Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis †

Empowering Foot Care Literacy Among People Living With Diabetes and Their Carers With an mHealth App: Protocol for a Feasibility Study

BACKGROUND

Diabetic foot ulcers (DFUs) cause significant morbidity affecting 19% to 34% of people living with diabetes mellitus. DFUs not only impair quality of life but may also result in limb loss and mortality. Patient education has been advocated to raise awareness of proper foot self-care and the necessity of seeking assistance when a foot wound occurs. Modern technologies, including mobile health (mHealth) interventions such as health apps, bring the potential for more cost-effective and scalable interventions.

OBJECTIVE

This study aims to examine the feasibility and usability of a newly developed mHealth app called Well Feet, which is a diabetes and foot care education app for individuals at risk of developing DFU.

METHODS

Well Feet was developed using an evidence-based and expert panel cocreation approach to deliver educational content available in 3 languages (ie, English, Chinese, and Malay) via animation videos and a range of additional features, including adaptive learning. A nonrandomized, single-arm feasibility study using a mixed methods approach with a series of validated questionnaires and focus group discussions will be conducted. In total, 40 patients and carers will be recruited from a tertiary hospital diabetes clinic to receive a 1-month mHealth intervention. The primary outcomes are the usability of the app and a qualitative perspective on user experience. Secondary outcomes include changes in foot care knowledge, self-management behaviors, and quality of life.

RESULTS

Patient recruitment began in July 2023, and the intervention and data collection will be completed by the end of September 2023. This study has been approved by National Healthcare Group Domain Specific Review Board (2022/00614) on February 10, 2023. The expected results will be published in spring 2024.

CONCLUSIONS

Through this feasibility study, the Well Feet DFU education app will undergo a comprehensive quantitative and qualitative evaluation of its usability and acceptance for future improvement in its design. With local contextualization, cultural adaptation, and its multilingual functionality, the app addresses a critical aspect of DFU health education and self-management in a multiethnic population. Findings from this study will refine and enhance the features of the app based on user feedback and shape the procedural framework for a subsequent randomized controlled trial to assess the effectiveness of Well Feet.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05564728; https://clinicaltrials.gov/study/NCT05564728.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52036.

Platelet-rich plasma for the treatment of diabetic foot ulcer: a systematic review

Background

With the increasing incidence of diabetes, diabetic foot ulcer(DFU) has become one of the most common and serious complications in people with diabetes. DFU is associated with significant morbidity and mortality, and can also result in significant economic, social and public health burdens. Due to peripheral neuropathy, peripheral vascular disease, hyperglycemic environment, inflammatory disorders and other factors, the healing of DFU is impaired or delayed, resulting in the formation of diabetic chronic refractory ulcer. Because of these pathological abnormalities in DFU, it may be difficult to promote wound healing with conventional therapies or antibiotics, whereas platelet-rich plasma(PRP) can promote wound healing by releasing various bioactive molecules stored in platelets, making it more promising than traditional antibiotics. Therefore, the purpose of this systematic review is to summarize and analyze the efficacy of PRP in the treatment of DFU.

Methods

A literature search was undertaken in PubMed, CNKI, EMB-ASE, the Cochrane Library, the WanFang Database and the WeiPu Database by computer. Included controlled studies evaluating the efficacy of PRP in the treatment of diabetic foot ulcers. The data extraction and assessment are on the basis of PRISMA.

Results

Twenty studies were evaluated, and nineteen measures for the evaluation of the efficacy of PRP in DFU treatment were introduced by eliminating relevant duplicate measures. The efficacy measures that were repeated in various studies mainly included the rate of complete ulcer healing, the percentage of ulcer area reduction, the time required for ulcer healing, wound complications (including infection rate, amputation rate, and degree of amputation), the rate of ulcer recurrence, and the cost and duration of hospitalization for DFU, as well as subsequent survival and quality of life scores. One of the most important indicators were healing rate, ulcer area reduction and healing time. The meta-analysis found that PRP was significantly improve the healing rate(OR = 4.37, 95% CI 3.02-6.33, P < 0.001) and shorten the healing time(MD = -3.21, 95% CI -3.83 to -2.59,P < 0.001)of patients with DFU when compared to the conventional treatment, but there was no significant difference in reducing the of ulcer area(MD = 5.67, 95% CI -0.77 to 12.11,P =0.08>0.05 ).

Conclusion

The application of PRP to DFU can improve ulcer healing rate and shorten ulcer healing time, but more clinical data are needed to clarify some efficacy measures. At the same time, a standardized preparation process for PRP is essential.

"They say to me 'You want to be a high shot and be like a tourist' so I stopped wearing shoes at home even though I know it is to protect my feet". The perceptions of patients on foot complications

BACKGROUND

Diabetic Foot Ulceration (DFU) is one of the serious complications for people with diabetes and it is also the most devastating but yet preventable complication. This study aimed to explore the perceptions of Type 2 Diabetes Mellitus (T2DM) patients on their foot complications and foot care practices in Fiji.

METHODS

A qualitative study design was used to recruit T2DM patients attending Diabetic clinic in Rotuma Hospital, Fiji from July to September, 2021. Purposive sampling was used to recruit 27 patients until data saturation is happened. Semi-structured one-on-one in-depth interviews that were audio-recorded were used to collect data which was then transcribed and manually analyzed using thematic analysis method.

RESULTS

This study found four main themes namely Knowledge and its determinants, Perceptions on personal practice and health care practice, Health seeking behaviors and Factors affecting footwear practices. T2DM patients had varying levels of knowledge about DFU and these levels of knowledge were attributed to lack of advice from healthcare providers, personal beliefs, culture and societal norms and lack of resources. Patients continued to practice self-care practices that they perceived to protect their feet from trauma and such practices have been passed down through a traditional knowledge system including stigma and beliefs. Culture and personal habits greatly impacted the practice of wearing footwear. Societal norms and traditions greatly impact how T2DM patients take care of their feet and their health in general.

CONCLUSION

Understanding personal beliefs and traditional influences surrounding the patients' environment is paramount in order to effectively implement public health prevention strategies against DFU.

Mesenchymal stem cells-based drug delivery systems for diabetic foot ulcer: A review

The complication of diabetes, which is known as diabetic foot ulcer (DFU), is a significant concern due to its association with high rates of disability and mortality. It not only severely affects patients’ quality of life, but also imposes a substantial burden on the healthcare system. In spite of efforts made in clinical practice, treating DFU remains a challenging task. While mesenchymal stem cell (MSC) therapy has been extensively studied in treating DFU, the current efficacy of DFU healing using this method is still inadequate. However, in recent years, several MSCs-based drug delivery systems have emerged, which have shown to increase the efficacy of MSC therapy, especially in treating DFU. This review summarized the application of diverse MSCs-based drug delivery systems in treating DFU and suggested potential prospects for the future research.

Diabetic foot problem in Nepal

Introduction

Nepal is a developing country where diabetes is becoming a major health challenge due to its high prevalence of 8.5% affecting around 2 million people. Due to limited resources, there are many barriers to providing affordable and convenient diabetes care or regular screening for complications. There is no reliable data on incidence, prevalence, and complications of diabetic foot problems in Nepal.

Methods

We conducted an online survey amongst senior physicians, who were members of 'Diabetes & Endocrine Association of Nepal' to assess their perception of diabetic foot problems in Nepal.

Results

Thirty-Eight physicians responded to the survey who saw a total of 17597 patients in the preceding month. They recalled seeing 647 with 'Diabetic Foot Ulcers', giving a crude Diabetic Foot Ulcer prevalence rate of 3.7%. They recalled seeing 2522 patients with painful neuropathy that required medical treatment, giving a crude painful neuropathy prevalence rate of 14.3%. A history of foot ulcer was present in an additional 578 patients. Previous minor amputation had been performed in 215 patients (1.2%) and major amputation in 135 patients (0.8%).

Discussion

Despite having expertise in various fields there is no dedicated multi-disciplinary diabetic foot clinic in Nepal. This survey shows that diabetic foot problems are abundant in Nepal and there is a need for structured multi-disciplinary approach for screening and treatment.

Counterintuitive relationship between the triglyceride glucose index and diabetic foot in diabetes patients: A cross-sectional study

BACKGROUND

Research has shown that insulin resistance (IR) is a known risk factor for diabetic foot (DF), and the triglyceride-glucose (TyG) index is a reliable and simple indicator of IR. However, less is known about the relationship between the TyG and the risk of DF. Here, we investigated the association between the TyG index and the prevalence of DF.

METHODS

The eligible records from the Departments of Endocrinology of Shandong Provincial Hospital Affiliated to Shandong First Medical University were screened (from December 1, 2012, to December 31, 2021), and a total of 8866 patients were enrolled. The TyG index was calculated as ln[(fasting triglycerides (mg/dL)×fasting glucose (mg/dL)/2)]. The continuous variables between the DF and the non-DF groups were compared by Student's t test or the Mann-Whitney U test, and categorical variables were compared by the chi-square test. Receiver operating characteristic curve (ROC) analysis was carried out to estimate the predictive value of the TyG index for DF. Logistic regression models were used to evaluate the associations between the quartiles of the TyG index and the risk of DF. Subgroup and sensitivity analyses were conducted.

RESULTS

The TyG index was significantly lower in the DF group than in the no-DF group. The logistic regression revealed that an increased TyG index was associated with a lower risk of DF after adjusting for potential confounders. In addition, an ROC analysis indicated the discriminatory ability of the TyG index in DF presence with an area under the curve (AUC) of 0.661 (95% CI 0.642-0.680, P < 0.001). Subgroup and sensitivity analysis also supported these robust results.

CONCLUSIONS

The TyG index was inversely and dose-dependently associated with the risk of DF in diabetes patients, indicating that elevated TyG index was a protective factor for DF. Future studies are therefore warranted to confirm our finding and to explore the detailed pathological mechanism involved in this process.

Identification of contributing factors, microorganisms and antimicrobial resistance involved in the complication of diabetic foot ulcer treatment

Diabetic foot ulcer (DFU) is a neurological and peripherical complication of diabetes with unknown etiology that is often associated with polymicrobial infections. The present study was conducted to investigate the contributing factors in 285 DFU patients, which included 200 patients with diabetic foot infections (DFI). Identification and characterization of infecting bacterial isolates were done followed by assessment of their pattern of susceptibility to commonly used antibiotics. Among the studied subjects, type 2 diabetes mellitus (T2DM), ulcer type, depth, grade, loss of sensation, infection type, affected foot, recurrence, smoking status, Body Mass Index (BMI), and obesity levels revealed significant disease risk association. Ulcer grades 1 and 2 were more common in males while grade 3 in females. Recurrent infections were significantly higher in females (P = 0.03). Diabetic duration, hyperglycemia, ulcer type, infection type and BMI were positively correlated with delayed wound healing. In DFI samples, 40.2% consisted of gram-negative bacteria, with Pseudomonas aeruginosa (37.5%) being the most common, while in the 60% gram-positive isolates Staphylococcus aureus (40.5%) was the predominant species. Staphylococcus epidermidis was found more frequently in females (P = 0.05). The isolated bacterial strains presented higher resistance against the tested antibiotics; however, ceftriaxone was effective against most of the pathogens. In the current study T2DM along with diabetes duration, obesity, ulcer severity with polymicrobial infection was found to play a strong role in DFI development, where gender predisposition was also observed in ulcer grade and infection. DFI was correlated with loss of sensation, infection type, affected foot, smoking status, BMI and obesity levels.

Gene therapy for diabetic foot ulcers: Interim analysis of a randomised, placebo-controlled phase 3 study of VM202 (ENGENSIS), a plasmid DNA expressing two isoforms of human hepatocyte growth factor

To evaluate the status of a 7-month phase 3 study conducted to test the effect of intramuscular injections of VM202 (ENGENSIS), a plasmid DNA encoding human hepatocyte growth factor, into the calf muscles of chronic nonhealing diabetic foot ulcers with concomitant peripheral artery disease. The phase 3 study, originally aimed to recruit 300 subjects, was discontinued because of slow patient recruitment. An unprespecified interim analysis was performed for the 44 subjects enrolled to assess the status and determine the future direction. Statistical analyses were carried out for the Intent-to-Treat (ITT) population and separately for subjects with neuroischemic ulcers, using a t-test and Fisher's exact test. A logistic regression analysis was also conducted. VM202 was safe and potentially should have benefits. In the ITT population (N = 44), there was a positive trend toward closure in the VM202 group from 3 to 6 months but with no statistical significance. Levels of ulcer volume or area were found to be highly skewed between the placebo and VM202 groups. Forty subjects, excluding four outliers in both arms, showed significant wound-closing effects at month 6 (P = .0457). In 23 patients with neuroischemic ulcers, the percentage of subjects reaching complete ulcer closure was significantly higher in the VM202 group at months 3, 4, and 5 (P = .0391, .0391, and .0361). When two outliers were excluded, a significant difference was evident in months 3, 4, 5, and 6 (P = .03 for all points). A potentially clinically meaningful 0.15 increase in Ankle-Brachial Index was observed in the VM202 group at day 210 in the ITT population (P = .0776). Intramuscular injections of VM202 plasmid DNA to calf muscle may have promise in the treatment of chronic neuroischemic diabetic foot ulcers (DFUs). Given the safety profile and potential healing effects, continuing a larger DFU study is warranted with modifications of the current protocol and expansion of enrolling sites.

Exploration of the common pathogenic link between COVID-19 and diabetic foot ulcers: An in silico approach

Background and Aims

The Coronavirus Disease-19 (COVID-19) is posing an ongoing threat to human health. Patients of diabetic foot ulcer (DFU) are susceptible to COVID-19-induced adverse outcomes. Nevertheless, investigations into their mutual molecular mechanisms have been limited to date. In the present work, we tried to uncover the shared pathogenesis and regulatory gene targets of COVID-19 and DFU.

Methods

In this study, we chose GSE161281 as the COVID-19 data set, which contained severe acute respiratory syndrome coronavirus 2 infected human induced embryonic stem cell-derived peripheral neurons (n = 2) with uninfected controls (n = 2). The GSE134431 designated as the DFU data set, comprising full-thickness DFU (n = 13) and diabetic foot skin (n = 8) samples from diabetic patients. The differential expressed genes (DEGs) were identified from GSE161281 and GSE134431, and the common DEGs between COVID-19 and DFU were extracted. Multifactor regulatory network and co-expression network of the common DEGs were analyzed, along with candidate drug prediction.

Results

Altogether, six common DEGs (dickkopf-related protein 1 [DKK1], serine proteinase inhibitor A3 [SERPINA3], ras homolog family member D [RHOD], myelin protein zero like 3 [MPZL3], Claudin-11 [CLDN11], and epidermal growth factor receptor pathway substrate 8-like 1 [EPS8L1]) were found between COVID-19 and DFU. Functional analyses indicated that pathways of apoptotic and Wnt signaling may contribute to progression of COVID-19. Gene co-expression network implied the shared pathways of immune regulation and cytokine response participated collectively in the development of DFU and COVID-19. A multifactor regulatory network was constructed integrating the corresponding microRNAs (miRNAs) and transcription factors. Additionally, we proposed potential drug objects for the combined therapy.

Conclusion

Our study revealed the shared molecular mechanisms underlying COVID-19 and DFU. The identified pivotal targets and common pathways can provide new perspectives for further research and assist the development of management strategies in patients of DFU complicated with COVID-19.

Non-Enhancing Tissue on Diabetic Foot Magnetic Resonance Imaging in Relation to Osteomyelitis Investigation: Magnetic Resonance Imaging Performance, Pitfalls and Clinical Considerations

Background: Geographic non-enhancing zones in diabetic foot magnetic resonance imaging (MRI) were first described in 2002. No previous report has described the impact and clinical significance of geographic non-enhancing tissue seen in the evaluation of diabetic foot MRI. Purpose: To evaluate the prevalence of devascularization areas on contrast-enhanced MRI in diabetic patients suspected of having foot osteomyelitis, the impact on the performance of the MRI assessment, and the possible pitfalls. Methods: A retrospective study was conducted between January 2016 and December 2017 during which 72 CE-MRIs of 1.5 and 3T were reviewed by 2 musculoskeletal radiologists for the presence of non-enhancing tissue areas and for osteomyelitis. A blinded third party collected clinical data including pathology reports, revascularization procedures, and surgical interventions. The prevalence of devascularization was calculated. Results: Among the 72 CE-MRIs (54 men, 18 women; mean age 64), 28 demonstrated non-enhancing areas (39%). All but 6 patients were found to have been correctly diagnosed on imaging (3 false positives, 2 false negatives, and 1 non-diagnostic). A greater discordance was also observed between the radiological and pathological diagnoses in the MRIs which showed non-enhancing tissue. Conclusion: Non-enhancing tissue is found in a non-negligible portion of diabetic foot MRIs and affects its diagnostic performance when looking for osteomyelitis. The recognition of these areas of devascularization may be helpful for the physician in planning the best treatment option for the patient.

Unraveling shared risk factors for diabetic foot ulcer: a comprehensive Mendelian randomization analysis

INTRODUCTION

Diabetic foot ulcer (DFU) stands as a severe diabetic lower extremity complication, characterized by high amputation rates, mortality, and economic burden. We propose using Mendelian randomization studies to explore shared and distinct risk factors for diabetic lower extremity complications.

RESEARCH DESIGN AND METHODS

We selected uncorrelated genetic variants associated with 85 phenotypes in five categories at the genome-wide significance level as instrumental variables. Genetic associations with DFU, diabetic polyneuropathy (DPN), and diabetic peripheral artery disease (DPAD) were obtained from the FinnGen and UK Biobank studies.

RESULTS

Body mass index (BMI) emerged as the only significant risk factor for DPAD, DPN, and DFU, independent of type 2 diabetes, fasting glucose, fasting insulin, and HbA1c. Educational attainment stood out as the sole significant protective factor against DPAD, DPN, and DFU. Glycemic traits below the type 2 diabetes diagnosis threshold showed associations with DPAD and DPN. While smoking history exhibited suggestive associations with DFU, indicators of poor nutrition, particularly total protein, mean corpuscular hemoglobin, and mean corpuscular volume, may also signal potential DFU occurrence.

CONCLUSIONS

Enhanced glycemic control and foot care are essential for the diabetic population with high BMI, limited education, smoking history, and indicators of poor nutrition. By focusing on these specific risk factors, healthcare interventions can be better tailored to prevent and manage DFU effectively.

The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers

ABSTRACT

Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.

Parenteral Vancomycin in the Treatment of MRSA-Associated Diabetic Foot Infections: An Unnecessary Risk

Diabetic foot infections (DFIs) are a common and costly complication of diabetes. Soft tissue and bone infections in DFIs frequently lead to amputation and/or sepsis which can be costly for both the patient and the healthcare system. Staphylococcus aureus is the most commonly identified causative agent in DFIs, and people with diabetes may have an increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA). In addition to increased susceptibility to severe infection, MRSA in DFIs is associated with high rates of treatment failure, morbidity, and hospitalization costs meaning appropriate treatment is a high priority. While hospitalized patients are usually treated with intravenous (IV) vancomycin, this can be costly in terms of inpatient stays, staffing costs, and adverse events. For example, vancomycin-associated acute kidney injury not only delays hospital discharge and increases costs but is also a particular concern for patients with diabetes who already have an increased risk of kidney problems. Vancomycin-resistant strains of S. aureus have also been identified, which means that alternative treatment options may need to be explored. Treatment alternatives to IV vancomycin, including oral antibiotics, have been shown to provide similar efficacy, with reduced costs, outpatient or home-based administration, and with fewer serious adverse effects. Although infectious disease specialists often use IV vancomycin alone, or in combination, as a first-line therapeutic option, they are increasingly seeing the value of outpatient or at-home oral antibiotics as an alternative. This manuscript reviews the evidence for true costs of vancomycin therapy for MRSA-associated DFIs and examines the alternatives.

Foot Plantar Pressure Abnormalities in Near Adulthood Patients with Type 1 Diabetes

Increased ulcer risk diminishes the quality of life in diabetes. This study assessed abnormalities in foot plantar pressure distribution in adolescents with T1D to detect early signs of ulcer risk. A total of 102 T1D patients, without diabetic neuropathy, were included (mean age 17.8 years, mean diabetes duration 7.4 year). Pedography was captured using Novel emed. Data from the study group were compared with reference data. The study revealed a statistically significant reduced foot contact area in both feet in the entire foot and under the head of the fifth metatarsal bone and the second toe. In both feet, the peak pressure was increased under the entire foot, hindfoot, midfoot, first metatarsal head, big toe, and second toe. There was no statistically significant difference in peak pressure. The mean plantar pressure rating was statistically significantly increased in both feet across the entire sole, in the hindfoot, midfoot, and first metatarsal head. T1D patients of age near adulthood without neuropathy have increased values in mean pressure and reduced contact area, pointing to the need of monitoring and preventive measures. These results point to the need of further research and analysis which should include various risk factor such as foot anatomy, body posture, or certain metabolic factors.

Sequential Anti-Infection and Proangiogenesis of DMOG@ZIF-8/Gelatin-PCL Electrospinning Dressing for Chronic Wound Healing

Bacterial infection and insufficient neovascularization are two major obstacles to the healing of chronic wounds. Here, we present an antibacterial and proangiogenic dressing by encapsulating dimethyloxalylglycine (DMOG) in zeolitic imidazolate framework-8 (ZIF-8) and electrospinning it with gelatin-polycaprolactone (Gel-PCL). As Gel-PCL nanofibers degrade, ZIF-8 nanoparticles decompose, sequentially releasing bactericidal zinc ions and angiogenic DMOG molecules. This cascade process matches the wound-healing stages, ensuring suitable bioavailability and an effective duration of the active components while minimizing their side effects. In vitro, zinc ions released from the dressing (2.5% DMOG@ZIF-8) can eliminate over 90% of Escherichia coli and Staphylococcus aureus without compromising fibroblast cell proliferation and adhesion. In vivo, the dressing can heal skin wounds in Staphylococcus aureus-infected diabetic rats within 2 weeks, facilitated by the DMOG molecules discharged from ZIF-8 (loading rate 21.3%). Immunohistochemical analysis confirmed the regulated expression of factors by zinc ions and DMOG molecules. This work provides new insights into the design of multifunctional dressings for the treatment of chronic wounds.

Why too soon? Predictors of time to diabetic peripheral neuropathy among newly diagnosed diabetes mellitus patients: a multicenter follow-up study at health-care setting of Ethiopia

BACKGROUND

Due to the rising number of diabetic patients, the burden of diabetic peripheral neuropathy (DPN) is clearly posing a major challenge to the long-term viability of the health-care system. Despite this, most DPN epidemiological research in eastern Africa, including Ethiopia, has so far been limited to survey studies. Thus, we determined the incidence of DPN and its predictors among diabetic patients in tertiary health-care setting of southwest Ethiopia.

METHODS

A multicenter retrospective follow-up study was carried out on 567 randomly selected diabetic patients. Data were entered using Epi-Data v4.6 and analyzed using R v4.0.4. The survival curves were estimated using the Kaplan-Meier, and compared using Log-rank test between groups of categorical variables. The PHA were evaluated using the Schoenfeld residuals test. Multivariable Gompertz proportional hazard model was used to examine the predictors of DPN at 5% level of significance.

RESULTS

Overall, of 567 DM patients 119 developed DPN with an incidence rate of 3.75, 95%CI [3.13, 4.49] per 100 PY. About 15.13% and 69% of DPN cases occurred within 2 and 5 years of DM diagnosis, respectively. In the multivariable Gompertz PH model, being female [AHR = 1.47; 95% CI (1.01, 2.15)], T2DM [AHR = 3.49 95% CI (1.82, 6.71)], having diabetic retinopathy [AHR = 1.9 95% CI (1.25, 2.91)], positive proteinuria [AHR = 2.22 95% CI (1.35, 3.65)], being obese [AHR = 3.94 95% CI (1.2, 12.89)] and overweight [AHR = 3.34 95% CI (1.09, 10.25)] significantly predicts the future risk of DPN.

CONCLUSION

Nearly, 7 in 10 of DPN cases occurred within short period of time (5 year) of DM diagnosis. Being female, T2DM, DR, positive proteinuria, obese and overweight significantly predicts the risk of DPN. Therefore, we recommend screening and early diagnosis of diabetes with its complication. While doing so, attention should be given for DM patients with DR and positive proteinuria at baseline.

The Preparation and Clinical Efficacy of Amnion-Derived Membranes: A Review

Biological tissues from various anatomical sources have been utilized for tissue transplantation and have developed into an important source of extracellular scaffolding material for regenerative medicine applications. Tissue scaffolds ideally integrate with host tissue and provide a homeostatic environment for cellular infiltration, growth, differentiation, and tissue resolution. The human amniotic membrane is considered an important source of scaffolding material due to its 3D structural architecture and function and as a source of growth factors and cytokines. This tissue source has been widely studied and used in various areas of tissue repair including intraoral reconstruction, corneal repair, tendon repair, microvascular reconstruction, nerve procedures, burns, and chronic wound treatment. The production of amniotic membrane allografts has not been standardized, resulting in a wide array of amniotic membrane products, including single, dual, and tri-layered products, such as amnion, chorion, amnion-chorion, amnion-amnion, and amnion-chorion-amnion allografts. Since these allografts are not processed using the same methods, they do not necessarily produce the same clinical responses. The aim of this review is to highlight the properties of different human allograft membranes, present the different processing and preservation methods, and discuss their use in tissue engineering and regenerative applications.

The Metabolic Characteristics of Patients at the Risk for Diabetic Foot Ulcer: A Comparative Study of Diabetic Patients with and without Diabetic Foot

Backgrounds and Objective

Diabetic foot is a relatively severe complication in patients with type 2 diabetes (T2D), with peripheral neuropathy and angiopathy frequently serving as risk factors. However, it is unknown how the other major systemic metabolic factors impacted the profile of these patients, besides glucose management. Thus, we investigated the distinct characteristics of patients with diabetic foot ulcers and their relationships with angiopathy.

Materials and Methods

We obtained the laboratory data of 334 diabetic patients at Shanghai Pudong Hospital from 2020 to 2023. The comparisons were performed between the groups with or without diabetic foot, including glucose metabolism, lipids profile, liver and kidney function, thyroid function, and serum iron. The association between metabolic factors and lower extremity computed tomography angiography (CTA) was analyzed.

Results

We found significant disparities between groups in relation to age, serum protein content, liver transferase, serum creatinine, estimated glomerular filtration rate (eGFR), serum uric acid (UA), small dense low-density lipoprotein (sdLDL), lipoprotein A (LP(a)), apolipoprotein A1 (APOA1), thyroid function, serum iron, and hemoglobin (Hb) (p<0.05). The Spearman correlational analyses showed that the severity of CTA, categorized by the unilateral or bilateral plaque or occlusion, was positively significantly correlated with UA (r=0.499), triglyceride (TG) (r=0.751), whereas inversely correlated with serum albumin (r=-0.510), alanine aminotransferase (r=-0.523), direct bilirubin (DBil) (r=-0.494), total bilirubin (TBil) (r=-0.550), Hb (r=-0.646).

Conclusion

This cross-section investigation showed that compared to T2D only, the patients with diabetic foot ulcer (DFU) might display similar glucose metabolic control context but adverse metabolic profiles, and this profile is associated with macrovascular angiopathy characteristics and their severity.

Distribution of multidrug-resistant bacterial infections in diabetic foot ulcers and risk factors for drug resistance: a retrospective analysis

Objective

To investigate the distribution, drug resistance and risk factors of multi-drug resistant bacterias (MDROs) in patients with Type 2 diabetic foot ulcers (DFU).

Method

The clinical data, foot secretions, pathogenic microorganisms and drug sensitivity tests of 147 patients with type 2 diabetes admitted to our department from January 2018 to December 2021 were analyzed. Patients were divided into two groups according to whether they had been infected with MDROs or not. Seventy-one cases were infected with MDROs as the case group, and the remaining 76 cases were the control group. Chi-square test and t-test were used to analyze the results of MDROs infection and DFU, and logistic multivariate regression was used to evaluate the risk factors of MDROs infection.

Results

A total of 71 strains were isolated from the MDROs-positive group, with the top three being Staphylococcus aureus (46.48%), Escherichia coli (22.53%), and Pseudomonas aeruginosa (18.31%), respectively. Logistic multifactorial regression analysis showed that history of previous antimicrobial exposure, neuroischemic wound, Wagner grade 3-5, and combined osteomyelitis were associated with Type 2 diabetic foot infection MDROs (P < 0.05).

Conclusion

Previous history of antimicrobial exposure, neuroischemic wounds, Wagner grade 3-5, and combined osteomyelitis are independent risk factors for MDROs, which can identify the risk factors for MDROs at an early stage and help to identify people at high risk of MDROs infection and take relevant comprehensive treatment in time to slow down the development of the disease.

Effect of hyperbaric oxygen treatment on diabetic foot ulcers: A meta-analysis

The meta-analysis aimed to assess the effect of hyperbaric oxygen treatment on diabetic foot ulcers. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 17 examinations from 1992 to 2022 were enrolled for the present meta-analysis, including 7219 people with diabetic foot ulcers. Hyperbaric oxygen treatment had a significantly higher healed ulcer (OR, 14.39; 95% CI, 4.02-51.52, p < 0.001), higher adverse event (OR, 2.14; 95% CI, 1.11-4.11, p = 0.02), lower mortality (OR, 0.22; 95% CI, 0.07-0.71, p = 0.01) and higher ulcer area reduction (MD, 23.39; 95% CI, 11.79-34.99, p < 0.001) compared to standard treatment in patients with diabetic foot ulcers. However, hyperbaric oxygen treatment and standard treatment had no significant difference in amputation (OR, 0.62; 95% CI, 0.22-1.75, p = 0.37), major amputation (OR, 0.59; 95% CI, 0.18-1.92, p = 0.38), minor amputation (OR, 0.64; 95% CI, 0.15-2.66, p = 0.54) and healing time (MD, -0.001; 95% CI, -0.76 to 0.75, p = 0.99) in patients with diabetic foot ulcers. The examined data revealed that hyperbaric oxygen treatment had a significantly higher healed ulcer, adverse event, and ulcer area reduction and lower mortality, however, there was no significant difference in amputation and healing time compared to standard treatment in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size and some of the comparisons had a low number of selected studies.

Association between triglyceride glucose index and severity of diabetic foot ulcers in type 2 diabetes mellitus

BACKGROUND

Triglyceride glucose (TyG) index is a good surrogate biomarker to evaluate insulin resistance (IR). The study aimed to investigate whether the TyG index is related to the severity of diabetic foot ulcers (DFUs) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 1059 T2DM patients were enrolled in this observational, retrospective, single-center study. TyG index was calculated as ln[fasting triglycerides (mg/dl) × fasting glucose (mg/ dl)/2]. The severity of DFUs was classified into mild-to-moderate DFUs (Wagner grade score < 3) and severe DFUs (Wagner grade score ≥ 3) based on Wagner classification. Patients were stratified according to the tertiles of TyG index. Logistic regression models were implemented to explore the association between TyG index and the severity of DFUs. Subgroup analyses were used to verify the reliability of results.

RESULTS

Compared with the reference lowest TyG tertile (T1), the highest tertile (T3) was associated with 0.377-fold increased risk of prevalence of severe DFUs (odds ratio [OR] 1.377, 95% confidence interval [CI] 1.017-1.865) (P = 0.039). After adjusting for potential confounders, the multivariable-adjusted OR and 95% CI were 1.506 (1.079-2.103) (P = 0.016) in patients with highest tertile. Moreover, subgroup analyses indicated that the association was stronger among men, patients with age ≥ 65 years, duration of diabetes more than 10 years, or without PAD.

CONCLUSIONS

Elevated TyG index is independently associated with severity of DFUs even after adjusting conventional confounders.

Relationship of Serum Vitamin D Levels With Diabetic Foot in Patients With Type 2 Diabetes Mellitus: A Cross-Sectional Study

Background and aims: Diabetic foot is one of the most severe complications in patients with diabetes mellitus and has been linked to 25-OH-vitamin D status. This study aims to determine the prevalence of 25-OH-vitamin D deficiency and its association with diabetic foot. Methods: Patients with type 2 diabetes mellitus were enrolled in this study. The patients were divided into the diabetic foot group (n = 95) and the non-diabetic foot group (n = 388). Weight, height, and waist circumference were measured. The 25-OH-vitamin D and the other biochemical tests were extracted from the electronic medical records. The difference in clinical parameters between the diabetic foot group and the non-diabetic foot group was analyzed, and the risk factors of the diabetic foot group were analyzed using logistic regression. Results: The prevalence of 25-OH-vitamin D deficiency was 44.6%, accounting for 57.9% of all the diabetic foot group patients and only 41.0% of the non-diabetic foot group patients. The mean serum 25-OH-vitamin D level was significantly different between the diabetic foot group and the non-diabetic foot group (19.8 ± 9.5 vs 24.1 ± 11.8; P = .011). Serum 25-OH-vitamin D and B12 were found to have a significant positive correlation (r = 0.410, P = <.01). The 25-OH-vitamin D level and body mass index were independently associated with diabetic foot (P = .043, OR = 1.21; P = .009, OR =  1.47), respectively. Conclusions: The 25-OH-vitamin D deficiency was higher in the diabetic foot group. More research is needed to understand the role of 25-OH-vitamin D in the development of diabetic foot.

Capacitive immunosensor based on grafted Anodic Aluminum Oxide for the detection of matrix metalloproteinase 9 found in chronic wounds

Chronic wounds impose a significant burden on healthcare resources, society and more specifically on patients. Preliminary research showed that as of today, there is not a system that can do a precise monitoring of these wounds so that healthcare systems can manage them with efficiency. The overall aim of our project is to produce a capacitive sensor able to detect a specific molecule in chronic wounds, thus giving information concerning its inflammation state. In this article, we present a system that uses nanoporous Anodic Aluminum Oxide (AAO) grafted with a commercially available anti-MMP9 antibody able to interact with Matrix Metalloproteinase 9, an enzyme that works as an indicator of inflammation. In order to produce a proof-of-concept we chose to compare two methods of functionalization followed by a thorough analysis with biological, electrical and optical testing. This study produced reproducible results for each functionalization method, chemisorption being the best choice for the immobilization of conventional antibodies on AAO-based sensors for a detection of MMP9 in pure and complex conditions. This proof-of-concept and its analysis allowed a better understanding of the needs of the overall project and will be helpful to produce a prototype of smart dressing in the near future.

Hotspots: Adherence in home foot temperature monitoring interventions for at-risk feet with diabetes-A narrative review

BACKGROUND

Home foot temperature monitoring (HFTM) is recommended for those at moderate to high ulcer risk. Where a > 2.2°C difference in temperature between feet (hotspot) is detected, it is suggested that individuals (1) notify a healthcare professional (HCP); (2) reduce daily steps by 50%. We assess adherence to this and HFTM upon detecting a recurrent hotspot.

METHODS

PubMed and Google Scholar were searched until 9 June 2023 for English-language peer-reviewed HFTM studies which reported adherence to HFTM, daily step reduction or HCP hotspot notification. The search returned 1030 results excluding duplicates of which 28 were shortlisted and 11 included.

RESULTS

Typical adherence among HFTM study participants for >3 days per week was 61%-93% or >80% of study duration was 55.6%-83.1%. Monitoring foot temperatures >50% of the study duration was associated with decreased ulcer risk (Odds Ratio: 0.50, p < 0.001) in one study (n = 173), but no additional risk reduction was found for >80% adherence. Voluntary dropout was 5.2% (Smart mats); 8.1% (sock sensor) and 4.8%-35.8% (infrared thermometers). Only 16.9%-52.5% of participants notified an HCP upon hotspot detection. Objective evidence of adherence to 50% reduction in daily steps upon hotspot detection was limited to one study where the average step reduction was a pedometer-measured 51.2%.

CONCLUSIONS

Ulcer risk reduction through HFTM is poorly understood given only half of the participants notify HCPs of recurrent hotspots and the number of reducing daily steps is largely unknown. HFTM adherence and dropout are variable and more research is needed to determine factors affecting adherence and those likely to adhere.

Electrochemical skin conductances values and clinical factors affecting sudomotor dysfunction in patients with prediabetes, type 1 diabetes, and type 2 diabetes: A single center experience

BACKGROUND AND AIM

Sudomotor dysfunction is linked to small fibers damage. We investigated sudomotor dysfunction in a large group of participants with diabetes, prediabetes, and nondiabetic healthy subjects. This study aimed to complete knowledge on sudomotor dysfunction in this population, especially regarding the threshold values for the electrochemical skin conductance (ESC) and factors affecting it.

MATERIALS AND METHODS

A total of 690 volunteers in four groups were included in the study (type 1 [T1DG]: n = 80, 61.3% women; type 2 diabetes [T2DG]: n = 438, 63.5% women; prediabetes [Pre-DG]: n = 88, 80.7% women; healthy control [HC-G]: n = 84, 67.5% women). All subjects were investigated for clinical diabetic peripheral polyneuropathy and sudomotor dysfunction. The characteristics of participants obtained from outpatient records were evaluated. We used the Sudoscan device to measure ESC which was normalized for BMI, to improve the discriminative capability of the method.

RESULTS

Diabetic polyneuropathy was found in 17.5% of T1DG, 27.4% of T1DG, and 10.2% of Pre-DG. The mean ESC/BMI was lower in subgroups with diabetic polyneuropathy than those without. Mean ESC/BMI was lowest in T2DG and highest in HC-G but comparable in T1DG and Pre-DG. We accepted the "mean ESC/BMI-1 SD" in the HC-G as the threshold for sudomotor dysfunction. Accordingly, the prevalence of sudomotor dysfunction was 18.8%, 44.3%, 59.1%, and 15% in T1DG, T2DG, Pre-DG, and HC-G, respectively. In T2DG, sudomotor dysfunction was found in 66.7% of persons with retinopathy, of which 56.3% had clinical diabetic polyneuropathy. The prevalence of sudomotor dysfunction in subjects with peripheral artery disease, chronic kidney disease, cardiovascular disease, and hypertension was 46.7%, 47.4%, 43.4%, and 50%, respectively, and 42.9%, 38.9%, 45.5%, and 37.3% of whom in the same order detected with clinical diabetic polyneuropathy. Considering the entire group, a logistic regression model demonstrated that the variables associated with SMD were: retinopathy (OR: 2.969; 95% CI: 1.723, 5.114), female gender (OR: 1.952; 95% CI: 1.287, 2.962), and e-GFR (OR: 0.989; 95% CI: 0.981, 0.998). Since the rate of complications was very low in T1DG, excluding this group, a new model similarly revealed that retinopathy and female gender were associated with SMD, however, the association with e-GFR was disappeared.

CONCLUSION

The prevalence of sudomotor dysfunction is high when established peripheral polyneuropathy was present in diabetes. Even though, sudomotor dysfunction can also occur before clinical polyneuropathy in both types of diabetes (T1DG: 18.8%, T2DG 44.3%), prediabetes (59.1%), and nondiabetic healthy subjects (15%). The variables associated with sudomotor dysfunction were retinopathy and female sex. Normalization of ESC for BMI would be a beneficial approach. However, before this method is included in the routine screening programs for diabetic polyneuropathy, large-scale and prospective studies are required to reach a consensus on the pathological threshold values.

Falls, fear of falling, and related factors in patients with diabetic foot disease

BACKGROUND

Falls and fear of falling (FOF) are common in patients with diabetic foot disease (DFD).

PURPOSE

To understand the relationship between falls, FOF, and related factors in patients with DFD.

METHOD

We recruited 70 patients being treated for DFD at two hospitals in Korea. A structured questionnaire was used in investigating fall experience, FOF, and related factors.

RESULTS

Among the participants, 42.8 % fell in the past year, and FOF was reported in 57.1 %. Rates of "no caregiver," "DFD duration (>1 year)," and "burning pain" were higher in fallers than non-fallers. The rates of "older adults (≥65 years of age)," "unemployed," "not using assistive devices," "visual impairment," and "hearing impairment" were higher in patients with FOF than in those without FOF. However, the level of balance confidence was lower in patients with FOF.

CONCLUSIONS

The fall experience of patients with DFD was associated with the presence of their caregiver, disease-related factors, and foot pain symptoms, while FOF was related to age and fall-related factors.

The effectiveness of motivational interviewing on adherence to wearing orthopedic shoes in people with diabetes at low-to-high risk of foot ulceration: A multicenter cluster-randomized controlled trial

AIM

To evaluate the effectiveness of motivational interviewing (MI) performed by MI-trained podiatrists in improving adherence to wearing orthopedic shoes in comparison to usual care in people with diabetes at low-to-high risk of ulceration.

METHODS

People with diabetes with loss of protective sensation and/or peripheral artery disease, and with orthopedic shoes prescription were allocated to receive one MI-consultation by a podiatrist randomized to MI training (n = 53) or usual care only (n = 68). Adherence was measured as the percentage of steps taken while wearing orthopedic shoes, determined using an insole temperature microsensor and wrist-worn activity tracker during one week at 3 and 6 months.

RESULTS

The proportion of participants ≥80 % adherent to wearing their orthopedic shoes was higher in the control group than in the MI-intervention group at 3 months (30.9 % versus 15.1 %; p = 0.044), and not significantly different at 6 months (22.1 % versus 13.2 %; p = 0.210). Average adherence was also higher in the control group than the intervention group at both 3 months (60.9 % versus 50.9 %; p = 0.029) and 6 months (59.9 % versus 49.5 %; p = 0.025).

CONCLUSIONS

One podiatrist-led MI-consultation in its current form did not result in higher adherence to wearing orthopedic shoes in people with diabetes 3 and 6 months after inclusion.

TRIAL REGISTRATION

Netherlands Trial Register NL7710 (available on the International Clinical Trials Registry Platform).

Negative pressure wound therapy promotes wound healing of diabetic foot ulcers by up-regulating PRDX2 in wound margin tissue

To understand the changes in the peroxiredoxin-2 (PRDX2) expression level in the wound margin tissue (T-PRDX2) of patients with diabetic foot ulcer (DFU) before and after negative pressure wound therapy (NPWT). Additionally, the study aimed to explore the association between PRDX2 expression and the treatment outcome of DFUs to provide a new theoretical basis for revealing the mechanism of NPWT promoting the healing of DFUs. Fifty-six type 2 diabetes patients with foot ulcers undergoing NPWT (the DFU group) and 28 patients with chronic lower limb skin ulcers with normal glucose tolerance undergoing NPWT (the skin ulcer control [SUC] group) were included in the study. T-PRDX2 was detected using Western blotting, and the superoxide dismutase (SOD) activity and the malondialdehyde (MDA) and glutathione (GSH) levels were detected using a biochemical method. In addition, in vitro experiments were conducted to determine the effect of PRDX2 expression on normal human dermal fibroblast (NHDF) proliferation, migration, and apoptosis. Before NPWT, the DFU group exhibited a significantly lower T-PRDX2 expression level compared with the SUC group. After one week of NPWT, the T-PRDX2 expression level, SOD activity, and GSH content in the wound margin tissues of the DFU and SUC groups significantly increased compared with the before NPWT levels. Conversely, the inflammatory indicators (white blood cell, neutrophil percentage, C-reactive protein, and procalcitonin) and MDA content were significantly lower than the before NPWT levels. The expression changes of T-PRDX2 before and after NPWT in the DFU and SUC groups were positively correlated with the 4-week wound healing rate. In vitro experiments demonstrated that PRDX2 could alleviate the oxidative stress in NHDFs, thereby promoting their proliferation and migration, while reducing cell apoptosis. NPWT promotes DFU healing by increasing T-PRDX2, and changes in the T-PRDX2 might be associated with the therapeutic effect of NPWT.

Multicomponent prediction of 2-year mortality and amputation in patients with diabetic foot using a random survival forest model: Uric acid, alanine transaminase, urine protein and platelet as important predictors

The current methods for the prediction of mortality and amputation for inpatients with diabetic foot (DF) use only conventional, simple variables, which limits their performance. Here, we used a random survival forest (RSF) model and multicomponent variables to improve the prediction of mortality and amputation for these patients. We performed a retrospective cohort study of 175 inpatients with DF who were recruited between 2014 and 2021. Thirty-one predictors in six categories were considered as potential covariates. Seventy percent (n = 122) of the participants were randomly selected to constitute a training set, and 30% (n = 53) were assigned to a testing set. The RSF model was used to screen appropriate variables for their value as predictors of 2-year all-cause mortality and amputation, and a multicomponent prediction model was established. Model performance was evaluated using the area under the curve (AUC) and the Hosmer-Lemeshow test. The AUCs were compared using the Delong test. Seventeen variables were selected to predict mortality and 23 were selected to predict amputation. Uric acid and alanine transaminase were the top two most useful variables for the prediction of mortality, whereas urine protein and platelet were the top variables for the prediction of amputation. The AUCs were 0.913 and 0.851 for the prediction of mortality for the training and testing sets, respectively; and the equivalent AUCs were 0.963 and 0.893 for the prediction of amputation. There were no significant differences between the AUCs for the training and testing sets for both the mortality and amputation models. These models showed a good degree of fit. Thus, the RSF model can predict mortality and amputation in inpatients with DF. This multicomponent prediction model could help clinicians consider predictors of different dimensions to effectively prevent DF from clinical outcomes .

The capacity of exosomes derived from adipose-derived stem cells to enhance wound healing in diabetes

The slow healing and nonhealing of diabetic wounds have long posed challenges for clinical practitioners. In the presence of elevated glucose levels, the body's regulatory mechanisms undergo alterations that impede normal wound healing processes, including cell proliferation, cytokine release, and growth factor activity. Consequently, the advancement of stem cell technology has sparked growing interest in utilizing stem cells and their derivatives as potential therapeutic agents to enhance diabetic wound healing. This paper aims to provide an academic review of the therapeutic effects of adipose-derived stem cell-EXOs (ADSC-EXOs) in diabetic wound healing. As a cell-free therapy, exosomes (EXOs) possess a multitude of proteins and growth factors that have been shown to be advantageous in promoting wound healing and mitigating the potential risks associated with stem cell therapy. By examining the current knowledge on ADSC-EXOs, this review seeks to offer insights and guidance for the potential application of EXOs in the treatment of diabetic wounds.

Accelerated wound healing induced by spinach extract in experimental model diabetic rats with streptozotocin

Patients with diabetes often have difficult-to-heal wounds. Spinacia oleracea extract comprises anti-inflammatory and anti-oxidative compounds; this research, therefore, studied the impact of Spinacia oleracea extracts on ulcer regeneration. This study was conducted on 72 adult Wistar rats (200 [Formula: see text] 20 g). They were randomly divided into six groups of twelve. A: Diabetic group receiving normal saline. B: Non-diabetic group receiving normal saline. C: Diabetic group receiving spinach aqueous extract. D: Diabetic group receiving spinach alcoholic extract. E: preventive group that received aqueous extract for 2 months. F: preventive group that received alcoholic extract for 2 months. Ulcer regeneration, vascular endothelium growth factor, blood sugar, and weight changes were measured on days 3, 7, 14, 21, and 30. Macroscopic investigation of the wounds non-diabetic control group, diabetic group, as well as spinach aqueous and alcoholic extract groups, were compared and there were significant changes (P < 0.05). Pathologic examination in the spinach aqueous and alcoholic extract groups, and nondiabetic group than in the diabetic group revealed significant advances (P <  0.05). On the third and seventh days, Vascular endothelium growth factor detected significant differences between groups (P < 0.05). Results indicate that, in regenerating diabetic ulcers, Spinacia oleracea may be effective. It influences the ulcer structure and speed.

MicroRNA-221-3p Targets THBS1 to Promote Wound Healing in Diabetes

Introduction

Diabetes foot ulcer (DFU) is a serious complication of diabetes characterized with chronic foot ulceration, poor wound healing (WH), and persistent inflammation. MiR-221-3p, as microRNA, has been shown to accelerate WH in previous study, but the underlying mechanisms are poorly understood.

Methods

In this study, we aimed to determine how miR-221-3p influences WH by targeting THBS1. The effect of miRNA-221-3p on wound healing of diabetes by epidermal injection of miRNA-221-3p agomir. In vitro generated human immortalized keratinocytes (HaCaT cells) were transfected with miR-mimics and negative control with high glucose treatment. The effects of miRNA-221-3p on cell apoptosis and angiogenesis using cell apoptosis assay and the tube formation assay, respectively. Direct target interaction of miR-221-3p and predicted target sites in 3'UTR of THBS1 were examined by luciferase reporter gene assay. Breeding miRNA-221 knockout mice for experimental verification.

Results

We found that miRNA-221-3p overexpression at the wound edge of normal mice and diabetes mice can promote WH. As contrast, WH of miR-221 knockout mice delayed with increased epithelial apoptosis and reduced angiogenesis in the dermis. miR-221-3p was found to inhibit apoptosis in HaCaT cells, and enhanced angiogenesis in human umbilical vein endothelial cells (HUVECs) that were co-cultured. Bioinformatics analysis as well as the dual-luciferase reporter assay revealed miR-221-3p to target 3' untranslated region of THBS1.

Conclusion

Our findings suggested miR-221-3p might exert an essential impact on diabetes WH via inhibition of THBS1 and lack of miR-221-3p possibly results in impaired healing in chronic wounds of type 2 diabetes. Therefore, developing medicine such as chemically modified analogs of miR-221-3p in future could benefit patients with DFU.

Bacterial profile and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa: a systematic review and meta-analysis

The number of diabetic foot ulcer patients is substantially increasing, with the rapidly rising burden of diabetic mellitus in sub-Saharan Africa. The data on the regional prevalence of diabetic foot ulcer infecting bacteria and their antimicrobial resistance patterns is crucial for its proper management. This systematic review and meta-analysis determined the pooled prevalence of bacterial profiles and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa. A comprehensive search of the literature was performed on CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Critical appraisal was done using the Joanna Briggs Institute's tool for prevalence studies. A pooled statistical meta-analysis was conducted using STATA Version 17.0. The I2 statistics and Egger's test were used to assess the heterogeneity and publication bias. The pooled prevalence and the corresponding 95% confidence interval of bacterial profiles and their antimicrobial resistance patterns were estimated using a random effect model. Eleven studies with a total of 1174 study participants and 1701 bacteria isolates were included. The pooled prevalence of the most common bacterial isolates obtained from DFU were S. aureus (34.34%), E. coli (21.16%), and P. aeruginosa (20.98%). The highest pooled resistance pattern of S. aureus was towards Gentamicin (57.96%) and Ciprofloxacin (52.45%). E.coli and K. Pneumoniae showed more than a 50% resistance rate for the most common antibiotics tested. Both gram-positive and gram-negative bacteria were associated with diabetic foot ulcers in sub-Saharan Africa. Our findings are important for planning treatment with the appropriate antibiotics in the region. The high antimicrobial resistance prevalence rate indicates the need for context-specific effective strategies aimed at infection prevention and evidence-based alternative therapies.

Chronic Wound Management: From Gauze to Homologous Cellular Matrix

BACKGROUND

Chronic wounds are a significant health problem with devastating consequences for patients' physical, social, and mental health, increasing healthcare systems' costs. Their prolonged healing times, economic burden, diminished quality of life, increased infection risk, and impact on patients' mobility and functionality make them a major concern for healthcare professionals.

PURPOSE

This review offers a multi-perspective analysis of the medical literature focusing on chronic wound management.

METHODS USED

We evaluated 48 articles from the last 21 years registered in the MEDLINE and Global Health databases. The articles included in our study had a minimum of 20 citations, patients > 18 years old, and focused on chronic, complex, and hard-to-heal wounds. Extracted data were summarized into a narrative synthesis using the same health-related quality of life instrument.

RESULTS

We evaluated the efficacy of existing wound care therapies from classical methods to modern concepts, and wound care products to regenerative medicine that uses a patient's pluripotent stem cells and growth factors. Regenerative medicine and stem cell therapies, biologic dressings and scaffolds, negative pressure wound therapy (NPWT), electrical stimulation, topical growth factors and cytokines, hyperbaric oxygen therapy (HBOT), advanced wound dressings, artificial intelligence (AI), and digital wound management are all part of the new arsenal of wound healing.

CONCLUSION

Periodic medical evaluation and proper use of modern wound care therapies, including the use of plasma-derived products [such as platelet-rich plasma (PRP) and platelet-rich fibrin (PRF)] combined with proper systemic support (adequate protein levels, blood sugar, vitamins involved in tissue regeneration, etc.) are the key to a faster wound healing, and, with the help of AI, can reach the fastest healing rate possible.

Determinants of healing of diabetic foot ulcer comparing two offloading modalities: A randomized prospective study

INTRODUCTION

Healing of Diabetic Foot ulcer is crucial to prevent amputation. Offloading is key treatment of diabetic foot ulcers, but choosing which offloading modality is still not clear. Besides, other factors that control ulcer healing, is a question that needs to be determined.

OBJECTIVE

to assess factors that affect ulcer healing, comparing two commonly used offloading devices, removable walker and cast-shoe.

METHODS

This is a Randomized Clinical Trial which recruited 87 patients with active diabetic foot ulcers randomly assigned to either a removable walker (W-arm) or a cast-shoe (C-arm) at 3:2 ratio. Both groups received the routine ulcer care, and were followed-up for 24 weeks. Different possible factors related to healing were assessed, and a regression model was built for the most predictive factors.

RESULTS

The 24-week healing rate was 81% for the walker group and 62 % for the cast-shoe group. The mean adherence was 55 % ± 26 % and 46 % ± 29 for the walker and cast shoe groups respectively. Ulcer healing was significantly positively associated with: better adherence, device type (walker), less SINBAD score (2 or less), absence of ischemia, absence of infection, smaller ulcer area, superficial ulcer, better 4-week area reduction, and better blood glucose control. The most important predictors were adherence, total SINBAD score and 4-week area reduction.

CONCLUSION

SINBAD score at initial presentation and the degree of adherence to offloading device, are two major determinants of ulcer healing. Ulcer area reduction at 4 weeks represents an important clinical parameter to predict and guide the success of ulcer management.

Cutaneous changes in diabetic patients: Primed for aberrant healing?

Cutaneous manifestations affect most patients with diabetes mellitus, clinically presenting with numerous dermatologic diseases from xerosis to diabetic foot ulcers (DFUs). Skin conditions not only impose a significantly impaired quality of life on individuals with diabetes but also predispose patients to further complications. Knowledge of cutaneous biology and the wound healing process under diabetic conditions is largely limited to animal models, and studies focusing on biology of the human condition of DFUs remain limited. In this review, we discuss the critical molecular, cellular, and structural changes to the skin in the hyperglycaemic and insulin-resistant environment of diabetes with a focus specifically on human-derived data. Elucidating the breadth of the cutaneous manifestations coupled with effective diabetes management is important for improving patient quality of life and averting future complications including wound healing disorders.

Efficacy and safety of unilateral tibial cortex transverse transport on bilateral diabetic foot ulcers: A propensity score matching study

Background

Tibial Cortex Transverse Transport (TTT) has been demonstrated to be an effective treatment for unilateral diabetic foot ulcers (UDFUs). However, this retrospective study was designed to compare the efficacy and safety of unilateral TTT on bilateral diabetic foot ulcers (BDFUs).

Methods

This retrospective study included a review of patients with TTT treated from January 2017 to August 2019, Propensity Score Matching (PSM) was performed to compare patients with BDFUs to those with UDFUs. Ulcer healing, recurrence, and major amputation rates were evaluated at 1-year follow-up. Changes in foot vessels were assessed in the BDFUs group using computed tomography angiography (CTA).

Results

A total of 140 patients with DFUs (106 UDFUs and 34 BDFUs) were included in the study. UDFUs and BDFUs were matched in a 1:1 ratio (34 in each group) using PSM. No significant difference was observed at 1-year-follow-up [91.2% (31/34) vs. 76.5% (26/34), OR 0.315 (95% CI 0.08 to 1.31), P ​= ​0.10] and 6-month-follow-up [70.6% (24/34) vs. 50.0% (17/34), OR 0.85 (95% CI 0.15 to 1.13), P ​= ​0.08] in two groups. Significant differences in rates of major amputation and recurrence between the groups (P ​> ​0.05) were not observed. The BDFUs group appeared more angiogenesis of the foot by CTA after 8 weeks of operation.

Conclusion

Results of this study suggest that severe BDFUs can be effectively treated by unilateral TTT. TTT is easy to operate and effective, which may be a good alternative for treating severe BDFUs.

The translational potential of this article

In previous retrospective clinical studies, TTT has demonstrated promising clinical outcomes in the management of diabetic foot ulcers. In this current study, we aim to investigate the potential use of TTT in treating distant tissue defects by evaluating the limited availability and safety of TTT for the management of bilateral diabetic foot. While additional basic and clinical research is necessary to fully elucidate the underlying mechanisms, our study offers insight into the potential therapeutic use of TTT for this condition.

Recent advances in strategies to target the behavior of macrophages in wound healing

Chronic wounds and scar formation are widespread due to limited suitable remedies. The macrophage is a crucial regulator in wound healing, controlling the onset and termination of inflammation and regulating other processes related to wound healing. The current breakthroughs in developing new medications and drug delivery methods have enabled the accurate targeting of macrophages in oncology and rheumatic disease therapies through clinical trials. These successes have cleared the way to utilize drugs targeting macrophages in various disorders. This review thus summarizes macrophage involvement in normal and pathologic wound healing. It further details the targets available for macrophage intervention and therapeutic strategies for targeting the behavior of macrophages in tissue repair and regeneration.

Hyaluronic acid/alginate-based biomimetic hydrogel membranes for accelerated diabetic wound repair

The study aims to develop a new multifunctional biopolymer-based hydrogel membrane dressing by adopting a solvent casting method for the controlled release of cefotaxime sodium at the wound site. Sodium alginate enhances collagen production in the skin, which provides tensile strength to healing tissue. Moreover, the significance of extracellular molecules such as hyaluronic acid in the wound the healing cascade renders these biopolymers an essential ingredient for the fabrication of hydrogel membranes via physical crosslinking (hydrogen bonding). These membranes were further investigated in terms of their structure, and surface morphology, as well as cell viability analysis. A membrane with the most suitable characteristics was chosen as a candidate for cefotaxime sodium loading and in vivo analysis. Results show that the 3D porous nature of developed membranes allows optimum water vapor and oxygen transmission (>8.21 mg/mL) to divert excessive wound exudate away from the diabetic wound bed, MTT assay confirmed cell viability at more than 80%. In vivo results confirmed that the CTX-HA-Alg-PVA hydrogel group showed rapid wound healing with accelerated re-epithelization and a decreased inflammatory response. Conclusively, these findings indicate that CTX-HA-Alg-PVA hydrogel membranes exhibit a suitable niche for use as dressing membranes for healing of diabetic wounds.

Pilot Study on the Relationship between Malnutrition and Grip Strength with Prognosis in Diabetic Foot

Sarcopenia and malnutrition have been associated in the elderly population with a poor prognosis in wound healing and with other adverse events, such as institutionalization or functional impairment. However, it is not known how these factors influence the prognosis of diabetic foot in the elderly. To answer this question, a prospective observational study of 45 patients over 65 years of age admitted with diagnoses of diabetic foot in a tertiary hospital has been conducted. All patients were assessed at admission and at 3 months after returning home to determine quality of life, pain, mobility and healing, overall hospital stay in relation to the presence of malnutrition (measured by BMI, CIPA scale and analytical parameters at admission of serum proteins and albumin), and sarcopenia measured by grip force, among other geriatric syndromes. The results found a relationship between altered sarcopenia and more pain and poorer quality of life, and altered BMI was related to a lower cure rate and worse mobility at follow-up. This study seems to indicate that, in the elderly population with diabetic foot, malnutrition and sarcopenia should be managed at the same time as the treatment of the diabetic foot itself.

The Use of Medical Grade Honey on Infected Chronic Diabetic Foot Ulcers-A Prospective Case-Control Study

Non-healing wounds are usually colonised and contaminated by different types of bacteria. An alternative to antibiotic treatment in patients with infected wounds with local signs of inflammation may be medical grade honey (MGH). MGH has antioxidant, antimicrobial, anti-inflammatory, and immunomodulatory features. This study aims to evaluate the effect of MGH therapy on infected non-healing wounds, especially for diabetic foot syndrome. Prospective, observational case series (n = 5) of patients with wounds of diabetic foot syndrome are presented. There were five males with an average age of 61.6 years. All wounds were treated with MGH, and the healing trajectory was rigorously and objectively monitored. In all cases, there was a gradual disappearance of odour, pain, and exudation. Moreover, the wound areas significantly reduced within 40 days and there was a decrease in glycated haemoglobin and glycaemia values. All these outcomes resulted in improved quality of life of the patients. Despite bacterial colonisation, antibiotic treatment was not necessary. All wounds were completely healed. MGH has antimicrobial, anti-inflammatory, and antioxidant effects in diabetic foot syndrome wounds, does not increase glycated haemoglobin or glycaemia levels, and thus constitutes an effective alternative to the use of antibiotics in the treatment of locally infected wounds.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: a national multicenter study

BACKGROUND AND PURPOSE

The lack of timely foot care among individuals with diabetics often lead to ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening practices among patients with type 2 diabetes in various cities across Iran.

METHODS

The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, and diabetic foot self-care (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow's 60-Second Screen.

RESULTS

The study included 1094 diabetic patients with, with a majority being female (64.8%) and married (92.5%). The average age of the participants was 57.6 ± 10.21 (mean ± SD), and the mean duration of diabetes was 11.56 ± 7.41 years. Based on Inlow's 60-Second Screen criteria, 58% of the patients should undergo yearly foot ulcer screening, 47% exhibited peripheral neuropathy, and 37% were found to have inappropriate footwear.

CONCLUSION

The high prevalence of peripheral neuropathy observed in approximately half of the participants across different regions of Iran underscores the importance of continuous patient education regarding foot care and appropriate footwear. Furthermore, regular foot ulcer screenings, following the recommended intervals outlined in Inlow's screening protocol, should be implemented to effectively manage diabetic foot complications.

Role of Increased miR-222-3p Expression in Peripheral Blood and Wound Marginal Tissues of Type 2 Diabetes Mellitus Patients with Diabetic Foot Ulcer

Purpose

To study the correlations of miR-222-3p expression in the peripheral blood and wound marginal tissues of type 2 diabetes mellitus (T2DM) patients with the onset of diabetic foot ulcer (DFU), as well as explore the clinical value possessed by miR-222-3p in the diagnosis and treatment outcomes of DFU.

Methods

The study included 70 T2DM patients who did not suffer foot ulcers (T2DM group), 146 T2DM patients who suffered foot ulcers (DFU group), as well as 70 normal controls (NC group). Quantitative real-time PCR determined the MiR-222-3p relative expression. Clinical features and risk factors regarding DFU were assessed. Multiple stepwise logistic regression analysis assisted in confirming whether miR-222-3p expression could serve for independently predicting the risk factors for DFU. ROC curve analysis evaluated the diagnostic value exhibited by miR-222-3p level against DFU.

Results

T2DM group exhibited an obviously higher MiR-222-3p expression relative to NC group [1.98 (0.98, 3.62) vs 0.92 (0.61, 1.87)] (P < 0.01), but DFU group exhibited an obviously higher miR-222-3p expression relative to T2DM group [5.61 (1.98, 10.24) vs 1.98 (0.98, 3.62)] (P < 0.01). Besides, miR-222-3p expression presented a negative correlation with DFU healing rate (P < 0.05). According to Kaplan-Meier survival curve analysis, the group with high miR-222-3p expression showed higher unhealed DFU cumulative rate relative to the group with low expression (log-rank, P = 0.011, 0.001, respectively). Multivariate logistic regression analysis confirmed that high miR-222-3p expressions could independently predict DFU risk (OR=3.85, 95% CI 1.18~12.37, P = 0.008). According to the ROC curve analysis, the AUC of miR-222-3p specific to DFU diagnosis reached 0.803, with the best sensitivity of 95.93% and best specificity of 96.27%.

Conclusion

The increased expression of miR-222-3p in the peripheral blood of T2DM patients is closely related to the occurrence of DFU. MiR-222-3p is a biomarker with potential clinical value in diagnosing and evaluating the prognosis of DFU.

Mussel-inspired self-healing hydrogel form pectin and cellulose for hemostasis and diabetic wound repairing

Diabetic wound is considered as a kind of chronic wound prone to infection and difficult to repair due to high glucose level in the blood of patients. In this research, a biodegradable self-healing hydrogel with mussel inspired bioadhesion and anti-oxidation properties is fabricated based on Schiff-base cross-linking. The hydrogel was designed from dopamine coupled pectin hydrazide (Pec-DH) and oxidized carboxymethyl cellulose (DCMC) for mEGF loading as a diabetic wound repair dressing. The Pectin and CMC as natural feedstock endowed the hydrogel with biodegradability to avoid possible side effects, while the coupled catechol structure could enhance the tissue adhesion of the hydrogel for hemostasis. The results showed the Pec-DH/DCMC hydrogel formed fast and can cover irregular wounds with good sealing effect. The catechol structure also improved the reactive oxygen species (ROS) scavenging ability of the hydrogel, which can eliminate the negative effect of ROS during wound healing. The in vivo diabetic wound healing experiment revealed the hydrogel as mEGF loading vehicle greatly enhanced the diabetic wound repairing rate in mice model. As a result, the Pec-DH/DCMC hydrogel could show advantages as EGF carrier in wound healing applications.

Exploring the relationship between self-management behaviour, family function and health information adoption behaviour in Chinese diabetic foot patients: a mixed-methods study protocol

INTRODUCTION

Diabetic foot is a major burden and threat to individuals, families and society, making it imperative to promote good self-management behaviour. However, although nurses have provided these patients with excellent health knowledge, their self-management remains unsatisfactory. Although researches have shown that self-management requires family involvement, no research has been conducted in China on family function, specifically in the diabetic foot. Therefore, this study aimed to explore the relationship between self-management, family functioning, and health information adoption behaviour and explain the formation's reason.

METHOD AND ANALYSIS

We will conduct a mixed-methods study using an exploratory sequential study design in Zhejiang, China. In the first phase, cross-section research will be conducted using a convenient sampling strategy on 225 diabetic foot patients. SPSS V.26 was used for correlation and multiple stepwise regression analyses. Structural equation modelling will be performed by using AMOS V.24. The researchers will conduct a semistructured interview to collect qualitative data and use NVivo to analyse. Ultimately, we will 'triangulate' to integrate quantitative and qualitative data.

ETHICS AND DISSEMINATION

This study received ethical clearance from the Ethics Review Committee, the affiliated Sir Run Run Shaw Hospital of Medicine School, Zhejiang University (approval no: 2023-0145). All data collection processes will abide by health and safety measures required by the national government. Written informed consent will be obtained from all participants. The study will produce one paper that will be disseminated, to local stakeholders and participants, via local and international conferences and publications in peer-reviewed journals.

Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis

OBJECTIVES

The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis.

METHODS

Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians.

RESULTS

A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%.

CONCLUSION

DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis.

KEY POINTS

• Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

Lower Extremity Amputation Rates in People With Diabetes Mellitus: A Retrospective Population Based Cohort Study in Zwolle Region, The Netherlands

OBJECTIVE

Lower extremity amputations are a major complication of diabetes mellitus (DM). In a previous Dutch study, the incident rate of major amputations was 89.2 per 100 000 person years. The primary aim of this study was to describe the lower extremity amputation rates in people with DM in the Zwolle region, where preventive and curative footcare is organised according to the guidelines of the International Working Group of the Diabetic Foot (IWGDF). The secondary aim was to evaluate outcomes and underlying characteristics of these people.

METHODS

This was a retrospective regional population based cohort study. Data from all people with DM treated in primary and secondary care, living in the region Zwolle were collected. All amputations in the period 2017 to 2019 were analysed. Comparisons were made between those with and without an amputation.

RESULTS

In the analysis 5 915 people with DM were included, with a mean age of 67.8 (IQR 57.9, 75.9) years. Of those people, 47% were women and the median HbA1c was 53 (IQR 47, 62) mmol/mol. Over the three year study period 68 amputations were performed in 59 people: 46 minor, 22 major. This translated into an average annual crude amputation incidence rate of non-traumatic major and minor amputations of 41.5 and 86.9 per 100 000 person years among people with diabetes. Compared with those not undergoing amputations, those who underwent an amputation were more often men, older, mainly had T2DM, were treated in secondary care, had higher diastolic blood pressure, worse diabetic footcare profile, longer DM duration and higher HbA1c. At the end of the follow up, 111 people died: 96 (1.6%) without and 15 (25.4%) with amputations (p < .001).

CONCLUSIONS

This retrospective study provides detailed insight into the rate of amputations in Dutch people with diabetes in the region Zwolle. Compared with previous Dutch estimates, these data suggest a considerable decrease in the major amputation incidence rate.