–C. The effective isothermal emissivity \((\varepsilon _{\mathrm{eff}})\) is calculated over the wavelength range from 450 nm to 850 nm for different assumed values of surface emissivity. Even when furnace temperature profiles are taken into account, the estimated emissivities change only slightly from the effective isothermal emissivity of the bare cell. These emissivity calculations are used to estimate the uncertainty in the temperature assignment due to the uncertainty in the emissivity of the blackbody.