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Suludere MA, Öz OK, Rogers LC, Wukich DK, Malone M, Lavery LA. MRSA infection, re-infection and clinical outcomes in diabetic foot infections. Wound Repair Regen 2024; 32:377-383. [PMID: 38419162 DOI: 10.1111/wrr.13164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/27/2024] [Accepted: 02/18/2024] [Indexed: 03/02/2024]
Abstract
The aim was to investigate methicillin-resistant Staphylococcus aureus (MRSA) incidence, conversion and outcomes in diabetic foot infections (DFIs). This is a pooled patient-level analysis of combined data sets from two randomised clinical trials including 219 patients admitted to the hospital with moderate or severe DFIs. Intraoperative bone and tissue cultures identified bacterial pathogens. We identified pathogens at index infections and subsequent re-infections. We identified MRSA conversion (MSSA to MRSA) in re-infections. MRSA incidence in index infections was 10.5%, with no difference between soft tissue infections (STIs) and osteomyelitis (OM). MRSA conversion occurred in 7.7% of the re-infections in patients who initially had MSSA in their cultures. Patients with re-infection were 2.2 times more likely to have MRSA compared to the first infection (10.5% vs. 25.8%, relative risk [RR] = 2.2, p = 0.001). Patients with MRSA had longer antibiotic treatment during the 1-year follow-up, compared to other pathogens (other 49.8 ± 34.7 days, MRSA 65.3 ± 41.5 days, p = 0.04). Furthermore, there were no differences in healing, time to heal, length of stay, re-infection, amputation, re-ulceration, re-admission, surgery after discharge and amputation after discharge compared to other pathogens. The incidence of MRSA at the index was 10.5% with no difference in STI and OM. MRSA incidence was 25.8% in re-infections. The RR of having MRSA was 2.2 times higher in re-infections. Patients with MRSA used more antibiotics during the 1-year follow-up. Furthermore, there were no differences in clinical outcomes compared to other bacterial pathogens.
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Affiliation(s)
- Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lee C Rogers
- Department of Orthopedic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Malone
- Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Liverpool, New South Wales, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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2
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Che D, Jiang Z, Xiang X, Zhao L, Liu X, Zhou B, Xie J, Li H, Lv Y, Cao D. Predictors of amputation in patients with diabetic foot ulcers: a multi-centre retrospective cohort study. Endocrine 2024; 85:181-189. [PMID: 38332209 DOI: 10.1007/s12020-024-03704-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Investigating risk factors for amputation in patients with diabetic foot ulcer (DFU) and developing a nomogram prediction model. METHODS We gathered case data of DFU patients from five medical institutions in Anhui Province, China. Following eligibility criteria, a retrospective case-control study was performed on data from 526 patients. RESULTS Among the 526 patients (mean age: 63.32 ± 12.14), 179 were female, and 347 were male; 264 underwent amputation. Univariate analysis identified several predictors for amputation, including Blood type-B, Ambulation, history of amputation (Hx. Of amputation), Bacterial culture-positive, Wagner grade, peripheral arterial disease (PAD), and laboratory parameters (HbA1c, Hb, CRP, ALB, FIB, PLT, Protein). In the multivariate regression, six variables emerged as independent predictors: Blood type-B (OR = 2.332, 95%CI [1.488-3.657], p < 0.001), Hx. Of amputation (2.298 [1.348-3.917], p = 0.002), Bacterial culture-positive (2.490 [1.618-3.830], p <0.001), Wagner 3 (1.787 [1.049-3.046], p = 0.033), Wagner 4-5 (4.272 [2.444-7.468], p <0.001), PAD (1.554 [1.030-2.345], p = 0.036). We developed a nomogram prediction model utilizing the aforementioned independent risk factors. The model demonstrated a favorable predictive ability for amputation risk, as evidenced by its area under the receiver operating characteristics (ROC) curve of 0.756 and the well-fitted corrected nomogram calibration curve. CONCLUSION Our findings underscore Blood type-B, Hx. Of amputation, Bacterial culture-positive, Wagner 3-5, and PAD as independent risk factors for amputation in DFU patients. The resultant nomogram exhibits substantial accuracy in predicting amputation occurrence. Timely identification of these risk factors can reduce DFU-related amputation rates.
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Affiliation(s)
- Dehui Che
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhengwan Jiang
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xinjian Xiang
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | | | - Xie Liu
- Taihe Hospital of Wannan Medical College, Shiyan, China
| | - Bingru Zhou
- The Affiliated Hospital of North Anhui College of Health Professions, Hefei, China
| | - Juan Xie
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Honghong Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yang Lv
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dongsheng Cao
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China.
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Tseng SL, Kang L, Li ZJ, Wang LQ, Li ZM, Li TH, Xiang JY, Huang JZ, Yu NZ, Long X. Adipose-derived stem cells in diabetic foot care: Bridging clinical trials and practical application. World J Diabetes 2024; 15:1162-1177. [PMID: 38983804 PMCID: PMC11229965 DOI: 10.4239/wjd.v15.i6.1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/03/2024] [Accepted: 04/19/2024] [Indexed: 06/11/2024] Open
Abstract
Diabetic foot ulcers (DFUs) pose a critical medical challenge, significantly im-pairing the quality of life of patients. Adipose-derived stem cells (ADSCs) have been identified as a promising therapeutic approach for improving wound healing in DFUs. Despite extensive exploration of the mechanical aspects of ADSC therapy against DFU, its clinical applications remain elusive. In this review, we aimed to bridge this gap by evaluating the use and advancements of ADSCs in the clinical management of DFUs. The review begins with a discussion of the classification and clinical management of diabetic foot conditions. It then discusses the current landscape of clinical trials, focusing on their geographic distribution, reported efficacy, safety profiles, treatment timing, administration techniques, and dosing considerations. Finally, the review discusses the preclinical strategies to enhance ADSC efficacy. This review shows that many trials exhibit biases in study design, unclear inclusion criteria, and intervention protocols. In conclusion, this review underscores the potential of ADSCs in DFU treatment and emphasizes the critical need for further research and refinement of therapeutic approaches, with a focus on improving the quality of future clinical trials to enhance treatment outcomes and advance the field of diabetic wound care.
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Affiliation(s)
- Song-Lu Tseng
- Department of Plastic and Reconstructive Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lin Kang
- Biomedical Engineering Facility, Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences Beijing, Beijing 100021, China
| | - Zhu-Jun Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li-Quan Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zi-Ming Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Tian-Hao Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jie-Yu Xiang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jiu-Zuo Huang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Nan-Ze Yu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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4
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Huang J, Yang J, Qi H, Xu M, Xu X, Zhu Y. Prediction models for amputation after diabetic foot: systematic review and critical appraisal. Diabetol Metab Syndr 2024; 16:126. [PMID: 38858732 PMCID: PMC11163763 DOI: 10.1186/s13098-024-01360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Numerous studies have developed or validated prediction models aimed at estimating the likelihood of amputation in diabetic foot (DF) patients. However, the quality and applicability of these models in clinical practice and future research remain uncertain. This study conducts a systematic review and assessment of the risk of bias and applicability of amputation prediction models among individuals with DF. METHODS A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, EBSCO CINAHL Plus, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedical Literature Database (CBM), and Weipu (VIP) from their inception to December 24, 2023. Two investigators independently screened the literature and extracted data using the checklist for critical appraisal and data extraction for systematic reviews of prediction modeling studies. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was employed to evaluate both the risk of bias and applicability. RESULTS A total of 20 studies were included in this analysis, comprising 17 development studies and three validation studies, encompassing 20 prediction models and 11 classification systems. The incidence of amputation in patients with DF ranged from 5.9 to 58.5%. Machine learning-based methods were employed in more than half of the studies. The reported area under the curve (AUC) varied from 0.560 to 0.939. Independent predictors consistently identified by multivariate models included age, gender, HbA1c, hemoglobin, white blood cell count, low-density lipoprotein cholesterol, diabetes duration, and Wagner's Classification. All studies were found to exhibit a high risk of bias, primarily attributed to inadequate handling of outcome events and missing data, lack of model performance assessment, and overfitting. CONCLUSIONS The assessment using PROBAST revealed a notable risk of bias in the existing prediction models for amputation in patients with DF. It is imperative for future studies to concentrate on enhancing the robustness of current prediction models or constructing new models with stringent methodologies.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin Yang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiou Qi
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Miaomiao Xu
- Orthopedics Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Operating Room, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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5
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Villa F, Marchandin H, Lavigne JP, Schuldiner S, Cellier N, Sotto A, Loubet P. Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management. Clin Microbiol Rev 2024:e0014323. [PMID: 38819166 DOI: 10.1128/cmr.00143-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.
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Affiliation(s)
- Fanny Villa
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Service de Microbiologie et Hygiène, Hospitalière, CHU Nîmes, Nîmes, France
| | - Jean-Philippe Lavigne
- VBIC, INSERM U1047, Univ Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Métaboliques et Endocriniennes, CHU Nîmes, Nîmes, France
| | | | - Albert Sotto
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Paul Loubet
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
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6
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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The unique multidisciplinarity of diabetes-related foot disease. Diabetes Metab Res Rev 2024; 40:e3804. [PMID: 38616492 DOI: 10.1002/dmrr.3804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Few diseases globally require treatment from so many different disciplines as diabetes-related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence-based treatment in diabetes-related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews, all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes-related foot disease.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Fran Game
- Research and Development Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- Cross I&D, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Univ-lille, Tourcoing, France
| | - Nicolaas C Schaper
- Division Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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7
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Monteiro-Soares M, Game F. Podcast on How to Classify Foot Ulcers in People with Diabetes (2023 Update of the IWGDF Guidelines on Classification). Diabetes Ther 2024:10.1007/s13300-023-01521-2. [PMID: 38509442 DOI: 10.1007/s13300-023-01521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/14/2023] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION In this podcast, we present the result of the 2023 scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. METHODS These guidelines were based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. We first assessed the value of each system independently and, in the second stage, chose the best one or two to be used in each clinical scenario. RESULTS We recommend (1) for communication among healthcare professionals to use the Site, Ischaemia, Neuropathy, Bacterial infection, Area, Depth (SINBAD) classification (first option) or consider using Wound, Ischaemia, foot Infection (WIfI) system (alternative option, when the required equipment and level of expertise are available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (2) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (3) for characterising a person with an infected ulcer: the use of the IDSA (Infection Diseases Society of America)/IWGDF (first option) classification or consider using the WIfI system (alternative option, when the required equipment and level of expertise are available and it is considered as feasible); (4) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (5) for the audit of outcome(s) of populations: the use of the SINBAD score. CONCLUSION Although there is no classification that fits all purposes, it is crucial that healthcare professionals standardize the way they characterise diabetes-related foot ulcers and guide their decision-making process by using validated classification systems.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross Health School Lisbon, Lisbon and Oporto University Faculty of Medicine, Oporto, Portugal.
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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9
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Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3647. [PMID: 37226568 DOI: 10.1002/dmrr.3647] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/26/2023]
Abstract
AIMS Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. RESULTS For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. CONCLUSION These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Science, Program Rehabilitation & Development, Amsterdam, Netherlands
| | - David G Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - Ryan T Crews
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, North Chicago, Illinois, USA
| | - Catherine Gooday
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Gustav Jarl
- Faculty of Medicine and Health, Department of Prosthetics and Orthotics, Örebro University, Örebro, Sweden
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - Klaus Kirketerp-Moller
- Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark
- Steno Diabetes Center, Copenhagen, Denmark
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
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10
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev 2024; 40:e3687. [PMID: 37779323 DOI: 10.1002/dmrr.3687] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 10/03/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, the Netherlands
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11
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Classification of foot ulcers in people with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3645. [PMID: 37132179 DOI: 10.1002/dmrr.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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12
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Bus SA, Sacco ICN, Monteiro-Soares M, Raspovic A, Paton J, Rasmussen A, Lavery LA, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3651. [PMID: 37302121 DOI: 10.1002/dmrr.3651] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 06/13/2023]
Abstract
AIMS This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals. MATERIALS AND METHODS We followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature including, where appropriate, meta-analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability. RESULTS We recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at-risk about appropriate foot self-care, educate not to walk without suitable foot protection, and treat any pre-ulcerative lesion on the foot. Educate moderate-to-high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low-to-moderate risk to undertake a, preferably supervised, foot-ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight-bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate-to-high-risk people with diabetes to help prevent (recurrence of) ulceration. CONCLUSIONS These recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Joanne Paton
- School of Health Professions, University of Plymouth, Plymouth, UK
| | | | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, The Netherlands
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13
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Jiang X, Zeng YE, Li C, Wang K, Yu DG. Enhancing diabetic wound healing: advances in electrospun scaffolds from pathogenesis to therapeutic applications. Front Bioeng Biotechnol 2024; 12:1354286. [PMID: 38375451 PMCID: PMC10875055 DOI: 10.3389/fbioe.2024.1354286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
Diabetic wounds are a significant subset of chronic wounds characterized by elevated levels of inflammatory cytokines, matrix metalloproteinases (MMPs), and reactive oxygen species (ROS). They are also associated with impaired angiogenesis, persistent infection, and a high likelihood of hospitalization, leading to a substantial economic burden for patients. In severe cases, amputation or even mortality may occur. Diabetic foot ulcers (DFUs) are a common complication of diabetes, with up to 25% of diabetic patients being at risk of developing foot ulcers over their lifetime, and more than 70% ultimately requiring amputation. Electrospun scaffolds exhibit a structural similarity to the extracellular matrix (ECM), promoting the adhesion, growth, and migration of fibroblasts, thereby facilitating the formation of new skin tissue at the wound site. The composition and size of electrospun scaffolds can be easily adjusted, enabling controlled drug release through fiber structure modifications. The porous nature of these scaffolds facilitates gas exchange and the absorption of wound exudate. Furthermore, the fiber surface can be readily modified to impart specific functionalities, making electrospinning nanofiber scaffolds highly promising for the treatment of diabetic wounds. This article provides a concise overview of the healing process in normal wounds and the pathological mechanisms underlying diabetic wounds, including complications such as diabetic foot ulcers. It also explores the advantages of electrospinning nanofiber scaffolds in diabetic wound treatment. Additionally, it summarizes findings from various studies on the use of different types of nanofiber scaffolds for diabetic wounds and reviews methods of drug loading onto nanofiber scaffolds. These advancements broaden the horizon for effectively treating diabetic wounds.
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Affiliation(s)
- Xuewen Jiang
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, China
| | - Yu-E Zeng
- Department of Neurology, Ruijin Hospital Lu Wan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chaofei Li
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ke Wang
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, China
| | - Deng-Guang Yu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai, China
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14
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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The International Working Group on the Diabetic Foot: Stories and Numbers Behind Three Decades of Evidence-Based Guidelines for the Management of Diabetes-Related Foot Disease. Diabetes Ther 2024; 15:19-31. [PMID: 37971638 PMCID: PMC10786793 DOI: 10.1007/s13300-023-01510-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
Foot disease is a devastating complication of diabetes. For almost 3 decades, the mission of the International Working Group on the Diabetic Foot (IWGDF) is to produce evidence-based guidelines to inform health care providers worldwide on strategies for the prevention and management of diabetes-related foot disease. In this publication, we aim to better inform the reader about 'the story behind' the IWGDF Guidelines and thus facilitate improved uptake of the recommendations described in the guidelines. The first IWGDF Guidelines were published in 1999, and these have been successfully updated every 4 years since. With each update, IWGDF has improved the methodological rigour and extended the topics covered. This has been possible thanks to the involvement of > 100 experts from > 60 countries, all voluntarily dedicating their time. We estimate that the 2023 update of the IWGDF Guidelines required a total 10 years of full-time work, which would have cost 2 million euros if the voluntary work had been financially compensated. The IWGDF Guidelines are not only published in English but also translated to support local implementation. Currently available translations serve 2.9 billion people globally in their native language. As an independent and multidisciplinary organisation, IWGDF hopes that the 2023 update will continue to stimulate clinicians from all different disciplines to deliver the best care possible for these patients, will motivate researchers to undertake the high-quality trials needed to deliver the new evidence to advance the field further, and collectively will support people with diabetes-related foot disease to minimize their disease burdens.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Vascular and Endovascular Surgery Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health-Lisbon, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine, Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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15
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Viadé J, Nicolás M, Bundó M, Sirvent M, Riera C, Sabriá M. A novel assessment, diagnostic and treatment system for diabetic foot. J Foot Ankle Res 2023; 16:84. [PMID: 38001471 PMCID: PMC10675945 DOI: 10.1186/s13047-023-00687-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/19/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND This report aims to present a novel system for the management of foot lesions in patients with diabetes. It was developed in the diabetic foot unit (DFU) of the Mutua de Terrassa University Hospital (HUMT) by primary care professionals, the Diabetic Foot Clinic (DFC), and during emergency cases treated by our group based on daily activities in patients with neuropathy or neuroischemia. BODY: This system considers five degrees of action based on two fixed variables: presence of infection and lesion depth. These two variables allowed the user to investigate aspects of the system until the overall action required by the pathology is made clear. These variables establish pathology stages of various severities that require different actions in aspects of care, management and treatment. CONCLUSION This tool facilitates diagnosis, treatment, and coordination among different members of a multidisciplinary team working in specialized hospital units, primary care centers, and emergency settings.
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Affiliation(s)
- Jordi Viadé
- Department of Endocrinology & Nutrition, Hospital Germans Trias I Pujol, Autonomous University of Barcelona, Badalona, Spain
| | - Maria Nicolás
- Private Practice Diabetic Foot Clinic, Autonomous University of Barcelona, Sabadell, Barcelona, Spain.
| | - Magdalena Bundó
- Primary Health Care Center Ronda Prim, Gerència d'Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de La Salut, Mataró, Spain
| | - Marc Sirvent
- Department General, University Hospital of Granollers, CIBERCV, ISCIII, Granollers, Spain
| | - Clàudia Riera
- Department of Angiology and Vascular Surgery, University Hospital Germans Trias I Pujol, Badalona, Barcelona, Spain
| | - Miquel Sabriá
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
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16
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Armstrong DG, Boulton AJM, Bus SA. Review of Diabetic Foot Ulcers-Reply. JAMA 2023; 330:1695-1696. [PMID: 37934222 DOI: 10.1001/jama.2023.17194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Affiliation(s)
- David G Armstrong
- Department of Surgery, Keck School of Medicine at the University of California, Los Angeles
| | - Andrew J M Boulton
- Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, England
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam, the Netherlands
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17
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Mukherjee P, Paul S, Dutta T, Nath S, Ghosh B, Chatterjee D, Mukhopadhyay S, Mukherjee S. Nasal MRSA carriage is a risk factor for development of antibiotic resistance in diabetic foot ulcers and is significantly higher than diabetic and non-diabetic individuals without foot ulcer. BMC Infect Dis 2023; 23:729. [PMID: 37884870 PMCID: PMC10601299 DOI: 10.1186/s12879-023-08673-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Diabetic foot ulcer (DFU) is a major complication of diabetes often impacted by polymicrobial infection in the wound site. Diabetic patients are immunocompromised in nature and hence vulnerable to infection once the skin barrier is breached. Microbiological culture-based methods show that Staphylococcus aureus (SA) is the most frequently isolated bacteria from the DFU wounds. SA and its most clinically important antibiotic resistant variant methicillin-resistant S. aureus (MRSA) are commonly found in the nasal vestibule and colonization of SA as well as MRSA in any wound site can aggravate the condition. We hypothesize that the presence of nasal MRSA carriage can serve as a potential risk factor contributing to the emergence of antibiotic resistance in diabetic foot ulcer wounds. METHODS In the present study, we have compared the carriage of SA and MRSA in nasal cavity and foot skin among DFU patients (D+F+, n = 50), diabetic patients without any ulcer (D+F-, n = 50), and healthy controls (D-F-, n = 40) by using bacterial culture and PCR based methods. The D+F+, D+F- and D-F-individuals were further categorized based on the presence or absence of MRSA and clinical parameters were compared between MRSA+ ve and MRSA-ve individuals in each of the three groups mentioned above. RESULTS Our results show that, (a) nasal MRSA carriage is significantly higher (p < 0.05) in D+F+ group than the D+F- and D-F- and significantly associated with wound MRSA carriage in D+ F+ individuals (O.R. = 4.09; 95% C.I. = 1.12-15.05) and (b) the HbA1C level is significantly higher (p < 0.02) in wound MRSA positive, compared to MRSA negative D+F+ patients. Interestingly more than half of the MRSA (64%) isolated from DFU wound were identified to be multidrug resistant. CONCLUSION These findings strongly suggest that nasal MRSA carriage can act as a risk factor for development of antibiotic resistance in diabetic foot ulcers and it is therefore important to screen nasal and wound sites of these patients regularly. We have also developed a rapid multiplex PCR assay to detect MRSA from clinical isolates or microbial DNA isolated from clinical samples in the hospital settings.
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Affiliation(s)
- Poulami Mukherjee
- Human Microbiome Research Laboratory, National Institute of Biomedical Genomics (NIBMG), Kalyani, West Bengal, India
- Present address: Ramakrishna Mission Seva Pratishthan/ Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
| | - Shouvik Paul
- Human Microbiome Research Laboratory, National Institute of Biomedical Genomics (NIBMG), Kalyani, West Bengal, India
- Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
| | - Tanmoy Dutta
- Human Microbiome Research Laboratory, National Institute of Biomedical Genomics (NIBMG), Kalyani, West Bengal, India
| | - Shankha Nath
- Human Microbiome Research Laboratory, National Institute of Biomedical Genomics (NIBMG), Kalyani, West Bengal, India
| | - Bikramaditya Ghosh
- Chemical Examination Laboratory, Govt of West Bengal, Kolkata, West Bengal, India
| | - Debika Chatterjee
- Dept. of Endocrinology and Metabolism, IPGME&R, Kolkata, West Bengal, India
| | | | - Souvik Mukherjee
- Human Microbiome Research Laboratory, National Institute of Biomedical Genomics (NIBMG), Kalyani, West Bengal, India.
- Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India.
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18
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Vossen LE, van Netten JJ, Bakker CD, Berendsen HA, Busch-Westbroek TE, Peters EJG, Sabelis LWE, Dijkgraaf MGW, Bus SA. An integrated personalized assistive devices approach to reduce the risk of foot ulcer recurrence in diabetes (DIASSIST): study protocol for a multicenter randomized controlled trial. Trials 2023; 24:663. [PMID: 37828618 PMCID: PMC10568814 DOI: 10.1186/s13063-023-07635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Preventing foot ulcers in people with diabetes can increase quality of life and reduce costs. Despite the availability of various interventions to prevent foot ulcers, recurrence rates remain high. We hypothesize that a multimodal treatment approach incorporating various footwear, self-management, and education interventions that matches an individual person's needs can reduce the risk of ulcer recurrence with beneficial cost-utility. The aim of this study is to assess the effect on foot ulcer recurrence, footwear adherence, and cost-utility of an integrated personalized assistive devices approach in high-risk people with diabetes. METHODS In a parallel-group multicenter randomized controlled trial, 126 adult participants with diabetes mellitus type 1 or 2, loss of protective sensation based on the presence of peripheral neuropathy, a healed plantar foot ulcer in the preceding 4 years, and possession of any type of custom-made footwear will be included. Participants will be randomly assigned to either enhanced therapy or usual care. Enhanced therapy consists of usual care and additionally a personalized treatment approach including pressure-optimized custom-made footwear, pressure-optimized custom-made footwear for indoor use, at-home daily foot temperature monitoring, and structured education, which includes motivational interviewing and personalized feedback on adherence and self-care. Participants will be followed for 12 months. Assessments include barefoot and in-shoe plantar pressure measurements; questionnaires concerning quality of life, costs, disease, and self-care knowledge; physical activity and footwear use monitoring; and clinical monitoring for foot ulcer outcomes. The study is powered for 3 primary outcomes: foot ulcer recurrence, footwear adherence, and cost-utility, the primary clinical, patient-related, and health-economic outcome respectively. DISCUSSION This is the first study to integrate multiple interventions for ulcer prevention into a personalized state-of-the-art treatment approach and assess their combined efficacy in a randomized controlled trial in people with diabetes at high ulcer risk. Proven effectiveness, usability, and cost-utility will facilitate implementation in healthcare, improve the quality of life of high-risk people with diabetes, and reduce treatment costs. TRIAL REGISTRATION ClinicalTrials.gov NCT05236660. Registered on 11 February 2022.
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Affiliation(s)
- Lisa E Vossen
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands.
| | - Jaap J van Netten
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Chantal D Bakker
- Department of Rehabilitation Medicine, Máxima Medisch Centrum Veldhoven, de Run 4600, 5504 DB, Veldhoven, the Netherlands
| | - Heleen A Berendsen
- Department of Rehabilitation Medicine, Reinier de Graaf Gasthuis Delft, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Tessa E Busch-Westbroek
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Edgar J G Peters
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, the Netherlands
| | - Louise W E Sabelis
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
- Rehabilitation Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, the Netherlands
| | - Marcel G W Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Methodology, Amsterdam Public Health, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sicco A Bus
- Rehabilitation Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Rehabilitation & Development, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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19
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Popa AD, Gavril RS, Popa IV, Mihalache L, Gherasim A, Niță G, Graur M, Arhire LI, Niță O. Survival Prediction in Diabetic Foot Ulcers: A Machine Learning Approach. J Clin Med 2023; 12:5816. [PMID: 37762756 PMCID: PMC10531505 DOI: 10.3390/jcm12185816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Our paper proposes the first machine learning model to predict long-term mortality in patients with diabetic foot ulcers (DFUs). The study includes 635 patients with DFUs admitted from January 2007 to December 2017, with a follow-up period extending until December 2020. Two multilayer perceptron (MLP) classifiers were developed. The first MLP model was developed to predict whether the patient will die in the next 5 years after the current hospitalization. The second MLP classifier was built to estimate whether the patient will die in the following 10 years. The 5-year and 10-year mortality models were based on the following predictors: age; the University of Texas Staging System for Diabetic Foot Ulcers score; the Wagner-Meggitt classification; the Saint Elian Wound Score System; glomerular filtration rate; topographic aspects and the depth of the lesion; and the presence of foot ischemia, cardiovascular disease, diabetic nephropathy, and hypertension. The accuracy for the 5-year and 10-year models was 0.7717 and 0.7598, respectively (for the training set) and 0.7244 and 0.7087, respectively (for the test set). Our findings indicate that it is possible to predict with good accuracy the risk of death in patients with DFUs using non-invasive and low-cost predictors.
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Affiliation(s)
- Alina Delia Popa
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Radu Sebastian Gavril
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Iolanda Valentina Popa
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Laura Mihalache
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Andreea Gherasim
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - George Niță
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Mariana Graur
- Faculty of Medicine and Biological Sciences, University “Ștefan cel Mare” of Suceava, 720229 Suceava, Romania;
| | - Lidia Iuliana Arhire
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
| | - Otilia Niță
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.D.P.); (L.M.); (A.G.); (G.N.); (L.I.A.); (O.N.)
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Schönborn M, Gregorczyk-Maga I, Batko K, Maga M, Bogucka K, Gawlik K, Pawlica-Gosiewska D, Maga P. Angiogenic and Microvascular Status Alterations after Endovascular Revascularization of Lower Limb Arteries among Patients with Diabetic Foot Syndrome: A Prospective 12-Month Follow-Up Study. J Clin Med 2023; 12:5581. [PMID: 37685648 PMCID: PMC10488381 DOI: 10.3390/jcm12175581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 07/31/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Peripheral arterial disease (PAD)-induced ischemia is an important component of diabetic foot syndrome (DFS). The results of revascularization of the lower extremity arteries (including percutaneous transluminal angioplasty [PTA]) do not always give satisfactory long-term results, which is due to many factors. The aim of the study was to investigate the alterations in selected circulating angiogenic factors and microcirculation parameters in 41 patients with DFS following PTA and analyze their relationships with clinical outcomes during 1-year follow-up. Our study revealed a general decrease in pro-angiogenic factor levels after PTA and their subsequent stabilization during subsequent observation. The results indicated a significant association between plasma circulating FGF-2 level and poor outcomes (including the incidence of restenosis/reocclusion of treated arteries) during 12 months of observation. The perioperative changes in FGF-2 showed a significant association with LDF alterations after PTA. Follow-up 1-3 months post-intervention showed a tendency towards elevated TcpO2, VEGF-A, and VEGF-R2 levels in patients free from adverse events. These results may provide a basis for further research on the potential use of selected circulating angiogenic factors for monitoring the treatment of patients with DFS following PTA.
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Affiliation(s)
- Martyna Schönborn
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Doctoral School of Medical and Health Sciences, Jagiellonian University, 31-007 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Iwona Gregorczyk-Maga
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, 31-008 Kraków, Poland;
| | - Krzysztof Batko
- Department of Research and Development, Medicine Economy Law Society (MELS) Foundation, 30-040 Krakow, Poland;
| | - Mikołaj Maga
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Katarzyna Bogucka
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Katarzyna Gawlik
- Department of Clinical Biochemistry, Jagiellonian University Medical College, 31-008 Krakow, Poland; (K.G.); (D.P.-G.)
| | - Dorota Pawlica-Gosiewska
- Department of Clinical Biochemistry, Jagiellonian University Medical College, 31-008 Krakow, Poland; (K.G.); (D.P.-G.)
| | - Paweł Maga
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
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Niță O, Arhire LI, Mihalache L, Popa AD, Niță G, Gherasim A, Graur M. Evaluating Classification Systems of Diabetic Foot Ulcer Severity: A 12-Year Retrospective Study on Factors Impacting Survival. Healthcare (Basel) 2023; 11:2077. [PMID: 37510519 PMCID: PMC10379067 DOI: 10.3390/healthcare11142077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: This study examines the survival of patients after their first presentation with diabetic foot ulcers (DFUs) to the regional Diabetes, Nutrition, and Metabolic Diseases Clinic within the Emergency Clinical Hospital "Sf. Spiridon", Iaşi, and analyzes the factors associated with this outcome. (2) Methods: In this retrospective study, patients with DFUs consecutively referred between 1 January 2007 and 31 December 2017 were followed up until 31 December 2020 (for 13 years). The study group included 659 subjects. (3) Results: During the study period, there were 278 deaths (42.2%) and the average survival time was 9 years. The length of hospitalization, diabetic nephropathy, chronic kidney disease, glomerular filtration rate, cardiovascular disease, hypertension, anemia, and DFU severity were the most significant contributors to the increase in mortality. Patients with severe ulcers, meaning DFUs involving the tendon, joint, or bone, had a higher mortality risk than those with superficial or pre-ulcerative lesions on initial presentation (Texas classification HR = 1.963, 95% CI: 1.063-3.617; Wagner-Meggitt classification HR = 1.889, 95% CI: 1.024-3.417, SINBAD Classification System and Score HR = 2.333, 95% CI: 1.258-4.326) after adjusting for confounding factors. (4) Conclusions: The findings of this study suggested that patients presenting with severe ulcers involving the tendon, joint, or bone exhibited a significantly higher risk of mortality, even when potential confounders were taken into consideration.
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Affiliation(s)
- Otilia Niță
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Lidia Iuliana Arhire
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Laura Mihalache
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Alina Delia Popa
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - George Niță
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Andreea Gherasim
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Mariana Graur
- Faculty of Medicine and Biological Sciences, University "Ștefan cel Mare" of Suceava, 720229 Suceava, Romania
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Abstract
Importance Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death. Observations Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years. Conclusions and Relevance Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.
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Affiliation(s)
- David G Armstrong
- Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles
| | - Tze-Woei Tan
- Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles
| | - Andrew J M Boulton
- Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, England
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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