Incidence, risk factors for amputation among patients with diabetic foot ulcer in a North Indian tertiary care hospital

Outcomes in Drainage Ankle Disarticulation vs Guillotine Transtibial Amputation in the Staged Approach to Below-Knee Amputation

A transtibial amputation is the traditional primary staged amputation for source control in the setting of non-salvageable lower extremity infection, trauma, or avascularity prior to progression to proximal amputation. The primary aim of the study is to compare preoperative risk factors and postoperative outcomes between patients who underwent transtibial amputation versus ankle disarticulation in staged amputations. A retrospective review of 152 patients that underwent staged below the knee amputation were compared between those that primarily underwent transtibial amputation (N = 70) versus ankle disarticulation (N = 82). The mean follow-up for all 152 patients was 2.1 years (range = 0.04-7.9 years). The odds of incisional healing were 3.2 times higher for patients with guillotine amputation compared to patients with ankle disarticulation (odds ratio [OR] = 3.2, 95% confidence interval [CI] = 1.437-7.057). The odds of postoperative infection is 7.4 times higher with ankle disarticulation compared to patients with guillotine amputation (OR = 7.345, 95% CI = 1.505-35.834). There were improved outcomes in patients that underwent staged below the knee amputation with primarily guillotine transtibial amputation compared to primarily ankle disarticulation. Ankle disarticulation should be reserved for more distal infections, to allow for adequate infectious control, in the aims of decreasing postoperative infection and improving incisional healing rates.Levels of Evidence: 3, Retrospective study.

Chemical Constituents from Agave applanata and Its Antihyperglycemic, Anti-inflammatory, and Antimicrobial Activities Associated with Its Tissue Repair Capability

Agave applanata is a Mexican agave whose fresh leaves are employed to prepare an ethanol tonic used to relieve diabetes. It is also applied to skin to relieve varicose and diabetic foot ulcers, including wounds, inflammation, and infections. In this study, the chemical composition of this ethanol tonic is established and its association with antihyperglycemic, anti-inflammatory, antimicrobial, and wound healing activities is discussed. The fresh leaves of A. applanata were extracted with ethanol : H2O (85 : 15). A fraction of this extract was lyophilized, and the remainder was partitioned into CH2Cl2, n-BuOH, and water. CH2Cl2 and n-BuOH fractions were subjected to a successive open column chromatography process. The structure of the isolated compounds was established using nuclear magnetic resonance and mass spectrometry spectra. The antihyperglycemic activity was evaluated through in vivo sucrose and glucose tolerance experiments, as well as ex vivo intestinal absorption and hepatic production of glucose. Wound healing and edema inhibition were assayed in mice. The minimum inhibitory concentrations (MICs) of the hydroalcoholic extract, its fractions, and pure compounds were determined through agar microdilution against the most isolated pathogens from diabetic foot ulcers. Fatty acids, β-sitosterol, stigmasterol, hecogenin (1: ), N-oleyl-D-glucosamine, β-daucosterol, sucrose, myo-inositol, and hecogenin-3-O-α-L-rhamnopyranosyl-(1 → 3)-β-D-xylopyranosyl-(1 → 2)-[β-D-xylopyranosyl-(1 → 3)-β-D-glucopyranosyl-(1 → 3)]-β-D-glucopyranosyl-(1 → 4)-β-D-galactopyranoside (2: ) were characterized. This research provides evidence for the pharmacological importance of A. applanata in maintaining normoglycemia, showing anti-inflammatory activity and antimicrobial effects against the microorganisms frequently found in diabetic foot ulcers. This plant plays an important role in wound healing and accelerated tissue reparation.

[Characteristics of Inflammatory Markers in Diabetic Foot Patients and Their Relationship With Prognosis of Diabetic Foot Ulcers]

Objective

To explore the characteristics of baseline inflammatory markers in diabetic foot patients and their relationship with the prognosis of diabetic foot ulcers.

Methods

The clinical data of diabetic foot patients (n=495) admitted to West China Hospital, Sichuan University since 2016 were retrospectively collected through the hospital electronic medical record system to analyze the characteristics of inflammatory markers and their relationship with the prognosis of diabetic foot ulcers.

Results

White blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels were significantly higher in patients defined as grade 4 on the Wagner Scale than those in patients defined as grade 0-3 on the Wagner Scale. Neutrophil percentage (NE%) was higher in Wagner grade-4 patients than those in Wagner grade-0 and grade-1 patients and higher in Wagner grade-3 patients than those in Wagner grade-0 patients. NE%, CRP, PCT, and IL-6 levels were positively correlated with the severity of diabetic foot, with the respective odds ratio (OR) at 95% confidence interval (CI) being 1.038 (1.019-1.056), 1.019 (1.012-1.026), 8.225 (2.015-33.576), and 1.017 (1.008-1.025). Using Wagner grade-0 patients as the reference, patients with higher WBC were more likely to progress to Wagner grade 2, 3, and 4, with the respective OR (95% CI) values being 1.260 (1.096-1.447), 1.188 (1.041-1.356), and 1.301 (1.137-1.490); patients with higher ESR were more likely to progress to Wagner grade 3 and 4, with the respective OR (95% CI) values being 1.030 (1.006-1.054) and 1.045 (1.019-1.071). Baseline ESR (P=0.008), CRP (P=0.039), and IL-6 (P=0.033) levels were lower in patients who had received antibiotics prior to their admission than those in patients who had not received antibiotics before admission. The levels of WBC, NE%, ESR, PCT, and IL-6 were lower in the full recovery group than those in the group of patients who did not respond to treatment. The higher the levels of NE% and IL-6, the worse the prognosis of diabetic foot ulcers became, with the respective OR (95% CI) values being 1.030 (1.010-1.051) and 1.008 (1.002-1.013).

Conclusion

The severity of diabetic foot ulcers increased with the rise in baseline levels of inflammatory markers. Elevated baseline NE% and IL-6 levels suggest a poor prognosis. Our findings suggest that early assessment of diabetic foot infection and standardized antibiotic therapy should be implemented to improve the prognosis.

Antibacterial Activity of Surfactin and Synergistic Effect with Conventional Antibiotics Against Methicillin-Resistant Staphylococcus aureus Isolated from Patients with Diabetic Foot Ulcers

Introduction

The prevalence of diabetic foot ulcers (DFUs) is increasing, leading to a huge financial burden and human suffering. Furthermore, antibiotic resistance is an urgent problem in the realm of clinical practice. Antimicrobial peptides are an effective and feasible strategy for combating infections caused by drug-resistant bacteria. Therefore, we investigated the in vitro antimicrobial ability of the lipopeptide surfactin, either alone or in combination with conventional antibiotics, against the standard and clinical strains of Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA), isolated from patients with DFUs.

Methods

The minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) of surfactin on the selected strains were evaluated by a microbroth dilution technique. The growth curves of the selected strains with and without surfactin were measured, and transmission electron microscopy was used to observe the structure of surfactin-treated bacterial cells. The biofilm inhibitory abilities of surfactin were assessed by crystal violet staining. The antimicrobial interactions between surfactin and conventional antibiotics were established using a checkerboard assay, as well as determining the mutant prevention concentration. The inhibitory effect of surfactin on penicillinase was tested by iodometry.

Results

The MIC and MBC values of surfactin ranged from 512 to 1024 µg/mL and 1024 to 2048 µg/mL, respectively. Moreover, surfactin significantly prevented the S. aureus biofilm formation and displayed limited toxicity on human red blood cells. The synergies between surfactin and ampicillin, oxacillin, and tetracycline against S. aureus were revealed. In vitro resistance was not readily produced by surfactin. The action of surfactin may be by disrupting bacterial cell membranes and inhibiting penicillinase.

Conclusion

Surfactin appears to be a potential option for the treatment of DFUs infected with MRSA, as it is capable of improving antimicrobial activities and can be used alone or in combination with conventional antibiotics to prevent or postpone the emergence of resistance.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Is the duration of diabetic foot ulcers an independent risk factor for developing diabetic foot osteomyelitis?

OBJECTIVE

This study aimed to determine whether the prolonged duration of diabetic foot ulcers was associated with an increased incidence of diabetic foot osteomyelitis.

STUDY DESIGN

A retrospective cohort study METHODS: The medical records of all patients who participated in the diabetic foot clinic between January 2015 and December 2020 were reviewed. Patients with new diabetic foot ulcers were monitored for diabetic foot osteomyelitis. The collected data included the patient's profile, comorbidities and complications, the ulcer profile (area, depth, location, duration, number of ulcers, inflammation, and history of the previous ulcer), and outcome. Univariate and multivariate Poisson regression analyses were used to assess risk variables for diabetic foot osteomyelitis.

RESULTS

Eight hundred and fifty-five patients were enrolled; 78 developed diabetic foot ulcers (cumulative incidence 9% over 6 years, average annual incidence 1.5%) and among these diabetic foot ulcers, 24 developed diabetic foot osteomyelitis (cumulative incidence 30% over 6 years, average annual incidence of 5%, incidence rate 0.1/person-year). Statistically significant risk factors for the development of diabetic foot osteomyelitis were ulcers that were deep to the bone (adjusted risk ratio 2.50, p = 0.04) and inflamed wounds (adjusted risk ratio 6.20, p = 0.02). The duration of diabetic foot ulcers was not associated with diabetic foot osteomyelitis (adjusted risk ratio 1.00, p = 0.98).

CONCLUSION

The duration was not an associated risk factor for diabetic foot osteomyelitis, while bone-deep ulcers and inflamed ulcers were found to be significant risk factors for the development of diabetic foot osteomyelitis.

Analysis of pre-hospital delay in Chinese patients with diabetic foot ulcers: Based on 46 cases

To study the causes of pre-hospital delay in Chinese patients with diabetic foot ulcers (DFUs). A retrospective study, investigating a case series of 46 DFUs treated at a single hospital, was conducted to evaluate wound condition, wound treatment, costs, and patients' complete medical records, and analyse the reasons causing the pre-hospital delay. We assessed 46 DFUs aged between 53 and 92 years old. The average pre-hospital delay was 5 months, with nearly 20% being delayed for more than 1 year. The average length of hospital stay in China was 21 days, with an average cost of $8672. Recurrence rate of DFUs was 21%, and three patients were recommended to transfer to upper-level hospital. Besides, the intervention was limited and homogenous and medical records were incomplete. Medical service users' limited understanding of diseases, high costs that patients need to afford, and unsatisfactory treatment by medical service providers are the main reasons for patients' delay in seeking treatment. Recommendations are offered to reduce the pre-hospital delay of Chinese patients with DFUs.

An Overview of Risk Factors for Diabetic Foot Amputation: An Observational, Single-centre, Retrospective Cohort Study

INTRODUCTION

Not only are early detection and treatment of diabetic foot ulcers important, but also acknowledging potential risk factors for amputation gives clinicians a considerable advantage in preventing amputations. Amputations impact both healthcare services and the physical and mental health of patients. This study aimed to investigate the risk factors for amputation in patients with diabetic foot ulcers.

METHODS

The sample for this study was patients with diabetic foot ulcers who were treated by the diabetic foot council at our hospital between 2005 and 2020. A total of 32 risk factors for amputation were identified and investigated among 518 patients.

RESULTS

Our univariate analysis showed that 24 of 32 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, seven risk factors remained statistically significant. The risk factors most significantly associated with amputation were Wagner grading, abnormal peripheral arteries, hypertension, high thrombocyte levels, low haematocrit levels, hypercholesterolaemia and male sex, respectively. The most common cause of death in patients with diabetes who have undergone amputation is cardiovascular disease, followed by sepsis.

CONCLUSION

To enable optimum treatment of patients with diabetic foot ulcers it is important for physicians to be aware of the amputation risk factors, and thus avoid amputations. Correcting risk factors, using suitable footwear and routinely inspecting feet are crucial factors for preventing amputations in patients with diabetic foot ulcers.

Predictive factors and nomogram to evaluate the risk of below-ankle re-amputation in patients with diabetic foot

BACKGROUND

Diabetes mellitus, as the most common metabolic disease, is common worldwide and represents a crucial global health concern. The purpose of this research was to investigate the related risk factors and to develop a re-amputation risk nomogram in diabetic patients who have undergone an amputation.

METHODS

A observational analysis was performed on 459 patients who have underwent amputation for diabetic foot from January 2014 through December 2019 at the First Affiliated Hospital of Wenzhou Medical University. The least absolute shrinkage and selection operator regression and stepwise regression methods were implemented to determine risk selection for the re-amputation risk model, and the predictive nomogram was established with these features. Calibration curve, receiver operating characteristic curve, and decision curve analysis of this re-amputation nomogram were assessed.

RESULTS

Predictors contained in this predictive model included smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI) and C-reactive protein (CRP). Good discrimination with a C-index of 0.725 (95% CI, 0.6624-0.7876) and good calibration were displayed with this predictive model. The decision curve analysis showed that this re-amputation nomogram predicting risk adds more benefit than none strategy if the threshold probability of a patient was >6% and <59%.

CONCLUSIONS

This novel re-amputation nomogram incorporating smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI), C-reactive protein (CRP), and smoking could be easily used to predict individual re-amputation risk prediction in diabetic foot patients who have undergone an amputation. In the future, further analysis and external testing will be needed as much as possible to reconfirm that this new Nomogram can accurately predict the risk of toe re-amputation.

Predicting Amputation in Patients With Diabetic Foot Ulcers: A Systematic Review

Foot ulcers are a leading cause of morbidity in diabetics. One of the known complications of diabetic foot ulcers is lower limb amputation which makes it a major socioeconomic problem. Currently, there’s a lack of knowledge on the predictors of amputations in diabetics with foot ulcers. We performed a systematic review of studies that identified risk factors of amputation in patients with diabetic foot ulcers. This systematic review aims to identify the predictors of amputation in order to optimize the management strategy and care plan. Medline database was searched and inclusion criteria were implemented for the selection of studies. The risk factors extracted were part of four categories: (i) history and physical examination, (ii) ulcer characteristics, (iii) lab results, and (iv) co-morbidities. The data extracted were in the form of odds ratios, 95% confidence intervals, and predictive values. The mean values with standard deviations of the included risk factors were recorded, and the incidence of risk factors among the amputation groups was identified or calculated when the data were sufficient. Seven articles were selected reporting on 3481 patients. This review identified peripheral arterial disease, neuropathy, high Wagner’s grade, osteomyelitis, postprandial glucose level, white cell count, c-reactive protein, erythrocyte sedimentation rate, low hemoglobin, and albumin as the most significant predictors of amputation.

Preventive foot self-care practice and associated factors among diabetic patients attending the university of Gondar comprehensive specialized referral hospital, Northwest Ethiopia, 2021

BACKGROUND

Diabetes mellitus is emerging as a major worldwide health problem that has a social, financial, and developmental impact on developing countries. Foot complications are among the most serious and costly complications of diabetes which lead to lower extremity amputation due to diabetic foot ulcers. Poor diabetic foot self-care practice is identified by different studies as a major contributing factor to diabetic foot ulcers. Therefore, this study was intended to assess foot self-care practice and associated factors among diabetic patients attending the University of Gondar comprehensive specialized referral hospital.

METHODS

A hospital-based cross-sectional study was conducted from July 1 to August 30, 2021, at the University of Gondar comprehensive specialized referral hospital. A systematic random sampling technique was employed to select 384 diabetic patients. A structured pretested interviewer-administered questionnaire was used to collect data. The data was entered in epi-info version 7, analyzed using SPSS version 21, and presented using frequencies, percentages, tables, and graphs. Bivariable and multivariable analyses were investigated using a binary logistic regression model. P-value < 0.05 and an odds ratio with a 95% confidence interval were used to determine the significance and strength of the association.

RESULTS

Of the 384 diabetic patients, 46.4% (95% CI (41.1%-51.6%)) of them had poor foot self-care practice. Being male [AOR = 0.54, 95% CI (0.32, 0.89)], couldn't read and write and completed primary education [AOR = 2.35, 95% CI (1.01, 5.43)] & [AOR = 2.92, 95% CI (1.39, 6.12)], living in rural area [AOR = 3.84, 95% CI (1.91, 7.75)], having diabetic complications [AOR = 2.19, 95% CI (1.07, 4.46)], taking both injection and pills [AOR = 0.33, 95% CI (0.12, 0.88)], having previous information about foot care [AOR = 0.12, 95% CI (0.06, 0.24)], and family support [AOR = 0.57, 95% CI (0.34, 0.94)] were determinants of poor foot self-care practice.

CONCLUSION

The adherence of diabetic patients toward foot self-care practice was poor. Being male, having low educational status, living in a rural area, having diabetic-related complications, taking both injections and pills, not having previous information about foot care, and having poor family support increases the odds of having poor foot self-care practice. Giving health education to patients and their caregivers about the basic principles of diabetes foot care, like regular inspection of feet and appropriate footwear at their regular follow-up time, should be emphasized.

Association of PVL Gene in MSSA and MRSA Strains among Diabetic Ulcer Patients from Odisha, India

Staphylococcus aureus has emerged as an important pathogen among diabetic foot ulcers in patients with diabetes. Infections with S. aureus in diabetic ulcers need surveillance of resistant microbial profile to provide the basis for empirical therapy for the reduction of lower extremities amputation. Panton valentine leucocidin (PVL) is considered as one of the major virulence gene of S. aureus which is responsible for destruction of white blood cells and tissue necrosis. This pore forming cytotoxin gene is carried out by both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) strains. The present study described the prevalence of PVL gene in MSSA and MRSA strains isolated from diabetic ulcer patients treated during November, 2019 to January, 2021 from a tertiary care hospital, Odisha. Infected tissue and blood samples from these patients were collected aseptically and sub-cultured using different media and standard techniques. The isolated genomic DNA of MSSA and MRSA strains were subjected to PCR assay for the detection of PVL gene. Two hundred ten S. aureus out of 402 diabetic ulcer patients were isolated having 59.52% MSSA and 40.47% MRSA strains. Wagner's grade III and grade IV ulcers were most prevalent in these ulcer patients. The prevalence of PVL gene in MSSA strains was more in comparison to MRSA strains. Forty five resistance patterns were observed from the antibiogram profiles of S. aureus. The present study highlighted that PVL gene could not be a marker for the detection of MRSA and MSSA strains in diabetic ulcer patients.

Factors Associated with Healing Outcomes in Primary Care Patients with Diabetic Foot Ulcers: A Retrospective Study in a Multiethnic Sample

OBJECTIVE

To identify and determine patient- and ulcer-related factors associated with healing outcomes within 3 months for patients with diabetic foot ulcer (DFU) in a multiethnic primary care sample.

METHODS

Retrospective data were collected over 3 months from 520 primary care patients with a DFU between April 1, 2016 and March 31, 2017. Multivariable prevalence ratios (PRs) were calculated using Poisson regression to find associations between patient- and ulcer-related factors and healing outcomes.

RESULTS

Most patients were male (66%) and Chinese (49.8%) and had a diabetes mellitus duration longer than 5 years (81.8%). Toe ulcers (64%) were most common. Healing occurred for 33.9% of participants; 19.1% and 1.5% underwent minor and major amputation, respectively. Wound sizes between 1 and 10 cm2 (PR, 0.61; 95% confidence interval [CI], 0.46-0.76; P < .001) and over 10 cm2 (PR, 0.55; 95% CI, 0.33-0.76; P = .003), ulcer duration 6 months or longer (PR, 0.36; 95% CI, 0.19-0.53; P < .001), ischemic ulcers (PR, 0.54; 95% CI, 0.22-0.86; P = .044), and neuroischemic ulcers (PR, 0.73; 95% CI, 0.53-0.93; P = .027) were negatively associated with healing outcomes. Women were more likely to experience healing (PR, 1.18; 95% CI, 0.91-1.45; P = .157).

CONCLUSIONS

Ulcer healing varied by sex and was affected by wound size, wound duration, and ischemic etiology, regardless of ethnicity. Prompt attention to these risk factors may reduce healing time. Further studies are warranted to elucidate the mechanism underlying sex differences in association with DFU healing.

Three Years Survival and Factor Predicting Amputation or Mortality in Patients with High Risk for Diabetic Foot Ulcer in Fatmawati General Hospital, Jakarta

Background:

Diabetic foot is one of major complication in diabetes patients with unfavorable outcome. Survival study in outpatients is limited and factors related are inconsistent. Survival and its modifiable risk factors should be identified early since the foot at risk status to reduce amputation/mortality in type 2 diabetes mellitus (T2DM).

Objective:

The aims of this study were to investigate survival probability for amputation or mortality, compare different ulcer risk classification, and figure out the relation of status of ulcer risk, age, gender, diabetes duration, body mass index, fasting plasma glucose, HbA1C, and LDL with amputation or mortality.

Methods:

This is a retrospective cohort study of 487 T2DM subjects who visited internal medicine outpatient clinic in Fatmawati General Hospital since January-December 2016. Status of ulcer risk and risk factors were extracted from medical record and lower-extremity amputation or mortality was observed in 3 years from baseline.

Result:

Three years overall survival is 85.7% (SE 0.17). Patients with high risk for foot ulcer have survival probability of 80.2% (SE 0.027), which is lower compared to non-high risk for foot ulcer with survival probability of 91.8% (SE 0.019). Patients with high risk for foot ulcer (aHR 2.386 [95% CI 1.356-4.20]; P = .003), aged ≥60 years old (aHR 2.051 [95% CI 1.173-3.585]; P = .012), and HbA1C ≥7% (aHR 2.022 [95% CI 1.067-3.830]; P = .031) were independently associated with amputation or mortality.

Conclusion:

T2DM patients with high risk for foot ulcer have lower survival probability and higher risk for amputation or mortality in 3 years compared to patients with non-high risk for foot ulcer. Status of ulcer risk, age ≥60 years, and HbA1C ≥7% were associated with amputation or mortality in 3 years observation.

Nitric Oxide-Releasing Bacterial Cellulose/Chitosan Crosslinked Hydrogels for the Treatment of Polymicrobial Wound Infections

Polymicrobial wound infections are a major cause of infectious disease-related morbidity and mortality worldwide. In this study, we prepared a nitric oxide (NO)-releasing oxidized bacterial cellulose/chitosan (BCTO/CHI) crosslinked hydrogel to effectively treat polymicrobial wound infections. Linear polyethyleneimine diazeniumdiolate (PEI/NO) was used as the NO donor. The aldehyde group of BCTO and the amine of CHI were used as crosslinked hydrogel-based materials; their high NO loading capacity and antibacterial activity on the treatment of polymicrobial-infected wounds were investigated. The blank and NO-loaded crosslinked hydrogels, namely BCTO-CHI and BCTO-CHI-PEI/NO, were characterized according to their morphologies, chemical properties, and drug loading. BCTO-CHI-PEI/NO exhibited sustained drug release over four days. The high NO loading of BCTO-CHI-PEI/NO enhanced the bactericidal efficacy against multiple bacteria compared with BCTO-CHI. Furthermore, compared with blank hydrogels, BCTO-CHI-PEI/NO has a favorable rheological property due to the addition of a polymer-based NO donor. Moreover, BCTO-CHI-PEI/NO significantly accelerated wound healing and re-epithelialization in a mouse model of polymicrobial-infected wounds. We also found that both crosslinked hydrogels were nontoxic to healthy mammalian fibroblast cells. Therefore, our data suggest that the BCTO-CHI-PEI/NO developed in this study improves the efficacy of NO in the treatment of polymicrobial wound infections.

"When nothing happens, nobody is afraid!" beliefs and perceptions around self-care and health-seeking behaviours: Voices of patients living with diabetic lower extremity amputation in primary care

Self-management and self-care are the cornerstone of diabetes care and an essential part of successfully preventing or delaying diabetes complications. Yet, despite being armed with the required information and guidance for self-management, self-care and adherence to foot self-care recommendations and compliance to medication among patients with diabetic foot ulcer and diabetic lower extremity amputations remain low and suboptimal. This study reveals in-depth account of nine such patients' beliefs and perceptions around their illness, their self-care, and their health-seeking behaviours. Patients living with diabetic lower extremity amputation displayed profound lack of knowledge of self-care of diabetes and foot and passive health-related behaviours. The overarching sense that "when nothing happens, nobody is afraid," points to a lack of motivation in taking charge of one's own health, whether this is with reference to treatment or care adherence, following recommended self-care advice, or seeking timely treatment. The Health Beliefs Model provides the theoretical framework for probing into the factors for the participants' suboptimal self-care and passive health-seeking behaviours. Two themes emerged from data analysis: profound knowledge deficit and passive health-related behaviours. The beliefs and perceptions around self-care and health-seeking behaviours for patients with lower extremity amputation are interpreted as the "ignorant self" with passive health-seeking behaviours. Patients with diabetes and diabetic foot diseases may benefit from personalized education, motivational interviewing, and family support.

Risk factors and incidence over time for lower extremity amputations in people with type 1 diabetes: an observational cohort study of 46,088 patients from the Swedish National Diabetes Registry

AIMS/HYPOTHESIS

The aim of this work was to study the incidence over time of lower extremity amputations and determine variables associated with increased risk of amputations in people with type 1 diabetes.

METHODS

Individuals with type 1 diabetes registered in the Swedish National Diabetes Registry with no previous amputation from 1 January 1998 and followed to 2 October 2019 were included. Time-updated Cox regression and gradient of risk per SD were used to evaluate the impact of risk factors on the incidence of amputation. Age- and sex-adjusted incidences were estimated over time.

RESULTS

Of 46,088 people with type 1 diabetes with no previous amputation (mean age 32.5 years [SD 14.5], 25,354 [55%] male sex), 1519 (3.3%) underwent amputation. Median follow-up was 12.4 years. The standardised incidence for any amputation in 1998-2001 was 2.84 (95% CI 2.32, 3.36) per 1000 person-years and decreased to 1.64 (95% CI 1.38, 1.90) per 1000 person-years in 2017-2019. The incidence for minor and major amputations showed a similar pattern. Hyperglycaemia and renal dysfunction were the strongest risk factors for amputation, followed by older age, male sex, cardiovascular comorbidities, smoking and hypertension. Glycaemic control and age- and sex-adjusted renal function improved during the corresponding time period as amputations decreased.

CONCLUSIONS/INTERPRETATION

The incidence of amputation and of the most prominent risk factors for amputation, including renal dysfunction and hyperglycaemia, has improved considerably during recent years for people with type 1 diabetes. This finding has important implications for quality of life, health economics and prognosis regarding CVD, indicating a trend shift in the treatment of type 1 diabetes.

Methicillin-Resistant Staphylococcus aureus (MRSA) Infection of Diabetic Foot Ulcers at a Tertiary Care Hospital in Accra, Ghana

Aim: This study investigated the spectrum of bacteria infecting the ulcers of individuals with diabetes at the Korle Bu Teaching Hospital in Accra, Ghana, focusing on Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA), with respect to their prevalence, factors predisposing to their infection of the ulcers, and antimicrobial resistance patterns. Methodology: This cross-sectional study was conducted at The Ulcer Clinic, Department of Surgery, Korle Bu Teaching Hospital, involving 100 diabetic foot ulcer patients. The ulcer of each study participant was swabbed and cultured bacteriologically, following standard procedures. Antimicrobial susceptibility testing was done for all S. aureus isolated, using the Kirby-Bauer method. Results: In total, 96% of the participants had their ulcers infected—32.3% (n = 31) of these had their ulcers infected with one bacterium, 47.9% (n = 46) with two bacteria, 18.8% (n = 18) with three bacteria, and 1.0% (n = 1) with four bacteria. The prevalence of S. aureus and MRSA were 19% and 6%, respectively. The distribution of the other bacteria was as follows: coagulase-negative Staphylococci (CoNS) (54%), Escherichia coli (24%), Pseudomonas spp. (19%), Citrobacter koseri and Morganella morgana (12% each), Klebsiella oxytoca (11%), Proteus vulgaris (8%), Enterococcus spp. (6%), Klebsiella pneumoniae (5%), Proteus mirabilis and Enterobacter spp. (4%), Klebsiella spp. (2%), and Streptococcus spp. (1%). The resistance rates of S. aureus decreased across penicillin (100%, n = 19), tetracycline (47.4%, n = 9), cotrimoxazole (42.1%, n = 8), cefoxitin (31.6%, n = 6), erythromycin and clindamycin (26.3% each, n = 5), norfloxacin and gentamicin (15.8% each, n = 3), rifampicin (10.5%, n = 2), linezolid (5.3%, n = 1), and fusidic acid (0.0%, n = 0). The proportion of multidrug resistance was 47.4% (n = 9). Except for foot ulcer infection with coagulase-negative Staphylococci, which was protective of S. aureus infection of the ulcers (OR = 0.029, p = 0.001, 95% CI = 0.004–0.231), no predictor of S. aureus, MRSA, or polymicrobial ulcer infection was identified. Conclusions: The prevalence of S. aureus and MRSA infection of the diabetic foot ulcers were high, but lower than those of the predominant infector, coagulase-negative Staphylococci and the next highest infecting agent, E. coli. Diabetic foot ulcers’ infection with coagulase-negative Staphylococci protected against their infection with S. aureus. The prevalence of multidrug resistance was high, highlighting the need to further intensify antimicrobial stewardship programmes.

Prevalence and Determinants of Peripheral Neuropathy Among Adult Type II Diabetes Mellitus Patients Attending a Non-communicable Disease Clinic in Rural South India

Background

Diabetic peripheral neuropathy (DPN) is one of the most common microvascular complications of diabetes. Almost half of the diabetic patients develop foot ulcer as a complication of DPN during their lifetime. The aim was to estimate the prevalence and identify the risk factors of diabetic peripheral neuropathy among adult diabetes mellitus (DM) patients.

Methods

A cross-sectional study was conducted among 421 type 2 DM patients attending Non-Communicable Disease (NCD) clinic in rural Puducherry through systematic random sampling. The study instruments used for data collection were a pre-tested semi-structured questionnaire, Michigan Neuropathy Screening Instrument (MNSI), Morisky Green Levine Scale (MGLS), physical measurements and recent laboratory results. The data was captured using Epicollect5 and analyzed using SPSS version 20.

Results

The prevalence of DPN was 31.1% (95% confidence interval (CI): 27.1%-35.1%). The mean age, duration of diabetes, and duration of foot symptoms were 57.91±10.61, 7.00±6.23, 5.56±5.26 years. Smoking (adjusted odds ratio (AOR) 3.14; 95% CI 1.73-5.69), mean duration of diabetes>5years (AOR 2.74; 95% CI 1.71-4.40), hyperglycemic status(>200mg/dl) (AOR 2.24; 95% CI 1.08-4.64) and unemployment (AOR 2.05; 95% CI 1.11-3.76) were found to be statistically significant determinants of DPN on binary logistic regression analysis.

Conclusions

A considerable proportion of diabetics are at risk of developing DPN among rural DM patients. More diligent screening in a primary health care setting and addressing the modifiable risk factors like smoking, obesity, physical inactivity, and uncontrolled hyperglycemia will delay or hamper DPN development among diabetic patients.

Spectrum of Bacterial Infections Associated with Diabetic Ulcer Patients

Diabetic ulceration is a multi-factorial problem which is responsible for considerable morbidity threatening the health care system. By knowing the clinical profile and bio-burden on diabetic ulcer, it is highly beneficial for health treatment. The purpose of the present study was to evaluate the diversity of major bacterial etiology in diabetic ulcer patients. The different samples like pus, swab, and infected tissues were collected from diabetic ulcer patients aseptically and samples were transported through cold chain to the laboratory. The samples were cultured in nutrient agar, mannitol salt agar, macConkey agar and blood agar. Suspected colonies were biochemically confirmed for the isolation of Staphylococcus aureus, Pseudomonas aeruginosa, E.coli and Klebsiella spp. In total 150 diabetic ulcer patients suffering from diabetic foot ulcers, gangrene, burn cases and accidental ulcer cases were analyzed. However, most of the patients developed mono-microbial infection; S.aureus was the most prevalent microbe in diabetic ulcer cases, which were positive for nucA gene.

Risk factors associated with lower extremity amputation in Sudanese individuals with diabetes: The need for improvement in primary health care system

Background:

Lower extremity amputation (LEA) in individuals with diabetes is a serious health issue with a considerable physical and social burden. The aim of this study was to assess the prevalence and risk factors associated with LEA in diabetic foot ulcer (DFU) patients.

Materials and Methods:

This was a cross-sectional health facility-based study that recruited 315 diabetes individuals with foot ulcers from the diabetes center in Khartoum, Sudan. Direct interviewing of subjects was used to obtain data, using a standardized validated questionnaire. Chi-square and logistic regression analysis were used in data analysis.

Results:

69.5% of the diabetic participants were aged 50 years old or more, and 71.1% were males. Most of the subjects (48.2%) were diabetics for a duration of >10 years, while more than one third (37.5%) of them were diabetic for 5–10 years. The majority (89.5%) had type 2 DM, while only 10.5% were type 1 DM. Two hundred forty-five patients had a left lower foot ulcer; 55.1% of the patients' ulcers were present in the toes, while 21.6% were in the foot sole. The overall prevalence of lower limb amputation was 17.1%. Individuals with diabetes patients with LEA had a higher incidence of hypertension (P = 0.000), retinopathy (P = 0.000), nephropathy (P = 0.002), ulcer size >2.5 cm (P = 0.000), and neuropathy (P = 0.000) through Chi-square analysis. Furthermore, logistic regression analysis showed that amputation was significantly associated with retinopathy (P = 0.000), size of ulcer (P = 0.000), and neuropathy (P = 0.016).

Conclusion:

The overall prevalence of LEA was 17.1%. The primary risks factors associated with amputation were presence of neuropathy and ulcer size >2.5 cm. Presence of retinopathy predispose diabetic individuals to amputation. Amputation is associated with disability and psychological problems; therefore, there is an urgent need for more improvement in preventative measures and primary health care system in low resource setting country like Sudan in order to decrease diabetes complications, especially patient's education about diabetes management by primary care physicians.

Escherichia coli Isolated from Diabetic Foot Osteomyelitis: Clonal Diversity, Resistance Profile, Virulence Potential, and Genome Adaptation

This study assessed the clonal diversity, the resistance profile and the virulence potential of Escherichia coli strains isolated from diabetic foot infection (DFI) and diabetic foot osteomyelitis (DFOM). A retrospective single-centre study was conducted on patients diagnosed with E. coli isolated from deep DFI and DFOM at Clinique du Pied Diabétique Gard-Occitanie (France) over a two-year period. Phylogenetic backgrounds, virulence factors (VFs) and antibiotic resistance profiles were determined. Whole-genome analysis of E. coli strains isolated from same patients at different periods were performed. From the two-years study period, 35 E. coli strains isolated from 33 patients were analysed; 73% were isolated from DFOM. The majority of the strains belonged to the virulent B2 and D phylogenetic groups (82%). These isolates exhibited a significant higher average of VFs number than strains belonging to other groups (p < 0.001). papG2 gene was significantly more detected in strains belonging to B2 phylogroup isolated from DFI compared to DFOM (p = 0.003). The most prevalent antibiotic resistance pattern was observed for ampicillin (82%), cotrimoxazole (45%), and ciprofloxacin (33%). The genome analysis of strains isolated at two periods in DFOM showed a decrease of the genome size, and this decrease was more important for the strain isolated at nine months (vs. four months). A shared mutation on the putative acyl-CoA dehydrogenase-encoding gene aidB was observed on both strains. E. coli isolates from DFOM were highly genetically diverse with different pathogenicity traits. Their adaptation in the bone structure could require genome reduction and some important modifications in the balance virulence/resistance of the bacteria.

Diabetic foot infection and osteomyelitis. Are deep-tissue cultures necessary?

Introduction

Diabetic foot infections (DFIs) are common and difficult to treat. The objective of this study was to compare swab and tissue cultures as indicators of appropriate treatment of DFIs.

Methods

This is a prospective study conducted during a 4-year period. All patients with DFIs and/or diabetic foot osteomyelitis (DFO) admitted to the University Hospital of Heraklion, Greece, were included. Clinical data were collected, while cultures taken with swabs and/or tissue biopsies were used as indicators of the microbiological cause and the appropriate treatment.

Results

In total, 83 individuals (62.7% males) with mean age of 72 years, were enrolled. Coexisting osteomyelitis was present in 18.1%. From tissue and pus cultures, 131 and 176 pathogens, respectively, were isolated. Gram-positive aerobes were the most common microorganisms, followed by Gram-negatives. Infection was polymicrobial in 40 (70.2%) out of 57 patients with tissue culture and in 54 (75.0%) out of 72 with pus culture. Microbiological results from tissue cultures were compatible with those from pus at a rate of 80%, while in cases of osteomyelitis concordance reached 100%. Multidrug-resistant organisms (MDROs) were isolated from 32 (24.4%) tissue and 44 (25%) pus cultures (p=0.910). Initial empirical antimicrobial treatment was considered inappropriate in 44.6% of cases.

Conclusions

A high concordance between easily taken swab cultures and those taken by biopsy was noted, especially in DFO. This was helpful for early change to appropriate treatment in cases where MDROs were isolated and empirical treatment was inappropriate. Further research is needed to confirm this observation in clinical practice.

Patient-level predictors of diabetes-related lower extremity amputations at a quaternary hospital in South Africa

INTRODUCTION

Diabetes-related lower extremity amputation has a major psycho-social and economic cost on the patient as well as a direct impact on financial expenditure within health facilities.

AIM

This study aimed to determine the incidence and patient-related factors related to diabetes-related amputations amongst patients that were referred to the quaternary hospital between 1 January 2014 and 31 December 2015.

METHODS

A retrospective cohort study. Data were retrieved from the medical record for each diabetes patient that was managed at IALCH during the study period. The following variables were collected: sociodemographic parameters (age, gender, and ethnicity) and diabetes-related parameters (type of diabetes) and additional complications.

RESULTS

Ninety-nine patients (0, 73%) of all diabetes patients managed were new diabetes-related lower-extremity amputations. There were statistically significant increased odds of female patients (OR: 1, 7) and patients with non-insulin dependent diabetes (OR: 1, 64) to have new diabetes-related amputations. Patients older than 60 years (OR: 1, 31); African patients (OR: 1, 35) patients with cardiovascular complications (OR: 1, 04) and patients with retinopathy (OR: 1, 48) were more likely to have diabetes-related amputations but not statistically significant.

CONCLUSIONS

A combination of primary preventive strategies, early detection and appropriate management of patients with diabetes and specific guidelines on the frequency, clinical and laboratory tests required for early diagnosis and referrals with early signs of diabetes-related complicationsat primary care level will assist in reducing the long term adverse outcomes including amputations.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis

PURPOSE

A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients.

METHODS

The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU.

CONCLUSIONS

Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.

Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation?

BACKGROUND

We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA).

METHODS

A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively.

RESULTS

The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control.

CONCLUSION

The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.

A qualitative study of the cognitive behavioral intention of patients with diabetes in rural China who have experienced delayed diagnosis and treatment

BACKGROUND

Great changes have taken place in terms of people's lifestyles and behavioral habits. Diabetes has become a threat to human health and is the most important noncommunicable disease. More than 60% of rural diabetic patients experience delayed diagnosis and treatment. In this study, we explore the inner experience of the delayed diagnosis and treatment of patients with diabetes in rural areas and provide a reference for targeted intervention.

METHODS

A qualitative research design was used to examine the cognitive behavioral intention of patients in rural areas with delayed diagnosis and treatment of diabetes. Thirteen diabetes patients with delayed diagnosis and treatment were sampled with maximum variation in rural Daqing City and Tangshan City in China. The data analysis involved several levels of analysis consistent with qualitative research.

RESULTS

The following themes were relevant to diabetes patients in rural areas with delayed diagnosis and treatment delay: "Lacked knowledge of diabetes", "Negative coping style", "Dissatisfaction with the existing medical service" and "Influence of social support".

CONCLUSIONS

The respondents' delayed diagnosis and treatment represent a common phenomenon. Medical personnel should provide interventions for patients and encourage them to go to the hospital on time.

Correlation between superficial and intra-operative specimens in diabetic foot infections: results of a cross-sectional Tunisian study

Objective

To determine the correlation between superficial, and intra-operative specimens in diabetic foot infections (DFIs).

Methods

We conducted a cross-sectional study in patients with DFIs hospitalized in a Tunisian teaching hospital. Superficial specimens were collected for all patients, and intra-operative specimens were collected in operated patients. The specimens were processed using standard microbiology techniques. Antimicrobial susceptibility testing was carried out according to the protocol established by the European Committee on Anti-microbial Susceptibility Testing. Intra-operative and superficial specimens were considered correlated if they isolated the same microorganism(s), or if they were both negative.

Results

One hundred twelve patients, 81 males and 31 females, mean age 56 years, were included. Superficial samples were positive in 77% of cases, and isolated 126 microorganisms. Among the positive samples, 71% were monomicrobial. The most frequently isolated microorganisms were Enterobacteriaceae (53%), followed by streptococci (21%) and Staphylococcus aureus (17%). Nine microorganisms (7%) were multi-drug resistant. Intra-operative samples were positive in 93% of cases. Superficial specimens were correlated to intra-operative specimens in 67% of cases. Initial antibiotic therapy was appropriate in 70% of cases. The lower-extremity amputation and the mortality rates were 41% and 1%, respectively.

Conclusion

In our study, DFIs were most frequently caused by Enterobacteriaceae and superficial specimens were correlated to intra-operative specimens in only two thirds of cases. Clinicians should emphasize on the systematic practice of intraoperative specimens in all patients with DFIs treated surgically, while well-performed superficial specimens could be useful for prescribing appropriate antibiotic therapy in other patients.

Factors associated with lower-extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital

Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C-reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C-peptide, triglyceride, high-density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable-adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015-1.709), 0.255 for triglyceride (95% CI: 0.067-0.975), and 20.947 for Wagner grades (95% CI: 4.216-104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.

Correlates of Self-Care Behaviors in Adults With Type 2 Diabetes and Comorbid Heart Failure

PURPOSE

The purpose of this study was to describe sociodemographic, clinical, and psychosocial correlates of diabetes self-care behaviors in adults with type 2 diabetes mellitus (T2D) and comorbid heart failure (HF).

METHOD

Baseline data of 180 participants from a clinical trial that tested a 6-month integrated self-care intervention for persons with comorbid HF and T2D were analyzed. Correlational bivariate and multiple logistic regression analyses were performed to examine correlates of diabetes self-care behaviors.

RESULT

Participants had a mean age of 58 ± 11years; the majority were male (n = 118, 66%) and African American (n = 119, 66%). Number of comorbidities >2 (P < .001), having more than a high school education (P < .05), and African American ethnicity (P < .05) predicted better exercise, self-monitoring blood glucose (SMBG), and foot care behaviors, respectively. The use of an aldosterone inhibitor (P < .05) predicted worse exercise performance, higher Charlson Comorbidity Index scores (P < .01) predicted worse SMBG, and treatment with diet plus medication (P < .05) and dyslipidemia (P < .001) predicted worse foot care.

CONCLUSION

Findings from this study provide new insights into the complex self-care requirements for T2D patients with comorbid HF. Integrated self-care interventions are clearly warranted in persons living with multiple chronic conditions for optimal health outcomes and the prevention of complications. Our sample of predominately African American men showed they had better T2D self-care behaviors than whites than previously reported. Additional research is needed to determine racial and gender differences on health outcomes in persons with T2D and comorbid HF.

PEI/NONOates-doped PLGA nanoparticles for eradicating methicillin-resistant Staphylococcus aureus biofilm in diabetic wounds via binding to the biofilm matrix

Wounds infected with methicillin-resistant Staphylococcus aureus (MRSA) biofilm represent a high risk in patients with diabetes. Nitric oxide (NO) has shown promise in dispersing biofilm and wound healing. For an effective treatment of MRSA biofilm-infected wounds, however, NO needs to be supplied to the biofilm matrix in a sustainable manner due to a short half-life and limited diffusion distance of NO. In this study, polyethylenimine/diazeniumdiolate (PEI/NONOate)-doped PLGA nanoparticles (PLGA-PEI/NO NPs) with an ability to bind to the biofilm matrix are developed to facilitate the NO delivery to MRSA biofilm-infected wound. In simulated wound fluid, PLGA-PEI/NO NPs show an extended NO release over 4 days. PLGA-PEI/NO NPs firmly bind to the MRSA biofilm matrix, resulting in a greatly enhanced anti-biofilm activity. Moreover, PLGA-PEI/NO NPs accelerate healing of MRSA biofilm-infected wounds in diabetic mice along with complete biofilm dispersal and reduced bacterial burden. These results suggest that the biofilm-binding NO-releasing NPs represent a promising NO delivery system for the treatments of biofilm-infected chronic wounds.

Diabetično stopalo kot zaplet sladkorne bolezni

Uvod: Diabetično stopalo je skupina sindromov, pri katerih nevropatija, ishemija in infekcija pripeljejo do destrukcije tkiva, končna posledica je zbolevnost, lahko pa tudi amputacija. Namen raziskave je bil ugotoviti pogostost pojava diabetičnega stopala pri pacientih s sladkorno boleznijo.Metode: V raziskavi je bila uporabljena raziskava mešanih metod. Tehnika zbiranja podatkov je bilo anketiranje 60 pacientov s sladkorno boleznijo in delno strukturiran intervju z dvema medicinskima sestrama, ki delata v diabetološki ambulanti. Kvantitativni podatki so bili analizirani z opisno in bivariatno statistiko. Kvalitativni podatki so bili analizirani s pomočjo metode analize vsebine.Rezultati: Ugotovili smo, da amputacija noge ni pogost zaplet diabetičnega stopala (U = 4,4, p = 0,217) in da ne moremo trditi, da je diabetično stopalo pogostejše pri moških kot pri ženskah (U = 0,6, p = 0,417), ter da so pacienti zelo dobro poučeni glede nege stopal in pravilne obutve.Diskusija in zaključek: Najpomembnejša informacija o zdravstveni vzgoji pri diabetičnem stopalu za paciente je, da so o tem zapletu ozaveščeni pisno in ustno. Diabetično stopalo za paciente najpogosteje prinese spremembo v kakovosti življenja. Možnost za nadaljevanje raziskave bi bila izvedba enake raziskave na večjem številu pacientov.

Community based study to assess the prevalence of diabetic foot syndrome and associated risk factors among people with diabetes mellitus

BACKGROUND

Diabetic foot is one of the most significant and devastating complication of diabetes. The objective of this study was to assess the prevalence of diabetic foot syndrome (DFS) and the associated risk factors among people with diabetes mellitus.

METHODS

A community based cross-sectional study was carried out among 620 subjects with diabetes mellitus (DM) in rural areas of Udupi district. The Michigan Neuropathy Screening Instrument was used to identify peripheral neuropathy. Ankle brachial index was used to identify peripheral arterial disease (PAD). Subjects with diabetic foot syndrome were classified according to the International Working Group on Diabetic Foot (IWGDF) classification system.

RESULTS

The overall prevalence of DFS was 51.8%. Among them 31.3, 11.9 and 8.5% belonged to category 1, 2 and 3 respectively. Multivariate logistic regression analysis showed advancing age, low socio-economic status, sedentary physical activity and longer duration of DM were significant independent correlates of DFS.

CONCLUSION

The overall prevalence of DFS was high among the study population; hence the screening for foot complications should start at the time of diagnosis of diabetes integrated with sustainable patient education at primary care level by training of health care providers at primary care level.

Methicillin-resistant Staphylococcus aureus nasal carriage and infection among patients with diabetic foot ulcer

PURPOSE

To evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in patients with diabetic foot ulcer (DFU) in Taiwan, and to assess the concordance between colonizing and clinical MRSA isolates from the patients.

METHOD

A total of 354 nasal specimens were collected from 112 to 242 diabetic patients with and without foot ulcer, respectively. MRSA clinical isolates from DFU wound cultures were collected for comparison.

RESULTS

Nasal carriage rate of S. aureus and MRSA was similar between diabetic patients with and without foot ulcer (15.2% vs. 16.9% for S. aureus and 5.4% vs. 1.7% for MRSA). Nasal S. aureus colonization was an independent predictor for wound S. aureus infection (Odds ratio [OR]: 5.33, 95% confidence interval [CI]: 1.61-17.59), so did nasal MRSA colonization (OR: 19.09, 95% CI: 2.12-171.91). The levels of glycated hemoglobin, and the usage with immunosuppressant agent were associated with S. aureus nasal colonization while oral hypoglycemic agent usage a protective factor. Sequence type 59/staphylococcal chromosome cassette mec IV or V, the local endemic community-associated clone, accounted for 42% and 70% of the clinical and colonizing isolates, respectively. Six of 10 patients with paired colonizing and clinical isolates, either MRSA or methicillin-sensitive S. aureus, had a genetically identical strain from a single patient.

CONCLUSION

Less than one-fifth of patients with DFU have nasal S. aureus, including MRSA, colonization; however, the colonization is significantly associated with S. aureus diabetic foot infection. Screening for S. aureus colonizing status in DFU patients might have a potential clinical implication.

Molecular and culture based assessment of bacterial pathogens in subjects with diabetic foot ulcer

INTRODUCTION

Expeditious and precise discerning of bacterial pathogens is a fundamental grail, of clinical diagnostic microbiology. Genotypic detection is a budding substitute to recognize phenotypic culture based processes in bacterial identification.

AIMS

We report a comparative evaluation of biochemical and genomic-based assays for exploring the commonest bacterial flora of infected diabetic foot ulcers along with clinical variables of subjects enrolled.

METHODS

The pathogens selected (i) Staphylococcus aureus ii) Pseudomonas aeruginosa, iii) Escherichia coli and iv) Klebsiella pneumonia, stood for the most frequent isolates of diabetic foot infection in previous studies from Northern India. Identification of these pathogens were done by conventional assays and polymerase chain reaction.

RESULTS

Of 50 specimens obtained from infected DFUs, 74% of cases were affirmative by bacteriological assays and 90% showed positivity via polymerase chain reaction (PCR). Among processed samples 44 isolates were detectable through phenotypic analysis and 65 bacteria by species-specific PCR. Thirteen samples and 21 isolates could not be scrutinized by phenotypic identification systems. The most prevalent pathogens identifiable were Klebsiella pneumonia, followed by Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli.

CONCLUSIONS

We have shown that PCR-based diagnostic methods improved the identification compared to conventional methods and highlight the incorporation of PCR due to shorten turnaround time translating into improved clinical outcomes.

Factors associated with amputation among patients with diabetic foot ulcers in a Saudi population

Objectives

A prospective study was conducted at the Armed Forces Hospital, Dhahran, Saudi Arabia, between January 2015 and December 2016 to identify the risk factors associated with amputation among diabetic foot ulcers DFUs patients.

Results

In total, 82 patients were recruited. Fifty-five of the patients were males (67.07%), the mean (SD) age of the participants was 60 (± 11.4) years, the mean duration of diabetes was 8.5 (± 3.7) years, and the mean haemoglobin A1c was 4.8 (± 2.8)%. In Univariate analysis, older age and high white blood cell count (WBC) were factors associated with amputation (OR = 1.1, 95% CI = 1–1.1, P = 0.012; and OR = 383, 95% CI = 7.9–18,665, P = 0.003, respectively). On the other hand, an ischaemic ulcer was half as likely as a neuropathic ulcer to lead to amputation (OR = 0.5, 95% CI = 0.3–0.9, P = 0.036), and a higher Wagner’s grade was found to be protective against amputation OR = 14.5, 95% CI = 4.3–49.4, P < 0.001. In conclusion, the current study showed that although a number of factors have been described to complicate diabetic ulcers by different researchers, none of those factors were identified in our study apart from older age and high WBC.

Predictive Laboratory Findings of Lower Extremity Amputation in Diabetic Patients: Meta-analysis

Lower extremity amputation is a source of morbidity and mortality among diabetic patients. This meta-analysis aimed to identify significant laboratory data in patients with diabetic foot ulcer with high rates of lower extremity amputation. We performed a systematic literature review and meta-analysis using MEDLINE, EMBASE, and Cochrane databases. We extracted and evaluated 11 variables from the included studies based on amputation rates. This study used the Newcastle-Ottawa Scale to assess the quality of the studies. The search strategy identified 101 publications from which we selected 16 articles for review. We identified HbA1c, fasting blood glucose, white blood cells, C-reactive protein, and erythrocyte sedimentation rate as predictive variables of higher major amputation rate. Although further investigation of long-term and prospective studies is needed, we identified 5 variables as predisposing factors for higher major amputation in diabetic patients through meta-analysis.

Association between estimated glomerular filtration rate and outcomes in patients with diabetic foot ulcers: a 3-year follow-up study

OBJECTIVE

End-stage renal disease and dialysis have been proven to be associated with poor prognoses in diabetic foot ulcers (DFUs). However, it has rarely been reported whether and to what extent milder renal insufficiency affects the prognosis. The purpose of this study was to investigate the categorized impact of estimated glomerular filtration (eGFR) on the outcomes of patients with DFU.

DESIGN AND METHODS

Three hundred and sixty-six DFU patients hospitalized in a Chinese tertiary hospital were recruited and classified into 4 groups according to the eGFRs as follows: normal (≥90), mildly reduced (60-89), moderately reduced (30-59), and severely reduced (<30). These patients were followed-up for an average of 37 months to observe the outcomes, including ulcer healing, amputation, ulcer recurrence, cardiac or cerebrovascular events and death. The associations between eGFR and the outcomes were analysed by Cox proportional-hazards models.

RESULTS

Compared to patients with normal eGFR, patients with moderately reduced eGFR had higher risk of healing failure (hazard ratio (HR) = 2.08, 95% confidence interval (CI): 1.13-3.82), cardiac events (HR = 5.25, 95% CI: 2.17-12.89) and death (HR = 3.54, 95% CI: 1.36-9.20). Severely reduced eGFR was associated with higher incidence of healing failure (HR = 2.84, 95% CI: 1.25-6.49) and death (HR = 4.45, 95% CI: 1.23-16.07). The impact of eGFR on ulcer recurrence and cerebrovascular events was not observed in all groups.

CONCLUSIONS

Moderately and severely reduced eGFR in patients with DFU were independent predictors for poor prognoses of both the limbs and the patients.

Characteristics Predicting the Outcome in Individuals with Diabetic Foot Ulcerations

BACKGROUND

We sought to determine patient and ulcer characteristics that predict wound healing in patients living with diabetes.

METHODS

A prospective observational study was conducted on 99 patients presenting with diabetic foot ulceration. Patient and ulcer characteristics were recorded. Patients were followed up for a maximum of 1 year.

RESULTS

After 1 year of follow-up, ulcer characteristics were more predictive of ulcer healing than were patient characteristics. Seventy-seven percent of ulcers had healed and 23% had not healed. Independent predictors of nonhealing were ulcer stage (P = .003), presence of biofilm (P = .020), and ulcer depth (P = .028). Although this study demonstrated that the baseline hemoglobin A_1c reading at the start of the study was not a significant predictor of foot ulcer outcome (P = .603, resolved versus amputated), on further statistical analyses, when hemoglobin A_1c was compared with the time taken for complete ulcer healing (n = 77), it proved to be significant (P = .009).

CONCLUSIONS

The factors influencing healing are ulcer stage, presence of biofilm, and ulcer depth. These findings have important implications for clinical practice, especially in an outpatient setting. Prediction of outcome may be helpful for health-care professionals in individualizing and optimizing clinical assessment and management of patients. Identification of determinants of outcome could result in improved health outcomes, improved quality of life, and fewer diabetes-related foot complications.

Understanding Diabetic Foot Infection and its Management

Diabetic Foot Ulcers (DFUs), a dreadful micro-vascular complication is liable for substantial increase in morbidity and mortality. DFU is a complicated amalgam of neuropathy, peripheral arterial diseases, foot deformities and infection. Spanning the spectrum from superficial cellulitis, microbial flora leads to chronic ostemyelitis and gangrenous extremity lower limb amputations. Wounds without affirmation of soft tissue or bone infection do not require antibiotic therapy. Treatment of mild and moderate infection requires empiric therapy covering gram-positive cocci, whereas severe or infection caused by drug resistant organisms needs broad spectrum anti-microbial targeting aggressive gram-negative aerobes and obligate anaerobes. Definitive therapy employed should be based on culture reports and clinical response. Evaluation of bone infection requires imaging by plain radiographs or MRI to increase sensitivity and specificity. Surgical interventions are must and may range from minor debridement to resections or revascularization and major amputations depending upon wound severity. On time and forceful management of diabetic foot ulcers by employing multidisciplinary management approaches focusing on prevention, learning, regular foot assessment, aggressive intervention, and optimal use of therapeutic footwear can often prevent exacerbation of the difficulty and eliminate the potential for amputation. Here, we review recent studies addressing diabetic foot infections with emphasis on pathophysiology, exclusive risk factors; evaluation including physical inspection, laboratory investigations, relevant treatment strategies and assessment of infection severity.

Relationship between amputation and risk factors in individuals with diabetes mellitus: A study with Brazilian patients

Individuals with diabetes develop lower extremity amputation for several reasons. Investigations into pathways to the development of complications are important both for treatment and prevention.

AIM

To evaluate the relationship between amputation and risk factors in people with diabetes mellitus.

MATERIALS AND METHOD

All participants included in this study (n=165) were recruited from the Diabetic Foot Program, developed in a Brazilian University, over seven years (2007-2014) and all information for this study was extracted from their clinical records.

RESULTS

The prevalence of amputation in patients with diabetes with four risk factors was up to 20% higher when compared to those with only one risk factor. The main predictive risk factors for amputation in this population were the presence of an ulcer and smoking.

CONCLUSION

The risk factors for amputation can be predicted for people with diabetes mellitus and, in the present study, the main factors were the presence of an ulcer and the smoking habit.

Culture-Based Screening of Aerobic Microbiome in Diabetic Foot Subjects and Developing Non-healing Ulcers

The study was carried on diabetic foot patients to deduce clinical attributes, the occurrence of the range of aerobic microbial flora and to assess their comparative in vitro susceptibility to the customarily used antimicrobials. We also studied the potential risk factors involved in the development of non-healing ulcers. A total of 87 organisms were isolated from 70 specimens, including Escherichia coli (19.5%) among the Gram-negative and Staphylococcus aureus (18.4%) among the Gram-positive as the predominant aerobes explored. Pseudomonas aeruginosa and E. coli were predominant isolates of non-healing ulcers. The antimicrobial sensitivity pattern revealed that vancomycin (100%) and amikacin (90.4%) exhibited highest sensitivity to Gram-positive cocci, while all strains of P. aeruginosa were sensitive toward imipenem (100%). The prevalent uncontrolled glycemic status, altered lipid spectra, the existence of neuropathy, and peripheral vascular disease, suggested predisposition toward the development of non-healing lesions. The study has underlined the need for continuous surveillance of bacteria and their antimicrobial sensitivity blueprints to provide the basis for empirical therapy and to minimize the risk of complications. Further, stringent clinical evaluation, and medical history will help in revealing the risk of developing non-healing status in diabetic foot ulcers.

Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection

The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a hospital-based case-control study

Background

Diabetic foot ulcers (DFU) may cause significant morbidity and lower extremity amputation (LEA) due to diabetic foot problems can occur more often compared to the general population. The purpose of the present study was to use an epidemiological design to determine and to quantify the risk factors of subsequent amputation in hospitalized DFU patients.

Methods

We performed a hospital-based, case–control study of 47 DFU patients with LEA and 47 control DFU patients without LEA. The control subjects were matched to cases in respect to age (±5 years), sex, and nutritional status, with ratio of 1:1. This study was conducted in Dr. Kariadi General Hospital Semarang between January 2012 and December 2014. Patients’ demographical data and all risk factors-related information were collected from clinical records using a short structural chart. Using LEA as the outcome variable, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) by logistic regression. Univariate and stepwise logistic regression analyses were used to assess the independent effect of selected risk factors associated with LEA. The data were analyzed in SPSS version 21.

Results

There were 47 case–control pairs, all of which were diagnosed with type 2 diabetes mellitus. Seven potential independent variables show a promise of influence, the latter being defined as p≤0.15 upon univariate analysis. Multivariable logistic regression identified levels of HbA1c ≥8% (OR 20.47, 95% CI 3.12–134.31; p=0.002), presence of peripheral arterial disease (PAD) (OR 12.97, 95% CI 3.44–48.88; p<0.001), hypertriglyceridemia (OR 5.58, 95% CI 1.74–17.91; p=0.004), and hypertension (OR 3.67, 95% CI 1.14–11.79; p=0.028) as the independent risk factors associated with subsequent LEA in DFU.

Conclusions

Several risk factors for LEA were identified. We found that HbA1c ≥8%, PAD, hypertriglyceridemia, and hypertension have been recognized as the predictors of LEA in this study. Good glycemic control, active investigation against PAD, and management of comorbidities such as hypertriglyceridemia and hypertension are considered important to reduce amputation risk.

Risk factors for major amputation in hospitalised diabetic foot patients

Diabetic foot ulcers are the main cause of non-traumatic lower extremity amputation. The objective of this study was to evaluate the risk factors for major amputation in diabetic foot patients. Eight hundred and sixty diabetic patients were admitted to the diabetic wound centre of the Korea University Guro Hospital for foot ulcers between January 2010 and December 2013. Among them, 837 patients were successfully monitored until complete healing. Ulcers in 809 patients (96·7%) healed without major amputation and those in 28 patients (3·3%) healed with major amputation. Data of 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology and serology were collected from patients in the two groups and compared. Among the 88 potential risk factors, statistically significant differences between the two groups were observed in 26 risk factors. In the univariate analysis, which was carried out for these 26 risk factors, statistically significant differences were observed in 22 risk factors. In a stepwise multiple logistic analysis, six of the 22 risk factors remained statistically significant. Multivariate-adjusted odds ratios were 11·673 for ulcers penetrating into the bone, 8·683 for dialysis, 6·740 for gastrointestinal (GI) disorders, 6·158 for hind foot ulcers, 0·641 for haemoglobin levels and 1·007 for fasting blood sugar levels. The risk factors for major amputation in diabetic foot patients were bony invasions, dialysis, GI disorders, hind foot locations, low levels of haemoglobin and elevated fasting blood sugar levels.

HbA1c and Lower Extremity Amputation Risk in Patients With Diabetes

In this meta-analysis, we aimed to assess glycosylated hemoglobin (HbA1c) level and lower extremity amputation (LEA) risk in patients with diabetes. Systematic computerized searches of the PubMed and Web of Knowledge were performed. We compared HbA1c level between groups with LEA and without LEA by meta-analysis; we also examined the dose–response relationship between HbA1c level and LEA risk. Sixteen studies were included in the meta-analysis. Eleven studies with 43 566 patients compared HbA1c between groups with and without LEA. The mean HbA1c (%) ranged from 8.3 to 12.5 in the group with LEA and from 7.4 to 11.3 in the group without LEA. The pooled weighted mean difference was 1.110 (95% confidence interval = 0.510-1.709; Z = 3.63, P = .008). The funnel plot was symmetrical, and Begg’s test ( z = 0.00, P = 1.000) and Egger’s test ( t = −0.02, P = .984) suggested no significant publication bias. Six studies with 109 933 patients included in the dose–response meta-analysis. The LEA incidence ranged from 0.3% to 14.6% between different HbA1c levels. Dose–response meta-analysis showed statistically significant association between HbA1c and LEA risk (χ2 = 65.51, P = .000). In linear model, the odds ratio for LEA incidence was 1.229 (95% confidence interval = 1.169-1.292) for every 1% HbA1c increase. In the spline model, the odds ratio of LEA risk increased with HbA1c levels, especially when HbA1c ranged from 5% to 9%. Our meta-analysis indicates that high level of HbA1c is an important risk factor for LEA in patients with diabetes. This evidence supports the strategy for lowering glucose levels to reduce amputation in patients with diabetes.

Gender differences of lower extremity amputation risk in patients with diabetic foot: a meta-analysis

In this meta-analysis, we aim to evaluate gender differences of lower extremity amputation risk in patients with diabetic foot. Systematic computerized searches of PubMed and Web of Knowledge were performed. The pooled odds ratio (OR) and 95% confidence interval (CI) for amputation risk were calculated. Twenty studies with 15 385 case (present amputation) and 438 760 control (absent amputation) patients were included in the meta-analysis. The pooled crude OR was 1.676 (95% CI 1.307-2.149; Z = 4.07, P = .000). In the retrospective study subgroup, the pooled OR was 1.708 (95% CI = 1.235-2.363; Z = 3.24, P = .001); in the prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.189-1.838; Z = 3.51, P = .000). The pooled adjusted OR was 1.439 (95% CI = 1.238-1.671; Z = 4.76, P = .000). In retrospective study subgroup, the pooled OR was 1.440 (95% CI = 1.208-1.717; Z = 4.07, P = .000); in prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.080-2.024; Z = 2.44, P = .015). No significant publication bias was found. Sensitivity analyses by omitting a heterogeneity study showed the results were robust. In conclusion, our meta-analysis indicates that men with diabetic foot have about one half increased amputation risk than women with diabetic foot. Men with diabetes should receive more complete follow-up and more adequate health education.

Pre-hospital delay in patients with diabetic foot problems: influencing factors and subsequent quality of care

AIMS

To assess pre-hospital patient delay and its associated variables in patients with diabetic foot problems.

METHODS

We classified 270 patients with diabetic foot problems retrospectively based on the distribution of pre-hospital delay. Clinical, demographic and socio-economic data were collected. Logistic regression analysis was performed to examine independent associations with patient delay.

RESULTS

The median pre-hospital delay time was 46.49 days. Patients reported short (≤ 1 week; 77 patients, 28.5%), moderate (> 1 week and ≤ 1 month; 106 patients, 39.3%) and long delays (> 1 month; 87 patients, 32.2%). In a univariate analysis, nine variables were associated with a longer delay (P < 0.05): (1) no previous ulcer; (2) no health insurance; (3) poor housing conditions; (4) low income level; (5) low educational level; (6) infrequent foot inspection; (7) few follow-up medical visits; (8) absence of diabetic foot education; (9) lack of knowledge of foot lesion warning signals. A multivariate analysis showed that absence of diabetic foot education (odds ratio 2.70, 95% CI 1.03-7.06, P = 0.043) and lack of knowledge of foot lesion warning signals (odds ratio 2.14, 95% CI 1.16-3.94, P = 0.015) were independent predictors of long patient delay. Long delay increased the risk of amputation (odds ratio 2.22, 95% CI 1.36-3.64, P = 0.002) and mortality (odds ratio 2.69, 95% CI 1.35-5.33, P = 0.005).

CONCLUSIONS

A number of factors were involved in pre-hospital delay among patients with diabetic foot problems and contributed to poor outcomes. We recommend developing a community intervention programme that targets at-risk communities to encourage earlier multidisciplinary team assessment to reduce disparities and improve foot outcomes in patients with diabetes.