Chapter V: Diabetic foot

Association between Mediterranean diet adherence and peripheral artery disease in type 2 diabetes mellitus: An observational study

INTRODUCTION

To evaluate the relationship between adherence to the Mediterranean diet (MD) and periphereal artery disease (PAD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

An observational sectional study was conducted with 174 patients diagnosed with T2DM, of which 78 patients had PAD. A patient was considered to have PAD if they obtained an ankle-brachial index (ABI) < 0.9 and/or absence of both distal pulses in one of the two feet. Data on sociodemographic and anthropometric variables, physical activity, smoking habits, biochemical blood parameters, and comorbidities were recorded. Good adherence to the MD was considered with a score ≥ 9 in MEDAS-14. Vascular factors independently associated with adherence to the MD in patients with T2DM were identified through multivariate logistic regression analysis.

RESULTS

ABI, DFU, intermittent claudication and pedal pulse absence correlated with MD adherence. DFU, intermittent claudication and posterior tibial pulse absence were associated with the final score obtained in the MEDAS-14. Nut consumption, white meat preference and sautéed dish intake were associated with PAD presence. Multivariate analysis linked MD adherence to sex (OR = 0.044, 95 % CI 0.003-0619), age (OR = 0.139, 95 % CI 0.029-0.666), duration of T2DM (OR = 7.383, 95 % CI 1.523-35.779) and age at diagnosis of T2DM (OR = 6082, 95 % IC 1.415-26.136), as well as the presence of DFU (OR = 0.000, 95 % IC 0.000-0.370) and intermittent claudication (OR = 0.004, 95 % IC 0.000-0.534).

CONCLUSIONS

Adherence to the MD is associated with a reduction in vascular complications in T2DM, highlighting its potential as a dietary intervention strategy.

Metformin Syncs CeO2 to Recover Intra- and Extra-Cellular ROS Homeostasis in Diabetic Wound Healing

Excessive generation of reactive oxygen species (ROS) poses a huge obstacle to the healing process of diabetic wounds, resulting in chronic, non-healing wounds. While numerous anti-ROS therapeutics have been developed, satisfied intra- and extra- cellular ROS homeostasis is hard to be established in diabetic wounds. To address this issue, a nanoparticle via loading metformin and CeO2 into mesoporous silica (MSN@Met-CeO2) is designed and synthesized, which is then encapsulated within ROS-responsive hydrogel and shaped as microneedles (MNs) for better application in diabetic wounds. Interestingly, a unique metformin-cerium chelate (Ce· 3Metformin) is formed during the synthesis of MSN@Met-CeO2 MN, which significantly strengthened the inhibitory effect of metformin on mitochondrial complex I. With the presence of Ce· 3Metformin, MSN@Met-CeO2 MN performed a remarkable effect on intracellular mtROS reduction as well as extracellular ROS elimination, the latter is primarily accomplished through the dissociative CeO2 in MSN@Met-CeO2 MN. In the mouse diabetic wound model, MSN@Met-CeO2 MN exhibited a superior pro-healing effect with accelerated inflammation resolution and enhanced angiogenesis, thus highlighting its significant potential for clinical application.

Adipose-derived stem cells in diabetic foot care: Bridging clinical trials and practical application

Diabetic foot ulcers (DFUs) pose a critical medical challenge, significantly im-pairing the quality of life of patients. Adipose-derived stem cells (ADSCs) have been identified as a promising therapeutic approach for improving wound healing in DFUs. Despite extensive exploration of the mechanical aspects of ADSC therapy against DFU, its clinical applications remain elusive. In this review, we aimed to bridge this gap by evaluating the use and advancements of ADSCs in the clinical management of DFUs. The review begins with a discussion of the classification and clinical management of diabetic foot conditions. It then discusses the current landscape of clinical trials, focusing on their geographic distribution, reported efficacy, safety profiles, treatment timing, administration techniques, and dosing considerations. Finally, the review discusses the preclinical strategies to enhance ADSC efficacy. This review shows that many trials exhibit biases in study design, unclear inclusion criteria, and intervention protocols. In conclusion, this review underscores the potential of ADSCs in DFU treatment and emphasizes the critical need for further research and refinement of therapeutic approaches, with a focus on improving the quality of future clinical trials to enhance treatment outcomes and advance the field of diabetic wound care.

Comparison of the Effects of Combined Femoral and Sciatic Nerves Block versus General Anesthesia on Hemodynamic Stability and Postoperative Complication in Patients with Diabetic Foot: A Prospective, Double-Blind and Randomized Controlled Trial

Background

Perioperative anesthetic management of patients with diabetic foot undergoing surgical treatment is challenging due to their poor cardiovascular health status. According to previous literature, general anesthesia and peripheral nerve block have their own advantages and disadvantages for such patients. We reported the effect of these two anesthesia techniques on perioperative hemodynamics and prognosis in these patients.

Methods

This study employed a prospective randomized controlled design, where patients meeting the inclusion criteria were assigned to two groups: the general anesthesia group (GA group) and the peripheral nerve block group (PNB group). The primary outcomes were the differences in intraoperative hemodynamic stability and the incidence of postoperative complications between the two groups. The second outcomes were postoperative numerical rating scale scores, analgesic drug remedies, postoperative sleep conditions monitored by sleep bracelets and health status assessed by EQ-5D-5 L scores.

Results

One hundred and nine subjects were enrolled in this study, including 54 in the GA group and 55 in the PNB group. The baseline parameters of the two groups were comparable. The GA group exhibited a significantly higher incidence of hypotension, and Colloid intake and total fluid intake were significantly higher in the GA group than in the PNB group. Additionally, a larger proportion of patients in the GA group. The scores of postoperative pain during the 48 hours after surgery were significantly higher, and more patients needed tramadol for postoperative analgesia during the 24 h after surgery in the GA group than in the PNB group. Patients in the PNB group slept better, first feeding time, earlier out-of-bed activity and earlier discharge from the hospital, compared to the GA group. However, there was no obvious difference in postoperative complications between the two groups except pharyngeal pain.

Conclusion

Peripheral nerve block is a better option in patients with diabetes undergoing elective below-knee surgery than general anesthesia.

Importance of Using Angiography for the Early Detection of Chronic Limb Ischemia in Diabetic Foot Wounds

Peripheral artery disease (PAD) affects millions of people worldwide, presenting with varying symptom severity, including chronic total occlusion of arteries, and occasionally, limb amputation. There are various interventions, such as atherectomy and the use of drug-coated balloons and stents, which have been developed to revascularize affected ischemic regions. However, each interventional approach must be individualized due to a patient's unique underlying conditions. Comorbid conditions, especially diabetes, play a significant role in PAD, as poorly controlled diabetes can accelerate PAD progression. For this reason, an early and accurate diagnosis of PAD is crucial, especially when symptoms may present dissimilar to classic PAD symptoms, often leading to misdiagnosis. The presented cases highlight the tailored interventions to revascularize arteries in patients with diabetic foot wounds utilizing catheters, stents, guidewires, and balloons, made possible after early angiogram. These interventions have been promising in treating PAD patients, and highlight the need for early diagnosis and timely and customized interventions to prevent limb amputation and mitigate potential complications.

Exploring the influence of dietary habits on foot risk in type 2 diabetes patients: An observational study

BACKGROUND & AIM

To date, there are no studies demonstrating the impact of the Mediterranean diet on the risk of diabetic foot ulcer. The aim of this research was to examine the connection between adherence to the Mediterranean diet and the level of risk of diabetic foot ulcers in individuals with type 2 diabetes.

METHODS

Observational pilot study collecting sociodemographic, anthropometric, lifestyle, and type 2 diabetes-related data. Loss of protective sensation was assessed using the Semmes Weinstein 5.07-10 g monofilament, considered altered when not perceived in four points. Vascular status was assessed by palpating pulses and ankle-brachial index, indicating peripheral arterial disease if ankle-brachial index was less than 0.9 or if both pulses were absent. Foot deformities were recorded. The risk of diabetic foot ulcers was stratified into two categories: no risk and risk of diabetic foot ulcers. Adherence to the Mediterranean diet was evaluated using the Mediterranean Diet Adherence Screener-14 questionnaire (good adherence with score >7).

RESULTS

Of the 174 patients with type 2 diabetes mellitus who participated (61.5% men and 38.5% women) with a mean age of 69.56 ± 8.86 years and a mean duration of type 2 diabetes of 15.34 ± 9.83 years. Non-adherent patients to the Mediterranean diet exhibited a higher association of diabetic foot ulcers (p = 0.030) and a lower average score on the Mediterranean Diet Adherence Screener-14 (p = 0.011). Additionally, a lower incidence of diabetic foot ulcers was observed in those who consumed nuts three or more times a week (p = 0.003) and sautéed foods two or more times a week (p = 0.003). Multivariate analysis highlighted the importance of physical activity (OR = 0.25, 95% CI 0.11-0.54; p < 0.001), podiatric treatment (OR = 2.59, 95% CI 1.21-5.56; p = 0.014), and duration of type 2 diabetes (OR = 3.25, 95% CI 1.76-5.99; p < 0.001) as significantly associated factors related to the risk of diabetic foot ulcers.

CONCLUSIONS

Adhering to the Mediterranean diet correlates with a lower incidence of diabetic foot ulcers in individuals diagnosed with type 2 diabetes mellitus. Furthermore, factors such as regular physical activity, podiatric treatment, and the duration of type 2 diabetes mellitus emerge as pivotal in preventing diabetic foot ulcers.

Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds

BACKGROUND

The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations.

METHODS

We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process.

RESULTS

Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001).

CONCLUSIONS

Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.

Impact of wound management strategies after revascularization for chronic limb-threatening ischemia

OBJECTIVE

There is no established consensus or guidelines for wound management after revascularization for patients with chronic limb-threatening ischemia (CLTI) without severe infection. This study is designed to evaluate the clinical effect of the wound management strategy on toe wounds after revascularization for CLTI.

METHODS

This retrospective cohort study was performed at eight institutions affiliated with Keio University School of Medicine in Japan and included 261 patients who underwent revascularization for CLTI between April 2019 and July 2021. We identified 132 patients with toe wounds from the database who had restored in-line blood flow to the foot. Patients were divided into two groups by the timing of toe resection after revascularization, which dictated the wound management policy. Group A (62 patients) underwent early toe amputation for suspected osteomyelitis, whereas group B (70 patients) underwent watchful waiting. The primary outcome was wound healing after revascularization; the secondary outcome was major amputation. We compared outcomes between groups A and B after propensity score matching.

RESULTS

Using propensity score matching, each patient in group A (33 patients) was matched with a patient in group B (33 patients). Wound healing in matched group A was significantly better than that in matched group B (respectively: 1-year wound healing rate: 90.0% vs 68.2%, P < .001; median wound healing time: 65 days vs 258 days, P < .01). Although five major amputations were necessary in matched group B, none were required in matched group A (P = .05). The high rate of major amputations in group B was attributed to the sudden exacerbation of infection. Limb salvage rate in matched group A exceeded matched group B (100.0% vs 90.5%: 1-year limb salvage rate, P = .02).

CONCLUSIONS

Early toe amputation for highly suspected osteomyelitis in patients with CLTI with toe wounds may expedite wound healing compared with watchful waiting, potentially avoiding unnecessary major amputation. Considering the wound management strategy is crucial when evaluating wound healing outcomes in patients with CLTI with revascularization.

Antibacterial microneedle patch releases oxygen to enhance diabetic wound healing

Cell growth and metabolism require an adequate supply of oxygen. However, obtaining sufficient oxygen from the blood circulating around diabetic wounds is challenging. Nevertheless, achieving a continuous and stable oxygen supply is required for these wounds to heal. Hence, in this study, we report a novel antibacterial oxygen-producing silk fibroin methacryloyl hydrogel microneedle (MN) patch comprising tips encapsulated with calcium peroxide and catalase and a base coated with antibacterial Ag nanoparticles (AgNPs). The tip of the MN patch continuously releases oxygen and inhibits the production of reactive oxygen species. This accelerates diabetic wound healing by promoting cellular accretion and migration, macrophage M2 polarization, and angiogenesis. The AgNPs at the base of the MN patch effectively combat microbial infection, further facilitating wound repair. These findings suggest that using this multifunctional oxygen-producing MN patch may be a promising strategy for diabetic wound healing in clinical settings.

Diabetic Foot Complications in Saudi Arabia: A Retrospective Study

REVIEW

A common chronic health problem among Saudi Arabians is diabetes mellitus (DM). One of the most serious complications of diabetes is diabetic foot (DMF).

AIM

The objective of this study was to identify the most common complications that develop among patients with DMF. In addition, we conducted a demographic analysis of chronic diabetic complications related to DMF.

MATERIAL AND METHODS

The study involved 100 DMF attending the Jeddah clinic of Dr Soliman Fakeeh Hospital. Several chronic complications associated with DMF were reported, including peripheral arterial disease (PAD), coronary artery disease (CAD), retinopathy, nephropathy, and neuropathy. We examined the feet for ulcers, gangrene, amputations, bone deformities, Charcot joints, osteoarthritis, septic arthritis, and osteomyelitis. By using B-mode ultrasound and spectral Doppler imaging, we imaged the posterior tibial and anterior tibial arteries.

RESULTS

People with poorly controlled diabetes mellitus type 2 (T2DM) are more likely to develop diabetic feet. The most common foot complications were foot ulcers (81%), foot amputations (31%), foot gangrene (29%) (29/100), bone deformities (22%) (22/100), ingrown toenails (17%) (17/100), Charcot's foot (10%) (10/100), and calluses (9%) (9/100). The majority of the patients suffered from hypertension and half had anaemia. Diabetic peripheral neuropathy affected about half of the patients, diabetic nephropathy affected one-third, and diabetic retinopathy affected 14%. Approximately a quarter (25/100) of the patients had CAD and less than half had PAD. There was atherosclerosis in 43% (43/100) of popliteal/infra-popliteal arteries. Twenty-two percent (22/100) of the anterior tibial arteries and 25% (25/100) of the posterior tibial arteries were stenotic or occluded. A biphasic mode was observed in 21% (21/100) of anterior tibial arteries, a monophasic mode in 9% (9/100), and a non-flowing mode in 3% (3/100). Twenty-three percent (23/100) of the posterior tibial arteries displayed biphasic Doppler modes, 5% (5/100) displayed monophasic modes, and 6% (6/100) displayed non-flowing modes. Conclusion: Diabetes foot is common among older males with poorly controlled T2DM. The most common foot complications were amputations, gangrene, foot ulcers, bone deformities, ingrown toenails, Charcot's foot, and calluses. Most DMF patients were anemic and hypertensive. Diabetes-related microvascular complications, such as diabetic peripheral neuropathy, nephropathy, and retinopathy, as well as macrovascular complications, such as coronary artery disease and peripheral arterial disease, were associated with DMF.

Epidemiological Insights into Diabetic Foot Amputation and its Correlates: A Provincial Study

Background

Diabetic foot ulcer and potential subsequent lower extremity amputation are major complications of diabetes mellitus and are also prominent morbidity factors that could affect patients' quality of life.

Objectives

This study aimed to assess the prevalence of diabetic foot amputation and explore correlates of amputation cause and type among subjects with diabetes mellitus in Tehran, Iran.

Methods

A descriptive cross-sectional study was conducted to assess the demographic, sociological, and clinical characteristics of subjects who had undergone lower extremity amputation due to diabetic foot ulcers, from 2011 to 2020, in two educational medical centers in Tehran, Iran. We examined the medical records of 4676 individuals who were admitted to Shariati and Sina hospitals due to diabetic foot issues. Information related to patient demographics (age, gender, marital status), social factors (education level, insurance), and clinical data (medical history, laboratory results, and characteristics of diabetic foot ulcers) was collected for subjects who had undergone lower extremity amputation due to diabetic foot ulcer. The collected data was reported using average values, standard deviations and proportions and analyzed using statistical tests.

Results

During one decade, 882 out of 4676 (18.8%) patients with diabetic foot ulcers underwent lower extremity amputations of various types in Sina and Shariati hospitals in Tehran, Iran. Of these, 692 (14.5%) were included for further analysis in the study and the rest were excluded due to lack of sufficient recorded data. About 75.9% of the study population was male, and the average age including both sexes was 60 years. About 92.7% were married, and on average, subjects had been afflicted with diabetes mellitus for 15.1 years. Statistical analysis using Pearson's chi-square test showed there was a significant association between the treatment regimen for diabetes mellitus and the type of amputation (P = .01), as well as between the duration of the disease and the cause of amputation (P = .01) and its type (P = .04).

Conclusion

diabetes mellitus related treatment regimen and duration of disease are significantly associated with amputation cause and type.

Diabetic microvascular disease in non-classical beds: the hidden impact beyond the retina, the kidney, and the peripheral nerves

Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.

Prussian blue nano-enzyme-assisted photodynamic therapy effectively eradicates MRSA infection in diabetic mouse skin wounds

Antibiotic therapy can induce the generation of severe bacterial resistance, further challenging the usability of currently available drugs and treatment options. Therefore, it is essential to develop new strategies to effectively eradicate drug-resistant bacteria. Herein, we have reported a combinational strategy for the eradication of drug-resistant bacteria by using chlorin e6 (Ce6) loaded Prussian blue nanoparticles (PB NPs). This nanocomplex showed strong catalase activity and photodynamic properties. In vitro experiments demonstrated that CPB-Ce6 NPs effectively kill MRSA by generating ROS under laser irradiation. Meanwhile, the nano-enzyme activity of CPB NPs can decompose H2O2 in the bacterial microenvironment to upregulate the O2 level, which in turn alleviates hypoxia in the microenvironment and improves the antibacterial effect of PDT. In vivo results demonstrated that CPB-Ce6 NPs with laser irradiation effectively cleared MRSA and promoted infected wound repair in a diabetic mouse model and normal mice through upregulating VEGF. Moreover, CPB-Ce6 NPs showed excellent biosafety profiles in vitro and in vivo. From our point of view, this PDT based on PB NPs with nano-enzyme activity may provide an effective treatment for infections associated with drug-resistant microbes and tissue repair.

Editor's Choice - Quality Assessment of European Society for Vascular Surgery Clinical Practice Guidelines

OBJECTIVE

An increasing number of clinical practice guidelines (CPGs) have emerged over recent years. To have clinical utility, they need to be rigorously developed and scientifically robust. Instruments have been developed to assess the quality of clinical guideline development and reporting. The aim of this study was to evaluate CPGs from the European Society for Vascular Surgery (ESVS) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

METHODS

CPGs published by the ESVS during the period January 2011 to January 2023 were included. Two independent reviewers assessed the guidelines after receiving training in the use and application of the AGREE II instrument. Inter-reviewer reliability was assessed with the intraclass correlation coefficient. Maximum scaled scores were 100. Statistical analysis was performed using SPSS Statistics v.26.

RESULTS

Sixteen guidelines were included in the study. Good inter-reviewer score reliability was found on statistical analysis (> 0.9). The mean ± standard deviation domain scores were 68.1 ± 20.3% for scope and purpose, 57.1 ± 21.1% for stakeholder involvement, 67.8 ± 19.5% for rigour of development, 78.1 ± 20.6% for clarity of presentation, 50.3 ± 15.4% for applicability, 77.6 ± 17.6% for editorial independence, and 69.8 ± 20.1% for overall quality. Stakeholder involvement and applicability have improved in quality over time but are still the lowest scoring domains.

CONCLUSION

Most ESVS clinical guidelines are of high quality and reporting. There is scope for improvement, specifically by addressing the domains of stakeholder involvement and clinical applicability.

A Novel Wound Therapy Modality: Autologous Wound Edge Dotted Full-Thickness Skin Grafting Improving Diabetic Foot Ulcer Healing

Aim

To explore the therapeutic efficacy of autologous wound edge-dotted full-thickness skin grafting in improving diabetic foot ulcer healing.

Methods

Sixty-three patients were divided into three groups: conventional wound therapy (CWT) (n = 23), platelet-rich plasma (PRP) (n = 20), and graft (n = 20). All participants were followed up for 12 weeks. The therapeutic efficacy of the three different wound treatment modalities was analyzed.

Results

After follow-up, 37 (58.7%) patients showed complete wound re-epithelialization, of which 10 (43.5%) occurred in the CWT group, 14 (70.0%) in the PRP group, and 13 (65.0%) in the graft group. Multivariate Cox analysis showed that the independent predictive factors for ulcer healing were different treatment modalities (graft: HR = 3.214, 95% CI=1.300-7.945, P < 0.05; platelet-rich plasma: HR = 3.075, 95% CI=1.320-7.161, P < 0.01), ABI (HR = 9.917, 95% CI=2.675-36.760, P < 0.01), and TcPO2 (HR = 1.040; 95% CI=1.005-1.076; P < 0.05). Stratified analysis showed that higher ABI in graft group or PRP group had higher wound healing rate (graft group: HR = 3.748, 95% CI=1.210-11.607, P < 0.05; PRP group: HR = 5.029, 95% CI=1.743-14.509, P < 0.05); higher TcPO2 in the graft group had higher wound healing rate (HR = 15.805, 95% CI=4.414-56.594, P < 0.01). Additionally, the wound healing time (P < 0.0167) and cumulative healing rate (P < 0.05) in both the PRP group and graft group were more advantageous. The graft group promotes wound re-epithelialization earlier and faster than in the CWT group and PRP group (P < 0.05). Meanwhile, the graft group had lower medical costs (P < 0.0167).

Conclusion

Autologous wound edge dotted full-thickness skin grafting has a higher cost-performance ratio than traditional diabetic foot ulcer wound care and is worthy of further clinical application.

Effects of nutrition intervention on the rehabilitation level and quality of life of patients with diabetes foot: Image observation based on image recognition technology

Today, the application of CT scanning technology is still limited. Therefore, an image observation method based on image recognition technology is proposed in this paper to study the impact of nutritional intervention on the rehabilitation level and quality of life of diabetic foot patients. Firstly, in view of the noise problems existing in CT images, this paper adopts the denoising technology, in which Gaussian noise and salt and pepper noise denoising algorithms are mainly used. Noise interference in the image can be removed by denoising processing, and the clarity and quality of the image can be improved. Subsequently, in order to improve the recognition and classification accuracy of the image, data enhancement and data standardization techniques are adopted to normalize the pixel values of the image, so as to make different images comparable, so as to improve the stability and classification accuracy of the model. Finally, CNN model is used to study image classification. The effects of nutritional intervention on the rehabilitation level and quality of life of patients with diabetic foot were investigated by setting up a comparative experiment. The results showed that nutrition intervention nursing can effectively improve the rehabilitation level of diabetic foot patients, improve the quality of life, improve nursing satisfaction.

STrain Analysis and Mapping of the Plantar Surface (STAMPS): A novel technique of plantar load analysis during gait

Diabetic foot ulceration is driven by peripheral neuropathy, resulting in abnormal foot biomechanics and elevated plantar load. Plantar load comprises normal pressure and tangential shear stress. Currently, there are no in-shoe devices measuring both components of plantar load. The STAMPS (STrain Analysis and Mapping of the Plantar Surface) system was developed to address this and utilises digital image correlation (DIC) to determine the strain sustained by a plastically deformable insole, providing an assessment of plantar load at the foot-surface interface during gait. STAMPS was developed as a multi-layered insole, comprising a deformable mid-layer, onto which a stochastic speckle pattern film is applied. A custom-built imaging platform is used to obtain high resolution pre- and post-walking images. Images are imported into commercially available DIC software (GOM Correlate, 2020) to obtain pointwise strain data. The strain and displacement data are exported and post-processed with custom analysis routines (MATLAB, Mathworks Inc.), to obtain the resultant global and regional peak strain (SMAG), antero-posterior strain (SAP) and medio-lateral strain (SML). To validate the core technique an experimental test process used a Universal Mechanical Tester (UMT) system (UMT TriboLab, Bruker) to apply controlled vertical and tangential load regimes to the proposed multi-layer insole. A pilot study was then conducted to assess the efficacy of using the STAMPS system to measure in-shoe plantar strain in three healthy participants. Each participant walked 10 steps on the STAMPS insole using a standardised shoe. They also walked 10 m in the same shoe using a plantar pressure measurement insole (Novel Pedar®) to record peak plantar pressure (PPP) as a gold-standard comparator. The results of the experimental validation tests show that with increased normal force, at a constant shear distance, SMAG increased in a linear fashion. Furthermore, they showed that with increased shear distance, at a constant force, SMAG increased. The results of the pilot study found participant 1 demonstrated greatest SMAG in the region toes 3-5 (15.31%). The highest mean SMAG for participant 2 was at the hallux (29.31%). Participant 3 exhibited highest strain in the regions of the first and second metatarsal heads (58.85% and 41.62% respectively). Increased PPP was strongly associated with increased SMAG with a Spearman's correlation coefficient 0.673 (p < 0.0001). This study has demonstrated the efficacy of a novel method to assess plantar load across the plantar surface of the foot. Experimental testing validated the sensitivity of the method to both normal pressure and tangential shear stress. This technique was successfully incorporated into the STAMPS insole to reliably measure and quantify the cumulative degree of strain sustained by a plastically deformable insole during a period of gait, which can be used to infer plantar loading patterns. Future work will explore how these measures relate to different pathologies, such as regions at risk of diabetic foot ulceration.

Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes

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

Antibiotic-laden bone cement for diabetic foot infected wounds: A systematic review and meta-analysis

Objective

A large body of literature has demonstrated the significant efficacy of antibiotic bone cement in treating infected diabetic foot wounds, but there is less corresponding evidence-based medical evidence. Therefore, this article provides a meta-analysis of the effectiveness of antibiotic bone cement in treating infected diabetic foot wounds to provide a reference basis for clinical treatment.

Methods

PubMed, Embase, Cochrane library, Scoup, China Knowledge Network (CNKI), Wanfang database, and the ClinicalTrials.gov were searched, and the search time was from the establishment of the database to October 2022, and two investigators independently. Two investigators independently screened eligible studies, evaluated the quality of the literature using the Cochrane Evaluation Manual, and performed statistical analysis of the data using RevMan 5.3 software.

Results

A total of nine randomized controlled studies (n=532) were included and, compared with the control group, antibiotic bone cement treatment reduced the time to wound healing (MD=-7.30 95% CI [-10.38, -4.23]), length of hospital stay (MD=-6.32, 95% CI [-10.15, -2.48]), time to bacterial conversion of the wound (MD=-5.15, 95% CI [-7.15,-2.19]), and the number of procedures (MD=-2.35, 95% CI [-3.68, -1.02]).

Conclusion

Antibiotic bone cement has significant advantages over traditional treatment of diabetic foot wound infection and is worthy of clinical promotion and application.

Systematic review registration

PROSPERO identifier, CDR 362293.

The impact of diabetic nephropathy and severe diabetic retinopathy on chronic limb threatening ischemia risk in individuals with type 1 diabetes: a nationwide, population study

Background

The prevalence, incidence and risk factors and especially the effect of diabetic nephropathy (DN) and diabetic retinopathy on the risk of chronic limb threatening ischemia (CLTI) have been sparsely studied in individuals with type 1 diabetes (T1D).

Methods

The prospective cohort study consisted of 4697 individuals with T1D from the nationwide Finnish Diabetic Nephropathy (FinnDiane) Study. Medical records were thoroughly reviewed in order to ascertain all CLTI events. The key risk factors were DN and severe diabetic retinopathy (SDR).

Findings

There were 319 events of confirmed CLTI, 102 prevalent events at baseline and 217 incident events during the follow-up of 11.9 (IQR 9.3-13.8) years. The 12-year cumulative incidence of CLTI was 4.6% (95% CI 4.0-5.3). Risk factors included presence of DN, SDR, age, duration of diabetes, HbA_1c, systolic blood pressure, triglycerides and current smoking. Sub-hazard ratios (SHRs) according to combinations of DN status and presence (+) or absence (-) of SDR were 4.8 (2.0-11.7) for normoalbuminuria/SDR+, 3.2 (1.1-9.4) for microalbuminuria/SDR-, 11.9 (5.4-26.5) for microalbuminuria/SDR+, 8.7 (3.2-23.2) for macroalbuminuria/SDR-, 15.6 (7.4-33.0) for macroalbuminuria/SDR+ and 37.9 (17.2-78.9) for kidney failure compared with individuals with normal albumin excretion rate and without SDR.

Interpretation

Diabetic nephropathy, especially kidney failure, is associated with high risk of limb threatening ischemia in individuals with T1D. The risk of CLTI increases gradually according to the severity of diabetic nephropathy. Also, diabetic retinopathy is independently and additively associated with high risk of CLTI.

Funding

This research was funded by grants from Folkhälsan Research Foundation, Academy of Finland (316664), Wilhelm and Else Stockmann Foundation, Liv och Hälsa Society, Novo Nordisk Foundation (NNF OC0013659), Finnish Foundation for Cardiovascular Research, Finnish Diabetes Research Foundation, Medical Society of Finland, Sigrid Jusélius Foundation and Helsinki University Hospital Research Funds.

Progress and Challenges of Diabetic Foot Diagnostic and Treatment

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

Diabetic Foot Care: A Screening on Primary Care Providers' Attitude and Practice in Riyadh, Saudi Arabia

Background and Objectives: Diabetic foot (DF) disease is one of the myriad complications of diabetes. Positive outcomes are expected through a multidisciplinary approach as provided by primary care providers (PCPs). This study aimed to assess the knowledge of DF and attitude of physicians in primary healthcare settings toward DF diagnosis and prevention in Saudi Arabia. Materials and Methods: This observational cross-sectional study used a self-administered questionnaire that was completed by family medicine consultants, residents, and general practitioners working in primary care settings in Riyadh. Results: Of the 152 physicians who completed the survey, (43.4%) completed more than 10 h of diabetes continuing medical education (CME) over the past three years. Most (96.1%) PCPs educate patients about foot self-inspection, and only (64.5%) perform foot inspection at every visit in high-risk diabetic foot patients. PCP knowledge about diagnosing and managing diabetic foot infection was suboptimal. Only 53.9% of participants reported performing a probe-to-bone in DF patients with open wounds. Conclusions: We identified knowledge and action gaps among PCPs. Physicians had acceptable knowledge about preventive measures. However, deficits were found regarding diagnosing and management of DF infections. We recommend addressing these knowledge gaps by incorporating DF lectures and workshops within family medicine conferences and residency programs.

The Relationship Between the Global Limb Anatomic Staging System Inframalleolar Modifier and the Outcomes of Diabetic Foot Ulcer with Peripheral Artery Disease

BACKGROUND

We aimed to investigate the relationship between the condition of the inframalleolar (IM) arteries, as assessed by the Global Limb Anatomic Staging System Inframalleolar (GLASS IM) modifier, and the outcomes of patients with diabetic foot ulcers.

METHODS

The data of 215 patients, who underwent endovascular therapy from January 2016 to May 2020 at our center, were retrospectively reviewed. Patients were divided into the P0, P1, and P2 groups according to the angiography results. The rates of ulcer healing, limb salvage, survival, and amputation-free survival were compared during the 2-year period after discharge.

RESULTS

Of the 216 affected limbs, 35 (16%) were classed as P0, 122 (57%) as P1, and 59 (27%) as P2. Compared with the P2 group, the P0 + P1 group had a higher ulcer healing rate (P = 0.001), a shorter ulcer healing time (P = 0.004), and a higher survival rate (P = 0.044). GLASS IM Modifier classification P2 was an independent predictor of nonhealing ulcers. No significant difference was observed between the P0 versus P1 groups.

CONCLUSIONS

GLASS IM modifier classification P2 is an independent risk factor for a poor outcome. GLASS IM modifier classification P0 versus P1 demonstrates similar outcomes to each other.

Efficacy and safety of topical oxygen therapy for diabetic foot ulcers: An updated systematic review and meta-analysis

To evaluate the efficacy and safety of topical oxygen therapy (TOT) in diabetic foot ulcers (DFUs), researchers systematically retrieved relevant studies from PubMed, EMBASE, Web of Science, CENTRAL and ClinicalTrials.gov. Relevant studies were searched from database inception to January 2022. Two researchers independently screened the literature, extracted data and assessed the quality of the included studies. Statistical analysis was performed in Stata 16.0. A total of seven RCTs involving 614 participants were included. Compared with the control group, the TOT group had a higher healing rate (RR = 1.63, 95% CI [1.33, 2.00]). According to descriptive analysis, TOT reduced the ulcer area and improved healing durability and quality of life. Furthermore, it had no effect on the occurrence of adverse events. However, it was unclear whether it would be able to reduce the healing time. The existing evidence suggests that TOT is effective and safe for chronic DFUs. Further studies are warranted to validate our findings.

The Effect of Foot Care Education for Patients with Diabetes on Knowledge, Self-Efficacy and Behavior: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to synthesize randomized controlled trials on the impact of foot care education on knowledge, self-efficacy and behavior in patients with diabetes. A search was made using PubMed, Web of Science, Science Direct, Google Scholar, YOK National Thesis Center and Google Scholar electronic databases for studies published between March 2003-January 2022. The search medical subject headings (MeSH) terms were diabetic foot, knowledge, self-efficacy, and behavior. Studies suitable for the systematic review and the meta-analysis met the following criteria (PICOS): target participants would be diagnosed with diabetes (population), diabetic foot education (intervention), comparison of the group receiving diabetic foot care education and routine care education, and the control group receiving only routine care education (comparison), studies evaluating the levels of knowledge, self-efficacy and behavior (outcome), randomized controlled trials (study design). Twenty-six studies were included in systematic review. Three studies for knowledge, 5 studies for behavior, 8 studies for self-efficacy were included in the meta-analysis (total sample: 2534, experiment: 1464, control: 1071). All of the studies had low reporting bias. The mean duration of educations for knowledge was 5.2 months. This duration was 4.8 months for behavior and 4.5 months for self-efficacy. In the random effect (since the homogeneity test: P < .001, this model was used), there were significantly difference in terms of knowledge (standardized mean difference (SMD): 1.656, 95% [CI]: 1.014-2.299, P < .001), and behavior (SMD: 1.045, 95% CI: 0.849-1.242, P < .001). But no difference was observed in terms of self-efficacy (SMD: 0.557, 95%CI: -0.402-1.517, P > .05). The results of a systematic review of twenty-six studies and a meta-analysis of 9 studies showed that diabetic foot education improved the level of knowledge and behavior of patients with diabetes, while not affecting their self-efficacy. Educational interventions with long-term follow-up are needed to address the growing health care needs of patients with diabetes.

Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study

Background

Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan.

Methods

This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics.

Results

During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31–0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001).

Conclusions

Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.

The Antimicrobial Effects of Bacterial Cellulose Produced by Komagataeibacter intermedius in Promoting Wound Healing in Diabetic Mice

As a conventional medical dressing, medical gauze does not adequately protect complex and hard-to-heal diabetic wounds and is likely to permit bacterial entry and infections. Therefore, it is necessary to develop novel dressings to promote wound healing in diabetic patients. Komagataeibacter intermedius was used to produce unmodified bacterial cellulose, which is rarely applied directly to diabetic wounds. The produced cellulose was evaluated for wound recovery rate, level of inflammation, epidermal histopathology, and antimicrobial activities in treated wounds. Diabetic mices' wounds treated with bacterial cellulose healed 1.63 times faster than those treated with gauze; the values for the skin indicators in bacterial cellulose treated wounds were more significant than those treated with gauze. Bacterial cellulose was more effective than gauze in promoting tissue proliferation with more complete epidermal layers and the formation of compact collagen in the histological examination. Moreover, wounds treated with bacterial cellulose alone had less water and glucose content than those treated with gauze; this led to an increase of 6.82 times in antimicrobial protection, lower levels of TNF-α and IL-6 (39.6% and 83.2%), and higher levels of IL-10 (2.07 times) than in mice wounds treated with gauze. The results show that bacterial cellulose produced using K. intermedius beneficially affects diabetic wound healing and creates a hygienic microenvironment by preventing inflammation. We suggest that bacterial cellulose can replace medical gauze as a wound dressing for diabetic patients.

Incidence, hospitalization and mortality and their changes over time in people with a first ever diabetic foot ulcer

AIMS

A diabetic foot ulcer (DFU) is a severe condition associated with morbidity and mortality. Population-based studies are rare and limited by access to reliable data. Without this data, efforts in primary prevention cannot be evaluated. Therefore, we examined the incidence and changes over time for the first DFU in people with diabetes. We also examined hospitalization and all-cause mortality and their changes over time.

METHODS

From the UK primary care CPRD GOLD database (2007-2017), we identified 129,624 people with diabetes by a prescription for insulin or a non-insulin anti-diabetic drug. DFUs were identified using Read codes and expressed as incidence rates (IRs). Changes over time were described using Poisson and logistic regression and expressed as incidence rate ratios (IRRs) and odds ratios (ORs) respectively.

RESULTS

The mean IR of first registered DFUs was 2.5 [95% CI: 2.1-2.9] per 1000 person-years for people with type 2 diabetes and 1.6 [1.3-1.9] per 1000 person-years for people with type 1. The IRs declined for people with type 2 diabetes (IRR per year: 0.97 [0.96-0.99]), while no changes were observed for people with type 1 diabetes (IRR per year: 0.96 [0.89-1.04]). Average hospitalization and 1-year mortality risk for people with type 2 diabetes were 8.2% [SD: 4.7] and 11.7% [SD: 2.2] respectively. Both declined over time (OR: 0.89 [0.84, 0.94] and 0.94 [0.89, 0.99]).

CONCLUSION

The decline in all IRs, hospitalizations and mortality in people with type 2 diabetes suggests that prevention and care of the first DFU has improved for this group in primary care in the UK.

Stem Cell-Based Therapy for Diabetic Foot Ulcers

Diabetic foot ulcer has become a worldwide clinical medical challenge as traditional treatments are not effective enough to reduce the amputation rate. Therefore, it is of great social significance to deeply study the pathogenesis and biological characteristics of the diabetic foot, explore new treatment strategies and promote their application. Stem cell-based therapy holds tremendous promise in the field of regenerative medicine, and its mechanisms include promoting angiogenesis, ameliorating neuroischemia and inflammation, and promoting collagen deposition. Studying the specific molecular mechanisms of stem cell therapy for diabetic foot has an important role and practical clinical significance in maximizing the repair properties of stem cells. In addition, effective application modalities are also crucial in order to improve the survival and viability of stem cells at the wound site. In this paper, we reviewed the specific molecular mechanisms of stem cell therapy for diabetic foot and the extended applications of stem cells in recent years, with the aim of contributing to the development of stem cell-based therapy in the repair of diabetic foot ulcers.

The Role of Early Revascularization and Biomarkers in the Management of Diabetic Foot Ulcers: A Single Center Experience

Diabetic neuropathy and Peripheral Arterial Disease (PAD) are the main etiological factors in foot ulceration. Herein, we report our experience of diabetic foot ulceration (DFU) management, with an analysis of the relationship between the rate of lower extremity amputation, in persons with infected DFU, after revascularization procedures performed to prevent major amputation. This study highlights the role of different biomarkers, showing their usefulness and potentiality in diabetic foot ulcer management, especially for the early diagnosis and therapy effectiveness monitoring. A retrospective analysis, from September 2016 to January 2021, of diabetic patients presenting diabetic foot with DFU, was performed. All patients were treated with at least one vascular procedure (endovascular, open, hybrid procedures) targeting PAD lesions. Outcomes measured were perioperative mortality and morbidity. Freedom from occlusion, primary and secondary patency, and amputation rate were registered. A total of 267 patients, with a mean age of 72.5 years, were included in the study. The major amputation rate was 6.2%, minor amputation rate was 17%. In our experience, extreme revascularization to obtain direct flow reduced the rate of amputations, with an increase in ulcer healing.

Cerium oxide nanoparticle conjugation to microRNA-146a mechanism of correction for impaired diabetic wound healing

Diabetic wounds represent a significant healthcare burden and are characterized by impaired wound healing due to increased oxidative stress and persistent inflammation. We have shown that CNP-miR146a synthesized by the conjugation of cerium oxide nanoparticles (CNP) to microRNA (miR)-146a improves diabetic wound healing. CNP are divalent metal oxides that act as free radical scavenger, while miR146a inhibits the pro-inflammatory NFκB pathway, so CNP-miR146a has a synergistic role in modulating both oxidative stress and inflammation. In this study, we define the mechanism(s) by which CNP-miR146a improves diabetic wound healing by examining immunohistochemical and gene expression analysis of markers of inflammation, oxidative stress, fibrosis, and angiogenesis. We have found that intradermal injection of CNP-miR146a increases wound collagen, enhances angiogenesis, and lowers inflammation and oxidative stress, ultimately promoting faster closure of diabetic wounds.

Plantar shear stress in the diabetic foot: A systematic review and meta-analysis

AIMS

Diabetic foot ulceration (DFU) is a multifactorial process involving undetected, repetitive trauma resulting in inflammation and tissue breakdown. Shear stress forms a major part of plantar load, the aim of this review is to determine whether elevated shear stress results in ulceration.

METHODS

A systematic review of the Ovid Medline, EMBASE, CINAHL and Cochrane library databases was performed. Studies involving patients with diabetes who underwent plantar shear stress assessment were included. The primary outcome was plantar shear stress in patients with diabetes who had a current/previous DFU compared with those with no prior ulceration. Meta-analysis was performed comparing shear stress between those with a current or previous DFU and those without, and those with diabetes and healthy controls.

RESULTS

The search strategy identified 1461 potentially relevant articles, 16 studies met the inclusion criteria, involving a total of 597 patients. Comparing shear stress between the current/previous DFU group and those without: Standardised mean difference (SMD) 0.62 (95% CI -0.01 to 1.25), in favour of greater shear stress within the DFU group, p = 0.05. Comparing shear stress between people with diabetes and healthy controls: 0.36 (95% CI -0.31 to 1.03), in favour of greater shear stress within the diabetes group, p = 0.29.

CONCLUSION

This review suggests that that patients with diabetes and a history of ulceration exhibit greater shear stress than their ulcer-free counterparts. This strengthens the premise that development of systems to measure shear stress may be helpful in DFU prediction and prevention.

Gut Microbiota and Complications of Type-2 Diabetes

The gut microbiota has been linked to the emergence of obesity, metabolic syndrome and the onset of type 2 diabetes through decreased glucose tolerance and insulin resistance. Uncontrolled diabetes can lead to serious health consequences such as impaired kidney function, blindness, stroke, myocardial infarction and lower limb amputation. Despite a variety of treatments currently available, cases of diabetes and resulting complications are on the rise. One promising new approach to diabetes focuses on modulating the gut microbiota with probiotics, prebiotics, synbiotics and fecal microbial transplantation. Differences in gut microbiota composition have been observed in preclinical animal models as well as patients with type 2 diabetes and complications such as diabetic nephropathy, diabetic retinopathy, diabetic neuropathy, cerebrovascular disease, coronary heart disease and peripheral artery disease compared to healthy controls. Severity of gut microbiota dysbiosis was associated with disease severity and restoration with probiotic administration in animal models and human patients has been associated with improvement of symptoms and disease progression. Characterizing the gut microbiota dysbiosis in different diseases and determining a causal relationship between the gut microbiota and disease can be beneficial in formulating therapeutic interventions for type 2 diabetes and associated complications. In this review, we present the most important findings regarding the role of the gut microbiota in type 2 diabetes and chronic complications as well as their underlying mechanisms.

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.

Guidelines and standards for comprehensive clinical diagnosis and interventional treatment for diabetic foot in China (Issue 7.0)

Diabetic foot (DF) is one of the most common complications of diabetes and is associated with high morbidity, disability, lethality and low cure-rate. The clinical diagnosis and treatment of DF need to be standardized. The Chinese Diabetic Foot Cell and Interventional Therapy Technology Alliance has released six editions of guidelines and standards for clinical diagnosis and interventional treatment of DF, which filled the gap in the domestic DF treatment standard and played an important role in improving the level of diagnosis and treatment in China. In line with the latest developments in diagnosis and treatment, the Alliance, along with other 89 institutions, developed and issued the new edition based on the sixth edition to help standardize the clinical diagnosis and treatment of DF in China.

Clinical foot measurements as a proxy for plantar pressure testing in people with diabetes

Background

High plantar pressures are associated with increased foot ulcer risk in people with diabetes. Identification of high plantar pressures in people with diabetes is clinically challenging due to time and cost constraints of plantar pressure testing. Factors affecting foot biomechanics, including reduced joint range of motion and foot deformity, are implicated in the development of high plantar pressures and may provide a method to clinically identify those at risk of pressure related complications. The aim of this study was to investigate the contribution of joint range of motion and foot deformity measures on plantar pressures in a community dwelling group with diabetes.

Methods

Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, weight bearing ankle dorsiflexion, hallux range of motion, lesser toe deformities and hallux abductus (HAV) scale were assessed in 136 adults with diabetes (52.2% male; mean age 68.4 years). Multivariate multiple linear regression was used to assess the effect of the four biomechanical factors plus neuropathy and body mass index on plantar pressure variables. Non-parametric bootstrapping was employed to determine the difference in plantar pressure variables for participants with two or more foot biomechanical pathologies compared to those with less than two pathologies.

Results

Almost one third (32%) of the cohort had two or more foot biomechanical pathologies. Participants with two or more foot biomechanical pathologies displayed significant increases in all barefoot plantar pressure regions (except forefoot), compared to those with less than two pathologies. No significant changes were found for the in-shoe plantar pressure variables. The regression model explains between 9.9% (95%CI: 8.4 to 11.4%) and 29.6% (95% CI: 28.2 to 31%), and between 2.5% (1.0 to 4.0%) and 43.8% (95% CI: 42.5–44.9%), of the variance in the barefoot and in-shoe plantar pressure variables respectively.

Conclusions

Participants presenting with two or more factors affecting foot biomechanics displayed higher peak pressures and pressure time integrals in all foot regions compared to those with less than two factors. The tests used in this study could help clinicians detect elevated plantar pressures in people with diabetes and present an opportunity for early preventative interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00494-4.

The role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a systematic review with meta-analysis of randomized controlled trials on limb amputation and ulcer healing

INTRODUCTION

Hyperbaric Oxygen Therapy (HBOT) is increasingly being used in the treatment of as diabetic foot ulcers (DFU). However, definitive evidence regarding its beneficial effects is still scarce. The present systematic review aims to analyse the role of HBOT in the prevention of limb amputation along with improvement of ulcer healing in patients with lower limbs DFU.

EVIDENCE ACQUISITION

Three databases were searched: PubMed, Scopus, and ISI Web of Knowledge. The search was enrolled during October 2020. Both titles and abstracts were examined by two independent reviewers. Only randomized controlled trials (RCTs) reporting a comparison between standard DFU treatment and standard treatment associated with HBOT were included. In all studies eligibility was assessed and data regarding studies characteristics, methods and considered outcomes was obtained. Odds ratio (OR) was used to evaluate amputation and complete ulcer healing rates. Percentage of ulcer reduction at two weeks was evaluated using the inverse variance method, and the values were compared using mean difference values. Meta-analysis was done using a fixed-effect model if I2 values were under 50%, and a random-effects model if not.

EVIDENCE SYNTHESIS

Eleven RCTs were included, with a total of 668 patients studied. Patients undergoing HBOT had lower risk of amputation (OR 0.53 95% CI 0.32-0.90, I2=31%). No difference was found in minor amputations (OR 0.89 95% CI 0.35-2.24, I2=69%). Regarding, healing rates, HBOT patients had greater chances of ulcer healing (OR 4,00 95% CI 1.54-10.44, I2=70%). It has also shown higher percentage of ulcer area reduction after two weeks of treatment in the HBOT group (mean difference 23.19%; 95% CI 14.86-31.52; I2=0%).

CONCLUSIONS

The present review offers evidence that adjuvant HBOT decreases risk of major amputation while promoting wound healing when combined to standard treatment in the management of DFU. These findings may have clinical relevance in a selected group of patients, yet further larger studies are still needed.

Adipose-derived stromal cells for nonhealing wounds: Emerging opportunities and challenges

Wound healing complications affect thousands of people each year, thus constituting a profound economic and medical burden. Chronic wounds are a highly complex problem that usually affects elderly patients as well as patients with comorbidities such as diabetes, cancer (surgery, radiotherapy/chemotherapy) or autoimmune diseases. Currently available methods of their treatment are not fully effective, so new solutions are constantly being sought. Cell-based therapies seem to have great potential for use in stimulating wound healing. In recent years, much effort has been focused on characterizing of adipose-derived mesenchymal stromal cells (AD-MSCs) and evaluating their clinical use in regenerative medicine and other medical fields. These cells are easily obtained in large amounts from adipose tissue and show a high proregenerative potential, mainly through paracrine activities. In this review, the process of healing acute and nonhealing (chronic) wounds is detailed, with a special attention paid to the wounds of patients with diabetes and cancer. In addition, the methods and technical aspects of AD-MSCs isolation, culture and transplantation in chronic wounds are described, and the characteristics, genetic stability and role of AD-MSCs in wound healing are also summarized. The biological properties of AD-MSCs isolated from subcutaneous and visceral adipose tissue are compared. Additionally, methods to increase their therapeutic potential as well as factors that may affect their biological functions are summarized. Finally, their therapeutic potential in the treatment of diabetic and oncological wounds is also discussed.

Diabetic foot disease: a systematic literature review of patient-reported outcome measures

PURPOSE

Diabetic foot disease is one of the most serious and expensive complications of diabetes. Patient-reported outcome measures (PROMs) analyse patients' perception of their disability, functionality and health. The goal of this work was to conduct a systematic review regarding the specific PROMs related to the evaluation of diabetic foot disease and to extract and analyse the values of their measurement properties.

METHODS

Electronic databases included were PubMed, CINAHL, Scopus, PEDro, Cochrane, SciELO and EMBASE. The search terms used were foot, diabet*, diabetic foot, questionnaire, patient-reported outcome, self-care, valid*, reliabil*. Studies whose did not satisfy the Critical Appraisals Skills Programme (CASP) Diagnostic Study Checklist were excluded. The measurement properties extracted were: Internal Consistency, Test-retest, Inter-rater and Intra-rater, Standard Error of Measurement, Minimum Detectable Measurement Difference, Content Validity, Construct Validity, Criterion Validity and Responsiveness.

RESULTS

The PROMs selected for this review were 12 questionnaires. The Diabetic foot self-care questionnaire (DFSQ-UMA) and the Questionnaire for Diabetes Related Foot Disease (Q-DFD) were the PROMs that showed the highest number of completed measurement properties.

CONCLUSION

According to the results, it is relevant to create specific questionnaires for the evaluation of diabetic foot disease. It seems appropriate to use both DFSQ-UMA and Q-DFD when assessing patients with diabetic foot disease.

Non-vascular contributing factors of diabetic foot ulcer severity in national referral hospital of Indonesia

PURPOSE

Diabetic foot ulcer (DFU) is a common chronic complication of type 2 diabetes mellitus (T2DM) in Indonesia, with a prevalence of 7.3%. However, the characteristics of these patients remain unclear. We investigated the characteristics of patients with DFU without peripheral arterial disease (PAD) and analyzed non-vascular factors related to severity of DFU in a tertiary care national referral hospital in Indonesia.

METHODS

This was a cross-sectional study including 123 hemodynamically stable DFU patients without PAD recruited from Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia from 2010-2015.

RESULTS

DFU patients were predominantly over 50 years old (75.6%) and diagnosed with T2DM for 5 years with poor glycemic control (82.7%) and peripheral neuropathy (91.3%). Most patients had anemia (86.7%), leukocytosis (84.6%), and were undernourished, as characterized by a low lipid profile (90.8%) and hypoalbuminemia (83.7%). Most had extensive size of ulcer at the initial visit, with a median size of 16.23 (2.92-60.16) cm2. Ulcers were mostly located of the forefoot (62.5%) and were caused by mechanical trauma (46.2%). Bivariate analysis revealed that significant factors for the development of DFU were related to DFU size, including duration of T2DM (p = 0.04), leukocyte levels (p =  < 0.01), and thrombocyte levels (p =  < 0.01). Multivariate analysis showed leucocyte (p = 0.03) and thrombocyte (p = 0.023) had significantly correlated with DFU severity.

CONCLUSION

Leucocyte and thrombocyte may be the greatest contributing non-vascular factors for severity of DFU in Indonesia.

[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

Application and Clinical Effectiveness of Antibiotic-Loaded Bone Cement to Promote Soft Tissue Granulation in the Treatment of Neuropathic Diabetic Foot Ulcers Complicated by Osteomyelitis: A Randomized Controlled Trial

This study explored the clinical effectiveness of antibiotic-loaded bone cement on primary treatment of diabetic foot infection. This is a randomized controlled study, including thirty-six patients with diabetic foot ulcer complicated by osteomyelitis who had undergone treatment between May 2018 and December 2019. Patients were randomly divided into control group (group A) and study group (group B). Patients in the intervention group received antibiotic-loaded bone cement repair as primary treatment, while patients in the control group received conventional vacuum sealing draining treatment. Clinical endpoints were assessed and compared between the two groups, including wound healing time, wound bacterial conversion, NRS pain score, number of wound dressing changes, and average hospitalization time. All patients were followed up for a period of 12 months after discharge. Results show that compared with the control group, patients in the study group had significant difference in the number of patients for baseline pathogens eradication, short NRS pain score, hospital length of stay and cost, wound surface reduction, healing time, low rate of complications, and infection recurrence. Based on the findings, we conclude that antibiotic-loaded bone cement can be used for treatment of wound in patient with diabetic foot infection. It can help to control wound infections, shorten hospital length of stay, reduce medical cost, and relieve both doctors' and patients' burden. The application of antibiotic-loaded bone cement is suitable for diabetic wound with soft tissue infection or osteomyelitis.

PREVALENCE OF HEARING SYMPTOMS RELATED TO PATULOUS EUSTACHIAN TUBE AFTER BARIATRIC SURGERY

Background:

Rapid and severe weight loss can result in the reduction of the ear tube lining fat tissue and it becomes patent, leading to symptoms such as autophony, aural fullness and tinnitus. Patients after bariatric surgery have, in theory, a predisposition to the development of such alteration.

Aim:

To evaluate the presence of patent tuba-related complaints in patients undergoing bariatric surgery, correlating with weight and body mass index (BMI) values, as well as demographic data.

Methods:

Cross-sectional study composed of the evaluation of patients undergoing bariatric surgery through a standardized questionnaire about the presence of symptoms compatible with ear tube patency.

Results:

Eighty patients were evaluated, 77 female and three males. The main comorbidity was systemic arterial hypertension (37.5%). Fifteen (18.75%) presented symptoms compatible with patent auditory/Eustachian tube - aural fullness and autophony - postoperatively. In symptomatic individuals the initial weight was 112 kg on average and the preoperative BMI was 45 kg/m², while in asymptomatic individuals the weight was 117 kg and BMI 47 kg/m². There was statistical significance in the comparison between individuals with and without symptoms in the variables of initial weight (p=0.00000), current weight (p=0.00029), preoperative BMI (p=0.00219) and postoperative BMI (p=0.00148).

Conclusion:

The presence of symptoms compatible with patent auditory/Eustachian tube was 18.75% of the patients submitted to bariatric surgery in the evaluated sample. Both preoperative weight and BMI were lower in symptomatic patients when compared with the asymptomatic group.

Below-the-Knee Intervention for Ischemic Diabetic Foot in Kurdistan, Iraq: A Case-Control Study

BACKGROUND

Management of the ischemic diabetic foot (DF) due to infrapopliteal arterial disease is challenging and controversial. Observation, bypass surgery, and endovascular intervention are the 3 available options. Outcome of percutaneous transluminal angioplasty (PTA) versus conservative therapy is evaluated in this prospective study from Sulaymaniyah, Iraq.

METHODS

Over 2 years starting at January 2018, 40 patients with ischemic DF underwent PTA and compared with a control group (n = 78) of ischemic DF managed conservatively. Besides clinical assessment, all patients underwent Doppler ultrasonography and computed tomography angiography while conventional angiography was reserved for PTA group. Patients who fulfilled the standard angiographic findings underwent standard PTA, and their outcome was compared with the control group.

RESULTS

Mean age was 64 years; 70% (n = 28) were men with a male: female ratio of 2.3: 1. Renal function was impaired in (n = 11, 27.5%), and 7 (17.5%) patients were smokers. The commonest clinical presentation was nonhealing ulcers (n = 39, 97.5%), and most patients (n = 39, 97.5%) had Fontaine IV and Rutherford V-VI grades. Most lesions were anatomically complex; Trans-Atlantic Inter-Society Consensus C and D types, Graziani class ≥4 (75%), long segment (n = 28, 70%), and chronic total occlusion (n = 26, 65%). Success rate was (n = 38, 95%), and no patient died. Ulcer healing was higher (67.5% vs. 34.6%), and ulcer recurrence was lower (20% vs. 47.4%) in PTA group but amputation rate was not significantly different (12.5% vs. 12.8%) (P < 0.05).

CONCLUSIONS

Although amputation and death rates were not significantly different, endovascular intervention achieved better ulcer healing in ischemic DF compared with the conservative approach.

EFFECTS OF PROBIOTICS SUPPLEMENTATION ON SKIN WOUND HEALING IN DIABETIC RATS

Background:

Chronic wounds in patients with Diabetes Mellitus often become incurable due to prolonged and excessive production of inflammatory cytokines. The use of probiotics modifies the intestinal microbiota and modulates inflammatory reactions.

Aim:

To evaluate the influence of perioperative supplementation with probiotics in the cutaneous healing process in diabetic rats.

Methods:

Forty-six rats were divided into four groups (C3, P3, C10, P10) according to the treatment (P=probiotic or C=control, both orally administered) and day of euthanasia, 3^rd or 10^th postoperative days. All rats were induced to Diabetes Mellitus 72 h before starting the experiment with alloxan. Supplementation was initiated five days before the incision and maintained until euthanasia. Scalpel incision was guided by a 2x2 cm mold and the wounds were left to heal per second-intention. The wounds were digitally measured. Collagen densitometry was done with Picrosirius Red staining. Histological parameters were analyzed by staining by H&E.

Results:

The contraction of the wound was faster in the P10 group which resulted in a smaller scar area (p=0.011). There was an increase in type I collagen deposition from the 3^rd to the 10^th postoperative day in the probiotic groups (p=0.016), which did not occur in the control group (p=0.487). The histological analysis showed a better degree of healing in the P10 group (p=0.005), with fewer polymorphonuclear (p<0.001) and more neovessels (p=0.001).

Conclusions:

Perioperative supplementation of probiotics stimulates skin wound healing in diabetic rats, possibly due to attenuation of the inflammatory response and increased neovascularization and type I collagen deposition.

Diabetic Foot. Part 1: Ulcers and Infections

Diabetes is a systemic disease that has achieved epidemic proportions in modern society. Ulcers and infections are common complications in the feet of patients with advanced stages of the disease, and are the main cause of amputation of the lower limb. Peripheral neuropathy is the primary cause of loss of the protective sensation of the feet and frequently leads to plantar pressure ulcers and osteoarticular disruption, which in turn develops into Charcot neuropathy (CN). Common co-factors that add to the morbidity of the disease and the risk of amputation in this population are obesity, peripheral arterial disease, immune and metabolic disorders. Orthopedic surgeons must be aware that the early detection and prevention of these comorbidities, through diligent medical care and patient education, can avoid these amputations.

Diabetic Foot. Part 2: Charcot Neuroarthropathy

Charcot neuroarthropathy (CN) is an unfortunate and common complication of patients with diabetes, most likely resulting from a lack of proper understanding of the disease, which leads to late diagnosis. It is commonly misdiagnosed as infection and treated with antibiotics and a frustrated attempt of surgical drainage, which will reveal only debris of the osteoarticular destruction. Proper education of diabetic patients and of the health care professionals involved in their treatment is essential for the recognition of the initial signs of CN. The general orthopedic surgeon is usually the first to treat these patients in the early stages of the disease and must be aware of the signs of CN in order to establish an accurate diagnosis and ensure proper treatment. In theory, this would make it possible to decrease the morbidity of this condition, as long as proper treatment is instituted early.

A Methodological Assessment of Diabetic Foot Syndrome Clinical Practice Guidelines

OBJECTIVE

Diabetic foot syndrome (DFS) contributes to significant morbidity in diabetic patients. Diagnostic and therapeutic approaches to DFS may be summarised in clinical practice guidelines (CPGs) to aid clinical practice but may only benefit patients if the CPG is of high quality. This study determines the methodological quality of DFS CPGs using a validated assessment tool to identify CPGs adequate for use in clinical practice.

METHODS

Medline, EMBASE, and CPG databases were searched to 31 May 2019. Reference lists were also searched. Full text English evidence based DFS CPGs were included. CPGs based on expert consensus, guideline summaries, or those only available if purchased were excluded. Four reviewers independently assessed methodological quality using the Appraisal of Guidelines for Research and Evaluation II instrument. An overall guideline assessment scaled score of ≥80% was considered to be of adequate quality to recommend use.

RESULTS

Sixteen CPGs were identified. Good inter-reviewer reliability (ICC 0.985, 95% CI 0.980-0.989) was achieved. Poor scores were noted in domains 2 (stakeholder involvement), 5 (applicability), and 6 (editorial independence). Significant methodological heterogeneity was observed in all domains with the most noted in domain 6 (mean scaled score 43.2 ± 32.1%). Four CPGs achieved overall assessment scores of ≥80%.

CONCLUSION

Four CPGs were considered to be adequate for clinical practice based on methodological quality. However, elements of methodological quality were still lacking, and all CPGs had areas for improvement, potentially through increased multidisciplinary team involvement and trial application of recommendations. Methodological rigour may be improved using structured approaches with validated CPG creation tools in the future. Future work should also assess recommendation accuracy using available validated assessment tools.