Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study

Geographic Variation in First Lower Extremity Amputations Related to Diabetes and/or Peripheral Arterial Disease

BACKGROUND

To assess trends of first cases of lower extremity amputation (LEA) related to diabetes and/or peripheral arterial disease (PAD), according to areas of residency and neighbourhood material and social deprivation quintiles, in the province of Quebec, Canada.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of first LEA (total, minor, and major) among adults 40 years of age and older with diabetes and/or PAD in fiscal years 2006 and 2019. Area of residency was compiled in 3 categories: (1) Montreal and other census metropolitan areas; (2) midsize agglomerations (10,000-100,000 inhabitants); and (3) small towns and rural areas (< 10,000 inhabitants). We also stratified according to neighbourhood material and social deprivation quintiles. One-year and 5-year all-cause mortality after first LEA were compared according to area of residency.

RESULTS

Among the 10,275 individuals who had a first LEA, age-standardized LEA rates remained stable between 2006 and 2019, whereas major LEA rates declined in all geographical areas and minor LEA rates increased (31.6%) in small towns and rural areas. In 2019, age-standardized LEA rates were higher in midsize agglomerations and small towns and rural areas compared with census metropolitan areas. Age-standardized LEA rates in 2019 were higher among the most deprived quintile compared with the most privileged quintile for material and social deprivation. No difference was observed in mortality after first LEA according to area of residency.

CONCLUSIONS

There are health disparities in the burden of diabetes and PAD related to first LEA in the province of Quebec. To improve preventive care and reduce the burden of LEA, targeted actions should be taken among the most deprived groups and rural settings.

From Morphology to Therapeutic Strategies: Exploring New Applications of Ultrasound for Diabetic Peripheral Neuropathy Diagnosis and Management

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes that can result in severe lower limb pain and amputation. Early detection and treatment of DPN are vital, but this condition is often missed due to a lack of symptoms and the insensitivity of testing methods. This article reviews various ultrasound imaging modalities in the direct and indirect evaluation of peripheral neuropathy. Moreover, how ultrasound-related therapeutic strategies are playing a role in clinical treatment is discussed. Finally, the application of innovative methodologies in the diagnosis of DPN, including ultrasound attenuation, photoacoustic imaging, and artificial intelligence, is described.

Biomarkers of local inflammation at the skin's surface may predict both pressure and diabetic foot ulcers

This commentary considers the similarities which exist between pressure ulcers (PUs) and diabetic foot ulcers (DFUs). It aims to describe what is known to be shared-both in theory and practice-by these wound types. It goes on to detail the literature surrounding the role of inflammation in both wound types. PUs occur following prolonged exposure to pressure or pressure in conjunction with shear, either due to impaired mobility or medical devices. As a result, inflammation occurs, causing cell damage. While DFUs are not associated with immobility, they are associated with altered mobility occurring as a result of complications of diabetes. The incidence and prevalence of both types of lesions are increased in the presence of multimorbidity. The prediction of either type of ulceration is challenging. Current risk assessment practices are reported to be ineffective at predicting when ulceration will occur. While systemic inflammation is easily measured, the presence of local or subclinical inflammation is harder to discern. In patients at risk of either DFUs or PUs, clinical signs and symptoms of inflammation may be masked, and systemic biomarkers of inflammation may not be elevated sufficiently to predict imminent damage until ulceration appears. The current literature suggests that the use of local biomarkers of inflammation at the skin's surface, namely oedema and temperature, may identify early tissue damage.

Chronic Kidney Disease and Charcot Neuro-Osteoarthropathy of Foot in Diabetes

INTRODUCTION

Charcot neuro-osteoarthropathy (CNO) occurs late in diabetes and may cause fracture, deformity, and higher mortality. Diabetic kidney disease (DKD) affects bone metabolism and contributes to mortality. However, there is no data on prevalence of CNO and its outcomes with coexisting DKD (or chronic kidney disease [CKD]).

METHODS

To ascertain the prevalence of CKD (pick CKD or DKD) among patients with CNO and delineate the remission of active CNO and subsequent lower extremity amputation and all-cause mortality during prospective follow-up. Consecutive patients with diabetic CNO (active or inactive) were enrolled and subsequently divided into those with and without CKD (pick CKD or DKD) (Group A and Group B, respectively). A preestablished timeframe of 36 weeks was utilized to evaluate the remission proportion of active CNO.

RESULTS

A total of 493 CNO patients were observed and 449 subjects (150 patients had active CNO) were further evaluated. The overall prevalence of diabetic nephropathy (DKD or CKD?) CNO was 43.7%. The proportion of patients achieving remission was significantly lower in Group A compared to Group B (OR 0.468, CI [0.239-0.934], P = .025), however, the median time for achieving remission was similar between the 2 groups (14 weeks vs 16 weeks, P = .885). Overall, all-cause mortality was notably higher Group A compared to Group B (OR 2.23, 95% CI [1.474-3.368]) over a median follow-up of 4 years. No significant differences were observed in rates of diabetic foot ulcers (58.2% vs 54.9%; P = .584) and amputations (17.4% vs 15.12%; P = .889) between Group A and Group B.

CONCLUSION

Patients of CNO with coexisting CKD have poor prognosis both in terms of likelihood of active CNO remission and higher mortality.

The risk factors in diabetic foot ulcers and predictive value of prognosis of wound tissue vascular endothelium growth factor

Diabetic foot ulcer (DFU) is a leading cause of high-level amputation in DM patients, with a low wound healing rate and a high incidence of infection. Vascular endothelial growth factor (VEGF) plays an important role in diabetes mellitus (DM) related complications. This study aims to explore the VEGF expression and its predictive value for prognosis in DFU, in order to provide basis for the prevention of DFU related adverse events. We analyzed 502 patients, with 328 in healing group and 174 in non-healing/recurrent group. The general clinical data and laboratory indicators of patients were compared through Spearman correlation analysis, ROC analysis and logistic regression analysis. Finally, the independent risk factors for adverse prognosis in DFU patients were confirmed. Spearman analysis reveals a positive correlation between the DFU healing rate and ABI, VEGF in wound tissue, and positive rate of VEGF expression, and a negative correlation with DM duration, FPG, HbA1c, TC, Scr, BUN, and serum VEGF. Further logistic regression analysis finds that the DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for adverse prognosis in DFU (p < 0.05). DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for prognosis in DFU patients. Patients with these risk factors should be screened in time, which is of great significance to prevent DFU related adverse events and improve outcomes.

Two-year incidence and risk factors of diabetic foot ulcer: second phase report of Ahvaz diabetic foot cohort (ADFC) study

AIM/INTRODUCTION

This study was designed as the second phase of a prospective cohort study to evaluate the incidence and risk factors of diabetic foot ulcers (DFU).

MATERIALS AND METHODS

The study was conducted in a university hospital in Iran. Each participant was checked and followed up for two years in terms of developing newfound DFU as ultimate outcome. We investigated the variables using univariate analysis and then by backward elimination multiple logistic regression.

RESULTS

We followed up 901 eligible patients with diabetes for two years. The mean age of the participants was 53.24 ± 11.46 years, and 58.53% of them were female. The two-year cumulative incidence of diabetic foot ulcer was 8% (95% CI 0.071, 0.089) [Incidence rate: 49.9 /1000 person-years]. However, the second-year incidence which was coincident with the COVID-19 pandemic was higher than the first-year incidence (4.18% and 1.8%, respectively). Based on our analysis, the following variables were the main risk factors for DFU incidence: former history of DFU or amputation [OR = 76.5, 95% CI(33.45,174.97), P value < 0.001], ill-fitting foot-wear [OR = 10.38, 95% CI(4.47,24.12), P value < 0.001], smoking [OR = 3.87,95%CI(1.28, 11.71),P value = 0.016], lack of preventive foot care [OR = 2.91%CI(1.02,8.29),P value = 0.045], and insufficient physical activity[OR = 2.25,95% CI(0.95,5.35),P value = 0.066].

CONCLUSION

Overall, the two-year cumulative incidence of diabetic foot ulcer was 8% [Incidence rate: 49.9 /1000 person-years]; however, the second-year incidence was higher than the first-year incidence which was coincident with the COVID-19 pandemic (4.18% and 1.8%, respectively). Independent risk factors of DFU occurrence were prior history of DFU or amputation, ill-fitting footwear, smoking, lack of preventive foot care, and insufficient physical activity.

Diabetic foot ulcers, their characteristics, and trends in survival: Real world outcomes at a tertiary care facility in India

AIMS

Characteristics of diabetes-related foot ulcers (DFU), association with recurrence and amputation are poorly described in the Asian Indian population.

METHODS

A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence.

RESULTS

Of 200 patients, 63.5 % were male, the median age was 62 years (Min-Max:40-86), and median BMI was 27.90 kg/m2 (Min-Max:18.5-42.7). Median duration of Diabetes mellitus was 15 years (Min-Max:2-43). Complete healing occurred at a median of three months (Min-Max:0.23-37.62). Amputation for the current ulcer was required in 43.4 % of individuals. Ulcer recurrence was documented in 42.4 % instances, 66.1 % evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation (Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5 %,2.5 %,8.2 % and 30.9 % respectively among those who underwent amputation versus 0 %,0 %,10.1 % and 24.5 % respectively for those who achieved healing.

CONCLUSIONS

Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30 %. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.

Economic burden of diabetic foot ulcer: a case of Iran

BACKGROUND

Diabetic foot ulcer (DFU) is known as a serious complication of diabetes mellitus in patients with diabetes, imposing heavy medical costs on healthcare systems due to its chronic nature. patients with severe diabetic foot ulcer are often disabled to work, and some of them may even die, leading to associated productivity losses. Since no previous study has investigated the economic burden of DFU in Iran, this study is to estimate the economic burden of diabetic foot disease in Iran.

METHODS

In this descriptive cross-sectional study, randomly selected samples consisted of 542 patients with DFU, hospitalized in the hospitals of Shahid Beheshti University of Medical Sciences. The demographic profile and cost data used in this analysis were derived from a researcher-designed checklist. Lost productivity was calculated based on Human Capital Approach, and the total economic cost of DFU was determined using patient-level data on costs and prevalence data from the global burden of diseases reports. All analyses were performed using SPSS software (Version 23), and Microsoft Excel (Version 19).

RESULTS

The economic burden of DFU in Iran in two scenarios of discounting future costs and not discounting them was about $8.7 billion and $35 billion, respectively (about 0.59 and 2.41% of GDP). 79.25% of the estimated costs in this study were indirect costs and productivity losses, of which 99.34% (7,918.4 million Dollars) were productivity losses due to premature death. 20.75% (2,064.4 million dollars) of the estimated costs in this study were direct costs. The average length of stay (LOS) was 8.10 days (SD = 9.32), and 73.3% of patients recovered and were discharged after hospitalization and 7.6% died. The majority of the costs are imposed on the age group of 60-69 year (53.42% of the productivity lost due to hospital length of stay, 58.91% of the productivity lost due to premature death & 40.41% of direct costs).

CONCLUSIONS

DFU represents a heavy burden to patients, Iran's health system, and the economy. Early prevention strategies need to be prioritized in making public health policies. These policies and decisions can be in the area of changing lifestyle, health education, changing people's behavior, and encouraging physical activity that targeted high-risk populations in order to reduce the prevalence of diabetic foot and resulting substantial economic burden.

Comparison of different concentrations of chlorhexidine-iodophor composite solution on human skin fibroblasts

OBJECTIVE

Chlorhexidine-iodophor (CHX-IP) composite solution is a polymer of chlorhexidine and iodophor produced with new technology, for use in diabetic foot infection. However, the effect of CHX-IP on the growth activity of fibroblasts remains unknown, thus the effects of different concentrations of CHX-IP composite solution on the viability and micromorphology of human skin fibroblasts were studied in vitro cell culture in this study.

METHOD

A cell viability assay was applied to calculate cell viability and an inverted fluorescence microscope was used to observe cell morphology over five days.

RESULTS

The results showed that the toxic effect of CHX-IP on fibroblasts was solution concentration-dependent and decreased over time. When the concentration of CHX-IP was 5.0mg/ml, 2.5mg/ml, 0.625mg/ml, 0.15625mg/ml, 0.078125mg/ml or 0mg/ml, the difference of optical density (OD) value on different days was statistically significant (p<0.05). There were statistically significant differences in the OD value of fibroblasts among different concentrations of CHX-IP on: day 2 (F=4.809, p=0.004); day 3 (F=21.508, p<0.001); day 4 (F=63.952, p<0.001); and day 5 (F=160.407, p<0.001). In addition, a concentration of 5.0mg/ml CHX-IP resulted in a fibroblastic viability rate of 0% on day 4, when CHX-IP was diluted to 2.5mg/ml or 1.25 mg/ml, fibroblastic viability rate decreased to 0% day 5. However, when the CHX-IP was diluted to 0.15625mg/ml or 0.078125mg/ml, the fibroblastic cell viability rate increased slightly on day 5. The morphology of cells observed under microscope indirectly supported this result.

CONCLUSION

The findings of this study showed that the toxic effect of CHX-IP on fibroblasts was solution concentration-dependent and decreased over time.

Current Advances in Wound Healing and Regenerative Medicine

Treating chronic wounds is a common and costly challenge worldwide. More advanced treatments are needed to improve wound healing and prevent severe complications such as infection and amputation. Like other medical fields, there have been advances in new technologies promoting wound healing potential. Regenerative medicine as a new method has aroused hope in treating chronic wounds. The technology improving wound healing includes using customizable matrices based on synthetic and natural polymers, different types of autologous and allogeneic cells at different differentiation phases, small molecules, peptides, and proteins as a growth factor, RNA interference, and gene therapy. In the last decade, various types of wound dressings have been designed. Emerging dressings include a variety of interactive/ bioactive dressings and tissue-engineering skin options. However, there is still no suitable and effective dressing to treat all chronic wounds. This article reviews different wounds and common treatments, advanced technologies and wound dressings, the advanced wound care market, and some interactive/bioactive wound dressings in the market.

Antibacterial, conductive nanocomposite hydrogel based on dextran, carboxymethyl chitosan and chitosan oligosaccharide for diabetic wound therapy and health monitoring

Diabetic severe wound healing is challenging and also carries a high risk of bacterial infection and may be accompanied by serious complications. Electrical stimulation (ES) can effectively promote wound healing, but its effectiveness is often limited by incomplete contact between the electrodes and the wound site. In order to improve the efficiency of electrical stimulation utilization and to avoid wound infection, a multi-dynamically crosslinked nanocomposite hydrogel was prepared from dextran modified with aldehyde groups and phenylboronic acid esters (Dex-FA-BA), carboxymethyl chitosan (CMCS), polyaniline grafted chitosan oligosaccharide (CP), and Epigallocatechin Gallate/Ca2+ modified melanin-like nanoparticles (CEMNPs), based on dynamic Schiff base bonds, phenylboronic acid/diol interactions, and hydrogen bonding. The CEMNPs have good photothermal conversion properties and antioxidant activity and can also enhance the mechanical properties of the hydrogel system. The CP endows the hydrogel with good electrical conductivity and sensing properties and can record the respiratory and heart rate of rats in real time. Based on the convolutional neural networks (CNN) algorithm constructed by ResNet9, the respiratory and heart rate signals can be distinguished with 93.9 % accuracy. This multifunctional nanocomposite hydrogel can provide a new strategy to promote chronic wound healing and achieve health monitoring effectively.

Region-wise severity analysis of diabetic plantar foot thermograms

OBJECTIVES

Diabetic foot ulcers (DFU) can be avoided if symptoms of diabetic foot complications are detected early and treated promptly. Early detection requires regular examination, which might be limited for many reasons. To identify affected or potentially affected regions in the diabetic plantar foot, the region-wise severity of the plantar foot must be known.

METHODS

A novel thermal diabetic foot dataset of 104 subjects was developed that is suitable for Indian healthcare conditions. The entire plantar foot thermogram is divided into three parts, i.e., forefoot, midfoot, and hindfoot. The division of plantar foot is based on the prevalence of foot ulcers and the load on the foot. To classify the severity levels, conventional machine learning (CML) techniques like logistic regression, decision tree, KNN, SVM, random forest, etc., and convolutional neural networks (CNN), such as EfficientNetB1, VGG-16, VGG-19, AlexNet, InceptionV3, etc., were applied and compared for robust outcomes.

RESULTS

The study successfully developed a thermal diabetic foot dataset, allowing for effective classification of diabetic foot ulcer severity using the CML and CNN techniques. The comparison of different methods revealed variations in performance, with certain approaches outperforming others.

CONCLUSIONS

The region-based severity analysis offers valuable insights for targeted interventions and preventive measures, contributing to a comprehensive assessment of diabetic foot ulcer severity. Further research and development in these techniques can enhance the detection and management of diabetic foot complications, ultimately improving patient outcomes.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm

BACKGROUND

The treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes.

METHODS

This is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation.

RESULTS

Outcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level.

CONCLUSIONS

Bone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Identification of types of wound bed tissue as a percentage and total wound area by planimetry in neuropathic and venous ulcers

BACKGROUND

Neuropathic and venous leg ulcers are chronic wounds associated with devitalized tissue and recurrent infection. Management should be guided by accurate tissue assessment, including the use of planimetry, which provides tissue types as a percentage of the total wound bed surface area.

OBJECTIVE

This innovative study aimed to assess and identify the wound bed tissues, as a percentage, of neuropathic and venous ulcers using digital planimetry, providing support to nurses optimize the management of necrotic tissues and, consequently, to avoid wound infection.

METHODS

This cross-sectional study enrolled 24 patients with chronic wounds who were assessed from January to March 2021 at the Wound Outpatients Clinic. The wound photographs were analyzed using Image J 1.53e and a smartphone with WoundDoc Plus® 2.8.2 via digital planimetry. Statistical analyses were performed using the binomial test, t-test, and Mann-Whitney.

RESULTS

Median wound areas (p=0.3263) did not differ between the group with 2 or 3 risk factors for delayed healing (Md: 31.7) and the group with up to 1 risk factor (Md: 5.3). A low exudate level was associated with the up-to-1-risk-factor-for-delayed-healing group (p=0.0405), while a medium level was associated with the two-or-three-risk-factor group (p=0.0247). A heat map displayed the tissue percentages in the wound bed. In the group with 2 or 3 risk factors for delayed healing, 91.7% (11/12) had less than 70% granulation tissue, which was the primary factor for this group (p<0.0001). Additionally, 66.7% (8/12) of patients with 2 or 3 risk factors for delayed healing exhibited discolored and/or dark red granulation tissue as the primary factor (p=0.0130).

CONCLUSION

This novel identification of wound area and tissue types as a percentage, using digital planimetry, can play a crucial role in assisting nurses in decision-making related to the appropriate management of devitalized tissues. Furthermore, this measurements may facilitate the conducting of virtual wound consultations and offer valuable support in the development of protocols aimed at preventing infection and biofilm formation in the wound bed.

Validity and reliability of Chinese version of the new diabetic foot ulcer assessment scale

A specific assessment tool is urgently needed to guide effective wound care for diabetic foot ulcers. However, the tool has not been available in Chinese. We aimed to culturally translate and verify the validity and reliability of the new Diabetic Foot Ulcer Assessment Scale (DFUAS). The original scale was translated into Chinese according to the Brislin guidelines. Patients satisfying the inclusion and exclusion criteria were recruited. Each of the included foot ulcers was evaluated independently by two wound care specialists using the new DFUAS and by the third wound care specialists at the same time using the Bates-Jensen Wound Assessment Tool according to per guidelines. 210 diabetic foot ulcers were included for data analysis. The S-CVI of the Chinese version of the DFUAS was 0.96, and the I-CVIs ranged from 0.89 to 0.98. The total Cronbach's Alpha of the scale was 0.709, and the corrected item-total correlation of the items ranged from 0.4 to 0.872. The DFUAS had high inter-observer reliability of 0.997, and there were weak, moderate, and strong correlations between each pair of the items. The Bland-Altman plots showed a good agreement between the scale and the Bates-Jensen Wound Assessment Tool. We concluded that the Chinese version of the DFUAS showed good validity and reliability and is a reliable instrument for the assessment of diabetic foot ulcers.

A paradigm shift for cardiovascular outcome evaluation in diabetes: Major adverse cardiovascular events (MACE) to major adverse vascular events (MAVE)

BACKGROUND AND AIMS

Drugs for diabetes are required to demonstrate cardiovascular safety through CV outcome trials (CVOT). The pre-defined end-points for cardiovascular outcome studies may not be sufficient to capture all clinically relevant atherosclerotic cardio vascular disease (ASCVD) events particularly peripheral arterial disease (PAD).

METHODS

We planned a scoping review and searched database to identify CVOT conducted in population with diabetes measuring lower limb events due to PAD as the primary outcome measure. We also searched CVOT for reported differential cardiovascular outcomes in population with PAD.

RESULTS

We identified that CV outcomes are measured as 3 point major adverse cardiovascular outcomes (3P-MACE) that includes nonfatal MI and nonfatal stroke or 4P-MACE that included additional unstable angina which is further expanded to 5P-MACE by the inclusion of hospitalization for heart failure (HHF). These CV end points are captured as surrogate for CV mortality based on the biological plausibility of relation between the surrogate and final outcome from pathophysiological studies. We found the prevalence of PAD is no lesser than other CV events in people with diabetes. Moreover, PAD contributes to the significant morbidity associated with diabetes as a surrogate for mortality. However, none of the CVOT with anti-diabetic drugs include PAD events as primary outcome measure despite the inclusion of 6-25 % participants with PAD in major CVOT. PAD outcomes are objectively measurable with tibial arterial waveforms and clinical end-point as lower extremity amputation. PAD outcomes do improve with treatment including intensive glycemic control and novel oral anticoagulants. We suggest the inclusion of PAD to MACE as a pre-specified outcome for a comprehensive capture of major adverse vascular event in future studies for people with diabetes.

CONCLUSIONS

MACE should be expanded to include PAD event as major adverse vascular event in cardiovascular outcome studies since PAD is clinically relevant and objectively measurable in diabetes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Lavandula stoechas on Wound Healing in an Experimental Diabetes Model

INTRODUCTION

Diabetic foot is a consequential and dangerous complication of diabetes, contributing to decreased quality of life, escalated hospitalizations, and increased mortality rates. Using an experimental model of diabetes, this study aims to investigate the effect of Lavandula stoechas on wound healing.

METHODS

A total of 35 albino Wistar rats, 250-350 grams in weight, were used. The rats were divided into five groups, seven rats in each group. Of these, 21 rats were induced with 50 mg/kg streptozotocin (STZ) to mimic the diabetic condition. Additionally, 14 rats remained non-diabetic and served as the control group. The diabetic rats were further divided into three subgroups. The non-diabetic group was split into two subgroups based on the dressing materials used (allicin, physiological serum, and control). Wound dimensions were assessed on Days 0, 7, 14, and 21. Biopsies were taken from the wound sites at the same time.

RESULTS

There were significant differences between groups on Days 7, 14, and 21. The percentage of healing was highest in the Lavandula Stoechas group on Days 7, 14, and 21. Microscopic examination of the biopsies supported accelerated wound healing on Days 7 and 14. Reduced mononuclear cell density and increased hair follicle and adipose tissue development were observed in the DM (diabetes mellitus)-Lavandula Stoechas group on Day 7. On Day 14, the DM-Lavandula Stoechas group increased collagen levels and hair follicles. Similarly, the non-DM-Lavandula Stoechas group showed reduced bullae, dermal edema, and intraepithelial edema on Day 7. This was followed by increased fibroblast levels on Day 14.

CONCLUSIONS

In conclusion, this study provides compelling evidence for the potential of Lavandula stoechas extract in the enhancement of diabetic wound healing. The multiple interactions revealed here highlight the need for further investigation into the underlying mechanisms. A cost-effective use of Lavandula stoechas opens up promising prospects in managing diabetic foot healing. This warrants additional research and clinical translation.

Early and Intensive Glycemic Control for Diabetic Foot Ulcer Healing: A Prospective Observational Nested Cohort Study

We aimed to assess the effect of glycemic control on diabetic foot ulcer (DFU) healing. A prospective nested cohort study was employed of individuals with poorly controlled diabetes (glycated hemoglobin [HbA1c] >9%) and neuropathic DFU of >2-week duration. All individuals received standard diabetes and ulcer interventions for 12 weeks. Baseline demographic characteristics, ulcer area (automated assessment by wound zoom camera), and biochemical parameters were analyzed. The cohort was stratified into ulcer healed and unhealed groups. Ulcer area and glycemic parameters at 4 and 12 weeks on follow up were compared. Forty-three individuals (47 DFU) with baseline HbA1c 11.6% and ulcer area 9.87 cm2 were enrolled. After 12 weeks, mean HbA1c was 7.2%, 17 ulcers closed (healed group) and 30 ulcers did not close (unhealed group). The median time to ulcer healing was 10 weeks. Individuals in the healed group had lower fasting blood glucose (P = .010), postprandial blood glucose (P = .006), and HbA1c at 4 weeks (P = .001), and 12 weeks (0.018) compared to the unhealed group. Cox-regression analysis that revealed lower baseline ulcer area (P = .013) and HbA1c at 4 weeks (P = .009) significantly predicted DFU healing by 12 weeks. Baseline ulcer area of >10.58 cm2 and HbA1c at 4 weeks of >8.15% predicted delayed DFU healing. In conclusion, early and intensive glycemic control in the first 4 weeks of treatment initiation is associated with greater healing of DFU independent of initial ulcer area.

Application of combined photobiomodulation and curcumin-loaded iron oxide nanoparticles considerably enhanced repair in an infected, delayed-repair wound model in diabetic rats compared to either treatment alone

Herein, we attempted to evaluate the therapeutic potential of photobiomodulation (PBM) and curcumin-loaded iron nanoparticles (CUR), alone and in combination, on wound closure rate (WCR), microbial flora by measuring colony-forming units (CFUs), the stereological and biomechanical properties of repairing wounds in the maturation stage of the wound healing course in an ischemic infected delayed healing wound model (IIDHWM) of type I diabetic (TIDM) rats. There were four groups: group 1 was the control, group 2 received CUR, rats in group 3 were exposed to PBM (80 Hz, 890 nm, and 0.2 J/cm2), and rats in group 4 received both PBM and CUR (PBM + CUR). We found CFU was decreased in groups 2, 3, and 4 compared to group 1 (p = 0.000 for all). Groups 2, 3, and 4 showed a considerable escalation in WCR compared to group 1 (p = 0.000 for all). In terms of wound strength parameters, substantial increases in bending stiffness and high-stress load were observed in groups 2, 3, and 4 compared to group 1 (p = 0.000 for all). Stereological examinations revealed decreases in neutrophil and macrophage counts and increases in fibroblast counts in groups 2, 3, and 4compared  to group 1 (p = 0.000 for all). Blood vessel counts were more dominant in the PBM and PBM + CUR groups over group 1 (p = 0.000 for all). CFU and wound strength as well as macrophage, neutrophil, and fibroblast counts were found to be improved in the PBM + CUR and PBM groups compared to the CUR group (ranging from p = 0.000 to p < 0.05). Better results were achieved in the PBM + CUR  treatment  over the PBM therapy. We determined therapy with PBM + CUR, PBM alone, and CUR alone substantially accelerated diabetic wound healing in an IIDHWM of TIDM rats compared to control  group. Concomitantly, the PBM + CUR and PBM groups attained significantly enhanced results for WCR, stereological parameters, and wound strength than the CUR group, with the PBM + CUR results being superior to those of the PBM group.

Fast-Track Pathway: An Effective Way to Boost Diabetic Foot Care

Diabetes is a chronic disease that challenges global health issues in many aspects. Diabetic foot ulcer (DFU) is one of the most common causes of reduced quality of life and increased hospitalization, amputation, treatment costs, and mortality in patients. Improper patients' knowledge, unsatisfactory education and training of healthcare workers, and limited facilities are the major cause of delayed referral and downscale management in DFUs. The diabetic foot clinical pathway is pivotal in providing best practices based on the latest standards and patient preferences. In the diabetic foot clinical pathway provided by the Iran Ministry of Health, the common concepts and grading systems are well defined for diabetic foot specialists so that patients can be diagnosed correctly and referred properly. Based on clinical examination guidelines, patients with diabetes are classified into low-risk, moderate-risk, high-risk, and active diabetic foot ulcer groups. One of this Pathway's main objectives is to prevent the patient from getting the first ulcer, prevent frequent recurrence ulcers, and most importantly, prevent minor and major amputation.

Detection, management, and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

The Prevalence of Anemia in Hospitalized Patients With Diabetic Foot Ulcer (DFU) and the Relationship Between the Severity of Anemia and the Severity of DFU

BACKGROUND AND AIMS

We aim to determine the prevalence of anemia in hospitalized patients with diabetic foot ulcers (DFUs) and estimate the relationship between the severity of anemia and diabetic foot ulcer.

MATERIALS AND METHODS

We retrospectively collected and evaluated the data of 323 patients hospitalized with diabetic foot ulcer (DFU). We included 299 type 2 diabetic patients with foot ulcers of neuropathic or neuroischemic nature with infection. Anemia was defined based on World Health Organization (WHO) criteria, and the severity of DFU was classified in University of Texas (UT) grades.

RESULTS

Anemia was detected in 94.3% of DFU, and the prevalence of mild, moderate, and severe anemia was 16.7%, 55.7%, and 27.6%, respectively. There was a significant difference in the mean hemoglobin (Hb) levels among the patients with varying grades of severity of DFU (1B: Hb=10.17±2.08 gm/dL, 2B: Hb=9.27±2.04 gm/dL, 3B: Hb=8.03±1.829 gm/dL; p value=<0.0001). The iron study was available in 141 (47.15%) patients and was suggestive of anemia of chronic disorder (mean serum iron=40.22±23.81 mcg/dL, mean total iron-binding capacity (TIBC)=239.34±67.24 mcg/dL, mean ferritin=378.05±141.337 ng/mL). TIBC significantly decreased (1B=262.13±61.05, 2B=233.65±71.26, 3B=222.43±74.18; p=0.04), and ferritin significantly increased (1B=309.9±70.76, 2B=351.73±94.22, 3B=488.58±170.4; p<0.0001) with increasing DFU severity. Hemoglobin was significantly decreased at the time of discharge in comparison to that at admission (9.3±2.1 gm/dL versus 8.8±1.5 gm/dL; p value=0.01). Red blood cell (RBC) counts, mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), lymphocyte counts, albumin, calcium, and high-density lipoprotein (HDL) significantly decreased with the increase of DFU severity. The duration of hospitalization, total leucocyte counts, neutrophil counts, and neutrophil-to-lymphocyte ratio (NLR) increased with the severity of DFU.

CONCLUSIONS

The prevalence of anemia was very high in DFU and more than three-fourths of the patients had moderate to severe anemia. The severity of anemia was associated with the severity of DFU. The most common cause of anemia was anemia of chronic disorder secondary to diabetic foot infection. During the period of hospitalization, hemoglobin decreased despite improvement in DFU infection.

Metrics of Gender Differences in Mortality Risk after Diabetic Foot Disease

BACKGROUND

The aim of this study was to clarify any gender differences in the mortality risk of people with DFD since patients with diabetic foot disease (DFD) are at a high risk of mortality and, at the same time, are more likely to be men.

METHODS

From regional administrative sources, the survival probability was retrospectively evaluated by the Kaplan-Meier method and using the Cox proportional-hazards model comparing people with DFD to those without DFD across the years 2011-2018 in Tuscany, Italy. Gender difference in mortality was evaluated by the ratio of hazard ratios (RHR) of men to women after initial DFD hospitalizations (n = 11,529) or in a cohort with prior history of DFD hospitalizations (n = 11,246).

RESULTS

In both cohorts, the survival probability after DFD was lower among women. Compared to those without DFD, after initial DFD hospitalizations, the mortality risk was significantly (18%) higher for men compared to women. This excess risk was particularly high after major amputations but also after ulcers, infections, gangrene, or Charcot, with a lower reduction after revascularization procedures among men. In the cohort that included people with a history of prior DFD hospitalizations, except for the risk of minor amputations being higher for men, there was no gender difference in mortality risk.

CONCLUSIONS

In people with DFD, the overall survival probability was lower among women. Compared to those without DFD after a first DFD hospitalization, men were at higher risk of mortality. This excess risk disappeared in groups with a history of previous DFD hospitalizations containing a greater percentage of women who were older and probably had a longer duration of diabetes and thus becoming, over time, progressively frailer than men.

Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers: A Phase 3 Randomized Clinical Trial

Importance

Preclinical and phase 1/2 studies with esmolol hydrochloride suggest its potential role in treatment of diabetic foot ulcers (DFUs).

Objective

To study the efficacy of topical esmolol for healing of uninfected DFUs.

Design, Setting, and Participants

A randomized, double-blind, multicenter, phase 3 clinical trial was conducted from December 26, 2018, to August 19, 2020, at 27 referral centers across India. Participants included adults with DFUs.

Interventions

Participants were randomized after a run-in phase (1 week) to receive esmolol, 14%, gel with standard of care (SoC), SoC only, or vehicle with SoC (3:3:1 proportion) for 12 weeks (treatment phase) and followed up subsequently until week 24.

Main Outcomes and Measures

The primary outcome was the proportion of wound closure within the 12-week treatment phase in the esmolol with SoC and SoC only groups. Analysis was conducted using an intention-to-treat safety evaluable population, full analysis set or efficacy-evaluable population, and per-protocol population comparing the esmolol plus SoC and SoC only treatment groups.

Results

In the study, 176 participants (122 men [69.3%]; mean [SD] age, 56.4 [9.0] years; mean [SD] hemoglobin A1c level, 8.6% [1.6%]) with DFUs classified as University of Texas Diabetic Wound Classification system grade IA and IC (mean [SD] ulcer area, 4.7 [2.9] cm2) were randomized to the 3 groups. A total of 140 participants were analyzed for efficacy. The proportion of participants in the esmolol with SoC group who achieved target ulcer closure within 12 weeks was 41 of 68 (60.3%) compared with 30 of 72 (41.7%) participants in the SoC only group (odds ratio [OR], 2.13; 95% CI, 1.08-4.17; P = .03). A total of 120 participants completed the end of study visit which were analyzed. Target ulcer closure by the end of the study (week 24) was achieved in 44 of 57 (77.2%) participants in the esmolol with SoC group and 35 of 63 (55.6%) participants in the SoC only group (OR, 2.71; 95% CI, 1.22-5.99; P = .01). The median time for ulcer closure was 85 days for the esmolol with SoC group and was not estimable for SoC only group. Significant benefits of Esmolol with SoC were seen in patients with factors that impede the healing of DFU. Treatment-emergent adverse events were noted in 18.8% of the participants, but most (87.3%) of these events were not attributable to the study drug.

Conclusions and Relevance

In this multicenter, randomized, double-blind clinical trial, the addition of esmolol to SoC was shown to significantly improve the healing of DFUs. With these results, topical esmolol may be an appropriate addition to SoC for treating DFUs.

Trial Registration

ClinicalTrials.gov Identifier: NCT03998436; Clinical Trial Registry, India CRI Number: CTRI/2018/11/016295.

Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes

Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.

Progress and Challenges of Diabetic Foot Diagnostic and Treatment

"Diabetic foot is one of the main long-term complications of diabetes, having a significant impact on a patient’s quality of life. However, prevention by daily checking of the limbs and observance of the rules of care remains particularly important to avoid total or partial amputation. This paper aims to highlight the main challenges and progress in the treatment of the diabetic foot. To achieve this, we analyzed a database consisting of more than 100 articles published in recent years, approaching the treatment of the diabetic foot. The main problems that occur with the diabetic foot are peripheral vascular disease and diabetic neuropathy. These can lead to blisters and skin lesions that can eventually lead to ulcers in the lower limbs and even amputation. In conclusion, prevention is the main method of treatment for diabetic foot, followed by the treatment of each complication depending on when it is identified and its severity. "

Global mortality of diabetic foot ulcer: A systematic review and meta-analysis of observational studies

AIM

To estimate the long-term mortality and risk factors in patients with diabetic foot ulcer (DFU).

METHODS

We systematically searched Medline (PubMed), Embase, Scopus, Web of Science, Cochrane Library, China Science and Technology Journal Database (CQVIP), China National Knowledge Infrastructure, the Chinese Biomedical Literature Database (SinoMed) and Wanfang Data from 1 January 2011 to 31 July 2022. All observational studies that reported long-term mortality of patients with DFU were included. Random effect models were used to pool the reconstructed participant data from Kaplan-Meier curves. The primary outcome was the long-term survival of patients with DFU. An aggregate data meta-analysis was also performed.

RESULTS

We identified 34 studies, with 124 376 participants representing 16 countries, among whom there were 51 386 deaths. Of these, 27 studies with 21 171 patients were included in the Kaplan-Meier-based meta-analysis. The estimated Kaplan-Meier-based survival rates were 86.9% (95% confidence interval [CI] 82.6%-91.5%) at 1 year, 66.9% (95% CI 59.3%-75.6%) at 3 years, 50.9% (95% CI 42.0%-61.7%) at 5 years and 23.1% (95% CI 15.2%-34.9%) at 10 years. The results of the aggregate data-based meta-analysis were similar. Cardiovascular disease and infection were the most common causes of death, accounting for 46.6% (95% CI 33.5%-59.7%) and 24.8% (95% CI 16.0%-33.5%), respectively. Patients with older age (per 1 year, hazard ratio [HR] 1.054, 95% CI 1.045-1.063), peripheral artery disease (HR 1.882, 95% CI 1.592-2.225), chronic kidney disease (HR 1.535, 95% CI 1.227-1.919), end-stage renal disease (HR 3.586, 95% CI 1.333-9.643), amputation (HR 2.415, 95% CI 1.323-4.408) and history of cardiovascular disease (HR 1.449, 95% CI 1.276-1.645) had higher mortality risk.

CONCLUSIONS

This meta-analysis found that the overall mortality of DFU was high, with nearly 50% mortality within 5 years. Cardiovascular disease and infection were the two leading causes of death.

Diabetic Foot Complications: A Retrospective Cohort Study

Diabetes mellitus is a highly prevalent disease globally and contributes to significant morbidity and mortality. As a consequence of multiple pathophysiologic changes which are associated with diabetes, these patients frequently suffer from foot-related disorders: infections, ulcerations, and gangrene. Approximately half of all amputations occur in diabetic individuals, usually as a complication of diabetic foot ulcers. In this retrospective study, we analyzed and characterized a cohort of 69 patients and their diabetes-related foot complications. The main characteristics of our cohort were as follows: older age at diagnosis (mean age 66); higher incidence of diabetes in males; predominantly urban patient population. The most frequent complications of the lower extremity were ulcerations and gangrene. Moreover, in our study, 35% of patients required surgical reintervention, and 27% suffered from complications, while 13% required ICU admission. However, diabetic foot lesions are preventable via simple interventions which pointedly reduce foot amputations. Early identification and the appropriate medical and surgical treatment of the complications associated with diabetic foot disease are important because they still remain common, complex and costly.

Intensive Glycemic Control for Diabetic Foot Ulcer Healing: A Multicentric, Randomized, Parallel Arm, Single-Blind, Controlled Study Protocol (INGLOBE Study)

Hyperglycemia impairs healing of diabetic foot ulcer (DFU). But there is no evidence regarding benefit of intensive glucose control for healing of DFU. We plan to conduct a randomized, parallel arm, controlled study to assess the role of intensive glycemic management in comparison to conventional glucose control for healing of DFU. Participants with neuropathic DFU (infected or uninfected) having hemoglobin A1c (HbA1c) >8% and without evidence of osteomyelitis from 7 tertiary care hospitals will be enrolled. They will undergo a 2-week run-in phase for optimization of comorbidities, ulcer debridement, and counseling regarding self-monitoring of blood glucose (SMBG). Subsequently, they will be randomized to “intensive glycemic control” arm defined by glycemic targets of fasting blood glucose (FBG) <130 mg/dL, postprandial BG <180 mg/dL, and HbA1c <8%, with basal-bolus insulin regimen and frequent titration of insulin to achieve glycemic targets. The “conventional” arm will continue on prior treatment (oral antidiabetic drugs) with no titration unless meeting rescue criteria. Ulcer area will be calculated by automated wound assessment device (WoundlyClinial app) weekly for first 4 weeks, and less frequently until the 24th week. Standard treatment for DFU, off-loading, and counseling for foot care will be provided in both arms. The primary outcome measure will be number of wounds closed at 12th and 24th weeks. A multivariate regression analysis will be performed to identify the predictors of wound healing with baseline HbA1c, diabetes duration, wound size, wound duration, and background therapies as independent variable. This study will provide the much needed guidance to set optimum glucose targets in people with DFU.

The progress and challenges of circRNA for diabetic foot ulcers: A mini-review

Since the Human Genome Project was successfully completed, humanity has entered a post-genome era, and the second-generation sequencing technology has gradually progressed and become more accurate. Meanwhile, circRNAs plays a crucial role in the regulation of diseases and potential clinical applications has gradually attracted the attention of physicians. However, the mechanisms of circRNAs regulation at the cellular and molecular level of diabetic foot ulcer (DFU) is still not well-understood. With the deepening of research, there have been many recent studies conducted to explore the effect of circRNAs on DFU. In this mini-review, we discuss the potential role of circRNAs as therapeutic targets and diagnostic markers for DFU in order to gain a better understanding of the molecular mechanisms that underlie the development of DFU and to establish a theoretical basis for accurate treatment and effective prevention.

The role of pathogens in diabetes pathogenesis and the potential of immunoproteomics as a diagnostic and prognostic tool

Diabetes mellitus (DM) is a group of metabolic diseases marked by hyperglycemia, which increases the risk of systemic infections. DM patients are at greater risk of hospitalization and mortality from bacterial, viral, and fungal infections. Poor glycemic control can result in skin, blood, bone, urinary, gastrointestinal, and respiratory tract infections and recurrent infections. Therefore, the evidence that infections play a critical role in DM progression and the hazard ratio for a person with DM dying from any infection is higher. Early diagnosis and better glycemic control can help prevent infections and improve treatment outcomes. Perhaps, half (49.7%) of the people living with DM are undiagnosed, resulting in a higher frequency of infections induced by the hyperglycemic milieu that favors immune dysfunction. Novel diagnostic and therapeutic markers for glycemic control and infection prevention are desirable. High-throughput blood-based immunoassays that screen infections and hyperglycemia are required to guide timely interventions and efficiently monitor treatment responses. The present review aims to collect information on the most common infections associated with DM, their origin, pathogenesis, and the potential of immunoproteomics assays in the early diagnosis of the infections. While infections are common in DM, their role in glycemic control and disease pathogenesis is poorly described. Nevertheless, more research is required to identify novel diagnostic and prognostic markers to understand DM pathogenesis and management of infections. Precise monitoring of diabetic infections by immunoproteomics may provide novel insights into disease pathogenesis and healthy prognosis.

Complications related to diabetic foot ulcer and associated social vulnerability factors at a referral centre in Brazil

Objective:

To analyse the prevalence and associated social vulnerability factors of complications related to diabetic foot ulcer (DFU) among individuals followed up in a public care centre in Brazil.

Method:

This is a cross-sectional study carried out with individuals followed up at the diabetic foot service of the State Referral Center for Diabetes and Endocrinology Assistance (CEDEBA) between December 2019 and October 2020, during the COVID-19 pandemic. Descriptive analysis and comparison of the prevalence of complications related to DFU were carried out. The factors associated with the outcome variables were verified by hierarchical logistic regression analysis.

Results:

Among the 253 participants in this study, 30.4% had an active ulcer, 57.1% had a previous ulcer and 45.1% had an amputation. Lower limb ulcers were positively associated with male sex (prevalence ratio (PR): 1.22 (1.04–1.43)) and negatively associated with age >60 years (PR: 0.71 (0.61–0.83)), screening for diabetic foot (PR: 0.79 (0.67–0.92)) and the use of public transport to access CEDEBA (PR: 0.82 (0.71–0.96)). On the other hand, amputations were positively associated with male sex (PR: 1.61 (1.23–2.11)) and not working (PR: 3.83 (1.48–9.95)) and negatively associated with age >60 years (PR: 0.57 (0.45–0.74)) and the use of public transport to access CEDEBA (PR: 0.63 (0.49–0.81)).

Conclusion:

The prevalence of complications was higher than in previous studies, and associated with sociodemographic and clinical characteristics. Further research should be encouraged to investigate the role that determinants of health play in the course of the disease, contributing to the construction of strategies that incorporate formulations developed in the social and economic spheres to broaden the impact of health actions on the prevention of major diabetic foot complications.

On diabetic foot ulcer knowledge gaps, innovation, evaluation, prediction markers, and clinical needs

Diabetic foot ulcers (DFUs) remain a very prevalent and challenging complication of diabetes worldwide due to high morbidity, high risks of lower extremity amputation and associated mortality. Despite major advances in diabetes treatment in general, there is a paucity of FDA approved technologies and therapies to promote successful healing. Furthermore, accurate biomarkers to identify patients at risk of non-healing and monitor response-to-therapy are significantly lacking. To date, research has been slowed by a lack of coordinated efforts among basic scientists and clinical researchers and confounded by non-standardized heterogenous collection of biospecimen and patient associated data. Novel technologies, especially those in the single and 'multiomics' arena, are being used to advance the study of diabetic foot ulcers but require pragmatic study design to ensure broad adoption following validation. These high throughput analyses offer promise to investigate potential biomarkers across wound trajectories and may support information on wound healing and pathophysiology not previously well understood. Additionally, these biomarkers may be used at the point-of-care. In combination with national scalable research efforts, which seek to address the limitations and better inform clinical practice, coordinated and integrative insights may lead to improved limb salvage rates.

Recent updates in the treatment of diabetic polyneuropathy

Distal symmetric diabetic peripheral polyneuropathy (DPN) is the most common form of neuropathy in the world, affecting 30 to 50% of diabetic individuals and resulting in significant morbidity and socioeconomic costs. This review summarizes updates in the diagnosis and management of DPN. Recently updated clinical criteria facilitate bedside diagnosis, and a number of new technologies are being explored for diagnostic confirmation in specific settings and for use as surrogate measures in clinical trials. Evolving literature indicates that distinct but overlapping mechanisms underlie neuropathy in type 1 versus type 2 diabetes, and there is a growing focus on the role of metabolic factors in the development and progression of DPN. Exercise-based lifestyle interventions have shown therapeutic promise. A variety of potential disease-modifying and symptomatic therapies are in development. Innovations in clinical trial design include the incorporation of detailed pain phenotyping and biomarkers for central sensitization.

Effects of Chlorhexidine-Iodophor Composite Solution on the Viability and Proliferation of Human Skin Fibroblasts Infected by S. aureus - An in Vitro Experiment

Background: The chlorhexidine-iodophor (CHX-IP) composite solution is a polymer of chlorhexidine and iodophor, applicable to the control of local microbial load and probably toxic to fibroblasts. However, the effect of CHX-IP on the viability and proliferation of human skin fibroblasts infected by Staphylococcus aureus (S. aureus) remains unknown. Objective: The effects of CHX-IP composite solution on the viability and proliferation of human skin fibroblasts infected by S. aureus were investigated in vitro cell culture in this study. Methods: Optimum multiplicity of infection (MOI) was determined to construct the S. aureus-fibroblast co-culture model. Cell Viability Assay was applied to obtain optical density (OD) value and calculate cell viability. 5-ethynyl-2'- deoxyuridine (EdU) assay was used to investigate the effect of CHX-IP on the proliferation of human skin fibroblasts infected by S. aureus. Results: 10:1 was the optimum MOI for the S. aureus-fibroblast co-culture model. The OD value of human skin fibroblasts infected by S. aureus increased in the blank control group, 0.625 mg/ml, 0.3125 mg/ml, 0.15625 mg/ml, and 0.075625 mg/ml groups after four hours. While that of the negative control group, 5 mg/ml, 2.5 mg/ml, and 1.25 mg/ml groups decreased over time. The two-way ANOVA results indicated that the OD value of human skin fibroblasts infected by S. aureus was significantly different among different CHX-IP concentration groups (F = 34.05, P < .001), and the interaction effect between concentration and time was significant (F = 9.442, P < .001). The results of the EdU cell proliferation assay showed that the blank control group, 0.625 mg/ml CHX-IP group, and 0.075625 mg/ml CHX-IP group had an enhanced fibroblasts cell proliferation, while the fibroblasts cell proliferation of the negative control group and 5 mg/ml CHX-IP group was inhibited. Conclusion: The viability and proliferation of human skin fibroblasts infected by S. aureus were inhibited, while specific concentrations of CHX-IP solution can counteract or even reverse the proliferation inhibition effect.

Impaired wound healing in diabetes

Impaired wound healing for patients with diabetes is due to a constellation of structural, biochemical, cellular and microbial factors. Hyperglycaemia and its associated inflammation contribute to immune dysfunction, vascular damage, neuropathy, cellular senescence, impaired transition beyond the inflammatory stage, microbiome disruptions, failed extracellular matrix formation, growth factor and cytokine imbalance, limited re-epithelialisation, and alterations in fibroblast migration and proliferation. Optimising glycaemic control remains the primary intervention to prevent continual dysfunction and comorbid disease progression.

Outcomes of Hallux Amputation Versus Partial First Ray Resection in People with Non-Healing Diabetic Foot Ulcers: A Pragmatic Observational Cohort Study

There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to determine the more definitive surgery between hallux amputation and partial first ray resection. We abstracted data from a cohort of 70 patients followed for a 1-year postoperative period to support clinical practice. We also attempted to identify patient characteristics leading to these outcomes. Our results suggested no statistical difference between the type of surgery and outcomes such as recurrence of DFU and amputation at 3, 6, and 12 months or death. However, there was a statistically significantly increased likelihood of re-ulceration for patients with CAD who underwent hallux amputation (p = 0.02). There was also a significantly increased likelihood of re-ulceration for people with depression or a history when the partial ray resection was performed (p = 0.02). Patients with prior amputation showed a higher probability of undergoing another re-amputation with partial ray resection (p = 0.01). Although the trends that emerge from this project are limited to what is observed in this statistical context, where the number of patients included and the number of total observations per outcome were limited, it highlights interesting data for future research to inform clinical decisions to support best practices for the benefit of patients.

Impact of acute hyperglycemic crisis episode on survival in individuals with diabetic foot ulcer using a machine learning approach

Objective

The outcome of DFUs concomitant with HCE remains unknown. This study aimed to investigate mortality rates and identify risk factors of mortality in patients with DFUs-HCE.

Methods

27 inpatients with DFUs-HCE were retrospectively enrolled in a cohort design, they were compared to 93 inpatients with DFUs in a city designated emergency center, between January 2016 and January 2021. After a 6-year followed-up, clinical characteristic, amputation and survival rates were compared. Extreme gradient boosting was further used to explore the relative importance of HCE and other risk factors to all-cause mortality in DFUs.

Results

Patients with DFUs-HCE were more likely to havedementia, acute kidney injury and septic shock, whereas DFUs were more likely to have diabetic peripheral neuropathy and ulcer recurrence (P<0.05). No significant difference was observed on the amputation rate and diabetes duration. Both Kaplan-Meier curves and adjusted Cox proportional model revealed that DFUs-HCE was associated with a higher mortality compared with DFUs (P<0.05). HCE significantly increased the risk of mortality in patients with DFUs (hazard ratio, 1.941; 95% CI 1.018-3.700; P = 0.044) and was independent from other confounding factors (age, sex, diabetes duration, Wagner grades and Charlson Comorbidity Index). The XGBoost model also revealed that HCE was one of the most important risk factors associated with all-cause mortality in patients with DFUs.

Conclusions

DFUs-HCE had significantly lower immediate survival rates (first 1-6 month) than DFUs alone. HCE is an important risk factor for death in DFUs patients.

High-Frequency 10-kHz Spinal Cord Stimulation Improves Health-Related Quality of Life in Patients With Refractory Painful Diabetic Neuropathy: 12-Month Results From a Randomized Controlled Trial

Objective

To evaluate high-frequency (10-kHz) spinal cord stimulation (SCS) treatment in refractory painful diabetic neuropathy.

Patients and Methods

A prospective, multicenter randomized controlled trial was conducted between Aug 28, 2017 and March 16, 2021, comparing conventional medical management (CMM) with 10-kHz SCS+CMM. The participants had hemoglobin A1c level of less than or equal to 10% and pain greater than or equal to 5 of 10 cm on visual analog scale, with painful diabetic neuropathy symptoms 12 months or more refractory to gabapentinoids and at least 1 other analgesic class. Assessments included measures of pain, neurologic function, and health-related quality of life (HRQoL) over 12 months with optional crossover at 6 months.

Results

The participants were randomized 1:1 to CMM (n=103) or 10-kHz SCS+CMM (n=113). At 6 months, 77 of 95 (81%) CMM group participants opted for crossover, whereas none of the 10-kHz SCS group participants did so. At 12 months, the mean pain relief from baseline among participants implanted with 10-kHz SCS was 74.3% (95% CI, 70.1-78.5), and 121 of 142 (85%) participants were treatment responders (≥50% pain relief). Treatment with 10-kHz SCS improved HRQoL, including a mean improvement in the EuroQol 5-dimensional questionnaire index score of 0.136 (95% CI, 0.104-0.169). The participants also reported significantly less pain interference with sleep, mood, and daily activities. At 12 months, 131 of 142 (92%) participants were "satisfied" or "very satisfied" with the 10-kHz SCS treatment.

Conclusion

The 10-kHz SCS treatment resulted in substantial pain relief and improvement in overall HRQoL 2.5- to 4.5-fold higher than the minimal clinically important difference. The outcomes were durable over 12 months and support 10-kHz SCS treatment in patients with refractory painful diabetic neuropathy.

Trial registration

clincaltrials.gov Identifier: NCT03228420.

Foot Self-Care Behaviour among People with Type 2 Diabetes mellitus Living in Rural Underserved Area of North India: A Community-Based Cross-Sectional Study

The objective of this study was to ascertain the foot self-care behaviour and its associated factors among people with type 2 diabetes mellitus (T2DM) living in the rural resource-constrained health setting of Punjab, North India. A community based cross sectional study was undertaken in the randomly selected underserved rural area of District Fatehgarh Sahib, Punjab, North India. A pre-validated Nottingham Assessment of Functional Footcare (NAFF) scale was administered to assess foot self-care behaviour, and participants were classified based on the percentage of a maximum possible score of 84 on the scale, as poor, if the score was <50%, satisfactory if score 50%-70% and >70% good foot self-care behaviour. A total of 700 participants' responses were recorded. The study results revealed that 84% (588) of the respondents had poor, 16% (112) had satisfactory, and none were following good foot self-care behaviour. An outcome of multivariable logistics regression suggested satisfactory foot self-care behaviour was significantly associated with foot self-care education, with an adjusted odds ratio (aOR) of 2.83 (95%, CI:1.62 - 4.93; p <0.01) among respondents who had received foot self-care education, literate than illiterate (aOR 2.50 95%, CI:1.31- 4.74; p <0.01) and women compared to men (aOR 1.69 95%, CI: 1.06 -2.70; p -0.26). This study revealed that foot self-care behaviours were alarmingly low among people with T2DM living in rural resource-constrained health settings of Punjab, North India, suggesting an urgent need to disseminate foot self-care education to prevent diabetes foot related complications.

Hyperbaric oxygen therapy as an adjunct to the standard wound care for the treatment of diabetic foot ulcers in Indian patients: a cost utility analysis

BACKGROUND

Diabetic foot ulcer (DFU) is a common complication of diabetes. Hyperbaric oxygen therapy (HBOT) is an adjunct treatment that expedites the healing of DFU.

AIM

To evaluate the cost-utility of using standard wound care (SWC) plus HBOT as compared to SWC alone for the treatment of DFU from a societal perspective in the Indian context.

METHOD

A Markov decision analysis model comparing SWC with and without HBOT was developed. Data for the model were derived from relevant literature and secondary data from India. The main outcome measures were minor and major lower extremity amputations (LEA) averted, incremental quality-adjusted-life-years (QALY) gained, incremental costs, incremental cost-effectiveness ratio (ICER) per amputation averted and ICER per QALY gained. Sensitivity and threshold analyses were also done.

RESULT

HBOT, when added to SWC, lowered the proportion of minor LEA and major LEA among patients with DFU by 6.1% and 4.2%, respectively. The discounted ICER was INR 193,939 [95% CI: 186,745-203,753] or US$ 2,621 [95% CI: 2,524-2,753] per QALY gained.

CONCLUSION

SWC plus HBOT is not cost-effective in India. Additional information is required on patient experiences with adjunctive HBOT, if it were to be adopted as the standard of care in India.

Mortality Risk Associated with Diabetic Foot Complications in People with or without History of Diabetic Foot Hospitalizations

The aim of this study was to evaluate the risk of death after hospitalizations for diabetic foot (DF) complications, comparing two different cohorts of people with or without a prior history of DF hospitalizations across the years 2011 to 2018 in Tuscany, Italy. The DF complications were categorized by administrative source datasets such as: amputations (both major and minor), gangrene, ulcers, infections, Charcot and revascularizations. A further aim was to present the trend over time of the first ever incidents of diabetic foot hospitalizations in Tuscany. The eight-year-mortality rate was higher in the cohort with prior hospitalizations (n = 6633; 59%) compared with the cohort with first incident DF hospitalizations (n = 5028; 44%). Amputations (especially major ones) and ulcers had the worst effect on survival in people without basal history of DF hospitalizations and respectively in those with a history of prior DF hospitalizations. In both cohorts, revascularization procedures, when compared to ulcers, were associated with a significantly reduced risk of mortality. The prevalence rate of minor amputations showed a slightly rising trend over time. This result agrees with the national trend. Conversely, the progressive increase over time of revascularizations, associated with the fractional decrease in the rate of gangrene, suggests a trend for more proactive behavior by DF care teams in Tuscany.

A Dual-Cross-Linked Hydrogel Patch for Promoting Diabetic Wound Healing

Diabetic wound treatment faces significant challenges in clinical settings. Alternative treatment approaches are needed. Continuous bleeding, disordered inflammatory regulation, obstruction of cell proliferation, and disturbance of tissue remodeling are the main characteristics of diabetic wound healing. Hydrogels made of either naturally derived or synthetic materials can potentially be designed with a variety of functions for managing the healing process of chronic wounds. Here, a hemostatic and anti-inflammatory hydrogel patch is designed for promoting diabetic wound healing. The hydrogel patch is derived from dual-cross-linked methacryloyl-substituted Bletilla Striata polysaccharide (B) and gelatin (G) via ultraviolet (UV) light. It is demonstrated that the B-G hydrogel can effectively regulate the M1/M2 phenotype of macrophages, significantly promote the proliferation and migration of fibroblasts in vitro, and accelerate angiogenesis. It can boost wound closure by normalizing epidermal tissue regeneration and depositing collagen appropriately in vivo without exogenous cytokine supplementation. Overall, the B-G bioactive hydrogel can promote diabetic wound healing in a simple, economical, effective, and safe manner.

Risk Factors for Multidrug-Resistant Organisms Infection in Diabetic Foot Ulcer

Objective

The aim of this study is to analyze the microbiological characteristics of diabetic foot ulcer (DFU) and drug resistance of multidrug-resistant organisms (MDROs) and to reveal the potential risk factors for MDROs. This provides a basis for early empiric antibiotic treatment.

Methods

This study included 348 patients with diabetic foot ulcer in Chu Hsien-I Memorial Hospital & Metabolic Disease Hospital of Tianjin Medical University between May 2020 and November 2021. A total of 475 strains of bacteria were cultured, among which 240 strains were multidrug-resistant bacteria, accounting for 51%. Binary logistic regression was used to analyze risk factors. First, univariate analysis was used to calculate the p value of variables, and then multivariate analysis was conducted for variables with p < 0.1 to analyze independent risk factors. Risk factors with p < 0.05 in multivariable analysis were considered as independent risk factors. The strength of the association was represented by odds ratio and 95% confidence interval.

Results

Univariable logistic regression analysis demonstrated that previous hospitalization, previous antibiotic therapy, ulcer size >4cm², surgical therapy, D-dimer, and CRP were associated with MDRO infection in patients with DFU. Multivariate logistic regression analysis demonstrated that previous hospitalization (OR = 1.91; 95% CI = 1.11–3.28; p = 0.02), ulcer size >4cm² (OR = 1.68; 95% CI = 1.03–2.76; p = 0.04), surgical therapy (OR = 2.14; 95% CI = 1.03–4.47; p = 0.04), and CRP (OR = 1.01; 95% CI = 1.00–1.01; p = 0.03) were independent risk factors for MDROs infection in diabetic foot patients. Drug resistance analysis may indicate that the proportion and drug resistance rate of Acinetobacter baumannii in Tianjin, China, have changed.

Conclusion

Previous hospitalization, ulcer size >4cm², surgical therapy and CRP were independent risk factors for MDROs infection in diabetic foot patients. Identifying these risk factors can help us identify the high-risk patients of diabetic foot with MDRO infection early. More attention to high-risk patients and more aggressive isolation precautions may reduce the incidence of MDRO infection in diabetic foot patients.

The Influence of Different Types of Diabetes on Vascular Complications

The final outcome of diabetes is chronic complications, of which vascular complications are the most serious, which is the main cause of death for diabetic patients and the direct cause of the increase in the cost of diabetes. Type 1 and type 2 diabetes are the main types of diabetes, and their pathogenesis is completely different. Type 1 diabetes is caused by genetics and immunity to destroy a large number of β cells, and insulin secretion is absolutely insufficient, which is more prone to microvascular complications. Type 2 diabetes is dominated by insulin resistance, leading to atherosclerosis, which is more likely to progress to macrovascular complications. This article explores the pathogenesis of two types of diabetes, analyzes the pathogenesis of different vascular complications, and tries to explain the different trends in the progression of different types of diabetes to vascular complications, in order to better prevent diabetes and its vascular complications.

Diabetic Foot Ulcer Infections and Pseudomonas aeruginosa Biofilm Production During the COVID-19 Pandemic

During the different waves of the coronavirus (COVID-19) pandemic, there has been an increased incidence of diabetes mellitus and diabetic foot infections. Among gram-negative bacteria, Pseudomonas aeruginosa is the predominant causative agent for diabetic foot ulcer infections in low-resource countries. P. aeruginosa possesses a variety of virulence factors, including biofilm formation. Biofilm formation is an important benchmark characteristic in the pathophysiology of diabetic foot ulceration. The main objective of the current study was to identify the most commonly isolated organisms and their antibiotic susceptibility patterns in diabetic foot patients during the COVID-19 pandemic. We also determined the genes associated with bacterial persistence and biofilm formation in the predominantly isolated organism. Accordingly, 100 wound swab samples were collected from diabetic foot patients from different hospitals in Alexandria, Egypt. Through phenotypic detection of biofilm formation, 93% (40) of the 43 P. aeruginosa isolates examined were categorized as biofilm producers. Molecular detection of the biofilm-encoding genes among the 43 P. aeruginosa isolates was as follows: algD (100%), pelF (88%) and pslD (49.7%), and this highlights a need for biofilm formation inhibitors to prevent the persistence of bacterial pathogens, and thus achieve better clinical outcomes in diabetic foot ulcer infections.

Novel topical esmolol hydrochloride improves wound healing in diabetes by inhibiting aldose reductase, generation of advanced glycation end products, and facilitating the migration of fibroblasts

AIMS/OBJECTIVES

Wound healing in people with diabetes is delayed secondary to impaired nitric oxide generation, advanced glycation end products (AGE), and poor migration of epithelial cells. We developed a novel topical esmolol hydrochloride (Galnobax) and assessed its efficacy for wound healing in streptozocin-induced diabetic hairless rat.

METHODS

All experiments were performed at an animal laboratory and tertiary-care research facility. Ex vivo aldose reductase inhibition was assessed from enzymes obtained from a bacterial culture (spectrophotometer), sorbitol content in homogenized red blood cells, and AGE in glucose and bovine serum by fluorometry following the addition of esmolol in varying concentrations. A scratch assay of human fibroblasts, endothelial cells, and keratinocytes was assessed under a high-glucose environment and after esmolol by phase-contrast microscopy. The efficacy evaluation of the topical application of Galnobax (14 and 20%) or vehicle was conducted in streptozotocin-induced diabetic hairless rats, and endogenous nitrite and hydroxyproline from homogenized wound tissue were measured along with pharmacokinetic and dermal toxicity in Hanford miniature swine.

RESULTS

Esmolol inhibited the formation of sorbitol by 59% in erythrocytes in comparison to glucose-induced sorbitol levels. AGE generation in bovine serum albumin was reduced at 1 mM esmolol concentrations (2.6 ± 1.7) compared with control (p < 0.05) and similar to that of diclofenac (2.5 ± 1.3). Esmolol at 1 and 10 µM enhanced the migration of fibroblasts, epithelial cells, and keratinocytes compared with control. The nitric oxide levels (day 7) were 44 and 112% higher with Galnobax (14%) than those of the diabetic group (p < 0.05) and the vehicle control group (p < 0.05), respectively. The days 7 and 14 hydroxyproline in the wound was higher by 22 and 44% following Galnobax (14%) compared with the diabetic and vehicle control groups. The wound area exhibited better reduction with Galnobax at 14% up to day 10 follow-up compared with the controls. The pharmacokinetic and dermal toxicity in miniature swine suggested no significant adverse event with Galnobax.

CONCLUSIONS

Topical esmolol hydrochloride is a novel, safe, and effective treatment modality that acts through pleotropic mechanisms to hasten wound healing in diabetes.