Patients with healed diabetic foot ulcer represent a cohort at highest risk for future fatal events

Analysis of factors influencing the recurrence of diabetic foot ulcers

OBJECTIVE

The aim of this study is to investigate the factors influencing the recurrence of diabetic foot ulcers (DFU) and provide guidance for reducing the recurrence rate.

METHODS

A total of 211 patients diagnosed with DFU who were hospitalized and discharged from the hospital from October 2015 to January 2020 were included as the study cohort. Participants were divided into two groups according to whether the foot ulcer recurred during the 2-year follow-up period: a recurrence group (n = 84) and a non-recurrence group (n = 127). The following data were collected and analyzed for the two groups of patients: general information, foot information, laboratory indicators, diabetes comorbidities, and complications.

RESULTS

(1) The overall recurrence rate of diabetic foot ulcers (DFU) within 2 years was 39.8%, indicating a high recurrence rate. (2) Significant differences were observed between the two patient groups in terms of BMI, HbA1c, TBIL, CRP, financial situation, foot deformity, first ulcer on the sole of the foot, previous amputation history, Wagner grade of the first ulcer, osteomyelitis, DFU duration (>60 days), lower limb vascular reconstruction, peripheral arterial disease (PAD), and diabetic peripheral neuropathy (DPN) (t = 2.455; Z = -1.988, -3.731, -3.618; χ2 = 7.88, 5.004, 3.906, 17.178, 16.237, 5.007, 24.642, 4.782, 29.334, 10.253). No significant differences were found for the other indicators. (3) Logistic regression analysis revealed that TBIL (OR = 0.886, p = 0.036) was a protective factor against ulcer recurrence. In contrast, PAD, previous amputation history, DPN, and the first ulcer on the sole of the foot (OR = 3.987, 6.758, 4.681, 2.405; p < 0.05 or p < 0.01) were identified as risk factors for ulcer recurrence.

CONCLUSION

Early screening and preventive education targeting high-risk factors such as DPN, PAD and the initial ulcer location on the sole of the foot are essential to mitigate the high long-term recurrence rate of DFU. Furthermore, the protective role of TBIL in preventing ulcer recurrence underscores the importance of monitoring bilirubin levels as part of a comprehensive management strategy for DFU patients.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Independent association of history of diabetic foot with all-cause mortality in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study

BACKGROUND

Foot ulcers and/or infections are common long-term complications of diabetes and are associated with increased mortality, especially from cardiovascular disease, though only a few studies have investigated the independent contribution of these events to risk of death. This study aimed at assessing the association of history of diabetic foot with all-cause mortality in individuals with type 2 diabetes, independent of cardiovascular risk factors, other complications, and comorbidities.

METHODS

This prospective cohort study enrolled 15,773 Caucasian patients in 19 Italian centers in the years 2006-2008. Prior lower extremity, coronary, and cerebrovascular events and major comorbidities were ascertained by medical records, diabetic retinopathy by fundoscopy, diabetic kidney disease by albuminuria and estimated glomerular filtration rate, cardiovascular risk factors by standard methods. All-cause mortality was retrieved for 15,656 patients on 31 October 2015.

RESULTS

At baseline, 892 patients (5.7%) had a history of diabetic foot, including ulcer/gangrene and/or amputation (n = 565; 3.58%), with (n = 126; 0.80%) or without (n = 439; 2.78%) lower limb revascularization, and revascularization alone (n = 330; 2.09%). History of diabetic foot was associated with all-cause death over a 7.42-year follow-up (adjusted hazard ratio, 1.502 [95% confidence interval, 1.346-1.676], p < 0.0001), independent of confounders, among which age, male sex, smoking, hemoglobin A1c, current treatments, other complications, comorbidities and, inversely, physical activity level and total and HDL cholesterol were correlated independently with mortality. Both ulcer/gangrene and amputation alone were independently associated with death, with a higher strength of association for amputation than for ulcer/gangrene (1.874 [1.144-3.070], p = 0.013 vs. 1.567 [1.353-1.814], p < 0.0001). Both ulcer/gangrene/amputation and lower limb revascularization alone were independently associated with death; mortality risk was much higher for ulcer/gangrene/amputation than for revascularization (1.641 [1.420-1.895], p < 0.0001 vs. 1.229 [1.024-1.475], p = 0.018) and further increased only slightly for combined ulcer/gangrene/amputation and revascularization (1.733 [1.368-2.196], p < 0.0001).

CONCLUSIONS

In patients with type 2 diabetes, an history of diabetic foot event, including ulcer/gangrene, amputation, and lower limb revascularization, was associated with a ~ 50% increased risk of subsequent death, independent of cardiovascular risk factors, other complications and severe comorbidities, which were also significantly associated with mortality. The association with mortality was greatest for amputation, whereas that for revascularization alone was relatively modest.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00715481, retrospectively registered 15 July, 2008.

Pilot Study on the Relationship between Malnutrition and Grip Strength with Prognosis in Diabetic Foot

Sarcopenia and malnutrition have been associated in the elderly population with a poor prognosis in wound healing and with other adverse events, such as institutionalization or functional impairment. However, it is not known how these factors influence the prognosis of diabetic foot in the elderly. To answer this question, a prospective observational study of 45 patients over 65 years of age admitted with diagnoses of diabetic foot in a tertiary hospital has been conducted. All patients were assessed at admission and at 3 months after returning home to determine quality of life, pain, mobility and healing, overall hospital stay in relation to the presence of malnutrition (measured by BMI, CIPA scale and analytical parameters at admission of serum proteins and albumin), and sarcopenia measured by grip force, among other geriatric syndromes. The results found a relationship between altered sarcopenia and more pain and poorer quality of life, and altered BMI was related to a lower cure rate and worse mobility at follow-up. This study seems to indicate that, in the elderly population with diabetic foot, malnutrition and sarcopenia should be managed at the same time as the treatment of the diabetic foot itself.

Machine learning predicts cardiovascular events in patients with diabetes: The Silesia Diabetes-Heart Project

We aimed to develop a machine learning (ML) model for predicting cardiovascular (CV) events in patients with diabetes (DM). This was a prospective, observational study where clinical data of patients with diabetes hospitalized in the diabetology center in Poland (years 2015 - 2020) were analyzed using ML. The occurrence of new CV events following discharge was collected in the follow-up time for up to 5 years and 9 months. An end-to-end ML technique which exploits the neighborhood component analysis for elaborating discriminative predictors, followed by a hybrid sampling/boosting classification algorithm, multiple logistic regression, or unsupervised hierarchical clustering was proposed. In 1735 patients with diabetes (53% female), there were 150 (8.65%) ones with a new CV event in the follow-up. Twelve most discriminative patients' parameters included coronary artery disease, heart failure, peripheral artery disease, stroke, diabetic foot disease, chronic kidney disease, eosinophil count, serum potassium level, and being treated with clopidogrel, heparin, proton pump inhibitor, and loop diuretic. Utilizing those variables resulted in the area under the receiver operating characteristic curve (AUC) ranging from 0.62 (95% Confidence Interval [CI] 0.56-0.68, p<0.01) to 0.72 (95%CI 0.66-0.77, p<0.01) across five non-overlapping test folds, whereas multiple logistic regression correctly determined 111/150 (74.00%) high-risk patients, and 989/1585 (62.40%) low-risk patients, resulting in 1100/1735 (63.40%) correctly classified patients (AUC: 0.72, 95%CI 0.66-0.77). ML algorithms can identify patients with diabetes at a high risk of new CV events based on a small number of interpretable and easy-to-obtain patients' parameters.

Clinical Features, Inflammatory Markers, and Limb Salvage in Older Adults with Diabetes-Related Foot Infections

Little information exists about diabetic foot infections (DFIs) in older patients. We hypothesize that older patients with DFIs have different clinical features and worse outcomes than younger patients. We conducted a prospective observational study consisting of a cohort of patients with diabetes and moderate to severe DFIs. Patients included in the cohort were dichotomized into two groups using percentile 75 (P75) of age as the cut-off value. Patients aged > P75 presented with more comorbidities and foot-related complications, a higher rate of peripheral arterial disease (PAD), worse renal function (higher values of blood urea nitrogen and creatinine, and lower values of estimated glomerular filtration rate), and lower values of HbA1c compared with younger patients. Infection severity, microbiological features, and inflammatory markers were similar in both groups. In the multivariate analysis, minor amputations were associated with age > P75 (OR = 2.8, 95% CI 1.3-5.9, p <0.01), necrosis (OR = 4.2, 95% CI 1.8-10.1, p < 0.01), and CRP values (OR = 1.045, 95% CI 1.018-1.073, p < 0.01). Major amputations were associated with a history of amputation (OR = 4.7, 95% CI 1.3-16.7, p = 0.01), PAD (OR = 4.3, 95% CI 1.2-14.6, p = 0.01), and albumin values (OR = 0.344, 95% CI 0.130-0.913, p = 0.03). In conclusion, limb salvage can be achieved in older patients with diabetes-related foot infections at the same rate as in younger patients, despite the fact that they have more comorbidities and foot-related complications, a higher rate of PAD, and worse renal function.

Management patterns and outcomes of patients hospitalized with diabetic foot ulcers at one tertiary care hospital

A diabetic foot ulcer is present in approximately 2.4% of hospitalized patients. Care for diabetic foot ulcers is highly variable. We sought to describe care practice patterns and risk factors for poor outcomes for patients hospitalized with a diabetic foot ulcer in our institution, an 894-bed tertiary care academic hospital located in downtown Chicago, IL. We conducted a retrospective cohort study of patients hospitalized with a diabetic foot ulcer between March 3rd, 2018 and December 31st, 2019. We categorized patients into having an uncomplicated ulcer or a complicated ulcer with cellulitis, wound infection, osteomyelitis, or gangrene. We evaluated rates of diagnostic resource utilization (imaging, cultures, biopsies, and antibiotics) and outcomes of osteomyelitis, amputation, and death. There were 305 patients of interest in the study cohort. A complicated lower extremity ulcer was found in 79% of patients. Amputation was required in 25% of patients, 21% were readmitted, and 13% died. Imaging was obtained in less than 50% of all patients, and in 60% or less of those with osteomyelitis. Bone biopsies were rarely acquired. Empiric antibiotics were prescribed in 77% of patients with osteomyelitis. Male, Black or African-American patients, and those with high Charlson score had the highest risk of poor outcomes. Care practices for patients hospitalized with diabetic foot ulcers were highly variable. Future interventions should target standardization to improve outcomes, with particular attention to health inequities as vulnerable populations have a higher risk of poor outcomes.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Arterial spin labeling magnetic resonance imaging quantifies tissue perfusion around foot ulcers

Objective

Tools that quantify tissue perfusion of the foot are deficient, contributing to the uncertainty in predicting ulcer healing potential. This pilot study aims to quantify peri-wound foot perfusion at various tissue depths using a novel application of pseudo-continuous arterial spin labeling magnetic resonance imaging.

Methods

Ten diabetic patients with neuropathic wounds and 20 healthy volunteers without wounds were recruited. Wounds were graded according to the Wound, Ischemia, Foot Infection (WIfI) system. All subjects underwent a noncontrasted ASL MRI of the foot for perfusion measurements. For healthy volunteers, perfusion was compared at rest and during sustained toe flexion between four regions: lateral plantar, medial plantar, lateral calcaneal, and medial calcaneal. Evaluations of diabetic volunteers compared perfusion between four zones: wound, near border, far border, and remote. Remote zone perfusion in diabetics was compared with perfusion in the plantar foot of healthy volunteers.

Results

There were 11 wounds, which were located over the metatarsal heads in five, the stump of a transmetatarsal amputation in three, the heel in two, and the mid foot in one. The median WIfI stage was 2. One patient had a WIfI ischemia grade of 1; the remaining patients' grades were 0. The mean ankle-brachial index was 1.0 ± 0.3. There were two patients with a WIfI foot infection grade of 1; the remaining patients' grades were 0. In healthy volunteers, plantar foot perfusion with sustained toe flexion was 43.9 ± 1.7 mL/100g/min and significantly higher than perfusion at rest (27.3 ± 2.7 mL/100g/min; P < .001). In diabetic patients, perfusion at the wound, near border, far border, and remote regions was 96.1 ± 10.7, 92.7 ± 9.4, 73.4 ± 8.2, and 62.8 ± 2.7 mL/100g/min. Although this perfusion pattern persisted throughout the depth of the wound, perfusion decreased with tissue depth. In the near border, perfusion at 20% of the wound depth was 124.0 ± 35.6 mL/100g/min and 69.9 ± 10.1 mL/100g/min at 100% (P = .006). Lastly, remote perfusion in diabetics was 2.3 times the plantar perfusion in healthy volunteers (27.3 ± 2.7 mL/100g/min; P < .001).

Conclusions

The pattern of resting tissue perfusion around nonischemic diabetic foot ulcers was successfully quantified with arterial spin labeling magnetic resonance imaging. Diabetic patients with wounds were hyperemic compared with healthy volunteers. There was a 1.5-fold increase in peri-wound tissue perfusion relative to the rest of the foot. This study is the first step in developing a tool to assess the perfusion deficit in ischemic wounds.

A Review on Newer Interventions for the Prevention of Diabetic Foot Disease

Diabetic foot disease (DFD), which includes ulcers on the foot, infections, and gangrene of the foot, is one of the leading causes of disability worldwide. About half of diabetic foot disease (DFD) patients have a recurrence in less than a year. To alleviate the burden of DFD globally, it is essential to give long-term medication to reduce the likelihood of recurrence. The effectiveness of telemedicine, wearable technologies, and sensors in DFD prevention is discussed in this review. Offloading footwear helps to cure and prevent ulcerated diabetic foot by distributing physical stress away from bony prominences. Sensors and wearables can record the temperatures of the foot, blood pressure (BP), and blood sugar levels and estimate lipid profile. These technologies have offered a practical means of reaching individuals in rural areas with a heightened risk of developing DFD. There is less need for in-person consultations with this strategy. This methodology is simple to operate and lessens reliance on patients. The benefits of adopting these remote monitoring approaches have been demonstrated in some studies with DFD-at-risk individuals. It is required to do more analysis to ascertain the effectiveness and value of incorporating different remote monitoring systems as part of an all-encompassing strategy to prevent DFD.

Impact of time in range during hospitalization on clinical outcomes in diabetic patients with toe amputation: a propensity score matching analysis

Purpose

In recent years, time in range (TIR), defined as a percentage within a target time range, has attracted much attention. This study was aimed to investigate the short-term effects of Time in Rang on diabetic patients undergoing toe amputation in a more specific and complete manner.

Methods

A retrospective analysis on patients with diabetic foot ulcer (DFU) treated by toe amputation or foot amputation at the First Affiliated Hospital of Wenzhou Medical University between January 2015 and December 2019 were evaluated. A 1:1 match was conducted between the TIR < 70% group and the TIR ≥ 70% group using the nearest neighbor matching algorithm. Data were analyzed using Chi-squared, Fisher’s exact, and Mann–Whitney U tests.

Results

Compared with patients in the TIR ≥ 70% group, patients in the TIR < 70% had a higher rate of re-amputation, and a higher rate of postoperative infection. Multivariate analysis revealed that smoking, lower extremity arterial disease and TIR < 70% were risk factors for surgery of re-amputation. The results of subgroup analysis found that the TIR < 70% was associated with a greater risk of re-amputation in patients with HbA1c < 7.5%, lower extremity arterial disease, and non-smokers.

Conclusions

TIR can be used as a short-term glycemic control indicator in patients with DFUs and should be widely accepted in clinical practice. However, a future multicenter prospective study is needed to determine the relationship between TIR and toe re-amputation in diabetic foot patients.

Time in range in relation to amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers

AIMS

The aim of this study was to evaluate the association of time in range (TIR) with amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers (DFUs).

MATERIALS AND METHODS

A retrospective analysis was performed on 303 hospitalised patients with DFUs. During hospitalisation, TIR, mean blood glucose (MBG), coefficient of variation (CV), time above range (TAR) and time below range (TBR) of patients were determined from seven-point blood glucose profiles. Participants were grouped based on their clinical outcomes (i.e., amputation and death). Logistic regression was employed to analyse the association of TIR with amputation and all-cause mortality of inpatients with DFUs.

RESULTS

Among the 303 enrolled patients, 50 (16.5%) had undergone amputation whereas seven (2.3%) were deceased. Blood glucose was determined in 41,012 samples obtained from all participants. Patients who underwent amputation had significantly lower TIR and higher MBG, CV, level 2 TAR and level 1 TBR whereas deceased patients had significantly lower TIR and higher MBG and level 2 TAR. Both amputation and all-cause mortality rate declined with an increase in TIR quartiles. Logistic regression showed association of TIR with amputation (p = 0.034) and all-cause mortality (p = 0.013) after controlling for 15 confounders. This association was similarly significant in all-cause mortality after further adjustment for CV (p = 0.022) and level 1 TBR (p = 0.021), respectively.

CONCLUSIONS

TIR is inversely associated with amputation and all-cause mortality of hospitalised patients with DFUs. Further prospective studies are warranted to establish a causal relationship between TIR and clinical outcomes in patients with DFUs.

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

Background:

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

Objective:

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

Methods:

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

Result:

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

Conclusion:

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

The associations of statin intake and the trabecular bone score and bone mineral density status in elderly Iranian individuals: a cross-sectional analysis of the Bushehr Elderly Health (BEH) program

In recent years, a growing interest on the impact of statin intake on bone health has emerged, although the reported results are controversial. The results of this study revealed that BMD at lumbar spine has a significant association with statin intake. However, such association appears to be weaker regarding TBS values compared to BMD. This study was performed with the aim of evaluating associations of statin intake with BMD and TBS using data from 2426 individuals aged ≥ 60 years from the second phase of the Bushehr Elderly Health (BEH) program. We found a positive association between statin and BMD at lumbar spine, whereas association between statin and TBS was detected only in the men in the final model.

INTRODUCTION

In recent years, a growing interest has been established to evaluate the impact of statin intake on bone health, although the reported results are controversial. This study aimed to evaluate the association of statin intake with bone health status according to BMD and TBS.

METHODS

This cross-sectional analysis used data from the elderly Iranian individuals who participated in the Bushehr Elderly Health (BEH) program. Dual x-ray absorptiometry (DXA) device was used to evaluate the BMD at lumbar spine (L1-L4), femoral neck, and total hip, as well as TBS at lumbar spine.

RESULTS

Among 2426 (1260 women and 1166 men) study participants, 778 were statin users. A positive significant association, irrespective of sex, was observed between statin intake and BMD at L1-L4, even after controlling for potential variables in total population (β = 0.016, p = 0.013). The mean TBS values at L1-L4 were negatively associated with statin intake in total population (β =  - 0.009, p = 0.001), while in the full adjusted model, significant positive association between TBS and statin intake was detected only in men (β = 0.013, p = 0.02).

CONCLUSION

The results of this study revealed that BMD at lumbar spine has a significant association with statin intake. However, such an association appears to be weaker regarding TBS values compared to BMD.

Differences in initial versus recurrent diabetic foot ulcers at a specialized tertiary diabetic foot care center in China

Objective

To investigate the characteristics of diabetic foot ulcer (DFU) recurrence.

Methods

A total of 573 patients with DFUs were recruited and divided into an initial group (395 patients) and a recurrence group (178 patients). The factors related to recurrence were analyzed using multivariate regression.

Results

The recurrence group had longer diabetes duration (odds ratio [OR] 192; 95% confidence interval 120, 252 vs. 156; 96, 240); lower glycated hemoglobin levels (OR 8.1; 95% CI 6.8, 9.6 vs. 9.1; 7.4, 10.5), and higher rates than the initial group of amputation (37.5% vs. 2.0%), history of vascular intervention (21.3% vs. 3.9%), retinopathy (77.7% vs. 64.7%), callus (44.4% vs. 20.8%), foot deformity (51.2% vs. 24.6%), and outdoor sports shoe wearing (34.0% vs. 21.2%). Multiple factor logistic regression analysis showed that diabetes duration (OR 1.004), callus (OR 2.769), vascular intervention (OR 2.824) and amputation (OR 22.256) were independent risk factors for DFU recurrence.

Conclusion

Diabetes duration, callus, history of vascular intervention, and amputation were independent risk factors for recurrent DFUs in a cohort of Chinese patients with active DFU. The prevention and treatment of DFUs, especially callus treatment, foot care, and blood glucose control, should be improved in China.

Cumulative long-term recurrence of diabetic foot ulcers in two cohorts from centres in Germany and the Czech Republic

AIMS

Our aim was to comprehensively estimate the incidence of diabetic foot ulcer (DFU) recurrence and corresponding risk factors in two cohorts.

METHODS

Prospective data from patients with active DFU from two diabetes centres in Germany (GER, n = 222) and the Czech Republic (CZ, n = 99) were analysed. Crude cumulative incidences were obtained. Additionally, time to recurrence and risk factors were investigated using multivariate Cox models.

RESULTS

69%(154) of patients in GER and 70%(69) in CZ experienced at least one DFU recurrence; 25%(56) in DEU and 15%(15) in CZ died; 5%(11) and 9%(9) were lost to follow-up. The crude cumulative incidence in the first year was 28% in GER and 25% in CZ; 68%/70% within ten years, and 69%/70% in 15 years. In GER, renal replacement therapy was associated with shorter time to recurrence (HR = 3.71, 95%CI:1.26-10.87); no history of DFU before the index lesion with longer time to recurrence (HR = 0.62, 0.42-0.92). In CZ, type 2 diabetes (HR = 2.57, 1.18-5.62) and index ulcer treatment by minor amputation (HR = 2.11, 1.03-4.33) were associated with shorter time to recurrence.

CONCLUSIONS

Cumulative DFU recurrence was approximately 70% in 15 years in both cohorts. We found a significantly higher risk of future recurrence in patients having a consecutive ulcer compared with the first ever ulcer.

Development of Predictive Nomograms for Clinical Use to Quantify the Risk of Amputation in Patients with Diabetic Foot Ulcer

OBJECTIVE

To determine the novel proposed nomogram model accuracy in the prediction of the lower-extremity amputations (LEA) risk in diabetic foot ulcer (DFU).

METHODS AND MATERIALS

In this retrospective study, data of 125 patients with diabetic foot ulcer who met the research criteria in Zhongnan Hospital of Wuhan University from January 2015 to December 2019 were collected by filling in the clinical investigation case report form. Firstly, univariate analysis was used to find the primary predictive factors of amputation in patients with diabetic foot ulcer. Secondly, single factor and multiple factor logistic regression analysis were employed to screen the independent influencing factors of amputation introducing the primary predictive factors selected from the univariate analysis. Thirdly, the independent influencing factors were applied to build a prediction model of amputation risk in patients with diabetic foot ulcer by using R4.3; then, the nomogram was established according to the selected variables visually. Finally, the performance of the prediction model was evaluated and verified by receiver working characteristic (ROC) curve, corrected calibration curve, and clinical decision curve.

RESULTS

7 primary predictive factors were selected by univariate analysis from 21 variables, including the course of diabetes, peripheral angiopathy of diabetic (PAD), glycosylated hemoglobin A1c (HbA1c), white blood cells (WBC), albumin (ALB), blood uric acid (BUA), and fibrinogen (FIB); single factor logistic regression analysis showed that albumin was a protective factor for amputation in patients with diabetic foot ulcer, and the other six factors were risk factors. Multivariate logical regression analysis illustrated that only five factors (the course of diabetes, PAD, HbA1c, WBC, and FIB) were independent risk factors for amputation in patients with diabetic foot ulcer. According to the area under curve (AUC) of ROC was 0.876 and corrected calibration curve of the nomogram displayed good fitting ability, the model established by these 5 independent risk factors exhibited good ability to predict the risk of amputation. The decision analysis curve (DCA) indicated that the nomogram model was more practical and accurate when the risk threshold was between 6% and 91%.

CONCLUSION

Our novel proposed nomogram showed that the course of diabetes, PAD, HbA1c, WBC, and FIB are the independent risk factors of amputation in patients with DFU. This prediction model was well developed and behaved a great accurate value for LEA so as to provide a useful tool for screening LEA risk and preventing DFU from developing into amputation.

Toe gaps and their assessment in footwear for people with diabetes: a narrative review

BACKGROUND

Adequate footwear fit is critical in preventing diabetes-related foot ulcers. One important element is the toe gap, the difference between foot length and internal footwear length available to the foot. We summarised the literature on toe gaps in studies assessing footwear worn by people with diabetes, the methods used to measure both foot length and internal footwear length and identify ambiguities which may impact on toe gap assessment in clinical practice, and suggest pragmatic solutions.

METHODS

The Google Scholar database was searched to April 2020 for peer-reviewed studies using keywords related to incorrectly fitting or ill-fitting and diabetes, foot and ulcer which returned 979 results. Included studies within this narrative review encompassed toe gap measurement to assess footwear worn by people with diabetes.

RESULTS

A total of eight studies were included after full paper review. Toe gap ranges as used in assessments of footwear worn by people with diabetes vary, with a minimum of 1.0-1.6 cm and a maximum of 1.5-2.0 cm, as do methods of measuring internal footwear length. Only three published studies suggested possible measuring devices.

CONCLUSIONS

Toe gap ranged as used when assessing footwear fit in people with diabetes vary and a gold standard device for internal footwear length measurement has yet to emerge. International guidelines provide welcome standardisation, but further research is needed to evaluate both the effect of toe gap ranges upon pressure, plantar stress response and ulceration and available measuring devices to facilitate development of toe gap measurement protocols that may further enhance consistency in practical assessments.

Angiopoietin-like 2 is a potential biomarker for diabetic foot patients

BACKGROUND

Circulating angiopoietin-like 2 (ANGPTL2) protein levels are known to be significantly increased in numerous chronic inflammatory diseases and are associated with the diagnosis and/or prognosis of cardiovascular diseases, diabetes, chronic kidney disease, and various types of cancers. However, no data regarding the relationship between ANGPTL2 and diabetic foot ulcers (DFUs) are available. Here, we explored the potential link between ANGPTL2 and DFUs.

METHODS

A total of 68 participants with type 2 diabetes mellitus (T2DM) were recruited, including 28 patients with DFU and 40 diabetic patients without DFUs. The clinical characteristics of T2DM patients with and without DFUs were compared. Serum concentrations of ANGPTL2 and VEGF were measured using enzyme-linked immunosorbent assay (ELISA) kits. The correlations between ANGPTL2 and clinical variables were analyzed. Multiple linear regression and logistic regression models were constructed to test the associations between ANGPTL2 and the severity and presence of DFUs.

RESULTS

Serum levels of ANGPTL2 were higher in patients with DFUs than those in diabetic controls. Serum ANGPTL2 levels were higher in the advanced stages of DFUs. Spearman correlation analysis revealed strong positive associations of ANGPTL2 with CRP, VEGF and ESR in all subjects. In addition, serum ANGPTL2 was still positively correlated with DFUs stage after adjusting the risk factors. After adjusting for age, sex, HbA1C and duration of diabetes, ANGPTL2 was found to be independently associated with the presence of DFUs.

CONCLUSIONS

Circulating ANGPTL2 levels are an independent risk factor for DFUs. This suggests that ANGPTL2 may play important roles in the development of DFUs, a possibility that needs to investigated in prospective studies.

Comparison of Mortality Rate and Severity of Pulmonary Involvement in Coronavirus Disease-2019 Adult Patients With and Without Type 2 Diabetes: A Cohort Study

OBJECTIVES

Patients with diabetes are potentially at higher risk of mortality due to coronavirus disease-2019 (COVID-19). In this study, we aimed to compare the outcomes and severity of pulmonary involvement in COVID-19 patients with and without diabetes.

METHODS

In this cohort study, we recruited patients with diabetes who were hospitalized due to COVID-19 during the period from February 2020 to May 2020. Hospitalized individuals without diabetes were enrolled as control subjects. All patients were followed for 90 days and clinical findings and patients' outcomes were reported.

RESULTS

Over a period of 4 months, 127 patients with diabetes and 127 individuals without diabetes with a diagnosis of COVID-19 were recruited. Their mean age was 65.70±12.51 years. Mortality was higher in the group with diabetes (22.8% vs 15.0%; p=0.109), although not significantly. More severe pulmonary involvement (p=0.015), extended hospital stay (p<0.001) and greater need for invasive ventilation (p=0.029) were reported in this population. Stepwise logistic regression revealed that diabetes was not independently associated with mortality (p=0.092). Older age (odds ratio [OR], 1.054; p=0.003), aggravated pulmonary involvement on admission (OR, 1.149; p=0.001), presence of comorbidities (OR, 1.290; p=0.020) and hypothyroidism (OR, 6.576; p=0.021) were associated with mortality. Diabetic foot infection had a strong positive correlation with mortality (OR, 49.819; p=0.016), whereas insulin therapy had a negative correlation (OR, 0.242; p=0.045).

CONCLUSIONS

The mortality rate due to COVID-19 did not differ significantly between patients with or without diabetes. Older age, macrovascular complications and presence of comorbidities could increase mortality in people with diabetes. Insulin therapy during hospitalization could attenuate the detrimental effects of hyperglycemia and improve prognosis of patients with COVID-19 and diabetes.

Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

Armstrong D. The Potential Role of Sensors, Wearables and Telehealth in the Remote Management of Diabetes-Related Foot Disease

Diabetes-related foot disease (DFD), which includes foot ulcers, infection and gangrene, is a leading cause of the global disability burden. About half of people who develop DFD experience a recurrence within one year. Long-term medical management to reduce the risk of recurrence is therefore important to reduce the global DFD burden. This review describes research assessing the value of sensors, wearables and telehealth in preventing DFD. Sensors and wearables have been developed to monitor foot temperature, plantar pressures, glucose, blood pressure and lipids. The monitoring of these risk factors along with telehealth consultations has promise as a method for remotely managing people who are at risk of DFD. This approach can potentially avoid or reduce the need for face-to-face consultations. Home foot temperature monitoring, continuous glucose monitoring and telehealth consultations are the approaches for which the most highly developed and user-friendly technology has been developed. A number of clinical studies in people at risk of DFD have demonstrated benefits when using one of these remote monitoring methods. Further development and evidence are needed for some of the other approaches, such as home plantar pressure and footwear adherence monitoring. As yet, no composite remote management program incorporating remote monitoring and the management of all the key risk factors for DFD has been developed and implemented. Further research assessing the feasibility and value of combining these remote monitoring approaches as a holistic way of preventing DFD is needed.

Evaluation of mortality risk factors in diabetic foot infections

Identifying risk factors for mortality is crucial in the management of diabetic foot syndrome. We aimed to evaluate risk factors for mortality in patients with diabetic foot infection (DFI). A retrospective chart review was conducted on 401 patients from 2010 through 2019. Our primary endpoint was in-hospital mortality. Patients were divided into two groups according to the outcome (survival or death). Clinical data were compared between the two groups statistically. A total of 401 patients were enrolled in the study, 280 (69.8%) of them were male and the mean age was 59.6 ± 11.1 years. The mean follow-up period was 23.7 ± 22.9 months. In-hospital mortality rate was 3%. Univariate analysis indicated that ischaemic wound (P = .023), hindfoot infection (P = .038), whole foot infection (P = .010), peripheral arterial disease (P = .024), high leucocyte levels (>12 040 K/μL) (P = .001), high thrombocyte levels (>378 000 K/μL) (P < 0.001), high C-reactive protein levels (>8.81 mg/dL) (P = .022), and polymicrobial growth in deep tissue culture (P = .041) were significant parameters in predicting mortality. In multivariate analysis, peripheral arterial disease (odds ratio [OR]: 13.430, 95% confidence interval [Cl]: 1.129-59.692; P = .040), high thrombocyte levels (OR: 1.000, 95% Cl: 1.000-1.000; P = .022), and polymicrobial growth in deep tissue culture (OR: 7.790, 95% Cl: 1.592-38.118; P = .011) were independent risk factors for mortality. In conclusion, peripheral arterial disease, high thrombocyte levels, and polymicrobial growth in deep tissue culture were independent risk factors for mortality in DFI.