A Longitudinal Study on the Association Between Diabetic Foot Disease and Health-Related Quality of Life in Adults With Type 2 Diabetes

Utilities for Complications Associated with Type 2 Diabetes: A Review of the Literature

INTRODUCTION

Utility values are used in health economic modeling analyses of type 2 diabetes (T2D) to quantify the effect of acute and long-term complications on quality of life (QoL). For accurate modeling projections, it is important that the utility values used are up to date, accurate and representative of the simulated model cohort.

METHODS

A literature review was performed to identify utility values for health states representing acute and chronic T2D-related complications including cardiovascular complications, stroke, renal disease, ophthalmic complications, neuropathy, diabetic foot, amputation and hypoglycemia. Searches were performed using the PubMed, Embase and Cochrane Library databases and limited to articles published since 2010. Supplementary searches were performed to identify data published at congresses in 2019-2023.

RESULTS

A total of 54 articles were identified that reported utility values for T2D-related complications. The most frequently used elicitation method/instrument was the EQ-5D (n = 42 studies) followed by the Short Form-6 dimensions (n = 6), time tradeoff (n = 5), the Health Utilities Index Mark 2 or Mark 3 (n = 2), 15D (n = 1), visual analog scale (n = 1) and standard gamble (n = 1). Stroke and amputation were consistently associated with the largest decrements in QoL. There is a lack of published data that distinguishes between severity of several complications including renal disease, retinopathy and neuropathy.

CONCLUSIONS

Diabetes-related complications can have a profound impact on QoL; therefore, it is important that these are captured accurately and appropriately in health economic models. Recently published utility values for diabetes-related complications that can be used to inform health economic models are summarized here.

Health-related quality of life in people with different diabetes-related foot ulcer health states: A cross-sectional study of healed, non-infected, infected, hospitalised and amputated ulcer states

AIMS

Diabetes-related foot ulcers (DFU) are a leading cause of infection, hospitalisation and amputation. However, to our knowledge no studies have compared the health-related quality of life (HRQoL) of people with DFU that were infected, hospitalised or amputated. This study aimed to investigate and compare the HRQoL of different groups of people with healed, non-infected, infected, hospitalised, or amputated DFU.

METHODS

This was a multi-centre cross-sectional study measuring the HRQoL of patients, attending one of 18 Diabetic Foot Services across Queensland, Australia, with one of five DFU health states: healed, non-infected, infected, hospitalised, amputated. HRQoL was measured using the EQ-5D-5L to estimate age-sex adjusted utility values.

RESULTS

Of 376 included patients (mean age 63 (12) years, 75% male), age-sex adjusted HRQoL utility estimates (95% CIs) were: healed DFU 0.57 (0.51-0.64), non-infected DFU 0.55 (0.49-0.62), infected DFU 0.45 (0.36-0.55), hospitalised DFU 0.53 (0.42-0.64), and amputated DFU 0.55 (0.46-0.63).

CONCLUSION

People in any DFU health state have considerably reduced HRQoL, with greatest reductions in those with infected DFU. These findings provide valuable HRQoL estimates and comparisons for several different important DFU health states, adding to our understanding of the impact of DFU on HRQoL and facilitating future economic evaluations.

Transcriptomic identification of genes expressed in invasive S. aureus diabetic foot ulcer infection

Introduction

Infection in diabetic foot ulcers (DFUs) is one of the major complications associated with patients with diabetes. Staphylococcus aureus is the most common offending pathogen in patients with infected DFU. Previous studies have suggested the application of species-specific antibodies against S. aureus for diagnosis and monitoring treatment response. Early and accurate identification of the main pathogen is critical for management of DFU infection. Understanding the host immune response against species-specific infection may facilitate diagnosis and may suggest potential intervention options to promote healing infected DFUs. We sought to investigate evolving host transcriptome associated with surgical treatment of S. aureus- infected DFU.

Methods

This study compared the transcriptome profile of 21 patients with S. aureus- infected DFU who underwent initial foot salvage therapy with irrigation and debridement followed by intravenous antibiotic therapy. Blood samples were collected at the recruitment (0 weeks) and 8 weeks after therapy to isolate peripheral blood mononuclear cells (PBMCs). We analyzed the PBMC expression of transcriptomes at two different time points (0 versus 8 weeks). Subjects were further divided into two groups at 8 weeks: healed (n = 17, 80.95%) versus non-healed (n = 4, 19.05%) based on the wound healing status. DESeq2 differential gene analysis was performed.

Results and discussion

An increased expression of IGHG1, IGHG2, IGHG3, IGLV3-21, and IGLV6-57 was noted during active infection at 0 weeks compared with that at 8 weeks. Lysine- and arginine-rich histones (HIST1H2AJ, HIST1H2AL, HIST1H2BM, HIST1H3B, and HIST1H3G) were upregulated at the initial phase of active infection at 0 weeks. CD177 and RRM2 were also upregulated at the initial phase of active infection (0 weeks) compared with that at 8 weeks of follow-up. Genes of heat shock protein members (HSPA1A, HSPE1, and HSP90B1) were high in not healed patients compared with that in healed patients 8 weeks after therapy. The outcome of our study suggests that the identification of genes evolution based on a transcriptomic profiling could be a useful tool for diagnosing infection and assessing severity and host immune response to therapies.

Quality of life and mental health measurements among patients with type 2 diabetes mellitus: a systematic review

BACKGROUND

Over the past few decades the benefits of assessing Quality of Life (QoL) and mental health in patients with Type 2 Diabetes Mellitus (T2DM) have steadily increased with limited studies relating to the most useful method to assess these patients. This study aims to identify, review, summarise, and evaluate the methodological quality for the most validated commonly used health-related QoL and mental health assessment measurements in diabetic patients.

METHODS

All original articles published on PubMed, MedLine, OVID, The Cochrane Register, Web of Science Conference Proceedings and Scopus databases were systematically reviewed between 2011 and 2022. A search strategy was developed for each database using all possible combinations of the following keywords: "type 2 diabetes mellitus", "quality of life", mental health", and "questionnaires". Studies conducted on patients with T2DM of ≥ 18 years with or without other clinical illnesses were included. Articles designed as a literature or systematic review conducted on either children or adolescents, healthy adults and/or with a small sample size were excluded.

RESULTS

A total of 489 articles were identified in all of the electronic medical databases. Of these articles, 40 were shown to meet our eligibility criteria to be included in this systematic review. Approximately, 60% of these studies were cross-sectional, 22.5% were clinical trials, and 17.5% of cohort studies. The top commonly used QoL measurements are the SF-12 identified in 19 studies, the SF-36, included in 16 studies, and the EuroQoL EQ-5D, found in 8 studies. Fifteen (37.5%) studies used only one questionnaire, while the remaining reviewed (62.5%) used more than one questionnaire. Finally, the majority (90%) of studies reported using self-administered questionnaires and only 4 used interviewer mode of administration.

CONCLUSION

Our evidence highlights that the commonly used questionnaire to evaluate the QoL and mental health is the SF-12 followed by SF-36. Both of these questionnaires are validated, reliable and supported in different languages. Moreover, using single or combined questionnaires as well as the mode of administration depends on the clinical research question and aim of the study.

How patients with diabetic foot ulcers experience telemedicine solutions: A scoping review

Diabetic foot ulcer (DFU) is a common, complex and severe complication of diabetes that is associated with severely decreased health-related quality of life. Treatment of DFUs calls for a multi-sectoral approach, incorporating interdisciplinary care pathways. Telemedicine (TM) may be used as a communication tool between caregivers across healthcare sectors to obligate the need for close follow-up, including early intervention in preventing the recurrence of DFU. The objective of this review was to identify, examine and conceptually map the available literature on patients' experiences and views regarding the use of TM solutions among patients with DFUs. We identified the Population, Concept and Context to pinpoint the focus of this review, word the research question and title as well as facilitate the literature search strategy. The literature examined stems from 13 sources. We imposed no restrictions on the methodological approach of the included studies, neither on the format. During the review process, four main maps emerged: "A whole human not merely a hole in a human," "Less of a burden on the family, the community and the environment," "Competences and continuity of care are essential for high-quality care" and "The quality and modality of the technology." Further investigation from both the patients' and the multi-sectoral caregivers' perspective is needed, focusing on whatever modifications of the TM intervention may fit the DFU care pathway better.

Transcriptomic fingerprint of bacterial infection in lower extremity ulcers

Clinicians and researchers utilize subjective, clinical classification systems to stratify lower extremity ulcer infections for treatment and research. The purpose of this study was to examine whether these clinical classifications are reflected in the ulcer's transcriptome. RNA sequencing (RNA‐seq) was performed on biopsies from clinically infected lower extremity ulcers (n = 44). Resulting sequences were aligned to the host reference genome to create a transcriptome profile. Differential gene expression analysis and gene ontology (GO) enrichment analysis were performed between ulcer severities as well as between sample groups identified by k‐means clustering. Lastly, a support vector classifier was trained to estimate clinical infection score or k‐means cluster based on a subset of genes. Clinical infection severity did not explain the major sources of variability among the samples and samples with the same clinical classification demonstrated high inter‐sample variability. High proportions of bacterial RNA were identified in some samples, which resulted in a strong effect on transcription and increased expression of genes associated with immune response and inflammation. K‐means clustering identified two clusters of samples, one of which contained all of the samples with high levels of bacterial RNA. A support vector classifier identified a fingerprint of 20 genes, including immune‐associated genes such as CXCL8, GADD45B, and HILPDA, which accurately identified samples with signs of infection via cross‐validation. This study identified a unique, host‐transcriptome signature in the presence of infecting bacteria, often incongruent with clinical infection‐severity classifications. This suggests that stratification of infection status based on a transcriptomic fingerprint may be useful as an objective classification method to classify infection severity, as well as a tool for studying host–pathogen interactions.

Pilot Experience on the Use of S54P4 Bioactive Glass in the Surgical Management of Diabetic Foot Osteomyelitis

To test safety and efficacy of bioactive glass, a novel material used to replace bone, able to completely bond itself to the host tissues on patients treated for osteomyelitis (OM) complicating a diabetic foot (DF). We evaluated a group of patients consecutively admitted in our department between September and December 2018, who underwent surgical DF procedures for OM and in whom the use of bioactive glass could limit the demolition phase of surgical procedure. Patients were treated with bioactive glass S53P4 on top of standard treatment directly in operating room. The patients were weekly controlled for 6 months or until complete healing. During follow-up, we analyzed primarily healing rate and secondarily time of healing, need for further debridement procedures, recurrences, and adverse or hypersensitivity reactions to study treatment. Ten DF patients were enrolled (male/female 6/4; mean age 56 ± 11 years; mean duration of diabetes 10.5 ± 4.7 years, mean hemoglobin A1c 7.2 ± 0.9%). Patients underwent surgical procedure during which, after an accurate debridement, bioactive glass was applied. A healing rate of 80% in a mean time of 34 ± 2 days, with only 1 patient who needed a second surgical look, was observed. Neither recurrences nor adverse events during follow-up were observed in treated patients. This pilot experience demonstrated that bioactive glass can be considered a useful tool for the surgical treatment of DF-related OM.