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Zhang L, Fu G, Deng Y, Nong Y, Huang J, Huang X, Wei F, Yu Y, Huang L, Zhang W, Tang M, Deng L, Han J, Zhou X, Wang Q, Lu W. Risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis and diabetic nephropathy: A 3-year follow-up study. Int Wound J 2022; 20:173-182. [PMID: 35673930 PMCID: PMC9797935 DOI: 10.1111/iwj.13861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/27/2022] [Indexed: 01/07/2023] Open
Abstract
This study aimed to explore the risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis (DFO) and diabetic nephropathy (DN). This is a prospective cohort study. Between May 2018 and May 2021, we selected 120 inpatients with comorbid severe diabetic foot infection (PEDIS Grade 3 or above) and DN for inclusion in our study. All cases were followed up for 36 months. The study outcomes were whether foot ulcer recurred and the time to recurrence. The risk factors of ulcer recurrence were analysed by comparing the data of the three groups. According to the recurrence of foot ulcer, the participants were divided into three groups: Group A (no foot ulcer recurrence, n = 89), Group B (foot ulcer recurrence within 12-36 months, n = 19) and Group C (foot ulcer recurrence within 6-12 months, n = 12). The multivariate Cox regression analysis showed that urine albumin-creatinine ratio (UACR) (HR: 1.008, 95% CI: 1.005-1.011, P < .001) and vibration perception threshold (VPT) (HR: 1.064, 95% CI: 1.032-1.096, P < .001) were identified as independent risk factors. Kaplan-Meier curves showed a significant positive association between UACR or VPT and the risk of foot ulcer recurrence (log rank, all P < .05). Areas under the ROC curves for UACR, VPT and the combination of UACR and VPT were 0.802, 0.799 and 0.842, respectively. The best cut-off values of UACR and VPT were 281.51 mg/g and 25.12 V, respectively. In summary, elevated UACR and VPT were independent risk factors. The best clinical cut-off values of UACR and VPT for prediction of foot ulcer recurrence were 281.51 mg/g and 25.12 V, respectively. Besides, our results suggested that microcirculation disorders rather than macrovascular complications play a major role in the recurrence of foot ulcer in patients with comorbid DFO and DN.
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Affiliation(s)
- Li Zhang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Guifen Fu
- The Nursing Department of Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Yongqing Deng
- The Family Planning Office of Guangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Yuechou Nong
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Jianhao Huang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Xiulu Huang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Fenglian Wei
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Yanqing Yu
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Litian Huang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Wenjiao Zhang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Meizhu Tang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Licai Deng
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Jiaxia Han
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Xing Zhou
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Qiu Wang
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
| | - Wensheng Lu
- The Department of Endocrinology and MetabolismGuangxi Academy of Medical Sciences and the People's Hospital of Guangxi Zhuang Autonomous RegionNanningP.R. China
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Chen X, Shen Y, Wang Y, Li Y, Guo S, Liang Y, Wang X, Zhou S, Hu X, Ma K, Tian R, Fei W, Sheng Y, Cao H, Que H. Decreased accuracy of erythrocyte sedimentation rate in diagnosing osteomyelitis in diabetic foot infection patients with severe renal impairment: A retrospective cross-sectional study. PLoS One 2022; 17:e0265769. [PMID: 35320298 PMCID: PMC8942204 DOI: 10.1371/journal.pone.0265769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/07/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Rapid diagnosis and treatment of diabetic foot osteomyelitis (DFO) could reduce the risk of amputation and death in patients with diabetic foot infection (DFI). Erythrocyte sedimentation rate (ESR) is considered the most useful serum inflammatory marker for the diagnosis of DFO. However, whether severe renal impairment (SRI) affects its diagnostic accuracy has not been reported previously. OBJECTIVE To investigate the accuracy of ESR in diagnosing DFO in DFI patients with and without SRI. METHODS This was a retrospective cross-sectional study. From the inpatient electronic medical record system, the investigators extracted demographic information, diagnostic information, and laboratory test results of patients with DFI who had been hospitalized in Longhua Hospital from January 1, 2016 to September 30, 2021. Logistic regression was performed to analyze the interaction between ESR and SRI with adjustment for potential confounders. The area under the curve (AUC), cutoff point, sensitivity, specificity, prevalence, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were analyzed by receiver operating characteristic (ROC) curve analysis and VassarStats. RESULTS A total of 364 DFI patients were included in the analysis. The logistic regression analysis results showed that elevated ESR increased the probability of diagnosing DFO (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.75-3.28; adjusted P < 0.001); SRI was not associated with the diagnosis of DFO (adjusted OR, 3.20; 95% CI, 0.40-25.32; adjusted P = 0.271), but it had an obstructive effect on the diagnosis of DFO by ESR (adjusted OR, 0.48; 95% CI, 0.23-0.99; adjusted P = 0.048). ROC analysis in DFI patients without SRI revealed that the AUC of ESR to diagnose DFO was 0.76 (95% CI, 0.71-0.81), with the cutoff value of 45 mm/h (sensitivity, 67.8%; specificity, 78.0%; prevalence, 44.7%; PPV, 71.3%; NPV, 75.0%; LR+, 3.08; LR-, 0.41). In contrast, in patients with SRI, the AUC of ESR to diagnose DFO was 0.57 (95% CI, 0.40-0.75), with the cutoff value of 42 mm/h (sensitivity, 95.0%; specificity, 29.2%; prevalence, 45.5%; PPV, 52.8%; NPV, 87.5%; LR+, 1.34; LR-, 0.17). CONCLUSIONS The accuracy of ESR in diagnosing DFO in DFI patients with SRI is reduced, and it may not have clinical diagnostic value in these patients.
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Affiliation(s)
- Xin Chen
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiting Shen
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuying Wang
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yang Li
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Thoracic Surgery, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shuyu Guo
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yue Liang
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xuanyu Wang
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Siyuan Zhou
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiaojie Hu
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kaiwen Ma
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rui Tian
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wenting Fei
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yuqin Sheng
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hengjie Cao
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Longhua Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Huafa Que
- Department of Surgery of Traditional Chinese Medicine, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, China
- * E-mail:
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Monami M, Ragghianti B, Nreu B, Lorenzoni V, Pozzan M, Silverii A, Turchetti G, Mannucci E. Major Amputation In Non-Healing Ulcers: Outcomes and Economic Issues. Data from a Cohort of Patients with Diabetic Foot Ulcers. INT J LOW EXTR WOUND 2022:15347346221097283. [PMID: 35477285 DOI: 10.1177/15347346221097283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Foot ulcers have a relevant economic impact on Health Care Systems and the cost-effectivenesseffectiveness of options is not clear. The aim of this study was the assessment of costs for ulcers treatment after 6, 12, and 18 months of follow-up, compared to those for major amputation. Methods: A retrospective study was carried out on 196 types 2 diabetic patients with foot ulcers. The principal endpoints were 1) the proportion of recovered patients among those with ulcers not healed after 6 and 12 months; 2) the assessment of direct costs for treatment of ulcers 6, 12, and 18 months of follow-up, as compared to the cost of major amputation. The economic evaluation was performed considering the perspective of the local health system. Results: Out of 196 patients, 85(46.2%), 131(71.6%), and 140(85.9%) healed within 6, 12, and 18 months, respectively. The average health cost during the 18-month follow-up was 5402€ per patient. We calculated hypothetical costs for three different scenarios, in which patients who did not heal within 6 months underwent a major amputation at 6, 1,2, or 18 months. Costs for the standard of care for all these scenarios (6,094, 7,256, and 7649€ for 6, 12, or 18 months, respectively) were significantly lower than that for major amputations (21,065€). Conclusions: A conservative approach appears more convenient than major amputations in ulcers not healing after 6 months, irrespective of the estimated risk of individual patients.
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Affiliation(s)
- Matteo Monami
- Diabetology, 18561Careggi Hospital and University of Florence, Firenze, Italy
| | | | - Besmir Nreu
- Diabetology, 18561Careggi Hospital and University of Florence, Firenze, Italy
| | | | - Marco Pozzan
- Diabetology, 18561Careggi Hospital and University of Florence, Firenze, Italy
| | - Antonio Silverii
- Diabetology, 18561Careggi Hospital and University of Florence, Firenze, Italy
| | | | - Edoardo Mannucci
- Diabetology, 18561Careggi Hospital and University of Florence, Firenze, Italy
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Expanding the definition beyond surveillance criteria reveals a large burden of osteomyelitis caused by group B Streptococcus in the United States Veterans Health Administration. BMC Infect Dis 2022; 22:237. [PMID: 35260097 PMCID: PMC8905819 DOI: 10.1186/s12879-022-07238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Background Population-based surveillance studies may underestimate osteomyelitis caused by Group B Streptococcus (GBS). We analyzed cases of GBS osteomyelitis, including patients diagnosed using an expanded case definition that incorporates cultures from non-sterile sites, as well as cultures from normally sterile sites.
Methods We retrospectively examined a cohort of veterans with the diagnosis of osteomyelitis between 2008 and 2017. Cases of definite GBS osteomyelitis required GBS isolation from normally sterile sites, (e.g., blood or bone). Cases of probable GBS osteomyelitis permitted GBS isolation from non-sterile sites (e.g., surgical sites, wounds). We compared comorbid conditions, lower extremity amputation and mortality rates in these groups. Results Among 1281 cases of GBS osteomyelitis, the median age was 63 years, 87% had diabetes mellitus and 37% had peripheral vascular disease. Similar characteristics were found in 768 (60%) cases classified as definite and 513 (40%) classified as probable GBS osteomyelitis. Polymicrobial infection was less frequent in patients with definite than with probable GBS osteomyelitis (45% vs. 85%; P < 0.001). Mortality rates within 1-year were similar for definite and probable GBS osteomyelitis (12% vs. 10%). Amputation within 1-year occurred in 21% of those with definite and 10% of those with probable GBS osteomyelitis of the lower extremity, with comparable rates in the subset with monomicrobial infection. Conclusions Expanding the definition of GBS osteomyelitis to include cases with cultures from non-sterile sites may be warranted, increasing the estimated burden of GBS osteomyelitis. This can help guide preventive efforts to reduce the impact of GBS osteomyelitis. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07238-0.
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Seghieri G, Policardo L, Gualdani E, Francesconi P. Gender Differences in the Risk of Adverse Outcomes After Incident Diabetic Foot Hospitalization: A Population Cohort Study. Curr Diabetes Rev 2022; 18:e270821195904. [PMID: 34455962 DOI: 10.2174/1573399817666210827121937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic Foot Disease (DFD) is more prevalent among males and is associated with an excess risk of cardiovascular events or mortality. AIMS This study aimed at exploring the risk of cardiovascular events, renal failure, and all-cause mortality after incident DFD hospitalizations, separately in males and females, to detect any gender difference in a cohort of 322,140 people with diabetes retrospectively followed up through administrative data sources in Tuscany, Italy, over the years 2011-2018. METHODS The Hazard Ratio (HR) for incident adverse outcomes after first hospitalizations for DFD, categorized as major/minor amputations (No.=449;3.89%), lower limbs' revascularizations (LLR: No.=2854;24.75%), and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to the risk of patients having a background of DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%). RESULTS DFD incidence rate was higher among males compared to females (1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD, the overall risk of coronary artery disease was significantly associated with the male gender and of stroke with the female gender. LEAD-no proc and LLR were associated with the risk of stroke only in females, whereas they were found to be associated with the risk of coronary artery disease among females to a significantly greater extent compared to males. The incident of renal failure was not associated with any DFD category. Amputations and LEAD-no proc significantly predicted high mortality risk only in females, while LLR showed reduced risk in both genders. Moreover, females had a greater risk of composite outcomes (death or cardiovascular events). Compared to the background of DFD, the risk was found to be 34% higher after amputations (HR: 1.34(1.04-1.72)) and 10% higher after LEAD-no proc (HR:1.10(1.03-1.18)), confirming that after incident DFD associated with vascular pathogenesis, females are at an increased risk of adverse events. CONCLUSION After incident DFD hospitalizations, females with DFD associated with amputations or arterial disease are at a greater risk of subsequent adverse cardiovascular events than those with a DFD background.
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Affiliation(s)
- Giuseppe Seghieri
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Laura Policardo
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Elisa Gualdani
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Paolo Francesconi
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
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Yin X, Zhu W, Liu C, Yao H, You J, Chen Y, Ying X, Li L. Association of continuous glucose monitoring-derived time in range with major amputation risk in diabetic foot osteomyelitis patients undergoing amputation. Ther Adv Endocrinol Metab 2022; 13:20420188221099337. [PMID: 35602463 PMCID: PMC9121454 DOI: 10.1177/20420188221099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/21/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The metrics generated from continuous glucose monitoring (CGM), such as time in range (TIR), are strongly correlated with diabetes complications. This study explored the association of perioperative CGM-derived metrics with major amputation risk in patients with diabetic foot osteomyelitis (DFO). METHODS This study recruited 55 DFO patients with grade 3-4 wounds according to the Wagner Diabetic Foot Ulcer Classification System, all of whom underwent CGM for 5 days during the perioperative period. The CGM-derived metrics were defined in accordance with the most recent international consensus recommendations. RESULTS Patients with major amputation had significantly less TIR and higher time below range (TBR) (all p < 0.05). In binary logistic regression analyses, a lower TIR was associated with the risk of major amputation (odds ratio: 0.83 (95% confidence interval: 0.71-0.99), p = 0.039). This association remained statistically significant after adjustments for age, sex, body mass index, type of diabetes, smoking, drinking, durations of diabetes and DFU, ankle-brachial index, albumin, estimated-glomerular filtration rate, Society for Vascular Surgery wound, ischemia, and foot infection (WIfi) stage, multidrug-resistant organisms, and hemoglobin A1c. Further adjustment for the mean amplitude of glycemic excursion (MAGE) reduced this association. TBR was also independently associated with the risk of major amputation (odds ratio: 1.60 (95% confidence interval: 1.17-2.18), p = 0.003); this association persisted after adjustment for MAGE. CONCLUSION Perioperative TIR (3.9-10.0 mmol/L) and TBR (<3.9 mmol/L) were significantly associated with major amputation in hospitalized patients with DFO.
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Affiliation(s)
| | | | - Chao Liu
- Department of Orthopedics, Zhejiang University
School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Huilan Yao
- Department of Nursing Education, Zhejiang
University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou,
China
| | - Jiaxing You
- Department of Orthopedics, Zhejiang University
School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Yixin Chen
- Department of Endocrinology, Zhejiang
University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou,
China
| | - Xiaofang Ying
- Department of Endocrinology, Jiangshan People’s
Hospital, Quzhou, China
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Monami M, Ragghianti B, Silverii A, Scatena A, Landi L, Cosentino C, Vitale V, Mannucci E. Retrospective Matched Case-Control Study on the Use of CO 2 Laser for the Treatment of Nonhealing Diabetic Foot Ulcers: The DULCIS-2 (Diabetic ULcer, CO 2 Laser, and Infections) Study. INT J LOW EXTR WOUND 2020; 21:471-476. [PMID: 33225783 DOI: 10.1177/1534734620960298] [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: 11/15/2022]
Abstract
PURPOSE Infection, which is one of the possible complications of diabetic foot ulcers (DFUs), makes the treatment of ulcers challenging because of its negative impact on healing processes and the high prevalence of multiresistant germs. This study is aimed at verifying the effect of a surgical CO2 laser (which reduces the bacterial load and allows a more accurate debridement), as compared with the traditional lancets, on the healing rate of DFU. METHODS The present case-control retrospective analysis was performed on patients with chronic (>6 months) DFU with Texas grade >1, treated with 80 W surgical CO2 laser (DEKA SmartXide2 C80, El.En. Group) and compared with a matched sample of patients with similar characteristics, who were treated with a traditional surgical approach. The debridement was performed trying to achieve the complete removal of nonviable tissues. The principal endpoint was the proportion of patients healed at 6 months. All analyses were carried out with SPSS 25.0. The study protocol was approved by the local ethical committee. RESULTS This study included 118 patients (59 cases and 59 controls). At 6 months, the proportion of healing patients was 35% and 18% in cases and controls, respectively (P = .034). The corresponding figure at 1 year was 62% and 38% (P = .009), whereas no difference was observed at 1, 2, and 3 months. No serious adverse event was observed. CONCLUSIONS In this article, we show for the first time that CO2 laser treatment, in comparison with traditional surgical approaches, can be associated with an increased healing rate in patients with DFU.
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Affiliation(s)
- Matteo Monami
- Careggi Hospital and University of Florence, Florence, Italy
| | | | | | | | - Letizia Landi
- Careggi Hospital and University of Florence, Florence, Italy
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Rubio JA, Jiménez S, Lázaro-Martínez JL. Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer. J Clin Med 2020; 9:jcm9093009. [PMID: 32961974 PMCID: PMC7565534 DOI: 10.3390/jcm9093009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.
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Affiliation(s)
- José Antonio Rubio
- Diabetic Foot Unit, Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, 28805 Madrid, Spain;
- Department of Biomedical Sciences, Universidad de Alcalá, Alcalá de Henares, 28805 Madrid, Spain
- Correspondence: ; Tel.: +34-918-878-100
| | - Sara Jiménez
- Diabetic Foot Unit, Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, 28805 Madrid, Spain;
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain;
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Adeleye OO, Ugwu ET, Gezawa ID, Okpe I, Ezeani I, Enamino M. Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study. BMC Endocr Disord 2020; 20:134. [PMID: 32859203 PMCID: PMC7455894 DOI: 10.1186/s12902-020-00614-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 08/24/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria. METHODS The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical, and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number. RESULTS Three hundred and twenty-three type 2 DM subjects with mean age and mean duration of DM of 57.2 ± 11.4 years and 8.7 ± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and the majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > 1 month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p < 0.001), positive blood cultures (p < 0.001), low HDL (p < 0.001), shock at presentation (p < 0.001), cardiac failure (p 0.027), and renal impairment (p < 0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349-5.971) were significantly predictive of mortality independent of other variables. CONCLUSIONS This study showed high intra-hospital mortality among patients with DFU, with the majority of deaths occurring among those with advanced ulcers, bacteraemia, cardiac failure, and renal impairment. Prompt attention to these factors might help improve survival from DFU in Nigeria.
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Affiliation(s)
| | - Ejiofor T. Ugwu
- Department of Medicine, Enugu State University of Science and Technology Enugu, Enugu, Nigeria
| | | | - Innocent Okpe
- Department of Medicine, Ahmadu Bello University Zaria, Zaria, Nigeria
| | - Ignatius Ezeani
- Department of Medicine, Federal Medical Center Umuahia, Umuahia, Abia Nigeria
| | - Marcelina Enamino
- Department of Medicine, Federal Medical Center Keffi, Keffi, Nasarawa Nigeria
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10
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Bessesen MT, Doros G, Henrie AM, Harrington KM, Hermos JA, Bonomo RA, Ferguson RE, Huang GD, Brown ST. A multicenter randomized placebo controlled trial of rifampin to reduce pedal amputations for osteomyelitis in veterans with diabetes (VA INTREPID). BMC Infect Dis 2020; 20:23. [PMID: 31914940 PMCID: PMC6950878 DOI: 10.1186/s12879-019-4751-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background The prevalence of diabetes mellitus continues to inexorably rise in the United States and throughout the world. Lower limb amputations are a devastating comorbid complication of diabetes mellitus. Osteomyelitis increases the risk of amputation fourfold and commonly presages death. Antimicrobial therapy for diabetic foot osteomyelitis (DFO) varies greatly, indicating that high quality data are needed to inform clinical decision making. Several small trials have indicated that the addition of rifampin to backbone antimicrobial regimens for osteomyelitis outside the setting of the diabetic foot results in 28 to 42% higher cure rates. Methods/design This is a prospective, randomized, double-blind investigation of the addition of 6 weeks of rifampin, 600 mg daily, vs. matched placebo (riboflavin) to standard-of-care, backbone antimicrobial therapy for DFO. The study population are patients enrolled in Veteran Health Administration (VHA), ages ≥18 and ≤ 89 years with diabetes mellitus and definite or probable osteomyelitis of the foot for whom an extended course of oral or intravenous antibiotics is planned. The primary endpoint is amputation-free survival. The primary hypothesis is that using rifampin as adjunctive therapy will lower the hazard rate compared with the group that does not use rifampin as adjunctive therapy. The primary hypothesis will be tested by means of a two-sided log-rank test with a 5% significance level. The test has 90% power to detect a hazard ratio of 0.67 or lower with a total of 880 study participants followed on average for 1.8 years. Discussion VA INTREPID will test if a rifampin-adjunctive antibiotic regimen increases amputation-free survival in patients seeking care in the VHA with DFO. A positive finding and its adoption by clinicians would reduce lower extremity amputations and their associated physical and emotional impact and reduce mortality for Veterans and for the general population with diabetic foot osteomyelitis. Given that rifampin-adjunctive regimens are currently employed for therapy for the majority of DFO cases in Europe, and only in a small minority of cases in the United States, the trial results will impact therapeutic decisions, even if the null hypothesis is not rejected. Trial registration Registered January 6, 2017 at ClinicalTrials.gov, NCT03012529.
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Affiliation(s)
- Mary T Bessesen
- Department of Veterans Affairs Eastern Colorado Healthcare System, Denver, CO, USA.,Division of Infectious Diseases, Department of Medicine, University of Colorado - Denver, Aurora, CO, USA
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Biostatistics, Boston University, Boston, MA, USA
| | - Adam M Henrie
- Department of Veterans Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Office of Research and Development, Albuquerque, NM, USA
| | - Kelly M Harrington
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - John A Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Robert A Bonomo
- Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Ryan E Ferguson
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Grant D Huang
- Department of Veterans Affairs, Cooperative Studies Program Central Office, Washington, DC, USA
| | - Sheldon T Brown
- James J. Peters VA Medical Center, New York, NY, USA. .,Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
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11
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Khalifa WA. Risk factors for diabetic foot ulcer recurrence: A prospective 2-year follow-up study in Egypt. Foot (Edinb) 2018; 35:11-15. [PMID: 29753996 DOI: 10.1016/j.foot.2017.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 12/18/2017] [Accepted: 12/23/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the frequency of diabetic foot ulcer recurrence and its potential risk factors. METHODS This study included 93 patients with type 2 diabetes and followed for 2 years after primary healed foot ulceration. Demographic, diabetes related, comorbid and ulcer related variables were investigated as risk factors. Multiple logistic regression analysis was used to identify independent risk factors. RESULTS 61.3% of patients had recurrent ulcers particularly in the forefoot (33.3%) and big toe (24.6%). Peripheral neuropathy, peripheral arterial disease or both were reported in 69%, 12% and 19% of feet with recurrent ulcers respectively. In multivariate analysis, the significant independent potential risk factors for recurrence of foot ulcers were smoking (P=0.040), poor glycemic control [HbA1c cutoff of 10%] (P=0.010), peripheral neuropathy with lost ankle reflex (P=0.0001), peripheral arterial disease (P=0.0001) and previous ulcer location (P=0.050). CONCLUSION The frequency rate of recurrent diabetic foot ulceration in patients with type 2 diabetes is high particularly in the first year despite regular follow-up and patient education.
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Affiliation(s)
- Walaa A Khalifa
- Department of Internal Medicine, Endocrinology and Diabetes Unit, Assiut University, Assiut, Egypt.
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