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Belik BM, Chumburidze IP, Shtilman MY, Yavruyan OA, Savchenko YP. [Complex treatment of patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome]. Khirurgiia (Mosk) 2020:81-87. [PMID: 32352675 DOI: 10.17116/hirurgia202004181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Of study is improving the results of treatment of patients with pyo-necrotic complications of diabetic foot syndrome by including the method of negative pressure wound treatment in the complex treatment program in combination with using of the combined antibacterial drug Cifran ST and immunocorrective therapy. MATERIAL AND METHODS The results of examination and treatment of 184 patients with pyo-necrotic complications of the neuropathic form of diabetic foot syndrome were analyzed. According to choice of treatment methods in the postoperative period all patients were divided into two groups. In 95 patients (group I), iodine-containing ointments based on polyethylene glycol were used for local treatment of purulent foot wounds and standard systemic antibacterial therapy was performed. In 89 patients (group II), negative pressure wound treatment (NPWT) was used to treat wounds in the postoperative period. In addition to standard parenteral antimicrobial therapy, these patients also received an oral combined antibacterial drug Cifran ST and immunocorrective cytokine therapy (Leukinferon). The analysis of the dynamics of the wound process was carried out based on the clinical picture and the results of cytological, bacteriological and immunological studies of the wound exudate. RESULTS The presented strategy of complex treatment of pyo-necrotic complications of the neuropathic form of diabetic foot syndrome allowed group II patients to significantly reduce the degree of microbial contamination of wounds, to achieve a faster regression of the content of proinflammatory and inflammatory cytokines in the wound exudate, as well as to reduce the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage in comparison with group I patients. This allowed group II patients to reduce the time of plastic closure of the wound from 24.3±0.5 to 15.6±1.7 days, to avoid generalization of infection, death and high level amputation of the limb. At the same time, 11.6% of patients in group I had high level limb amputation due to generalization of infection. The mortality rate in group I was 5.3%. CONCLUSIONS Adding of vacuum therapy of wounds, systemic antimicrobial therapy using the combined antibacterial drug Cifran ST and immunocorrective cytokine therapy in the complex treatment program for patients with neuropathic form of diabetic foot syndrome after radical surgical treatment of the pyo-necrotic lesion allows reducing the time of wound cleansing and the transition of the pyo-necrotic process to the reparative stage. On the other hand, this makes it possible for this category of patients to perform plastic closure of the wound at an earlier date, avoid generalization of infection and high level amputation of the limb.
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Affiliation(s)
- B M Belik
- Rostov State Medical University of the Ministry of Health of Russia, Department of General Surgery, Rostov-on-Don, Russia
| | - I P Chumburidze
- Rostov State Medical University of the Ministry of Health of Russia, Department of Surgical Diseases No. 3, Rostov-on-Don, Russia
| | - M Yu Shtilman
- Rostov State Medical University of the Ministry of Health of Russia, Department of Surgical Diseases No. 3, Rostov-on-Don, Russia
| | - O A Yavruyan
- Rostov State Medical University of the Ministry of Health of Russia, Department of Surgical Diseases No. 3, Rostov-on-Don, Russia
| | - Yu P Savchenko
- Kuban State Medical University of the Ministry of Health of Russia, Department of General Surgery, Krasnodar, Russia
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152
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Allison GM, Flanagin E. How ESKD complicates the management of diabetic foot ulcers: The vital role of the dialysis team in prevention, early detection, and support of multidisciplinary treatment to reduce lower extremity amputations. Semin Dial 2020; 33:245-253. [PMID: 32277523 DOI: 10.1111/sdi.12875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Diabetic foot ulcers do not heal as well in ESKD as in the absence of kidney failure, and rates of recurrent foot ulcers, as well as lower extremity amputation, are higher. This review of the literature highlights the vital role of the dialysis team in prevention, early detection, and support of treatment of diabetic foot ulcers. Our review has five goals-(a) increase nephrologists' understanding of the high morbidity and mortality associated with chronic foot ulcers and (lower extrimity) LE amputations in ESKD; (b) promote nephrologists' understanding of grading systems for diabetic foot ulcer severity, in order to expedite communication with local diabetic foot experts; (c) promote collaboration between nephrologists and infectious disease specialists regarding the dose, route, and delivery logistics of intravenous antibiotics for infected chronic foot ulcers, in particular in the presence of osteomyelitis and other deep-seated infections; (d) increase the awareness of dialysis nurses, technicians, dietitians, social workers and administrators regarding evidence-based and multidisciplinary approaches to patients' diabetic foot ulcers; (e) encourage the application of published works integrating patient-centered diabetic foot education into the dialysis setting to reduce lower extremity amputations.
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Affiliation(s)
- Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA, USA.,Center for Wound Healing and Hyperbaric Medicine, Tufts Medical Center, Boston, MA, USA
| | - Erin Flanagin
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
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153
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Rastogi A, Goyal G, Kesavan R, Bal A, Kumar H, Kamath P, Jude EB, Armstrong DG, Bhansali A. Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study. Diabetes Res Clin Pract 2020; 162:108113. [PMID: 32165163 DOI: 10.1016/j.diabres.2020.108113] [Citation(s) in RCA: 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: 01/19/2020] [Revised: 02/20/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
AIMS This long-term prospective study evaluated limb amputation and mortality after the first neuropathic diabetic foot ulcer (DFU). METHODS A total of 2880 patients with neuropathic DFU (DFU group) and a similar number of patients of diabetes without DFU (nDFU) matched for age and diabetes duration were prospectively assessed at five referral-centers over 14 years. Pre-defined outcome was death during follow-up. Various diabetic co-morbidities and amputation were assessed as mortality predictors. RESULTS Overall, 501 (17.4%) patients in DFU group died compared to 89 (3.1%) (p < 0.01) in nDFU group during a median follow-up of 7(1-14) years. The 5- and 10-year mortality was 22% and 71% in the DFU group with a median survival of 7.72 (7.37-8.08) years compared to 3% (p < 0.01) and 5% (p < 0.01) and survival of 12.6 (10.5-12.7) years (p < 0.001) in nDFU group. 29.3% patients had limb amputations. The mortality risk was independent of glycemic control [OR 1.03 (0.80-1.32; p = 0.83)]. However, diabetes duration > 10 years [OR 1.31(1.02-1.70, p = 0.035)], nephropathy [OR 1.47 (1.04-2.09, p < 0.030)], minor 1.85 (1.40-2.44; p < 0.001) or major amputation 2.96 (2.01-4.34, p < 0.001)] predicted mortality. CONCLUSIONS Every one-in-three individual with neuropathic DFU has amputation and every sixth individual has an early demise. Prevalent nephropathy and incident amputation following DFU predicts mortality.
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Affiliation(s)
- Ashu Rastogi
- Deptt. of Endocrinology, PGIMER, Chandigarh, India.
| | - Ghanshyam Goyal
- ILS Hospital, Salt Lake, Kolkata, India; SVS Marwari Hospital, Amhesrst Street, Kolkata, India
| | | | - Arun Bal
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Harish Kumar
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priyatham Kamath
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Edward B Jude
- Tameside Hospital, NHS Foundation and Trust, Ashton under Lyne, Manchester, UK
| | - David G Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, USA
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154
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Zhang Y, Shen X, He L, Zhao F, Yan S. Association of sarcopenia and muscle mass with both peripheral neuropathy and nerve function in patients with type 2 diabetes. Diabetes Res Clin Pract 2020; 162:108096. [PMID: 32109517 DOI: 10.1016/j.diabres.2020.108096] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/14/2020] [Accepted: 02/24/2020] [Indexed: 01/06/2023]
Abstract
AIM This study aimed to investigate the association of sarcopenia and muscle mass with both peripheral neuropathy and nerve function in type 2 diabetes mellitus. METHODS A total of 1794 patients (937 men and 857 women) with type 2 diabetes, with a mean age of 60.22 years, were enrolled for a cross-sectional study; of these, 183 patients were enrolled for a follow-up study with a median follow-up of 2.7 years. All participants underwent nerve conduction studies and muscle mass index (ASM/HT2) measurements. The composite Z scores for the sensory nerve conduction velocity (SCV) and the motor nerve conduction velocity (MCV) were calculated. The changes in ASM/HT2, SCV, and MCV were calculated from the measurements nearly 2 years apart and classified into three groups: a decrease in ASM/HT2 of >3%, a minor change within ±3%, and an increase in ASM/HT2 of >3%. RESULTS The ASM/HT2 of men was positively associated with the composite Z scores of MCV and SCV, and sarcopenia highly correlated with DPN after adjusting for confounding factors. The optimal cutoff point for ASM/HT2 that indicated DPN was 7.09 kg/m2. Furthermore, increases in ASM/HT2 independently predicted a greater benefit of MCV and SCV increment outcomes, whereas a minor change in ASM/HT2 only significantly associated with lower benefit in terms of SCV increment. However, this phenomenon was not observed in women. CONCLUSIONS Sarcopenia and DPN exhibited a close association. The increased muscle mass improved the partial MCVs and SCVs. However, a sex-related discrepancy was observed in this phenomenon.
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Affiliation(s)
- Yongze Zhang
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Ximei Shen
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Lanlan He
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Graduate Student of Department of Endocrinology, The First Affiliated Hospital of Fujian Medical University, Diabetes Research Institute of Fujian Province, Fuzhou 350005, Fujian, China
| | - Fengying Zhao
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China
| | - Sunjie Yan
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China; Diabetes Research Institute of Fujian Province, 20 Cha Zhong Road, Fuzhou, Fujian 350005, China.
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155
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Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res 2020; 13:16. [PMID: 32209136 PMCID: PMC7092527 DOI: 10.1186/s13047-020-00383-2] [Citation(s) in RCA: 363] [Impact Index Per Article: 90.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/17/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation. METHODS We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute. RESULTS Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable. CONCLUSION Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.
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Affiliation(s)
- David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA.
| | - Mark A Swerdlow
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Alexandria A Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Michael S Conte
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - William V Padula
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Sicco A Bus
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
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156
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He R, Li Q, Shen W, Wang T, Lu H, Lu J, Lu F, Luo M, Zhang J, Gao H, Wang D, Xing W, Jia W, Liu F. The efficacy and safety of cold atmospheric plasma as a novel therapy for diabetic wound in vitro and in vivo. Int Wound J 2020; 17:851-863. [PMID: 32168435 DOI: 10.1111/iwj.13341] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/21/2020] [Accepted: 03/04/2020] [Indexed: 12/30/2022] Open
Abstract
Cold atmospheric plasma (CAP) is a group of various chemical active species, such as ozone and nitric oxide, generated by working gas. CAP was demonstrated to have an effect on tissue regeneration and wound healing. We conducted this study to evaluate the efficacy and safety of CAP as a novel therapy for diabetic wounds in vitro and in vivo. The plasma consists of ionised helium gas that is produced by a high-voltage and high-frequency power supply. Eight-week-old male db/db mice and C57BL mice were treated with helium gas (control group), 90s' CAP (low-dose group), and 180s' CAP (high-dose group). Mice were treated and observed for 2 weeks. Skin samples from around the wound and blood samples were collected. Our in vitro analysis included scratch wound-healing assays by using human HaCaT immortalised human epidermal cells. After 14 days of treatment, CAP could obviously promote diabetic wound healing. Wound closure rates were significantly higher in the low-dose group and high-dose groups compared with the control group. Meanwhile, compared with the control group, the protein expression of IL-6, tumour necrosis factor-α, inducible nitric oxide synthase, and superoxide dismutase in two CAP groups significantly decreased, while the protein expression of vascular endothelial growth factor and transforming growth factor-β in two CAP groups significantly increased (all P < .05); these data show good agreement with the change in mRNA level (all P < .05). In vitro, scratch wound-healing assays showed that plasma treatment could effectively ensure healing within 3 minutes of exposure (all P < .05). In addition, no difference was found in histological observations of normal skin and the level of serum alanine transaminase, aspartate aminotransferase, blood urea nitrogen, creatinine, and white blood cells among the CAP groups and control group. CAP treatment for 3 minutes every day improves wound healing in diabetic mice by suppressing inflammation, reducing oxidative stress, and enhancing angiogenesis, involving several proteins signalling, and it is safe for the liver and kidney.
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Affiliation(s)
- Rui He
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qin Li
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Wenqi Shen
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tao Wang
- Department of Vascular Surgery, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Huijuan Lu
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junxi Lu
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fendi Lu
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ming Luo
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Jiankang Zhang
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Haiwei Gao
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Dong Wang
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Wanli Xing
- Capital Bio Corporation, National Engineering Research Center for Beijing Biochip Technology, Beijing, China
| | - Weiping Jia
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fang Liu
- Shanghai Key Laboratory of Diabetes, Shanghai Institute for Diabetes, Shanghai Clinical Medical Centre of Diabetes, Shanghai Key Clinical Centre of Metabolic Diseases, Department of Endocrinology and Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
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157
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Boyko EJ. How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3241. [PMID: 31845475 DOI: 10.1002/dmrr.3241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Abstract
Assessment of ischaemia and interventions to improve perfusion are key elements in the management of the diabetic foot ulcer to achieve wound healing. This article will review, analyse and interpret the value of clinical information in determining the likelihood of limb ischaemia and thereby the need for referral to a vascular specialist. I conducted an historical review of the genesis of several currently recommended clinical signs and their diagnostic properties in the assessment of limb ischaemia. Changes in limb ischaemia probability based on such results were calculated using Bayes theorem, and the use of such probabilities is discussed in the context of the threshold approach to clinical decision making. Some clinical signs have negligible value in altering probability of limb ischaemia, possibly because they were advocated by Buerger for the diagnosis of thromboangiitis obliterans, an occlusive vascular disease of a different pathophysiology than atherosclerosis. Pedal pulse palpation, the most widely studied clinical sign, will marginally change a pre-test probability of ischaemia of 50% to 76% if positive (abnormal pulses) and to 36% if negative (normal pulses). Higher or lower pre-test probabilities of ischaemia will change the post-test probabilities such that these are too low or high to rule in or rule out ischaemia, respectively. Individual clinical signs convey little information regarding the presence of limb ischaemia but may have some value in combination or with pre-test probability near 50% in the assessment of ischaemia and the decision to refer for a vascular consultation.
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Affiliation(s)
- Edward J Boyko
- Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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158
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Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3276. [PMID: 31958217 DOI: 10.1002/dmrr.3276] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [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: 12/24/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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Affiliation(s)
| | - Rachael O Forsythe
- British Heart Foundation/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, AZ
| | - Sigrid Nikol
- Department of Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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159
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Rothenberg GM, Page J, Stuck R, Spencer C, Kaplan L, Gordon I. Remote Temperature Monitoring of the Diabetic Foot: From Research to Practice. Fed Pract 2020; 37:114-124. [PMID: 32317847 PMCID: PMC7170172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Diabetic foot ulcers (DFUs) are devastating, common, and costly. The mortality of veterans following a DFU is sobering with ulceration recognized as a significant marker of disease severity. Given the dramatic impact of diabetic foot complications to the veteran and the US health care system, the US Department of Veterans Affairs (VA) has long recognized the importance of preventive care for those at risk. Telemedicine has been suggested as a modality to reach veterans at high risk of chronic wound formation. OBSERVATIONS The purpose of this review is to: (1) present the evidence supporting once-daily remote temperature monitoring (RTM), a telemedicine approach critical to improving both veteran access to care and diabetic foot outcomes; (2) summarize a 2017 study published by VA providers who have advanced clinical understanding of RTM; (3) present previously unpublished data from this study comparing high-risk VA and non-VA cohorts, highlighting the opportunity for additional focus on DFU prevention within the VA; and (4) report on recent VA use of a RTM technology based on this research, emphasizing lessons learned and best practices. CONCLUSIONS There is a significant opportunity to shift diabetic foot care from treatment to prevention, improving veteran outcomes and reducing resource utilization. RTM is an evidence-based, recommended, but underused telemedicine solution that can catalyze this needed paradigm shift.
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Affiliation(s)
- Gary M Rothenberg
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
| | - Jeffrey Page
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
| | - Rodney Stuck
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
| | - Charles Spencer
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
| | - Lonnie Kaplan
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
| | - Ian Gordon
- is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. is a Vascular Surgeon at the Long Beach VA Medical Center in California
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160
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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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161
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Monge L, Gnavi R, Carnà P, Broglio F, Boffano GM, Giorda CB. Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study. Acta Diabetol 2020; 57:221-228. [PMID: 31468200 DOI: 10.1007/s00592-019-01412-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/22/2019] [Indexed: 12/30/2022]
Abstract
AIMS The aim of our study was to estimate the overall rate of first hospitalizations for diabetic foot (DF) regardless of the outcome in amputations, as well as the mortality rate with their determinants in the period 2012-2016 in Piedmont Region in Italy. METHODS The study included all the subjects registered in the Regional Diabetes Registry and alive as at January 1, 2012. DF cases were identified by record linkage with the regional hospital discharge database. Incident cases of diabetic foot were followed up for mortality. RESULTS The 5-year rates were 1762, 324, and 343 × 100,000 patients for first hospitalization without amputations, with major amputations, and with minor amputations, respectively. Patients not undergoing amputations were more than 70% of the cohort. Patients with the more severe stages of diabetes and those with low education were at higher risk of each type of hospitalization. The risk of death during a mean follow-up of 2.5 years was about 16, 18, and 30% among patients without amputations, with major amputations, and with minor amputations, respectively. Males, insulin-treated patients, those affected with severe diabetes complications, particularly on dialysis, and those with lower levels of education were at higher risk. CONCLUSIONS The heavier burden of DF on hospitalizations is due to cases without amputation, a condition that is seldom considered in the diabetes literature. The severity of diabetes, preexisting complications, and low educational levels are associated with both first hospitalization and subsequent survival at any level of severity of DF.
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Affiliation(s)
- Luca Monge
- Diabetic Foot Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
| | | | - Paolo Carnà
- Epidemiology Unit, ASL TO3, Grugliasco, TO, Italy
| | - Fabio Broglio
- Department of Medical Science, University of Turin, Turin, Italy
| | - Gian Mario Boffano
- Diabetic Foot Center, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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162
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Chen L, Ma W, Tang W, Zha P, Wang C, Chen D, Lei F, Li T, Tang X, Ran X. Prevalence of Obstructive Sleep Apnea in Patients With Diabetic Foot Ulcers. Front Endocrinol (Lausanne) 2020; 11:416. [PMID: 32760345 PMCID: PMC7371781 DOI: 10.3389/fendo.2020.00416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/26/2020] [Indexed: 02/05/2023] Open
Abstract
Objectives: Diabetic foot ulcers (DFUs) are a considerable burden on patients and the healthcare service system. Patients with DFUs have many risk factors that might contribute to obstructive sleep apnea (OSA). The purposes of this study were to assess the prevalence of OSA and associated features in patients with DFUs. Methods: Between July 2017 and June 2019, we recruited 245 consecutive patients who sought for treatment at West China Hospital because of DFUs. Polysomnography data from 127 Patients were included in the final analysis. Results: Of the 127 patients, with a median age of 64 years (interquartile range, 55-73 years; range, 36-86 years) and a mean body mass index (BMI) 24.09 ± 0.37 kg/m2, 91 (72%) were men. The prevalence of OSA [apnea-hypopnea index (AHI) ≧5/h] was 92% in men and 97% in women (P = 0.304). Moderate to severe OSA (AHI ≧15/h) was noted in 44 men (48%) and 26 women (72%) (P = 0.015). The risk factors associated with the severity of OSA were sex, age, smoking, alcohol use, and duration of diabetes. After multivariable adjustment, duration of diabetes and age were independent predictive factors of the severity of OSA. No significant association was observed between BMI, waist circumference, Epworth score, and the severity of OSA. There were no significant associations between OSA and ischemic heart disease, cerebral infarction, hypertension, diabetic retinopathy, diabetic kidney disease, and peripheral artery disease. Conclusions: The prevalence of OSA was high in patients with DFUs, with moderate to severe OSA accounting for more than half of the patients. Age and duration of diabetes were independent predictive factors of the severity of OSA.
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Affiliation(s)
- Lihong Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wanxia Ma
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Weiwei Tang
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Panpan Zha
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chun Wang
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Dawei Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Lei
- State Key Laboratory of Biotherapy, Sleep Medicine Center, Mental Health Center, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
| | - Taomei Li
- State Key Laboratory of Biotherapy, Sleep Medicine Center, Mental Health Center, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangdong Tang
- State Key Laboratory of Biotherapy, Sleep Medicine Center, Mental Health Center, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xingwu Ran
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Xingwu Ran
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163
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Akturk A, van Netten JJ, Scheer R, Vermeer M, van Baal JG. Ulcer-free survival days and ulcer healing in patients with diabetic foot ulcers: A prospective cohort study. Int Wound J 2019; 16:1365-1372. [PMID: 31429183 PMCID: PMC7948914 DOI: 10.1111/iwj.13199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/02/2019] [Accepted: 08/04/2019] [Indexed: 01/22/2023] Open
Abstract
Healing rates may not give a complete indication of the effectiveness and management of diabetic foot ulcers because of high recurrence rates. The most important outcome for patients is remaining ulcer-free; however, this has hardly been investigated. The aim of our study was to prospectively investigate ulcer-free survival days and ulcer healing in patients with diabetic foot ulcers. This was a prospective cohort study of all referrals to our diabetic foot expertise centre from December 2014 to April 2017. Outcomes were determined after a minimum follow-up period of 12 months. Primary outcomes were ulcer-free survival days and 12-month healing percentages. Predictors for ulcer-free survival days and healing were investigated in multivariate analyses. A total of 158 patients were included. Median ulcer-free survival days in the healed group were 233 days (interquartile range [IQR] 121-312) and 131 days (IQR 0-298) in the overall population. The healing rate at 12-month follow up was 67% (106/158), and the recurrence rate was 31% (33/106). Independent predictors of ulcer-free survival days were duration of diabetes, peripheral artery disease (PAD), cardiovascular disease, end-stage renal disease (ESRD), and infection. Ulcer-free survival days are related to PAD and cardiovascular disease, and ulcer-free survival days should be the main outcome when comparing the effectiveness of management and prevention of the diabetic foot ulcers.
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Affiliation(s)
- Afram Akturk
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Jaap J. van Netten
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
- Amsterdam UMC, University of AmsterdamDepartment of Rehabilitation, Amsterdam Movement SciencesAmsterdamThe Netherlands
- School of Clinical SciencesQueensland University of TechnologyBrisbaneAustralia
| | - Rene Scheer
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Marloes Vermeer
- ZGT AcademyZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
| | - Jeff G. van Baal
- Department of SurgeryZiekenhuisgroep Twente (ZGT)Almelo and HengeloThe Netherlands
- University of CardiffCardiffUK
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164
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Moon KC, Kim SB, Han SK, Jeong SH, Dhong ES. Risk factors for major amputation in hospitalized diabetic patients with forefoot ulcers. Diabetes Res Clin Pract 2019; 158:107905. [PMID: 31676331 DOI: 10.1016/j.diabres.2019.107905] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/04/2019] [Accepted: 10/25/2019] [Indexed: 01/13/2023]
Abstract
AIMS The purpose of this study was to investigate the risk factors for major amputation in patients hospitalized with diabetic forefoot ulcers. METHODS Between January 2003 and December 2018, a total of 1792 diabetic patients were admitted to the diabetic wound center for the management of diabetic foot ulcers. Among the patients, 1032 diabetic patients with forefoot ulcers were included in this study. Nine hundred and eighty-three patients (95%) healed without major amputations while 49 patients (5%) healed after major amputations. Data related to 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology, and serology were collected from the patients in these two groups for comparison. RESULTS Among the 88 potential risk factors, 34 showed statistically significant differences between the two groups. In the univariate analysis of 88 risk factors, 33 showed statistically significant differences. In stepwise multiple logistic regression analysis, four of the 33 risk factors remained statistically significant. The multivariate-adjusted odds ratios for gender, magnesium levels, platelet levels, and glycated hemoglobin (HbA1c) levels were 8.216, 2.480, 1.009, and 0.570, respectively. CONCLUSION Risk factors for major amputation in patients hospitalized with diabetic forefoot ulcers include male gender, increased magnesium, increased platelet levels, and low levels of HbA1c.
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Affiliation(s)
- Kyung-Chul Moon
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
| | - Soo-Byn Kim
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
| | - Seung-Kyu Han
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea.
| | - Seong-Ho Jeong
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
| | - Eun-Sang Dhong
- Department of Plastic Surgery, Korea University Guro Hospital, Seoul, South Korea
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165
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Selvarajah D, Kar D, Khunti K, Davies MJ, Scott AR, Walker J, Tesfaye S. Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. Lancet Diabetes Endocrinol 2019; 7:938-948. [PMID: 31624024 DOI: 10.1016/s2213-8587(19)30081-6] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is a common complication of both type 1 and 2 diabetes. It is a leading cause of lower-limb amputation and disabling neuropathic pain. Amputations in patients with diabetes have a devastating effect on quality of life and are associated with an alarmingly low life expectancy (on average only 2 years from the amputation). Amputation also places a substantial financial burden on health-care systems and society in general. With the introduction of national diabetes eye screening programmes, the prevalence of blindness in working-age adults is falling. This is not the case, however, with diabetes related amputations. In this Review, we appraise innovative point-of-care devices that enable the early diagnosis of DPN and assess the evidence for early risk factor-based management strategies to reduce the incidence and slow the progression of DPN. We also propose a framework for screening and early multifactorial interventions as the best prospect for preventing or halting DPN and its devastating sequelae.
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Affiliation(s)
- Dinesh Selvarajah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
| | - Debasish Kar
- Derbyshire Community Health Services NHS Foundation Trust, Bakewell, UK; Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Adrian R Scott
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jeremy Walker
- Department of Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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166
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Mohseni S, Aalaa M, Atlasi R, Mohajeri Tehrani MR, Sanjari M, Amini MR. The effectiveness of negative pressure wound therapy as a novel management of diabetic foot ulcers: an overview of systematic reviews. J Diabetes Metab Disord 2019; 18:625-641. [PMID: 31890688 DOI: 10.1007/s40200-019-00447-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
Abstract
Background Diabetic foot ulcer (DFU) is one the serious disabling conditions in patients with diabetes. Several approaches are available to manage DFU including Negative Pressure Wound Therapy (NPWT). The objective of this overview is systematically reviewing the related reviews about the effectiveness, safety, and cost benefits of NPWT interventions. Methods In October 2018, electronic databases including Medline, Embase, Scopous, Web of Science, the Cochrane Library and Google scholar were searched for systematic reviews about the NPWT's effectiveness and safety in DFUs. The Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist was used for the appraisal of the systematic reviews. According to this checklist the studies were categorized as high, moderate, low and critically low quality. Results The electronic searches yielded 6889 studies. After excluding duplicates and those not fellfield the inclusion criteria, 23 systematic reviews were considered. The sample size of the reviews ranged between 20 and 2800 patients published since 2004 to 2018. Twenty systematic reviews (86.95%) included only randomized clinical trials (RCT). Regarding the AMSTAR-2 checklist, 7 studies were assigned to high quality, 8 were categorized as low quality and 8 studies belonged to the critically low quality groups. Accordingly, three, two and one out of seven high quality studies approved the effectiveness, safety and cost benefit of the NPWT therapy, respectively. However, some of them declared that there is some flaws in RCTs designing. Conclusion This overview illustrated that either systematic reviews or the included RCTs had wide variety of quality and heterogeneity in order to provide high level of evidence. Hence, well-designed RCTs as well as meta-analysis are required to shade the light on different aspects of NPWT.
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Affiliation(s)
- Shahrzad Mohseni
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aalaa
- 2Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Rasha Atlasi
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Reza Mohajeri Tehrani
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
| | - Mohamad Reza Amini
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
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167
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Barati G, Rahmani A, Nadri S. In vitro differentiation of conjunctiva mesenchymal stem cells into insulin producing cells on natural and synthetic electrospun scaffolds. Biologicals 2019; 62:33-38. [PMID: 31635936 DOI: 10.1016/j.biologicals.2019.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 10/04/2019] [Accepted: 10/14/2019] [Indexed: 12/29/2022] Open
Abstract
Polymers are used in tissue engineering as a scaffold. In this study the differentiation capability of conjunctiva mesenchymal stem cells (CJMSCs) on natural and synthetic nanofibrous electrospun scaffolds into insulin producing cells (IPCs) were studied. Natural Silk fibroin and synthetic PLLA polymers were used to fabricate electrospun scaffolds. These scaffolds are characterized by SEM and CJMSCs were differentiated into IPCs on these scaffolds. The differentiation efficiency was measured by analysis the expression of specific pancreatic markers by RT-qPCR and insulin release capacity via ELISA. Microscopy analysis showed the fabrication of uniform nanofibers and the formation of the islet-like clusters at the end of differentiation period. Significant differences in expression of Pdx-1 and glucagon were observed in PLLA scaffold compared to Silk scaffold (Fold: 1.625 and 1.434, respectively; P-value ≤ 0.0001 for both). Furthermore, insulin secretion at high glucose concentration was significantly higher in cells differentiated on PLLA scaffold than those cultured on Silk scaffold (P-value: 0.012). The scaffolds can enhance the differentiation of IPCs from CJMSCs. In this way, PLLA synthetic scaffold was more efficient than Silk natural scaffold. We conclude that the nanofibrous scaffolds reported herein could be used as a potential supportive matrix for islet tissue engineering.
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Affiliation(s)
- Ghasem Barati
- Department of Medical Biotechnology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ali Rahmani
- Department of Medical Nanotechnology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Samad Nadri
- Department of Medical Nanotechnology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran; Zanjan Metabolic Diseases Research Center, Zanjan University of Medical Sciences, Zanjan, Iran; Zanjan Pharmaceutical Nanotechnology Research Center, Zanjan University of Medical Sciences, Zanjan, Iran.
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168
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Niederauer MQ, Michalek JE, Liu Q, Papas KK, Lavery LA, Armstrong DG. Continuous diffusion of oxygen improves diabetic foot ulcer healing when compared with a placebo control: a randomised, double-blind, multicentre study. J Wound Care 2019; 27:S30-S45. [PMID: 30207844 DOI: 10.12968/jowc.2018.27.sup9.s30] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether continuous diffusion of oxygen improves healing in people receiving treatment for diabetic foot ulcers (DFU). METHOD A double-blind, placebo control randomised study to receive either active continuous diffusion of oxygen (CDO) therapy using an active CDO device, or a fully operational placebo device without delivering oxygen. Patients were followed until closure or 12 weeks. Patients, caretakers, treating physicians and independent evaluators were blinded to the study arm. All patients received identical offloading, debridement, dressings and follow-up. RESULTS We enrolled 146 people with DFUs (77% male, aged 56.3±12.4 years). A significantly higher proportion (195%) of DFUs healed in the CDO arm compared with placebo (32.4% versus 16.7%, p=0.033). The time to 50% DFU closure was significantly shorter in patients that received CDO therapy (mean 18.4 versus 28.9 days, p=0.001). There were no differences in overall adverse events (p=0.66) or ulcer-related adverse events (p=0.30) in the active and placebo treatment groups. The relative performance of active CDO over placebo became greater when used in larger wounds (273%), in more chronic wounds (334%) and in weight bearing wounds (465%). CONCLUSION The results of this study demonstrate that CDO leads to higher proportion of healed DFUs (p=0.033) and a faster time to closure compared with placebo in people with DFUs (p=0.015). Relative performance did not vary significantly with wound size (p=0.80), but revealed better relative performance in more chronic wounds (p=0.008) and in weight-bearing wounds (p=0.003).
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Affiliation(s)
| | - Joel E Michalek
- Professor and Vice-Chair of Department of Epidemiology and Biostatistics, UT Health, San Antonio, TX, US
| | - Qianqian Liu
- Biostatistician-Associate in Department of Epidemiology and Biostatistics, UT Health, San Antonio, TX, US
| | - Klearchos K Papas
- Scientific Director of Institute for Cellular Transplantation, University of Arizona, Tucson, AZ, US
| | - Lawrence A Lavery
- Professor of Plastic Surgery, Orthopaedic Surgery and Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, US
| | - David G Armstrong
- Professor of Clinical Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, US
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169
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Lin CW, Hung SY, Huang CH, Yeh JT, Huang YY. Diabetic Foot Infection Presenting Systemic Inflammatory Response Syndrome: A Unique Disorder of Systemic Reaction from Infection of the Most Distal Body. J Clin Med 2019; 8:jcm8101538. [PMID: 31557854 PMCID: PMC6832445 DOI: 10.3390/jcm8101538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022] Open
Abstract
Diabetic foot infection (DFI) is a major complication of diabetic foot that lead to nontraumatic lower-extremity amputation (LEA). Such distal infection of the body having systemic inflammatory response syndrome (SIRS) is rarely reported. Consecutive patients treated for limb-threatening DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 to 2017. Clinical factors, laboratory data, perfusion, extent, depth, infection and sensation (PEDIS) wound score in 519 subjects with grade 3 DFI and 203 presenting SIRS (28.1%) were compared. Major LEA and in-hospital mortality were defined as poor prognosis. Patients presenting SIRS had poor prognosis compared with those with grade 3 DFI (14.3% versus 6.6% for major LEA and 6.4% versus 3.5% for in-hospital mortality). Age, wound size, and HbA1c were independent risk factors favoring SIRS presentation. Perfusion grade 3 (odds ratio 3.37, p = 0.044) and history of major adverse cardiac events (OR 2.41, p = 0.036) were the independent factors for poor prognosis in treating patients with DFI presenting SIRS. SIRS when presented in patients with DFI is not only limb- but life-threatening as well. Clinicians should be aware of the clinical factors that are prone to develop and those affecting the prognosis in treating patients with limb-threatening foot infections.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Jiun-Ting Yeh
- Department of Plastic surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan.
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan.
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170
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Persky JD, Langan T, Smith CN, Burns PR. Plantar Approach for Midfoot Wedge Resection to Reconstruct the Rocker Bottom Foot. J Foot Ankle Surg 2019; 58:1030-1035. [PMID: 31474393 DOI: 10.1053/j.jfas.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 02/03/2023]
Abstract
Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.
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Affiliation(s)
- Justin D Persky
- Resident, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Travis Langan
- Fellow, Orthopedic Foot and Ankle Center, Westerville, OH
| | - Clair N Smith
- Biostatistician, Clinical Outcomes Research, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick R Burns
- Assistant Professor, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA; Director, Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, Pittsburgh, PA; Chief, Podiatry Section, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA
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171
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Wang J, Zeng XX, Cai W, Han ZB, Zhu LY, Liu JY, Xu JX. Safety and Efficacy of Placenta-Derived Mesenchymal Stem Cell Treatment for Diabetic Patients with Critical Limb Ischemia: A Pilot Study. Exp Clin Endocrinol Diabetes 2019; 129:542-548. [PMID: 31412379 DOI: 10.1055/a-0978-4972] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM Diabetic foot has become the main cause of non-traumatic amputation. Stem cell therapy, especially mesenchymal stem cells (MSCs), holds a great promise as a therapy for diabetic foot with ischemia limb arterial disease. The aim of this pilot study is to evaluate the safety and efficacy of placenta-derived MSCs (P-MSCs) treatment for diabetic patients with critical limb ischemia (CLI). METHODS Four eligible diabetic patients with CLI were consecutively enrolled in this pilot study. On the base of the standard-of-care treatment, these patients accepted P-MSCs treatment by intramuscular injection for successive 3 times at an interval of 4 weeks, and the safety and efficacy of placenta-derived MSCs (P-MSCs) treatment were evaluated. RESULTS There were no serious adverse events during the period of P-MSCs injection and the 24-weeks follow-up period. The clinical ischemic features of patients were improved 24 weeks after P-MSCs treatment. The scores of resting pain and limb coldness significantly decreased, and pain-free walking distance significantly increased from baseline to 24 weeks after P-MSCs therapy. The resting ankle brachial index increased, but no statistically significant difference was found. The findings of magnetic resonance angiography showed the increase of collateral vessel formation in one patient, but there were no significant changes observed in the other patients. CONCLUSIONS The data in this pilot study indicated that multiple intramuscular P-MSCs injections may be a safe and effective alternative therapy for diabetic patients with CLI, and larger, placebo-controlled, perspective studies are needed to prove these results.
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Affiliation(s)
- Jiao Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Xiang-Xia Zeng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Wei Cai
- Department of Medical Genetics and Cell biology, Medical College of Nanchang University, Nanchang, P.R. China
| | - Zhi-Bo Han
- The Stem Cell Engineering Research Center of Jiangxi Province, Shangrao, P.R. China
| | - Ling-Yan Zhu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Jian-Ying Liu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Ji-Xiong Xu
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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172
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Amadou C, Carlier A, Amouyal C, Bourron O, Aubert C, Couture T, Fourniols E, Ha Van G, Rouanet S, Hartemann A. Five-year mortality in patients with diabetic foot ulcer during 2009-2010 was lower than expected. DIABETES & METABOLISM 2019; 46:230-235. [PMID: 31400509 DOI: 10.1016/j.diabet.2019.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/03/2019] [Accepted: 04/07/2019] [Indexed: 11/24/2022]
Abstract
AIM Mortality rates are decreasing in patients with diabetes. However, as this observation also concerns patients with diabetic foot ulcer (DFU), additional data are needed. For this reason, our study evaluated the 5-year mortality rate in patients with DFU during 2009-2010 and identified risk factors associated with mortality. METHODS Consecutive patients who attended a clinic for new DFU during 2009-2010 were followed until healing and at 1 year. Data on mortality were collected at year 5. Multivariate Cox proportional-hazards model was used to identify mortality risk factors. RESULTS A total of 347 patients were included: mean age was 65±12 years, diabetes duration was 16 [10; 27] years; 13% were on dialysis; and 7% had an organ transplant. At 5 years, 49 patients (14%) were considered lost to follow-up. Total mortality rate at 5 years was 35%, and 16% in patients with neuropathy. On multivariate analyses, mortality was positively associated with: age [hazard ratio (HR): 1.05 (1.03-1.07), P<0.0001]; duration of diabetes [HR: 1.02 (1.001-1.03], P=0.03]; PEDIS perfusion grade 2 vs. 1 [HR: 2.35 (1.28-4.29), P=0.006)]; PEDIS perfusion grade 3 vs. 1 [HR: 3.14 (1.58-6.24), P=0.001); and ulcer duration at year 1 [HR 2.09 (1.35-3.22), P=0.0009]. CONCLUSION Mortality rates were not as high as expected despite the large number of comorbidities, suggesting that progress has been made in the health management of these patients. In particular, patients with neuropathic foot ulcer had a survival rate of 84% at 5 years.
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Affiliation(s)
- C Amadou
- Diabetology department, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - A Carlier
- Diabetology department, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Inserm, CIC-1421, Department of Pharmacology, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Université, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - C Amouyal
- Inserm, Sorbonne-Université, Research Unit on Cardiovascular, Metabolic and Nutrition Diseases (UMRS-1166), Institute of Cardiometabolism and Nutrition, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - O Bourron
- Diabetology department, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Inserm, CIC-1421, Department of Pharmacology, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Université, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - C Aubert
- Department of Internal Medicine, Fribourg Hospital, Fribourg, Switzerland
| | - T Couture
- Sorbonne Université, 91, boulevard de l'Hôpital, 75013 Paris, France; Department of Vascular Surgery, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Fourniols
- Department of Orthopedic Surgery, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - G Ha Van
- Diabetology department, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France
| | - S Rouanet
- StatEthic SASU, 73, rue Paul-Vaillant-Couturier, 92300 Levallois-Perret, France
| | - A Hartemann
- Diabetology department, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Inserm, CIC-1421, Department of Pharmacology, Pitié-Salpêtrière Hospital, AP-HP, 83, boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Université, 91, boulevard de l'Hôpital, 75013 Paris, France.
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173
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Zhang S, Wang S, Xu L, He Y, Xiang J, Tang Z. Clinical Outcomes of Transmetatarsal Amputation in Patients with Diabetic Foot Ulcers Treated without Revascularization. Diabetes Ther 2019; 10:1465-1472. [PMID: 31243732 PMCID: PMC6612342 DOI: 10.1007/s13300-019-0653-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Most studies on outcomes of transmetatarsal amputation (TMA) have been for patients who underwent revascularization. This study was performed to evaluate the outcomes of TMA in diabetic patients without revascularization. METHODS One hundred two diabetic patients who were not candidates for revascularization underwent TMA and received a multidisciplinary treatment. These patients were followed up for a mean period of 38 months to observe the outcomes, including wound healing, above-the-ankle amputation and death. The associations between variables and the outcomes were analyzed by Cox regression analysis. RESULTS By the end of the follow-up, 97 patients with full data were analyzed. Sixty-three (64.9%) patients had wounds healed completely after a median interval of 8 months, 16 (16.5%) patients underwent above-the-ankle amputation, and 26 (26.8%) died. Cox regression analysis showed that patients with higher ABI (RR = 3.097, 95% CI: 1.587-6.043) and serum albumin (RR = 2.755, 95% CI: 1.335-5.687) exhibited a higher probability of wound healing. CONCLUSIONS Diabetic patients who were not candidates for revascularization who underwent TMA could achieve a satisfactory wound healing rate with a multidisciplinary treatment. ABI and serum albumin were significant predictors of wound healing.
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Affiliation(s)
- Shanshan Zhang
- Department of Endocrine and Metabolic Diseases, Shengli Oilfield Central Hospital, Dongying, 257034, China
| | - Shumin Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Lei Xu
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Yang He
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Jiali Xiang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Zhengyi Tang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital Affiliated To Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China.
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174
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Mader JK, Haas W, Aberer F, Boulgaropoulos B, Baumann P, Pandis M, Horvath K, Aziz F, Köhler G, Pieber TR, Plank J, Sourij H. Patients with healed diabetic foot ulcer represent a cohort at highest risk for future fatal events. Sci Rep 2019; 9:10325. [PMID: 31316149 PMCID: PMC6637072 DOI: 10.1038/s41598-019-46961-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 07/08/2019] [Indexed: 12/14/2022] Open
Abstract
Patients with previous diabetic foot ulcer are prone to re-ulceration and (re)amputation, to various comorbidities, have significantly impaired quality of life and increased mortality. We aimed to evaluate the risk of foot related complications and mortality in a high-risk population of patients with healed diabetic foot syndrome over a decade. 91 patients with recently healed diabetic foot ulcer were invited for follow-up at 1, 6 and 11 years after inclusion. Patient characteristics at inclusion were: 40 women, 65 ± 11 years, diabetes type 1 (n = 6) or 2 (n = 85), BMI 28.5 ± 4.4 kg/m2, and HbA1c 68 ± 17 mmol/mol. Comorbidities included neuropathy (n = 91), peripheral artery disease (PAD), history of minor (n = 25) or major (n = 5, 5.5%) amputation, nephropathy (n = 40) and retinopathy (n = 53). Ulceration recurred in 71 (65%) patients, time to first recurrence was 1.8 ± 2.4 years (mean ± SD). 21 patients had to undergo (re)amputation (minor n = 19, major n = 2), time to amputation was 3.6 ± 1.9 years. Over time, 3 further major amputations were required in patients with an initial minor amputation. Thirty-three (36%) of the initially included patients completed the follow-up period of 11.0 ± 0.6 years. 58 patients (64%) died during the observational period, time to death was 5 ± 3 years in this group. We found overall high mortality of 64% throughout the follow-up period of 11 years in high-risk patients with healed diabetic foot syndrome. Presence of PAD, prior amputation and nephropathy as well as poor glycemic control were significantly predictive for death.
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Affiliation(s)
- Julia K Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
| | - Waltraud Haas
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Felix Aberer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Beate Boulgaropoulos
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.,Joanneum Research Forschungsgesellschaft m.b.H, HEALTH - Institute for Biomedicine and Health Sciences, Neue Stiftingtalstrasse 2, A-8010, Graz, Austria
| | - Petra Baumann
- Joanneum Research Forschungsgesellschaft m.b.H, HEALTH - Institute for Biomedicine and Health Sciences, Neue Stiftingtalstrasse 2, A-8010, Graz, Austria
| | - Marlene Pandis
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Karl Horvath
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.,Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Auenbruggerplatz 20, A-8036, Graz, Austria
| | - Faisal Aziz
- Center for Biomarker Research in Medicine (CBmed), Stiftingtalstrasse 5, 8010, Graz, Austria
| | - Gerd Köhler
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.,Joanneum Research Forschungsgesellschaft m.b.H, HEALTH - Institute for Biomedicine and Health Sciences, Neue Stiftingtalstrasse 2, A-8010, Graz, Austria
| | - Johannes Plank
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria
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175
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Brekelmans W, Borger van der Burg BLS, Vroom MA, Kreuger MJ, Schrander van der Meer AM, Hoencamp R. Prevalence of foot ulcers in dialysis-dependent patients. Wound Repair Regen 2019; 27:687-692. [PMID: 31298805 DOI: 10.1111/wrr.12750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/19/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
Hemodialysis patients are at high risk for foot ulceration. The aim of this prospective study was to describe the prevalence and risk factors for foot ulcers in hemodialysis-dependent patients. From 2012 until 2015, all hemodialysis patients (n = 66) above18 years of age, treated at the Alrijne Hospital (Leiderdorp, the Netherlands), were included. Demographics and medical history were collected and the quality of life was measured. Data were collected on common risk factors for foot ulceration: peripheral arterial disease, peripheral neuropathy with or without foot deformities, diabetes mellitus (DM), hypertension, smoking, previous foot ulcer, edema, pedicure attendance, and orthopedic footwear. Sixty-six hemodialysis patients were evaluated; the prevalence of foot ulcer was 21/66 (31.8%). Risk factors were history of foot ulceration in 27/66 (40.9%), ankle-brachial index (ABI) <0.9, and toe pressure < 80 mmHg in 38/66 (57.6%). The percentage of DM in the group of foot-ulcers was higher 13/21 (61.9%) vs. 20/45 (44.4%) in the non-ulcer group, this was not significant (p = 0.183). No differences were found in ABI, toe pressure, peripheral neuropathy and foot deformity, between the DM and non DM group. The mortality between ulcer vs. no ulcer was significant different: 13/21 (61.9%) vs. 11/45 (24.4%) (p = 0.003). Approximately, one-third of hemodialysis patient have a foot ulcer 21/66 (32%). Arterial insufficiency is associated with an increased risk of foot ulcers. In patients with a foot ulcer, survival is significantly lower than in patients without a foot ulcer; interventions to reduce foot ulceration should be implemented for all hemodialysis patients and include frequent inspection, and prompt treatment. Further research should focus on the prevention of foot ulcers in dialysis-dependent patients.
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Affiliation(s)
- Wouter Brekelmans
- Division of Surgery Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Alrijne Wound Centre, Leiderdorp, The Netherlands.,Division of Surgery Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Boudewijn L S Borger van der Burg
- Division of Surgery Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Alrijne Wound Centre, Leiderdorp, The Netherlands.,Division of Surgery Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Michiel A Vroom
- Division of Surgery Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Division of Vital Functions, University Medical Center, Utrecht, The Netherlands
| | - Marrigje J Kreuger
- Division Tropical Medicine & International Health, Nordic Medical Centre, Addis, Abeda, Ethiopia
| | | | - Rigo Hoencamp
- Division of Surgery Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Alrijne Wound Centre, Leiderdorp, The Netherlands.,Division of Surgery Leids Universitair Medisch Centrum, Leiden, The Netherlands.,Ministry of Defence, The Hague, The Netherlands
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176
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Fu J, Zhang Y, Chu J, Wang X, Yan W, Zhang Q, Liu H. Reduced Graphene Oxide Incorporated Acellular Dermal Composite Scaffold Enables Efficient Local Delivery of Mesenchymal Stem Cells for Accelerating Diabetic Wound Healing. ACS Biomater Sci Eng 2019; 5:4054-4066. [PMID: 33448807 DOI: 10.1021/acsbiomaterials.9b00485] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic skin wounds caused by diabetes mellitus (DM) have been acknowledged as one of the most intractable complications. Local transplantation of mesenchymal stem cells (MSCs) is a promising method, but strategies for stabilizing and efficiently delivering active MSCs according to the wound circumstance with high proteolysis remain the main barrier. Hereon, the study demonstrates the feasibility of incorporating reduced graphene oxide (RGO) nanoparticles with an acellular dermal matrix (ADM) to improve physicochemical characteristics of natural scaffold material and fabricate a highly efficient local transplantation system for MSCs in diabetic wound healing. Under the influence of RGO nanoparticles, the ADM-RGO composite scaffolds achieved high stability and strong mechanical behaviors. In vitro, conductive ADM-RGO scaffolds demonstrated an admirable milieu for stem cells adhesion and proliferation. After having been cocultured with MSCs, the ADM-RGO-MSC composite scaffolds were transplanted into the full-thickness wound of a diabetic model that was induced by streptozotocin (STZ) to evaluate its effects. As a result, the ADM-RGO composite scaffold delivered with MSCs supported robust vascularization and collagen deposition as well as rapid re-epithelialization during diabetic wound healing. Overall, the versatile nature of the ADM-RGO composite scaffold makes it an efficient transplanting mediator for pluripotent stem cells in tissue engineering applications. The composite scaffold delivered with MSCs presents a promising approach for nonhealing diabetic wounds.
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Affiliation(s)
- JinPing Fu
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - Yue Zhang
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - Jing Chu
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - Xiao Wang
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - WenXia Yan
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - Qiong Zhang
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
| | - HanPing Liu
- Department of College of Biophotonics, South China Normal University, No. 55 Zhongshan Avenue West, Tianhe District, Guangzhou, Guangdong 510631, China
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177
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Walker CA, Rahman A, Gipson-Jones TL, Harris CM. Hospitalists' Needs Assessment and Perceived Barriers in Wound Care Management: A Quality Improvement Project. J Wound Ostomy Continence Nurs 2019; 46:98-105. [PMID: 30844867 DOI: 10.1097/won.0000000000000512] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The purpose of this quality improvement project was to determine hospitalists' knowledge, practices, and perspectives related to management of pressure injuries and neuropathic/diabetic foot complications (having a foot ulcer or subsequent development of a foot infection because of a foot ulcer). We also sought to identify resources for and knowledge-based barriers to management of these wounds. This quality improvement effort targeted an interdisciplinary group of 55 hospitalists in internal medicine that consisted of 8 nurse practitioners, 10 physician assistants, and 38 physicians. The site of this initiative was the Johns Hopkins Bayview Medical Center, a 342-bed academic hospital located in the mid-Atlantic United States (Baltimore Maryland). The first phase of our quality improvement project comprised an online survey to identify hospitalists' knowledge, practices, and opinions on inpatient management of pressure injuries and diabetic foot complications. The second phase involved semistructured focus groups attended by hospitalists to identify resource gaps and barriers inferred by survey results. Twenty-nine of 55 (52%) hospitalists responded to the survey; 72% indicated no formal training in wound care. Over 90% had little to no confidence in management of pressure injuries and diabetic foot complications. In a separate ranking section of the survey, respondents selected lack of knowledge/confidence 12 of 29 (41.3%) and resources 9 of 29 (31.0%) as number 1 barriers to wound care. Managing patients with obesity was identified as a second major barrier from 10 of 29 selected options (34.5%). Eighteen of 55 (33%) hospitalists attended focus group sessions acknowledging barriers to wound care that included provider education, information technology, system factors, and interprofessional engagement. Attendees welcomed additional educational and ancillary resource support.
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Affiliation(s)
- Cynthia A Walker
- Cynthia A. Walker, MSN, RN, APRN-CNS, CWON, Interprofessional Practice & Patient Safety, Johns Hopkins Bayview Medical Center, Baltimore, Maryland. Alphonsa Rahman, DNP, APRN-CNS, CCRN, Interprofessional Practice & Patient Safety, Johns Hopkins Bayview Medical Center, Baltimore, Maryland. Trina L. Gipson-Jones, PhD, Hampton University, School of Nursing, Hampton, Virginia. Ché Matthew Harris, MD, MS, FACP, Department of General Internal Medicine, Johns Hopkins School of Medicine, Joint Appointment Johns Hopkins School of Nursing, Division of Hospital Medicine, Collaborative Inpatient Medicine Service, Baltimore, Maryland
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178
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Ding H, Fu XL, Miao WW, Mao XC, Zhan MQ, Chen HL. Efficacy of Autologous Platelet-Rich Gel for Diabetic Foot Wound Healing: A Meta-Analysis of 15 Randomized Controlled Trials. Adv Wound Care (New Rochelle) 2019; 8:195-207. [PMID: 31737414 DOI: 10.1089/wound.2018.0861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/06/2018] [Indexed: 01/02/2023] Open
Abstract
Objectives: The meta-analysis was performed to summarize the available evidence and determine the healing effectiveness of autologous platelet-rich gel (APG) on diabetic foot (DF) wounds. Approach: PubMed and The Cochrane Library and CNKI databases were searched to identify prior randomized controlled trials. Methodological qualities of included studies were assessed using Cochrane Handbook for Systematic Reviews of Intervention. Healing rate was considered the primary outcome; the secondary outcomes included healing time and adverse events. Results: Fifteen studies involving a total of 827 subjects were analyzed in the meta-analysis. Considering the primary outcome, the average healing rate in APG group was 85.8% and ranged from 68.4% to 100%. Relatively, the control group was 57.4% and ranged from 18.2% to 75.0%. Eligible studies were compared with a fixed effects model (I 2 = 0.0%, p = 0.496), indicating a higher healing rate with APG (risk ratio [RR] 1.44, 95% confidence interval [CI]: 1.32-1.57, z = 8.50, p < 0.001). The leave-one-out sensitivity analysis is robust. Considering the secondary outcomes, APG therapy needed less time (weighted mean difference -10.75 days, 95% CI: -11.67 to 8.86 days, z = 14.34, p < 0.001) and had fewer adverse events (RR 0.44, 95% CI: 0.25-0.76, z = 2.94, p = 0.003). Innovation: APG therapy is an innovative and effective approach to promote DF wound healing and reduce healing time and adverse events. Conclusion: The meta-analysis demonstrates that APG therapy has a positive effect on the treatment of DF wounds. However, additional well-designed and high-quality studies are needed to reach a conclusion with more confidence.
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Affiliation(s)
- Hui Ding
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - Xue-Lei Fu
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - Wei-Wei Miao
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - Xing-Chun Mao
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - Min-Qi Zhan
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
| | - Hong-Lin Chen
- School of Nursing, Nantong University, Nantong, Jiangsu, PR China
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179
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Feng C, Qianqian S, Jianhua H, Yu Z, Yipeng W, Jianguo Z, Guixing Q. Treatment experience for full-thickness wound dehiscence with cerebrospinal fluid leakage following posterior primary spine surgery: Three case reports. Medicine (Baltimore) 2019; 98:e15126. [PMID: 30985675 PMCID: PMC6485832 DOI: 10.1097/md.0000000000015126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Full-thickness wound dehiscence with cerebrospinal fluid (CSF) leakage following posterior spine surgery is a rare but troublesome complication. In the present study, 3 clinical cases associated with this entity are reported. PATIENT CONCERNS The first case developed incision effusion 5 days after posterior decompression and internal fixation for lumbar spinal stenosis. The second case has the same diagnosis and treatment with the first case. She developed intraoperative CSF leak and incision effusion 7 days after the surgery. The third case developed incision effusion 6 days after posterior single door laminoplasty for cervical spondylosis. DIAGNOSIS All cases developed CSF leak, incision effusion and finally full-thickness wound dehiscence on the postoperative period. INTERVENTIONS Bed rest, drainage, vacuum sealing drainage (VSD), and reoperations were applied in all of the patients. Trapezius flap transfer was applied to the third case. One lumbar patient developed deep infection and meningitis; thus, the internal fixation and bone graft were removed. OUTCOMES All of the patients received wound healing finally and were followed up for >6 months. No incision complications reoccurred, and preoperative symptoms significantly relieved. LESSONS Several techniques can be adopted to minimize the incidence of complications and proper surgical repair is the most important. Lumbar cistern drainage and VSD are recommended. Some other available options of management will also help.
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180
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Al Wahbi A. Operative versus non-operative treatment in diabetic dry toe gangrene. Diabetes Metab Syndr 2019; 13:959-963. [PMID: 31336551 DOI: 10.1016/j.dsx.2018.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/26/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene. METHODS We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation. RESULTS One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up. CONCLUSION Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.
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Affiliation(s)
- Abdullah Al Wahbi
- King Saud University for Health Sciences, Division of Vascular Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
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181
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Xiang J, Wang S, He Y, Xu L, Zhang S, Tang Z. Reasonable Glycemic Control Would Help Wound Healing During the Treatment of Diabetic Foot Ulcers. Diabetes Ther 2019; 10:95-105. [PMID: 30465160 PMCID: PMC6349287 DOI: 10.1007/s13300-018-0536-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The effect of glycemic control on wound healing in patients with diabetic foot ulcers (DFUs) is inconsistent among different studies. This study was performed to investigate the association between level of hemoglobin A1c (HbA1c) at baseline as well as during treatment and wound healing and mortality in patients with DFU. METHODS Hospitalized DFU patients were recruited consecutively with their basic clinical data collected and treated according to clinical practice guidelines. These patients were followed-up for 1 year to observe the outcomes, including ulcer healing and death. The associations between baseline HbA1c level or mean HbA1c level during treatment and wound healing as well as mortality were evaluated in univariate and multivariate logistic regression models. RESULTS By the end of the follow-up, 40 (13.4%) patients had died. A total of 168 (65.1%) patients achieved ulcer healing in the remaining 258 living participants. Baseline HbA1c was not associated with ulcer healing in unadjusted or adjusted models (P > 0.05). The wound healing rate was higher (OR 2.01, 95% CI 1.02-3.96, P < 0.05) after adjustment when HbA1c was controlled between 7.0% and 8.0% during treatment compared to HbA1c controlled at less than 7.0%. This probability of ulcer healing increased to 3 (OR = 3.01, 95% CI 1.32-6.86, P = 0.01) after adjustment in the subgroup with baseline HbA1c no more than 8.0%. Neither baseline HbA1c nor mean HbA1c during treatment presented any correlation with 1-year death rate. CONCLUSION A reasonable HbA1c target, a range between 7.0% and 8.0% during treatment, could facilitate ulcer healing without increase of mortality in patients with DFU, especially for those with better glycemic control at admission.
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Affiliation(s)
- Jiali Xiang
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China
| | - Shumin Wang
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China
| | - Yang He
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China
| | - Lei Xu
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China
| | - Shanshan Zhang
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China
| | - Zhengyi Tang
- Department of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai Institute of Endocrine and Metabolism Disease, Shanghai, 200025, China.
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182
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Jeyaraman K, Berhane T, Hamilton M, Chandra AP, Falhammar H. Mortality in patients with diabetic foot ulcer: a retrospective study of 513 cases from a single Centre in the Northern Territory of Australia. BMC Endocr Disord 2019; 19:1. [PMID: 30606164 PMCID: PMC6318899 DOI: 10.1186/s12902-018-0327-2] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFU) are a common problem in longstanding diabetes. However, mortality outcomes in Australian patients with DFU are still unclear. METHODS All patients with DFU presenting for the first time to the Multi-Disciplinary Foot Clinic (MDFC) at Royal Darwin Hospital, Northern Territory Australia, between January 2003 and June 2015 were included in this study. These patients were followed until 2017, or death. Individual patient data was extracted from hospital and primary care information systems. Kaplan-Meier survival curves were developed. The association between various risk factors and mortality was analysed using Cox regression. RESULTS In total 666 subjects were screened, and 513 were included in the final analysis. Of these subjects, 247 were Indigenous and 266 were non-Indigenous. The median follow-up period was 5.8 years (IQR, 3.1-9.8). The mean age at inclusion was 59.9 ± 12.3 years and 62.8% were males. The majority (93.6%) had type 2 diabetes and the median diabetes duration was 7 years (IQR, 3-12). There were 199 deaths, with a 5-year-mortality rate of 24.6%, and a 10-year-mortality rate of 45.4%. The mean age at death was 64.6 ± 11.8 years. In a multivariate analysis, the following variables were associated with mortality (adjusted HR, 95% CI): age 1.04 (1.02-1.05, P < 0.001); chronic kidney disease 1.22 (1.11-1.33, P < 0.001), and plasma albumin 0.96 (0.94-0.99, P < 0.05). The most common causes of death were chronic kidney disease (24.6%), cardiovascular events (19.6%), sepsis (15.6%), respiratory failure (10.0%), malignancy (9.5%) and multi-organ failure (5.0%). CONCLUSION Patients with DFU have high mortality. Age, chronic kidney disease, and low albumin levels increase the risk of mortality. Strategies should focus on ulcer prevention and aggressive risk factor reduction.
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Affiliation(s)
- Kanakamani Jeyaraman
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory Australia
| | - Thomas Berhane
- Department of Prosthetics and Orthotics, Royal Darwin Hospital, Darwin, Northern Territory Australia
| | - Mark Hamilton
- Department of Vascular Surgery, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
| | - Abhilash P. Chandra
- Department of Vascular Surgery, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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183
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Verde PE. The hierarchical metaregression approach and learning from clinical evidence. Biom J 2019; 61:535-557. [PMID: 30600534 DOI: 10.1002/bimj.201700266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 11/12/2022]
Abstract
The hierarchical metaregression (HMR) approach is a multiparameter Bayesian approach for meta-analysis, which generalizes the standard mixed effects models by explicitly modeling the data collection process in the meta-analysis. The HMR allows to investigate the potential external validity of experimental results as well as to assess the internal validity of the studies included in a systematic review. The HMR automatically identifies studies presenting conflicting evidence and it downweights their influence in the meta-analysis. In addition, the HMR allows to perform cross-evidence synthesis, which combines aggregated results from randomized controlled trials to predict effectiveness in a single-arm observational study with individual participant data (IPD). In this paper, we evaluate the HMR approach using simulated data examples. We present a new real case study in diabetes research, along with a new R package called jarbes (just a rather Bayesian evidence synthesis), which automatizes the complex computations involved in the HMR.
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Affiliation(s)
- Pablo Emilio Verde
- Coordination Center for Clinical Trials, Düsseldorf University Hospital, Moorenstr, Düsseldorf, Germany
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184
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Ning J, Zhao H, Chen B, Mi EZ, Yang Z, Qing W, Lam KWJ, Yi B, Chen Q, Gu J, Ichim T, Bogin V, Lu K, Ma D. Argon Mitigates Impaired Wound Healing Process and Enhances Wound Healing In Vitro and In Vivo. Theranostics 2019; 9:477-490. [PMID: 30809288 PMCID: PMC6376177 DOI: 10.7150/thno.29361] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/04/2018] [Indexed: 12/26/2022] Open
Abstract
Diabetic foot ulcers are associated with significant morbidity and mortality, and current treatments are far from optimal. Chronic wounds in diabetes are characterised by impaired angiogenesis, leukocyte function, fibroblast proliferation, and keratinocyte migration and proliferation. Methods: We tested the effect of exposure to argon gas on endothelial cell, fibroblast, macrophage and keratinocyte cell cultures in vitro and in vivo of a streptozotocin-induced diabetic mouse model. Results: Exposure to normobaric argon gas promotes multiple steps of the wound healing process. Argon accelerated angiogenesis, associated with upregulation of pro-angiogenic Angiopoietin-1 and vascular endothelial growth factor (VEGF) signalling in vitro and in vivo. Treatment with argon enhanced expression of transforming growth factor (TGF)-β, early recruitment of macrophages and keratinocyte proliferation. Argon had a pro-survival effect, inducing expression of cytoprotective mediators B-cell lymphoma 2 and heme oxygenase 1. Argon was able to accelerate wound closure in a diabetic mouse model. Conclusion: Together these findings indicate that argon gas may be a promising candidate for clinical use in treatment of diabetic ulcers.
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185
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Lin CW, Armstrong DG, Lin CH, Liu PH, Hung SY, Lee SR, Huang CH, Huang YY. Nationwide trends in the epidemiology of diabetic foot complications and lower-extremity amputation over an 8-year period. BMJ Open Diabetes Res Care 2019; 7:e000795. [PMID: 31749971 PMCID: PMC6827817 DOI: 10.1136/bmjdrc-2019-000795] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/12/2019] [Accepted: 09/24/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To study the prevalence and trends of lower extremity complications of diabetes over an 8-year period in a single nation. RESEARCH DESIGN AND METHODS Nationwide data for people with type 2 diabetes (T2D) and diabetic foot complications (DFCs) were analyzed over an 8-year period (2007-2014) from National Health Insurance Research Database using the International Classification of Diseases, Ninth Revision disease coding. The DFCs were defined as ulcers, infections, gangrene, and hospitalization for peripheral arterial disease (PAD). Trends of patient characteristics, foot presentation, and the execution of major procedures were studied, including lower-extremity amputations (LEAs). RESULTS Along with the T2D population increasing over time, the absolute number of people with DFCs increased by 33.4%, but retained a prevalence of around 2% per year. The annual incident of LEAs decreased from 2.85 to 2.06 per 1000 T2D population (p=0.001) with the major LEA proportion decreasing from 56.2% to 47.4% (p<0.001).The mean age of patients increased from 65.3 to 66.3 years and most of the associated comorbidities of diabetes were increased. For example, end-stage renal disease increased from 4.9% to 7.7% (p=0.008). The incidence of gangrene on presentation decreased from 14.7% to 11.3% (p<0.001) with a concomitant increase in vascular interventions (6.2% to 19.5%, p<0.001). CONCLUSIONS DFCs remain a sustained major medical problem. These nationwide long-term data suggest trends toward older people with greater comorbidities such as PAD and renal disease. Nevertheless, promising trends of reducing gangrene on presentation paired with increases in vascular interventions support continued vigilance and rapid, coordinated interdisciplinary diabetic foot care.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - 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, USA
| | - Chia-Hung Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Pi-Hua Liu
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Shu-Ru Lee
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
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186
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Jansen RB, Møller Christensen T, Bülow J, Rørdam L, Holstein PE, Svendsen OL. Long-term effects on the progress of neuropathy after diabetic Charcot foot: an 8.5-year prospective case–control study. BMC Res Notes 2018; 11:140. [PMID: 29458435 PMCID: PMC5819300 DOI: 10.1186/s13104-018-3253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/14/2018] [Indexed: 11/23/2022] Open
Abstract
Objective Charcot foot is a severe complication to diabetes mellitus, associated with diabetic neuropathy. Any long-term effects of a Charcot foot on the progress of neuropathy are still largely unexplored. The objective was to investigate whether a previous Charcot foot had any long-term effects on the progress of neuropathy. Results An 8.5-year follow-up case–control study of 49 individuals with diabetes mellitus, 24 of whom also had Charcot foot at baseline visit in 2005–2007. Neuropathy was assessed with a questionnaire, biothesiometry, heart rate variability and venous occlusion plethysmography. Of the 49 baseline participants, 22 were able to participate in the follow-up. Twelve had passed away in the meantime. Heart rate variability was unchanged in both groups; from 9.7 to 7.2 beats/min (p = 0.053) in the Charcot group, and 14.3 to 12.6 beats/min (p = 0.762) in the control group. Somato-sensoric neuropathy showed no difference between baseline and follow-up in the Charcot group (from 39.1 to 38.5 V) (p = 0.946), but a significantly worsened sensitivity in the control group (from 25.1 to 38.9 V) (p = 0.002). In conclusion, we found that any differences in somatic or cardial autonomic neuropathy present at baseline had disappeared at follow-up after 8.5 years. Electronic supplementary material The online version of this article (10.1186/s13104-018-3253-5) contains supplementary material, which is available to authorized users.
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187
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Scain SF, Franzen E, Hirakata VN. Effects of nursing care on patients in an educational program for prevention of diabetic foot. ACTA ACUST UNITED AC 2018; 39:e20170230. [PMID: 30517431 DOI: 10.1590/1983-1447.2018.20170230] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/31/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Identify in patients with type 2 diabetes what changes in the feet would be associated with demographic, clinical, biochemical and treatment characteristics and which would increase the risk of mortality. METHODS Retrospective longitudinal study evaluating the alterations in feet of outpatients attended at a nursing visit. Data from the clinical history and foot exam were collected from 918 medical records of a convenience sample. RESULTS At 10 years, the cumulative mortality attributable to peripheral polyneuropathy was 44.7%, to peripheral artery disease was 71.7%, to both conditions were 62.4%, and to amputation was 67.6%. After multivariate analysis, duration of nursing follow-up remained as the only protective factor against death (p < 0.001). CONCLUSIONS The risk of death in these patients decreased when they had consultations with a nurse educator. Ischemic feet, amputation, and coronary artery disease remained independent risk factors.
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Affiliation(s)
- Suzana Fiore Scain
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Enfermagem Ambulatorial. Porto Alegre, Rio Grande do Sul, Brasil
| | - Elenara Franzen
- Hospital de Clínicas de Porto Alegre (HCPA), Serviço de Enfermagem Ambulatorial. Porto Alegre, Rio Grande do Sul, Brasil
| | - Vânia Naomi Hirakata
- Hospital de Clínicas de Porto Alegre (HCPA), Unidade de Bioestatística. Porto Alegre, Rio Grande do Sul, Brasil
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188
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Boodoo C, Perry JA, Leung G, Cross KM, Isaranuwatchai W. Cost-effectiveness of telemonitoring screening for diabetic foot ulcer: a mathematical model. CMAJ Open 2018; 6:E486-E494. [PMID: 30337474 PMCID: PMC6201712 DOI: 10.9778/cmajo.20180088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND One of the most common (and costly) complications of diabetes are diabetic foot ulcers, which often result in lower-extremity amputation. Regular foot care can reduce complications; however, roughly half of Canadians with diabetes do not participate in screening. We sought to evaluate the economic effects of using telemonitoring for diabetic foot ulcer prevention using mathematical modelling. METHODS We used Markov modelling to compare current screening standards (standard care) to population-wide and targeted (high-risk) telemonitoring programs in a hypothetical cohort of Canadian patients aged 60 years. We varied the effectiveness (or outcome), defined as the proportion of diabetic foot ulcers prevented, to explore cost-effectiveness using model parameters from published literature and clinical experts. RESULTS At 20%-40% effectiveness, population-based prevention resulted in 0.00399-0.00790 quality-adjusted life years (QALYs) gained per person over 5 years and an incremental cost of $479-$402 compared to standard care. At 15%-40% effectiveness, high-risk prevention resulted in a cost decrease per person over 5 years ($1.26-$25.55), with health benefits of 0.000207-0.00058 QALYs gained. INTERPRETATION The use of telemonitoring in the diabetic lower extremity can offer patients better quality of life and can be cost-effective compared to current Canadian screening practices. Future work should focus on developing and validating technologies based on objective outcome measures for remote monitoring of the diabetic foot.
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Affiliation(s)
- Chris Boodoo
- Department of Medical Imaging (Boodoo, Leung), Division of Plastic Surgery (Perry, Cross), Centre for Excellence in Economic Analysis Research (Isaranuwatchai) and Keenan Research Centre for Biomedical Science (Leung, Cross), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Isaranuwatchai), University of Toronto, Toronto, Ont
| | - Julie A Perry
- Department of Medical Imaging (Boodoo, Leung), Division of Plastic Surgery (Perry, Cross), Centre for Excellence in Economic Analysis Research (Isaranuwatchai) and Keenan Research Centre for Biomedical Science (Leung, Cross), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Isaranuwatchai), University of Toronto, Toronto, Ont
| | - General Leung
- Department of Medical Imaging (Boodoo, Leung), Division of Plastic Surgery (Perry, Cross), Centre for Excellence in Economic Analysis Research (Isaranuwatchai) and Keenan Research Centre for Biomedical Science (Leung, Cross), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Isaranuwatchai), University of Toronto, Toronto, Ont
| | - Karen M Cross
- Department of Medical Imaging (Boodoo, Leung), Division of Plastic Surgery (Perry, Cross), Centre for Excellence in Economic Analysis Research (Isaranuwatchai) and Keenan Research Centre for Biomedical Science (Leung, Cross), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Isaranuwatchai), University of Toronto, Toronto, Ont
| | - Wanrudee Isaranuwatchai
- Department of Medical Imaging (Boodoo, Leung), Division of Plastic Surgery (Perry, Cross), Centre for Excellence in Economic Analysis Research (Isaranuwatchai) and Keenan Research Centre for Biomedical Science (Leung, Cross), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation (Isaranuwatchai), University of Toronto, Toronto, Ont.
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190
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Walters ET, Kim PJ. Diabetic Foot Ulcer: Prevention, Management, and Controversies. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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191
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Nikoloudi M, Eleftheriadou I, Tentolouris A, Kosta OA, Tentolouris N. Diabetic Foot Infections: Update on Management. Curr Infect Dis Rep 2018; 20:40. [PMID: 30069605 DOI: 10.1007/s11908-018-0645-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Diabetic foot infections (DFIs) are common in patients with diabetes mellitus complicated by foot ulcers and can be classified in different categories based on their severity. In this report, we present the diagnosis and management of DFIs according to their classification. RECENT FINDINGS While appropriate antibiotic regiments and surgical techniques for the treatment of DFIs are well established, new technologies and techniques for example in medical imaging, wound care modalities, and supplementary therapy approaches show potentially promising results in preventing DFIs. As with every complex disease, fine tuning DFI management can be challenging as it requires careful evaluation of different parameters. It demands timely action, close collaboration of different specialties, and patient cooperation.
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Affiliation(s)
- Maria Nikoloudi
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 17 Agiou Thoma Street, Athens, Greece
| | - Ioanna Eleftheriadou
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 17 Agiou Thoma Street, Athens, Greece
| | - Anastasios Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 17 Agiou Thoma Street, Athens, Greece
| | - Ourania A Kosta
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 17 Agiou Thoma Street, Athens, Greece
| | - Nikolaos Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 17 Agiou Thoma Street, Athens, Greece.
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The Predictive Factors Associated With Comorbidities for Treatment Response in Outpatients With King Classification III Diabetes Foot Ulcers. Ann Plast Surg 2018; 81:S39-S43. [PMID: 29851722 DOI: 10.1097/sap.0000000000001500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study is to investigate the preexisting predictive factors associated with comorbidities for diabetic foot ulcer (DFU) in King classification III at an outpatient clinic. METHOD This prospective study included 100 patients with DFU in King classification III treated at outpatient clinics in Chiayi Chang Gung Memorial Hospital from January 2011 to December 2011. The least follow-up time was 1 year. Medical documentations were in respect of patient's baseline characteristics, associated history, presence of comorbidities, follow-up time, and condition of wounds. Patients were divided into success group (healed or healing with wound reduction), stagnate group, and failure group (amputation or infection, need in-hospital medical service) in accordance with the treatment response of wounds. χ Test, Fisher exact test, and 1-way analysis of variance were used for variables in 3-group comparison, whereas Student t test was applied in 2-group comparison. The predictive factors with P value less than 0.1 were further investigated using the model of univariate logistic regression. RESULTS With 3-group stratification according to treatment response-failure (n = 8), stagnate (n = 22), and success (n = 70)-the occurrence rate of retinopathy was higher in the treatment stagnate group (42.1%) than in the treatment failure (14.3%) and success groups (12.5%; P = 0.019); the rate of previous percutaneous transluminal angioplasty (PTA) history was higher in the treatment failure group (25%) than in the treatment stagnate (4.8%) and success groups (1.5%; P = 0.020). With 2-group stratification-failure (n = 8) versus nonfailure (n = 92), and success (n = 70) versus nonsuccess (n = 30)-PTA history was strongly associated with treatment failure (odds ratio [OR], 14.33; 95% confidence interval [CI], 1.71-120.32; P = 0.014), whereas retinopathy (OR, 0.21; 95% CI, 0.07-0.65; P = 0.006) was the major negative predictor for treatment success. Previous debridement met borderline significance to predict treatment nonsuccess (OR, 0.09; 95% CI, 0.01-1.01; P = 0.051). Sex, age, associated history, dyslipidemia, hypertension, coronary artery disease, cerebrovascular accident, chronic kidney disease, and end-stage renal disease and wound condition had no statistical significance. CONCLUSIONS Previous PTA and retinopathy, which indicated preexisting severe vasculopathy, are univariate predictive factors for treatment failure and nonsuccess, respectively, in patients with King classification III DFU. With the subdivision of King classification III DFU, medical history taking and fundus examination are acceptable methods for risk screening at an outpatient clinic.
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Kampen WU, Westphal F, Van den Wyngaert T, Strobel K, Kuwert T, Van der Bruggen W, Gnanasegaran G, Jens JH, Paycha F. SPECT/CT in Postoperative Foot and Ankle Pain. Semin Nucl Med 2018; 48:454-468. [PMID: 30193651 DOI: 10.1053/j.semnuclmed.2018.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Postoperative pain is a clinically relevant issue in orthopedic patients, affecting more than 40% 1 year after foot and ankle surgery. Because of the very complex anatomy with many different joints and several motion axes, clinical examination and conventional imaging are sometimes not sufficient to identify a local pain generator. Local uptake of bone-seeking radiopharmaceuticals is known to correlate accurately with sites of pain generating foci and, thus, bone scintigraphy has been an established method to evaluate these respective patients for many years. However, the specificity is rather low if only planar images are acquired. The development of SPECT and especially of hybrid SPECT and CT imaging has significantly enhanced the specificity of this technique. The combination of both functional and morphological imaging, ideally performed with a dedicated SPECT/CT system to minimize misregistration owing to motion artifacts and to enhance image quality by attenuation correction, allows an early and reliable detection of pathologic bone processes, even in patients where radiological imaging with MRI or CT is hampered by metal implants. In diabetic patients with a neuropathic Charcot osteoarthropathy, infection can be differentiated from inflammatory bone alterations (causing bone marrow edema) almost certainly using SPECT/CT with radiolabeled white blood cells and antigranulocyte antibodies, allowing an individual and precise treatment planning either in the initial course of the disease or even after surgery. This article reviews the most frequent clinical challenges in patients after foot and ankle surgery, including a description of the various surgical procedures, the different imaging options with their advantages and disadvantages, and aims to integrate bone SPECT/CT into the clinical diagnostic workup.
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Affiliation(s)
| | - Florian Westphal
- Department of Endoprothetic and Joint Surgery, Tabea Hospital, Hamburg, Germany
| | - Tim Van den Wyngaert
- Department of Nuclear Medicine, Antwerp University Hospital, Edegem, Belgium.; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Klaus Strobel
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Germany
| | - Wouter Van der Bruggen
- Department of Radiology and Nuclear Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - Gopinath Gnanasegaran
- Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jan-Hauke Jens
- Department of Endoprothetic and Joint Surgery, Tabea Hospital, Hamburg, Germany
| | - Frédéric Paycha
- Department of Nuclear Medicine, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
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Jeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJM. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care 2018; 41:645-652. [PMID: 29559450 DOI: 10.2337/dc17-1836] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/04/2018] [Indexed: 02/03/2023]
Abstract
Diabetic foot ulcers remain a major health care problem. They are common, result in considerable suffering, frequently recur, and are associated with high mortality, as well as considerable health care costs. While national and international guidance exists, the evidence base for much of routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individuals. It is probable that this contributes to the geographic variation in outcome that has been documented in a number of countries. This article considers these issues in depth and emphasizes the urgent need to improve the design and conduct of clinical trials in this field, as well as to undertake systematic comparison of the results of routine care in different health economies. There is strong suggestive evidence to indicate that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes.
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Affiliation(s)
- William J Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, U.K.
| | - Loretta Vileikyte
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K., and Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | | | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Andrew J M Boulton
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K., and Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
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Wang S, He Y, Xu L, Zhang S, Gu X, Gu J, Shi J, Shen Y, Tang Z. Association between QTc interval prolongation and outcomes of diabetic foot ulcers: Data from a 4-year follow-up study in China. Diabetes Res Clin Pract 2018; 138:26-34. [PMID: 29382590 DOI: 10.1016/j.diabres.2018.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/30/2017] [Accepted: 01/23/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine whether QTc interval prolongation is an independent risk factor of outcomes in patients with diabetic foot ulcers (DFU). RESEARCH DESIGN AND METHODS 331 patients with type 2 diabetes and DFU hospitalized in a Chinese tertiary hospital were recruited. ECG was done at baseline and QTc interval was calculated through Bazett's formula. Participants were classified into 2 groups according to the QTc interval as prolonged (≥440 ms) or not (<440 ms). These patients were followed-up for an average of 48 months to observe the outcomes, including ulcer healing, ulcer recurrence, nonfatal cerebral or cardiovascular events (NCCVE), cerebral cardiovascular death, cardiac death and all-cause death. The associations between the risk of outcomes and QTc interval prolongation, as well as per 1-SD increase in QTc interval were analyzed by Cox proportional-hazards models. RESULTS In terms of the univariate Cox proportional hazard models, patients with QTc interval prolongation had a higher all-cause mortality (HR = 1.621, 95%CI: 1.040-2.526, P = .013), higher cardiac mortality (HR = 2.011 95%CI: 1.106-3.657, P = .019), higher cerebral cardiovascular mortality (HR = 1.525, 95%CI: 0.8151-2.852, P = .045). The multivariate analysis showed that QTc prolongation was an independent risk factor for cardiac death (HR = 5.465, 95%CI: 2.818-8.112, P = .039). Similar results were obtained when QTc interval was used as a continue variable, a 1-SD increase in QTc interval was associated with an 5.883 times risk for cardiac mortality (HR = 6.883, 95%CI: 4.153-9.613, P = .012). The association between QTc interval prolongation with ulcer healing, recurrence and NCCVE were not observed either in univariate or multivariate analysis (P > .05). CONCLUSION QTc interval prolongation was a plausible predictor for cardiac death in DFU patients, but it cannot accurately predict ulcer healing or recurrence.
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Affiliation(s)
- Shumin Wang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Yang He
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Lei Xu
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Shanshan Zhang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China
| | - Xueming Gu
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Junyi Gu
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Jianyuan Shi
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Yaping Shen
- Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China
| | - Zhengyi Tang
- Shanghai Clinical Center for Endocrine and Metabolism Diseases, Yuanyang Subdivision for Diabetic Foot Disease, Shanghai Institute of Endocrine and Metabolism Disease, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200025, China; Department of Internal Medicine, Shanghai Yuanyang Hospital, Shanghai 200031, China.
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Novel Multivalent Wound-Healing Ointment Provides Bioburden Control and Moisture Management: A Retrospective Registry Data Analysis. Adv Skin Wound Care 2018; 29:461-8. [PMID: 27632443 DOI: 10.1097/01.asw.0000490193.96840.9e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this retrospective registry data analysis was to explore the effectiveness of a novel multivalent topical ointment (Terrasil Infection Control Wound Care Ointment; Aspiera Medical, Woonsocket, Rhode Island), containing a patented mineral complex and 0.2% benzethonium chloride in the treatment of nonhealing acute and chronic wounds. DESIGN Aspiera Medical designed a registry to capture physician experiences and treatment results with Terrasil Infection Control Wound Care Ointment. Physicians were asked to enter deidentified patient data into an online registry. SETTING Wound clinics in the United States were asked to participate in the registry. PATIENTS Physicians at 4 wound clinics treated 30 patients (26 of whom completed the treatment) with various chronic wounds that had persisted for an average of 6 months and entered treatment data into the registry. INTERVENTIONS Patients applied the ointment according to physician orders. Concurrent treatments used by patients included offloading, compression wraps, and dressings, such as collagen and calcium alginate. Patients were treated until complete wound closure or lost to follow-up. MAIN OUTCOME MEASURES Physicians calculated each patient's percentage wound reduction at each visit. MAIN RESULTS Thirty patients were entered into the registry. Pretreatment and posttreatment measurements were available for 26 of them. Patients achieved an average surface area reduction of 84% in a mean of 23 days' treatment. CONCLUSION The antimicrobial and moisturizing ointment studied appears to be effective in promoting wound closure in a variety of acute and chronic wounds. Wounds studied included diabetic foot ulcers, venous leg ulcers, venous stasis ulcers, surgical infections, burns, and insect bites. The results of this registry data analysis will be used to inform planned clinical trials.
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Huang YY, Lin CW, Yang HM, Hung SY, Chen IW. Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene. J Foot Ankle Res 2018; 11:1. [PMID: 29312468 PMCID: PMC5755273 DOI: 10.1186/s13047-017-0243-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 12/19/2017] [Indexed: 01/22/2023] Open
Abstract
Background Infectious gangrene of the foot is a serious complication of diabetes that usually leads to a certain level of lower-extremity amputation (LEA). Nevertheless, the long-term survival and factors associated with mortality in such patients have yet to be elucidated. Methods A total of 157 patients with type 2 diabetes who received treatment for infectious foot gangrene at a major diabetic foot center in Taiwan from 2002 to 2009 were enrolled, of whom 90 had major LEAs (above the ankle) and 67 had minor LEAs (below the ankle). Clinical data during treatment were used for the analysis of survival and LEA, and survival was tracked after treatment until December 2012. Results Of the 157 patients, 109 died, with a median survival time of 3.12 years and 5-year survival rate of 40%. Age [hazard ratio 1.04 (95% confidence interval 1.01–1.06)], and major LEA [1.80 (1.05–3.09)] were independent factors associated with mortality. Patients with minor LEAs had a better median survival than those with major LEAs (5.5 and 1.9 years, respectively, P < 0.01). An abnormal ankle-brachial index was an independent risk factor [odds ratio 3.12 (95% CI 1.18–8.24)] for a poor outcome (major LEA) after adjusting for age, smoking status, hypertension, major adverse cardiac events, and renal function. Conclusions Efforts to limit amputations below the ankle resulted in better survival of patients with infectious foot gangrene. An abnormal ankle-brachial index may guide physicians to make appropriate decisions with regards to the amputation level.
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Affiliation(s)
- Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan.,Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan
| | - Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan
| | - Hui-Mei Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan
| | - I-Wen Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, 5, Fuxing St., Guishan Dist, Taoyuan City, 333 Taiwan
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Ndosi M, Wright‐Hughes A, Brown S, Backhouse M, Lipsky BA, Bhogal M, Reynolds C, Vowden P, Jude EB, Nixon J, Nelson EA. Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study. Diabet Med 2018; 35:78-88. [PMID: 29083500 PMCID: PMC5765512 DOI: 10.1111/dme.13537] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2017] [Indexed: 01/07/2023]
Abstract
AIMS To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer. METHODS This multicentre, prospective, observational study reviewed participants' data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants' notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence. RESULTS In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06). CONCLUSIONS Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.
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Affiliation(s)
- M. Ndosi
- Department of Nursing and MidwiferyUniversity of the West of EnglandBristolUK
- Academic Rheumatology UnitUniversity Hospitals Bristol NHS Foundation TrustBristolUK
| | | | - S. Brown
- Clinical Trials Research UnitUniversity of LeedsLeedsUK
| | - M. Backhouse
- Leeds Institute of Rheumatic and Musculoskeletal MedicineUniversity of LeedsLeedsUK
| | - B. A. Lipsky
- Division of Medical SciencesUniversity of OxfordOxfordUK
| | - M. Bhogal
- School of Biomedical SciencesUniversity of LeedsLeedsUK
| | - C. Reynolds
- Clinical Trials Research UnitUniversity of LeedsLeedsUK
| | | | - E. B. Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust Ashton‐Under‐LyneUK
- University of ManchesterManchesterUK
| | - J. Nixon
- Clinical Trials Research UnitUniversity of LeedsLeedsUK
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Yazdanpanah L, Shahbazian H, Nazari I, Arti HR, Ahmadi F, Mohammadianinejad SE, Cheraghian B, Hesam S. Incidence and Risk Factors of Diabetic Foot Ulcer: A Population-Based Diabetic Foot Cohort (ADFC Study)-Two-Year Follow-Up Study. Int J Endocrinol 2018; 2018:7631659. [PMID: 29736169 PMCID: PMC5875034 DOI: 10.1155/2018/7631659] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/30/2018] [Indexed: 01/30/2023] Open
Abstract
AIM/INTRODUCTION This study was carried out to assess the incidence and risk factors of diabetic foot ulcer (DFU). MATERIALS AND METHODS In this prospective cohort study in a university hospital, all the participants were examined and followed up for new DFU as final outcome for two years. To analyze the data, the variables were first evaluated with a univariate analysis. Then variables with P value < 0.2 were tested with a multivariate analysis, using backward-elimination multiple logistic regression. RESULTS Among 605 patients, 39 cases had DFU, so we followed up the remaining 566 patients without any present or history of DFU. A two-year cumulative incidence of diabetic foot ulcer was 5.62% (95% CI 3.89-8.02). After analysis, previous history of DFU or amputation [OR = 9.65, 95% CI (2.13-43.78), P value = 0.003], insulin usage [OR = 5.78, 95% CI (2.37-14.07), P value < 0.01], gender [OR = 3.23, 95% CI (1.33-7.83), P value = 0.01], distal neuropathy [OR = 3.37, 95% CI (1.40-8.09), P value = 0.007], and foot deformity [OR = 3.02, 95% CI (1.10-8.29), P value = 0.032] had a statistically significant relationship with DFU incidence. CONCLUSION Our data showed that the average annual DFU incidence is about 2.8%. Independent risk factors of DFU development were previous history of DFU or amputation, insulin consumption, gender, distal neuropathy, and foot deformity. These findings provide support for a multifactorial etiology for DFU.
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Affiliation(s)
- Leila Yazdanpanah
- Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hajieh Shahbazian
- Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Iraj Nazari
- Department of Vascular Surgery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hamid Reza Arti
- Department of Orthopedic, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fatemeh Ahmadi
- Infectious Disease Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Bahman Cheraghian
- Department of Epidemiology and Biostatistics, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Saeed Hesam
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Shin JY, Roh SG, Sharaf B, Lee NH. Risk of major limb amputation in diabetic foot ulcer and accompanying disease: A meta-analysis. J Plast Reconstr Aesthet Surg 2017; 70:1681-1688. [DOI: 10.1016/j.bjps.2017.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/09/2017] [Accepted: 07/26/2017] [Indexed: 01/11/2023]
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