Management of the Diabetic Foot

Comparative Efficacy of Regenerative Therapies for Diabetic Foot Ulcers: A Network Meta-analysis

BACKGROUND

Diabetic foot ulcer (DFU) is one of the most dreaded complications of diabetes mellitus and is associated with a high risk of lower limb amputation and mortality. Because the efficacy of conventional treatments for DFUs is often limited, regenerative medicine therapy, such as growth factors and stem cells, may provide a solution to chronic wound healing. In this study, we compared several kinds of regenerative therapy for treating DFUs in terms of efficacy.

METHODS

We systemically searched relevant studies on PubMed, Cochrane Library, and EMBASE. Randomized clinical trials on conventional treatment combined with platelet-rich plasma (PRP), epidermal growth factor (EGF), or stem cell therapy, compared with conventional treatment alone in patients with DFUs, were included in this study.

RESULTS

A total of 1454 patients from 23 randomized controlled trials (RCTs) were included in the network meta-analysis. In terms of the number of completely healed ulcers, no significant difference was noted between PRP, stem cell therapy, and EGF group. We also performed surface under the cumulative ranking curve analyses to predict the rank of each intervention by the number of completely healed ulcers. The predicted ranking was as follows: stem cell, PRP, EGF, and the control group (conventional treatment alone). Furthermore, when we compared the mean of the wound healing time of DFUs among these four interventions, we found that the PRP group achieved significantly earlier ulcer healing than the stem cell, EGF, and control groups. No significant difference was observed in the time needed for wound healing between the stem cell and EGF groups. Funnel plot analysis demonstrated no publication bias.

CONCLUSIONS

PRP combined with conventional treatment significantly accelerates wound healing for DFUs. The mean wound healing time was similar between the stem cell and EGF groups. However, additional reviews of rigorous, large, well-designed RCTs are warranted for further validation of our findings.

The effects of immune cell phenotypes and plasma metabolomes on diabetic foot ulcer: a Mendelian randomization study and mediation analysis

This study investigates the causal relationships between plasma metabolites, immune cell phenotypes, and diabetic foot ulcer (DFU). A Mendelian randomization (MR) study was conducted, which included 731 immune cell phenotypes, 1400 metabolites, and DFU. The primary analytical approach was the inverse variance-weighted method. Sensitivity analyses were performed to assess heterogeneity and pleiotropy, and MR analyses in the reverse direction were conducted to examine the possibility of reverse causation. In addition, a mediation analysis was performed to reveal how metabolites mediate the impact of immune cells on DFU. Through MR, reverse MR and sensitivity analysis, the casualty was found in 17 immune cell phenotypes and 18 metabolites. A total of 15 mediating relationships were identified through mediation analysis, including 9 metabolites and 10 immune cell phenotypes. Among them, the highest mediation proportion was citrulline levels mediating CD24+ CD27+ AC (absolute count, B cell panel) to DFU, with a proportion of 11.60%. In conclusion, the study identified causal relationships between 10 immune cell phenotypes mediated by 9 metabolites. These discoveries offered fresh perspectives on the processes behind DFU and laid the groundwork for subsequent studies to create specific treatments for DFU.

Assessment of the diabetic foot in inpatients

Diabetic foot disease is a severe complication of diabetes, leading to significant morbidity and lower limb amputations. This review explores the pathophysiology of diabetic foot disease, highlighting the roles of peripheral neuropathy, peripheral arterial disease and immunosuppression in the development of foot ulcers and infections. Key intrinsic and extrinsic risk factors, including long-standing diabetes, poor glycaemic control, inappropriate footwear and trauma are discussed. The importance of comprehensive diabetic foot assessments using diagnostic tools such as the Ipswich Touch Test and Doppler studies is emphasised for early detection and management. Challenges such as delays in referral to specialist care, limited access to multidisciplinary foot teams, and staffing shortages are identified as critical barriers to effective care. The review builds upon extant literature by integrating the most recent evidence, including the 2023 guidelines from the International Working Group on the Diabetic Foot. It emphasises practical application, detailed referral pathways and multidisciplinary care strategies, offering updated tools and insights to improve clinical outcomes and address the often overlooked aspects within inpatient services. Future directions encompass advances in imaging, telemedicine and patient education, which may further optimise preventive and therapeutic strategies for diabetic foot disease.

Adherence Monitor for Measurement of Removable Cast Walker Wear-Time: Multiple Sensors and Predictive Analytics Improve Accuracy

BACKGROUND

Treatment of diabetes and its complications is a primary health care expense. Up to 25% of people with diabetes will develop diabetic foot ulcers (DFUs). Removable cast walker (RCW) boots commonly prescribed for DFU treatment, promote healing, and provide offloading and wound protection. Patient RCW removal for hygiene and wound care can lead to decreased adherence and treatment effectiveness. This study evaluated a new system for wear-time adherence measurement using multiple sensor types.

METHODS

An electronic wear-time monitor was developed, which included internal and external temperature sensors, an accelerometer, and capacitive proximity foot and ankle sensors. Time-stamped and date-stamped data were saved once per minute for up to 22 days. Ten healthy volunteer subjects were recruited to wear an RCW for two weeks while keeping a diary of don/doff times. Sensor data were then compared with volunteers' wear diaries using confusion matrix predictive analytics.

RESULTS

Algorithms were developed for data processing. Correlation coefficients between algorithms and diaries were calculated for individual and multiple sensor combinations. Differential temperature and accelerometer algorithms were significantly better at predicting subject wear-time than individual temperature sensor algorithms (P = .009, P = .001, respectively). Foot proximity had significantly better correlation with subject diaries than temperature (P = .024), and acceleration algorithms (P = .005). Multi-sensor analysis showed high correlation (.96) with wear-time from subject diaries.

CONCLUSIONS

Removable cast walker wear-time can be accurately determined using an electronic data recorder and multiple sensors. Wear-time measurement accuracy can be improved using algorithms that operate on data from multiple sensors that use a variety of sensor technologies.

Application of 3D printing in the treatment of diabetic foot ulcers: current status and new insights

Background and Aims

Diabetic foot ulcers (DFUs) are a serious complication of diabetes mellitus (DM), affecting around 25% of individuals with DM. Primary treatment of a DFU involves wound off-loading, surgical debridement, dressings to provide a moist wound environment, vascular assessment, and appropriate antibiotics through a multidisciplinary approach. Three-dimensional (3D) printing technology is considered an innovative tool for the management of DFUs. The utilization of 3D printing technology in the treatment of DFU involves the modernization of traditional methods and the exploration of new techniques. This review discusses recent advancements in 3D printing technology for the application of DFU care, and the development of personalized interventions for the treatment of DFUs.

Methods

We searched the electronic database for the years 2019-2024. Studies related to the use of 3D printing technology in Diabetic foot were included.

Results

A total of 25 identified articles based on database search and citation network analysis. After removing duplicates, 18 articles remained, and three articles that did not meet the inclusion criteria were removed after reading the title/abstract. A total of 97 relevant articles were included during the reading of references. In total, 112 articles were included.

Conclusion

3D printing technology offers unparalleled advantages, particularly in the realm of personalized treatment. The amalgamation of traditional treatment methods with 3D printing has yielded favorable outcomes in decelerating the progression of DFUs and facilitating wound healing. However, there is a limited body of research regarding the utilization of 3D printing technology in the domain of DFUs.

Delayed treatment of diabetic foot ulcer in patients with type 2 diabetes and its prediction model

BACKGROUND

Diabetic foot (DF) is a serious complication of type 2 diabetes. This study aimed to investigate the factors associated with DF occurrence and the role of delayed medical care in a cohort of patients with type 2 diabetes.

AIM

To reveal the impact of delayed medical treatment on the development of DF in patients with type 2 diabetes and to establish a predictive model for DF.

METHODS

In this retrospective cohort study, 292 patients with type 2 diabetes who underwent examination at our hospital from January 2023 to December 2023 were selected and divided into the DF group (n = 82, DF) and nondiabetic foot group (n = 210, NDF). Differential and correlation analyses of demographic indicators, laboratory parameters, and delayed medical treatment were conducted for the two groups. Logistic regression was applied to determine influencing factors. Receiver operating characteristic (ROC) analysis was performed, and indicators with good predictive value were selected to establish a combined predictive model.

RESULTS

The DF group had significantly higher body mass index (BMI) (P < 0.001), disease duration (P = 0.012), plasma glucose levels (P < 0.001), and HbA1c (P < 0.001) than the NDF group. The NDF group had significantly higher Acute Thrombosis and Myocardial Infarction Health Service System (ATMHSS) scores (P < 0.001) and a significantly lower delayed medical treatment rate (72.38% vs 13.41%, P < 0.001). BMI, duration of diabetes, plasma glucose levels, HbA1c, diabetic peripheral neuropathy, and nephropathy were all positively correlated with DF occurrence. ATMHSS scores were negatively correlated with delayed time to seek medical treatment. The logistic regression model revealed that BMI, duration of diabetes, plasma glucose levels, HbA1c, presence of diabetic peripheral neuropathy and nephropathy, ATMHSS scores, and delayed time to seek medical treatment were influencing factors for DF. ROC analysis indicated that plasma glucose levels, HbA1c, and delayed medical treatment had good predictive value with an area under the curve of 0.933 for the combined predictive model.

CONCLUSION

Delayed medical treatment significantly affects the probability of DF occurrence in patients with diabetes. Plasma glucose levels, HbA1c levels, and the combined predictive model of delayed medical treatment demonstrate good predictive value.

Advancements in diabetic foot insoles: a comprehensive review of design, manufacturing, and performance evaluation

The escalating prevalence of diabetes has accentuated the significance of addressing the associated diabetic foot problem as a major public health concern. Effectively offloading plantar pressure stands out as a crucial factor in preventing diabetic foot complications. This review comprehensively examines the design, manufacturing, and evaluation strategies employed in the development of diabetic foot insoles. Furthermore, it offers innovative insights and guidance for enhancing their performance and facilitating clinical applications. Insoles designed with total contact customization, utilizing softer and highly absorbent materials, as well as incorporating elliptical porous structures or triply periodic minimal surface structures, prove to be more adept at preventing diabetic foot complications. Fused Deposition Modeling is commonly employed for manufacturing; however, due to limitations in printing complex structures, Selective Laser Sintering is recommended for intricate insole designs. Preceding clinical implementation, in silico and in vitro testing methodologies play a crucial role in thoroughly evaluating the pressure-offloading efficacy of these insoles. Future research directions include advancing inverse design through machine learning, exploring topology optimization for lightweight solutions, integrating flexible sensor configurations, and innovating new skin-like materials tailored for diabetic foot insoles. These endeavors aim to further propel the development and effectiveness of diabetic foot management strategies. Future research avenues should explore inverse design methodologies based on machine learning, topology optimization for lightweight structures, the integration of flexible sensors, and the development of novel skin-like materials specifically tailored for diabetic foot insoles. Advancements in these areas hold promise for further enhancing the effectiveness and applicability of diabetic foot prevention measures.

Adjuvant effect of antimicrobial photodynamic therapy (aPDT) in the treatment of diabetic foot ulcers: A case series

This study aimed to evaluate the clinical evolution of patients with diabetic foot ulcer treated with antimicrobial photodynamic therapy (aPDT) using the Bates-Jensen (BJ) scale. A total of 21 patients were monitored, with an average age of 58 years. Patients underwent the standard treatment protocol of the institution, supplemented with aPDT utilizing 0.01% methylene blue (MB) and laser irradiation (660 nm, 100 mW, 6 J per point). Following aPDT, the lesions were protected with hydrofiber dressings containing silver. The Bates-Jensen Scale was employed at pre-treatment and post-aPDT sessions to assess lesion progression. The results demonstrated a significant difference between pre- and post-treatment values in the overall BJ score. The use of MB in aPDT proved to be an effective, safe, well-tolerated treatment with high patient adherence and the potential for implementation in the care of diabetic foot conditions.

Cutaneous changes in diabetic patients: Primed for aberrant healing?

Cutaneous manifestations affect most patients with diabetes mellitus, clinically presenting with numerous dermatologic diseases from xerosis to diabetic foot ulcers (DFUs). Skin conditions not only impose a significantly impaired quality of life on individuals with diabetes but also predispose patients to further complications. Knowledge of cutaneous biology and the wound healing process under diabetic conditions is largely limited to animal models, and studies focusing on biology of the human condition of DFUs remain limited. In this review, we discuss the critical molecular, cellular, and structural changes to the skin in the hyperglycaemic and insulin-resistant environment of diabetes with a focus specifically on human-derived data. Elucidating the breadth of the cutaneous manifestations coupled with effective diabetes management is important for improving patient quality of life and averting future complications including wound healing disorders.

Diabetic Peripheral Neuropathy Associated with Foot Ulcer: One of a Kind

Significance: Diabetic peripheral neuropathy (DPN) associated with a diabetic foot ulcer (DFU) is likely to be complicated with critical factors such as biofilm infection and compromised skin barrier function of the diabetic skin. Repaired skin with a history of biofilm infection is known to be compromised in barrier function. Loss of barrier function is also observed in the oxidative stress affected diabetic and aged skin. Recent Advances: Loss of barrier function makes the skin prone to biofilm infection and cellulitis, which contributes to chronic inflammation and vasculopathy. Hyperglycemia favors biofilm formation as glucose lowering led to reduction in biofilm development. While vasculopathy limits oxygen supply, the O2 cost of inflammation is high increasing hypoxia severity. Critical Issues: The host nervous system can be inhabited by bacteria. Because electrical impulses are a part of microbial physiology, polymicrobial colonization of the host's neural circuit is likely to influence transmission of action potential. The identification of perineural apatite in diabetic patients with peripheral neuropathy suggests bacterial involvement. DPN starts in both feet at the same time. Future Directions: Pair-matched studies of DPN in the foot affected with DFU (i.e., DFU-DPN) compared with DPN in the without ulcer, and intact skin barrier function, are likely to provide critical insight that would help inform effective care strategies. This review characterizes DFU-DPN from a translational science point of view presenting a new paradigm that recognizes the current literature in the context of factors that are unique to DFU-DPN.