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Bus SA, Armstrong DG, Gooday C, Jarl G, Caravaggi C, Viswanathan V, Lazzarini PA. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3274. [PMID: 32176441 DOI: 10.1002/dmrr.3274] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/15/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Carlo Caravaggi
- Diabetic Foot Department, IRCCS Multimedica Group, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Bus SA, van Netten JJ, Monteiro‐Soares M, Lipsky BA, Schaper NC. Diabetic foot disease: "The Times They are A Changin' ". Diabetes Metab Res Rev 2020; 36 Suppl 1:e3249. [PMID: 32176443 PMCID: PMC7154668 DOI: 10.1002/dmrr.3249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022]
Abstract
Diabetic foot disease greatly impacts both affected patients and society, but remains the "Cinderella" of diabetes-related complications. However, recent progress in research and guideline development have led to increased awareness of the problem and improved clinical outcomes. Thus, it is time for a shift in global perception of this increasingly prevalent problem. In this special issue, we present 7 up-to-date clinical guidelines and 10 systematic reviews developed by the International Working Group on the Diabetic Foot, together with 17 informative and stimulating related papers. These guidelines offer new recommendations on ulcer classification, diagnosis of infection severity, and vascular assessment, to assist in ulcer risk stratification, diagnosis and interdisciplinary communication. Key developments include providing guidance on methodological assessment of research papers; expanding the evidence base for ulcer treatment by the use of wound products and offloading treatment and suggestions for improving ulcer prevention through technological advances in patient monitoring of risk factors and footwear. The 17 invited papers discuss related topics ranging from stem cell research to patient psychology and describe the way forward in diabetic foot care. While there is much more to learn, the new knowledge of underlying pathways, advancements in diagnosis, treatment and prevention presented in this supplement should help improve outcomes and reduce the great and growing burden of diabetic foot disease.
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Affiliation(s)
- Sicco A. Bus
- Amsterdam UMC, University of AmsterdamRehabilitation Medicine, Amsterdam Movement SciencesAmsterdamThe Netherlands
| | - Jaap J. van Netten
- Amsterdam UMC, University of AmsterdamRehabilitation Medicine, Amsterdam Movement SciencesAmsterdamThe Netherlands
| | - Matilde Monteiro‐Soares
- MEDCIDS: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS – Center for Health Technology and Services Research, Faculdade de Medicina daUniversidade do PortoPortoPortugal
| | | | - Nicolaas C. Schaper
- Division of EndocrinologyMUMC+, CARIM and CAPHRI InstituteMaastrichtThe Netherlands
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Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3266. [PMID: 32176447 DOI: 10.1002/dmrr.3266] [Citation(s) in RCA: 329] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.
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Affiliation(s)
- Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Academic Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Academic Medical Center, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | | | - Benjamin A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
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154
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Choke E, Tang TY, Cheng SC, Tay JS. Treatment of lower limb ischaemia in patients with diabetes. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3262. [PMID: 31833236 DOI: 10.1002/dmrr.3262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/11/2022]
Abstract
Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.
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Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Shin C Cheng
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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155
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van Netten JJ, Sacco ICN, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Bus SA. Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3271. [PMID: 31957306 DOI: 10.1002/dmrr.3271] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/01/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown. METHODS The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables. RESULTS We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting. CONCLUSIONS Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech, and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC, Australia
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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156
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Woldemariam GT, Atnafu NT, Radie YT, Wolde GT, Gebreagziabher TT, Gebrehiwot TG, Teka YH, Hagos MG, Hagezom HM, Yigzaw HB, Gebremedhin HT, Mezgebo HM, Gebremariam A. Determinants of Diabetic Foot Ulcer Among Adult Patients with Diabetes Attending the Diabetic Clinic in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: Unmatched Case-Control Study. Diabetes Metab Syndr Obes 2020; 13:3739-3747. [PMID: 33116723 PMCID: PMC7571574 DOI: 10.2147/dmso.s265988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/19/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic foot ulcer is among the commonest complications of diabetic mellitus attributed to a number of morbidity and mortality cases in diabetic patients. Nowadays, the incidence of diabetic foot ulcer is increasing due to the increased prevalence of diabetes. However, the risk factors of the problem are less studied in Ethiopia. Hence, this study was conducted to assess the determinants of diabetic foot ulcer among adult patients with diabetes attending a diabetic clinic in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia in 2019. PATIENTS AND METHODS An institution-based unmatched case-control study was conducted on 161 patients with diabetes (53 patients with diabetes with foot ulcer and 108 patients with diabetes without foot ulcer). Cases were selected from patients with diabetes with foot ulcer by consecutive sampling technique and controls from patients with diabetes without diabetic foot ulcer by systematic random sampling technique. A binary logistic regression model was used to assess the association between the dependent and independent variables. All variables with a P-value<0.25 were included in the multivariable analysis. Statistical significance was declared at P-value<0.05 with 95% confidence interval. RESULTS In this study, 28 (52.8%) cases and 55 (50.9%) controls were male. Taking insulin alone (AOR=2.75, 95% CI=1.04-7.23), having peripheral neuropathy (AOR=7.56, 95% CI=2.82-20.24), not inspecting feet daily (AOR=5.61, 95% CI=2.24-14.05), and using moisturizing cream between toes (AOR=3.35, 95% CI=1.35-8.32) were positively associated with diabetic foot ulcer, whereas employed (AOR=0.35, 95% CI=0.14-0.87) and combined treatment (insulin and oral hypoglycemic agents) (AOR=0.11, 95% CI=0.02-0.57) were negatively associated with diabetic foot ulcer. CONCLUSION Diabetic foot ulcer was significantly associated with occupation, kind of treatment of diabetes mellitus taking, peripheral neuropathy, inspecting feet daily, and putting moisturizing cream between toes. It will be helpful if diabetic patients inspect their feet on a daily basis and do not put moisturizing cream between their toes.
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Affiliation(s)
- Guesh Teklu Woldemariam
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
- Correspondence: Guesh Teklu WoldemariamDepartment of Nursing, College of Medicine and Health Sciences, Adigrat University, Postal Address: 50, Tigrai, EthiopiaTel +251940304140 Email
| | - Niguse Tadele Atnafu
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yosief Tsige Radie
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | - Yared Haileselassie Teka
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Milete Gebrehiwot Hagos
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Haftamu Mamo Hagezom
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Hailu Belay Yigzaw
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Haftom Tesfay Gebremedhin
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Hagos Mehari Mezgebo
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Alem Gebremariam
- Department of Public Health, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
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157
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Berlanga-Acosta JA, Guillén-Nieto GE, Rodríguez-Rodríguez N, Mendoza-Mari Y, Bringas-Vega ML, Berlanga-Saez JO, García del Barco Herrera D, Martinez-Jimenez I, Hernandez-Gutierrez S, Valdés-Sosa PA. Cellular Senescence as the Pathogenic Hub of Diabetes-Related Wound Chronicity. Front Endocrinol (Lausanne) 2020; 11:573032. [PMID: 33042026 PMCID: PMC7525211 DOI: 10.3389/fendo.2020.573032] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/13/2020] [Indexed: 01/10/2023] Open
Abstract
Diabetes is constantly increasing at a rate that outpaces genetic variation and approaches to pandemic magnitude. Skin cells physiology and the cutaneous healing response are progressively undermined in diabetes which predisposes to lower limb ulceration, recidivism, and subsequent lower extremities amputation as a frightened complication. The molecular operators whereby diabetes reduces tissues resilience and hampers the repair mechanisms remain elusive. We have accrued the notion that diabetic environment embraces preconditioning factors that definitively propel premature cellular senescence, and that ulcer cells senescence impair the healing response. Hyperglycemia/oxidative stress/mitochondrial and DNA damage may act as major drivers sculpturing the senescent phenotype. We review here historical and recent evidences that substantiate the hypothesis that diabetic foot ulcers healing trajectory, is definitively impinged by a self-expanding and self-perpetuative senescent cells society that drives wound chronicity. This society may be fostered by a diabetic archetypal secretome that induces replicative senescence in dermal fibroblasts, endothelial cells, and keratinocytes. Mesenchymal stem cells are also susceptible to major diabetic senescence drivers, which accounts for the inability of these cells to appropriately assist in diabetics wound healing. Thus, the use of autologous stem cells has not translated in significant clinical outcomes. Novel and multifaceted therapeutic approaches are required to pharmacologically mitigate the diabetic cellular senescence operators and reduce the secondary multi-organs complications. The senescent cells society and its adjunctive secretome could be an ideal local target to manipulate diabetic ulcers and prevent wound chronification and acute recidivism. This futuristic goal demands harnessing the diabetic wound chronicity epigenomic signature.
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Affiliation(s)
- Jorge A. Berlanga-Acosta
- The Clinical Hospital Chengdu Brain Sciences Institute, University of Electronic Science and Technology of China, Chengdu, China
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | - Gerardo E. Guillén-Nieto
- The Clinical Hospital Chengdu Brain Sciences Institute, University of Electronic Science and Technology of China, Chengdu, China
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | - Nadia Rodríguez-Rodríguez
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | - Yssel Mendoza-Mari
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | - Maria Luisa Bringas-Vega
- The Clinical Hospital Chengdu Brain Sciences Institute, University of Electronic Science and Technology of China, Chengdu, China
- Cuban Neurosciences Center, Playa, Cuba
| | - Jorge O. Berlanga-Saez
- Applied Mathematics Department, Institute of Mathematics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Diana García del Barco Herrera
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | - Indira Martinez-Jimenez
- Tissue Repair, Wound Healing and Cytoprotection Research Group, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Playa, Cuba
| | | | - Pedro A. Valdés-Sosa
- The Clinical Hospital Chengdu Brain Sciences Institute, University of Electronic Science and Technology of China, Chengdu, China
- Cuban Neurosciences Center, Playa, Cuba
- *Correspondence: Pedro A. Valdés-Sosa
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158
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Panagoulias GS, Eleftheriadou I, Papanas N, Manes C, Kamenov Z, Tesic D, Bousboulas S, Tentolouris A, Jude EB, Tentolouris N. Dryness of Foot Skin Assessed by the Visual Indicator Test and Risk of Diabetic Foot Ulceration: A Prospective Observational Study. Front Endocrinol (Lausanne) 2020; 11:625. [PMID: 33013702 PMCID: PMC7506164 DOI: 10.3389/fendo.2020.00625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/30/2020] [Indexed: 12/24/2022] Open
Abstract
Research Question: Previous cross-sectional studies have shown an association between sudomotor dysfunction and diabetic foot ulceration (DFU). The aim of this prospective multicenter study was to determine the role of dryness of foot skin and of established neurological modalities in the prediction of risk for foot ulceration in a cohort of individuals with diabetes mellitus (DM). Design: The study was conducted from 2012 to 2017. A total of 308 subjects with DM without history of DFU or critical limb ischemia completed the study. Diabetic neuropathy was assessed using the neuropathy symptom score (NSS) and neuropathy disability score (NDS). In a subset of participants, vibration perception threshold (VPT) was evaluated. Dryness of foot skin was assessed by the visual indicator plaster method (IPM). The diagnostic performance of the above neurological modalities for prediction of DFU was tested by receiver operating characteristic curve (ROC) analysis. Results: During the 6-year follow-up, 55 patients (annual ulceration incidence 2.97%) developed DFU. Multivariate Cox-regression analysis after controlling for the effect of age, gender, and DM duration demonstrated that the risk (hazard ratio, 95% confidence intervals) of DFU increased significantly with either abnormal IPM (3.319, 1.460-7.545, p = 0.004) or high (≥6) NDS (2.782, 1.546-5.007, p = 0.001) or high (≥25 volts) VPT (2.587, 1.277-5.242, p = 0.008). ROC analysis showed that all neurological modalities could discriminate participants who developed DFU (p < 0.001). IPM testing showed high sensitivity (0.86) and low specificity (0.49), while high vs. low NDS and VPT showed low sensitivity (0.40 and 0.39, respectively) and high specificity (0.87 and 0.89, respectively) for identification of patients at risk for DFU. Conclusion: Dryness of foot skin assessed by the IPM predicts the development of DFU. IPM testing has high sensitivity, whereas high NDS and VPT have high specificity in identifying subjects at risk for DFU. The IPM can be included in the screening methods for identification of the foot at risk.
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Affiliation(s)
- Georgios S. Panagoulias
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ioanna Eleftheriadou
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine, Diabetes Center, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Christos Manes
- Diabetes Center, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Zdravko Kamenov
- Diabetes Outpatient Clinic, University Hospital Alexandrovska, Medical University—Sofia, Sofia, Bulgaria
| | - Dragan Tesic
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, Clinical Center of Vojvodina, Medical Faculty, University Novi Sad, Novi Sad, Serbia
| | - Stavros Bousboulas
- Diabetes Outpatient Clinic, “St. Panteleimon” General State Hospital, Nikaia, Greece
| | - Anastasios Tentolouris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Edward B. Jude
- Tameside Hospital NHS Foundation Trust and University of Manchester, Ashton-under-Lyne, United Kingdom
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
- *Correspondence: Nikolaos Tentolouris
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