Impact of severe diabetic kidney disease on the clinical outcome of autologous cell therapy in people with diabetes and critical limb ischaemia

AIM

To assess the impact of autologous cell therapy on critical limb ischaemia in people with diabetes and diabetic kidney disease.

METHODS

A total of 59 people with diabetes (type 1 or type 2) and critical limb ischaemia, persisting after standard revascularization, were treated with cell therapy in our foot clinic over 7 years; this group comprised 17 people with and 42 without severe diabetic kidney disease. The control group had the same inclusion criteria, but was treated conservatively and comprised 21 people with and 23 without severe diabetic kidney disease. Severe diabetic kidney disease was defined as chronic kidney disease stages 4-5 (GFR <30 ml/min/1.73 m²). Death and amputation-free survival were assessed during the 18-month follow-up; changes in transcutaneous oxygen pressure were evaluated at 6 and 12 months after cell therapy.

RESULTS

Transcutaneous oxygen pressure increased significantly in both groups receiving cell therapy compared to baseline (both P<0.01); no significant change in either of the control groups was observed. The cell therapy severe diabetic kidney disease group had a significantly longer amputation-free survival time compared to the severe diabetic kidney disease control group (hazard ratio 0.36, 95% CI 0.14-0.91; P=0.042); there was no difference in the non-severe diabetic kidney disease groups. The severe diabetic kidney disease control group had a tendency to have higher mortality (hazard ratio 2.82, 95% CI 0.81-9.80; P=0.062) than the non-severe diabetic kidney disease control group, but there was no difference between the severe diabetic kidney disease and non-severe diabetic kidney disease cell therapy groups.

CONCLUSIONS

The present study shows that autologous cell therapy in people with severe diabetic kidney disease significantly improved critical limb ischaemia and lengthened amputation-free survival in comparison with conservative treatment; however, the treatment did not influence overall survival.

Diabetic foot infections: Application of a nisin-biogel to complement the activity of conventional antibiotics and antiseptics against Staphylococcus aureus biofilms

BACKGROUND

Diabetic foot infections (DFIs) are a frequent complication of Diabetes mellitus and a major cause of nontraumatic limb amputations. The Gram-positive bacterium Staphylococcus aureus, known for its resilient biofilms and antibiotic resistant profile, is the most frequent DFI pathogen. It is urgent to develop innovative treatments for these infections, being the antimicrobial peptide (AMP) nisin a potential candidate. We have previously proposed the use of a guar gum biogel as a delivery system for nisin. Here, we evaluated the potential of the nisin-biogel to enhance the efficacy of conventional antibiotics and antiseptics against DFIs S. aureus clinical isolates.

METHODS

A collection of 23 S. aureus strains isolated from DFI patients, including multidrug- and methicillin-resistant strains, was used. The antimicrobial activity of the nisin-biogel was tested alone and in different combinations with the antiseptic chlorhexidine and the antibiotics clindamycin, gentamicin and vancomycin. Isolates' in vitro susceptibility to the different protocols was assessed using broth microdilution methods in order to determine their ability to inhibit and/or eradicate established S. aureus biofilms. Antimicrobials were added to the 96-well plates every 8 h to simulate a typical DFI treatment protocol. Statistical analysis was conducted using RCBD ANOVA in SPSS.

RESULTS

The nisin-biogel showed a high antibacterial activity against biofilms formed by DFI S. aureus. The combined protocol using nisin-biogel and chlorhexidine presented the highest efficacy in biofilm formation inhibition, significantly higher (p<0.05) than the ones presented by the antibiotics-based protocols tested. Regarding biofilm eradication, there were no significant differences (p>0.05) between the activity of the combination nisin-biogel plus chlorhexidine and the conventional antibiotic-based protocols.

CONCLUSIONS

Results provide a valuable contribution for the development of complementary strategies to conventional antibiotics protocols. A combined protocol including chlorhexidine and nisin-biogel could be potentially applied in medical centres, contributing for the reduction of antibiotic administration, selection pressure on DFI pathogens and resistance strains dissemination.

Trends in Lower Limb Amputation in Patients with Diabetic Foot Based on Vascular Intervention of Peripheral Arterial Disease in Korea: a Population-based Nationwide Study

BACKGROUND

Peripheral arterial disease (PAD) is known as the greatest risk factor affecting the amputation of diabetic foot. Thus, it is crucial to understand the epidemiology of PAD associated with diabetic foot and the relationship between PTA and amputation in predicting prognosis. However, no such multi-year data are available in Korea. Thus, the purpose of this study was to investigate trends of amputation involving diabetic foot based on vascular interventions for PAD in Korea.

METHODS

This study was conducted using six-year data obtained from Health Insurance Review and Assessment Service from January 1, 2011 to December 31, 2016. Our study included data pertaining to diabetic foot, PAD, and vascular intervention codes (percutaneous transluminal angioplasty [PTA, M6597], percutaneous intravascular installation of stent-graft [PIISG, M6605], and percutaneous intravascular atherectomy [PIA, M6620]). We analyzed the number of vascular interventions and minor and major amputations each year. The relationship between annual amputation and vascular intervention was analyzed using χ² test.

RESULTS

The overall number of vascular interventions increased from 253 (PTA, 111; PIISG, 140; and PIA, 2) in 2011 to 1,230 (PTA, 745; PIISG, 470; and PIA, 15) in 2016. During the same period, the number of minor amputations increased from 2,534 to 3,319 while major amputations decreased from 980 to 956. The proportion of minor amputations among patients who underwent vascular intervention was significantly increased from 19.34% in 2011 to 21.45% in 2016 while the proportion of major amputations among these patients was significantly reduced from 9.88% to 4.27%. In addition, the association between vascular intervention and amputation increased from 0.56 (spearman correlation coefficient) in 2011 to 0.62 in 2016.

CONCLUSION

In diabetic foot patients, increase in vascular intervention resulted in a change in amputation pattern, showing statistically significant correlation.

Below-the-ankle arterial disease severely impairs the outcomes of diabetic patients with ischemic foot ulcers

AIM

To evaluate the impact of below-the-ankle (BTA) arterial disease in people with ischemic diabetic foot ulcers (DFUs).

METHODS

Patients with ischemic DFUs treated by a pre-set limb salvage protocol including peripheral revascularization were included. They were divided in two groups according to the involvement of BTA arteries (BTA+) or not (BTA-). Not healing, minor amputation, major amputation and mortality have been evaluated as primary outcome. Revascularization failure has been evaluated as secondary outcome.

RESULTS

The study group was composed of 272 patients, 120 (44.1%) belonging to BTA+ group and 152 (55.9%) to BTA-. After 1 year of follow-up the outcomes for BTA+ and BTA- were respectively: not healing (40.8 vs 17.8%, p < 0.0001), minor amputation (80.8 vs 20.4%, p < 0.0001), major amputation (18.3 vs 6.6%, p = 0.002), mortality (16.7% vs 10.5%, p = 0.001). The rate of revascularization failure was respectively 38.3 vs 11.2%, p < 0.0001. At the multivariate analysis BTA arterial disease resulted an independent predictor of not healing [OR 3.5 (CI 95% 2.3-6.1) p = 0.0001], minor amputation [OR 3.1 (1.5-5.9) p < 0.0001] and revascularization failure [OR 3.5 (1.9-6.3) p = 0.0001]. BTA+ patients with successful BTA revascularization showed lower rate of not healing (37.8 vs 89.1%) p < 0.0001, minor amputation (74.3 vs 91.3%) p = 0.002 and major amputation (8.1 vs 34.8%) p = 0.0003 in comparison to patients with unsuccessful BTA revascularization.

CONCLUSION

BTA arterial disease severely impairs the outcomes of diabetics with ischemic foot ulcers. BTA revascularization reduces the rate of not healing, minor and major amputation.

[Lower limb arterial disease in patients with diabetes]

Lower limb arteriopathy is a frequent and potentially serious complication of diabetes. In fact, it largely explains the high incidence of lower limb amputations in diabetic patients as well as a significant impairment of quality of life in the case of intermittent claudication or decubitus pain. The severity of the disease is also based on the associated cardiovascular morbidity and mortality. The diagnosis is primarily made by the clinical examination, completed by functional hemodynamic tests (ankle/brachial index, transcutaneous oxygen pressure and toe pressure) and possibly imaging tests (arterial Doppler and arteriography of the lower limbs). The treatment of lower limbs arterial disease will depend on the vascular symptomatology, the severity of the vascular lesions evaluated by the hemodynamic tests and by the anatomical characteristics of the vascular lesions.

[Spontaneous Expulsion of a Necrotic Metatarsal Head from a Dorsal Foot Ulcer in Osteomyelitis]

Spontaneous Expulsion of a Necrotic Metatarsal Head from a Dorsal Foot Ulcer in Osteomyelitis Abstract. Osteomyelitis of metatarsal bones is a dreaded complication of foot ulcers of various etiologies, often resulting in amputation of part of the affected limb. In this article, a case is presented in which a spontaneous expulsion of the necrotic bone part occurred, after which the ulcer could heal completely.

Oral amoxicillin-clavulanate for treating diabetic foot infections

AIM

To assess amoxicillin-clavulanate (AMC) for the oral therapy of diabetic foot infections (DFIs), especially for diabetic foot osteomyelitis (DFO).

METHODS

We performed a retrospective cohort analysis among 794 DFI episodes, including 339 DFO cases.

RESULTS

The median duration of antibiotic therapy after surgical debridement (including partial amputation) was 30 days (DFO, 30 days). Oral AMC was prescribed for a median of 20 days (interquartile range, 12-30 days). The median ratio of oral AMC among the entire antibiotic treatment was 0.9 (interquartile range, 0.7-1.0). After a median follow-up of 3.3 years, 178 DFIs (22%) overall recurred (DFO, 75; 22%). Overall, oral AMC led to 74% remission compared with 79% with other regimens (χ² -test; P = 0.15). In multivariate analyses and stratified subgroup analyses, oral AMC resulted in similar clinical outcomes to other antimicrobial regimens, when used orally from the start, after an initial parenteral therapy, or when prescribed for DFO.

CONCLUSIONS

Oral AMC is a reasonable option when treating patients with DFIs and DFOs.

Gender difference in the risk for cardiovascular events or mortality of patients with diabetic foot syndrome

AIMS

Diabetic foot syndrome (DFS) increases the risk for atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or mortality. The present study aims at ascertaining whether such DFS-related excess risk differs between genders, retrospectively investigating a population with diabetes from Tuscany, Italy, followed-up for 6 years (2011-2016).

METHODS

People with diabetes living in Tuscany on January 1st 2011 identified by administrative databases, were divided by baseline history of prior DFS hospitalizations, stratified by presence/absence of peripheral vascular disease and evaluating, by Cox regression analysis, whether adjusted DFS-related excess risk of incident ASCVD, CKD or mortality differed between genders.

RESULTS

In an overall population of 165,650 subjects with diabetes (81,829M/83,821F), basal prevalence of DFS was twice higher among males, who were moreover at a significantly greater risk of all considered outcomes along the 6-year period. On the contrary, baseline DFS significantly increased the hospitalization risk for ASCVD, CKD and mortality equally or at a slightly greater extent in females, while the risk for stroke was significantly associated with DFS only among females (HR: 1.622 (1.314-1.980); p = 0.0001 vs. HR: 1.132 (0.955-1.332); p = NS). This finding was even reinforced in non-vascular DFS, which was associated with a significant raised risk for stroke, heart failure or mortality exclusively in females.

CONCLUSIONS

In this population, DFS prevalence and overall risk for ASCVD, CKD or mortality were significantly higher among males. Baseline co-presence of DFS, however, conferred a similar adjusted risk for all these outcomes between genders, and in case of non-vascular DFS the risk was significantly increased only among females.

Complications associated with the approach to metatarsal head resection in diabetic foot osteomyelitis

The aim of this study was to evaluate the recovery time and the development of complications in the dorsal and plantar approach to metatarsal head resections (MHR) in patients with diabetic foot ulcers complicated by osteomyelitis. A retrospective study was carried out involving 108 patients who underwent MHRs for the treatment of diabetic foot osteomyelitis. Two cohorts were defined: dorsal approach with incision closed with sutures and plantar approach with ulcer healed using conservative treatment. The main outcomes were the weeks until healing and complications related to the approaches. Fifty-three patients (49.1%) underwent a plantar approach and 55 (50.9%) a dorsal approach. Both approaches rendered similar healing times. However, the patients undergoing a dorsal approach developed more post-surgical complications than patients treated through a plantar approach. The dorsal approach intervention was performed on smaller and shallower ulcers; however, more complications developed at follow up using this approach than through a plantar approach for MHR complicated with osteomyelitis.

Can we predict vascular status and culture result based through wound status in diabetic foot infection?

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

Operative versus non-operative treatment in diabetic dry toe gangrene

BACKGROUND AND AIM

Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene.

METHODS

We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation.

RESULTS

One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up.

CONCLUSION

Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.

A neglected causative agent in diabetic foot infection: a retrospective evaluation of 13 patients with fungal etiology

Background/aim

Clinicians often neglect fungal infections and do not routinely investigate deep tissue from the wound for fungal culture and sensitivity due to insufficient information in the literature. In this study, we aimed to evaluate fungal etiology of invasive fungal diabetic foot which is rarely reported in the literature.

Materials and methods

The patients who were unresponsive to antibiotic therapy and those with positive fungal in bone or deep tissue culture were enrolled in the study. Detailed hospital records were retrieved for demographics and clinical features.

Results

A total of 13 patients who were diagnosed with invasive fungal diabetic foot (ten females, three males, mean age 59.8 ± 9 years) were included. All of the patients had type-2 diabetes mellitus. Eleven (84.6%) patients had mixed infection. The most common cause of fungal infections of diabetic foot ulcers was the Candida species. Ten (76.9%) patients underwent amputation, two (15.4%) patients refused amputation, and one patient died before surgery.

Conclusion

Invasive fungal infections may also be a causative pathogen in deep tissue infections. Therefore, fungal pathogens should be considered in patients unresponsive to long-term antibiotic therapy. Early detection of fungal infections in high-risk individuals is critical for the prevention of severe consequences such as foot amputation.

Clinical outcomes among morbidly obese patients hospitalized with diabetic foot complications

The aim of the study is to investigate effects of morbid obesity on patients hospitalized with diabetic foot ulcers and infections (DFU/Is). This retrospective cohort study of hospitalized adults investigated patients with a principal diagnosis of DFU/Is, and compared outcomes based on weight. The primary outcome was lower limb amputations. Secondary outcomes included in-hospital mortality, morbidity (sepsis and discharge disposition), resource utilization (length of stay [LOS] and total hospitalization charges). Multivariate analyses adjusted for confounders. A total of 31 730 admissions were included; 14% were morbidly obese. Patients with morbid obesity had overall lower rates of amputations (adjusted odds ratio [aOR]: 0.60; 95% confidence interval [CI]: 0.45-0.80). There was no difference in mortality rates between those who were morbidly obese and the non-morbidly obese patients (aOR: 3.89 [95% CI: 0.79-19.30]). Combined data from 2010 to 2014 have found higher odds of sepsis in morbidly obese patients compared with non-morbidly obese patients after adjusting for confounders (aOR: 1.49 [1.09-2.02], P = 0.01). Patients with morbid obesity were less likely to be discharged to home (aOR: 0.82 [95% CI: 0.70-0.95]), had longer LOS (adjusted mean difference [aMD]: 0.47 [95% CI: 0.13-0.81]) and higher hospital charges (aMD: $3205 [95% CI: $3373-$6037]). Despite having lower amputation rates compared to those who are not morbidly obese, patients with morbid obesity hospitalized for DFU/Is succumbed to sepsis more frequently and had less favourable utilization metrics. Specialized care pathways may be needed to enhance the value of care delivered to this high-risk population.

Correlation of HbA1c and S. creatinine along with microbiological profiling of infected ulcers; cases of diabetic patients

STATEMENT OF THE PROBLEM

The rate of diabetes mellitus is increasing globally as a result of increased levels of blood glucose. The elevated blood glucose level results due to impairment in the production and action of insulin. An increase in glycated hemoglobin is associated with higher blood glucose levels that further results in nephropathy, neuropathy, retinopathy, and cardiovascular disease. Therefore, the study has investigated the correlation between HbA1c and creatinine levels among diabetic patients, suffering from foot ulcerations.

METHODS

A prospective cohort hospital based-study has retrieved hospital records of patients during January 2009 and February 2015. A total of 192 patients, admitted in the Rajiv Gandhi Centre for Diabetes and Endocrinology, of Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India were recruited.

RESULTS

It has been examined that there is a positive correlation between ulcer duration and BMI, amputation rate and BMI, gender and BMI, hospital stay and BMI, HbA1c and BMI, Hb and BMI and triglyceride and BMI at 5% level of significance.

CONCLUSION

Findings have shown positive association with gender, diabetes duration, ulcer size, grade of ulcer, amputation rate, hospital stay, Hb, SGOT/AST and triglyceride.

Factors Associated with Health-Related Quality of Life among Jordanian Patients with Diabetic Foot Ulcer

OBJECTIVE

This study is aimed at determining factors associated with the quality of life among Jordanian diabetic patients with foot ulcers.

METHODS

144 consecutive patients with diabetic foot ulcers aged ≥ 18 years who were attending the diabetic foot clinic at a diabetes-specialized center were included in this study. Health-related quality of life was assessed using two self-administered questionnaires: Diabetic Foot Scale-Short Form (DFS-SF) and Short Form-8 (SF-8).

RESULTS

Patients with diabetic foot ulcer had low mean DFS-SF score and low mean scores on physical and mental component summary scales (PCS8 and MCS8). Males had significantly higher DFS-SF score indicating better health-related quality of life than females (P value 0.038). A patient with stressful life events had significantly lower health-related quality of life using DFS-SF scale and SF-8 summary scales. Patients with peripheral vascular disease (PVD) and patients with obesity had lower DFS-SF and PCS8 quality of life.

CONCLUSION

Patients with diabetic foot ulcer had low quality of life. Female gender, obesity, presence of PVD, and stressful life events were the most important factors associated with lower quality of life in patients with diabetic foot ulcer.

Distribution of the Highest Plantar Pressure Regions in Patients with Diabetes and Its Association with Peripheral Neuropathy, Gender, Age, and BMI: One Centre Study

The abnormal plantar pressure distribution and value play a key role in the formation of plantar calluses and diabetic foot ulcer. The prevalence of the highest pressure different distribution and its association with various factors among patients with diabetes is not well known. The study purpose was to evaluate the prevalence of different regions for the highest pressure on the sole and its association with selected factors among patients with diabetes. Medical records of nonulcer patients were retrospectively analysed. The relationship between pressure patterns on the sole obtained during a pedobarographic test as a semiquantitative assessment with colourful print analysis and neuropathy, gender, age, and BMI was searched. The most common location of the highest pressure was the central part of the forefoot. No association was found between the different highest pressure regions and age, sensory neuropathy, calluses, and foot deformities. The highest pressure on the lateral part of the foot and midfoot was observed more often in females and in patients with a BMI ≥ 35. The prevalence of the highest pressure on the forefoot was more common in patients with a BMI < 35. Conclusions. The most frequent regions of the highest pressure on the sole in patients with diabetes were the central part of the forefoot (2-3 metatarsal heads) with no simple relationship to the assessed variables other than BMI < 35. Female gender and higher BMI seem to be responsible for shifting the place of the highest pressure to other places of the foot.

Lower Limb Nonhealing Ulcers Associated With Chronic Diabetes: A Case Series

INTRODUCTION

Chronic, nonhealing skin ulcers of the lower limbs associated with diabetes pose a clinical challenge as their treatment requires more sophisticated and delicate approaches than in patients without diabetes.

OBJECTIVE

Herein, the authors demonstrate and discuss the implementation of their use of topical traditional Chinese medicines in several sample cases of lower limb nonhealing ulcers in patients with diabetes.

MATERIALS AND METHODS

A series of diabetic ulcer cases were treated with various approaches. First, the approach employed with each patient was determined based on ulcer location, depth, inflammatory extent, and local circulation. Next, an exploratory incision was performed to evaluate eschar condition. Finally, the therapy applied was modified depending on specific case characteristics.

RESULTS

The primary therapeutic approaches employed were: (1) selective partial ablation, including fenestration and encroachment; (2) debridement, which avoids secondary injury when local circulation is good; and (3) the turning-over method, in which necrotic tissue is cleaned down to the basal layer via application of a topical Chinese medicine that reduces inflammation and promotes chronic ulcer healing.

CONCLUSIONS

These therapeutic approaches alleviated local inflammatory damage and adverse systemic reactions, which is an important basis for further treatment (eg, anti-infection treatment, blood glucose reduction, blood pressure control, organ function improvement, circulation promotion, and nutritional support).

Clinical treatment of diabetic foot ulcer combined with Budd-Chiari syndrome: A case report

RATIONALE

Diabetic foot ulcer is a severe complication of diabetes, and most patients with diabetic foot ulcer require amputation. The incidence of Budd-Chiari syndrome is low; it is relatively rare. Diabetic foot ulcer combined with Budd-Chiari syndrome has not been reported so far.

PATIENT CONCERNS

A 52-year-old man presented with uncontrolled high body temperature, continued expansion of the lower leg and foot ulcer with increasing malodor.

DIAGNOSIS

The patient was diagnosed with Wagner grade 4 diabetic foot ulcer combined with Budd-Chiari syndrome.

INTERVENTIONS

Critical treatment was performed immediately after his admission to the hospital. After the patient's condition was stable, we performed an interventional procedure to relieve the inferior vena cava obstruction. Debridement was then performed on the diabetic foot ulcer. Finally, skin grafting was performed due to condition of the wound. We completed moist healing and vacuum sealing drainage throughout the treatment process.

OUTCOMES

The patient was hospitalized for 56 days, and all his right lower extremity ulcers eventually healed.

LESSONS

In the treatment of diabetic foot ulcer combined with Budd-Chiari syndrome, it is necessary to develop a unified treatment plan that includes the timely treatment of Budd-Chiari syndrome upon admission, the strategic use of debridement, and the application of moist healing and vacuum sealing drainage.

Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible

No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ ² or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = -2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.

A Tale of Two Eras: Mining Big Data from Electronic Health Records to Determine Limb Salvage Rates with Podiatry

AIMS/HYPOTHESIS

Diabetic foot complications remain very prevalent in the US and worldwide, and a major risk for devastating amputations. We evaluated the impact of establishing a fully integrated and specialized Podiatry service into a large tertiary academic health system to implement structured and targeted preventative foot care on limb salvage rates.

METHODS

Cross-sectional cohorts' data mining analysis was conducted of all encounters for diabetes and any foot complications between 2000-2005 and 2010-2015, preceding and after full implementation of podiatry service, respectively. The primary outcome was the change in major non-traumatic lower extremity amputations. Secondary outcomes included minor non-traumatic lower extremity amputations, other diabetic foot complications, limb salvage procedures as documented by procedural coding, and location (outpatient, inpatient, ED) of service rendered.

RESULTS

We analyzed 100 million patient encounters that met the above criteria. Compared with the initial cohort, integration of specialized podiatry services resulted in a significant decrease in the number of major amputations from 127 to 85/year (p<0.05), and halved the amputations rate from 0.004% to 0.002% (p<0.05). Rates of minor lower extremity amputations remained unchanged (p>0.10), while the rates of preventative procedures including foot ulcer debridement doubled (0.0002% to 0.0004% ; p<0.03). Diagnoses of diabetic foot complications increased significantly (p<0.05) and shifted toward the outpatient setting.

CONCLUSION

Full integration of specialized Podiatry service led to a significant decrease in major amputation rates, supporting teamwork between podiatry and diabetes health-care providers is essential to performing timely diabetic foot complications management, preventative procedures leading to limb salvage, and a shift in the care location.

Mortality and complications after treatment of acute diabetic Charcot foot

AIMS

Charcot foot is a rare but disabling complication to diabetic neuropathy, and can cause permanent, limb-threatening deformities. The aim of this study was to investigate a population of patients a Charcot foot on a case-by-case basis, in order to assess the consequences of an acute Charcot foot and its complications.

METHODS

The study was conducted a retrospective study of patients admitted to the Copenhagen Wound Healing Center between 1996 and 2015 with the diagnosis of Charcot foot (DM14.6) and diabetes mellitus type 1 or 2 (DE10.X and DE11.X). Physical and electronic records were used, and compared to data from the Danish Diabetes Registry.

RESULTS

In total 392 patients were identified of which 173 were included. There were 26% with type 1 diabetes (initial HbA1c 81.7 ± 21.4 mmol/mol) and 74% with type 2 diabetes (initial HbA1c 66.5 ± 20.3 mmol/mol). Primary off-loading was with a removable walker in 95% of the cases (average off-loading time 8.3 months). The 5-year mortality was 14% with a mean survival time of 12.7 years. There was an association between lack of compliance and occurrence of foot complications, as well as between having a Charcot foot and leaving the workforce.

CONCLUSION

More patients had type 1 diabetes compared to the background population, and they had a higher HbA1c than the general population of diabetes patients. A total of 67% developed complications such as ulcers, while patients non-compliant to treatment did significantly worse than those being compliant. The 5-year mortality was low, 14%, and comparable to diabetes patients without Charcot foot.

Association between thermal threshold abnormalities and peripheral artery disease in patients with type 2 diabetes

Both diabetic peripheral neuropathy and peripheral arterial disease (PAD) cause foot ulcers and often result in non-traumatic amputations in patients with type 2 diabetes. This study aimed to evaluate the association between clinical variables, PAD, and subclinical diabetic small fiber peripheral neuropathy detected by abnormal thermal thresholds of the lower extremities in patients with type 2 diabetes.We investigated 725 consecutive patients with type 2 diabetes (male/female: 372/353; mean age, 67 ± 11 years) who did not have apparent cardiovascular disease (including coronary artery disease, arrhythmia, and stroke) and who underwent the quantitative sensory test for thermal (warm and cold) thresholds of the lower limbs and ankle-brachial index (ABI)/toe-brachial index (TBI) examinations in 2015. The analyses included glycated hemoglobin, estimated glomerular filtration rate, and other characteristics.In total, 539 (74.3%) patients showed an abnormality of at least 1 thermal threshold in their feet. All patients with an abnormal ABI (<0.9) had concurrent impaired thermal thresholds, and 93% (87/94) of patients with an abnormal TBI experienced abnormal thermal thresholds in the lower limbs. Age- and sex-adjusted TBI and estimated glomerular filtration rate were significantly correlated to abnormal thermal thresholds. In the multivariate analysis, fasting plasma glucose, and glycated hemoglobin were independently associated with abnormal thermal thresholds in the lower extremities.Subclinical thermal threshold abnormalities of the feet are significantly associated with PAD and nephropathy in patients who have type 2 diabetes without cardiovascular disease.

Morbidity and mortality of infected diabetic foot managed in general surgical department

BACKGROUND

Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers.

METHODS

It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality.

RESULTS

This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08  23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92  33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41  16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055  0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004  0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014  1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039  1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071  0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298  0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088  0.354], p<0.001)  and Pre-operative stay (OR=1.083, 95%CI [1.033  1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48  0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76  0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558  7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038  1.147], p=0.001) was predictive of reintervention.

CONCLUSIONS

Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.

A Novel Method for the Determination of Vancomycin in Serum by High-Performance Liquid Chromatography-Tandem Mass Spectrometry and Its Application in Patients with Diabetic Foot Infections

A novel, precise, and accurate high-performance liquid chromatography-tandem mass spectrometry (Q-trap-MS) method was developed, optimized, and validated for determination of vancomycin in human serum using norvancomycin as an internal standard. Effect of different parameters on the analysis was evaluated. ZORBAX SB-C18 column (150 × 4.6 mm, 5 μm) using water (containing 0.1% formic acid, v/v)⁻acetonitrile (containing 0.1% formic acid, v/v) as a mobile phase was chosen. The calibration curve was linear over the concentration ranges of 1 to 2000 ng/mL for vancomycin. The limit of detection (LOD) and limit of quantification (LOQ) for vancomycin were 0.3 and 1.0 ng/mL. Recoveries were between 87.2 and 102.3%, which gave satisfactory precision. A total of 100 serum samples (from 50 patients with diabetic foot proven Gram-positive infection and 50 nondiabetic patients with pneumonia requiring hospitalization and antibiotic therapy) were analyzed by this method. The trough vancomycin concentrations of diabetic foot infection (DFI) patients and nondiabetic patients were 8.20 ± 2.83 μg/mL (range: 4.80⁻14.2 μg/mL) and 15.80 ± 5.43 μg/mL (range: 8.60⁻19.5 μg/mL), respectively. The method is sensitive, precise, and reproducible, it could be applied for routine laboratory analysis of vancomycin in serum samples.

Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study

AIMS

To assess the prevalence of risk factors for obstructive sleep apnoea in people with diabetic foot ulcers and to determine whether this risk predicts diabetic foot ulcer healing.

METHODS

We studied 94 consecutive people (69% men) with diabetic foot ulcers (Type 2 diabetes, n=66, Type 1 diabetes, n=28) attending a university hospital foot unit. All participants were screened for obstructive sleep apnoea using the STOP-BANG questionnaire, with a score ≥4 identifying high risk of obstructive sleep apnoea. The primary outcome was poor diabetic foot ulcer healing, defined as diabetic foot ulcer recurrence (diabetic foot ulcers which healed and re-ulcerated in same anatomical position) and/or diabetic foot ulcer persistence (no evidence of healing on clinical examination). All participants were evaluated at 12 months.

RESULTS

Of the 94 participants, 60 (64%) had a STOP-BANG score ≥4. Over 12 months, 27 participants with a score ≥4 had poor diabetic foot ulcer healing as compared to seven with a score <4 (45% vs 20.5%; P=0.025). A STOP-BANG score ≥4 significantly increased the relative risk of poor healing more than twofold, independently of other risk factors in multivariable analyses.

CONCLUSIONS

There is a high prevalence of features and risk of obstructive sleep apnoea in people with diabetic foot ulcers. A STOP-BANG score ≥4 predicts poor diabetic foot ulcer healing. Obstructive sleep apnoea may be a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.

Diabetic foot infection: A critical complication

The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.

Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot

OBJECTIVE

The main purpose of this study was to investigate the diagnostic value of dynamic contrast-enhanced MRI (DCE-MRI) in differentiating osteomyelitis from acute neuropathic arthropathy in the diabetic foot.

MATERIALS AND METHODS

This prospective study was carried out on 30 diabetic foot patients, with a mean age of 51 years. The patients all underwent clinical examinations, laboratory examinations and DCE-MRI. The DCE-MRI parameters (K^trans, K_ep and V_e) of the regions of acute neuropathic arthropathy and osteomyelitis were calculated. Receiver operating characteristic curves (ROCs) were used to identify the DCE-MRI parameters that showed the highest accuracy in differentiating the acute neuropathic arthropathy from the osteomyelitic regions. Pearson correlation coefficients were used to assess the correlations among the DCE-MRI parameters, the level of C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR).

RESULTS

The K^trans, K_ep and V_e values of the osteomyelitic regions were higher than those of the acute neuropathic arthropathy regions, and significant differences were found between the two groups (P = 0.000, P = 0.000, P = 0.000). The ROC analysis showed that K^trans and V_e performed best in differentiating osteomyelitis from acute neuropathic arthropathy, both with an area under the curve of 0.938. The Pearson correlation coefficients showed that the DCE-MRI parameters correlated significantly with the level of CRP and ESR (P = 0.000, P = 0.014, P = 0.000; P = 0.000, P = 0.000, P = 0.013).

CONCLUSIONS

Our results showed that DCE-MRI may provide reproducible parameters that can reliably differentiate osteomyelitis from acute neuropathic arthropathy.

Effects of Non-thermal, Non-cavitational Ultrasound Exposure on Human Diabetic Ulcer Healing and Inflammatory Gene Expression in a Pilot Study

The purpose of this clinical study was to assess, in a limited patient population, the potential for a novel advanced wound care treatment based on low-frequency (20 kHz) low-intensity (spatial peak temporal peak intensity <100 mW/cm²; i.e., pressure amplitude of 55 kPa) ultrasound (LFLI-US), to affect wound closure rate in human diabetic foot ulcers (DFUs) and to effect changes in the relative expression of pro-inflammatory and anti-inflammatory genes. The ratio of expression of these genes, termed the M1/M2 score because it was inspired by the transition of macrophages from pro-inflammatory (M1) to anti-inflammatory (M2) phenotypes as wound healing progresses, was previously presented as a potential healing indicator for DFUs treated with the standard of care. We previously found that non-cavitational, non-thermal LFLI-US delivered with a pulse repetition frequency of 25 Hz was effective at improving wound healing in a pilot study of 20 patients with chronic venous ulcers. In this study, we assessed the potential for weekly LFLI-US exposures to affect wound healing in patients with diabetic ulcers, and we analyzed temporal changes in the M1/M2 score in debrided diabetic wound tissue. Although this was a limited patient population of only 8 patients, wounds treated with LFLI-US exhibited a significantly faster reduction in wound size compared with sham-treated patients (p < 0.001). In addition, the value of the M1/M2 score decreased for all healing diabetic ulcers and increased for all non-healing diabetic ulcers, suggesting that the M1/M2 score could be useful as an indicator of treatment efficacy for advanced DFU treatments. Such an indicator would facilitate clinical decision making, ensuring optimal wound management and thus contributing to reduction of health care expenses. Moreover, the results presented may contribute to an understanding of the mechanisms underlying ultrasonically assisted chronic wound healing. Knowledge of these mechanisms could lead to personalized or patient-tailored treatment.

Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis on 33 870 patients

AIMS

The diabetic foot syndrome (DFS) is a serious complication in patients with diabetes increasing the risk for minor/major amputations. This analysis aimed to examine differences in diabetes patients with or without DFS stratified by type 1 (T1D) or type 2 diabetes (T2D).

MATERIAL AND METHODS

Adult patients (≥20y of age) with diabetes from the German/Austrian diabetes patients follow-up registry (DPV) were included. The cross-sectional study comprised 45 722 subjects with T1D (n_DFS  = 2966) and 313 264 with T2D (n_DFS  = 30 904). In DFS, minor/major amputations were analysed. To compare HbA_1C , neuropathy, nephropathy, cardiovascular disease risk factors, and macrovascular complications between patients with or without DFS, regression models were conducted. Confounders: age, sex, diabetes duration.

RESULTS

In patients with DFS, a minor amputation was documented in 27.2% (T1D) and 25.9% (T2D), a major amputation in 10.2% (T1D) and 11.3% (T2D). Regression models revealed that neuropathy was more frequent in subjects with DFS compared with patients without DFS (T1D: 70.7 vs 29.8%; T2D: 59.4% vs 36.9%; both P < 0.0001). Hypertension, nephropathy, peripheral vascular disease, stroke, or myocardial infarction was more common compared with patients without DFS (all P < 0.0001). In T1D with DFS, a slightly higher HbA_1C (8.11% vs 7.95%; P < 0.0001) and in T2D with DFS a lower HbA_1C (7.49% vs 7.69%; P < 0.0001) was observed.

CONCLUSIONS

One third of the patients with DFS had an amputation of the lower extremity. Especially neuropathy or peripheral vascular disease was more prevalent in patients with DFS. New concepts to prevent DFS-induced amputations and to reduce cardiovascular risk factors before the occurrence of DFS are necessary.

Open-label Extension Phase of a Chronic Diabetic Foot Ulcer Multicenter, Controlled, Randomized Clinical Trial Using Cryopreserved Placental Membrane

OBJECTIVE

The results of the single-arm, open-label extension phase of the Grafix (cryopreserved placental membrane; CPM; Osiris Therapeutics, Inc, Columbia, MD) multicenter, blinded, randomized, controlled clinical trial for chronic diabetic foot ulcers (DFUs) is reported.

MATERIALS AND METHODS

Twenty-six patients in the standard wound care (SWC) arm whose DFUs did not close in the blinded phase chose to receive weekly applications of the CPM in an open-label extension phase.

RESULTS

In the extension phase, 17 (65.4%) patients closed their wounds in a median of 34 days and 3 visits. There were fewer total adverse events (AEs) (24 CPM vs. 52 SWC) and index wound-related infections (5 CPM vs. 12 SWC) during the CPM application compared with the number of AEs for the same patients during the SWC treatment in the blinded phase of the trial.

CONCLUSIONS

These results corroborate the benefits of this CPM combined with SWC over SWC alone for chronic DFUs previously reported for the blinded randomized phase of the trial, which directly relate to lower health care costs.

Peripheral arterial disease increases the risk of multidrug-resistant bacteria and amputation in diabetic foot infections

Background/aim

The aim of this study was to investigate the microbiological profile and resistance rates of diabetic foot infections (DFIs) and to determine the effect of peripheral arterial disease (PAD) on the microbiology, clinical condition, and treatment outcomes.

Materials and methods

Characteristics, laboratory and imaging data, and the treatment modalities of patients admitted to our hospital with a diagnosis of DFI (PEDIS classification 3–4) during 2005–2016 were analyzed according to the presence of PAD.

Results

Of 112 patients who were included in this study, 86 (76.8%) had PAD. Patients with PAD were older and had higher amputation rates (P < 0.05). A microbiological profile of patients revealed a predominance of gram-positive bacteria (57.1%). Staphylococcus aureus and Streptococcus spp. were the most frequently encountered bacteria. Incidence of Pseudomonas spp. infection was higher in the PAD group (P < 0.05). Of all patients, 24.1% had multidrug-resistant (MDR) microorganisms in their wound cultures. Presence of MDR bacteria in patients with PAD was 4.9-fold higher than that in patients without PAD (P < 0.05).

Conclusion

This retrospective study indicates that PAD has a significant role, especially in elderly patients with DFIs. Patients should be promptly evaluated and treated for PAD to prevent infections with resistant microorganisms and limb loss.

Implantable Nanomedical Scaffold Facilitates Healing of Chronic Lower Extremity Wounds

BACKGROUND

Chronic, nonhealing wounds are a growing health care problem in the United States, affecting more than 6.5 million patients annually.

OBJECTIVE

This retrospective study evaluates the clinical efficacy and utility of an implantable nanomedical scaffold in the treatment of chronic, nonhealing lower extremity wounds in patients with multiple comorbidities.

MATERIALS AND METHODS

Data from patients with chronic wounds that had persisted for ≥ 4 weeks and were unresponsive to existing advanced wound care modalities were included in the study. Wounds received the implantable nanomedical scaffold weekly, or as deemed appropriate, for up to 12 weeks based on physician assessment of wound status.

RESULTS

A total of 82 wounds were included in this study; wound types consisted of 34 diabetic foot ulcers, 34 venous leg ulcers, and 14 other wounds. Overall, treated wounds demonstrated progressive and sustained wound area reduction over the course of treatment, with 85% achieving complete closure at 12 weeks.

CONCLUSIONS

The implantable nanomedical scaffold proved to be an effective alternative to existing wound matrices capable of supporting the natural wound healing process and may provide significant benefits as part of the treatment algorithm for challenging chronic wounds.

Severe Vitamin D3 Deficiency in the Majority of Patients with Diabetic Foot Ulcers

Diabetic foot ulcers are a severe complication in patients with diabetes mellitus. Vitamin D is associated with impaired β-cell function and insulin resistance, and is necessary for wound healing and bone metabolism. We measured the serum concentrations of 25-hydroxyvitamin D₃ in 104 patients (63 inpatients, 41 outpatients) with diabetic foot ulcers and compared them to 99 healthy humans (control) and 103 patients with diabetes mellitus type 2 without diabetic foot ulcers. Calcium, creatinine, and parathyroid hormone were measured in patients with diabetic foot ulcers. The data were analysed together with glycosylated hemoglobin A1c and the severity of diabetic foot lesions according to the Armstrong classification. Levels of 25-hydroxyvitamin D₃ were lower (11.8±11.3 ng/ml, p<0.001) in patients with diabetic foot ulcers (mean age 70±12 years) than in the control group (27.2±12.2 ng/ml). No difference was found between in- and outpatients. Fifty-eight (55.8%) of patients with diabetic foot ulcers had a severe 25-hydroxyvitamin D₃ deficiency with levels below 10 ng/ml. Only 12% of the patients had 25-hydroxyvitamin D₃ levels above 20 ng/ml. Secondary hyperparathyroidism was found in 27.9% of patients and 11.5% of the patients were hypocalcemic. There was a negative correlation (r=-0.241) (p<00.1) between Armstrong classification and 25-hydroxyvitamin D₃ status. In conclusion, patients with diabetic foot syndrome are at high risk of 25-hydroxyvitamin D₃ deficiency. Thus, any patient with diabetic foot syndrome should undergo 25-hydroxyvitamin D₃ measurement and supplementation, if values are found to be decreased.

Safety and Efficacy of an Autologous Blood Clot Product in the Management of Texas 1A or 2A Neuropathic Diabetic Foot Ulcers: A Prospective, Multicenter, Open Label Pilot Study

OBJECTIVE

This pilot study evaluates safety in terms of the occurrence of adverse events (AEs) as well as the efficacy in terms of complete wound healing rates of a blood clot product when applied to chronic neuropathic diabetic foot ulcers (DFUs).

MATERIALS AND METHODS

Participants were chosen from patients with DFUs visiting the wound care clinic. Up to 10 mL of blood drawn from each participant was injected into the product's clotting tray. Within 12 minutes, the blood clot product was formed, applied to the single DFU of each participant, and covered with primary and secondary dressings. Patients received up to 12 blood clot product applications every 5 to 9 days for up to 12 weeks.

RESULTS

Twenty patients were enrolled; 20 were analyzed in the intent-to-treat (ITT) population and 18 were in the per-protocol (PP) population. Thirty-two AEs occurred (only 2 were possibly device related). The mean AE rate for both the ITT and PP populations was 1.6. The proportion of wounds healed in the ITT and PP populations was 13 out of 20 (65%) and 13 out of 18 (72.2%), respectively. Percentage area reduction (PAR) for the ITT population at 4 and 12 weeks was 61.6% and 67.1%, respectively; the PARs for the PP population were 60.3% and 76.2% at 4 and 12 weeks, respectively. Mean times to wound healing were 59 days and 56 days in the ITT and PP populations, respectively.

CONCLUSIONS

This study demonstrates that the blood clot product is safe and efficacious for treating DFUs.

Physical activity and exercise on diabetic foot related outcomes: A systematic review

BACKGROUND

Diabetic foot is one of the most common complications of diabetes. It has the potential risk of pathologic consequences including infection, ulceration and amputation, but a growing body of evidence suggests that physical activity and exercise may improve diabetic foot outcomes.

OBJECTIVE

To analyze de effects of exercise and physical activity interventions on diabetic foot outcomes.

METHODS

A comprehensive and systematic search was conducted according to PRISMA recommendations. Only controlled clinical trials with patients with diabetes were included.

RESULTS

Six studies, involving 418 patients with diabetes, were included. Two studies used only aerobic exercise; two studies combined aerobic, resistance and balance exercise; and two studies combined aerobic and balance exercise by Thai Chin Chuan methods. Physical activity and exercise significantly improved nerve velocity conduction, peripheral sensory function and foot peak pressure distribution. Moreover, the ulcers incidence rate per year was lower in the intervention groups, compared with the controls [0.02 vs. 0.12].

CONCLUSION

This review suggests evidence that physical activity and exercise is an effective non-pharmacological intervention to improve diabetic foot related outcomes. Combined multi-disciplinary treatments are more effective in the prevention of foot complications in patients with diabetes.

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Association between QTc interval prolongation and outcomes of diabetic foot ulcers: Data from a 4-year follow-up study in China

OBJECTIVES

To examine whether QTc interval prolongation is an independent risk factor of outcomes in patients with diabetic foot ulcers (DFU).

RESEARCH DESIGN AND METHODS

331 patients with type 2 diabetes and DFU hospitalized in a Chinese tertiary hospital were recruited. ECG was done at baseline and QTc interval was calculated through Bazett's formula. Participants were classified into 2 groups according to the QTc interval as prolonged (≥440 ms) or not (<440 ms). These patients were followed-up for an average of 48 months to observe the outcomes, including ulcer healing, ulcer recurrence, nonfatal cerebral or cardiovascular events (NCCVE), cerebral cardiovascular death, cardiac death and all-cause death. The associations between the risk of outcomes and QTc interval prolongation, as well as per 1-SD increase in QTc interval were analyzed by Cox proportional-hazards models.

RESULTS

In terms of the univariate Cox proportional hazard models, patients with QTc interval prolongation had a higher all-cause mortality (HR = 1.621, 95%CI: 1.040-2.526, P = .013), higher cardiac mortality (HR = 2.011 95%CI: 1.106-3.657, P = .019), higher cerebral cardiovascular mortality (HR = 1.525, 95%CI: 0.8151-2.852, P = .045). The multivariate analysis showed that QTc prolongation was an independent risk factor for cardiac death (HR = 5.465, 95%CI: 2.818-8.112, P = .039). Similar results were obtained when QTc interval was used as a continue variable, a 1-SD increase in QTc interval was associated with an 5.883 times risk for cardiac mortality (HR = 6.883, 95%CI: 4.153-9.613, P = .012). The association between QTc interval prolongation with ulcer healing, recurrence and NCCVE were not observed either in univariate or multivariate analysis (P > .05).

CONCLUSION

QTc interval prolongation was a plausible predictor for cardiac death in DFU patients, but it cannot accurately predict ulcer healing or recurrence.

CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England

OBJECTIVE

To determine the extent of agreement and patterns of disagreement between wound swab and tissue samples in patients with an infected diabetic foot ulcer (DFU).

DESIGN

Multicentre, prospective, cross-sectional study.

SETTING

Primary and secondary care foot ulcer/diabetic outpatient clinics and hospital wards across England.

PARTICIPANTS

Inclusion criteria: consenting patients aged ≥18 years; diabetes mellitus; suspected infected DFU.

EXCLUSION CRITERIA

clinically inappropriate to take either sample.

INTERVENTIONS

Wound swab obtained using Levine's technique; tissue samples collected using a sterile dermal curette or scalpel.

OUTCOME MEASURES

Coprimary: reported presence, and number, of pathogens per sample; prevalence of resistance to antimicrobials among likely pathogens. Secondary: recommended change in antibiotic therapy based on blinded clinical review; adverse events; sampling costs.

RESULTS

400 consenting patients (79% male) from 25 centres.Most prevalent reported pathogens were Staphylococcus aureus (43.8%), Streptococcus (16.7%) and other aerobic Gram-positive cocci (70.6%). At least one potential pathogen was reported from 70.1% of wound swab and 86.1% of tissue samples. Pathogen results differed between sampling methods in 58% of patients, with more pathogens and fewer contaminants reported from tissue specimens.The majority of pathogens were reported significantly more frequently in tissue than wound swab samples (P<0.01), with equal disagreement for S. aureus and Pseudomonas aeruginosa. Blinded clinicians more often recommended a change in antibiotic regimen based on tissue compared with wound swab results (increase of 8.9%, 95% CI 2.65% to 15.3%). Ulcer pain and bleeding occurred more often after tissue collection versus wound swabs (pain: 9.3%, 1.3%; bleeding: 6.8%, 1.5%, respectively).

CONCLUSION

Reports of tissue samples more frequently identified pathogens, and less frequently identified non-pathogens compared with wound swab samples. Blinded clinicians more often recommended changes in antibiotic therapy based on tissue compared with wound swab specimens. Further research is needed to determine the effect of the additional information provided by tissue samples.

TRIAL REGISTRATION NUMBER

ISRCTN52608451.

Complications during the treatment of diabetic foot osteomyelitis

AIM

To identify complications of medical treatment in patients with diabetic foot osteomyelitis (DFO).

METHODS

We reviewed 143 records of consecutive patients admitted with DFO, confirmed by bone histopathology or culture. Complications monitored included acute kidney injuries (AKI), development of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), gastrointestinal complications, and venous catheter related complications during a 12months follow-up period.

RESULTS

Forty-seven AKI episodes were reported during follow-up; half occurred during the first hospitalization with involvement of antimicrobial therapy in 14 events (29.8%). Patients with AKI were more likely to have recurrent ulcerations (69.2% vs. 45.2%, p=0.02), recurrent infections (38.5% vs. 17.3%, p=0.01), and recurrent hospitalizations (43.6% vs. 28.8%, p=0.02) during follow-up. Only 14 MRSA isolates were found in bone samples at baseline (9.8%). Resistant strains of MRSA and VRE were identified in twenty-one patients (14.7%) during follow-up. Patients re-hospitalized for infection were more likely to have resistant bacterial strains (52.6% vs. 25.8%, p=0.02).

CONCLUSIONS

In this study, the rates of VRE and MRSA in bone biopsies of patients with DFO were lower than in previous reports. Acute kidney injury occurred frequently in our patient population but might not be associated with antibiotic exposure.

Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study

AIMS

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

METHODS

This multicentre, prospective, observational study reviewed participants' data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants' notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence.

RESULTS

In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06).

CONCLUSIONS

Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.

The impact of glycaemic variability on wound healing in the diabetic foot - A retrospective study of new ulcers presenting to a specialist multidisciplinary foot clinic

AIMS

Glycaemic variability - the visit-to-visit variation in HbA1c - plays a possible role in the development of micro and macrovascular disease in patients with diabetes. Whether HbA1c variability is a factor determining wound healing in diabetic foot ulcers remains unknown. We aimed to determine whether HbA1c variability is associated with foot ulcer healing time.

METHODS

A retrospective analysis of patients presenting to our specialist multidisciplinary foot clinic between July 2013 and March 2015, with at least three HbA1c measurements within five years of presentation and more than two follow-up reviews. HbA1c variation was measured by magnitude of standard deviation.

RESULTS

629 new referrals were seen between July 2013 and March 2015. Of these, 172 patients had their number of days to healing recorded and sufficient numbers of HbA1c values to determine variability. The overall geometric mean days to heal was 91.1 days (SD 80.8-102.7). In the low HbA1c variability group the geometric mean days to heal was 78.0 days (60.2-101.2) vs 126.9 days (102.0-158.0) in the high Hb1Ac variability group (p = .032). Those with low HbA1c (<58 mmol/mol) and low variability healed faster than those with high HbA1c and high variability (73.5 days [59.5-90.8] vs 111.0 days [92.0-134.0], p = .007). Additionally, our results show that time to healing is more dependent on the mean HbA1c than the variability in HbA1c (p = .007).

CONCLUSIONS/INTERPRETATION

Our data suggest that there was a significant association between HbA1c variability and healing time in diabetic foot ulcers.

Update on management of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

Chronic non-healing wounds in geriatrics

Chronic non-healing wounds represent a frequent comorbidity among geriatric patients. Non-healing wounds increase patients morbidity and mortality and significantly decrease their quality of life. Prognosis of these wounds depends on etiology, overall health condition of the patient and also on the proper treatment. In this review we outline the classification of non-healing wounds and focus in more detail on the most frequent types: venous and arterial leg ulcers, diabetic foot syndrome and pressure ulcers. Key words: diabetic foot ulcers - chronic venous insufficiency - chronic wounds - limb ischemia - non-healing wounds - pressure ulcers.

Clinical and microbiological profile of diabetic foot ulcer patients in a tertiary care hospital

AIM

To evaluate the clinical and microbiological profile of diabetic foot ulcer patients admitted to a tertiary care hospital.

METHODOLOGY

This study recruited 120 diabetic foot ulcer patients of all grade. Their medical records were evaluated retrospectively.

RESULTS

We found that median age of patient was 60(52, 67.75) years. 68.3% of patients were males. Median duration of diabetes mellitus was 15(10, 20) years. Mean HbA1C and fasting glucose was 10.3±2.3 and 167.6±52.42 respectively. Neuropathy (35%) and peripheral vascular disease (23.3%) was major micro vascular and macro vascular complication associated. Different locations of ulcers were toe (23.3%), sole (20%), dorsum (18.3%), shin (16.6%), heel (13.3%), and ankle (8.3%). Bacterial infection was seen in 81.66% patients out of which 23.3% had poly microbial infection.

CONCLUSION

Diabetic foot ulcer patient had poor blood glucose control with elevated HbA1C and fasting blood glucose level. Neuropathy and peripheral vascular disease, hypertension were major complications. Staphylococcus aureus, Pseudomonas aeruginosa were common infecting bacteria.

Malignant Transformation of a Site of Prior Diabetic Foot Ulceration to Verrucous Carcinoma: A Case Report

The case of a 62-year-old Caucasian man with type 1 diabetes who developed malignant transformation of an area of prior diabetic foot ulceration (DFU) is reported. He had significant hallux valgus deformity, multiple episodes of healing and breakdown, and eventual transformation to verrucous carcinoma (VC). This case report highlights the malignant transformation of a site of previous DFU to VC, which, to the best of the authors' knowledge, has not yet been described in the literature. There has been little research performed that examines VC in the diabetic population. This case report also highlights the importance of clinical suspicion for malignant transformation as well as the use of subsequent biopsy when necessary.

All-cause and cardiovascular mortality in a consecutive series of patients with diabetic foot osteomyelitis

BACKGROUND

Mortality in patients with type 2 diabetes and diabetic foot osteomyelitis (DFO) have been explored in few small studies with a short follow-up. Aim of the present study is to assess all-cause and cardiovascular mortality and predictors of mortality in a consecutive series of patients with DFO.

RESEARCH DESIGN AND METHODS

Patients with a diagnosis of DFO, attending the Diabetic Foot Unit of San Donato Hospital in Arezzo between January 1st, 2012 and December 31st, 2013, were included in this retrospective study. Information on all-cause mortality up to December 1st, 2016, was obtained from the registry of the Local Health Unit of Arezzo, which contains updated records of all persons living in Tuscany.

RESULTS

One hundred ninety-four patients were included in the study. During a mean period of observation of 2.8±1.4years, 73 (37.6%) died, with a yearly rate of 13.2%. Of the 73 deaths, 59 were attributable to cardiovascular causes. After adjusting for possible confounders in a Cox analysis, site of osteomyelitis (hindfoot vs mid/forefoot) was associated with a higher mortality, and surgical treatment with a lower mortality.

CONCLUSIONS

Mortality in patients with DFO appears to be much higher than that reported in clinical series of patients with diabetic foot ulcers, particularly when hindfoot is affected.

Effect of puerarin on type II diabetes mellitus with orthopaedic footwear

In recent years, the antioxidant efficacy of puerarin has been recognized. However, there is less research on Puerarin used in diabetes. This paper analyzes the effect of puerarin on type II diabetes mellitus induced by streptozotocin combined with orthopaedic footwear. In this study, 80 Sprague Dawley (SD) rats were fed with high fat and high sucrose diet for one month, and 1% streptozotocin (STZ) was used to induce type II diabetes mellitus. After 6 weeks aerobic exercise and puerarin intervention in rats, the effect of aerobic exercise and puerarin intervention on antioxidant ability in diabetic rats was investigated. The results showed that aerobic exercise and puerarin intervention can improve the insulin resistance in rats. Meanwhile, the annual incidence of foot ulcers in diabetic patients is 2%, while orthopaedic footwear can reduce the probability of diabetic foot ulcers. In general, exercise and puerarin intervention can really play a role in the prevention and treatment of diabetes, such as improving the metabolic status of diabetic patients and reducing their dependence on drugs.