Inter-rater reliability of four validated diabetic foot ulcer classification systems

Prediction model for lower limb amputation in hospitalized diabetic foot patients using classification and regression trees

BACKGROUND

The decision to perform amputation of a limb in a patient with diabetic foot ulcer (DFU) is not an easy task. Prediction models aim to help the surgeon in decision making scenarios. Currently there are no prediction model to determine lower limb amputation during the first 30 days of hospitalization for patients with DFU.

METHODS

Classification And Regression Tree analysis was applied on data from a retrospective cohort of patients hospitalized for the management of diabetic foot ulcer, using an existing database from two Orthopaedics and Traumatology departments. The secondary analysis identified independent variables that can predict lower limb amputation (mayor or minor) during the first 30 days of hospitalization.

RESULTS

Of the 573 patients in the database, 290 feet underwent a lower limb amputation during the first 30 days of hospitalization. Six different models were developed using a loss matrix to evaluate the error of not detecting false negatives. The selected tree produced 13 terminal nodes and after the pruning process, only one division remained in the optimal tree (Sensitivity: 69%, Specificity: 75%, Area Under the Curve: 0.76, Complexity Parameter: 0.01, Error: 0.85). Among the studied variables, the Wagner classification with a cut-off grade of 3 exceeded others in its predicting capacity.

CONCLUSIONS

Wagner classification was the variable with the best capacity for predicting amputation within 30 days. Infectious state and vascular occlusion described indirectly by this classification reflects the importance of taking quick decisions in those patients with a higher compromise of these two conditions. Finally, an external validation of the model is still required.

LEVEL OF EVIDENCE

III.

Risk factors for 30-day hospital readmission in patients with diabetic foot

INTRODUCTION

Diabetic foot (DF) is part of the natural history of diabetes mellitus, ulceration being a severe complication with a prevalence of approximately 6.3 %, which confers a significant economic burden. Hospital readmission in the first thirty (30) days is considered a measure of quality of healthcare and it's been identified that the most preventable causes are the ones that occur in this period. This study seeks to identify the risk factors associated with readmission of patients with DF.

METHODS

A case-control study was done by performing a secondary analysis of a database. Descriptive statistics were used for all variables of interest, bivariate analysis to identify statistically significant variables, and a logistic regression model for multivariate analysis.

RESULTS

575 cases were analyzed (113 cases, 462 controls). A 20 % incidence rate of 30-day readmission was identified. Statistically significant differences were found in relation to the institution of attention (Hospital Universitario de la Samaritana: OR 1.9, p value < 0.01, 95 % CI 1.2-3.0; Hospital Universitario San Ignacio: OR 0.5, p value < 0.01, 95 % CI 0.3-0.8) and the reasons for readmission before 30 days, especially due to surgical site infection (SSI) (OR 7.1, p value < 0.01, 95 % CI 4.1-12.4), sepsis (OR 8.4, p value 0.02, 95 % CI 1.2-94.0), dehiscence in amputation stump (OR 16.4, p value < 0.01, 95 % CI 4.2-93.1) and decompensation of other pathologies (OR 3.5, p value < 0.01, 95 % CI 2.1-5.7).

CONCLUSION

The hospital readmission rate before 30 days for our population compares to current literature. Our results were consistent with exacerbation of chronic pathologies, but other relevant variables not mentioned in other studies were the hospital in which patients were taken care of, the presence of SSI, sepsis, and dehiscence of the amputation stump. We consider thoughtful and close screening of patients at risk in an outpatient setting might identify possible readmissions.

Citizens can help to map putative transmission sites for snail-borne diseases

INTRODUCTION

Schistosomiasis and fasciolosis are snail-borne diseases of great medical and veterinary health importance. The World Health Organization recommends complementing drug treatment with snail control and community involvement for disease elimination, but there is a general lack of snail experts and hence snail distribution data. Therefore, we adopted a citizen science approach and involved citizens in the monitoring of medically and veterinary important snail taxa.

MATERIALS AND METHODS

Snail data was collected weekly by 25 trained citizen scientists (CSs) at 76 sites around southern Lake Albert (Uganda) for 20 months. At each site, snails were searched for 30 minutes, sorted, target snail hosts identified to genus level, counted and data submitted through a smartphone application. The quality of this data was assessed by comparing it to monthly data collected by an 'expert' malacologist using the same sampling protocol. Generalised binomial logistic and linear mixed-effects models were used to analyse the variables for agreement between the CSs and expert.

FINDINGS

The binary agreement in presence/absence of Biomphalaria, Bulinus and Radix snails reported by the expert and CSs ranged between 70% and 86% (900 reports) with an average of 17% false negatives (sites wrongly defined as snail-free). The agreement for Biomphalaria and Radix increased with snail abundance, and false negatives decreased when the number of snails collected by citizens was aggregated per month. Site type significantly predicted binary agreement, which was lowest at lake sites (55%) and highest at spring sites (99%) with variations across genera. Similar temporal trends in snail abundance were recorded despite the expert reporting higher abundance. However, the relative abundance was consistent across site types. The match between the sites with highest Biomphalaria spp. abundance identified by CSs and expert was consistently high (~84.1%) and increased over time.

CONCLUSIONS AND RECOMMENDATIONS

Our results demonstrate the potential of citizen science to map putative schistosomiasis transmission sites. We therefore argue that this inclusive, powerful and cost-effective approach can be more sustainable than top-down monitoring and intervention campaigns.

Classification of foot ulcers in people with diabetes: A systematic review

BACKGROUND

Classification and scoring systems can help both clinical management and audit the outcomes of routine care.

AIM

This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot.

METHODS

We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer.

RESULTS

We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost.

CONCLUSION

Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.

Use of the SINBAD score as a predicting tool for major adverse foot events in patients with diabetic foot ulcer: A French multicentre study

OBJECTIVE

To assess the relationship between the site, ischaemia, neuropathy, bacterial infection, area, depth (SINBAD) score and major adverse foot events in patients with diabetes and foot ulcers.

METHODS

For this retrospective ancillary study, patients (n = 537) followed for a diabetic foot ulcer (DFU) in six French hospitals were included between 1 February 2019 and 17 March 2019, and between 1 February 2020 and 17 March 2020. The SINBAD score was assessed at inclusion. The frequency of a composite outcome consisting of eight major adverse foot events (MAFE) was assessed after 5-6 months of follow-up: hospitalisation for DFU, septic surgery, revascularisation, minor amputation, major amputation, death, secondary infection and ulcer recurrence. A logistical regression explored the link between the SINBAD score and MAFE and each of its component.

RESULTS

A low SINBAD score (from 0 to 3) was observed in 61% of patients and a high (from 4 to 6) in 39%. MAFE occurred in, respectively, 24% and 28% of these patients. Multivariate analyses showed a significant relationship between the SINBAD score and MAFE, with the continuous SINBAD score: odds ratio (OR) 1.72 [95% CI (1.51-1.97)] or dichotomic SINBAD score (values: 0-3 and 4-6): OR 3.71 [95% CI (2.54-5.42)]. The SINBAD score (continuous or dichotomic) at inclusion was also significantly associated with six out of the eight components of the MAFE.

CONCLUSIONS

The SINBAD score is a useful tool for predicting major adverse foot events.

The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers

ABSTRACT

Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.

Limb Salvage in Severe Diabetic Foot Infection

Severe diabetic foot infections (DFI) are both limb threatening and life threatening and associated with negative impact on health-related quality of life. Most severe DFIs require surgical intervention, and the goal of treatment should be preservation of limb function in addition to eradication of infection. Minor amputations are required in approximately 40% and major amputations in approximately 20% of patients. Significant risk factors for lower extremity amputation included male gender, smoking, previous amputation, osteomyelitis, peripheral artery disease, retinopathy, severe infections, gangrene, neuroischemic diabetic foot infections, leukocytosis, positive wound cultures, and isolation of gram-negative bacteria.

ENERGI-F703 gel, as a new topical treatment for diabetic foot and leg ulcers: A multicenter, randomized, double-blind, phase II trial

BACKGROUND

Diabetic foot and leg ulcers are a major cause of disability among patients with diabetes mellitus. A topical gel called ENERGI-F703, applied twice daily and with adenine as its active pharmaceutical ingredient, accelerated wound healing in diabetic mice. The current study evaluated the safety and efficacy of ENERGI-F703 for patients with diabetic foot and leg ulcers.

METHODS

This randomized, double-blind, multicenter, phase II trial recruited patients from eight medical centers in Taiwan. Patients with intractable diabetic foot and leg ulcers (Wagner Grade 1-3 without active osteomyelitis) were randomly assigned (2:1) to receive topical ENERGI-F703 gel or vehicle gel twice daily for 12 weeks or until complete ulcer closure. The investigator, enrolled patients and site personnel were masked to treatment allocation. Intention to treat (ITT) population and safety population were patient to primary analyses and safety analyses, respectively. Primary outcome was complete ulcer closure rate at the end of treatment. This trial is registered with ClinicalTrials.gov, number NCT02672436.

FINDINGS

Starting from March 15^th, 2017 to December 26^th, 2019, 141 patients were enrolled as safety population and randomized into ENERGI-F703 gel (n = 95) group or vehicle gel (n = 46) group. In ITT population, ENERGI-F703 (n = 90) and vehicle group showed ulcer closure rates of 36.7% (95% CI = 26.75% - 47.49%) and 26.2% (95% CI = 13.86% - 42.04%) with difference of 9.74 % (95 % CI = -6.74% - 26.23%) and 25% quartiles of the time to complete ulcer closure of 69 days and 84 days, respectively. There were 25 (26.3%) patients in ENERGI-F703 group and 11 (23.9%) patients in vehicle group experiencing serious adverse events and five deaths occurred during the study period, none of them related to the treatment.

INTERPRETATION

Our study suggests that ENERGI-F703 gel is a safe and well-tolerated treatment for chronic diabetic foot and leg ulcers. Further studies are needed to corroborate our findings in light of limitations.

FUNDING

Energenesis Biomedical Co., Ltd.

A Retrospective Cohort Study on Diabetic Foot Disease: Ascertainment of Ulcer Locations by Age Group

Background and aims

Diabetic foot ulcer location is a known independent predictor for cure with a better healing gradient proximal to distal. Although advanced age is one of the main factors associated with greater diabetic foot ulcer severity, there are no studies evaluating diabetic foot ulcer location specifically in the elderly population in an outpatient setting. This study evaluated diabetic foot ulcer location and age-group interactions in diabetic foot presentation.

Methods

A retrospective cohort study including adult patients with diabetic foot ulcers observed on their first visit to our center's Diabetic Foot Unit in 2018, divided into younger adults (YA) (18 to 64 years) and older adults (OA) (≥65 years).

Results

A total of 435 patients were included in the study with 159 (36.6%) in the YA, and 276 (63.4%) in the OA group.

Neuro-ischemic diabetic foot ulcers were more frequent in the OA group (71.4% vs 43.4%, p<0.001). The number of patients with a history of diabetic foot ulcers was lower in the OA group (18.1% vs 25.2%, p=0.03). A smaller proportion of forefoot diabetic foot ulcers (74.9% vs 86.2%, p=0.007) and plantar location diabetic foot ulcers (9.4% vs 24.5%, p<0.001) occurred in the OA group.

By univariate logistic regression analysis, we found two associations with older age: proximal (odds ratio (OR) 2.09 (1.23-3.53), p=0.006), and non-plantar (OR 3.13 (1.82-5.37), p<0.001) diabetic foot ulcer location. After adjusting for potential confounders in a multivariate analysis, older age lost the association to more proximal (OR 1.72 (0.94-3.15), p=0.081) and non-plantar (OR 1.78 (0.83-3.77), p=0.133) diabetic foot ulcer location.

Conclusions

There are essential age differences in diabetic foot ulcer presentation. The OA group more frequently presents neuro-ischemic diabetic foot ulcers with more proximal and non-plantar locations.

The Charcot Foot: An Emerging Public Health Problem for African Diabetes Patients

Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant (P < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes.

The effects of dietary/herbal supplements and the serum levels of micronutrients on the healing of diabetic foot ulcers in animal and human models: a systematic review

PURPOSE

Diabetic Foot Ulcer (DFU) is one of the common and serious complications in patients with Diabetes Mellitus (DM) worldwide. Given the considerable tendency of patients suffering from DFU to use the complementary therapies, the objectives of this study were to: (i) summarize the effects of dietary and herbal supplements on DFU characteristics and metabolic parameters in both animal models and clinical trials, and (ii) evaluate any links between the serum levels of micronutrients and DFU in observational studies.

METHODS

A systematic search in five electronic databases including PubMed/Medline, Scopus, Web of Science, Embase, and Cochrane Library was conducted to find relevant English language published from 1990 until 31 December 2018.

RESULTS

Of a total of 8603 studies, 30 eligible papers including animal studies (n = 15), clinical trials (n = 7), and observational works (n = 8) were included in the systematic review. We found that some dietary/herbal supplements and micronutrients had positive effects on the wound healing. However, limited evidence is existed. Also, lower serum levels of vitamin D, C, vitamin E, and selenium in patients with DFU were likely to increase the risk of DFU, leading to impaired wound healing.

CONCLUSION

Findings suggested that some dietary and herbal supplements such as Vitamin D, Magnesium, Vitamin E, Probiotic, Zinc, and Pycnogenol would be effective on wound healing of DFUs. However, further high-quality randomized controlled clinical trials and prospective cohort studies are needed to clarify the roles of micronutrients and other dietary and herbal supplements on the progress and treatment of DFU.