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Hahn HM, Lee DH, Lee IJ. Ready-to-Use Micronized Human Acellular Dermal Matrix to Accelerate Wound Healing in Diabetic Foot Ulcers: A Prospective Randomized Pilot Study. Adv Skin Wound Care 2021; 34:1-6. [PMID: 33852465 DOI: 10.1097/01.asw.0000741512.57300.6d] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine and report clinical outcomes of a ready-to-use micronized dermal matrix for diabetic foot ulcers (DFUs) and compare it to treatment with conventional negative-pressure wound therapy (NPWT) only. METHODS The researchers randomly allocated 30 DFUs Wagner grade 2 or higher from 30 adult patients into two groups. The control group (n = 15) was treated with conventional NPWT, and the experimental group (n = 15) was treated with micronized dermal matrix and NPWT. The researchers evaluated the following outcomes: granulation tissue formation, proportion of patients with closed or granulated wounds at 42 and 120 days, achievement of complete wound healing in the 6 months of follow-up, and intervals from enrollment to final surgical procedures. RESULTS All 15 wounds treated with the micronized matrix showed healthy granulation tissue without noticeable complications during follow-up. At 42 days, 46.7% of wounds in the experimental group had closed compared with 28.6% in the conventional NPWT group (P = .007). At 120 days, 86.7% of the experimental group had completely closed wounds, compared with 57.1% in the conventional therapy group (P = .040). During the 6-month follow-up period, 93.3% of the experimental group achieved complete wound healing compared with 85.7% of the conventional therapy group (P = .468). CONCLUSIONS The healing outcomes for DFUs in the experimental group were superior when micronized matrix treatment was combined with NPWT.
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Affiliation(s)
- Hyung Min Hahn
- At the Ajou University School of Medicine, Suwon, Republic of Korea, Hyung Min Hahn, MD, is Assistant Professor; Dong Hwan Lee, MD, is a Resident; Il Jae Lee, MD, PhD, is Associate Professor, Department of Plastic and Reconstructive Surgery. Acknowledgments: The authors thank Editage ( www.editage.co.kr ) for English language editing. This research was supported by a Korea Health Industry Development Institute grant to Ajou University Medical Center. The authors have disclosed no other financial relationships related to this article. Submitted May 28, 2020; accepted in revised form September 3, 2020
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Simoneau A, Rojubally S, Mohammedi K, Monlun M, Foussard N, Rigalleau V, Blanco L. Glucose control and infection of diabetic foot ulcer. J Diabetes Complications 2021; 35:107772. [PMID: 33487541 DOI: 10.1016/j.jdiacomp.2020.107772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/06/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Amélie Simoneau
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France.
| | - Saad Rojubally
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
| | - Marie Monlun
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
| | - Ninon Foussard
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
| | - Laurence Blanco
- Bordeaux CHU and University, Endocrinology-Nutrition, 33000 Bordeaux, France
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153
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Ramanathan B, Duraisamy R, Venkatramanasami BTD, Abbas MK, Balamurugan A. Association of glycaemic status and outcomes in diabetic foot problems: a retrospective evidence from South India. J Basic Clin Physiol Pharmacol 2021; 33:155-162. [PMID: 33618439 DOI: 10.1515/jbcpp-2020-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Emerging shreds of evidence indicates that the risk of diabetic foot ulcer and associated morbidity can be reduced through the intensive glycemic control. There are very few studies which assessed the effects of glycemic control on diabetic foot problems among Indian patients. We aimed to assess the effect of glycemic control on the outcomes of diabetic foot problems among adult type 2 diabetes (T2DM) patients with foot ulcers. METHODS A cross sectional study was conducted among the T2DM patients from a tertiary care teaching hospital in South India. The demographic characters, risk factors, treatment characters, glycemic status were collected among the patients and analyzed against the outcomes of diabetic foot ulcers by reviewing their medical records. Descriptive statistics were used to present the data. The Chi-square test and ANOVA were used for was used for the categorical variables and continuous parameters to identify the factors affecting the outcomes, respectively. All analysis was performed in SPSS v21. RESULTS Out of the 100 participants included in the study, 70% were male. The majority (78%) were from an age group of 40 to 70 years, and the mean age was found to be 59.91 ± 10.6 years. The mean duration of diabetes was 9.66 years. Only ankle-brachial Index score (p=0.001) was significantly associated with the type of ulcers, whereas other factors not (p>0.05). A high level of average HbA1c, BMI, ABI index and poor glycemic status was associated with a significant debridement strategy and longer duration of hospitalization; however, it was not substantial. CONCLUSION Our study inferred that poor glycemic status is associated with a significant debridement strategy and longer duration of hospitalization. However, these findings need to be strengthened with adequately powered prospective studies.
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Affiliation(s)
- Balamurugan Ramanathan
- Department of General Medicine, Karuna Medical College, Vilayodi, Chittur, Palakkad, Kerala, India
| | - Ramesh Duraisamy
- Department of General Medicine, Coimbatore Medical College & Hospital, Coimbatore, Tamilnadu, India
| | | | - Manoj Kumar Abbas
- Kovai Diabetes Speciality Centre & Hospital, Coimbatore, Tamilnadu, India
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Abstract
Objectives: To avoid hospital spread of Coronavirus-2019 (COVID-19) and to analyze out of hospital outcomes after amputation. Methods: Prospective analysis of data obtained from 60 diabetic patients in 2020 was performed at Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina. Personal protection equipment included double surgical mask, glasses, disposable surgical coats, and surgical masks for patients. Swabs were used to take samples from wounds. We randomly divided patients in 2 groups of 30 patients each. In pre-operative treatment, we used local anesthesia lidocaine hydrochloride 2% (Belupo, Koprivnica, Croatia) in group A and systemic analgesia intravenous tramadol chloride 100 mg intravenous (Krka, Novo Mesto, Slovenia) in group B. Wounds were surgically treated each day and heal spontaneously. Periodical control exams were performed. Results: Wound healing did not present any statistically significant differences between groups (group A: 69±21.97 and B: 61±22.13 days, t=−1.22; p=0.11). No statistically significant differences (p<0.05) between groups A and B in wound healing regarding to gender or cigarette use was noted. Conclusion: No significant differences in amputation treatment between the 2 comparative groups were noted. No confirmed COVID-19 infections in medical staff who performed surgical interventions or in treated patients were detected.
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Affiliation(s)
- Haris Vukas
- From the Department of Vascular Surgery (Vukas), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica, Zenica; from the Department of Vascular Surgery (Dragan Piljic), Cardiovascular Surgery Clinic, and from the Intensive Care (Dilista Piljic), University Clinical Center Tuzla, Clinic of Infective Disease, Tuzla, Bosnia and Herzegovina.
| | - Dragan Piljic
- From the Department of Vascular Surgery (Vukas), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica, Zenica; from the Department of Vascular Surgery (Dragan Piljic), Cardiovascular Surgery Clinic, and from the Intensive Care (Dilista Piljic), University Clinical Center Tuzla, Clinic of Infective Disease, Tuzla, Bosnia and Herzegovina.
| | - Samra Kadić-Vukas
- From the Department of Vascular Surgery (Vukas), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica, Zenica; from the Department of Vascular Surgery (Dragan Piljic), Cardiovascular Surgery Clinic, and from the Intensive Care (Dilista Piljic), University Clinical Center Tuzla, Clinic of Infective Disease, Tuzla, Bosnia and Herzegovina.
| | - Dilista Piljic
- From the Department of Vascular Surgery (Vukas), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica, Zenica; from the Department of Vascular Surgery (Dragan Piljic), Cardiovascular Surgery Clinic, and from the Intensive Care (Dilista Piljic), University Clinical Center Tuzla, Clinic of Infective Disease, Tuzla, Bosnia and Herzegovina.
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155
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Sen P, Demirdal T. Predictive ability of LRINEC score in the prediction of limb loss and mortality in diabetic foot infection. Diagn Microbiol Infect Dis 2021; 100:115323. [PMID: 33556651 DOI: 10.1016/j.diagmicrobio.2021.115323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/03/2021] [Accepted: 01/18/2021] [Indexed: 01/22/2023]
Abstract
It was aimed to analyze the effectiveness of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in predicting amputation and mortality in diabetic foot infection (DFI). Data of 416 patients who were hospitalized for DFI were recorded retrospectively. LRINEC scores were calculated for each patient from laboratory data. The diagnostic performance of LRINEC score was investigated in amputated/nonamputated and survived/deceased patient groups. Median LRINEC score of patients who underwent amputation was higher than those without amputation (P < 0.001). The area under the curve (AUC) value for LRINEC score was 0.638 with the cut-off point of ≥5 in predicting amputation. Median LRINEC score of deceased patients was higher than those who survived (P= 0.022). AUC value for LRINEC score was 0.663 with the cut-off point of ≥7 in predicting mortality. LRINEC score may be a promising scoring system in predicting both amputation and mortality in DFI.
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Affiliation(s)
- Pinar Sen
- Izmir Katip Celebi University Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey.
| | - Tuna Demirdal
- Izmir Katip Celebi University Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
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Fejfarová V, Matuška J, Jude E, Piťhová P, Flekač M, Roztočil K, Wosková V, Dubský M, Jirkovská A, Bém R, Husáková J, Lánská V. Stimulation TcPO2 Testing Improves Diagnosis of Peripheral Arterial Disease in Patients With Diabetic Foot. Front Endocrinol (Lausanne) 2021; 12:744195. [PMID: 34956078 PMCID: PMC8704582 DOI: 10.3389/fendo.2021.744195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND All diagnostic procedures of peripheral arterial disease (PAD) in diabetic foot (DF) are complicated due to diabetes mellitus and its late complications.The aim of our study is to enhance diagnosis of PAD using a novel transcutaneous oximetry (TcPO2) stimulation test. METHODS The study comprised patients with mild-to-moderate PAD(WIfI-I 1 or 2) and baseline TcPO2 values of 30-50 mmHg.TcPO2 was measured across 107 different angiosomes. Stimulation examination involved a modification of the Ratschow test. All patients underwent PAD assessment (systolic blood pressures (SBP), toe pressures (TP), the ankle-brachial indexes (ABI) and toe-brachial indexes (TBI), duplex ultrasound of circulation). Angiosomes were divided into two groups based on ultrasound findings: group M(n=60) with monophasic flow; group T(n=47) with triphasic flow. Large vessel parameters and TcPO2 at rest and after exercise (minimal TcPO2, changes in TcPO2 from baseline (Δ,%), TcPO2 recovery time) measured during the stimulation test were compared between study groups. RESULTS During the TcPO2 stimulation exercise test, group M exhibited significantly lower minimal TcPO2 (26.2 ± 11.1 vs. 31.4 ± 9.4 mmHg; p<0.01), greater Δ and percentage decreases from resting TcPO2 (p=0.014 and p=0.007, respectively) and longer TcPO2 recovery times (446 ± 134 vs. 370 ± 81ms;p=0.0005) compared to group T. SBPs, TPs and indexes were significantly lower in group M compared to group T. Sensitivity and specificity of TcPO2 stimulation parameters during PAD detection increased significantly to the level of SBP, ABI, TP and TBI. CONCLUSION Compared to resting TcPO2, TcPO2 measured during stimulation improves detection of latent forms of PAD and restenosis/obliterations of previously treated arteries in diabetic foot patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov [https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009V7W&selectaction=Edit&uid=U0005381&ts=2&cx=3j24u2], identifier NCT04404699.
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Affiliation(s)
- Vladimíra Fejfarová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- *Correspondence: Vladimíra Fejfarová,
| | - Jiří Matuška
- MATMED, Vascular Outpatient Clinic, Hodonín, Czechia
| | - Edward Jude
- Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, United Kingdom
| | - Pavlína Piťhová
- Diabetes Centre, Second Faculty of Medicine, Motol Teaching Hospital, Prague, Czechia
| | - Milan Flekač
- First Faculty of Medicine, Charles University, Prague, Czechia
| | - Karel Roztočil
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Veronika Wosková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Alexandra Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Robert Bém
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jitka Husáková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Věra Lánská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
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Gariani K, Lebowitz D, Kressmann B, Gariani J, Uçkay I. X-Ray Versus Magnetic Resonance Imaging in Diabetic Foot Osteomyelitis: A Clinical Comparison. Curr Diabetes Rev 2021; 17:373-377. [PMID: 32729421 DOI: 10.2174/1573399816999200729124134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Radiographic imaging is an important diagnostic tool in diabetic foot osteomyelitis (DFO). It is unknown whether DFO cases diagnosed with conventional X-ray versus positive Magnetic Resonance Imaging (MRI) differ regarding epidemiology and treatment outcome. Theoretically, signs of inflammation on MRI without bone lesions might be easier to treat. METHODS Our clinical pathway for diabetic foot infections discourages the use of MRI for the diagnosis of DFO. We compared the epidemiology and therapy of non-amputated DFO with positive features on conventional X-ray, MRI, or both. Radiology specialists interpreted the images. The intraoperative aspect of bone during amputation and the results of bone cultures were considered the gold standard for DFO diagnosis. RESULTS We prospectively followed 390 DFO episodes in 186 adult patients for a median of 2.9 years and performed 318 conventional X-rays (median costs 100 Swiss Francs; 100 US$) and 47 (47/390; 12%) MRI scans (median 800 Swiss Francs; 800 US $). Among them, 18 episodes were associated with positive MRI findings but lacked bone lesions on X-ray. After debridement, the median duration of systemic antibiotics was 28 days for MRI-only episodes and 30 days for X-ray-positive cases (Wilcoxonranksum- test; p=0.26). The corresponding median numbers of surgical debridements were 1 and 1; and recurrence was witnessed in 25% and 28%, respectively. In multivariate logistic regression analysis, MRI-only episodes did not alter the remission rate (odds ratio 0.5, 95%CI 0.1-5.2). CONCLUSION According to our clinical pathway, DFO episodes with positive MRI findings only did not differ epidemiologically from the remaining DFO cases and did not influence the choice of therapy nor remission rate.
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Affiliation(s)
- Karim Gariani
- Division of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dan Lebowitz
- Division of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Benjamin Kressmann
- Clinical Pathway of Diabetic Foot Infections, University of Geneva Hospitals and Medical School, 1211 Geneva, Switzerland
| | - Joanna Gariani
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Ilker Uçkay
- Clinical Pathway of Diabetic Foot Infections, University of Geneva Hospitals and Medical School, 1211 Geneva, Switzerland
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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159
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Yang MC, Huang YY, Hsieh SH, Sun JH, Wang CC, Lin CH. Ankle-Brachial Index Is Independently Associated With Cardiovascular Outcomes and Foot Ulcers in Asian Patients With Type 2 Diabetes Mellitus. Front Endocrinol (Lausanne) 2021; 12:752995. [PMID: 34867797 PMCID: PMC8637053 DOI: 10.3389/fendo.2021.752995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIMS The ankle-brachial index (ABI) is an efficient tool for objectively documenting the presence of lower-extremity peripheral arterial disease (PAD). The predictive factors of cardiovascular events and diabetic foot ulcer were not clear from the ABI examination in Taiwanese patients with type 2 diabetes mellitus (DM). METHODS We enrolled 482 patients with type 2 DM who regularly visited the outpatient department of Chang Gung Memorial Hospital and received ABI as well as brachial-ankle pulse wave velocity (ba-PWV) examinations from 2010 to 2017. Age, gender, PAD symptoms, comorbidities, family history of chronic diseases, lifestyle (smoking, alcohol consumption, and exercise), height, weight, waist circumference, monofilament testing and foot ulcer status were studied. RESULTS There were 104 (22%) patients (mean age, 67.8 years) with the ABI <1.0. These patients with low ABI (ABI<1.0) had a significantly older age (p=0.001), higher delta PWV (p<0.001), higher rates of stroke (p=0.007), myocardial infarction (p=0.016), and foot ulcer (p=0.039). In a multivariable analysis model, the adjusted odds ratio (aOR) for myocardial infarction, stroke, and foot ulcers associated with low ABI were 1.219 (0.397-3.743, p=0.729), 1.204 (0.556-2.610, p=0.638), and 2.712 (1.199-6.133, p=0.017), respectively. The patients with low PWV (PWV<1400 cm/s) were significantly younger (p<0.001) and had a lower rate of hypertension (p<0.001), and higher percentages of stroke (p=0.027) and dialysis (p=0.041) family history. CONCLUSIONS Low ABI was associated with cardiovascular events and diabetic foot ulcer independently in patients with type 2 DM.
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Affiliation(s)
- Ming-Chi Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Sheng-Hwu Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jui-Hung Sun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Ching Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- *Correspondence: Chia-Hung Lin,
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Mendame Ehya RE, Zhang H, Qi B, Yu A. Application and Clinical Effectiveness of Antibiotic-Loaded Bone Cement to Promote Soft Tissue Granulation in the Treatment of Neuropathic Diabetic Foot Ulcers Complicated by Osteomyelitis: A Randomized Controlled Trial. J Diabetes Res 2021; 2021:9911072. [PMID: 34337074 PMCID: PMC8294998 DOI: 10.1155/2021/9911072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/25/2021] [Indexed: 11/17/2022] Open
Abstract
This study explored the clinical effectiveness of antibiotic-loaded bone cement on primary treatment of diabetic foot infection. This is a randomized controlled study, including thirty-six patients with diabetic foot ulcer complicated by osteomyelitis who had undergone treatment between May 2018 and December 2019. Patients were randomly divided into control group (group A) and study group (group B). Patients in the intervention group received antibiotic-loaded bone cement repair as primary treatment, while patients in the control group received conventional vacuum sealing draining treatment. Clinical endpoints were assessed and compared between the two groups, including wound healing time, wound bacterial conversion, NRS pain score, number of wound dressing changes, and average hospitalization time. All patients were followed up for a period of 12 months after discharge. Results show that compared with the control group, patients in the study group had significant difference in the number of patients for baseline pathogens eradication, short NRS pain score, hospital length of stay and cost, wound surface reduction, healing time, low rate of complications, and infection recurrence. Based on the findings, we conclude that antibiotic-loaded bone cement can be used for treatment of wound in patient with diabetic foot infection. It can help to control wound infections, shorten hospital length of stay, reduce medical cost, and relieve both doctors' and patients' burden. The application of antibiotic-loaded bone cement is suitable for diabetic wound with soft tissue infection or osteomyelitis.
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Affiliation(s)
- Regis Ernest Mendame Ehya
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Hao Zhang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Baiwen Qi
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
| | - Aixi Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071 Hubei, China
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161
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Mohamad M, Pham TT, Jornayvaz FR, Pignel R, Glauser F, Suva D. [Management of a foot ulcer in a patient with diabetes]. Rev Med Suisse 2020; 16:2446-2452. [PMID: 33325663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Despite a benign appearance, any foot injury occurring in a patient with diabetes requires multidisciplinary management if dreaded complications such as amputation are to be avoided. From a pathophysiological point of view, foot ulcer generally results from the combination of lower extremity neuropathy, mechanical overload, immunopathy and vascular insufficiency. The treatment associates in all cases an offloading and one or more debridements. Depending on the grade of the ulcer, adjuvant treatments, such as antibiotic therapy, revascularization, and hyperbaric oxygen therapy may be indicated.
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Affiliation(s)
- Morad Mohamad
- Service d'orthopédie et traumatologie de l'appareil moteur, Département de chirurgie, HUG, 1211 Genève 14
| | - Truong-Thanh Pham
- Service d'orthopédie et traumatologie de l'appareil moteur, Département de chirurgie, HUG, 1211 Genève 14
- Service des maladies infectieuses, Département de médecine, HUG, 1211 Genève 14
| | - François R Jornayvaz
- Service d'endocrinologie, diabétologie, nutrition et éducation thérapeutique du patient, HUG, 1211 Genève 14
| | - Rodrigue Pignel
- Service des urgences, Département de médecine aiguë, HUG, 1211 Genève 14
| | - Frédéric Glauser
- Service d'angiologie et d'hémostase, Département de médecine, HUG, 1211 Genève 14
| | - Domizio Suva
- Service d'orthopédie et traumatologie de l'appareil moteur, Département de chirurgie, HUG, 1211 Genève 14
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Balaban J, Bijelic R, Milicevic S, Stanetic K, Grbic N. Correlation Between Extracutaneous Microvascular Complications and Diabetic Foot Ulcers in Patients with Type 2 Diabetes Mellitus. Med Arch 2020; 74:444-449. [PMID: 33603269 PMCID: PMC7879372 DOI: 10.5455/medarh.2020.74.443-448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/13/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Diabetes is a metabolic disease that is taking an epidemic proportion around the world. The occurrence of microvascular complications and diabetic foot ulcer is associated with an increased mortality and morbidity incidence, which is the most serious complication of this disease, which significantly reduce the quality of patient life. OBJECTIVE The aim of the study was to determine the correlation of extracutaneous microvascular complications with diabetic foot ulcer in patients with type 2 diabetes. METHOD The study was prospective, and included 160 patients with type 2 diabetes. It was conducted at the University Clinical Center of the Republic of Srpska in the period from January 2016 until December 2019. The respondents were adults, of both sexes, suffering from type 2 diabetes, in whom complications of this disease are present. Glycemic control was established based on a target HbA1c value of 7%. RESULTS Of the 160 patients in the study, 53.8% were men and 46.2% were women. The average age of the patients was 70.11%±10.05 years. Extracutaneous microvascular complications were present in 85 patients (53.1%); of which 30.2% had well-regulated glycemia (HbA1c≤7.0%), while 61.5% (p<0.001) had unregulated glycemia (HbA1c≥7.0). Polyneuropathy was present in 23.3% of patients with HbA1c≤7.0%, while 41.0% of patients had HbA1c≥7.0% (p<0.043). Nephropathy with HbA1c≤7.0% was present in 36.8% of cases compared to patients with HbA1c≥7.0 in whom the prevalence was 36.8% (p<0.004). Out of total, 25.6% had retinopathy with HbA1c≤7.0%, while in 41.9% of patients with HbA1c≥7.0% (p <0.067). Diabetic ulcer foot was present in 13 patients with HbA1c≥7 (11.1%) compared to patients with HbA1c≤7.0% where there was no occurrence of this complication 0.0% (p<0.021). At the same time, 5.6% of patients had a diabetic foot ulcer with polyneuropathy (p=0.010), 4.4% had neuropathy (p=0.058) and 5.6% had retinopathy (p=0.014). CONCLUSION The high incidence of extracutaneous microvascular complications and diabetic foot ulcer in patients with type 2 diabetes requires a multidisciplinary approach of medical professionals that includes prevention of risk factors and good regulation of glycemia.
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Affiliation(s)
- Jagoda Balaban
- Skin and Venereal Diseases Clinic, University Clinical Centre of the Republic of Srpska, Banjaluka, Bosnia and Herzegovina
| | - Radojka Bijelic
- Primary Health Care Center, Banjaluka, Bosnia and Herzegovina
| | - Snjezana Milicevic
- Clinic of Urology, University Clinical Centre of the Republic of Srpska, Banjaluka, Bosnia and Herzegovina
| | - Kosana Stanetic
- Primary Health Care Center, Banjaluka, Bosnia and Herzegovina
| | - Nebojsa Grbic
- Clinic of Urology, University Clinical Centre of the Republic of Srpska, Banjaluka, Bosnia and Herzegovina
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Zou M, Cai Y, Hu P, Cao Y, Luo X, Fan X, Zhang B, Wu X, Jiang N, Lin Q, Zhou H, Xue Y, Gao F. Analysis of the Composition and Functions of the Microbiome in Diabetic Foot Osteomyelitis Based on 16S rRNA and Metagenome Sequencing Technology. Diabetes 2020; 69:2423-2439. [PMID: 32801139 DOI: 10.2337/db20-0503] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/16/2020] [Indexed: 11/13/2022]
Abstract
Metagenome sequencing has not been used in infected bone specimens. This prospective observational study explored the microbiome and its function in patients with diabetic foot osteomyelitis (DFO) and posttraumatic foot osteomyelitis (PFO) based on 16S rRNA sequencing and metagenome sequencing technologies. Spearman analysis was used to explore the correlation between dominant species and clinical indicators of patients with DFO. High-throughput sequencing showed that all the specimens were polymicrobial. The microbial diversity was significantly higher in the DFO group than in the PFO group. Firmicutes, Prevotellaceae, and Prevotella were the most abundant microbes in the DFO group. The most abundant microbes in the PFO group were Proteobacteria, Halomonadaceae, and Halomonas Prevotella denticola, Prevotella jejuni, and Prevotella fusca had positive correlation with the duration of diabetic foot infection (DFI_d). Proteus vulgaris was positively correlated with the infection index, while Bacteroides fragilis was negatively correlated. The microbial functional genes were more abundant in the DFO group than in the PFO group. Metagenome sequencing is feasible for the analysis of the microbiome in infected bone specimens. Gram-negative bacteria and anaerobes are dominant in DFO.
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Affiliation(s)
- Mengchen Zou
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yulan Cai
- Department of Endocrinology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ping Hu
- Department of Geriatric Medicine, Xiaogan Central Hospital, Xiaogan, China
| | - Yin Cao
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiangrong Luo
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xinzhao Fan
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bao Zhang
- School of Public Health and Tropic Medicine, Southern Medical University, Guangzhou, China
| | - Xianbo Wu
- School of Public Health and Tropic Medicine, Southern Medical University, Guangzhou, China
| | - Nan Jiang
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingrong Lin
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Zhou
- Department of Hospital Infection Management of Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaoming Xue
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fang Gao
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
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164
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Tan TL, Lim SH, Ruslan Mustapa M, Ganeswary R. Pericardial abscess: The corollary of disseminated Methicillin-resistant Staphylococcus aureus following diabetic foot ulcer infection. Med J Malaysia 2020; 75:742-744. [PMID: 33219189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) purulent pericarditis, characterised by frank pus collection or microscopic pyogenic effusion in the pericardium represents the most serious form of pericardial infection. The route of MRSA acquisition in pericardial abscess commonly occurs via the blood stream infection and it is more commonly observed among immunocompromised individuals. To date, diabetic foot ulcer infection rarely disseminates and becomes a nidus for pericardial infection. Herein, we report an unusual case of MRSA pericardial abscess in a 44-year-old man who presented at Hospital Seri Manjung, Malaysia with cardiac tamponade. Past medical history indicated that he was recently treated for infected diabetic foot ulcer with MRSA bacteraemia one week earlier. Despite adequate pericardial drainage and extended parenteral vancomycin therapy, this case ended in fatality on day 42 of admission due to nosocomial infection. It is hoped that this report serves to increase the vigilance among clinicians that diabetic foot ulcer infections have the potential to progress to pericardial abscess in the presence of MRSA bacteraemia, although they may appear seemingly innocuous at presentation. Systemic vancomycin must be instituted promptly when MRSA bacteraemia is confirmed in order to circumvent the propagation of MRSA.
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Affiliation(s)
- T L Tan
- Hospital Seri Manjung, Department of Internal Medicine, Perak, Ministry of Health, Malaysia.
| | - S H Lim
- Hospital Seri Manjung, Department of Internal Medicine, Perak, Ministry of Health, Malaysia
| | - M Ruslan Mustapa
- Hospital Seri Manjung, Department of Internal Medicine, Perak, Ministry of Health, Malaysia
| | - R Ganeswary
- Hospital Seri Manjung, Department of Radiology, Perak, Ministry of Health, Malaysia
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165
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Lee S, Mey L, Szymanska AF, Takhar HS, Cuccia DJ, Mazhar A, Yu K. SFDI biomarkers provide a quantitative ulcer risk metric and can be used to predict diabetic foot ulcer onset. J Diabetes Complications 2020; 34:107624. [PMID: 32522482 DOI: 10.1016/j.jdiacomp.2020.107624] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/08/2020] [Accepted: 05/08/2020] [Indexed: 11/16/2022]
Abstract
AIMS Annually, up to 4% of people with diabetes present with a chronic foot ulcer. Quantitative real-time testing to identify patients at risk for ulceration can guide preventative care. Here, we assess whether a non-invasive optical imaging technique, Spatial Frequency Domain Imaging (SFDI), can identify patients at the highest risk for ulceration and predict ulcer onset. METHODS We imaged 252 subjects with diabetes at Kaiser Permanente, Southern California. SFDI derived tissue biomarkers of microcirculation were compared between subjects with and without a history of ulceration, and subjects who did or did not develop ulcers after 1 year. RESULTS Feet of subjects at the highest risk (i.e. history of ulceration) had significantly lower hemoglobin in the papillary dermis (HbT1), along with higher oxygenation (StO2) due to poor extraction. These subjects also had more homogeneous hemoglobin spread in the reticular dermis (HbT2) and tissue scattering (related to skin structure). Prediction based on HbT1 and tissue scattering identified new ulcerations and performed with sensitivity/specificity of 68.8%/64.8% and 75.0%/69.1%, respectively. CONCLUSION These results show that SFDI hemoglobin distribution and oxygenation biomarkers provide a quantitative basis for ulcer risk stratification and ulcer onset prediction.
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Affiliation(s)
- Suzette Lee
- Kaiser Permanente, Southern California Pasadena, CA, United States of America.
| | - Leann Mey
- Kaiser Permanente, Southern California Pasadena, CA, United States of America
| | | | - Harpreet S Takhar
- Kaiser Permanente, Southern California Pasadena, CA, United States of America
| | | | | | - Kalvin Yu
- Kaiser Permanente, Southern California Pasadena, CA, United States of America
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Brodell JD, Ayers BC, Baumhauer JF, DiGiovanni BF, Flemister AS, Ketz JP, Oh I. Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection. J Am Acad Orthop Surg 2020; 28:684-691. [PMID: 32769724 DOI: 10.5435/jaaos-d-19-00757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- James D Brodell
- From the Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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Thomas HM, Ahangar P, Hofma BR, Strudwick XL, Fitridge R, Mills SJ, Cowin AJ. Attenuation of Flightless I Increases Human Pericyte Proliferation, Migration and Angiogenic Functions and Improves Healing in Murine Diabetic Wounds. Int J Mol Sci 2020; 21:ijms21165599. [PMID: 32764293 PMCID: PMC7460558 DOI: 10.3390/ijms21165599] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 12/14/2022] Open
Abstract
Pericytes are peri-vascular mural cells which have an important role in the homeostatic regulation of inflammatory and angiogenic processes. Flightless I (Flii) is a cytoskeletal protein involved in regulating cellular functions, but its involvement in pericyte activities during wound healing is unknown. Exacerbated inflammation and reduced angiogenesis are hallmarks of impaired diabetic healing responses, and strategies aimed at regulating these processes are vital for improving healing outcomes. To determine the effect of altering Flii expression on pericyte function, in vitro and in vivo studies were performed to assess the effect on healing, inflammation and angiogenesis in diabetic wounds. Here, we demonstrated that human diabetic wounds display upregulated expression of the Flii protein in conjunction with a depletion in the number of platelet derived growth factor receptor β (PDGFRβ) +/ neural glial antigen 2 (NG2) + pericytes present in the dermis. Human pericytes were found to be positive for Flii and attenuating its expression in vitro through siRNA knockdown led to enhanced proliferation, migration and angiogenic functions. Genetic knockdown of Flii in a streptozotocin-induced murine model of diabetes led to increased numbers of pericytes within the wound. This was associated with dampened inflammation, an increased rate of angiogenic repair and improved wound healing. Our findings show that Flii expression directly impacts pericyte functions, including proliferation, motility and angiogenic responses. This suggests that Flii regulation of pericyte function may be in part responsible for the changes in pericyte-related processes observed in diabetic wounds.
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Affiliation(s)
- Hannah M Thomas
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Parinaz Ahangar
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Benjamin R Hofma
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Xanthe L Strudwick
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide 5000, Australia;
| | - Stuart J Mills
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Cell Therapy Manufacturing Cooperative Research Centre, Adelaide 5000, Australia
| | - Allison J Cowin
- Future Industries Institute, University of South Australia, Adelaide 5000, Australia; (H.M.T.); (P.A.); (B.R.H.); (X.L.S.); (S.J.M.)
- Clinical and Health Sciences, University of South Australia, Adelaide 5000, Australia
- Correspondence: ; Tel.: +61-883-025-018
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Caetano AP, Conde Vasco I, Veloso Gomes F, Costa NV, Luz JH, Spaepen E, Formiga A, Coimbra É, Neves J, Bilhim T. Successful Revascularization has a Significant Impact on Limb Salvage Rate and Wound Healing for Patients with Diabetic Foot Ulcers: Single-Centre Retrospective Analysis with a Multidisciplinary Approach. Cardiovasc Intervent Radiol 2020; 43:1449-1459. [PMID: 32743744 DOI: 10.1007/s00270-020-02604-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Analyze the impact of endovascular revascularization on major amputation rates and wound healing for patients with diabetic foot ulcers (DFUs). MATERIALS AND METHODS Single-center retrospective study from 2014-2018 including 314 patients with DFUs submitted to endovascular revascularizations. Group A-patients with a successful endovascular revascularization (n = 285; 90.8%); Group B-patients submitted to a failed attempt of endovascular revascularization (n = 29; 9.2%). Baseline data were not significantly different between the 2 groups (p > 0.05). Both groups were compared regarding: major amputation rates; wound healing, mortality and adverse events. Survival and regression analyses were used. RESULTS Mean follow-up time was 734.1 ± 610.2 days. Major amputation rates were 3.9% versus 24.1% (p < 0.0001) and complete wound healing was 53.7% versus 20.7% (p < 0.0001) for patients from Group A versus Group B, respectively. Major adverse events were registered in 2 patients (one from each group); minor adverse events included 10 patients from Group A and 2 patients from Group B (p = 0.3654). Major amputation rates were: 3.9% versus 27.5% at 1 year; 4.6% versus 27.5% at 2-5 years for Group A versus Group B, respectively (p < 0.0001). Survival rates were: 87.8% at 1 year; 84.4% at 2 years; and 77.9% at 5 years with no significant differences between groups. Predictors for major amputation included failed revascularization (p < 0.0001), older age (p = 0.0394), prior stroke (0.0018), dialysis (0.0476). Predictors for mortality included older age (p < 0.0001) and coronary artery disease (p = 0.0388). CONCLUSION Endovascular revascularization for patients with DFUs is safe and has a significant impact on limb salvage and wound healing.
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Affiliation(s)
- António Proença Caetano
- Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Inês Conde Vasco
- Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
| | - Filipe Veloso Gomes
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Nuno Vasco Costa
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - José Hugo Luz
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
- Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Ana Formiga
- Diabetic Foot Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
| | - Élia Coimbra
- Head Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
| | - José Neves
- Head of Diabetic Foot Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal
| | - Tiago Bilhim
- Interventional Radiology Unit, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central (CHULC), 1069-166, Lisbon, Portugal.
- Nova Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
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169
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He YX, Kang K, Jia GX. Effect of sarcopenia combined with platelet-rich plasma on transverse tibial bone transport in diabetic foot. J BIOL REG HOMEOS AG 2020; 34:1451-1457. [PMID: 32883065 DOI: 10.23812/20-203-l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Y X He
- Department of Orthopaedics Trauma, The Third Hospital of Shijiazhuang, Shijiazhuang, China
| | - K Kang
- Department of Orthopaedics, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - G X Jia
- Department of Orthopaedics, The First Hospital of Hebei Medical University, Shijiazhuang, China
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170
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Meloni M, Izzo V, Giurato L, Gandini R, Uccioli L. Management of diabetic persons with foot ulceration during COVID-19 health care emergency: Effectiveness of a new triage pathway. Diabetes Res Clin Pract 2020; 165:108245. [PMID: 32497745 PMCID: PMC7263238 DOI: 10.1016/j.diabres.2020.108245] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/27/2022]
Abstract
AIM To define the outcomes of persons with diabetes and foot ulcers (DFUs) managed through a specific triage pathway during the COVID-19 crisis. METHODS Patients who had an active DFU during the COVID-19 emergency were included. All participants were managed using a specific triage system driven both by ulcer'severity and concomitant co-diseases. Subjects with severely complicated DFUs were urgently referred to hospital regardless of the concomitant comorbidities. Subjects with complicated DFUs received outpatient evaluation (within 48-72 h) and were admitted to hospital if required (revascularization, surgical intervention, intravenous antibiotic therapy); after the first outpatient visit or hospitalization, patients were followed according to the number of comorbidities (in the case of 3 or more comorbidities patients were followed up by telemedicine). Patients with uncomplicated DFUs were managed by telemedicine after outpatient evaluation. Healing, major amputation, death and rate of COVID-19 infection were evaluated. The minimum follow-up was 1 month. RESULTS The study group included 151 patients. The mean age was 69.9 ± 14.2 years, 58.9% were male and 91.4% had type 2 diabetes; 58.7% had severely complicated, 21% complicated and 20.3% uncomplicated DFUs. Among those, 78.8% presented with 3 or more comorbidities. One hundred and six patients had regular clinical follow-ups, while 45 were managed through telemedicine. Forty-one (27.1%) patients healed, 3 (1.9%) had major amputations and 3 (1.9%) died. One patient (0.6%) reported COVID-19 positivity due to infection acquired at home. CONCLUSION The triage pathway adopted during the COVID-19 pandemic showed adequate management of DFUs and no cases of hospital virus exposure.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy.
| | - Valentina Izzo
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
| | - Laura Giurato
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
| | | | - Luigi Uccioli
- Diabetic Foot Unit, University of Tor Vergata, Rome, Italy
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de Oliveira Kaizer UA, Alexandre NMC, Rodrigues RCM, Cornélio ME, de Melo Lima MH, São‐João TM. Measurement properties and factor analysis of the Diabetic Foot Ulcer Scale-short form (DFS-SF). Int Wound J 2020; 17:670-682. [PMID: 32065735 PMCID: PMC7949341 DOI: 10.1111/iwj.13310] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 01/22/2023] Open
Abstract
The purpose of this paper is to provide measurement properties evaluation and factor analysis of the Brazilian version of the diabetic foot ulcer scale-short form (DFS-SF). This methodological study evaluated the measurement properties of the DFS-SF by ceiling and floor effect reliability, responsiveness, and structural construct validity. The study included 290 people with diabetic foot under regular follow-up in a specialised outpatient clinic in inland São Paulo. Reliability was assessed by internal consistency using Cronbach's alpha and composite reliability. Ceiling and floor effects were assessed by the percentage of participants who scored the 15% worst (floor) and 15% best (ceiling) possible scale results. Validity was tested by correlating the instrument values with the domains of the Brazilian version of the Short Form Health Survey (SF-36). Responsiveness (n = 34) was accessed through the wound area obtained by photography and evaluated by the Image J Features program and the DFS-SF score at two moments, with a 4-week interval between them. The instrument had good evidence of reliability, shown by adequate internal consistency (Cronbach's alpha in domains >0.70) and compound reliability (0.84 > CC > 0.92); and of convergent validity, by significant positive correlations of moderate to strong magnitude with SF-36. Structural construct validity was examined by applying the DFS-SF confirmatory factor analysis, which indicated that the Brazilian version of the instrument is properly fitted to the original dimensional structure. The ceiling and floor effect analysis showed no ceiling or floor effects. Responsiveness was observed in the wound area, but not in the DFS-SF scores in the times. The Brazilian version of the DFS-SF presented evidence of validity and reliability, suggesting that this instrument is a valid tool for assessing the quality of life of people with diabetic foot in the Brazilian population.
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Zhang Y, Wang S, Liu M, Yao S, Fang S, Cheng H, Chen Q. Adjunctive rifampin therapy for diabetic foot osteomyelitis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20375. [PMID: 32481422 DOI: 10.1097/md.0000000000020375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The prevalence of diabetes continues to rise around the world. Diabetic foot is a serious complication of diabetes, and diabetic patients with diabetic foot osteomyelitis (DFO) have a fourfold increased risk of amputation, usually indicating death. Therefore, it is particularly important to seek a more effective treatment for DFO. The treatment of DFO varies from person to person, and antimicrobial therapies vary widely. A large number of clinical studies have shown that rifampicin adjuvant therapy can reduce the rate of amputation and mortality in DFO patients. However, there is no systematic summary of clinical evidence, which limits the clinical application of rifampicin. Therefore, we attempted to provide high-quality evidence for the clinical efficacy and safety of rifampin in the adjuvant treatment of DFO through this meta-analysis. METHODS English literature is mainly searched in Cochrane Library, PubMed, EMBASE and Web of Science, while Chinese literature is from CNKI, CBM, VIP and Wangfang databases. At the same time, we will search clinical registration tests and gray literature. Two methodologically trained researchers will read the title, abstract, and full text, and independently select qualified literature based on inclusion and exclusion criteria. Binary data is expressed as relative risk, continuous data is expressed as mean difference or standard mean difference. The final data are synthesized using a fixed effect model or a random effect model, depending on the presence of heterogeneity. In the end, the patient's amputation rate and mortality were the main research indicators. Survival rate, HbA1c, serum creatinine, changes in ulcer area, and SF-36 quality of life assessment were used as secondary indicators. We will perform a sensitivity analysis to assess the stability of the results. Then the publication bias was evaluated by funnel plot analysis and Egger test. Finally, we will use a "recommendation grading, evaluation, formulation and evaluation" system to assess the quality of the evidence. All data analysis will be meta-analyzed by the statistical software RevMan software version 5.3. RESULTS This study will provide a high-quality comprehensive report on the effectiveness and safety of rifampicin in the treatment of DFO, and our findings will be published in peer-reviewed journals. CONCLUSION This systematic review and meta-analysis will provide a comprehensive summary and careful evaluation of rifampicin as an adjuvant treatment of DFO with a view to providing multiple options for clinical treatment of the disease. REGISTRATION NUMBER:: is INPLASY202040084.
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Affiliation(s)
- Yanli Zhang
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, P.R. China
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Manas AB, Taori S, Ahluwalia R, Slim H, Manu C, Rashid H, Kavarthapu V, Edmonds M, Vas PRJ. Admission Time Deep Swab Specimens Compared With Surgical Bone Sampling in Hospitalized Individuals With Diabetic Foot Osteomyelitis and Soft Tissue Infection. INT J LOW EXTR WOUND 2020; 20:300-308. [PMID: 32370639 DOI: 10.1177/1534734620916386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharging ulcer probing to the bone and the subsequent surgical bone sample (SBS) taken during surgical debridement was made. A total of 63 subjects (age 60.8 ± 13.5 years, 75% male, 80% Type 2 diabetes, HbA1C 8.9%±2.2%) were included. The proportion of Gram-positive (DWS 49% v SBS 52%) and Gram-negative (DWS 60% v SBS 60%) isolates was similar between the techniques. However, the overall concordance of isolates between the two techniques was only fair (κ=0.302). The best concordance was observed for Staphylococcus aureus (κ=0.571) and MRSA (κ=0.644). There was a correlation between number of isolates in SBS with prior antibiotic therapy of any duration (r= -0.358, p=0.005) and with the duration of ulceration (r=0.296, p=0.045); no clinical correlations were found for DWS. Prior antibiotic therapy (p=0.03) and duration of ulceration <8 weeks (p=0.025) were predictive of negative growth on SBS. In conclusion, we found only a fair concordance between deep wound swabs acquired at admission and surgical bone specimens in those presenting with a severe diabetic foot infection and features of osteomyelitis. Ensuring early surgical debridement of all infected tissue and obtaining bone specimens should be considered a clinical priority, which may also reduce the likelihood of negative growth on SBS.
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Affiliation(s)
| | - Surabhi Taori
- Diabetes Foot Unit, King's College Hospital, London, UK
- School of Immunology & Microbial Sciences, King's College, London, UK
| | | | - Hani Slim
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - C Manu
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - Hisham Rashid
- Diabetes Foot Unit, King's College Hospital, London, UK
| | | | | | - Prashanth R J Vas
- Diabetes Foot Unit, King's College Hospital, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
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Black C, Fan KL, Defazio MV, Luvisa K, Reynolds K, Kotha VS, Attinger CE, Evans KK. Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population. Plast Reconstr Surg 2020; 145:1302-1312. [PMID: 32332556 DOI: 10.1097/prs.0000000000006791] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. METHODS A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). RESULTS One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. CONCLUSIONS This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Cara Black
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kenneth L Fan
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Michael V Defazio
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kyle Luvisa
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Kyle Reynolds
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Vikas S Kotha
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Christopher E Attinger
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
| | - Karen K Evans
- From the Departments of Plastic and Reconstructive Surgery and Vascular Surgery, MedStar Georgetown University Hospital; Georgetown University School of Medicine; and the University of Texas M. D. Anderson Cancer Center
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175
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Woods TJ, Tesfay F, Speck P, Kaambwa B. Economic evaluations considering costs and outcomes of diabetic foot ulcer infections: A systematic review. PLoS One 2020; 15:e0232395. [PMID: 32353082 PMCID: PMC7192475 DOI: 10.1371/journal.pone.0232395] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 04/14/2020] [Indexed: 12/30/2022] Open
Abstract
Background Diabetic foot ulcer (DFU) is a severe complication of diabetes and particularly susceptible to infection. DFU infection intervention efficacy is declining due to antimicrobial resistance and a systematic review of economic evaluations considering their economic feasibility is timely and required. Aim To obtain and critically appraise all available full economic evaluations jointly considering costs and outcomes of infected DFUs. Methods A literature search was conducted across MedLine, CINAHL, Scopus and Cochrane Database seeking evaluations published from inception to 2019 using specific key concepts. Eligibility criteria were defined to guide study selection. Articles were identified by screening of titles and abstracts, followed by a full-text review before inclusion. We identified 352 papers that report economic analysis of the costs and outcomes of interventions aimed at diabetic foot ulcer infections. Key characteristics of eligible economic evaluations were extracted, and their quality assessed against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results 542 records were screened and 39 full-texts assessed for eligibility. A total of 19 papers were included in the final analysis. All studies except one identified cost-saving or cost-effective interventions. The evaluations included in the final analysis were so heterogeneous that comparison of them was not possible. All studies were of “excellent”, “very good” or “good” quality when assessed against the CHEERS checklist. Conclusions Consistent identification of cost-effective and cost-saving interventions may help to reduce the DFU healthcare burden. Future research should involve clinical implementation of interventions with parallel economic evaluation rather than model-based evaluations.
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Affiliation(s)
- Taylor-Jade Woods
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
- * E-mail:
| | - Fisaha Tesfay
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
| | - Peter Speck
- College of Science and Engineering, Flinders University, Bedford Park, South Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
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176
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Julien G, Francois M, Vernet-Garnier V, Bajolet O, Lebrun D, Hentzien M, Ohl X, Diallo S, Bani-Sadr F. Short duration of post-amputation antibiotic therapy in diabetic foot patients with total resection of osteomyelitis. Med Mal Infect 2020; 50:433-435. [PMID: 32360115 DOI: 10.1016/j.medmal.2020.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/07/2020] [Accepted: 04/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Short duration of post-amputation antibiotic therapy (2-5 days) is recommended in patients with diabetic foot osteomyelitis after total resection of infected bone tissue. OBJECTIVE To evaluate the long-term effectiveness of short-duration post-amputation antibiotic therapy in diabetic patients with total resection of osteomyelitis assessed by sterile bone bacteriological samples obtained from the resection margin. METHODS The endpoint was the absence of osteomyelitis relapse at 6 months, defined as recurrence of osteomyelitis with the need for surgical revision and/or new bone antibiotic therapy. RESULTS Among 15 patients included, 12 (80%) were cured without recurrence of osteomyelitis at 6 months, with a mean duration of antibiotic therapy of 8.3±5.9 days post surgery. This result is comparable to literature data, while all of them reported longer duration of antibiotic therapy and/or shorter follow-up. CONCLUSION Short duration of post-amputation antibiotic therapy in diabetic patients with sterile bacteriological samples obtained from resection margin seems effective.
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Affiliation(s)
- G Julien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - M Francois
- Department of endocrinology-diabetology, Reims teaching hospitals, Reims, France
| | - V Vernet-Garnier
- Department of bacteriology, Reims teaching hospitals, Reims, France
| | - O Bajolet
- Department of hygiene, Reims teaching hospitals, Reims, France
| | - D Lebrun
- Department of internal medicine and infectious diseases, Manchester hospital, Charleville-Mezieres, France
| | - M Hentzien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - X Ohl
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - S Diallo
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - F Bani-Sadr
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France.
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177
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Zakariah NA, Bajuri MY, Hassan R, Ismail Z, Md Mansor M, Othman H, Nasuruddin DN. Is Procalcitonin more superior to hs-CRP in the diagnosis of infection in diabetic foot ulcer? Malays J Pathol 2020; 42:77-84. [PMID: 32342934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Procalcitonin (PCT) has recently emerged as a marker for diagnosing infection. This study aimed to compare the performance of PCT and other infection markers in diagnosing infected diabetic foot ulcer (IDFU). MATERIALS AND METHODS A total of 128 diabetic patients with foot ulcers were recruited and divided into two groups, consisting of 73 patients in the IDFU group and 55 in the non-infected diabetic foot ulcer (NIDFU). The severity of infection in IDFU patients was graded based on the Infectious Disease Society of America-International Working Group on the Diabetic Foot classification. Blood samples from all the patients were collected for measurement of PCT, high sensitivity C-reactive protein (hs-CRP) and white cell count (WBC). The area under the receiver operating curves (AUC) were then constructed and analysed. RESULTS PCT, hs-CRP and WBC levels were significantly higher in the IDFU group compared to NIDFU with hs-CRP demonstrated the highest AUC (0.91; p <0.001) followed by PCT (0.814; p < 0.001) and lastly WBC (0.775; p < 0.001). The best cut off value, sensitivity and specificity for the presence of infection in diabetic foot, were 3.47 mg/dL, 80% and 89% for hs-CRP, 0.11 ng/ml, 70% and 87% for PCT and 11.8x109/L, 60% and 90% for WBC. All the infection markers showed significant positive correlations with infection severity of DFU. CONCLUSION This study showed that hs-CRP is a more sensitive marker for diagnosing IDFU. Although PCT is useful in differentiating IDFU from NIDFU, the use of PCT is not necessary as it adds little value to the current practice.
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Affiliation(s)
- N A Zakariah
- University Kebangsaan Malaysia Medical Centre, Department of Pathology, Kuala Lumpur, Malaysia.
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178
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Rastogi A, Goyal G, Kesavan R, Bal A, Kumar H, Kamath P, Jude EB, Armstrong DG, Bhansali A. Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study. Diabetes Res Clin Pract 2020; 162:108113. [PMID: 32165163 DOI: 10.1016/j.diabres.2020.108113] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/20/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
AIMS This long-term prospective study evaluated limb amputation and mortality after the first neuropathic diabetic foot ulcer (DFU). METHODS A total of 2880 patients with neuropathic DFU (DFU group) and a similar number of patients of diabetes without DFU (nDFU) matched for age and diabetes duration were prospectively assessed at five referral-centers over 14 years. Pre-defined outcome was death during follow-up. Various diabetic co-morbidities and amputation were assessed as mortality predictors. RESULTS Overall, 501 (17.4%) patients in DFU group died compared to 89 (3.1%) (p < 0.01) in nDFU group during a median follow-up of 7(1-14) years. The 5- and 10-year mortality was 22% and 71% in the DFU group with a median survival of 7.72 (7.37-8.08) years compared to 3% (p < 0.01) and 5% (p < 0.01) and survival of 12.6 (10.5-12.7) years (p < 0.001) in nDFU group. 29.3% patients had limb amputations. The mortality risk was independent of glycemic control [OR 1.03 (0.80-1.32; p = 0.83)]. However, diabetes duration > 10 years [OR 1.31(1.02-1.70, p = 0.035)], nephropathy [OR 1.47 (1.04-2.09, p < 0.030)], minor 1.85 (1.40-2.44; p < 0.001) or major amputation 2.96 (2.01-4.34, p < 0.001)] predicted mortality. CONCLUSIONS Every one-in-three individual with neuropathic DFU has amputation and every sixth individual has an early demise. Prevalent nephropathy and incident amputation following DFU predicts mortality.
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Affiliation(s)
- Ashu Rastogi
- Deptt. of Endocrinology, PGIMER, Chandigarh, India.
| | - Ghanshyam Goyal
- ILS Hospital, Salt Lake, Kolkata, India; SVS Marwari Hospital, Amhesrst Street, Kolkata, India
| | | | - Arun Bal
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Harish Kumar
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priyatham Kamath
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Edward B Jude
- Tameside Hospital, NHS Foundation and Trust, Ashton under Lyne, Manchester, UK
| | - David G Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, USA
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3277. [PMID: 32176448 DOI: 10.1002/dmrr.3277] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023]
Abstract
The accurate identification of peripheral artery disease (PAD) in patients with diabetes and foot ulceration is important, in order to inform timely management and to plan intervention including revascularisation. A variety of non-invasive tests are available to diagnose PAD at the bedside, but there is no consensus as to the most useful test, or the accuracy of these bedside investigations when compared to reference imaging tests such as magnetic resonance angiography, computed tomography angiography, digital subtraction angiography or colour duplex ultrasound. Members of the International Working Group of the Diabetic Foot updated our previous systematic review, to include all eligible studies published between 1980 and 2018. Some 15 380 titles were screened, resulting in 15 eligible studies (comprising 1563 patients, of which >80% in each study had diabetes) that evaluated an index bedside test for PAD against a reference imaging test. The primary endpoints were positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We found that the most commonly evaluated test parameter was ankle brachial index (ABI) <0.9, which may be useful to suggest the presence of PAD (PLR 6.5) but an ABI value between 0.9 and 1.3 does not rule out PAD (NLR 0.31). A toe brachial index >0.75 makes the diagnosis of PAD less likely (NLR 0.14-0.24), whereas pulse oximetry may be used to suggest the presence of PAD (if toe saturation < 2% lower than finger saturation; PLR 17.23-30) or render PAD less likely (NLR 0.2-0.27). We found that the presence of triphasic tibial waveforms has the best performance value for excluding a diagnosis of PAD (NLR 0.09-0.28), but was evaluated in only two studies. In addition, we found that beside clinical examination (including palpation of foot pulses) cannot reliably exclude PAD (NLR 0.75), as evaluated in one study. Overall, the quality of data is generally poor and there is insufficient evidence to recommend one bedside test over another. While there have been six additional publications in the last 4 years that met our inclusion criteria, more robust evidence is required to achieve consensus on the most useful non-invasive bedside test to diagnose PAD.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation, University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki University Hospital, Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Seattle, Washington
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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180
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Boyko EJ. How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3241. [PMID: 31845475 DOI: 10.1002/dmrr.3241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Abstract
Assessment of ischaemia and interventions to improve perfusion are key elements in the management of the diabetic foot ulcer to achieve wound healing. This article will review, analyse and interpret the value of clinical information in determining the likelihood of limb ischaemia and thereby the need for referral to a vascular specialist. I conducted an historical review of the genesis of several currently recommended clinical signs and their diagnostic properties in the assessment of limb ischaemia. Changes in limb ischaemia probability based on such results were calculated using Bayes theorem, and the use of such probabilities is discussed in the context of the threshold approach to clinical decision making. Some clinical signs have negligible value in altering probability of limb ischaemia, possibly because they were advocated by Buerger for the diagnosis of thromboangiitis obliterans, an occlusive vascular disease of a different pathophysiology than atherosclerosis. Pedal pulse palpation, the most widely studied clinical sign, will marginally change a pre-test probability of ischaemia of 50% to 76% if positive (abnormal pulses) and to 36% if negative (normal pulses). Higher or lower pre-test probabilities of ischaemia will change the post-test probabilities such that these are too low or high to rule in or rule out ischaemia, respectively. Individual clinical signs convey little information regarding the presence of limb ischaemia but may have some value in combination or with pre-test probability near 50% in the assessment of ischaemia and the decision to refer for a vascular consultation.
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Affiliation(s)
- Edward J Boyko
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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181
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Sharma S, Schaper N, Rayman G. Microangiopathy: Is it relevant to wound healing in diabetic foot disease? Diabetes Metab Res Rev 2020; 36 Suppl 1:e3244. [PMID: 31845461 DOI: 10.1002/dmrr.3244] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/18/2019] [Indexed: 12/15/2022]
Abstract
Chronic diabetic complications - both microvascular and macrovascular - have become serious health issues with their increasing prevalence paralleling the dramatic rise of the diabetic population worldwide. Of these complications, foot disease is a major cause of morbidity and mortality, consuming more health care resource than all other complications combined. Diabetic polyneuropathy and peripheral vascular disease constitute the two main risk factors, with trauma and foot infection being the most important initiating factors and contributors to delayed healing. Intracellular oxidative stress mediated by hyperglycaemia along with hypertension, dyslipidaemia and smoking constitute the main pathological processes in the aetiology of both macrovascular and microvascular disease. Whilst the former remains the major cause of overall mortality in diabetes, the role of microangiopathy in the pathogenesis of diabetes foot disease and its contribution to delayed wound healing in diabetes has yet to be fully understood and indeed continues to be debated. This article will review the key findings to date on structural and functional microvascular abnormalities in the diabetic foot skin and consider their contribution to impaired would healing.
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Affiliation(s)
- Sanjeev Sharma
- Diabetes Research unit, Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Nicolaas Schaper
- Department of Internal Medicine and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, Netherlands
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Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3276. [PMID: 31958217 DOI: 10.1002/dmrr.3276] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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Affiliation(s)
| | - Rachael O Forsythe
- British Heart Foundation/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, AZ
| | - Sigrid Nikol
- Department of Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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183
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Abstract
BACKGROUND Diabetic foot (DF) problems are common throughout the world, about one-fourth of them develop a foot ulcer and serious cases would suffer from amputation, which seriously affects the patient's work and life. Previous studies indicated that acupuncture as adjuvant therapy would be effective in treating DF. However, these studies have no consistent results. Therefore, the aim of our study was to explore the efficacy and safety of acupuncture as adjuvant therapy for DF. METHODS The randomized controlled trials associated with acupuncture therapy (or as adjuvant therapy) for DF will be included. We will search 6 electronic databases relevant to health sciences, including PubMed, Embase, the Cochrane Library, the Chinese databases Sino-Med, CNKI, and WANFANG database. All searches were from databases inception to March 30, 2019. The primary outcomes are the total curative effective rate, and the hemodynamic parameter and adverse events will be deemed as secondary outcomes. The Stata15.1 software and Review Manager (RevMan 5.3; Cochrane Collaboration, Copenhagen, Denmark) will be used for analysis, to assess the bias risk, subgroup analysis, and data synthesis. RESULTS In this systematic review and meta-analysis, we will synthesize the studies to assess the safety and efficacy of acupuncture as adjuvant therapy for DF. CONCLUSION The summary of our study will clarify whether acupuncture as adjuvant therapy could be an efficient method for DF.
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Affiliation(s)
- Maosheng Lee
- Guangzhou University of Chinese Medicine, University Town of Guangzhou, Panyu District, Guangzhou City
- Department of Endocrinology, Shenzhen Traditional Chinese Medicine Hospital, Futian District, Shenzhen City, Guangdong Province, China
| | - Huilin Li
- Department of Endocrinology, Shenzhen Traditional Chinese Medicine Hospital, Futian District, Shenzhen City, Guangdong Province, China
| | - Deliang Liu
- Department of Endocrinology, Shenzhen Traditional Chinese Medicine Hospital, Futian District, Shenzhen City, Guangdong Province, China
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184
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Fitridge R, Pena G, Mills JL. The patient presenting with chronic limb-threatening ischaemia. Does diabetes influence presentation, limb outcomes and survival? Diabetes Metab Res Rev 2020; 36 Suppl 1:e3242. [PMID: 31867854 DOI: 10.1002/dmrr.3242] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/18/2019] [Indexed: 11/05/2022]
Abstract
Peripheral arterial disease (PAD) confers an elevated risk of major amputation and delayed wound healing in diabetic patients with foot ulcers. The major international vascular societies recently developed evidence-based guidelines for the assessment and management of patients with chronic limb-threatening ischaemia (CLTI). CLTI represents the cohort of diabetic and non-diabetic patients who have PAD which is of sufficient severity to delay wound healing and increase amputation risk. Diabetic patients with CLTI are more likely to present with tissue loss, infection and have less favourable anatomy for revascularization than those without diabetes. Although diabetes is not consistently reported as a strong independent risk factor for limb loss, major morbidity and mortality in CLTI patients, it is impossible in clinical practice to isolate diabetes from comorbidities, such as end-stage renal disease and coronary artery disease which occur more commonly in diabetic patients. Treatment of CLTI in the diabetic patient is complex and should involve a multi-disciplinary team to optimize outcomes. Clinicians should use an integrated approach to management based on patient risk assessment, an assessment of the severity of the foot pathology and a structured anatomical assessment of arterial disease as suggested by the Global Vascular Guidelines for CLTI.
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Affiliation(s)
- Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Guilherme Pena
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Texas
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185
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Abstract
Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.
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Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Shin C Cheng
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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186
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Aicale R, Cipollaro L, Esposito S, Maffulli N. An evidence based narrative review on treatment of diabetic foot osteomyelitis. Surgeon 2020; 18:311-320. [PMID: 32081665 DOI: 10.1016/j.surge.2020.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 12/18/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The diagnosis of diabetic food infection is usually clinical, and its severity is related to location and depth of the lesion, and the presence of necrosis or gangrene. Osteomyelitis of the foot and ankle can be extremely debilitating, and, in the preantibiotic era acute staphylococcal osteomyelitis carried a mortality rate of 50%. The microbiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial. Indeed, gram-negative and gram-positive bacilli can be identified using molecular techniques applied to bone biopsies compared to conventional techniques. The aim of the present study is to report a complete overview regarding medical and surgical management of diabetic foot osteomyelitis (DFO) in combination or alone. MATERIALS AND METHODS We performed a search in PubMed and Scopus electronic databases (up to January 2019) of articles assessing the epidemiology, diagnostic strategy and pharmacological treatment of diabetic foot infection. In the search strategy, we used various combinations of the following key terms: infection, orthopaedic, diabetic foot, management, DFO. RESULTS This article discusses the definition, epidemiology, microbiological assessment, clinical evaluation, pharmacological and surgical management and a comparison between them, of DFO. After the initial literature search and removal of duplicate records, a total of 756 potentially relevant citations were identified. After a further screening and according to the inclusion criteria, a total of 65 articles were included in the present review. CONCLUSION The association of antibiotic and surgical therapy seems to be more effective compared to each one alone. The lack of comparison studies and randomized controlled trials makes it difficult to give information about the efficacy of the different management therapies.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
| | - Lucio Cipollaro
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
| | - Silvano Esposito
- Department of Infectious Diseases, School of Medicine and Surgery, University of Salerno, Salerno, Italy.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK; Keele University, School of Medicine, Institute of Science and Technology in Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, UK.
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187
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Min KR, Galvis A, Baquerizo Nole KL, Sinha R, Clarke J, Kirsner RS, Ajdic D. Association between baseline abundance of Peptoniphilus, a Gram-positive anaerobic coccus, and wound healing outcomes of DFUs. PLoS One 2020; 15:e0227006. [PMID: 31978071 PMCID: PMC6980618 DOI: 10.1371/journal.pone.0227006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/09/2019] [Indexed: 12/31/2022] Open
Abstract
Diabetic foot ulcers (DFUs) lead to nearly 100,000 lower limb amputations annually in the United States. DFUs are colonized by complex microbial communities, and infection is one of the most common reasons for diabetes-related hospitalizations and amputations. In this study, we examined how DFU microbiomes respond to initial sharp debridement and offloading and how the initial composition associates with 4 week healing outcomes. We employed 16S rRNA next generation sequencing to perform microbial profiling on 50 samples collected from 10 patients with vascularized neuropathic DFUs. Debrided wound samples were obtained at initial visit and after one week from two DFU locations, wound bed and wound edge. Samples of the foot skin outside of the wounds were also collected for comparison. We showed that DFU wound beds are colonized by a greater number of distinct bacterial phylotypes compared to the wound edge or skin outside the wound. However, no significant microbiome diversity changes occurred at the wound sites after one week of standard care. Finally, increased initial abundance of Gram-positive anaerobic cocci (GPAC), especially Peptoniphilus (p < 0.05; n = 5 subjects), was associated with impaired healing; thus, GPAC's abundance could be a predictor of the wound-healing outcome.
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Affiliation(s)
- Kyung R. Min
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, United States of America
| | - Adriana Galvis
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, United States of America
| | - Katherine L. Baquerizo Nole
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, United States of America
| | - Rohita Sinha
- Department of Statistics, University of Nebraska-Lincoln, Lincoln, Nebraska, United States of America
| | - Jennifer Clarke
- Department of Statistics, University of Nebraska-Lincoln, Lincoln, Nebraska, United States of America
| | - Robert S. Kirsner
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, United States of America
| | - Dragana Ajdic
- Dr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, United States of America
- * E-mail:
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188
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Abstract
Hyperbaric oxygen (HBO2) therapy is an adjunct treatment for diabetic foot ulcers. Since plausible mechanisms of action for this treatment include increased angiogenesis and high tissue oxygen concentrations, concerns about deterioration of retinopathy have been raised. The aim of this study was to evaluate the effects of HBO2 on visual acuity (VA) and retinopathy in patients with chronic diabetic foot ulcers during a two-year follow-up period. This is a randomized, single-center, double-blinded and placebo-controlled clinical trial evaluating the effects of HBO2 in patients with diabetes mellitus and chronic foot ulcers. All study participants underwent an ophthalmological examination before the first study treatment and then at three, six, 12 and 24 months. Fifty patients with a median age of 67 years were included. Visual acuity was similar between groups and did not change during the two-year observation period. No differences in retinopathy were seen between groups; neither were any differences found in numbers or areas of bleedings, hard exudates, microaneurysms or edemas, nor between groups or visits. New clinically significant macular edema was identified in four eyes in the HBO2 group and in three eyes in the placebo group. In this population of diabetic foot ulcer patients HBO2 seems to be neutral in an ophthalmological perspective. From a retinal point of view, we could not identify any indication of harmful effects of HBO2 on the microvascular bed in the placebo group.
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Affiliation(s)
- Anders Sellman
- Institution of Clinical Sciences in Lund, Lund University, Lund, Sweden
| | - Per Katzman
- Institution of Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
| | - Sten Andreasson
- Institution of Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Ophthalmology, Skåne University Hospital, Lund, Sweden
| | - Magnus Lõndahl
- Institution of Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
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189
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Gezawa ID, Ugwu ET, Ezeani I, Adeleye O, Okpe I, Enamino M. Anemia in patients with diabetic foot ulcer and its impact on disease outcome among Nigerians: Results from the MEDFUN study. PLoS One 2019; 14:e0226226. [PMID: 31846473 PMCID: PMC6917259 DOI: 10.1371/journal.pone.0226226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/21/2019] [Indexed: 12/19/2022] Open
Abstract
Background Diabetes is a life-long and debilitating disease that is fraught with both acute and chronic complications. Of particular concern to sufferers of the disease is the development of foot problems. These problems range from foot deformities to slowly healing or non-healing ulcers (that may necessitate amputation) and in the worst-case scenario, to death. Identification and prompt treatment of comorbid conditions, such as anemia may improve outcome in patients with diabetic foot ulcers (DFU). We determined the prevalence of anemia in Nigerians with DFU and its impact on disease outcome. Methods We prospectively followed 336 patients with diabetes hospitalized for DFU and managed by a multidisciplinary team until discharge or death. Demographic and diabetes-related information and ulcer characteristics were documented. We evaluated each patient for neuropathy, vasculopathy and medical co-morbidities. Relevant laboratory and imaging studies were performed. We present the results of the sub-group analysis of patients with anemia to determine its prevalence and impact on disease outcome in patients with DFU in the MEDFUN study. Results Anemia was detected in 180(53.6%) subjects with 88(48.9%) of them requiring blood transfusion. Significant demographic and clinical determinants of anemia were ulcer duration more than one month prior to hospitalization (p<0.009), PAD (p<0.001) and presence of gangrene (p<0.001). The comorbid conditions that were significantly associated with anemia included proteinuria (p<0.003), osteomyelitis (p<0.006), moderate (p<0.002) as well as severe (p<0.001) vascular stenosis, history of stroke (p<0.014) and renal impairment (p<0.002). Anemia was significantly associated with poor wound healing (p<0.009), amputation (p<0.036) and risk of death (p<0.034). Conclusion We detected anemia in more than half of our cohort with DFU. We found significant association between anemia and poor wound healing, amputation and mortality among our studied subjects. Future studies should explore whether prompt correction of anemia in subjects hospitalized for DFU would improve outcome.
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Affiliation(s)
- Ibrahim D. Gezawa
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Bayero University, Kano, Nigeria
- * E-mail:
| | - Ejiofor T. Ugwu
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Ignatius Ezeani
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Federal Medical Center, Umuahia, Nigeria
| | - Olufunmilayo Adeleye
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Lagos State University, Lagos, Nigeria
| | - Innocent Okpe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Marcelina Enamino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Federal Medical Center, Keffi, Nigeria
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190
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Dudareva M, Kümin M, Vach W, Kaier K, Ferguson J, McNally M, Scarborough M. Short or Long Antibiotic Regimes in Orthopaedics (SOLARIO): a randomised controlled open-label non-inferiority trial of duration of systemic antibiotics in adults with orthopaedic infection treated operatively with local antibiotic therapy. Trials 2019; 20:693. [PMID: 31815653 PMCID: PMC6902346 DOI: 10.1186/s13063-019-3832-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/22/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Orthopaedic infections, such as osteomyelitis, diabetic foot infection and prosthetic joint infection, are most commonly treated by a combination of surgical debridement and a prolonged course of systemic antibiotics, usually for at least 4-6 weeks. Use of local antibiotics, implanted directly into the site of infection at the time of surgery, may improve antibiotic delivery and allow us to shorten the duration of systemic antibiotic therapy, thereby limiting the frequency of side effects, cost and selection pressure for antimicrobial resistance. METHODS SOLARIO is a multicentre open-label randomised controlled non-inferiority trial comparing short and long systemic antibiotic therapy alongside local antibiotic therapy. Adult patients with orthopaedic infection, who have given informed consent, will be eligible to participate in the study provided that no micro-organisms identified from deep tissue samples are resistant to locally implanted antibiotics. Participants will be randomised in a 1:1 ratio to receive either a short course (≤ 7 days) or currently recommended long course (≥ 4 weeks) of systemic antibiotics. The primary outcome will be treatment failure by 12 months after surgery, as ascertained by an independent Endpoint Committee blinded to treatment allocation. An absolute non-inferiority margin of 10% will be used for both per-protocol and intention-to-treat populations. Secondary outcomes will include probable and definite treatment failure, serious adverse events, treatment side effects, quality of life scores and cost analysis. DISCUSSION This study aims to assess a treatment strategy that may enable the reduction of systemic antibiotic use for patients with orthopaedic infection. If this strategy is non-inferior, this will be to the advantage of patients and contribute to antimicrobial stewardship. TRIAL REGISTRATION Clinicaltrials.gov, NCT03806166. Registered on 11 November 2019.
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Affiliation(s)
- Maria Dudareva
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK.
| | - Michelle Kümin
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Werner Vach
- Department of Orthopaedics and Traumatology, Universitätsspital Basel, Basel, Switzerland
| | - Klaus Kaier
- Institute of Medical Biometry and Medical Informatics, Universitätsklinikums Freiburg, Freiburg, Germany
| | - Jamie Ferguson
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Martin McNally
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Matthew Scarborough
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
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191
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Ottofaro T, Lane M, Sciarretta JD. Use of Acellular Urinary Bladder Matrix for Accelerated Soft Tissue Recovery in Complicated Gangrenous Diabetic Foot Infections. Am Surg 2019; 85:e606-e607. [PMID: 31908243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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192
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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592019-01376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 05/28/2023]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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193
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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592-019-01376-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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194
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Sun Y, Gao Y, Chen J, Sun H, Cai YT, Ge L, Li YN, Zhang J, Tian JH. Evidence mapping of recommendations on diagnosis and therapeutic strategies for diabetes foot: an international review of 22 guidelines. Metabolism 2019; 100:153956. [PMID: 31394109 DOI: 10.1016/j.metabol.2019.153956] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 07/18/2019] [Accepted: 08/01/2019] [Indexed: 12/14/2022]
Abstract
To systematically review clinical practice guidelines (CPGs) on diabetes foot and assess the consistency of recommendations, quality of CPGs and to present an evidence-map for explicating research trends and gaps. We performed a literature search on PubMed, Embase, and Web of Science, guideline databases and websites of diabetes society to include the diabetic CPGs. The basic information, recommendations for the diabetic foot, methodological quality and reporting quality of diabetic CPGs were exacted by the Excel. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE II instrument and RIGHT checklist. R3.5.1 software was used to create all bubble plots. A total of 22 diabetic CPGs were included, eight CPGs were from different professional diabetes societies. Recommendations on diabetic foot complications involve Diabetic foot ulcer (DFU), Charcot neuropathy (CN) and Osteomyelitis (OM). Eight DFU diagnostic systems presented in 22 CPGs. According to the recommendations of diabetic CPGs, the treatment of DFU can be summarized in four major items; six recommendations on CN diagnosis and six recommendations on treatment of CN were consistent among studies. However, there were inconsistencies in three OM diagnosis recommendations and four OM treatment recommendations. Some recommendations in CPGs were not very specific and clear, and hence they were not reliable for OM diagnosis and treatment. Once these inconsistencies are resolved, validated, accurate and effective diagnosis and treatment of diabetes foot will lead to reduced costs and adverse complications. The results of this review add to our knowledge and promote the development of trustworthy CPGs on diabetes.
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Affiliation(s)
- Yue Sun
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Ji Chen
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Hao Sun
- School of Information Engineering, Zhengzhou University, Henan Province, China
| | - Yi-Tong Cai
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China
| | - Long Ge
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China; School of Public Health, Lanzhou University, Lanzhou City, Gansu Province, China
| | - Ya-Nan Li
- Binzhou Maternal and Child Health Care Hospital, Binzhou City, Shandong Province, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
| | - Jin-Hui Tian
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou City, Gansu Province, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou City, Gansu Province, China; WHO Collaborating Center for Guideline Implementation and Knowledge Translation, China.
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Wilson BM, Bessesen MT, Doros G, Brown ST, Saade E, Hermos J, Perez F, Skalweit M, Spellberg B, Bonomo RA. Adjunctive Rifampin Therapy For Diabetic Foot Osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1916003. [PMID: 31755948 PMCID: PMC6902814 DOI: 10.1001/jamanetworkopen.2019.16003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Among patients diagnosed with diabetes, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers, and 20% to 60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis. OBJECTIVE To compare the clinical outcomes of patients treated for DFO in the Veterans Health Administration (VHA) with and without adjunctive rifampin. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used VHA databases to identify index DFO cases from January 1, 2009, through December 31, 2013, and analyzed patients alive and without high-level amputation at 90 days after diagnosis in whom antibiotic therapy was initiated within 6 weeks of diagnosis. Patients with death or major amputation within 90 days of diagnosis, who were not treated with systemic antibiotics dispensed by the VHA within 6 weeks of diagnosis, or who were treated at facilities where rifampin was not dispensed for DFO were excluded. The retrospective cohort to inform the planning of a multisite randomized clinical trial was first investigated in spring 2015; retrospective analysis was performed from February 2017 through September 2019. EXPOSURES Patients initiating rifampin therapy within 6 weeks of the DFO diagnosis and receiving the drug for at least 14 days within 90 days of diagnosis were considered treated with rifampin. Patients not administered rifampin within 90 days of diagnosis served as the comparator group. MAIN OUTCOMES AND MEASURES A combined end point of mortality or amputation within 2 years of diagnosis was analyzed. Differences in times to event were evaluated using log-rank tests. Differences in event rates were compared using χ2 tests and multivariable logistic regression. RESULTS The analysis population included 130 patients treated with rifampin and 6044 treated without rifampin (total of 6174; 6085 men [98.6%]; mean [SD] age, 64.9 [9.7] years). Lower event rates were observed among the rifampin group (35 of 130 [26.9%] vs 2250 of 6044 [37.2%]; P = .02). Patients treated with rifampin were younger (mean [SD] age, 62.2 [9.4] vs 64.9 [9.6] years), had fewer comorbidities (mean [SD] Charlson comorbidity index score, 3.5 [1.8] vs 4.0 [2.2]), had more infectious disease specialty consultations (63 of 130 [48.5%] vs 1960 of 6044 [32.4%]), and more often had Staphylococcus aureus identified in cultures (55 of 130 [42.3%] vs 1755 of 6044 [29.0%]) than patients not treated with rifampin. A logistic regression estimating the odds of events and controlling for these and other covariates yielded a significant association of rifampin (odds ratio, 0.65; 95% CI, 0.43-0.96; P = .04). CONCLUSIONS AND RELEVANCE In this cohort study, patients administered rifampin experienced lower rates of death and amputation than patients not treated with rifampin, which remained significant after adjustment for confounders. These results coupled with existing evidence from small clinical trials suggest the addition of rifampin to current treatment regimens may be a useful antimicrobial option in the treatment of DFO.
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Affiliation(s)
- Brigid M. Wilson
- Research Service and Geriatric Research, Education, and Clinical Center (GRECC),VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary T. Bessesen
- Division of Infectious Diseases, University of Colorado, Denver, School of Medicine, Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Boston University School of Medicine, Boston, Massachusetts
| | - Sheldon T. Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elie Saade
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Service, VA Northeast Ohio Healthcare System, Cleveland
- University Hospitals of Cleveland, Cleveland, Ohio
| | - John Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Federico Perez
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
| | - Marion Skalweit
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Robert A. Bonomo
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- CWRU (Case Western Reserve University)–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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196
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Sen P, Demirdal T, Emir B. Meta-analysis of risk factors for amputation in diabetic foot infections. Diabetes Metab Res Rev 2019; 35:e3165. [PMID: 30953392 DOI: 10.1002/dmrr.3165] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Knowledge of risk factors is crucial to develop management and treatment protocols for the prevention of lower extremity amputation for patients with diabetic foot infections (DFIs). METHODS We searched the research literature for studies reporting risk factors for lower extremity amputation in patients with DFI. The main outcome variables included both minor and major amputations. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42018118543). RESULTS A total of 2471 potential articles from the database search met the inclusion criteria. After reviewing the titles, abstracts, and full texts, remaining 25 articles were included in the final analysis. We identified 6132 patients with DFI in the 25 included articles. Of these, 1873 patients who underwent amputation were investigated. Male gender (odds ratio [OR]: 1.31), smoking (OR: 1.38), history of amputation (OR: 1.47), history of osteomyelitis (OR: 1.94), peripheral arterial disease (OR: 2.35), retinopathy (OR: 1.32), International Working Group on the Diabetic Foot (IWGDF) grades 3 and 4 (OR: 1.7 and 2.5), Wagner grades 4 and 5 (OR: 4.3 and 6.4), gangrene/necrosis (OR: 9.9), osteomyelitis (OR: 4.5), neuroischaemic DFI (OR: 3.06), severe infection (OR: 3.12), length of hospitalization (standardized mean difference [SMD]: 0.7), leukocytosis (OR: 1.76), mean erythrocyte sedimentation rate (ESR) (SMD: 0.5), mean C-reactive protein (CRP) (SMD: 0.8), tissue culture positivity (OR: 1.61), and isolation of Gram-negative bacteria from tissue culture (OR: 1.5) were found as predictors of amputation in DFI. CONCLUSIONS The present study highlighted some differences in diabetic foot ulcers and DFIs in terms of risk factors for lower extremity amputation. These data provide detailed information about risk factors for amputations among patients with DFI, thus contributing to the creation of new classification systems for assessment of high-risk patients.
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Affiliation(s)
- Pinar Sen
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Busra Emir
- Department of Biostatistics, Izmir Katip Celebi University School of Medicine, Izmir, Turkey
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197
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Demirtas D, Kucukosmanoglu M. In patients with diabetic foot, improved left ventricular functions are detected by strain echocardiography after the diabetic foot treatment: A cross-sectional study. Medicine (Baltimore) 2019; 98:e17217. [PMID: 31567978 PMCID: PMC6756686 DOI: 10.1097/md.0000000000017217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Diabetic foot is a macrovascular complication of diabetes mellitus (DM). In the literature, the relationship between diabetic foot and another macrovascular complication of DM is not clear. The aim of this study was to determine the current left ventricular (LV) systolic function in patients with diabetic foot and to investigate the effect of diabetic foot treatment on LV systolic functions.In this study, 54 patients with diabetic foot and 22 patients without diabetic foot were included. Routine anamnesis, physical examination, echocardiography, and laboratory examinations were performed. In addition, LV global longitudinal strain (LV-GLS) was measured by strain echocardiography technique. LV ejection fraction (LV-EF) and LV-GLS measurements were repeated with echocardiography at the 3rd month of diabetic foot treatment.The incidence of cardiovascular risk factors such as smoking, hypertension, and coronary artery disease was found to be higher in patients with diabetic foot. (P < .05 for each one). Similarly, in patients with diabetic foot, glucose, Hemoglobin A1c, neutrophil, sedimentation, urea, creatinine, potassium, uric acid, alanine aminotransferase, aspartate aminotransferase, C-reactive protein, and brain natriuretic protein were higher; high-density lipoprotein cholesterol level was found to be significantly lower. LV wall thicknesses and diameters were higher and LV-EF was lower in patients with diabetic foot (P < .05 each one). LV-GLS values were significantly lower in patients with diabetic foot (P < .05). Although no significant change was found in the LV-EF value at the 3rd-month follow-up echocardiography (48.6% ± 7.0% vs 48.5% ± 5.9% and P = .747), it was detected that LV-GLS values (17.3 ± 2.1 vs 18.4 ± 2.3) were significantly increased (P < .001).LV systolic function was significantly affected in patients with diabetic foot. This may be related to the increased frequency of cardiovascular risk factors in these patients. However, the significant improvement in LV-GLS values after the diabetic foot treatment showed that diabetic foot itself was an important cause of LV systolic dysfunction.
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Affiliation(s)
- Derya Demirtas
- Department of Internal Medicine, University of Health Sciences
| | - Mehmet Kucukosmanoglu
- Department of Cardiology, University of Health Sciences - Adana Health Practices and Research Center, Adana, Turkey
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198
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Majid Z, Qadar LT, Haque A. Foot burn from Motorcycles, exacerbated by Polyneuropathy in Diabetics: A rising concern in Pakistan. J PAK MED ASSOC 2019; 69:1410. [PMID: 31511742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Zainab Majid
- Fourth Year Student, Dow Medical College, Karachi, Pakistan
| | | | - Ayema Haque
- Fourth Year Student, Dow Medical College, Karachi, Pakistan
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199
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Waibel FWA, Uçkay I, Sairanen K, Waibel L, Berli MC, Böni T, Gariani K, Lipsky BA. Diabetic calcaneal osteomyelitis. Infez Med 2019; 27:225-238. [PMID: 31545766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Diabetic foot infection (DFI), a multi-facetted disease requiring a multidisciplinary approach for successful treatment, mostly affects the forefoot. Calcaneal osteomyelitis (CO) is an uncommon presentation of DFI with a somewhat different epidemiology, clinical features, and approach to management. These patients, compared to those with non-calcaneal DFI, more often require special surgical techniques and off-loading approaches. In this narrative review targeted to non-surgical clinicians, we explore how CO differs from other types of DFI affecting other anatomical locations. Based on our review of the literature and personal experience, we also highlight important issues regarding the management of CO osteomyelitis, including the need for specialized surgical approaches.
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Affiliation(s)
- Felix W A Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland; Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Kati Sairanen
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
| | - Lorenz Waibel
- Department of Radiology, University Hospital Freiburg, Germany
| | - Martin C Berli
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Thomas Böni
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Karim Gariani
- Service of Diabetology and Endocrinology, Geneva University Hospitals, Switzerland
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Cestaro G, Fasolini F, Regusci L, Torre A, De Monti M. NPWTid in the treatment of infected diabetic foot. G Chir 2019; 40:445-449. [PMID: 32003728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Negative Pressure Wound Therapy with instillation therapy and dwelling time (NPWTid) represents a good tool to treat severely infected non-healing wounds. This topical treatment consists of negative pressure and retrograde instillation of antiseptic/antibiotic Romasolutions into the wound surface, to promote cleansing and consequently the healing process. We reported our initial experience (five cases) in the treatment of severely infected diabetic foot, that can be considered a life-threatening condition. In our case reports, patients presented with clinical signs and symptoms of severe sepsis. Our treatment based on multidisciplinary approach (surgical, NPWTid, interventional radiology, skin grafts) had satisfying results. NPWT represented an important support to treatment of these diabetic patients.
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