Epidemiology of Type 2 Diabetic Foot Problems and Predictive Factors for Amputation in China

Risk Factors for Major Amputation in Diabetic Foot Ulcer Patients

BACKGROUND

The purpose of our study was to identify the new and the more specific risk factors for major amputation in patients with diabetic foot ulcer (DFU).

METHODS

We used data from the Electronic Medical Record (EMR) database of our hospital from February 2014 to July 2020. Patients with DFU and amputation were included in the study. The logistic regression model was adjusted for demographic characteristics and related comorbidities between major and minor amputation groups.

RESULTS

Among 3654 patients with DFU, 363 (9.9%) were amputated. Patients with major versus minor amputation, in multivariable logistic regression models, major amputation independent factors included previous amputation history (odds ratio [OR] 2.31 [95% CI 1.17-4.53], p = 0.02), smoking (2.58 [1.31-5.07], p = 0.01), coronary artery disease (CAD) (2.67 [1.35-5.29], p = 0.03), ankle brachial index (ABI) <0.4 (15.77 [7.51-33.13], p < 0.01), Wagner 5 (5.50 [1.89-16.01], p < 0.01), activated partial thromboplastin time (APTT) (1.23 [1.03-1.48], p = 0.01), glycosylated hemoglobin A1c (HbA1c) (1.23 [1.03-1.48], p = 0.03), hemoglobin (Hb) (0.98 [0.96-1.00], p = 0.01), plasma albumin (ALB) (0.88 [0.81-0.95], p < 0.01) and white blood cell (WBC) (1.10 [1.04-1.16], p < 0.01).

CONCLUSION

Major amputation was associated with previous amputation history, smoking, CAD, Wagner 5, ABI <0.4, HbA1c, Hb, ALB, WBC, and APTT might be a new independent factor. In view of these factors, early prevention and guidance promptly orientated by multidisciplinary is of great significance to reduce the disability rate and economic burden.

Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia

Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.

Clinical outcome and determinants of amputation in a large cohort of Iranian patients with diabetic foot ulcers

OBJECTIVE

Determining the predictive factors of diabetes foot ulcer (DFU) development and lower extremity amputations (LEA) in patients with diabetes mellitus (DM) is of great importance to compose risk stratification models. The aim of this study is to investigate the outcome and predictors of LEA in patients with DFU in large sample of Iranian patients.

METHODS

This prospective cohort study was conducted during a 2-year period from 2014 to 2016, in Shiraz, southern Iran. All the patients with type 1 and 2 DM and DFU were included in the cohort and were followed for 2 years at least. They were visited in the clinic on a monthly basis and development of new DFU and LEA were recorded. The two-year free-DFU survival and predictors of the DFU development and LEA were recorded. Multivariate regression models were used to determine the factors.

RESULTS

A total number of 432 patients with mean age of 56.8 ± 13.3 years were included. The two-year DFU-free survival rate was 0.826. The two-year DFU-free survival was associated with male gender (p = 0.005), foot deformity (p = 0.002), history of prior DFU (p < 0.001), cigarette smoking (p = 0.032), nephropathy (p = 0.005), retinopathy (p = 0.007), ischemic heart disease (p = 0.043), and neuropathy (p < 0.001).

CONCLUSION

Development of new DFU is associated with higher age, longer duration of disease, and type I diabetes. LEA was associated with increased white blood cell (WBC), Creatinine and ulcer history for major amputation and ulcer history, fasting blood sugar (FBS), infection, revascularization history, and foot deformity, for minor amputation.

Angiopoietin-like 2 is a potential biomarker for diabetic foot patients

BACKGROUND

Circulating angiopoietin-like 2 (ANGPTL2) protein levels are known to be significantly increased in numerous chronic inflammatory diseases and are associated with the diagnosis and/or prognosis of cardiovascular diseases, diabetes, chronic kidney disease, and various types of cancers. However, no data regarding the relationship between ANGPTL2 and diabetic foot ulcers (DFUs) are available. Here, we explored the potential link between ANGPTL2 and DFUs.

METHODS

A total of 68 participants with type 2 diabetes mellitus (T2DM) were recruited, including 28 patients with DFU and 40 diabetic patients without DFUs. The clinical characteristics of T2DM patients with and without DFUs were compared. Serum concentrations of ANGPTL2 and VEGF were measured using enzyme-linked immunosorbent assay (ELISA) kits. The correlations between ANGPTL2 and clinical variables were analyzed. Multiple linear regression and logistic regression models were constructed to test the associations between ANGPTL2 and the severity and presence of DFUs.

RESULTS

Serum levels of ANGPTL2 were higher in patients with DFUs than those in diabetic controls. Serum ANGPTL2 levels were higher in the advanced stages of DFUs. Spearman correlation analysis revealed strong positive associations of ANGPTL2 with CRP, VEGF and ESR in all subjects. In addition, serum ANGPTL2 was still positively correlated with DFUs stage after adjusting the risk factors. After adjusting for age, sex, HbA1C and duration of diabetes, ANGPTL2 was found to be independently associated with the presence of DFUs.

CONCLUSIONS

Circulating ANGPTL2 levels are an independent risk factor for DFUs. This suggests that ANGPTL2 may play important roles in the development of DFUs, a possibility that needs to investigated in prospective studies.

Application of 3D Bioprinting Technologies to the Management and Treatment of Diabetic Foot Ulcers

Diabetes mellitus (DM) is a chronic metabolic disease with increasing prevalence worldwide. Diabetic foot ulcers (DFUs) are a serious complication of DM. It is estimated that 15-25% of DM patients develop DFU at least once in their lifetime. The lack of effective wound dressings and targeted therapy for DFUs often results in prolonged hospitalization and amputations. As the incidence of DM is projected to rise, the demand for specialized DFU wound management will continue to increase. Hence, it is of great interest to improve and develop effective DFU-specific wound dressings and therapies. In the last decade, 3D bioprinting technology has made a great contribution to the healthcare sector, with the development of personalized prosthetics, implants, and bioengineered tissues. In this review, we discuss the challenges faced in DFU wound management and how 3D bioprinting technology can be applied to advance current treatment methods, such as biomanufacturing of composite 3D human skin substitutes for skin grafting and the development of DFU-appropriate wound dressings. Future co-development of 3D bioprinting technologies with novel treatment approaches to mitigate DFU-specific pathophysiological challenges will be key to limiting the healthcare burden associated with the increasing prevalence of DM.

Combined Transplantation of Mesenchymal Stem Cells and Endothelial Colony-Forming Cells Accelerates Refractory Diabetic Foot Ulcer Healing

Background

This study is aimed at investigating the effect of combined transplantation of umbilical cord mesenchymal stem cells (UCMSCs) and umbilical cord blood-derived endothelial colony-forming cells (ECFCs) on diabetic foot ulcer healing and at providing a novel therapy for chronic diabetic foot ulcer.

Methods

We reported the treatment of refractory diabetic foot ulcers in twelve patients. Among them, five patients had two or more wounds; thus, one wound in the same patient was treated with cell injection, and other wounds were regarded as self-controls. The remaining seven patients had only one wound; therefore, the difference between the area of wound before and after treatment was estimated. The UCMSCs and ECFCs were injected into the wound along with topically applied hyaluronic acid (HA).

Results

In this report, we compared the healing rate of multiple separate wounds in the same foot of the same patient: one treated with cell injection combined with topically applied HA-based hydrogel and was later covered by the hydrocolloid dressings, while the self-control wounds were only treated with conventional therapy and covered by the hydrocolloid dressings. The wound underwent cell injection showed accelerated healing in comparison to control wound within the first week after treatment. In other diabetic patients with only one refractory wound, the healing rate after cell transplantation was significantly faster than that before injection. Two large wounds healed without needing skin grafts after combination therapy of cell injection and HA. After four weeks of combination treatment, wound closure was reached in six patients, and the wounds of the other six patients were significantly reduced in size.

Conclusions

Our study suggests that the combination of UCMSCs, ECFCs, and HA can safely synergize the accelerated healing of refractory diabetic foot ulcers.

Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies

OBJECTIVE

To evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs).

RESEARCH DESIGN AND METHODS

Medline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842).

RESULTS

Of 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes.

CONCLUSIONS

Our findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis

PURPOSE

A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients.

METHODS

The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU.

CONCLUSIONS

Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.

A study on diabetic foot ulcers in Central rural India to formulate empiric antimicrobial therapy

AIM

This study was carried out on patients with diabetic foot ulcer (DFU) to assess the clinical characteristics, spectrum of microbial flora, antibiotic sensitivity, and devise an empiric antimicrobial therapy.

MATERIAL METHODS

Clinical data and tissue samples were collected from 105 diabetic foot ulcer patients between December 2018 and November 2019. The collected samples were processed as per Clinical and Laboratory Standards Institute guidelines and clinical and microbiological data was analyzed.

RESULTS

In this study of 105 patients, DFU was most common in males in 5th and 6th decade of life. Majority of patients had poor glycemic control and neuropathy. Of 110 bacterial isolates obtained from 97 samples, 73.7% were Gram-negative bacteria, and 27.3% were Gram-positive. Most of samples (48.6%) showed growth of single bacteria, growth of two bacteria and polymicrobial growth was seen in 28.6% and 15.2% of tissue samples respectively of which. Pseudomonas was predominant isolate (27.3%) sensitive to imipenem (90%), amikacin (86.6%), gentamicin (83.3%), and cefotaxime (80%) followed by Staphylococcus aureus (19.1%) sensitive to amikacin and gentamicin (100%), and ofloxacin (90%). Pseudomonas, E. coli, Proteus and Klebsiella were highly resistant to ampicillin and amoxicillin-clavulanic acid.

CONCLUSION

This study showed DFU are common in 5th and 6th decades of life. Gram-negative bacteria are predominant infective organism. Most of both Gram-negative and Gram-positive bacteria are resistant to variable degrees to commonly used antibiotics and sensitive to aminoglycosides. Amikacin and gentamicin can be used as empiric antibiotics for treatment of DFU infections.

Advanced Glycation End Products Enhance Biofilm Formation by Promoting Extracellular DNA Release Through sigB Upregulation in Staphylococcus aureus

Bacterial biofilms do serious harm to the diabetic foot ulcer (DFU) because they play a crucial role in infection invasion and spread. Staphylococcus aureus, the predominant Gram-positive bacteria in diabetic foot infection (DFI), is often associated with colonization and biofilm formation. Through biofilm formation tests in vitro, we observed that S. aureus bacteria isolated from DFU wounds were more prone to form biofilms than those from non-diabetic patients, while there was no difference in blood sugar between the biofilm (+) diabetics (DB+) and biofilm (-) diabetics (DB-). Furthermore, we found that advanced glycation end products (AGEs) promoted the biofilm formation of S. aureus in clinical isolates and laboratory strains in vitro, including a methicillin-resistant strain. Analysis of biofilm components demonstrated that the biofilms formed mainly by increasing extracellular DNA (eDNA) release; remarkably, the S. aureus global regulator sigB was upregulated, and its downstream factor lrgA was downregulated after AGE treatments. Mechanism studies using a sigB-deleted mutant (Newman-ΔsigB) confirmed that AGEs decreased expression of lrgA via induction of sigB, which is responsible for eDNA release and is a required component for S. aureus biofilm development. In conclusion, the present study suggests that AGEs promote S. aureus biofilm formation via an eDNA-dependent pathway by regulating sigB. The data generated by this study will provide experimental proof and theoretical support to improve DFU infection healing.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

An Efficacy Predictive Method for Diabetic Ulcers Based on Higher-Order Markov Chain-Set Pair Analysis

Background

Clinical comprehensive decision-making of diabetic ulcers includes curative effect evaluation and curative effect prediction. Nevertheless, there are few studies on the prediction of diabetic ulcers.

Methods

Set pair analysis (SPA) was used to assess the curative effect evaluation, and therapeutic effect was evaluated by connection degree (CD). The higher-order Markov chain-SPA curative effect prediction model was established to predict the future curative effect development. The predicted results with higher-order Markov chain-SPA and traditional first-order Markov-SPA model were compared with the actual results of the patients to verify the effectiveness of prediction.

Results

The connection degree of index levels I and II of 15 patients with diabetic ulcers after traditional Chinese medicine (TCM) treatment increased with time, while that of index levels IV and V decreased, indicating that the curative effect tends to improve. The higher-order Markov chain-SPA model was used to predict the curative effect. The results showed that the relative errors were fewer than the traditional first-order Markov-SPA model.

Conclusions

The present study suggests that a method of SPA combined with higher-order Markov-SPA is relatively effective and can be applied to the clinical prediction of diabetic ulcers, which has higher accuracy than traditional first-order curative effect prediction model.

Analysis of Diabetes Mellitus-Related Amputations in the State of Espírito Santo, Brazil

Background and objectives: Diabetes mellitus (DM) stands out among the most important public health problems worldwide since it represents a high burden on health systems and is associated with higher hospitalization rates, and a higher incidence of cardiovascular diseases. Amputations are among the most common complications, leading to disability and increasing care costs. This research aims to analyze the prevalence of DM-related amputations, comorbidities and associated risk factors in the diabetic population residing in the State of Espírito Santo, Brazil. Materials and Methods: This is a quantitative, exploratory, cross-sectional study with a time series design and the use of secondary data registered and followed by the system of Registration and Monitoring of Hypertension and Diabetes-SisHiperdia. Results: The sample consisted of 64,196 diabetic patients, out of them, 3.9% had type 1 DM, 10.9% with type 2 DM, and 85.2% with DM coexisting with hypertension. Most were female (66.6%), aged 40 to 59 years (45.6%), and 60 years and older (45.2%). The prevalence of DM-related amputations in the analyzed sample was 1.2% in type 1 DM, 1.5% in type 2 DM, and 2.2% in concomitant DM and hypertension. Higher amputation rates were observed in males in the age group above 60 years in type 1 DM and type 2 DM and were slightly higher in the age groups up to 29 years in DM with hypertension. A higher prevalence of amputation was related to smoking, physical inactivity, acute myocardial infarction (AMI), stroke, chronic kidney disease (CKD), and diabetic foot (DF) in all types of DM. Conclusions: The present study showed a significant prevalence of DM-related amputations. An increased prevalence was evidenced when correlated with smoking, physical inactivity, AMI, stroke, CKD, and DF with significant statistical associations, except for a sedentary lifestyle in type 1 DM.

Phenotypes and outcomes in middle-aged patients with diabetic foot ulcers: a retrospective cohort study

BACKGROUND

Although ageing could increase the risk of delayed healing in diabetic foot ulcers (DFUs) patients, data from middle-aged patients remains greatly limited. The purpose of this study was to explore the clinical phenotypes, outcomes and predictive factors of DFU in middle-aged patients.

METHODS

A retrospective cohort study conducted with 422 consecutive inpatients with DFUs who visited our hospital between May 2010 and September 2017; participants were recruited and assigned according to age to either the middle-aged group or the elderly group. The Demographics, ulcer characteristics, comorbidities and diabetes complications, laboratory tests, socioeconomic data and final outcomes were collected. Moreover, predictive factors of adverse outcomes in middle-aged DFUs patients were assessed.

RESULTS

Middle-aged patients were more likely to have worse lifestyle and glucose control, were more likely to have microangiopathy as a complication, and tended to have larger and deeper ulcers; however, these patients also had higher rates of healing and lower rates of mortality and major amputaion than elderly patients. Severe infection,living alone,current smoking cigarettes, and having a high white blood cell count were independent risk factors for adverse outcomes in middle-aged patients.

CONCLUSIONS

DFUs are relatively common in middle-aged patients with diabetes, and these patients have unique clinical phenotypes and risk profiles. Nonetheless, further investigation is needed to clarify whether intervention targeting these easily recognizable risk factors can improve healing and survival rates in middle-aged DFU patients.

Efficacy and Safety of TurboHawk Plaque Rotation Combined With Drug-coated Balloon in Treating Diabetic Patients With Lower Extremity Arterial Disease

To evaluate the efficacy and safety of TurboHawk plaque rotation system combined with drug-coated balloon in treating lower extremity arterial disease (LEAD) of diabetes patients, a total of 145 diabetic patients with LEAD from March 2015 to September 2016 were recruited in our study. Lower extremity arterial disease was diagnosed by ultrasound and CT angiography (CTA). According to the surgical method, 65 cases underwent TurboHawk plaque rotation combined with drug-coated balloon (group A), 80 cases underwent simple drug-coated balloon expansion (group B). The characteristics of lesion, function test, ankle-brachial index (ABI), and postoperative complications were analyzed. All the patients were followed up at 1, 3, 6, 12, and 24 months after operation. At baseline, there was no difference in all the characteristics between the 2 groups. The early postoperation minimum lumen diameter (MLD), lumen stenosis rate, and ABI in 2 groups both improved. As the follow-up time increased, patients in group A had significantly higher MLD and ABL value, as well as lower level of lumen stenosis rate, restenosis rate, late lumen loss, and target lesion revascularization (all P < .05). Accordingly, functional testing revealed the 6-minute walk distance, 6-minute claudication distance, resting ABI, and post-exercise ABI in group A were significantly higher than those in group B (all P < .05). Besides, major graft reintervention (4.62% vs 11.25%) and major adverse limb events (6.15% vs 12.5%) in group A occurred less frequently than group B (all P < .05). In conclusion, the long-term effect of the combined approach was better than only drug-coated balloon in LEAD in Chinese diabetes patients.

Proximal Tibial Cortex Transverse Distraction Facilitating Healing and Limb Salvage in Severe and Recalcitrant Diabetic Foot Ulcers

BACKGROUND

The management of severe and recalcitrant diabetic foot ulcers is challenging. Distraction osteogenesis is accompanied by vascularization and regeneration of the surrounding tissues. Longitudinal distraction of the proximal tibia stimulates increased and prolonged blood flow to the distal tibia. However, the effects of transverse distraction of the proximal tibia cortex on severe and recalcitrant diabetic foot ulcers are largely unknown.

QUESTIONS/PURPOSES

(1) Does tibial cortex transverse distraction increase healing and decrease major amputation and recurrence of severe and recalcitrant diabetic foot ulcers compared with routine management (which generally included débridement, revascularization, negative pressure wound therapy, local or free flaps, or skin grafts as indicated)? (2) Does neovascularization and perfusion increase at the foot after the procedure? (3) What are the complications of tibial cortex transverse distraction in patients with severe and recalcitrant diabetic foot ulcers?

METHODS

Between July 2014 and March 2017, we treated 136 patients with diabetes mellitus and University of Texas Grade 2B to 3D ulcers (wound penetrating to the tendon, capsule, bone, or joint with infection and/or ischemia). The patients had failed to respond to treatment for at least 6 months, and their ulcers had a mean ± SD area of 44 cm ± 10 cm. All 136 patients underwent tibial cortex transverse distraction (partial corticotomy of the upper tibia, which was in normal condition, followed by 4 weeks of transverse distraction medially then laterally). We compared these patients with the last 137 consecutive patients we treated with standard surgical treatment, consisting of débridement, revascularization, local or free flap or skin equivalent, or graft reconstruction along with negative-pressure wound therapy between May 2011 and June 2013; there was a 1-year period during which both treatments were in use, and we did not include patients whose procedures were performed during this time in either group. Patients in both groups received standard off-loading and wound care. The patients lost to follow-up by 2 years (0.7% of the treatment group [one of 137] and 1.4% of the control group [two of 139]; p = 0.57) were excluded. The patients in the treatment and control groups had a mean age of 61 years and 60 years, respectively, and they were predominantly men in both groups (70% [95 of 136] versus 64% [88 of 137]; p = 0.32). There were no differences with respect to parameters associated with the likelihood of ulcer healing, such as diabetes and ulcer duration, ulcer grades and area, smoking, and arterial status. We compared the groups with respect to ulcer healing (complete epithelialization without discharge, maintained for at least 2 weeks, which was determined by an assessor not involved with clinical care) in a 2-year follow-up, the proportion of ulcers that healed by 6 months, major amputation, recurrence, and complications in the 2-year follow-up. Foot arterial status and perfusion were assessed in the tibial cortex transverse distraction group using CT angiography and perfusion imaging.

RESULTS

The tibial cortex transverse distraction group had a higher proportion of ulcers that healed in the 2-year follow-up than the control group (96% [131 of 136] versus 68% [98 of 137]; odds ratio 10.40 [95% confidence interval 3.96 to 27.43]; p < 0.001). By 6 months, a higher proportion of ulcers healed in the tibia cortex transverse distraction group than the control group (93% [126 of 136] versus 41% [56 of 137]; OR 18.2 [95% CI 8.80 to 37.76]; p < 0.001). Lower proportions of patients in the tibia cortex transverse distraction group underwent major amputation (2.9% [four of 136] versus 23% [31 of 137], OR 0.10 [95% CI 0.04 to 0.30]; p < 0.001) or had recurrences 2.9% (4 of 136) versus 17% (23 of 137), OR 0.20 [95% CI 0.05 to 0.45]; p < 0.001) than the control group in 2-year follow-up. In the feet of the patients in the tibial cortex transverse distraction group, there was a higher density of small vessels (19 ± 2.1/mm versus 9 ± 1.9/mm; mean difference 10/mm; p = 0.010), higher blood flow (24 ± 5 mL/100 g/min versus 8 ± 2.4 mL/100 g/min, mean difference 16 mL/100 g/min; p = 0.004) and blood volume (2.5 ± 0.29 mL/100 g versus 1.3 ± 0.33 mL/100 g, mean difference 1.2 mL/100 g; p = 0.03) 12 weeks postoperatively than preoperatively. Complications included closed fractures at the corticotomy site (in 1.5% of patients; two of 136), which were treated with closed reduction and healed, as well as pin-site infections (in 2.2% of patients; three of 136), which were treated with dressing changes and they resolved without osteomyelitis.

CONCLUSIONS

Proximal tibial cortex transverse distraction substantially facilitated healing and limb salvage and decreased the recurrence of severe and recalcitrant diabetic foot ulcers. The surgical techniques were relatively straightforward although the treatment was unorthodox, and the complications were few and minor. These findings suggest that tibial cortex transverse distraction is an effective procedure to treat severe and recalcitrant diabetic foot ulcers compared with standard surgical therapy. Randomized controlled trials are required to confirm these findings.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Clinical study for external washing by traditional Chinese medicine in the treatment of multiple infectious wounds of diabetic foot: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Diabetic foot (DF) is among the most serious complications of type 2 diabetes. DF infection (DFI) is a key factor in the deterioration and development of DF, so controlling infection plays an important role in the treatment of the disease. Traditional Chinese medicine foot bath has been widely used in China as a complementary and alternative therapy to improve circulation and infection control of DF. However, the existing evidence shows that its efficacy and safety are still insufficient. We report a study protocol about a multicenter, double-blind, randomized, placebo controlled trial which aims to make well-designed clinical trials to evaluate the efficacy and safety of herbal medicine foot bath decoction (FBD) and explore the mechanism of external washing of Chinese herbs in DFI.

METHODS

This study is a multicenter, double-blind, randomized, placebo controlled clinical trial in which 60 eligible participants were randomly divided into an experimental group and control group at a 1:2 ratio. Both groups received the same basic treatment for DF disease, the experimental group used FBD and ordinary dressing changes, while half of the patients in the control group received placebo and ordinary dressings, and the other half received placebo and silver ion dressings. Patients in both groups will be evaluated weekly for efficacy during the intervention. The primary efficacy indicators include the types of wound pathogens, interleukin 6 and tumor necrosis factor α. Secondary efficacy indicators included blood glucose, blood lipids, wound area, lower extremity blood vessel diameter, blood flow speed, walking speed, walking distance, and traditional Chinese medicine syndrome scores. We will also conduct a safety evaluation of the drug at the end of the trial.

DISCUSSION

This multicenter, double-blind, randomized, placebo clinical trial not only provides data on the efficacy and safety of FBD, but also provides a novel treatment strategy for clinicians and DF patients.

Banxia Xiexin Decoction Ameliorates t-BHP-Induced Apoptosis in Pancreatic Beta Cells by Activating the PI3K/AKT/FOXO1 Signaling Pathway

BACKGROUND

Banxia Xiexin Decoction (BXXD) reportedly regulates glycolipid metabolism and inhibits pancreatic β-cell apoptosis. This study is aimed at investigating the protective effect of BXXD on tert-butyl hydroperoxide- (t-BHP-) induced apoptosis in MIN6 cells and the underlying mechanisms.

METHODS

MIN6 cells were preincubated with BXXD or liraglutide (Li) with or without PI3K inhibitor LY294002 (LY) for 12 h, following which t-BHP was added to induce MIN6 cell apoptosis. The protective effects of BXXD on MIN6 cells were evaluated by detecting cell viability and proliferation and glucose-stimulated insulin secretion (GSIS). The antiapoptotic effects were evaluated by Hoechst 33342 staining and terminal deoxynucleotidyl transferase dUTP nick end labeling assay (TUNEL). Malondialdehyde and glutathione peroxidase content and superoxide dismutase activity were measured using commercial kits. The expression of PI3K/AKT/FOXO1 signaling pathway-related signal molecules, and that of apoptotic indicators Bax, P27, and Caspase-3, was quantified using western blotting.

RESULTS

Preincubation with BXXD significantly improved t-BHP-induced proliferation inhibition and apoptosis and enhanced GSIS. t-BHP induced the generation of reactive oxygen species and inhibited the activities of antioxidant enzymes, which could be neutralized by pretreatment with BXXD. BXXD promoted the phosphorylation of AKT and FOXO1 in t-BHP-induced MIN6 cells. Moreover, BXXD attenuated the expression of related apoptotic indicators Bax, P27, and Caspase-3. LY abolished these effects of BXXD.

CONCLUSION

BXXD protected MIN6 cells against t-BHP-induced apoptosis and improved insulin secretory function through modulation of the PI3K/AKT pathway and the downstream FOXO1, thus suggesting a novel therapeutic approach for type 2 diabetes mellitus (T2DM).

Malnutrition assessed by controlling nutritional status is correlated to carotid atherosclerosis in patients with type 2 diabetes

Diabetes and malnutrition sometimes overlap. Little is known about the relationship between malnutrition and subclinical atherosclerosis in patients with type 2 diabetes. This cross-sectional study investigated this relationship in patients with type 2 diabetes. We evaluated the relationships between malnutrition assessed by controlling nutritional status (CONUT) score and subclinical atherosclerosis assessed by carotid intima-media thickness (IMT) and carotid plaque scores in 461 consecutive patients with type 2 diabetes. Nutritional assessment indicated that 38% of patients were malnourished (CONUT ≥3). Carotid IMT and carotid plaque scores were significantly higher in patients with malnutrition. Multivariate linear regression analyses revealed that a high CONUT score (CONUT ≥3) was correlated with mean IMT (β = 0.196, p = 0.043) and max IMT (β = 0.243, p = 0.011) in patients taking statins and was also correlated with mean IMT (β = 0.287, p = 0.004), max IMT (β = 0.308, p = 0.002), and plaque score (β = 0.190, p = 0.044) in patients not taking statins after adjusting for age, sex, duration of diabetes, body mass index, hemoglobin A1c, creatine, smoking, and hypertension. Our results demonstrate a relationship between malnutrition and subclinical atherosclerosis in patients with type 2 diabetes.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

Factors associated with lower-extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital

Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C-reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C-peptide, triglyceride, high-density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable-adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015-1.709), 0.255 for triglyceride (95% CI: 0.067-0.975), and 20.947 for Wagner grades (95% CI: 4.216-104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.

Principles of STAGE Management for Diabetic Foot Ulcers Based on the Wagner and Texas Classification Systems

The current Wagner and Texas classifications of diabetic foot ulcers (DFUs) are used worldwide to assess the extent of foot lesions, but wound treatment principles based on both the classification systems are lacking. We have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification systems. The STAGE principles refer to the principles of surgical intervention during wound treatment of DFUs and emphasize that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." During treatment, microcirculation improvement and microvascular angiogenesis (A) are essential for granulation tissue formation in the bone (skeleton, S) and tendons (T) and healing of the wound with reepithelialization (E). We defined the above mentioned steps as the STAGE principles, namely, layer-by-layer incision and step-by-step management (Phase A is essential for the treatments in Phases S-T and G-E). Ulcers or gangrene formed during Phases S-T or T should be treated according to the STAGE or TAGE principles, respectively. Similar treatment principles are applied in the other phases. However, treatments at each phase are not isolated and can be performed simultaneously. The STAGE principle can be combined with the tissue, infection, moisture, and wound edge (TIME) and TIME-H chronic wound treatment principles to eliminate the shortcomings of a single principle in wound management.

Patients' clinical charecteristics and predictors for diabetic foot amputation

INTRODUCTION

Medical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients.

METHODS

In this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed.

RESULTS

Of the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p<0,05). Amputees also exhibited significantly longer smoking histories (p<0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p=0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision.

CONCLUSION

The following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4-5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.

Treatment of Diabetic Foot Gangrene Using the STAGE Principle: A Case Series

Diabetic foot gangrene with lower extremity ischemia can preclude amputation. However, wound treatment principles based on the Wagner classification system are lacking. We proposed the STAGE principle for the surgical management of diabetic foot wounds. The STAGE principle guides surgical intervention during the wound treatment of diabetic foot ulcers and emphasizes that "based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound." We applied the STAGE principle for the treatment of 7 patients with an ankle brachial index <0.5 and Wagner grade 4 diabetic foot gangrene. The average ankle brachial index was 0.42 (0.32-0.48; SD = 0.06), and male patients smoked an average of 1.28 packs/day (0.4-2; SD = 0.63). The average wound duration was 45.86 days (14-63 days; SD = 18.46). The average wound healing time was 8.86 months (5-13 months; SD = 2.36). The follow-up time was 37.71 months (3-84 months; SD = 25.04; median = 36 months). Patient 1 received endovascular interventional therapy twice for the lower extremity artery, and the wound healed. After 3 months of follow-up, the patient exhibited recurrence. After the third application of endovascular interventional therapy for the lower extremity artery, the blood supply was improved, and the wound healed after 1 month. In summary, the treatment of 7 cases of diabetic foot gangrene with severe lower extremity ischemia using the STAGE principle resulted in remarkable efficacy.

A meta-analysis of the relationship between foot local characteristics and major lower extremity amputation in diabetic foot patients

OBJECTIVE

To clarify and quantify risk factors among local characteristics of the foot for major amputation in diabetic foot patients.

METHODS

Articles published before January 2018 on PubMed and Embase were conducted observational studies about risk factors for major amputation in patients with diabetic foot were retrieved and systematically reviewed by using Stata 12.0 statistical software.

RESULTS

A total of 4668 major amputees and 65 831 controls were reported in 18 observational studies. Across the studies, the overall odds ratios (ORs) and 95% confidence intervals (CIs) of significant risk factors are ulcer reaching bone (OR, 11.796; 95% CI, 6.905-20.152), gangrene (OR, 6.487; 95% CI, 4.088-10.293), hindfoot position (OR, 3.913; 95% CI, 2.254-6.795), decreased ankle-brachial index (ABI) (OR, 2.522; 95% CI, 1.805-3.523), infection (OR, 2.516; 95% CI, 1.708-3.706), peripheral arterial disease (PAD) (OR, 2.114; 95% CI, 1.326-3.372). While there is no significant difference in the size of the ulcer, neuropathy, Charcot foot, osteomyelitis and intermittent claudication (OR, 1.15; 95% CI, 0.85-1.54).

CONCLUSION

Factors among local characteristics of the foot associated with major amputation in patients with diabetic foot are the ulcer reaching bone, gangrene, hindfoot position, decreased ABI, infection, and PAD, a negative risk factor for the risk of amputation. Further studies are required to provide more details of foot local characteristics.

Human umbilical cord mesenchymal stem cells implantation accelerates cutaneous wound healing in diabetic rats via the Wnt signaling pathway

OBJECTIVE

Difficulty in wound healing is one common complication of diabetes mellitus. The study explored whether the therapeutic effect of human umbilical cord mesenchymal stem cells (hUCMSCs) on diabetic ulcer wound was enhanced by the activation of the Wnt signaling pathway.

METHODS

Rat diabetic model was established by intraperitoneal injection of Streptozotocin (STZ). hUCMSCs were purified and seeded on the collagen-chitosan laser drilling acellular dermal matrix (CCLDADM) scaffold, which was subsequently implanted into the cutaneous wound of normal and diabetic rats, followed by daily injection of Wnt signaling pathway agonist (Wnt3a) or antagonist (sFRP3) at the edge of the scaffold. Wound healing was checked on days 7, 14, and 21, and the fibrous tissue deposition, capillaries, and epidermal regeneration at the wound were examined by hematoxylin-eosin staining. The hUCMSCs-CCLDADM scaffold was cultured in vitro and treated with Wnt3a or sFRP3, followed by evaluation of cell proliferation, cell proliferation rate, survival status, and altered protein levels in the Wnt signaling pathway using BrdU staining, CCK-8 assay, live/dead staining, and Western blotting, respectively.

RESULTS

On days 7 and 14 postoperatively, the speed of wound healing was significantly lower in diabetic rats than that in normal control rats. This phenomenon was significantly improved by the activation of the Wnt signaling pathway that also elevated the fibrous protein deposition and the abundance of capillary in the granulation tissue. Conversely, blockade of Wnt signaling slowed the healing of skin wound in diabetic rats. The activation of Wnt signaling pathway promoted the proliferation and differentiation and decreased the apoptosis of hUCMSCs, thereby elevating the number of living hUCMSCs on the CCLDADM scaffold, while the suppression exerted a contrary effect.

CONCLUSION

The activation of the Wnt signaling pathway promotes the healing of diabetic skin wound by the regulation of proliferation and differentiation of hUCMSCs on the CCLDADM scaffold.

Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan

Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ± 14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79-2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76-1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19-3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.

Prevalence and related risk factors of diabetic foot ulcer in Ahvaz, south west of Iran

AIMS

The aim of this study was to evaluate the prevalence of diabetic foot ulcer and its related risk factors.

MATERIALS AND METHODS

In this descriptive cross-sectional study, 605 patients with diabetes were evaluated in July 2014. A checklist was used to obtain demographic data, diabetes related data, past medical history, and physical examination data.

RESULTS

The prevalence of diabetic foot ulcer was 6.4% (95% CI: 4.64-8.73). Seventeen cases of them were female (4.9%). In univariate analysis, the following variables had statistically significant relationship with DFU prevalence: diabetes duration, educational level, 10 g monofilament sensation, Ankle Brachial Index (ABI) and Body Mass Index (BMI). Patients' age, glycemic control and smoking did not show any significant relationship with DFU. After logistic regression analysis, the patients with decreased 10 g monofilament sensation had DFU more than patients with normal sensation (OR = 8.84, 95% CI: 3.5-22.3). Abnormal ABI increased the odds of DFU (OR = 5.6, 95% CI: 1.3-24.18). The DFU prevalence in patients with diabetes duration of 11-20 years, was more than patients with ≤5 years (OR = 3.8, 95% CI: 1.33-10.8).The odds of DFU development in educated patients compared with illiterate patients was 0.27(95% CI: 0.12-0.57). BMI had a significant relationship with DFU prevalence. The odds in overweight patients was 0.259(95% CI: 0.108-0.623) and in obese patients was 0.263 (95% CI: 0.1-0.687).

CONCLUSION

The prevalence of DFU was 6.4% in this study. Final associated risk factors of DFU were decreased 10 g monofilament sensation, abnormal ABI, diabetes duration, educational level and BMI.

Pseudomonas aeruginosa infection alters the macrophage phenotype switching process during wound healing in diabetic mice

Macrophages play critical roles in wound healing process. They switch from "classically activated" (M1) phenotype in the early inflammatory phase to "alternatively activated" (M2) phenotype in the later healing phase. However, the dynamic process of macrophage phenotype switching in diabetic wounds burdened with bacteria is unclear. In this report, Pseudomonas aeruginosa, frequently detected in diabetic foot ulcers, was inoculated into cutaneous wounds of db/db diabetic mice to mimic bacterium-infected diabetic wound healing. We observed that P. aeruginosa infection impaired diabetic wound healing and quickly promoted the expression of pro-inflammatory genes (M1 macrophage markers) tumor necrosis factor-α (tnf-α), interleukin-1β (il-1β) and il-6 in wounds. The expression of markers of M2 macrophages, including il-10, arginase-1, and ym1 were also upregulated. In addition, similar gene expression patterns were observed in macrophages isolated directly from wounds. Immunostaining showed that P. aeruginosa infection increased both the ratios of M1 and M2 macrophages in wounds compared with that in control groups, which was further confirmed by in vitro culturing macrophages with P. aeruginosa and skin fibroblast conditioned medium. However, the ratios of the expression levels of pro-inflammatory genes to anti-inflammatory gene il-10 was increased markedly in P. aeruginosa infected wounds and macrophages compared with that in control groups, and P. aeruginosa prolonged the presence of M1 macrophages in the wounds. These data demonstrated that P. aeruginosa in diabetic wounds activates a mixed M1/M2 macrophage phenotype with an excessive activation of M1 phenotype or relatively inadequate activation of M2 phenotype.

Three-week topical treatment with placenta-derived mesenchymal stem cells hydrogel in a patient with diabetic foot ulcer: A case report

RATIONALE

Diabetic foot ulcer (DFU) is a chronic complication of diabetes characterized by continuity, repeatability, and nonhealing. In recent years, mesenchymal stem cells hydrogel complex has been a new emerging technique in the treatment of DFU. The placenta-derived mesenchymal stem cells (PDMSCs) hydrogel is multipotent, and can secrete growth factors, cytokines, and immunomodulatory substances which could accelerate wound healing.

PATIENT CONCERNS

In this case report, we present a 57-year-old female with type 2 diabetes mellitus and a 20-day DFU.A wound bed located at the dorsalis pedis of the right foot, and conventional therapies had no effect on the foot.

DIAGNOSES

The patient was confirmed a diagnosis of type 2 DM with diabetic foot (Wagner classification III).

INTERVENTIONS

To assess the efficacy and safety of PDMSCs hydrogel in wound repair and to improve the rate of wound healing, we administered PDMSCs hydrogel (cell number: 1 × 10/cells/cm) topically into the wound with the patient's permission.

OUTCOMES

The patient's foot ulcer was almost healed, and foot function in walking was well preserved. No complications were observed. No recurrence occurred in the subsequent 6 months.

LESSONS

To the best of our knowledge, this is the first patient globally to receive PDMSCs hydrogel to treat DFU. The present case study suggests that PDMSCs hydrogel may provide a new approach to DFU treatment. Clinical Trial Registration-URL: http://www.chictr.org.cn/searchproj.aspx:chiCRT-ONC-16008732.

Smoking increases the risk of diabetic foot amputation: A meta-analysis

Accumulating evidence suggests that smoking is associated with diabetic foot amputation. However, the currently available results are inconsistent and controversial. Therefore, the present study performed a meta-analysis to systematically review the association between smoking and diabetic foot amputation and to investigate the risk factors of diabetic foot amputation. Public databases, including PubMed and Embase, were searched prior to 29th February 2016. The heterogeneity was assessed using the Cochran's Q statistic and the I² statistic, and odds ratio (OR) and 95% confidence interval (CI) were calculated and pooled appropriately. Sensitivity analysis was performed to evaluate the stability of the results. In addition, Egger's test was applied to assess any potential publication bias. Based on the research, a total of eight studies, including five cohort studies and three case control studies were included. The data indicated that smoking significantly increased the risk of diabetic foot amputation (OR=1.65; 95% CI, 1.09-2.50; P<0.0001) compared with non-smoking. Sensitivity analysis demonstrated that the pooled analysis did not vary substantially following the exclusion of any one study. Additionally, there was no evidence of publication bias (Egger's test, t=0.1378; P=0.8958). Furthermore, no significant difference was observed between the minor and major amputation groups in patients who smoked (OR=0.79; 95% CI, 0.24-2.58). The results of the present meta-analysis suggested that smoking is a notable risk factor for diabetic foot amputation. Smoking cessation appears to reduce the risk of diabetic foot amputation.

Predictive Laboratory Findings of Lower Extremity Amputation in Diabetic Patients: Meta-analysis

Lower extremity amputation is a source of morbidity and mortality among diabetic patients. This meta-analysis aimed to identify significant laboratory data in patients with diabetic foot ulcer with high rates of lower extremity amputation. We performed a systematic literature review and meta-analysis using MEDLINE, EMBASE, and Cochrane databases. We extracted and evaluated 11 variables from the included studies based on amputation rates. This study used the Newcastle-Ottawa Scale to assess the quality of the studies. The search strategy identified 101 publications from which we selected 16 articles for review. We identified HbA1c, fasting blood glucose, white blood cells, C-reactive protein, and erythrocyte sedimentation rate as predictive variables of higher major amputation rate. Although further investigation of long-term and prospective studies is needed, we identified 5 variables as predisposing factors for higher major amputation in diabetic patients through meta-analysis.

Empirical Antibiotic Treatment in Diabetic Foot Infection: A Study Focusing on the Culture and Antibiotic Sensitivity in a Population From Southern China

Diabetic foot and subsequent diabetic ulcer infections are the most devastating complication of diabetes. This study was conducted to explore the bacterial spectrum, sensitivity of microbials, and analysis of the empirical antibiotic regimens in our health center. The study included patients with diabetic foot ulcer infection (DFI) seen from 2009 to 2014. The patients included had all information covering the physical examination, laboratory tests, and image examinations. We sent appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all participants. A total of 312 patients were included: 52, 112, 95 and 53 patients within uninfected, mild, moderate, and severe infection groups. The total percentages of Gram-positive cocci (GPCs) and Gram-negative rods (GNRs) were 54% and 48.8% ( P = 0.63). The most common GPC was Staphylococcus aureus (22.4%) and GNR was Pseudomonas aeruginosa (11.9%). Methicillin-resistant Staphylococcus aureus was isolated from 21 patients (6.7%). Even in the mild infection group, there was no significant difference between GPC and GNR infection, irrespective of recent antibiotic use ( P = 0.053). The most frequently used empirical antibiotics in our center were second-/third-generation cephalosporin ± clindamycin, both in the mild and moderate/severe infection groups. In our center, the amoxicillin/clavulanate or ampicillin/sulbactam (β-L-ase 1) and second-/third-generation cephalosporins were highly resistant to the common GNR (30%-60%). The ticarcillin/clavulanate, piperacillin/tazuobactam (β-L-ase 2), fluoroquinolone, and group 2 carbapenem had good sensitivity. This study presents a comprehensive microbiological survey of diabetic foot ulcers in inpatients and provides reliable evidence of the local microbial epidemiology and sensitivity of antibiotics, which may help us improve clinical outcomes in DFI patients.

Influence of Epidemiologic and Patient Behavior–Related Predictors on Amputation Rates in Diabetic Patients

Amputation of patients with diabetic foot is a major issue worldwide, particularly from a medical and economic standpoint. This meta-analysis aimed to identify significant risk factors of high amputation rate among epidemiologic and patient behavior–related predictors in diabetic patients. A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. Seven variables were extracted from the included studies and evaluated based on amputation rate. The Newcastle-Ottawa scale was used to assess the quality of the studies. The search strategy identified 101 publications. After screening, 33 articles were selected for review. Male sex and smoking were identified as significant risk factors of high amputation rate of diabetic foot. Although further investigation of long-term and randomized controlled studies is needed, we identified 2 variables as significant risk factors for high amputation rate in diabetic patients in this meta-analysis.

Minor amputation does not negatively affect health-related quality of life as compared with conservative treatment in patients with a diabetic foot ulcer: An observational study

BACKGROUND

Health-related quality of life (HRQoL) is poor in patients with persistent diabetic foot ulcers and poor HRQoL predicts worse outcomes in these patients. Amputation is often considered a treatment failure, which is why conservative treatment is generally preferred over amputation. However, it is unclear whether minor amputation negatively affects HRQoL compared with conservative treatment in patients with diabetic foot ulcers.

METHODS

In the cohort of the multicenter, prospective, observational Eurodiale study, we determined difference in change of HRQoL measured by EQ-5D between patients with a diabetic foot ulcers that healed after conservative treatment (n = 676) and after minor amputation (n = 145). Propensity score was used to adjust for known confounders, attempting to overcome lack of randomization.

RESULTS

Baseline HRQoL was not significantly different between patients treated conservatively and undergoing minor amputation. In addition, there was no difference in the change of HRQoL between these groups. In patients who healed 6 to 12 months after the first visit, HRQoL on the anxiety/depression subscale even appeared to improve more in those who underwent minor amputation.

CONCLUSIONS

Minor amputation was not associated with a negative impact on HRQoL in patients with a diabetic foot ulcers. It may therefore not be considered treatment failure in terms of HRQoL but rather a viable treatment option. A randomized controlled trial is warranted to further examine the influence of minor amputations on health-related quality of life.

Mesenchymal Stem Cells Improve Healing of Diabetic Foot Ulcer

Mesenchymal stem cells (MSCs), an ideal cell source for regenerative therapy with no ethical issues, play an important role in diabetic foot ulcer (DFU). Growing evidence has demonstrated that MSCs transplantation can accelerate wound closure, ameliorate clinical parameters, and avoid amputation. In this review, we clarify the mechanism of preclinical studies, as well as safety and efficacy of clinical trials in the treatment of DFU. Bone marrow-derived mesenchymal stem cells (BM-MSCs), compared with MSCs derived from other tissues, may be a suitable cell type that can provide easy, effective, and cost-efficient transplantation to treat DFU and protect patients from amputation.

Bacterial Profile and Antibiotic Resistance in Patients with Diabetic Foot Ulcer in Guangzhou, Southern China: Focus on the Differences among Different Wagner's Grades, IDSA/IWGDF Grades, and Ulcer Types

OBJECTIVE

To understand the bacterial profile and antibiotic resistance patterns in diabetic foot infection (DFI) in different Wagner's grades, IDSA/IWGDF grades, and different ulcer types in Guangzhou, in order to provide more detailed suggestion to the clinician about the empirical antibiotic choice.

METHODS

207 bacteria were collected from 117 DFIs in Sun Yat-sen Memorial Hospital from Jan.1, 2010, to Dec.31, 2015. The clinical data and microbial information were analyzed.

RESULTS

The proportion of Gram-negative bacteria (GNB) was higher than Gram-positive bacteria (GPB) (54.1% versus 45.9%), in which Enterobacteriaceae (73.2%) and Staphylococcus (65.2%) were predominant, respectively. With an increasing of Wagner's grades and IDSA/IWGDF grades, the proportion of GNB bacterial infection, especially Pseudomonas, was increased. Neuro-ischemic ulcer (N-IFU) was more susceptible to GNB infection. Furthermore, with the aggravation of the wound and infection, the antibiotic resistance rates were obviously increased. GPB isolated in ischemic foot ulcer (IFU) showed more resistance than the N-IFU, while GNB isolates were on the opposite.

CONCLUSIONS

Different bacterial profiles and antibiotic sensitivity were found in different DFU grades and types. Clinician should try to stay updated in antibiotic resistance pattern of common pathogens in their area. This paper provided them the detailed information in this region.

Factors associated with foot ulceration of people with diabetes mellitus living in rural areas

Objective To analyze the factors associated with the risk of ulceration in the feet of people with diabetes mellitus living in rural areas. Methods This is a cross-sectional study conducted with 293 individuals with diabetes mellitus, aged 40 years or older, living in the south of Brazil, in 2014. We analyzed socioeconomic variables, clinical conditions and foot self-care. We used the Poisson multiple regression model and the Prevalence Ratio (PR) and p-value<0.05 as a measure of association. Results 43.7% of the sample presented risk of foot ulceration. The highest prevalence of foot ulceration risk was associated with people with lower purchasing power (PRadjusted=1.62/IC95%:1.52-2.22), with retinopathy (PRadjusted=1.30/IC95%:1.12-1.68) and alteration in foot moisture (PRadjusted=1.57/IC95%:1.22-2.01). We identified low education level (64.2%), high prevalence of arterial hypertension (86.3%) and onychomycosis in the feet (72%). Conclusions Diabetic patients need an assessment of the risk of foot ulceration, especially those with longer diagnosis, chronic complications and low socio-educational level.

Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation

Diabetes mellitus is a common metabolic disorder. Among various complications, diabetic neuropathy and peripheral vascular disorders are closely associated with diabetic foot ulcers (DFUs). Lower extremity ulcers and amputations are ongoing problems among individuals with diabetes. There are several classification systems for DFUs; however, no prognostic system has to date been accepted as the gold standard or the optimum prediction tool for amputations. A retrospective study was designed. Demographic data and baseline laboratory data were gathered and scored or evaluated using five representative DFU classification systems. These included (i) the diabetic ulcer severity score (DUSS); (ii) University of Texas (UT) diabetic wound classification; (iii) Meggitt-Wagner classification; (iv) depth of the ulcer, extent of bacterial colonisation, phase of ulcer and association aetiology (DEPA) scoring system; and (v) site, ischaemia, neuropathy, bacterial infection and depth (SINBAD) score. Finally, a statistical analysis was performed. A total of 137 patients were included in this study. During the follow-up, DFU had healed in 51·1% of subjects and 48·9% of the individuals underwent lower extremity amputations (LEAs). In a univariable logistic regression analysis, history of previous DFU, hypertension, neuropathy, haemoglobin, C-reactive protein (CRP) and ankle-brachial index (ABI) showed a statistically significant difference between the healed group and the LEA group. Moreover, the stages, grades or overall prognostic ability of all five classifications were highly associated with the overall occurrence of LEA. On multivariable logistic regression analysis of the risk of LEA, all classifications showed a significant positive trend with an increased number of amputations. All the five classification systems exhibited high sensitivity, specificity, classification accuracy, positive predictive, negative predictive and area under the curve (AUC) values. They showed substantial accuracy and their main variables were associated with LEA occurrence. The Wagner and UT systems, although they are relatively simple to assess, were better predictors of LEA.

Differences in foot self-care and lifestyle between men and women with diabetes mellitus

OBJECTIVE

to investigate differences with regard to foot self-care and lifestyle between men and women with diabetes mellitus.

METHOD

cross-sectional study conducted in a sample of 1,515 individuals with diabetes mellitus aged 40 years old or older. Poisson regression models were used to identity differences in foot self-care deficit and lifestyle between sexes, adjusting for socioeconomic and clinical characteristics, smoking and alcohol consumption.

RESULTS

foot self-care deficit, characterized by not regularly drying between toes; not regularly checking feet; walking barefoot; poor hygiene and inappropriately trimmed nails, was significantly higher among men, though men presented a lower prevalence of feet scaling and use of inappropriate shoes when compared to women. With regard to lifestyle, men presented less healthy habits, such as not adhering to a proper diet and taking laboratory exams to check for lipid profile at the frequency recommended.

CONCLUSION

the nursing team should take into account gender differences concerning foot self-care and lifestyle when implementing educational activities and interventions intended to decrease risk factors for foot ulceration.

OBJETIVO

investigar as diferenças no autocuidado com os pés e no estilo de vida entre mulheres e homens diabéticos.

MÉTODO

estudo transversal realizado com uma amostra de 1.515 diabéticos com 40 anos ou mais. Foram utilizados modelos de regressão de Poisson para identificar diferenças entre os sexos na prevalência de déficit de autocuidado com os pés e no estilo de vida, ajustando-se por características socioeconômicas, clínicas, tabagismo e alcoolismo.

RESULTADOS

a prevalência de déficit de autocuidado com os pés, caracterizada por baixa frequência de secagem dos espaços interdigitais; da não avaliação periódica dos pés; do hábito de andar descalço; de higiene insatisfatória e corte inadequado de unhas foi significativamente maior entre os homens. Contudo, eles apresentaram menor prevalência na prática de escaldar os pés e no uso de calçados inadequados em comparação às mulheres. Em relação ao estilo de vida, os homens também apresentaram comportamentos menos saudáveis pois tem significativamente menor controle alimentar e não realizam os exames laboratoriais referentes ao perfil lipídico na frequência recomendada.

CONCLUSÃO

considerar as diferenças de gênero no autocuidado com os pés e no estilo de vida permite à equipe de enfermagem direcionar atividades educacionais e intervenções nos fatores de risco à ulceração dos pés.

OBJETIVO

investigar las diferencias en el autocuidado de los pies y estilo de vida entre mujeres y hombres diabéticos.

MÉTODO

estudio transversal realizado con una muestra de 1.515 diabéticos con 40 años o más. Fueron utilizados los modelos de regresión de Poisson para identificar diferencias entre los sexos en la prevalencia de déficit de autocuidado de los pies y estilo de vida, ajustándolas por características socioeconómicas, clínicas, tabaquismo y alcoholismo.

RESULTADOS

la prevalencia de déficit de autocuidado de los pies, caracterizada por: baja frecuencia de secado de los espacios interdigitales; falta de evaluación periódica de los pies; hábito de andar descalzo; higiene insatisfactoria; y, corte inadecuado de uñas, fue significativamente mayor entre los hombre. Sin embargo, estos presentaron menor prevalencia en la práctica de escaldar los pies y en el uso de calzados inadecuados en comparación a las mujeres. En relación al estilo de vida, los hombres también presentaron comportamientos menos saludables ya que tienen significativamente menor control alimentario y no realizan los exámenes de laboratorio referentes al perfil lipídico, con la frecuencia recomendada.

CONCLUSIÓN

considerar las diferencias de género en el autocuidado de los pies y en el estilo de vida, le permite al equipo de enfermería realizar actividades educacionales e intervenciones en los factores de riesgo para la ulceración de los pies.

The impact of nutritional status on treatment outcomes of patients with limb-threatening diabetic foot ulcers

AIM

This study aimed to investigate the nutritional status of patients with limb-threatening diabetic foot ulcers (DFUs) and its impact on treatment outcomes.

METHODS

A total of 478 consecutive patients (mean age, 65.4years) treated for limb-threatening DFUs were enrolled. Nutritional status assessment using the Mini Nutritional Assessment (MNA) and Geriatric Nutritional Risk Index (GNRI) was performed by three qualified dieticians within 48hours of admission. Limb-preservation outcomes were stratified into major lower extremity amputation (LEA) (above the ankle, n=33), minor LEA (distal to ankle, n=117) and no amputation (non-LEA, n=328).

RESULTS

Most patients were identified as being at risk of malnutrition (70.5%) or malnourished (14.6%) (mean MNA score, 20.6±3.4). MNA scores decreased with increasing severity of LEA (mean, 21.1, 20.0, and 17.9, respectively; P for linear trend <0.001), associated inversely with the tendency to require LEA (P for linear trend was 0.001), and associated independently with both major and minor LEA outcomes (adjusted odds ratio [aOR]=0.80, 95% confidence interval [CI], 0.65-0.99, P=0.042 and aOR=0.89, 95% CI, 0.80-0.99, P=0.032, respectively). The predictive value was sustained in patients younger than age 65years. Though GNRI results had similar associations with outcomes, its predictive value was limited in minor LEA and younger population.

CONCLUSIONS

Patients' nutritional status was shown to have significant influence on limb-preservation outcomes for limb-threatening DFUs. Nutritional assessment of this patient population using the MNA is recommended.