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Pereira MG, Vilaça M, Braga D, Madureira A, Da Silva J, Santos D, Carvalho E. Healing profiles in patients with a chronic diabetic foot ulcer: An exploratory study with machine learning. Wound Repair Regen 2023; 31:793-803. [PMID: 38073283 DOI: 10.1111/wrr.13141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 12/26/2023]
Abstract
Diabetic foot ulcers (DFU) are one of the most frequent and debilitating complications of diabetes. DFU wound healing is a highly complex process, resulting in significant medical, economic and social challenges. Therefore, early identification of patients with a high-risk profile would be important to adequate treatment and more successful health outcomes. This study explores risk assessment profiles for DFU healing and healing prognosis, using machine learning predictive approaches and decision tree algorithms. Patients were evaluated at baseline (T0; N = 158) and 2 months later (T1; N = 108) on sociodemographic, clinical, biochemical and psychological variables. The performance evaluation of the models comprised F1-score, accuracy, precision and recall. Only profiles with F1-score >0.7 were selected for analysis. According to the two profiles generated for DFU healing, the most important predictive factors were illness representations on T1 IPQ-B (IPQ-B ≤ 9.5 and < 10.5) and the DFU duration (≤ 13 weeks). The two predictive models for DFU healing prognosis suggest that biochemical factors are the best predictors of a favorable healing prognosis, namely IL-6, microRNA-146a-5p and PECAM-1 at T0 and angiopoietin-2 at T1. Illness perception at T0 (IPQ-B ≤ 39.5) also emerged as a relevant predictor for healing prognosis. The results emphasize the importance of DFU duration, illness perception and biochemical markers as predictors of healing in chronic DFUs. Future research is needed to confirm and test the obtained predictive models.
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Haris F, Jan YK, Liau BY, Hsieh CW, Shen WC, Tai CC, Shih YH, Lung CW. The effects of different inner pressures of air insoles and walking durations on peak plantar pressure. Medicine (Baltimore) 2023; 102:e35704. [PMID: 37904356 PMCID: PMC10615489 DOI: 10.1097/md.0000000000035704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/28/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Exercise reduces chronic complications in individuals with diabetes and peripheral vascular diseases. In clinical practice, the use of air insole may reduce peak plantar pressure (PPP), and risk for diabetic foot ulcers (DFUs). However, there is no guideline on selecting air insole pressure for effectively reducing PPP. Therefore, this study aimed to investigate the effects of different air insole pressure on PPP at different walking durations. METHODS We tested 13 participants using repeated measures study design, including 3 air insole pressures (80, 160, and 240 mm Hg) and 2 walking durations (10 and 20 minutes) for 6 walking conditions. PPP values at the first toe, first metatarsal head, and second metatarsal head were calculated. RESULTS The one-way ANOVA showed significant pairwise differences of PPP at 20 minutes duration in the first metatarsal head between 80 and 240 mm Hg (P = .007) and between 160 and 240 mm Hg (P = .038); in the second metatarsal head between 80 and 240 mm Hg (P = .043). The paired t test confirmed that walking duration significantly has lower PPP at 10 minutes than 20 minutes with 240 mm Hg air insole in the first metatarsal head (P = .012) and the second metatarsal head (P = .027). CONCLUSION People at risk of foot ulcers are suggested to wear shoes with 80 mm Hg of air insole for reducing PPP in the first metatarsal head and the second metatarsal head. Moreover, people may avoid wearing the stiffer insole (240 mm Hg) for more than 20 minutes.
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Meloni M, Bellia A, Giurato L, Andreadi A, Uccioli L, Lauro D. Response to the letter of Tariq and colleagues on the paper "below‑the‑ankle arterial disease: a new marker of coronary artery disease in patients with diabetes and foot ulcers". Acta Diabetol 2023; 60:1417-1418. [PMID: 37368026 DOI: 10.1007/s00592-023-02134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023]
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Zhang H, Huang C, Bai J, Wang J. Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis. Int Wound J 2023; 20:3035-3047. [PMID: 37095728 PMCID: PMC10502264 DOI: 10.1111/iwj.14179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/26/2023] Open
Abstract
A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.
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Tariq UB, Kumar S. Response to "Below‑the‑ankle arterial disease: a new marker of coronary artery disease in patients with diabetes and foot ulcers". Acta Diabetol 2023; 60:1419-1420. [PMID: 37462765 DOI: 10.1007/s00592-023-02153-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/02/2023] [Indexed: 08/23/2023]
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Jongebloed-Westra M, Exterkate SH, van Netten JJ, Kappert KDR, Koffijberg H, Bode C, van Gemert-Pijnen JEWC, Ten Klooster PM. The effectiveness of motivational interviewing on adherence to wearing orthopedic shoes in people with diabetes at low-to-high risk of foot ulceration: A multicenter cluster-randomized controlled trial. Diabetes Res Clin Pract 2023; 204:110903. [PMID: 37704109 DOI: 10.1016/j.diabres.2023.110903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/25/2023] [Accepted: 09/11/2023] [Indexed: 09/15/2023]
Abstract
AIM To evaluate the effectiveness of motivational interviewing (MI) performed by MI-trained podiatrists in improving adherence to wearing orthopedic shoes in comparison to usual care in people with diabetes at low-to-high risk of ulceration. METHODS People with diabetes with loss of protective sensation and/or peripheral artery disease, and with orthopedic shoes prescription were allocated to receive one MI-consultation by a podiatrist randomized to MI training (n = 53) or usual care only (n = 68). Adherence was measured as the percentage of steps taken while wearing orthopedic shoes, determined using an insole temperature microsensor and wrist-worn activity tracker during one week at 3 and 6 months. RESULTS The proportion of participants ≥80 % adherent to wearing their orthopedic shoes was higher in the control group than in the MI-intervention group at 3 months (30.9 % versus 15.1 %; p = 0.044), and not significantly different at 6 months (22.1 % versus 13.2 %; p = 0.210). Average adherence was also higher in the control group than the intervention group at both 3 months (60.9 % versus 50.9 %; p = 0.029) and 6 months (59.9 % versus 49.5 %; p = 0.025). CONCLUSIONS One podiatrist-led MI-consultation in its current form did not result in higher adherence to wearing orthopedic shoes in people with diabetes 3 and 6 months after inclusion. TRIAL REGISTRATION Netherlands Trial Register NL7710 (available on the International Clinical Trials Registry Platform).
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Li X, Kou S, Chen G, Zhao B, Xue J, Ding R, Zhao X, Ye M, Yang Y, Yue R, Li F. The relationship between vitamin D deficiency and diabetic foot ulcer: A meta-analysis. Int Wound J 2023; 20:3015-3022. [PMID: 37194326 PMCID: PMC10502267 DOI: 10.1111/iwj.14177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/18/2023] Open
Abstract
A meta-analysis investigation to measure the relationship between vitamin D deficiency (VDD) and diabetic foot ulcer (DFU). A comprehensive literature inspection till February 2023 was applied and 1765 interrelated investigations were reviewed. The 15 chosen investigations enclosed 2648 individuals with diabetes mellitus in the chosen investigations' starting point, 1413 of them were with DFUs, and 1235 were without DFUs. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the relationship between VDD and DFU by the dichotomous and continuous approaches and a fixed or random model. Individuals with DFUs had significantly lower vitamin D levels (VDL) (MD, -7.14; 95% CI, -8.83 to -5.44, P < 0.001) compared to those without DFU individuals. Individuals with DFUs had a significantly higher number of VDD individuals (OR, 2.27; 95% CI, 1.63-3.16, P < 0.001) compared to those without DFU individuals. Individuals with DFU had significantly lower VDL and a significantly higher number of VDD individuals compared to those without DFU individuals. However, caused of the small sample sizes of several chosen investigations for this meta-analysis, care must be exercised when dealing with its values.
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Zima J, Jairath N. Enhancing Self-Management Skills of Patients With Existing Diabetic Foot Ulcerations: A Quality Improvement Project. J Wound Ostomy Continence Nurs 2023; 50:413-419. [PMID: 37713353 DOI: 10.1097/won.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
PURPOSE The purpose of this quality improvement initiative was to determine the impact of a nurse-administered foot care intervention bundle (NA-FCIB) upon self-management knowledge, skills, and outcomes in patients with diabetic foot ulcerations. PARTICIPANTS AND SETTING The sample comprised 39 patients being treated for diabetic foot ulceration at a wound care clinic in a tertiary care hospital in Arlington, Virginia. The project was conducted from August 2017 to February 2018. APPROACH This quality improvement project used the Johns Hopkins Plan-Do-Study-Act Method supplemented by self-regulation theory for diabetic patient education and evidence in clinical literature. The 12-week-long intervention included one-on-one teaching in the prevention of ulcerations and optimal care of the diabetic foot, blood glucose level tracking logs, patient "teach-back" and skills demonstration, and free foot care tools. OUTCOMES From baseline to post-NA-FCIB, the number of participants knowing the reasons for temperature foot protection increased by 92%, those knowing major factors leading to diabetic foot ulceration by 85%, those knowing what to look for in the foot self-exam by 85%, and those able to demonstrate correct foot self-exam by 84%. The number of participants understanding proper footwear increased by 74%, and those identifying ways to avoid/decrease the likelihood of diabetic foot ulcers by 72%. Mean serum hemoglobin A1c (HgbA1c) levels decreased from baseline to postintervention (8.27%; SD 2.05% vs 7.46%; SD 1.58%; P = .002). IMPLICATIONS FOR PRACTICE The NA-FCIB intervention was successfully incorporated into routine clinic care as the standard of care. Our experience suggests that the NA-FCIB may be feasible and effective for use at comparable wound care clinics and may have secondary benefits for HgbA1c regulation.
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Halschou-Jensen PM, Sauer J, Bouchelouche P, Fabrin J, Brorson S, Ohrt-Nissen S. Improved Healing of Diabetic Foot Ulcers After High-dose Vitamin D: A Randomized Double-blinded Clinical Trial. INT J LOW EXTR WOUND 2023; 22:466-474. [PMID: 34213957 DOI: 10.1177/15347346211020268] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. Chronic foot ulcers are a major cause of morbidity in people with diabetes with a lifetime risk of 25%. Treatment is challenging and the recurrence rates of foot ulcers are >50% after 3 years. Vitamin D deficiency is more common in people with diabetes with chronic foot ulcers, compared to both people without diabetes as well as people with diabetes but without foot ulcers. Purpose/aim of study. To assess the efficacy of high-dose compared to low-dose Cholecalciferol vitamin D3 on healing of chronic diabetic foot ulcers. Materials and methods. We included people with diabetes with one or more foot ulcers lasting for more than 6 weeks. Patients were randomly allocated to either a daily oral intake of high-dose (170 μg) or low-dose (20 μg) vitamin D3 (Cholecalciferol). We saw patients in the outpatient clinic after 4, 12, 24, 36, and 48 weeks. At each visit, we measured the ulcer with a specialized camera, and associated software and the area (cm2) was calculated. Patients and assessors were blinded to treatment allocation. We followed all patients for 48 weeks or until wound healing or surgical treatment. Findings/results. We included 48 patients in the analysis (24 in each group), with a total of 64 ulcers. Among them 41 ulcers were followed until healing or 48-week follow-up and 20 ulcers were surgically treated during the study period. Three patients were lost for follow-up. The intention-to-treat analysis showed a significantly higher rate of ulcer healing in the high-dose group with 21 of 30 (70%) healed ulcers compared to 12 of 34 (35%) in the low-dose group (P = .012). Median ulcer reduction at final follow-up was 100% (interquartile range [IQR]: 72-100) in the high-dose group and 57% (IQR: -28 to 100) in the low-dose group. Furthermore, we found a significant effect of high-dose vitamin D on ulcer reduction in the repeated measures analysis of variance. Conclusions. We found high-dose vitamin D3 to be efficient, compared to low-dose vitamin D3, in promoting healing in chronic diabetic foot ulcers.
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Enhancing Self-Management Skills of Patients With Existing Diabetic Foot Ulcerations: A Quality Improvement Project. J Wound Ostomy Continence Nurs 2023; 50:E9. [PMID: 37713354 DOI: 10.1097/won.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
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Naemi R, Balasubramanian G, Darvel T, Chockalingam N. Predicting diabetic foot ulceration using routinely collected data in a foot clinic. What level of prognostic accuracy can be achieved? Diabetes Metab Res Rev 2023; 39:e3674. [PMID: 37350019 DOI: 10.1002/dmrr.3674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/26/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Abstract
This study aimed to investigate the efficacy of using routinely collected clinical data in predicting the risk of diabetic foot ulcer (DFU). The first objective was to develop a prognostic model based on the most important risk factors objectively selected from a set of 39 clinical measures. The second objective was to compare the prediction accuracy of the developed model against that of a model based on only the 3 risk factors that were suggested in the systematic review and meta-analyses study (PODUS). In a cohort study, a set of 12 continuous and 27 categorical data from patients (n = 203 M/F:99/104) who attended a specialised diabetic foot clinic were collected at baseline. These patients were then followed-up for 24 months during which 24 (M/F:17/7) patients had DFU. Multivariate logistic regression was used to develop a prognostic model using the identified risk factors that achieved p < 0.2 based on univariate logistic regression. The final prognostic model included 4 risk factors (Adjusted-OR [95% CI]; p) in total. Impaired sensation (116.082 [12.06-1117.287]; p = 0.000) and presence of callus (6.257 [1.312-29.836]; p = 0.021) were significant (p < 0.05), while having dry skin (5.497 [0.866-34.89]; p = 0.071) and Onychomycosis (6.386 [0.856-47.670]; p = 0.071) that stayed in the model were not significant. The accuracy of the model with these 4 risk factors was 92.3%, where sensitivity and specificity were 78.9%, and 94.0% respectively. The 78.9% sensitivity of our prognostic 4-risk factor model was superior to the 50% sensitivity that was achieved when the three risk factors proposed by PODUS were used. Also our proposed model based on the above 4 risk factors showed to predict the DFU with higher overall prognostic accuracy. These findings have implications for developing prognostic models and clinical prediction rules in specific patient populations to more accurately predict DFU.
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Yip K, Yip Y, Tsui W. Thoughts and experiences regarding leg amputation among patients with diabetic foot ulcers: A phenomenological study. Int Wound J 2023; 20:2159-2168. [PMID: 36718017 PMCID: PMC10333000 DOI: 10.1111/iwj.14094] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/07/2023] [Indexed: 02/01/2023] Open
Abstract
Despite lower-limb amputation being common among patients with diabetic foot ulcers, few studies have qualitatively investigated the patients' perspectives. Therefore, this study aimed to explore the thoughts and experiences of patients with diabetic foot ulcers regarding lower-limb amputation in Hong Kong. A phenomenological study using individual, semi-structured interviews was conducted with 18 participants with foot ulcers recruited in Hong Kong between July and September 2022. The interviews were audio-recorded, transcribed verbatim, and analysed using an interpretative phenomenological approach and a constant comparison strategy. The results highlighted four substantial themes: (a) coping or being alone and taciturn, (b) altered appearance impacting one's sense of maintaining social relations, (c) thoughts about self-efficacy and encountering a new normal, and (d) the possibility of a reduced gap in physical consequences between the old and new self. This study provided different perspectives of patients with a history of diabetic foot ulcers, even in cases where lower-limb amputation has not yet been performed. The results demonstrate that lower-limb amputation is considered a forbidden topic. This makes it culturally difficult for Chinese patients to discuss the matter with healthcare authorities and family members. Healthcare workers should be aware of how they communicate regarding lower-limb amputation.
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Ferreira G, Faria S, Carvalho A, Pereira MG. Relaxation intervention to improve diabetic foot ulcer healing: Results from a pilot randomized controlled study. Wound Repair Regen 2023; 31:528-541. [PMID: 37078427 DOI: 10.1111/wrr.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
This pilot randomised controlled study (RCT) aimed to assess the feasibility and acceptability of a progressive muscle relaxation with guided imagery intervention (experimental group [EG]) compared to a neutral guided imagery placebo (active control group [ACG]) and standard care to diabetic foot ulcer [DFU] treatment (passive control group [PCG]), to decide on the need for a definitive RCT. Diabetic foot patients with one or two chronic DFU and significant levels of stress/anxiety/depression were recruited and assessed during a period of 6 months, at three moments. Primary outcomes: feasibility rates and satisfaction with relaxation sessions. Secondary outcomes: DFU healing score, DFU-related quality of life (DFUQoL), physical and mental HRQoL, stress and emotional distress, DFU representations, arterial blood pressure, and heart rate. A total of 146 patients completed the baseline (T0) assessment with 54 participants presenting significant distress being randomised into three groups. Patients were assessed 2 months post-intervention (T1) and 4 months after T1 (T2). Feasibility rates showed reduced values on eligibility, recruitment and inclusion in the study, although with an acceptable rate of refusal lower than 10%. On average, participants reported being satisfied with relaxation sessions and recommended them to other patients. Differences between groups showed that, at T1, PCG participants reported higher levels of stress than those from EG and ACG. Within-group differences showed improvements in stress, distress, DFUQoL and DFU extent over time only in EG and ACG. Only EG showed significant changes in DFU representations at T1. The results suggest that relaxation may be a promising coping strategy to deal with DFU distress and an important adjuvant therapy for DFU healing, supporting the implementation of a definitive RCT.
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Vijaya Raghavan J, Ksheera Sagar S, Dorai VK, Samuel R, Arunachalam P, Chaluvanarayana HC, Belahalli P, Kalpana SR, Jhunjhunwala S. Cholesterol Levels and Monocyte Phenotype Are Predictors of Nonhealing in Individuals with Low-Grade Diabetic Foot Ulcers: A Prospective Cohort Study. Adv Wound Care (New Rochelle) 2023; 12:316-326. [PMID: 35651281 DOI: 10.1089/wound.2021.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective: Inflammation has been linked to progression of diabetic foot ulcers (DFU); however, specific predictive markers of nonhealing are scarce. The goal of this study was to identify biochemical and immunological parameters from the blood as predictors of nonhealing in grade 1 and grade 2 DFU. Approach: Individuals with low-grade foot ulcers were enrolled in the study to determine if histopathological, biochemical, and immunological parameters could be used to predict individuals whose ulcers would not heal. Data analysis was performed using traditional univariate analyses as well as univariate and multivariable logistic regression, and STROBE guidelines were used for reporting data. Results: Among the 52 individuals who completed the study, we observe that no single histopathological and biochemical parameter was predictive. Conventional univariate analysis and univariate logistic regression analysis showed that the expression of the cell surface proteins CD63, HLA-DR, and CD11b on monocytes was significantly lower in nonhealed individuals, but with moderate discriminative ability. In comparison, a multivariable logistic regression model identified four of the 31 parameters to be salient predictors with low density lipoprotein (LDL) cholesterol (odds ratio [OR] 18.83, confidence interval [CI] 18.83-342) and cell-surface expression of CD63 on monocytes (OR 0.12, CI 0.12-0.45) showing significance and demonstrating high discrimination ability. Innovation: The approach of using a combination of biochemical and immunological parameters to predict ulcer healing is new. Conclusion: Through this study we conclude that LDL cholesterol and cell-surface expression of CD63 on monocytes strongly correlate with nonhealing in individuals with grade 1 and grade 2 DFU.
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Ferreira G, Bernardo AC, Carvalho A, Pereira MG. Relax to Heal? Perspectives of Patients with Diabetic Foot Ulcers and Health Professionals on Relaxation Sessions for Wound Healing. Adv Skin Wound Care 2023; 36:1-10. [PMID: 37017401 DOI: 10.1097/01.asw.0000922832.62539.a3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVE To explore patients' and healthcare professionals' (HPs') perspectives on the suitability/acceptability of a relaxation intervention, its effects on patients' well-being and diabetic foot ulcer (DFU) healing, and its incorporation into the multidisciplinary management of patients with diabetic foot. METHODS This qualitative study was nested within a three-arm pilot randomized controlled trial. Patients with a chronic DFU received four relaxation sessions. Investigators then interviewed patients, physicians, and nurses involved with diabetic foot consultations. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis. RESULTS Five themes emerged from patient's interviews about the suitability/acceptability of the relaxation intervention: perceptions regarding the psychological intervention, distress, the relaxation technique, changes in the patient's life, and changes in DFU/contribution to healing. Three themes emerged from interviews with HPs: perceptions regarding relaxation, changes in the patient, and changes in DFU/healing. Regarding the feasibility of the relaxation intervention, three themes emerged for both patients and HPs: suggested modifications, stressors/difficulties, and impact of COVID-19 pandemic. The utility theme emerged only in HP interviews, with subthemes of patients' distress, psychological interventions, relaxation intervention, and integration of the psychologist in the team. CONCLUSIONS These findings provide evidence for the suitability/acceptability, feasibility, and utility of a relaxation intervention in diabetic foot consultations.
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Feron F, Amouyal C, Hartemann A, Van GH, Bourron O, Dierick-Gallet A, Michaux C, Santos MD, Baudot M, Devaux G, Taboureau O, Andreelli F. The short-term prognosis of diabetic foot ulceration is independent of nutritional status at admission. J Wound Care 2023; 32:312-317. [PMID: 37094929 DOI: 10.12968/jowc.2023.32.5.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Diabetic foot ulcers are one of the complications of diabetes. Malnutrition is one of the risk factors for wounds but, on the other hand, diabetic foot ulceration may promote malnutrition. In this single-centre retrospective study we evaluated the frequency of malnutrition at first admission and the severity of foot ulceration. We demonstrated that malnutrition at admission correlated with duration of hospitalisation and with death rate rather than with the risk of amputation. Our data challenged the concept that protein-energy deficiency may worsen the prognosis of diabetic foot ulcers. Nevertheless, it is still important to screen nutritional status at baseline and during the follow-up in order to start specific nutritional support therapy as soon as possible in order to reduce morbidity/mortality related to malnutrition.
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Hemmati F, Tafti N, Nourouzi E, Turk SB, Karimi MT, Sharifmoradi K, Kashani RV. Custom-Made Ethyl Vinyl Acetate Insoles with Arch Support Could Improve Static Balance in Diabetic Women with Neuropathic Foot. J Am Podiatr Med Assoc 2023; 113:20-222. [PMID: 37463186 DOI: 10.7547/20-222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Individuals with diabetic neuropathy may experience plantar ulcers and postural instability. Although use of an insole with arch support has the potential to decrease the incidence of plantar ulcers, the choice of proper design and material density concerning postural stability is challenging. The objective of this pilot study was to conduct a preliminary evaluation of the immediate effects of custom-made ethyl vinyl acetate insoles with arch support and Shore A values of 30 or 50 on static balance in patients with diabetes and neuropathic foot/feet. METHODS Ten women with diabetes participated in this study. Static balance was analyzed while in double-limb standing with eyes closed and eyes open and while standing on a dominant limb with eyes open wearing shoes only and wearing shoes and insoles with Shore A values of 30 and 50. RESULTS With insole, the mean values of center of pressure excursions decreased significantly while standing on double limbs with eyes closed. The improvement in static balance was greater while using the insole with greater density; however, the difference was not statistically significant. CONCLUSIONS An insole with arch support made of ethyl vinyl acetate Shore A of 30 and 50, which could decrease plantar pressure concentration, had no negative effect on the static balance of diabetes. Therefore, further research on the long-term effects of such insoles on the static balance of diabetes is suggested.
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Carter MJ, Frykberg RG, Oropallo A, Sen CK, Armstrong DG, Nair HK, Serena TE. Efficacy of Topical Wound Oxygen Therapy in Healing Chronic Diabetic Foot Ulcers: Systematic Review and Meta-Analysis. Adv Wound Care (New Rochelle) 2023; 12:177-186. [PMID: 35593010 PMCID: PMC9885545 DOI: 10.1089/wound.2022.0041] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/13/2022] [Indexed: 02/03/2023] Open
Abstract
Objective: To conduct a systematic review and meta-analysis of recently published randomized controlled trials (RCTs) that employed the use of topical oxygen therapy (TOT) as an adjunct therapy in the treatment of Wagner 1 and 2 diabetic foot ulcers. Approach: Following a literature search of eligible studies from 2010 onward, four RCTs were included. Studies were analyzed for patient and wound characteristics, outcomes, risk of bias, and quality of the evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. A random-effects meta-analysis for complete wound healing was carried out due to statistical heterogeneity of included studies. Results: Risk of bias judgment (RoB2 analysis) resulted in one low-risk trial and three trials with some risk. One study was determined to be the origin of the statistical heterogeneity. Pooled results showed statistical significance with a risk ratio (RR) of 1.59 (95% confidence interval [CI]: 1.07-2.37; p = 0.021). Sensitivity analysis, based on imputed values for missing outcomes, demonstrated that both the RR and 95% CIs changed little. The GRADE ratings for each domain were as follows: (a) risk of bias: moderate (3); (b) imprecision: moderate (2), high (1); (c) inconsistency: low (2), high (1); (d) indirectness: moderate (2), high (1); and (e) publication bias: moderate (1), high (2). Overall, the evidence was moderate. Innovation: Our study shows that TOT is a viable diabetic foot ulcer therapy. Conclusions: These data support the use of TOT for the treatment of chronic Wagner 1 or 2 diabetic foot ulcers in the absence of infection and ischemia.
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Borderie G, Foussard N, Larroumet A, Blanco L, Barbet-Massin MA, Ducos C, Rigo M, Arab LR, Domenge F, Mohammedi K, Ducasse E, Caradu C, Delyfer MN, Korobelnik JF, Rigalleau V. Diabetic retinopathy relates to the incidence of foot ulcers and amputations in type 2 diabetes. Diabetes Metab Res Rev 2023; 39:e3605. [PMID: 36575816 DOI: 10.1002/dmrr.3605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/31/2022] [Accepted: 12/14/2022] [Indexed: 12/29/2022]
Abstract
AIMS We investigated whether Diabetic Retinopathy (DR) is related to Diabetic Foot Ulcer (DFU) development, adjusted for the stratification of the International Work Group on Diabetic Foot (IWGDF) guidance. MATERIALS AND METHODS DR and IWGDF stratification was registered retrospectively in patients hospitalised from 2009 to 2017 for uncontrolled and/or complicated type 2 diabetes. New DFUs were registered until 2020. Survival analyses categorised the subjects for DR, and multivariate Cox regression adjusted for confounders. RESULTS The 522 patients (57.9% male) were 62 ± 9 years old with a diabetes duration of 14 ± 10 years, HbA1c of 8.7 ± 1.8%, 33.9% macroangiopathies and 44.8% diabetic kidney diseases. Their grades of DFU risk were 0 for 43.3%, 1 for 23.9%, 2 for 7.1%, and 3 for 25.6%. During the 52 months follow-up (Inter Quartile Range: 32-71), 58 new DFUs and 18 lower-limb amputations occurred, mostly in patients with DR present in 140 (26.8%) patients. Adjusted for age, sex and conventional risk factors (duration and control of diabetes, arterial hypertension, and dyslipidemia), and other complications (macroangiopathy and diabetic kidney disease), DR was associated with a greater incidence of DFUs. Adjusted for the IWGDF classification, DR was related to new DFUs (HR: 2.51, 95%Confidence Interval [CI]: 1.48-4.26) and amputations (HR: 3.56, 95%CI: 1.26-10.07). This relationship persisted in ascending IWGDF grades with incidences of DFUs from 2/1000 (grade 0, no DR) to 121/1000 patient-years (grade 3 and DR) and amputations from 0 (grade 0, no DR) to 38/1000 patient-years (grade 3 and DR). CONCLUSIONS Diabetic retinopathy independently relates to the incidence of foot ulcers and amputations in patients hospitalised for type 2 diabetes.
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Vanherwegen AS, Lauwers P, Lavens A, Doggen K, Dirinck E. Sex differences in diabetic foot ulcer severity and outcome in Belgium. PLoS One 2023; 18:e0281886. [PMID: 36795662 PMCID: PMC9934352 DOI: 10.1371/journal.pone.0281886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/02/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Sex differences are increasingly recognized to play an important role in the epidemiology, treatment and outcomes of many diseases. This study aims to describe differences between sexes in patient characteristics, ulcer severity and outcome after 6 months in individuals with a diabetic foot ulcer (DFU). METHODS A total of 1,771 patients with moderate to severe DFU participated in a national prospective, multicenter cohort study. Data were collected on demographics, medical history, current DFU and outcome. For data analysis, a Generalized Estimating Equation model and an adjusted Cox proportional hazards regression were used. RESULTS The vast majority of patients included were male (72%). Ulcers in men were deeper, more frequently displaying probe to bone, and more frequently deeply infected. Twice as many men presented with systemic infection as women. Men demonstrated a higher prevalence of previous lower limb revascularization, while women presented more frequently with renal insufficiency. Smoking was more common in men than in women. No differences in presentation delay were observed. In the Cox regression analysis, women had a 26% higher chance of healing without major amputation as a first event (hazard ratio 1.258 (95% confidence interval 1.048-1.509)). CONCLUSIONS Men presented with more severe DFU than women, although no increase in presentation delay was observed. Moreover, female sex was significantly associated with a higher probability of ulcer healing as a first event. Among many possible contributing factors, a worse vascular state associated with a higher rate of (previous) smoking in men stands out.
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Borderie G, Foussard N, Larroumet A, Blanco L, Domenge F, Mohammedi K, Ducasse E, Caradu C, Rigalleau V. Albuminuric diabetic kidney disease predicts foot ulcers in type 2 diabetes. J Diabetes Complications 2023; 37:108403. [PMID: 36641879 DOI: 10.1016/j.jdiacomp.2023.108403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/24/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
Diabetic Foot Ulcers (DFU) are feared among individuals with diabetic kidney disease (DKD), but it is unclear whether they are more frequent, especially in normoalbuminuric DKD. Five hundred and twenty patients admitted in our diabetology ward from 2007 to 2017 were followed up during 54 ± 26 months. New DFUs were registered, and their relationship with the initial renal status was analyzed by LogRank and multivariate Cox regression analysis. The 520 subjects were mainly men (57.9 %), 62 ± 9 years old, with a duration of diabetes of 14 ± 10 years, HbA1c: 8.7 ± 1.8 % (72 ± 19 mmol/mol), and complications: 33.7 % macroangiopathies, 22.1 % previous foot ulcers, 44.8 % DKD, 26.9 % retinopathies. Fifty-seven new DFU occurred, mainly in subjects with DKD. DKD was related to later DFU (HR: 1.79; 95%CI: 1.05-3.07), this relationship stayed significant adjusted for age, gender, and a history of previous DFU (HR: 3.61; 95%CI: 2.11-6.18), and further adjusted for the duration of diabetes, HbA1c, BMI, arterial hypertension, and dyslipidemia. Among the 233 subjects with DKD, 129 (55.3 %) had an isolated AER > 30 mg/24H, 41 (17.6 %) had an isolated eGFR<60 mL/min/1.73 m2, and 63 (27.0 %) cumulated both abnormalities. By Cox regression analysis adjusted for age and gender, albuminuric DKDs were related to later DFU: with eGFR≥60: HR: 1.91; 95%CI: 1.02-3.59, with eGFR<60: HR: 2.53; 95%CI: 1.25-5.10, whereas normoalbuminuric DKD was not: HR: 1.04; 95%CI: 0.35-3.07, despite similar rates of neuropathies, peripheral arterial diseases, and retinopathies. In people with type 2 diabetes, albuminuric DKD was associated with two to three folds increased risk of DFUs, whereas normoalbuminuric DKD was not.
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Samad Omar A, Ahmad Faiz K, Mir Islam Saeed K, Ahmad Humayoun F, Safi K. Epidemiologic and clinical characteristics of diabetic foot ulcer among patients with diabetes in Afghanistan: An IDF supported initiative. Diabetes Res Clin Pract 2023; 196:110227. [PMID: 36543291 DOI: 10.1016/j.diabres.2022.110227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/04/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Abstract
AIM The aim is to illustrate epidemiological and clinical characteristics of diabetic patients with foot ulcer (DFU) in Kabul diabetic medical center (KDMC), Afghanistan. METHOD It is a descriptive study explaining the characteristics of diabetic patients with DFU admitted to KDMC, between 1/9/2019 to 31/8/2020 which is a center for management of diabetic patients including DFU. The university of Texas diabetic classification for DFU was used. RESULTS Totally 3159 patients admitted to KMDC of whom 47.4% were females and 96.7% type 2 diabetes. The proportion of DFU was 9.2%. The patients' mean age was 55.4 ± 10.6 years and 78% were coming from Kabul. Prevalence of smoking and snuff use were 8.6% and 5.6% respectively. Majority of females 93% were housewives. The duration of diabetes was 5-19 years. Almost two-third were under glycaemia and HbA1c control and 9.2% had history of amputation. The common symptoms were burning, aching, numbness and tingling. The most common cause of DFU was both neuropathy and arteriopathy. After treatment 16% were referred for orthopedic procedures. CONCLUSIONS DFU affects almost one-tenth of diabetics while a significant number of patients attend at late stage requiring orthopedic treatment. Monitoring of diabetic patients to prevent DFU is important is recommended.
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McDermott K, Fang M, Boulton AJ, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care 2023; 46:209-221. [PMID: 36548709 PMCID: PMC9797649 DOI: 10.2337/dci22-0043] [Citation(s) in RCA: 108] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/02/2022] [Indexed: 12/24/2022]
Abstract
Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.
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Zulbaran-Rojas A, Park C, El-Refaei N, Lepow B, Najafi B. Home-Based Electrical Stimulation to Accelerate Wound Healing-A Double-Blinded Randomized Control Trial. J Diabetes Sci Technol 2023; 17:15-24. [PMID: 34328024 PMCID: PMC9846397 DOI: 10.1177/19322968211035128] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Electrical stimulation (E-Stim) may offer a unique adjunctive treatment to heal complicated diabetic foot ulcers (DFU). Our primary goal is to examine the effectiveness of daily home-based E-Stim therapy to speed-up wound healing. METHODS Patients with chronic DFUs and mild to severe peripheral arterial disease (PAD) were recruited and randomized to either control (CG) or intervention (IG) groups. The IG received 1-hour home-based E-Stim therapy on daily basis for 4 weeks (4W). E-Stim was delivered through electrical pads placed above the ankle joint using a bio-electric stimulation technology (BEST®) platform (Tennant Biomodulator® PRO). The CG was provided with an identical but non-functional device for the same period. The primary outcome included wound area reduction at 4W from baseline (BL). RESULTS Thirty-eight patients were recruited and 5 were removed due to non-compliance or infection, leaving 33 participants (IG, n = 16; CG, n =17). At 4W, the IG showed a significant wound area reduction of 22% (BL: 7.4 ± 8.5 cm2 vs 4W: 5.8 ± 8.0 cm2, P = 0.002). Average of wound area was unchanged in the CG (P = 0.982). The self-report adherence to daily home-therapy was 93.9%. CONCLUSIONS Daily home-based E-Stim provides early results on the feasibility, acceptability, and effectiveness of E-Stim as an adjunctive therapy to speed up wound healings in patients with chronic DFU and mild to severe PAD.
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Tehan PE, Burrows T, Hawes MB, Linton C, Norbury K, Peterson B, Walsh A, White D, Chuter VH. Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study. Diabet Med 2023; 40:e14951. [PMID: 36054775 PMCID: PMC10087534 DOI: 10.1111/dme.14951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population. RESEARCH DESIGN AND METHODS This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation. RESULTS A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03). CONCLUSIONS In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.
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