[Culture and metagenomics as bacterial identification methods in patients with diabetic foot ulcers: a systematic review]

BACKGROUND

Diabetic foot osteomyelitis (DFO) is a serious complication of infected ulcers in a diabetic patient. The identification of the infecting microorganisms is generally by culture, which causes a bias. Recently, metagenomics has been used for microbial identification.

AIM

To systematically review the scientific literature related to DFO in the last 10 years to evaluate if culture and metagenomics are complementary.

MATERIAL AND METHODS

To carry out the systematic review, PRISMA and Rayyan were used for the selection of studies, using three databases, using the keywords diabetes, osteomyelitis, culture and microbiome. Articles in English or Spanish were included, containing information related to bacterial identification in DFO. Characteristics of the technique, patients and frequency of bacterial appearance were collected.

RESULTS

Twenty six articles were included, 19 used culture and 7 metagenomics. The patients were predominantly men (68%), with an average age of 61 years, 83% had type 2 diabetes and comorbidities, mainly vascular and neuropathy. The Families with the highest frequency of appearance using the culture technique were Enterobacteriaceae (29.3%) and Staphylococcaceae(28.3%) and with metagenomics Peptoniphilaceae (22.1%) and Staphylococcaceae (9.4%). Peptoniphilaceae were not identified in culture, although they were frequently identified by metagenomics. Methicillin- resistant Staphylococcus aureus, regularly identified by culture, was not identified using metagenomics.

CONCLUSIONS

Comparing results, there is a certain complementarity between microbiological culture and sequencing to identify bacteria present in DFO.

Adherence to a Healthy Lifestyle in Association With Microvascular Complications Among Adults With Type 2 Diabetes

IMPORTANCE

The association between an overall healthy lifestyle and the subsequent risk of microvascular complications among patients with diabetes remains unclear.

OBJECTIVE

To examine the association between adherence to a healthy lifestyle before and after diabetes diagnosis and the risk of subsequent microvascular complications among adults with diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included incident patients with type 2 diabetes who were free of cardiovascular disease and cancer at the time of diabetes diagnosis and completed the diabetes supplementary questionnaires in the Nurses' Health Study (in 2000 and 2005) and the Health Professionals Follow-Up Study (in 2000, 2004, and 2008) in the US. Data were analyzed from April to August 2021.

EXPOSURES

Diet and lifestyle factors before and after diabetes diagnosis were assessed by validated questionnaires. A healthy lifestyle consisted of nonsmoking, having a healthy body weight (a body mass index of ≥18.5 or <25), engaging in moderate-to-vigorous physical activity (≥150 minutes per week), consuming a high-quality diet (top 40th percentile of the Alternative Healthy Eating Index), and moderate alcohol drinking (5-15 g/d for women and 5-30 g/d for men).

MAIN OUTCOMES AND MEASURES

Physician-diagnosed microvascular complications including diabetic neuropathy, retinopathy, nephropathy, and foot disorders were self-reported at questionnaire surveys.

RESULTS

A total of 7077 patients with type 2 diabetes were included in the cohort (4982 women in NHS and 2095 men in HPFS, mean [SD] age 61 [8.8], 94.2% White). During follow-up, 2878 patients developed microvascular complications. After multivariable adjustment, adherence to a healthy lifestyle before and after diabetes diagnosis were both associated with a lower risk of developing microvascular complications. The relative risk (RR) for participants with 4 or more low-risk lifestyle factors before diabetes diagnosis compared with zero was 0.73 (95% CI, 0.60-0.91) for any microvascular complications, 0.71 (95% CI, 0.54-0.93) for diabetic neuropathy, 0.76 (95% CI, 0.57-1.01) for diabetic retinopathy, 0.42 (95% CI, 0.23-0.79) for diabetic nephropathy, and 0.60 (95% CI, 0.35-1.00) for diabetic foot disorders. Similar results were observed for adherence to a healthy lifestyle after diabetes diagnosis, with an RR of 0.68 (95% CI, 0.55-0.83) for any microvascular complications, 0.67 (95% CI, 0.51-0.88) for diabetic neuropathy, 0.65 (95% CI, 0.48-0.86) for diabetic retinopathy, 0.57 (95% CI, 0.34-0.98) for diabetic nephropathy, and 0.62 (95% CI, 0.37-1.05) for diabetic foot disorders. In addition, greater improvement in lifestyle factors from before to after diabetes diagnosis was also significantly associated with a lower risk of neuropathy or total microvascular complications. Each increment in number of low-risk lifestyle factors was associated with a 6% (RR, 0.94; 95% CI, 0.90-0.98) lower risk for any microvascular complications and a 9% (RR, 0.91; 95% CI, 0.86-0.96) lower risk for diabetic neuropathy. Consistent results were observed when analyses were stratified by age at diabetes diagnosis, sex/cohort, or lifestyle factors before diabetes diagnosis.

CONCLUSIONS AND RELEVANCE

In this cohort study, adhering to an overall healthy lifestyle was associated with a significantly lower risk of microvascular complications among individuals with diabetes. These findings suggest substantial reduction in the burden of microvascular complications associated with adopting a healthy lifestyle among patients with type 2 diabetes.

Management patterns and outcomes of patients hospitalized with diabetic foot ulcers at one tertiary care hospital

A diabetic foot ulcer is present in approximately 2.4% of hospitalized patients. Care for diabetic foot ulcers is highly variable. We sought to describe care practice patterns and risk factors for poor outcomes for patients hospitalized with a diabetic foot ulcer in our institution, an 894-bed tertiary care academic hospital located in downtown Chicago, IL. We conducted a retrospective cohort study of patients hospitalized with a diabetic foot ulcer between March 3rd, 2018 and December 31st, 2019. We categorized patients into having an uncomplicated ulcer or a complicated ulcer with cellulitis, wound infection, osteomyelitis, or gangrene. We evaluated rates of diagnostic resource utilization (imaging, cultures, biopsies, and antibiotics) and outcomes of osteomyelitis, amputation, and death. There were 305 patients of interest in the study cohort. A complicated lower extremity ulcer was found in 79% of patients. Amputation was required in 25% of patients, 21% were readmitted, and 13% died. Imaging was obtained in less than 50% of all patients, and in 60% or less of those with osteomyelitis. Bone biopsies were rarely acquired. Empiric antibiotics were prescribed in 77% of patients with osteomyelitis. Male, Black or African-American patients, and those with high Charlson score had the highest risk of poor outcomes. Care practices for patients hospitalized with diabetic foot ulcers were highly variable. Future interventions should target standardization to improve outcomes, with particular attention to health inequities as vulnerable populations have a higher risk of poor outcomes.

[Clinical Characteristics and Prognosis of Diabetic Foot Ulcers Patients of Different Renal Function Statuses]

Objective

To explore the clinical characteristics and the prognosis of diabetic foot ulcers (DFU) inpatients of different renal function statuses.

Methods

A retrospective analysis of 962 inpatients with DFU was conducted. The patients were divided into three groups according to their renal function statuses, and the clinical characteristics of the three groups were compared to identify differences. In addition, the patients were followed up in outpatient clinics or by telephone and their prognostic status and risk factors for death were analyzed.

Results

Analysis of the clinical characteristics showed that, compared with diabetic patients with normal renal function or mild renal function impairment, diabetic patients with moderate and severe renal function impairment had a longer course of disease ( P<0.001). Patients with foot ulcers of Wagner grade 4 predominates the moderate and severe renal function impairment groups ( P<0.05). Patients in the moderate and severe renal function impairment groups had a relatively higher proportion of comorbidities, including hypertension, coronary heart disease, and peripheral arterial disease ( P<0.05). These patients had relatively lower levels of glycosylated hemoglobin and hemoglobin (all P<0.05) and relatively higher levels of neutrophil ratio and procalcitonin (all P<0.05). Of the two groups, patients in the moderate renal function impairment group were older ( P<0.001) and had lower ankle-brachial index ( P<0.001). The severe renal function impairment group had a higher proportion of patients with foot ulcers of Wagner grades 3 and 5 (all P<0.05). For the purpose of conducting prognostic analysis, 748 patients were followed up in outpatient clinics or by telephone for a median length of 41 months. Among them, 239 died. The all-cause mortality was 31.9%, and the mortality in the three groups was 25.8%, 46.2% ( P<0.001), and 59.4% ( P<0.001), respectively. The survival rate of patients in the moderate and severe renal function impairment groups was significantly lower than those in the normal renal function and mild renal function impairment groups ( P<0.001). Univariate Cox regression analysis showed that age, concomitant coronary heart disease and peripheral arterial disease, degree of renal function impairment, and foot ulcers of Wagner grade 4 and 5 were associated with all-cause deaths. Furthermore, multivariate Cox regression analysis showed that moderate and severe renal function impairment was an independent risk factor for all-cause deaths in DFU patients ( P<0.001).

Conclusions

As renal function impairment worsens, patients with DFU present clinical characteristics of greater complexity, higher risks of cardiovascular events, and higher mortality. It is essential to prevent kidney damage and foot ulcers, to pay attention to the cardiovascular risks of DFU patients with moderate and severe renal function impairment, and to reduce mortality.

Bone marrow-derived mesenchymal stem cells: A promising therapeutic option for the treatment of diabetic foot ulcers

Chronic wounds fail to heal through the three normal stages of healing (inflammatory, proliferative, and remodelling), resulting in a chronic tissue injury that is not repaired within the average time limit. Patients suffering from type 1 and type 2 diabetes are prone to develop diabetic foot ulcers (DFUs), which commonly develop into chronic wounds that are non treatable with conventional therapies. DFU develops due to various risk factors, such as peripheral neuropathy, peripheral vascular disease, arterial insufficiency, foot deformities, trauma and impaired resistance to infection. DFUs have gradually become a major problem in the health care system worldwide. In this review, we not only focus on the pathogenesis of DFU but also comprehensively summarize the outcomes of preclinical and clinical studies thus far and the potential therapeutic mechanism of bone marrow-derived mesenchymal stem cells (BMSCs) for the treatment of DFU. Based on the published results, BMSC transplantation can contribute to wound healing through growth factor secretion, anti-inflammation, differentiation into tissue-specific cells, neovascularization, re-epithelialization and angiogenesis in DFUs. Moreover, clinical trials showed that BMSC treatment in patients with diabetic ulcers improved ulcer healing and the ankle-brachial index, ameliorated pain scores, and enhanced claudication walking distances with no reported complications. In conclusion, although BMSC transplantation exhibits promising therapeutic potential in DFU treatment, additional studies should be performed to confirm their efficacy and long-term safety in DFU patients.

Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis

AIMS/HYPOTHESIS

This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020.

METHODS

Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated.

RESULTS

23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men.

CONCLUSIONS

Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.

Diabetic foot infection - diagnosis and treatment

Diabetic foot (DF) is one of the most serious complications of diabetes, leading to high morbidity and mortality in patients with diabetes, significantly affecting their quality of life and placing a huge burden on the healthcare system. Diabetic foot infection (DFI) is a major factor in the non-healing of diabetic ulcerations of the lower limbs, increases the number of hospital admissions, prolongs their duration and is a frequent cause of increased number of amputations. The most serious form of foot infection is osteomyelitis. Management of infection in SDN includes proper diagnosis, including obtaining appropriate specimens for culture, indication of rational antimicrobial therapy or early surgical intervention, and provision of all other necessary wound care and overall patient care to prevent recurrence of DFI.

[Preliminary Application of Contrast-Enhanced Ultrasound in the Treatment of Diabetic Ulcers]

Objective

To investigate the role of contrast-enhanced ultrasound (CEUS) in the treatment of diabetic ulcers.

Methods

The clinical data of 27 diabetic patients, who underwent CEUS examination of their ulcers in our hospital between April 2021 and July 2022 were collected. Among them, 26 patients suffered from diabetic foot ulcers, 5 of whom underwent amputation during hospitalization, and one patient suffered from hip ulcer. The 27 patients' mean age was (64.08±12.57) years. Fasting blood glucose levels of the patients were 3.36-34.61 mmol/L, with a mean of (10.62±8.77) mmol/L. Their glycosylated hemoglobin levels were 5.80%-10.70%, with an average of 7.96%±1.50%. Philips EPIQ7 ultrasound system with L9-3 linear probe of 3-9 MHz was used. First, the patients' ulcers were examined with conventional ultrasound to observe for abnormal echo. Then, 2.4 mL SonoVue (Bracco, Italy), a contrast agent, was injected intravenously through the elbow to look for effusion/pus, sinus tract, or dead space in the lesion area, and images were acquired.

Results

Among the 27 patients, except for 5 with amputation stumps, 22 patients had wound areas ranging from 0.16 cm 2 to 215 cm 2, all being accompanied by sinus tract formation. Ten patients underwent ultrasound examination during their treatment. The positive rate of the results of conventional ultrasound was 50% (5/10) for identifying effusion/pus and pseudoaneurysm in the deep area of ulcers, while the positive rate of CEUS results was 100% (10/10). In addition to the lesions found by conventional ultrasound, CEUS also found large sinus tracts or dead spaces in the deep surface of ulcers in 5 additional patients. Of the 27 patients, 17 underwent ultrasound examination of the healing status of sinus tracts and dead spaces in the deep areas of ulcers before discharge. No sinus tracts in the deep areas of the ulcers were found by conventional ultrasound. However, relatively small dead spaces or sinus tracts in the deep areas of the ulcers were found in 10 patients by CEUS. Conventional ultrasound and CEUS found that 1 patient had a small amount of fluid in the amputation stump. In the remaining 6 patients, no deep sinus tracts in the ulcers were found by either conventional ultrasound or CUES, and the ulcers healed completely.

Conclusion

By examining microvascular perfusion in diabetic wounds with CEUS, we can observe the extent of sinus tracts during treatment and whether the sinus tracts have healed or whether there are still dead spaces before patient discharge, which provides support for clinical decision-making concerning the treatment of diabetic ulcers.

Retrospective study of outcomes of short versus long duration of antibiotic therapy for residual osteomyelitis in surgically resected diabetic foot infection

INTRODUCTION

Optimal treatment duration for residual osteomyelitis (OM) post-amputation in diabetic foot infection (DFI) remains unclear, with resultant heterogeneity in prescribing noted in clinical practice. We aimed to identify a difference in outcomes of long duration of antibiotics (LD) with short duration (SD) in patients with culture-positive proximal bone specimen post-amputation.

METHODS

In this single-centre retrospective cohort study (Melbourne, Australia), we analysed antibiotic duration of DFI patients requiring amputation with culture-positive proximal bone specimen over a 31 month period (January 2019-September 2021). Primary outcome was reamputation or debridement at the same and/or contiguous site of amputation at 6 months. Secondary outcomes were readmission to hospital and/or recommencement of antibiotics for DFI at the same and/or contiguous site at 6 months.

RESULTS

Among 92 patients (83% male, median age 67 years), 26 received <4 weeks (SD) and 66 received ≥4 weeks (LD) antibiotic therapy. In the SD group, primary outcome occurred in 9 patients (35%) compared with 15 patients (23%) in the LD group (P = 0.246). Both secondary outcomes occurred in 12 patients (46%) in the SD group compared with 18 patients (27%) in the LD group (P = 0.086). Adjusted logistic regression analysis showed SD was not significantly associated with primary outcome [OR 1.12 (95% CI 0.38-3.31)] or secondary outcomes [OR 1.67 (95% CI 0.60-4.66)].

CONCLUSIONS

This single-centre experience did not demonstrate significant difference in outcomes between antibiotic duration of <4 weeks and ≥4 weeks in DFI patients with culture-positive proximal bone specimen post-amputation. These data provide background for larger international randomized control trials to establish optimal treatment duration.

Diabetic Foot Complications: A Retrospective Cohort Study

Diabetes mellitus is a highly prevalent disease globally and contributes to significant morbidity and mortality. As a consequence of multiple pathophysiologic changes which are associated with diabetes, these patients frequently suffer from foot-related disorders: infections, ulcerations, and gangrene. Approximately half of all amputations occur in diabetic individuals, usually as a complication of diabetic foot ulcers. In this retrospective study, we analyzed and characterized a cohort of 69 patients and their diabetes-related foot complications. The main characteristics of our cohort were as follows: older age at diagnosis (mean age 66); higher incidence of diabetes in males; predominantly urban patient population. The most frequent complications of the lower extremity were ulcerations and gangrene. Moreover, in our study, 35% of patients required surgical reintervention, and 27% suffered from complications, while 13% required ICU admission. However, diabetic foot lesions are preventable via simple interventions which pointedly reduce foot amputations. Early identification and the appropriate medical and surgical treatment of the complications associated with diabetic foot disease are important because they still remain common, complex and costly.

Distal symmetrical polyneuropathy is present in all individuals with diabetes and foot ulcers - and does not associate with healing time

We estimated the occurrence of diabetic neuropathy using six different diagnostic modalities in individuals with newly diagnosed diabetic foot ulcers (DFUs) and assessed the association with DFU healing time. All individuals with DFU had distal symmetrical polyneuropathy. Presence of neuropathy did not associate with ulcer healing time (p ≥ 0.12).

Surgery without postoperative antibiotic treatment in diabetic foot osteomyelitis is not associated with recurrence or limb loss

Not using antibiotics after surgical treatment of diabetic foot osteomyelitis was not associated with failure of the surgery, recurrences, or limb loss. Antibiotics were given in doubtful complicated cases such as severe infections, cases with necrosis, foul-smelling lesions and patients requiring revascularization.

Indicators of optimal diabetes care and burden of diabetes complications in Africa: a systematic review and meta-analysis

OBJECTIVE

Contemporary data on the attainment of optimal diabetes treatment goals and the burden of diabetes complications in adult populations with type 2 diabetes in Africa are lacking. We aimed to document the current status of attainment of three key indicators of optimal diabetes care and the prevalence of five diabetes complications in adult African populations with type 2 diabetes.

METHODS

We systematically searched Embase, PubMed and the Cochrane library for published studies from January 2000 to December 2020. Included studies reported any information on the proportion of attainment of optimal glycated haemoglobin (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) goals and/or prevalence of five diabetes complications (diabetic peripheral neuropathy, retinopathy, nephropathy, foot ulcers and peripheral arterial disease). Random effect model meta-analysis was performed to determine the pooled proportion of attainment of the three treatment goals and the prevalence of five diabetes complications.

RESULTS

In total, 109 studies with a total of 63 890 participants (53.3% being females) were included in the meta-analysis. Most of the studies were conducted in Eastern African countries (n=44, 40.4%). The pooled proportion of attainment of an optimal HbA1c, BP and LDLC goal was 27% (95% CI 24 to 30, I²=94.7%), 38% (95% CI 30 to 46, I²=98.7%) and 42% (95% CI 32 to 52, I²=97.4%), respectively. The pooled prevalence of diabetic peripheral neuropathy, retinopathy, diabetic nephropathy, peripheral arterial disease and foot ulcers was 38% (95% CI 31 to 45, I²=98.2%), 32% (95% CI 28 to 36, I²=98%), 31% (95% CI 22 to 41, I²=99.3%), 19% (95% CI 12 to 25, I²=98.1%) and 11% (95% CI 9 to 14, I²=97.4%), respectively.

CONCLUSION

Attainment of optimal diabetes treatment goals, especially HbA1c, in adult patients with type 2 diabetes in Africa remains a challenge. Diabetes complications, especially diabetic peripheral neuropathy and retinopathy, are highly prevalent in adult populations with type 2 diabetes in Africa.

[Clinical Characteristics of Diabetic Patients with Initial and Recurrent Foot Ulcers]

Objective

To explore the risk factors for the recurrence of foot ulcers by analyzing clinical characteristics of the patients with diabetic foot ulcers (DFU) in West China Hospital, Sichuan University.

Methods

A retrospective analysis was carried out with the clinical data of 817 DFU patients hospitalized at West China Hospital, Sichuan University between January 1, 2012 and December 31, 2020. The patients were divided into an initial ulceration group (502 cases) and a recurrent ulceration group (315 cases) according to their history of foot ulcers. The differences in clinical characteristics between the two groups were compared, and multivariate logistic regression analysis was conducted to identify the risk factors associated with the recurrence of foot ulcers.

Results

Initial and recurrent DFU patients both had predominantly neuro-ischemic foot ulcers, and the most common sites of ulceration were the first and fifth toes in both groups. Compared with the initial DFU group, more patients in the recurrent group had foot ulcers of Wagner grade 3 and ulcerous wounds located on calluses ( P<0.05), and fewer patients in the recurrent group suffered from foot gangrene ( P<0.05). Patients with recurrent DFU had lower glycated hemoglobin, platelet counts, and fibrinogen levels ( P<0.05), and higher serum uric acid and creatinine levels ( P<0.05). Hemoglobin, white blood cell count, estimated glomerular filtration rate, erythrocyte sedimentation rate and C-reactive protein levels were not significantly different between the two groups ( P>0.05). Multivariable logistic regression analysis showed that male sex ( OR=1.555, 95% CI: 1.097-2.204, P=0.013), duration of diabetes≥10 years ( OR=2.369, 95% CI: 1.473-3.810, P<0.001), history of amputation ( OR=4.518, 95% CI: 2.386-8.553, P<0.001), foot osteoporosis ( OR=1.711, 95% CI: 1.065 to 2.751, P=0.027), ulcerous wound located on foot callus ( OR=1.786, 95% CI: 1.058-3.012, P=0.030), and coronary heart disease ( OR=0.668, 95% CI:0.453-0.987, P=0.043) were significantly associated with the recurrence of foot ulcers.

Conclusions

Male sex, duration of diabetes being over 10 years, history of previous amputation, foot osteoporosis, and ulcerous wounds located on foot callus are independent risk factors of recurrent foot ulcers in patients with DFU. Therefore, even after their foot ulcers have healed, special attention should be given to the care of foot for patients with DFU, which may reduce the recurrence of foot ulcers.

Diabetic foot disease in subjects with End-stage renal Disease: A nationwide study over 14 years highlighting an emerging threat

AIMS

To disclose prevalence, demographic, foot characteristics as well as management and lower-extremity amputations (LEAs) of subjects with end-stage renal disease (ESRD) on diabetic foot diseases (DFDs).

METHODS

Data were derived from the Taiwan National Health Insurance Research Database between 2004 and 2017. DFDs were defined as ulcers, infections, or severe peripheral arterial diseases (PADs) in patients with type 2 diabetes. Clinical characteristics were analyzed between subjects with and without ESRD.

RESULTS

Subjects with ESRD have increased impacts on the DFD population either from annual prevalence (2.7 % to 10.42 %, P for trend < 0.001), or proportional representation in LEAs (7.91 % to 26.37 %, P < 0.001) over 14 years. The annual trends for major-LEAs rates have decreased in both subjects with and without ESRD (13.67 % to 5.82 % and 3.48 % to 1.47 %, both P < 0.001). Notably, the concomitant increase of endovascular treatments (EVTs) (7.09 % to 29.41 %, P < 0.001) was associated with the decrease of major-LEAs (P for interaction < 0.001) in subjects with ESRD.

CONCLUSIONS

As the annual prevalence of subjects with ESRD has increased 3.9-fold over years, they now account for more than 30% of annual major-LEA of the total DFD population. Interdisciplinary team approach and aggressive EVTs might reduce major-LEAs in these patients.

[Comparative Analysis of Clinical Efficacy of Negative Pressure Wound Therapy Plus Lavage System in the Treatment of Wagner Grade 3-5 Diabetic Foot Ulcers Combined with Infection]

Objective

To compare and analyze the clinical efficacy of negative pressure wound therapy (NPWT) combined with lavage system in the treatment of Wagner grade 3-5 diabetic foot ulcers combined with infections.

Methods

The clinical data of 100 patients with Wagner grade 3-5 diabetic foot ulcers combined with infections admitted to our department between January 2016 and January 2020 were retrospectively analyzed. According to the methods of surgical wound management, they were divided into two groups, a combination treatment group treated by NPWT plus a lavage system and a single treatment group receiving NPWT only. Patients were studied for the types of bacterial infection found in the wounds, the amount of time it took for the wound bacterial culture to turn negative, and the status of blood inflammatory indicators, including white blood cell count and C-reactive protein (CRP). Data concerning hospitalization were collected, including the waiting time before the first operation, the number of operations, length of hospital stay, NPWT usage time, and wound closure time. In addition, data concerning patient condition after discharge were also collected, including the duration of out-of-hospital antibiotic use, the final wound healing rate, the final wound healing time, and long-term wound complications, which include wound dehiscence, new ulcer, infection recurrence, readmission, reoperation, and amputation.

Results

There were no statistically significant differences in age, sex, course of disease, lesion side, lesion size and combined diseases between the two groups. Likewise, there was no significant difference in the species and genus, or the composition of bacteria found in the wounds ( P>0.05). However, the combination treatment group showed better results than the single treatment group did in the amount of time it took for wound bacterial culture to turn negative ( P<0.05). As for the blood inflammatory indicators, there was no significant difference between the two groups except that the CRP of the combination group decreased more significantly than that of the single treatment group did at one week postop. The number of surgeries, length of hospital stay, NPWT use time, and wound closure time were lower in the combination treatment group than those in the single treatment group ( P<0.05). However, there was no significant difference in long-term wound complications between the two groups.

Conclusion

When applying NPWT plus lavage system in the treatment of Wagner grade 3-5 diabetic foot ulcers combined with infection, wound infection can be controlled effectively at an early stage and the amount of time needed for wound bacterial culture to turn negative can also be reduced. In addition, the combination treatment stimulates granulation growth of the wounds to effectively cover the wound at an early stage.

Incidence and predictor of diabetic foot ulcer and its association with change in fasting blood sugar among diabetes mellitus patients at referral hospitals in Northwest Ethiopia, 2021

Background

Diabetes mellitus is one of the global public health problems and fasting blood sugar is an important indicator of diabetes management. Uncontrolled diabetes can lead to diabetic foot ulcers, which is a common and disabling complication. The association between fasting blood glucose level and the incidence of diabetic foot ulcers is rarely considered, and knowing its predictors is good for clinical decision-making. Therefore, the aim of this study was to determine the incidence and predictors of diabetic foot ulcers and its association with changes in fasting blood sugar among diabetes mellitus patients at referral hospitals in Northwest Ethiopia.

Methods

A multicenter retrospective follow-up study was conducted at a referral hospital in Northwest Ethiopia. A total of 539 newly diagnosed DM patients who had follow-up from 2010 to 2020 were selected using a computer-generated simple random sampling technique. Data was entered using Epi-Data 4.6 and analyzed in R software version 4.1. A Cox proportional hazard with a linear mixed effect model was jointly modeled and 95% Cl was used to select significant variables. AIC and BIC were used for model comparison.

Result

A total of 539 diabetes patients were followed for a total of 28727.53 person-month observations. Overall, 65 (12.1%) patients developed diabetic foot ulcers with incidence rate of 2.26/1000-person month observation with a 95% CI of [1.77, 2.88]. Being rural (AHR = 2.30, 95%CI: [1.23, 4.29]), being a DM patient with Diabetic Neuropathy (AHR = 2.61, 95%CI: [1.12, 6.06]), and having peripheral arterial disease(PAD) (AHR = 2.96, 95%CI: [1.37, 6.40]) were significant predictors of DFU. The time-dependent lagged value of fasting blood sugar change was significantly associated to the incident of DFU (α = 1.85, AHR = 6.35, 95%CI [2.40, 16.79]).

Conclusion and recommendation

In this study, the incidence of DFU was higher than in previous studies and was influenced by multiple factors like rural residence, having neuropathy, and PAD were significant predictors of the incidence of DFU. In addition, longitudinal changes in fasting blood sugar were associated with an increased risk of DFU. Health professionals and DM patients should give greater attention to the identified risk factors for DFU were recommended.

Outpatient clinic attendance and outcomes among patients hospitalized with diabetic foot ulcers

BACKGROUND

There are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs).

METHODS

Retrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge ("30-day post-discharge clinic attendance"). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI).

RESULTS

Among 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19-1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge.

CONCLUSION

We found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.

Association among Current Smoking, Alcohol Consumption, Regular Exercise, and Lower Extremity Amputation in Patients with Diabetic Foot: Nationwide Population-Based Study

BACKGRUOUND

The present study investigates whether modifiable behavioral factors of current cigarette smoking, heavy alcohol consumption, and regular exercise are associated with risk of lower extremity amputation (LEA) in diabetic patients.

METHODS

A total of 2,644,440 diabetic patients (aged ≥20 years) was analyzed using the database of the Korean National Health Insurance Service. Cox proportional hazard regression was used to assess adjusted hazard ratios (HRs) for the behavioral factors with risk of LEA under adjustment for potential confounders.

RESULTS

The risk of LEA was significantly increased by current cigarette smoking and heavy alcohol consumption (HR, 1.436; 95% confidence interval [CI], 1.367 to 1.508 and HR, 1.082; 95% CI, 1.011 to 1.158) but significantly decreased with regular exercise (HR, 0.745; 95% CI, 0.706 to 0.786) after adjusting for age, sex, smoking, alcohol consumption, exercise, low income, hypertension, dyslipidemia, body mass index, using insulin or oral antidiabetic drugs, and diabetic duration. A synergistically increased risk of LEA was observed with larger number of risky behaviors.

CONCLUSION

Modification of behaviors of current smoking, heavy alcohol intake, and exercise prevents LEA and can improve physical, emotional, and social quality of life in diabetic patients.

Identification of Charcot Foot: A Case Report

Neuropathy is a painful and potentially devastating complication of diabetes mellitus affecting many patients. Neuropathy can lead to foot ulcers, infections, and subsequent amputations. Nerve damage from peripheral neuropathy may lead to Charcot neuropathic osteoarthropathy, commonly known as Charcot foot. Flesh wounds and weakened bones causing microfractures of the foot and ankle may lead to foot malformations. Early recognition and care are essential for the treatment of Charcot foot and prevention of further injury. This article discusses the use of monofilament testing for diabetic neuropathy, increasing awareness of Charcot foot, and introducing a screening algorithm for Charcot foot.

Cilostazol-induced Acute Kidney Injury in A Patient With Diabetic Foot Ulcer: A Case Report and Review of Literature

INTRODUCTION

Cilostazol is an antiplatelet agent, that has been recently used as an adjunctive therapy in the management of diabetic foot ulcers. Headache, diarrhea, palpitations, and edema are reported as common side effects.

CASE PRESENTATION

A 53-year-old woman was admitted to hospital, with decreased urine output and increased serum creatinine level. She had taken Cilostazol for the first time, for only one day, so the diagnosis of acute kidney injury, probably drug-induced acute interstitial nephritis, due to Cilostazol use, was made. Her kidney function did not improve despite Cilostazol discontinuation and therefore, empirical corticosteroid therapy was initiated. Her urine output increased and her serum creatinine level significantly decreased, on the third day of treatment. She was discharged with acceptable kidney function. Follow-up visits showed gradual normalization of serum creatinine in the next 62 days.

CONCLUSION

Based on our case, we may draw the conclusion that, Cilostazol may cause nephrotoxicity at any point after ingestion.  DOI: 10.52547/ijkd.6980.

The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm

It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.

Amputation and infection are the greatest fears in patients with diabetes foot complications

AIMS

To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications.

METHODS

478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy.

RESULTS

Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation.

CONCLUSION

Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

Temporal trends in non-traumatic lower extremity amputations (LEAs) and their association with 12-month mortality in people with diabetes, 2004-2016

AIMS

To assess trends in hospital admissions for non-traumatic lower extremity amputations (LEAs) and for mortality following LEAs in adult patients with type 1 diabetes (T1DM) or type 2 diabetes (T2DM) admitted to hospitals in Victoria, Australia during 2004-2016.

METHODS

Using hospital discharge data, we calculated age- and sex- adjusted admission rates for incident cases of any LEA, minor LEAs, major LEAs and 12-month mortality following any LEAs for patients according to diabetes type. Joinpoint regression analysis was used to identify changes in linear trends that were described as average annual percentage change (AAPC).

RESULTS

Significant declines in rates of admission for any LEA (AAPC -4.9), minor LEAs (-3.0 %) and major LEAs (AAPC -11.5 %) were seen for patients with T2DM. Overall, admission rates for any LEA did not significantly change for patients with T1DM during 2004 and 2016, however, we detected a significant rise in admissions for any LEAs (AAPC +5.1) in female patients with T1DM. This increase was most prominent in younger (<60 years) patients undergoing minor LEAs. During 2009-2016, younger patients with type 1 DM, regardless of sex, also experienced significant increases in admissions for any LEA (AAPC +14) and major LEAs (AAPC +15). Mortality associated with LEAs in T2DM declines, with a 12-month mortality rate of 6.3 %) associated with LEAs in T2M decline (AAPC -4.2 %) whereas rates for T1DM remained stable (1.9 %) during 2004-2016.

CONCLUSIONS

There were significant differences in LEA hospital admission trends by type of diabetes, age and sex. The decline in LEAs and its associated mortality is welcome news for patients with T2DM. However, reasons for the increase in LEAs in younger patients with T1DM remain to be determined.

[Association between the diabetic foot amputation index and metabolic compensation in diabetes mellitus]

BACKGROUND

Diabetic foot amputation is a public health challenge due to the increasing prevalence of type 2 diabetes mellitus (T2D). Although there are many health indicators aimed at the management and control of T2D and its complications, amputations persist.

AIM

To evaluate the association between diabetic foot amputation index and indicators of care and management of T2D in primary care centers of the eastern section of Santiago, Chile.

MATERIAL AND METHODS

We conducted a mixed ecological study and included information from the Monthly Statistical report of different public health centers from 2014 to 2018. We also analyzed the hospital discharge records from an individual tertiary public health center. The annual index for diabetic foot amputation per 100,000 diabetic patients was used as a response variable. The diabetic compensation percentage was calculated as the proportion of adults with a glycosylated hemoglobin below 7% or the proportion of older people with a value below 8%. The diabetic decompensation percentage was calculated as the proportion of people with a glycosylated hemoglobin over 9%.

RESULTS

A high variability in demographic and management indicators was observed between communes and centers in the study period. Bivariate analysis showed a significant correlation between the amputation index, decompensation, and insulin use. In a regression analysis, the amputation index was significantly associated with the diabetic compensation percentage (β = -3.5; p < 0.05) and a high decompensation percentage (β = 12.3; p < 0.005).

CONCLUSIONS

The diabetic foot amputation index was associated with diabetic compensation and decompensation indicators.

Experience in the use of dalbavancin in diabetic foot infection

OBJECTIVE

To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital.

METHODS

A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate is estimated at 90 days after finishing the treatment.

RESULTS

A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000 mg followed by 500 mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%).

CONCLUSION

Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.

Decreased accuracy of erythrocyte sedimentation rate in diagnosing osteomyelitis in diabetic foot infection patients with severe renal impairment: A retrospective cross-sectional study

BACKGROUND

Rapid diagnosis and treatment of diabetic foot osteomyelitis (DFO) could reduce the risk of amputation and death in patients with diabetic foot infection (DFI). Erythrocyte sedimentation rate (ESR) is considered the most useful serum inflammatory marker for the diagnosis of DFO. However, whether severe renal impairment (SRI) affects its diagnostic accuracy has not been reported previously.

OBJECTIVE

To investigate the accuracy of ESR in diagnosing DFO in DFI patients with and without SRI.

METHODS

This was a retrospective cross-sectional study. From the inpatient electronic medical record system, the investigators extracted demographic information, diagnostic information, and laboratory test results of patients with DFI who had been hospitalized in Longhua Hospital from January 1, 2016 to September 30, 2021. Logistic regression was performed to analyze the interaction between ESR and SRI with adjustment for potential confounders. The area under the curve (AUC), cutoff point, sensitivity, specificity, prevalence, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were analyzed by receiver operating characteristic (ROC) curve analysis and VassarStats.

RESULTS

A total of 364 DFI patients were included in the analysis. The logistic regression analysis results showed that elevated ESR increased the probability of diagnosing DFO (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.75-3.28; adjusted P < 0.001); SRI was not associated with the diagnosis of DFO (adjusted OR, 3.20; 95% CI, 0.40-25.32; adjusted P = 0.271), but it had an obstructive effect on the diagnosis of DFO by ESR (adjusted OR, 0.48; 95% CI, 0.23-0.99; adjusted P = 0.048). ROC analysis in DFI patients without SRI revealed that the AUC of ESR to diagnose DFO was 0.76 (95% CI, 0.71-0.81), with the cutoff value of 45 mm/h (sensitivity, 67.8%; specificity, 78.0%; prevalence, 44.7%; PPV, 71.3%; NPV, 75.0%; LR+, 3.08; LR-, 0.41). In contrast, in patients with SRI, the AUC of ESR to diagnose DFO was 0.57 (95% CI, 0.40-0.75), with the cutoff value of 42 mm/h (sensitivity, 95.0%; specificity, 29.2%; prevalence, 45.5%; PPV, 52.8%; NPV, 87.5%; LR+, 1.34; LR-, 0.17).

CONCLUSIONS

The accuracy of ESR in diagnosing DFO in DFI patients with SRI is reduced, and it may not have clinical diagnostic value in these patients.

Treatment of osteomyelitis of the toes without amputation in the wound clinic setting

Ulcers of the distal toe are common in patients with toe deformities and many times are complicated by osteomyelitis of the phalanx. Amputation of the toe is the standard treatment in many institutions; however, this can lead to abnormal biomechanics of the foot predisposing the patient to recurrent ulceration and further amputations, especially in patients with diabetes and those with neuropathy. It has been found that conservative, local operative procedures to remove the infected bone can avoid these complications and even avoid long-term antibiotic therapy. Many of these procedures can be performed in the wound clinic. To show its utility, a case report of this procedure and a small series of these patients treated in the wound clinic are presented.

The efficacy of inflammatory markers in diagnosing infected diabetic foot ulcers and diabetic foot osteomyelitis: Systematic review and meta-analysis

Background

Diabetes foot ulcer (DFU) is a complication of diabetes mellitus. Accurate diagnosis of DFU severity through inflammatory markers will assist in reducing impact on quality of life. We aimed to ascertain the diagnostic test accuracy of commonly used inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and white cell count (WCC) for the diagnosis and differentiation between DFU grades based on the International Working Group on the Diabetic Foot classification system.

Methods

This systematic review explored studies that investigated one or more of the above-listed index tests aiding in diagnosing infected DFU. This review was registered on PROSPERO database (ID = CRD42021255618) and searched 5 databases including an assessment of the references of included studies. Records were manually screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 16 studies were included which were assessed for quality using QUADAS-2 tool and meta-analysed using Meta-Disc v1.4.

Results

CRP had the greatest area under the curve (AUC) of 0.893 for diagnosing grade 2 DFU. This returned a pooled sensitivity and specificity of 77.4% (95% CI: 72% to 82%) and 84.3% (95% CI: 79% to 89%) respectively. In terms of diagnosing grade 3 DFU, procalcitonin had the highest AUC value of 0.844 when compared with other markers. The pooled sensitivity of PCT was calculated as 85.5% (95% CI: 79% to 90%) and specificity as 68.9% (95% CI: 63% to 75%).

Conclusion

CRP and PCT are the best markers for diagnosing grade 2 and grade 3 DFU respectively. Other markers are also valuable when used in conjunction with clinical judgement. The findings accentuate the necessity of further research to establish standardised cut-off values for these inflammatory markers in diagnosing diabetic foot ulcers.

Deep Personal Multitask Prediction of Diabetes Complication with Attentive Interactions Predicting Diabetes Complications by Multitask-Learning

Objective

Diabetic complications have brought a tremendous burden for diabetic patients, but the problem of predicting diabetic complications is still unresolved. Our aim is to explore the relationship between hemoglobin A1C (HbA1c), insulin (INS), and glucose (GLU) and diabetic complications in combination with individual factors and to effectively predict multiple complications of diabetes.

Methods

This was a real-world study. Data were collected from 40,913 participants with an average age of 48 years from the Department of Endocrinology of Ruijin Hospital in Shanghai. We proposed deep personal multitask prediction of diabetes complication with attentive interactions (DPMP-DC) to predict the five complication models of diabetes, including diabetic retinopathy, diabetic nephropathy, diabetic peripheral neuropathy, diabetic foot disease, and diabetic cardiovascular disease.

Results

Our model has an accuracy rate of 88.01% for diabetic retinopathy, 89.58% for diabetic nephropathy, 85.77% for diabetic neuropathy, 80.56% for diabetic foot disease, and 82.48% for diabetic cardiovascular disease. The multitasking accuracy of multiple complications is 84.67%, and the missed diagnosis rate is 9.07%.

Conclusion

We put forward the method of interactive integration with individual factors of patients for the first time in diabetic complications, which reflect the differences between individuals. Our multitask model using the hard sharing mechanism provides better prediction than prior single prediction models.

Incidence, hospitalization and mortality and their changes over time in people with a first ever diabetic foot ulcer

AIMS

A diabetic foot ulcer (DFU) is a severe condition associated with morbidity and mortality. Population-based studies are rare and limited by access to reliable data. Without this data, efforts in primary prevention cannot be evaluated. Therefore, we examined the incidence and changes over time for the first DFU in people with diabetes. We also examined hospitalization and all-cause mortality and their changes over time.

METHODS

From the UK primary care CPRD GOLD database (2007-2017), we identified 129,624 people with diabetes by a prescription for insulin or a non-insulin anti-diabetic drug. DFUs were identified using Read codes and expressed as incidence rates (IRs). Changes over time were described using Poisson and logistic regression and expressed as incidence rate ratios (IRRs) and odds ratios (ORs) respectively.

RESULTS

The mean IR of first registered DFUs was 2.5 [95% CI: 2.1-2.9] per 1000 person-years for people with type 2 diabetes and 1.6 [1.3-1.9] per 1000 person-years for people with type 1. The IRs declined for people with type 2 diabetes (IRR per year: 0.97 [0.96-0.99]), while no changes were observed for people with type 1 diabetes (IRR per year: 0.96 [0.89-1.04]). Average hospitalization and 1-year mortality risk for people with type 2 diabetes were 8.2% [SD: 4.7] and 11.7% [SD: 2.2] respectively. Both declined over time (OR: 0.89 [0.84, 0.94] and 0.94 [0.89, 0.99]).

CONCLUSION

The decline in all IRs, hospitalizations and mortality in people with type 2 diabetes suggests that prevention and care of the first DFU has improved for this group in primary care in the UK.

Treatment of fusarium osteomyelitis in a diabetic foot ulcer complicated by antineoplastic chemotherapy

INTRODUCTION

Diabetic foot osteomyelitis (DFO) is a severe complication of diabetic foot ulcerations (DFUs). Fusarium osteomyelitis in patients who are severely immunocompromised is not well documented in current literature. Fusarium is an invasive fungal species that has been shown to respond poorly to antifungal therapy alone, and bone debridement is usually required. Treatment for DFO may consist of surgical amputation, antimicrobial therapy, and/or conservative surgery (CS) or bone debridement.

CASE PRESENTATION

The authors present a case of Fusarium osteomyelitis in a 77-year-old female with type 2 diabetes and acute myeloid leukemia, simultaneously undergoing chemotherapy. The patient had a DFU to the second digit with DFO suggested by magnetic resonance imaging. Bone cultures revealed coagulase-negative staphylococci and Fusarium species. Due to the patient's severely immunocompromised state, they were treated with CS and joint antifungal and antibiotic therapy. The DFU was healed in 6 weeks with no reoccurrence at 6 months.

CONCLUSIONS

This case report, to the authors' knowledge, is the first to demonstrate successful remission of Fusarium osteomyelitis with a conservative procedure and adjunct antifungal therapy in an immunocompromised patient.

Microbiome Characterization of Infected Diabetic Foot Ulcers in Association With Clinical Outcomes: Traditional Cultures Versus Molecular Sequencing Methods

Background

Infected diabetic foot ulcers (IDFU) are a major complication of diabetes mellitus. These potentially limb-threatening ulcers are challenging to treat due to impaired wound healing characterizing diabetic patients and the complex microbial environment of these ulcers.

Aim

To analyze the microbiome of IDFU in association with clinical outcomes.

Methods

Wound biopsies from IDFU were obtained from hospitalized patients and were analyzed using traditional microbiology cultures, 16S rRNA sequencing and metagenomic sequencing. Patients’ characteristics, culture-based results and sequencing data were analyzed in association with clinical outcomes.

Results

A total of 31 patients were enrolled. Gram-negative bacteria dominated the IDFU samples (79%, 59% and 54% of metagenomics, 16S rRNA and cultures results, respectively, p<0.001). 16S rRNA and metagenomic sequencing detected significantly more anaerobic bacteria, as compared to conventional cultures (59% and 76%, respectively vs. 26% in cultures, p=0.001). Culture-based results showed that Staphylococcus aureus was more prevalent among patients who were treated conservatively (p=0.048). In metagenomic analysis, the Bacteroides genus was more prevalent among patients who underwent amputation (p<0.001). Analysis of metagenomic-based functional data showed that antibiotic resistance genes and genes related to biofilm production and to bacterial virulent factors were more prevalent in IDFU that resulted in amputation (p<0.001).

Conclusion

Sequencing tools uncover the complex biodiversity of IDFU and emphasize the high prevalence of anaerobes and Gram-negative bacteria in these ulcers. Furthermore, sequencing results highlight possible associations among certain genera, species, and bacterial functional genes to clinical outcomes.

Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months

AIMS

To investigate factors independently associated with time-to-(being)-ulcer-free, time-varying effects and predict adjusted ulcer-free probabilities, in a large prospective cohort with diabetes-related foot ulcers (DFU) followed-up for 24 months.

METHODS

Patients presenting with DFU(s) to 65 Diabetic Foot Services across Queensland, Australia, between July-2011 and December-2017 were included. Demographic, comorbidity, limb, ulcer, and treatment factors were captured at presentation. Patients were followed-up until ulcer-free (all DFU(s) healed), amputation, death or two years. Factors associated with time-to-ulcer-free were investigated using both Cox proportional hazards and flexible parametric survival models to explore time-varying effects and plot predicted adjusted ulcer-free probability graphs.

RESULTS

Of 4,709 included patients (median age 63 years, 69.5% male), median time-to-ulcer-free was 112 days (IQR:40->730), with 68.4% ulcer-free within two years. Factors independently associated with longer time-to-ulcer-free were each year of age younger than 60 years, living in a regional or remote area, smoking, neuropathy, peripheral artery disease (PAD), ulcer size >1 cm², deep ulcer and mild infection (all p < 0.05). Time-varying effects were found for PAD and ulcer size limiting their association to six months only. Shorter time-to-ulcer-free was associated with recent DFU treatment by a podiatrist and receiving knee-high offloading treatment (both p < 0.05). Predicted adjusted ulcer-free probability graphs reported largest differences in time-to-ulcer-free over 24-months for geographical remoteness and PAD factors.

CONCLUSIONS

Multiple factors predicted longer and shorter time-to-ulcer-free in people presenting with DFUs. Considering these factors, their time-varying effects and adjusted ulcer-free probability graphs, should aid the prediction of the likely time-to-(being)-ulcer-free for DFU patients.

Influence of Foot Ulceration on All-Cause and Cardiovascular Mortality in Diabetic Patients: A Case-Control Study

PURPOSE

The purpose of this study was to analyze the influence of a diabetic foot ulcer on all-cause and cardiovascular disease (CVD) mortality.

DESIGN

Retrospective case-control study.

SUBJECTS AND SETTING OUTPATIENTS

Eighty-eight patients with new-onset diabetic foot ulceration (DFU) were paired with 176 patients without DFU (controls). The study setting was the Department of Endocrinology, Sun Yat-sen Memorial Hospital, located in Guangzhou, China.

METHODS

Cause-specific mortality was recorded during a median follow-up duration of 6.20 years up to 1 March 2016. Records review dates were from January 1, 2004, to December 31, 2010.

RESULTS

The all-cause mortality rate for the DFU group and the control group was 48.9% and 22.7%, respectively. The risk of all-cause death in the DFU group was 3.126 times higher than that in the control group (risk ratio [RR]= 3.126; 95% CI, 1.998-4.891; P = .000). The CVD mortality rate of the DFU group and the control group was 12.5% and 6.8%, respectively. The risk of CVD death in the DFU group was 3.277 times higher than that in the control group (RR = 3.277; 95% CI, 1.392-7.715; P = .007).

CONCLUSIONS

Development of a diabetic foot ulcer was associated with a significantly higher all-cause and CVD-related death risk than that in a control group of persons with diabetes mellitus without DFU.

[Treatment of acute and chronic ulcers]

Chronic ulcers are most often seen as a complication to venous leg ulcers, diabetic foot ulcers and pressure ulcers. Ulcers often display an underlying medical condition, which makes it mandatory to treat these individuals in a multidisciplinary setting. Modern ulcer therapy has changed over the latest decade, and as described in this review a number of new modalities have been included. The major group of ulcers often presents with well-defined features, but attention should be directed towards ulcers with atypic appearance such as ulcers related to calciphylaxis, hypertension (Martorell) and pyoderma.

Time in range in relation to amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers

AIMS

The aim of this study was to evaluate the association of time in range (TIR) with amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers (DFUs).

MATERIALS AND METHODS

A retrospective analysis was performed on 303 hospitalised patients with DFUs. During hospitalisation, TIR, mean blood glucose (MBG), coefficient of variation (CV), time above range (TAR) and time below range (TBR) of patients were determined from seven-point blood glucose profiles. Participants were grouped based on their clinical outcomes (i.e., amputation and death). Logistic regression was employed to analyse the association of TIR with amputation and all-cause mortality of inpatients with DFUs.

RESULTS

Among the 303 enrolled patients, 50 (16.5%) had undergone amputation whereas seven (2.3%) were deceased. Blood glucose was determined in 41,012 samples obtained from all participants. Patients who underwent amputation had significantly lower TIR and higher MBG, CV, level 2 TAR and level 1 TBR whereas deceased patients had significantly lower TIR and higher MBG and level 2 TAR. Both amputation and all-cause mortality rate declined with an increase in TIR quartiles. Logistic regression showed association of TIR with amputation (p = 0.034) and all-cause mortality (p = 0.013) after controlling for 15 confounders. This association was similarly significant in all-cause mortality after further adjustment for CV (p = 0.022) and level 1 TBR (p = 0.021), respectively.

CONCLUSIONS

TIR is inversely associated with amputation and all-cause mortality of hospitalised patients with DFUs. Further prospective studies are warranted to establish a causal relationship between TIR and clinical outcomes in patients with DFUs.

Case Report: A novel WRN mutation in Werner syndrome patient with diabetic foot disease and myelodysplastic syndrome

Werner syndrome is an autosomal recessive rare disease caused by a WRN gene mutation, which is rarely reported in the Chinese population. We report the clinical and genetic data of a Chinese patient with Werner syndrome. The proband was a 40-year-old male patient who presented with diabetic foot ulcers, accompanied by short stature, cataracts, hypogonadism, and hair thinning, and myelodysplastic syndrome (MDS) occurred after 18 months. Genetic sequencing showed there were compound heterozygous mutations as c.3384-1G>C and c.3744dupA in the WRN gene. The c.3744dupA mutation is a novel pathogenic variation for Werner syndrome.

Case report: Successful treatment of human diabetic foot ulcer using low-intensity diagnostic ultrasound combined with microbubbles: Two cases

BACKGROUND

Diabetic foot ulcer (DFU) is one of the serious complications of diabetes, which has high disability rate and mortality. Low-intensity ultrasound combined with microbubbles in blood circulation can enhance the blood perfusion effect of local soft tissue, which has the potential to promote the healing of diabetic ulcer. Here, we report how this method was used to help the healing of two patients with chronic refractory DFUs.

CASE PRESENTATION

In case 1, a 56-year-old man with 3-years history of type 2 diabetes had a 3.0×2.0 cm ulcer which infected with staphylococcus aureus on his right calf for more than half a month. In case 2, a 70-year-old man with 10-years history of type 2 diabetes presented with an 8-month right heel ulcer that developed to 7.5×4.6 cm. And he also had hyperlipidemia, hypertension, and renal impairment. Both patients were enrolled in our study to receive treatment of low-intensity diagnostic ultrasound (LIDUS) combined with microbubbles. They were discharged after a 20-minute daily standard treatment for 7 consecutive days. The ulcers in both cases completely healed in 60 days and 150 days, respectively, and haven't recurred for more than one year of follow-up.

CONCLUSION

It is feasible, safe, and effective to use commercial LIDUS combined with commercial microbubbles in the treatment of diabetic lower extremity ulcers. This study may provide an innovative and non-invasive method for the treatment of DFUs.

Stem Cell Therapy for Diabetic Foot Ulcers: Theory and Practice

Diabetic foot ulcers are associated with increases in limb amputation, morbidity, and mortality. Recently, a stem cell application is emerging as promising adjuvant therapy. We presented available remedies by conducting a literature review on the application, safety, and efficacy of stem cell therapy. Relevant literature, including randomized control trials and article journals, was obtained from reputable search engines (PubMed, Scopus, and Web of Science). We analyzed five credible cohorts, with variable sources of stem cells, in a total of 216 participants, 151 males and 65 females, age (mean ± SD) of 64.5 ± 9.6 years. With an average success of 86.41% in all Wagner-II lesions, mesenchymal SCA (stem cell application) is safe and effective, hence can significantly prevent limb amputation.

Frailty Is Associated with Impaired Diabetic Foot Ulcer Healing and All-Cause Re-Hospitalization

BACKGROUND

Diabetic Foot Ulcers (DFUs) are a common and feared complication of type 1 and type 2 diabetes. People with DFUs often present a significant clinical complexity due to multimorbidity, frailty, polypharmacy, and disabling conditions. Frailty, defined using the accumulation of health deficits model, has shown to predict worsening health status, hospitalizations, and death in older persons. There are no clinical studies, to date, that have examined the prevalence and effect of frailty on DFUs outcomes. The aim of our study was to explore the impact of frailty on DFUs healing and re-hospitalization in a cohort of patients hospitalized with DFUs.

DESIGN

prospective cohort study.

SETTING AND PARTICIPANTS

The frailty status of 76 consecutive hospitalized patients with DFUs was assessed by using the Frailty Index (FI).

MEASUREMENTS

The primary outcome was the non-healing of the DFU. Secondary outcome was re-hospitalization events (for any cause) within 6 months from hospital discharge. Frailty was defined as FI>0.25.

RESULTS

Out of 76 patients (median age 65 years, range 31-84), 56 (74%) were frail. At six months, 81.5% of frail patients had non-healing of the DFU compared to 55% in non-frail patients (p=0.02). The rate of of re-hospitalization was also higher in frail compared to non-frail (90.3% vs 54%, respectively; p=0.01) patients. In multivariable analyses, frailty was significantly associated with a more than fivefold increased risk of DFU non-healing [odds ratio 5.54 (95% confidence interval 1.28-23.91), p=0.02]. Similarly, re-hospitalization was also significantly higher in frail patients compared to the non-frail ones.

CONCLUSIONS

In hospitalized patients with DFUs, frailty was highly prevalent. Frailty emerged as an independent risk factor for DFU non-healing and re-hospitalization events. Patients with DFUs require a comprehensive assessment of their frailty status which would enable personalization of their management and interventions.

Efficacy of moxibustion in diabetes peripheral neuropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus. The main clinical manifestations of DPN include pain, numbness, paraesthesia, and weakness of the lower limbs which often leads to diabetic foot ulceration, eventually resulting in amputation. Based on Traditional Chinese Medicine theory, moxibustion has a great effect on treating and preventing DPN. However, randomized clinical trials done to evaluate the efficacy of this treatment are still lacking. Hence, this study is carried out to evaluate the effectiveness and safety of moxibustion therapy on diabetic peripheral neuropathy.

METHODS

This study will be a pilot, interventional, randomized, 2-armed, parallel, singled-masked, controlled trial. A total of 40 diabetes mellitus patients with peripheral neuropathy will be recruited and assigned randomly into 2 groups (moxibustion group and waiting group) at a 1:1 ratio. This trial consists of an 8-week intervention period and a 4-week follow-up period. During the intervention period, the moxibustion group will take 3 moxibustion sessions per week, whereas no intervention will be done on the waiting group to act as the control group. The outcome will be assessed by an outcome assessor who is unaware of the group assignment. The primary outcome will be pain assessment measured with algometry, Leeds Assessment of Neuropathic Symptoms and Signs pain scale, visual analogue scale, and neuropathy pain scale. The secondary outcome will be an evaluation of functional performance capacity with 6 minutes walking test, evaluation of the Foot and Ankle Ability Measure, and serum HbA1c and albumin levels.

DISCUSSION

We hope that this trial will provide valuable insights on the efficacy of moxibustion in the management of diabetic peripheral neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov Registry No.: NCT04894461 (URL: https://clinicaltrials.gov/ct2/show/NCT04894461?term=NCT04894461&draw=2&rank=1) Registered on May 20, 2021.

Complications from ankle arthrodesis in diabetes-related Charcot foot syndrome

INTRODUCTION

Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes.

METHODS

The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared.

RESULTS

Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001).

CONCLUSION

Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN.

LEVEL OF EVIDENCE

Cohort study; Level of evidence, 3.

Predicting Clinical Outcomes in a Diabetic Foot Ulcer Population Using Fluorescence Imaging

OBJECTIVE

To retrospectively evaluate a cohort of patients with diabetic foot ulcers to determine if the rate of microcirculatory flow detected by fluorescence imaging within the wound and surrounding tissue is associated with healing outcomes.

METHODS

Tissue perfusion parameters used for the current analysis were the ingress rate (IR) within the wound bed (R01) and in an area remote from the wound (REF), as well as time to first blush. Wounds were then categorized based on their outcome (healed, healing, chronic nonhealing, partial foot amputation, proximal amputation below the knee) and compared between patients with positive or negative wound healing outcomes.

RESULTS

The final study cohort included 61 wounds and demonstrated that a higher IR within R01 and REF areas was significantly associated with positive outcomes, whereas time to first blush was not. A two-predictor logistic model found a significant relationship between IR (R01 and REF) and odds of wound healing.

CONCLUSIONS

Fluorescence imaging evaluation of a diabetic foot ulcer can provide valuable information on healing outcomes that can help determine if a wound is progressing toward healing and therefore may help inform the need for advanced wound modalities, referrals, and amputation.

Associations between Nutrients and Foot Ulceration in Diabetes: A Systematic Review

We reviewed the literature to evaluate potential associations between vitamins, nutrients, nutritional status or nutritional interventions and presence or healing of foot ulceration in diabetes. Embase, Medline, PubMed, and the Cochrane Library were searched for studies published prior to September 2020. We assessed eligible studies for the association between nutritional status or interventions and foot ulcers. Fifteen studies met the inclusion criteria and were included in this review. Overall, there is a correlation between poor nutritional status and the presence of foot ulceration or a delay in healing. However, there is not enough data to reach conclusions about whether the relationships are causal or only association. Further research is required to test whether any forms of nutritional supplementation improve foot ulcer healing.

Bilateral Charcot Arthropathy Treated with Bolt-Beam Constructs in the Setting of Unilateral Foot Ulcers: A Report of 2 Cases

CASE

Two type-2 diabetic patients presented with bilateral Charcot arthropathy with midfoot collapse and presence of foot ulcerations on one side. The ulcerated extremity in each patient was treated surgically with fusion bolt, beam, and plate constructs in the setting of open ulceration. Bilateral extremities were treated surgically and went on to bony union and wound healing.

CONCLUSION

Charcot arthropathy with open ulcers can be managed acutely with debridement, resection of bone, and arthrodesis. Waiting for ulcers to heal before internal fixation is performed may not be necessary in all situations.

Hospital admission for type 2 diabetes mellitus under the Universal Coverage Scheme in Thailand: A time- and geographical-trend analysis, 2009-2016

BACKGROUND

Descriptive analyses of 2009-2016 were performed using the data of the Universal Coverage Scheme (UCS) which covers nearly 70 percent of the Thai population. The analyses described the time and geographical trends of nationwide admission rates of type 2 diabetes mellitus (T2DM) and its complications, including chronic kidney disease (CKD), myocardial infarction, cerebrovascular diseases, retinopathy, cataract, and diabetic foot amputation.

METHODS AND FINDINGS

The database of T2DM patients aged 15-100 years who were admitted between 2009 and 2016 under the UCS and that of the UCS population were retrieved for the analyses. The admitted cases of T2DM were extracted from the database using disease codes of principal and secondary diagnoses defined by the International Classification of Diseases 9th and 10th Revisions. The T2DM admission rates in 2009-2016 were the number of admissions divided by the number of the UCS population. The standardized admission rates (SARs)were further estimated in contrast to the expected number of admissions considering age and sex composition of the UCS population in each region. A linearly increased trend was found in T2DM admission rates from 2009 to 2016. Female admission rates were persistently higher than that of males. In 2016, an increase in the T2DM admission rates was observed among the older ages relative to that in 2009. Although the SARs of T2DM were generally higher in Bangkok and central regions in 2009, except that with CKD and foot amputation which had higher trends in northeastern regions, the geographical inequalities were fairly reduced by 2016.

CONCLUSION

Admission rates of T2DM and its major complications increased in Thailand from 2009 to 2016. Although the overall geographical inequalities in the SARs of T2DM were reduced in the country, further efforts are required to improve the health system and policies focusing on risk factors and regions to manage the increasing T2DM.

Predictive values of foot plantar pressure assessment in patients with midfoot deformity secondary to Charcot neuroarthropathy

AIMS

The principal aim of this study was to identify a cut-off point along the spectrum of peak plantar midfoot pressure that has an optimum combination of sensitivity and specificity to screen for neuropathic ulceration in patients with Charcot neuroarthropathy (CN).

METHODS

A 1-year outcome study was performed in twenty-five patients with diabetes, affected with chronic CN midfoot deformity. Peak plantar pressure (PPP) and pressure/time Integral (PTI) in the midfoot region were registered. For selecting the optimal diagnostic cut-off points on the scale of pressure measurement, ROC curves were used.

RESULTS

Twelve (48%) patients developed a plantar midfoot ulcer. Baseline PPP (24.04 ± 6.33 Vs. 12.85 ± 3.29 N/cm²) and PTI (11.89 ± 4.60 Vs. 5.42 ± 2.26 N/cm²/s) were significantly higher in the ulcerated group (p < .001 and p < .001, respectively). Using ROC analyses, optimal cut-off point for PPP was 16.45 N/cm², yielding a sensitivity of 92% and a specificity of 85%; and for PTI, optimal cut-off point was 7.2 N/cm²/s, yielding a sensitivity of 92% and a specificity of 77%.

CONCLUSIONS

Patients with CN midfoot deformity with cut-off values for PPP of 16.45 N/cm² and PTI of 7.2 N/cm²/s showed an elevated risk of neuropathic ulceration in the plantar area of the midfoot.

Monocyte phenotype as a predictive marker for wound healing in diabetes-related foot ulcers

AIMS

Delayed healing of diabetes-related foot ulcers (DRFUs) is associated with increased macrophage and matrix metalloproteinases (MMPs) at the wound site. Whether circulating monocyte phenotype and/or MMPs are altered in association with wound healing outcome is unknown, and was investigated in this study.

METHODS

Blood was obtained from 21 participants with DRFU, at initial visit (V1), week-4 (V2), and week-8 (V3) for measurement of monocyte number (CD14⁺), phenotype (CD16, CD163) and chemokine receptors (CCRs) by flow cytometry, and circulating MMPs and TIMP-1 by ELISA.

RESULTS

Six wounds healed during the study. At V1, non-classical CD16⁺⁺ monocytes and MMP-3 were higher in healed vs unhealed (both p < 0.05). At V3, the increased %CD16⁺⁺ persisted and %CCR2⁺ was decreased in healed, but no other monocyte markers nor MMP/TIMP differed between groups. Increased wound closure rate (WCR) at V3 correlated with increased %CD16⁺⁺ monocytes and decreased MMP-2 at V1 or V1 + V2. Receiver operating characteristic (ROC) curves yielded an area-under-the-curve of %CD16⁺⁺ at V1 of 0.78 to predict ulcer healing at V3.

CONCLUSIONS

These results indicate that circulating monocyte phenotype and MMPs alter as DRFUs heal. The relationship of %CD16⁺⁺ monocytes with WCR and ROC curve suggest a predictive role of %CD16⁺⁺ monocytes for ulcer healing.