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Dos Santos CM, de Souza Lima da Silveira PR, da Rocha RB, da Silva Sousa FM, Fontenele Alves R, Silva Barros AC, Saura Cardoso V. Adherence to Self-care and Quality of Life of Patients with Diabetic Foot Ulcers Treated with Low-Level Laser Therapy: An Exploratory Study. Adv Skin Wound Care 2024; 37:1-10. [PMID: 39037103 DOI: 10.1097/asw.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
OBJECTIVE To evaluate the quality of life (QoL) of patients with a diabetic foot ulcer undergoing treatment with low-level laser therapy (LLLT) at 904 nm and its association with self-care. METHODS In this randomized, exploratory study, participants were divided into the following four groups: control group (CG) with LLLT placebo, LLLT group 1 (LG1) at 10 J/cm2, LLLT group 2 (LG2) at 8 J/cm2, and LLLT group 3 (LG3) at 4 J/cm2. Participants received light therapy (or placebo) twice a week, for a total of 20 sessions. Researchers assessed participants' QoL using the Short-Form 36 questionnaire. RESULTS Sixty-two participants were included in the analysis (CG = 18, LG1 = 14, LG2 = 17, LG3 = 13). The LG1 group showed a higher proportion of healing, whereas the CG group showed a lower proportion than the other groups. The LG1 group showed a relationship between physical limitations and blood glucose monitoring, pain and foot care, and general health status (GHS) and foot care. The GL2 group showed a relationship between physical limitations and blood glucose monitoring, vitality and foot care, and GHS and diet. CONCLUSIONS Low-level laser therapy had a positive impact on QoL as assessed by the Short-Form 36 questionnaire (functional capacity, vitality, and pain domains), and there was a positive association between QoL and self-care in the LLLT groups (physical limitations, pain, GHS, and vitality domains).
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Affiliation(s)
- Cristiana Maria Dos Santos
- At the Integrated Center of Medical Specialties, Parnaíba, Piauí, Brazil, Cristiana Maria dos Santos, MSc, PT, and Pedro Renan de Souza Lima da Silveira, MSc, PT, are Physical Therapists. Rebeca Barbosa da Rocha, MSc, PT, is Assistant Professor, Delta Parnaíba Federal University, Parnaíba, Piauí, Brazil. Also at the Integrated Center of Medical Specialties, Fernanda Mello da Silva Sousa, MSc, PT, and Rayana Fontenele Alves, MSc, PT, are Physical Therapists. Also at Delta Parnaíba Federal University, Ana Carolina Silva Barros, PT, is Student, and Vinicius Saura Cardoso, PhD, PT, is Associate Professor
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Zhang X, Lang Z. Clinical Study on the treatment of chronic infectious ulcers using Platelet-Rich technology combined with moist dressings. Pak J Med Sci 2024; 40:1443-1447. [PMID: 39092025 PMCID: PMC11255822 DOI: 10.12669/pjms.40.7.8468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/13/2023] [Accepted: 03/27/2024] [Indexed: 08/04/2024] Open
Abstract
Objective To explore the clinical efficacy of platelet-rich technology combined with moist dressings in the treatment of chronic infectious ulcers. Methods This was a retrospective study. The subjects of the study were 48 patients with chronic infectious ulcers in Sichuan Provincial Orthopedics Hospital from January 2019 to June 2022. Enrolled patients were randomly divided into four groups(n=12), and received different treatment methods respectively. Further analysis and comparison were performed on the changes in wound volume, wound healing status, wound bacterial culture results, and the incidence of adverse reactions among the four groups. Results Three months after debridement, the wound volume of all four groups of patients was significantly reduced compared with that before debridement, with a statistically significant difference in intra-Group-Comparison(P<0.05). The inter-Group-Comparison revealed a statistically significant difference in wound volume in Group-A, Group-B, and Group-C than that in Group-D(P<0.05). After treatment, the wound healing status of patients in groups A, B, and C was significantly better than that of patients in Group-D, with a statistically significant difference(P<0.05). During treatment, patients in all four groups had decreased count of would bacteria, and showed negative results of wound bacterial culture by the three-month follow-up. No serious adverse reactions were observed in the four groups during treatment, and all improved after management, with no statistically significant difference in the incidence of adverse reactions(P>0.05). Conclusion Platelet-rich technology combined with moist dressings may effectively promote the repair of chronic infectious ulcer wounds, with good clinical safety.
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Affiliation(s)
- Xu Zhang
- Xu Zhang, Department of Orthopedics, Sichuan Provincial Orthopedics Hospital, Chengdu 610000, Sichuan, China
| | - Zhigang Lang
- Zhigang Lang, Department of Orthopedics, Sichuan Provincial Orthopedics Hospital, Chengdu 610000, Sichuan, China
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Sánchez CA, De Vries E, Gil F, Niño ME. Prediction model for lower limb amputation in hospitalized diabetic foot patients using classification and regression trees. Foot Ankle Surg 2024; 30:471-479. [PMID: 38575484 DOI: 10.1016/j.fas.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/01/2024] [Accepted: 03/16/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The decision to perform amputation of a limb in a patient with diabetic foot ulcer (DFU) is not an easy task. Prediction models aim to help the surgeon in decision making scenarios. Currently there are no prediction model to determine lower limb amputation during the first 30 days of hospitalization for patients with DFU. METHODS Classification And Regression Tree analysis was applied on data from a retrospective cohort of patients hospitalized for the management of diabetic foot ulcer, using an existing database from two Orthopaedics and Traumatology departments. The secondary analysis identified independent variables that can predict lower limb amputation (mayor or minor) during the first 30 days of hospitalization. RESULTS Of the 573 patients in the database, 290 feet underwent a lower limb amputation during the first 30 days of hospitalization. Six different models were developed using a loss matrix to evaluate the error of not detecting false negatives. The selected tree produced 13 terminal nodes and after the pruning process, only one division remained in the optimal tree (Sensitivity: 69%, Specificity: 75%, Area Under the Curve: 0.76, Complexity Parameter: 0.01, Error: 0.85). Among the studied variables, the Wagner classification with a cut-off grade of 3 exceeded others in its predicting capacity. CONCLUSIONS Wagner classification was the variable with the best capacity for predicting amputation within 30 days. Infectious state and vascular occlusion described indirectly by this classification reflects the importance of taking quick decisions in those patients with a higher compromise of these two conditions. Finally, an external validation of the model is still required. LEVEL OF EVIDENCE III.
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Affiliation(s)
- C A Sánchez
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia; Department of Orthopaedics and Traumatology, Hospital Universitario de la Samaritana, Bogotá, Colombia.
| | - E De Vries
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - F Gil
- Department of Orthopaedics and Traumatology, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - M E Niño
- Foot and ankle surgery, Clínica del Country and Hospital Militar Central, Bogotá, Colombia
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Sun Y, Zhou Y, Dai Y, Pan Y, Xiao Y, Yu Y. Predictors of post-healing recurrence in patients with diabetic foot ulcers: A systematic review and meta-analysis. J Tissue Viability 2024:S0965-206X(24)00108-6. [PMID: 39004600 DOI: 10.1016/j.jtv.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/15/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Diabetic foot ulcer is one of the most prevalent, serious, and costly consequences of diabetes, often associated with peripheral neuropathy and peripheral arterial disease. These ulcers contribute to high disability and mortality rates in patients and pose a major challenge to clinical management. OBJECTIVE To systematically review the risk prediction models for post-healing recurrence in diabetic foot ulcer (DFU) patients, so as to provide a reference for clinical staff to choose appropriate prediction models. METHODS The authors searched five databases (Cochrane Library, PubMed, Web of Science, EMBASE, and Chinese Biomedical Database) from their inception to September 23, 2023, for relevant literature. After data extraction, the quality of the literature was evaluated using the Predictive Model Research Bias Risk and Suitability Assessment tool (PROBAST). Meta-analysis was performed using STATA 17.0 software. RESULTS A total of 9 studies involving 5956 patients were included. The recurrence rate after DFU healing ranged from 6.2 % to 41.4 %. Nine studies established 15 risk prediction models, and the area under the curve (AUC) ranged from 0.660 to 0.940, of which 12 models had an AUC≥0.7, indicating good prediction performance. The combined AUC value of the 9 validation models was 0.83 (95 % confidence interval: 0.79-0.88). Hosmer-Lemeshow test was performed for 10 models, external validation for 5 models, and internal validation for 6 models. Meta-analysis showed that 14 predictors, such as age and living alone, could predict post-healing recurrence in DFU patients (p < 0.05). CONCLUSION To enhance the quality of these risk prediction models, there is potential for future improvements in terms of follow-up duration, model calibration, and validation processes.
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Affiliation(s)
- Yujian Sun
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Yue Zhou
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Yu Dai
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Yufan Pan
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Yi Xiao
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Yufeng Yu
- Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
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Xu J, Gao J, Li H, Zhu Z, Liu J, Gao C. The risk factors in diabetic foot ulcers and predictive value of prognosis of wound tissue vascular endothelium growth factor. Sci Rep 2024; 14:14120. [PMID: 38898068 PMCID: PMC11187195 DOI: 10.1038/s41598-024-64009-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
Diabetic foot ulcer (DFU) is a leading cause of high-level amputation in DM patients, with a low wound healing rate and a high incidence of infection. Vascular endothelial growth factor (VEGF) plays an important role in diabetes mellitus (DM) related complications. This study aims to explore the VEGF expression and its predictive value for prognosis in DFU, in order to provide basis for the prevention of DFU related adverse events. We analyzed 502 patients, with 328 in healing group and 174 in non-healing/recurrent group. The general clinical data and laboratory indicators of patients were compared through Spearman correlation analysis, ROC analysis and logistic regression analysis. Finally, the independent risk factors for adverse prognosis in DFU patients were confirmed. Spearman analysis reveals a positive correlation between the DFU healing rate and ABI, VEGF in wound tissue, and positive rate of VEGF expression, and a negative correlation with DM duration, FPG, HbA1c, TC, Scr, BUN, and serum VEGF. Further logistic regression analysis finds that the DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for adverse prognosis in DFU (p < 0.05). DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for prognosis in DFU patients. Patients with these risk factors should be screened in time, which is of great significance to prevent DFU related adverse events and improve outcomes.
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Affiliation(s)
- Jing Xu
- Department of Oncology, The Second People's Hospital of Lianyungang, No. 41 Hailiandong Road, Haizhou District, Lianyungang, 222006, China
| | - Jian Gao
- Department of Orthopedics, The Sixth Affiliated Hospital of Xinjiang Medical University, No. 39 Wuxingnan Road, Tian Shan District, Urumqi, 830002, China
| | - Hui Li
- Department of Internal Medicine, Urumqi Maternal and Child Health Care Hospital, No. 3838, Convention and Exhibition Avenue, Midong District, Urumqi, 831400, China
| | - Zhoujun Zhu
- Department of Orthopedics, The Sixth Affiliated Hospital of Xinjiang Medical University, No. 39 Wuxingnan Road, Tian Shan District, Urumqi, 830002, China
| | - Junliang Liu
- Department of Orthopedics, Weihai Stomatological Hospital, No. 268, Tongyi South Road, Huancui District, Weihai, 264299, China
| | - Chong Gao
- Department of Orthopedics, The Second People's Hospital of Lianyungang, No. 41 Hailiandong Road, Haizhou District, Lianyungang, 222006, China.
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Huang J, Yang J, Qi H, Xu M, Xu X, Zhu Y. Prediction models for amputation after diabetic foot: systematic review and critical appraisal. Diabetol Metab Syndr 2024; 16:126. [PMID: 38858732 PMCID: PMC11163763 DOI: 10.1186/s13098-024-01360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Numerous studies have developed or validated prediction models aimed at estimating the likelihood of amputation in diabetic foot (DF) patients. However, the quality and applicability of these models in clinical practice and future research remain uncertain. This study conducts a systematic review and assessment of the risk of bias and applicability of amputation prediction models among individuals with DF. METHODS A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, EBSCO CINAHL Plus, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedical Literature Database (CBM), and Weipu (VIP) from their inception to December 24, 2023. Two investigators independently screened the literature and extracted data using the checklist for critical appraisal and data extraction for systematic reviews of prediction modeling studies. The Prediction Model Risk of Bias Assessment Tool (PROBAST) checklist was employed to evaluate both the risk of bias and applicability. RESULTS A total of 20 studies were included in this analysis, comprising 17 development studies and three validation studies, encompassing 20 prediction models and 11 classification systems. The incidence of amputation in patients with DF ranged from 5.9 to 58.5%. Machine learning-based methods were employed in more than half of the studies. The reported area under the curve (AUC) varied from 0.560 to 0.939. Independent predictors consistently identified by multivariate models included age, gender, HbA1c, hemoglobin, white blood cell count, low-density lipoprotein cholesterol, diabetes duration, and Wagner's Classification. All studies were found to exhibit a high risk of bias, primarily attributed to inadequate handling of outcome events and missing data, lack of model performance assessment, and overfitting. CONCLUSIONS The assessment using PROBAST revealed a notable risk of bias in the existing prediction models for amputation in patients with DF. It is imperative for future studies to concentrate on enhancing the robustness of current prediction models or constructing new models with stringent methodologies.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin Yang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiou Qi
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Miaomiao Xu
- Orthopedics Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Operating Room, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Duarte EG, Lopes CF, Gaio DRF, Mariúba JVDO, Cerqueira LDO, Manhanelli MAB, Navarro TP, Castro AA, de Araujo WJB, Pedrosa H, Galli J, de Luccia N, de Paula C, Reis F, Bohatch MS, de Oliveira TF, da Silva AFV, de Oliveira JCP, Joviliano EÉ. Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot. J Vasc Bras 2024; 23:e20230087. [PMID: 38803655 PMCID: PMC11129855 DOI: 10.1590/1677-5449.202300872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/12/2023] [Indexed: 05/29/2024] Open
Abstract
The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.
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Affiliation(s)
- Eliud Garcia Duarte
- Hospital Estadual de Urgência e Emergência do Estado do Espírito Santo – HEUE, Departamento de Cirurgia Vascular, Vitória, ES, Brasil.
| | - Cicero Fidelis Lopes
- Universidade Federal da Bahia – UFBA, Departamento de Cirurgia Vascular, Salvador, BA, Brasil.
| | | | | | | | | | - Tulio Pinho Navarro
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
| | - Aldemar Araújo Castro
- Universidade Estadual de Ciências da Saúde de Alagoas – UNCISAL, Departamento de Cirurgia Vascular, Maceió, AL, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Hermelinda Pedrosa
- Hospital Regional de Taguatinga – HRT, Departamento de Cirurgia Vascular, Brasília, DF, Brasil.
| | - Júnio Galli
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Nelson de Luccia
- Universidade de São Paulo – USP, Faculdade de Medicina, Hospital das Clínicas – HC, São Paulo, SP, Brasil.
| | - Clayton de Paula
- Rede D’or São Luiz, Departamento de Cirurgia Vascular, São Paulo, SP, Brasil.
| | - Fernando Reis
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | - Milton Sérgio Bohatch
- Faculdade de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | | | | | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia Vascular, Rio de Janeiro, RJ, Brasil.
| | - Edwaldo Édner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Departamento de Cirurgia Vascular, Ribeirão Preto, SP, Brasil.
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Mitroi RM, Roșu MM, Clenciu D, Pădureanu V, Mitrea A, Grigore MA, Mazilu ER, Rădulescu D, Vladu IM. Vasculitis and infectious risk in a patient with type 2 diabetes mellitus: A case report. Exp Ther Med 2024; 27:234. [PMID: 38628659 PMCID: PMC11019656 DOI: 10.3892/etm.2024.12522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 01/16/2024] [Indexed: 04/19/2024] Open
Abstract
The connection between vasculitis and infection is complex. The present study described a typical situation for a patient with unbalanced type 2 diabetes and chronic complications, in which a lack of adherence to the protection and care measures ultimately led to the appearance of some of the worst consequences of the condition, namely, ulceration, gangrene and amputation. In the context of an unstable condition with significant metabolic imbalance there was an impaired response to infections in the present patient, and the amputation resulted in wound persistence and ulcer development, followed by superinfection with methicillin-resistant Staphylococcus aureus according to the antibiogram performed. In this case, an episode of vasculitis was triggered without evidence of bacteraemia. The present case report highlighted the importance of proper hygiene and good metabolic control in patients with diabetes that suffer from amputations and conditions that expose them to certain complications, including vasculitis.
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Affiliation(s)
- Roxana Mădălina Mitroi
- Department of Diabetes, Nutrition and Metabolic Diseases, County Clinical Emergency Hospital of Craiova, 200642 Craiova, Romania
| | - Maria Magdalena Roșu
- Department of Diabetes, Nutrition and Metabolic Diseases, County Clinical Emergency Hospital of Craiova, 200642 Craiova, Romania
- Department of Diabetes, Nutrition and Metabolic Diseases, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Diana Clenciu
- Department of Diabetes, Nutrition and Metabolic Diseases, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department of Diabetes, Nutrition and Metabolic Diseases, Clinical Municipal Hospital ‘Philanthropy’ of Craiova, 200143 Craiova, Romania
| | - Vlad Pădureanu
- Department of Internal Medicine, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Adina Mitrea
- Department of Diabetes, Nutrition and Metabolic Diseases, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Department of Diabetes, Nutrition and Metabolic Diseases, Clinical Municipal Hospital ‘Philanthropy’ of Craiova, 200143 Craiova, Romania
| | - Maria Andreea Grigore
- Department of Diabetes, Nutrition and Metabolic Diseases, County Clinical Emergency Hospital of Craiova, 200642 Craiova, Romania
| | - Emilia Roxana Mazilu
- Department of Diabetes, Nutrition and Metabolic Diseases, County Clinical Emergency Hospital of Craiova, 200642 Craiova, Romania
| | - Dumitru Rădulescu
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ionela Mihaela Vladu
- Department of Diabetes, Nutrition and Metabolic Diseases, County Clinical Emergency Hospital of Craiova, 200642 Craiova, Romania
- Department of Diabetes, Nutrition and Metabolic Diseases, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Park SB, Lim CH, Chun DI, Kim YJ, Kim TH, Park JM. The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection. Sci Rep 2024; 14:9260. [PMID: 38649465 PMCID: PMC11035640 DOI: 10.1038/s41598-024-59764-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.
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Affiliation(s)
- Soo Bin Park
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Chae Hong Lim
- Department of Nuclear Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jung Mi Park
- Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Gyeonggi, Republic of Korea.
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Huang X, Li Z, Zhai Z, Wang Q, Wei R, Mo J, Huang J, Lu W. Association Between Metabolic Dysfunction-Associated Fatty Liver Disease and MACCEs in Patients with Diabetic Foot Ulcers: An Ambispective Longitudinal Cohort Study. Diabetes Metab Syndr Obes 2024; 17:1119-1130. [PMID: 38465347 PMCID: PMC10924916 DOI: 10.2147/dmso.s447897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/28/2024] [Indexed: 03/12/2024] Open
Abstract
Aim Metabolic dysfunction-related fatty liver disease (MAFLD) is closely related to metabolic disorders. However, the relationship between MAFLD and the prognosis in diabetic foot ulcers (DFUs) remains unclear. This study aimed to explore the association between MAFLD and the risk of major adverse cardiac and cerebral events (MACCEs) in patients with DFUs. Methods 889 inpatients with DFUs (PEDIS/TEXAS mild and above) were included in this study from 2013 to 2023. All participants were placed into non-MAFLD (n = 643) and MAFLD (n = 246) groups and followed up every 6 months for 10.9 years with a median of 63 months through in-person outpatient interviews and family fixed-line telephone visits. The association between MAFLD and the risk of MACCEs was evaluated through Multivariate Cox regression analyses, Stratified analyses and Kaplan-Meier survival analyses. Results Of the 889 subjects, 214 (24.07%) experienced MACCEs. Multivariate Cox regression analysis showed that MAFLD was independently associated with MACCEs (P < 0.001), of which with non-fatal myocardial infarction (P = 0.04), non-fatal stroke (P = 0.047), coronary artery revascularization (P = 0.002), heart failure (P = 0.029), and all-cause mortality (P = 0.021), respectively. The stratified analysis revealed that compared with non-MAFLD (HR=1), DFUs with MAFLD had a 2.64-fold increased risk for MACCEs (P <0.001; P for interaction = 0.001) in peripheral arterial disease (PAD) subgroup. Kaplan-Meier analysis evidenced that the MAFLD group had a higher cumulative incidence of MACCEs (log-rank, all P < 0.05). Conclusion MAFLD is a high-risk factor for MACCEs in patients with DFUs. The findings will remind clinicians to pay more attention to MAFLD in patients with DFUs, especially in patients with DFUs combined with PAD as early as possible in clinical practice and adopt timely effective intervention strategies to prevent the occurrence of MACCEs to improve the clinical prognosis in patients with DFUs.
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Affiliation(s)
- Xiuxian Huang
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Zhengming Li
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Zhenwei Zhai
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Qiu Wang
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Rongyan Wei
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Jiacheng Mo
- Information Network Center of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Jianhao Huang
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
| | - Wensheng Lu
- Department of Endocrinology and Metabolism of Guangxi Academy of Medical Sciences, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, 530021, People's Republic of China
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11
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Wang K, Wang Y, Shi W, Shen K, Tao K, Ling R, Huang Y, Fu X, Hu D. Diagnosis and treatment of diabetic foot ulcer complicated with lower extremity vasculopathy: Consensus recommendation from the Chinese Medical Association (CMA), Chinese Medical Doctor Association (CMDA). Diabetes Metab Res Rev 2024; 40:e3776. [PMID: 38402455 DOI: 10.1002/dmrr.3776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 11/29/2023] [Accepted: 12/20/2023] [Indexed: 02/26/2024]
Abstract
Diabetic foot ulcer complicated with lower extremity vasculopathy is highly prevalent, slow healing and have a poor prognosis. The final progression leads to amputation, or may even be life-threatening, seriously affecting patients' quality of life. The treatment of lower extremity vasculopathy is the focus of clinical practice and is vital to improving the healing process of diabetic foot ulcers. Recently, a number of clinical trials on diabetic foot ulcers with lower extremity vasculopathy have been reported. A joint group of Chinese Medical Association (CMA) and Chinese Medical Doctor Association (CMDA) expert representatives reviewed and reached a consensus on the guidelines for the clinical diagnosis and treatment of this kind of disease. These guidelines are based on evidence from the literature and cover the pathogenesis of diabetic foot ulcers complicated with lower extremity vasculopathy and the application of new treatment approaches. These guidelines have been put forward to guide practitioners on the best approaches for screening, diagnosing and treating diabetic foot ulcers with lower extremity vasculopathy, with the aim of providing optimal, evidence-based management for medical personnel working with diabetic foot wound repair and treatment.
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Affiliation(s)
- Kejia Wang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yunchuan Wang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Wenlong Shi
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Kuo Shen
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Ke Tao
- Department of Wound Repair, Wound Repair and Regenerative Medicine Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yuesheng Huang
- Department of Wound Repair, Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology Hospital, Southern University of Science and Technology School of Medicine, Shenzhen, China
| | - Xiaobing Fu
- Research Center for Tissue Repair and Regeneration Affiliated to the Medical Innovation Research Department and 4th Medical Center, PLA General Hospital and PLA Medical College, Beijing, China
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
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12
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Classification of foot ulcers in people with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3645. [PMID: 37132179 DOI: 10.1002/dmrr.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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13
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Moon KC, Cha JH, Han SK, Son JW. Developing a Practical Tool for Predicting Wound Healing Outcomes of Patients with Diabetic Forefoot Ulcers: Focus on Vasculopathy and Infection. Adv Skin Wound Care 2024; 37:95-101. [PMID: 38241452 DOI: 10.1097/asw.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To develop a preliminary risk scoring system to predict the prognosis of patients with diabetic forefoot ulcers based on the severity of vasculopathy and infection, which are the major risk factors for amputation. METHODS Forefoot was defined as the distal part of the foot composed of the metatarsal bones and phalanges and associated soft tissue structures. The degree of vasculopathy was graded as V0, V1, or V2 according to transcutaneous partial oxygen tension values and toe pressure. The degree of infection was graded as I0, I1, or I2 according to tissue and bone biopsy culture results. The risk scores were calculated by adding the scores for the degree of vasculopathy and infection and ranged from 0 to 4. Wound healing outcomes were graded as healed without amputation, minor amputation, or major amputation. The authors evaluated wound healing outcomes according to risk scores. RESULTS As the risk score increased, the proportion of patients who underwent both major and minor amputations increased (P < .001). In the multivariate logistic analysis, the odds ratios of amputation also increased as the risk score increased. Patients with a risk score of 4 were 75- and 19-fold more likely to undergo major and minor amputations, respectively, than patients with a risk score of 0 (P = .006 and P < .001). CONCLUSIONS The risk score can be used as an indicator to predict the probability of amputation in patients with diabetic forefoot ulcers.
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Affiliation(s)
- Kyung-Chul Moon
- At Korea University Medical Center, Seoul, South Korea, Kyung-Chul Moon, MD, PhD, is Clinical Associate Professor, Department of Plastic Surgery; Ji-Hwan Cha, MD, is Plastic Surgery Resident; Seung-Kyu Han, MD, PhD, is Professor, Department of Plastic Surgery; and Ji-Won Son, RN, is Plastic Surgery Nurse
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14
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Chang Y, Huang Y, Hung S, Yeh J, Lin C, Chen I, Wei H, Yang H, Huang C. Are current wound classifications valid for predicting prognosis in people treated for limb-threatening diabetic foot ulcers? Int Wound J 2024; 21:e14338. [PMID: 37555265 PMCID: PMC10777762 DOI: 10.1111/iwj.14338] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 07/20/2023] [Indexed: 08/10/2023] Open
Abstract
This study aims to investigate whether the current wound classifications were valid for the treatment prognosis of subjects treated for limb-threatening diabetic foot ulcers (LTDFU). A total of 1548 patients with LTDFU and infection were studied, with wounds recorded using the Wagner, Texas, PEDIS and WIfI classifications while major lower extremity amputations (LEAs) or in-hospital mortality incidences were defined as poor outcomes. Among them, 153 (9.9%) patients received major LEAs and 38 (2.5%) patients died. After adjustments, the Wagner classification and Texas stage as well as clinical factors such as comorbidity with major adverse cardiac events (MACE), being under dialysis and having serum levels of C-reactive protein (CRP) and albumin were independent factors for prognosis. For patients without dialysis, Wagner and Texas stage stood out independently for prognosis. For patients on dialysis, only levels of CRP (odds ratio [OR] = 2.2 in Wagner, OR = 2.0 in WIfI, OR = 2.2 in Texas, OR = 2.3 in PEDIS) and albumin (OR = 0.4 in four classifications) were valid predictors. The Wagner system and Texas stage were valid for predicting prognosis in treatment for LTDFUs, suggesting a role of vascular perfusion. MACE history, levels of CRP and albumin level should assist in prediction; more significantly, only levels of CRP and albumin appeared valid for those subjects undergoing dialysis.
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Affiliation(s)
- Ya‐Chu Chang
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
| | - Yu‐Yao Huang
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
- College of Medicine, Chang Gung UniversityTaoyuan CityTaiwan
| | - Shih‐Yuan Hung
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
- College of Medicine, Chang Gung UniversityTaoyuan CityTaiwan
| | - Jiun‐Ting Yeh
- Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive SurgeryChang Gung Memorial Hospital, Chang Gung UniversityTaoyuan CityTaiwan
| | - Cheng‐Wei Lin
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
- College of Medicine, Chang Gung UniversityTaoyuan CityTaiwan
| | - I‐Wen Chen
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
- College of Medicine, Chang Gung UniversityTaoyuan CityTaiwan
| | - Hung‐Hui Wei
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
| | - Hui‐Mei Yang
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
| | - Chung‐Huei Huang
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital at LinkouTaoyuan CityTaiwan
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15
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Magruder ML, Yao VJH, Rodriguez AN, Ng MK, Piuzzi NS, Mont MA. History of Diabetic Foot Ulcer is Associated With Increased Risk of Prosthetic Joint Infection and Sepsis After Total Joint Arthroplasty. J Arthroplasty 2024; 39:250-254. [PMID: 37536397 DOI: 10.1016/j.arth.2023.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) are common sequelae of diabetes mellitus. Currently, the effect of DFUs on total joint arthroplasty (TJA) outcomes is sparsely evaluated. This study investigated whether DFU patients undergoing TJA increases risk of (1) prosthetic joint infections (PJI), (2) surgical site infections (SSI), (3) sepsis, (4) readmissions, and (5) revisions. METHODS Using PearlDiver, a retrospective query from January 1, 2010 to October 31, 2020 was performed. DFU patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) were included and 1:5 propensity score matched with controls using age, sex, body mass index, and various comorbidities (33,155 TKA patients [DFU = 5,529; control = 27,626]; 17,146 THA patients [DFU = 2,862; control = 14,284]). Outcomes included rates of PJI, SSI, sepsis, readmissions, and revisions. Multivariate logistical regressions calculated odds ratios (ORs), 95% confidence intervals, and P values (P < .001 as significance threshold). RESULTS DFU increased risk of sepsis within 90 days of TKA (OR 4.59; P < .001) and THA (OR 4.87; P < .001). DFU did not increase risk of PJI at 90 days for TKA (OR 0.8; P = .1) or THA (OR 0.85; P = .34) but did by 2 years post-TKA (OR 1.51; P < .001) and THA (OR 1.55; P < .001). Risk of SSI increased in DFU cohort following TKA and THA at 90 days and 2 years and at 90-day readmissions and 2-year revisions. CONCLUSION DFU patients undergoing TJA demonstrated increased risk of postoperative sepsis and PJI. Furthermore, DFU patients demonstrated an increased risk of SSI, readmissions, and revisions. Providers should counsel DFU patients about postoperative risks.
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Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Vincent J H Yao
- Sophie Davis Biomedical Education Program at the CUNY School of Medicine, New York, New York
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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16
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Ha Van G, Schuldiner S, Sultan A, Bouillet B, Martini J, Vouillarmet J, Menai M, Foucher A, Bourron O, Hartemann A, Perrier A. Use of the SINBAD score as a predicting tool for major adverse foot events in patients with diabetic foot ulcer: A French multicentre study. Diabetes Metab Res Rev 2023; 39:e3705. [PMID: 37525456 DOI: 10.1002/dmrr.3705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/07/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE To assess the relationship between the site, ischaemia, neuropathy, bacterial infection, area, depth (SINBAD) score and major adverse foot events in patients with diabetes and foot ulcers. METHODS For this retrospective ancillary study, patients (n = 537) followed for a diabetic foot ulcer (DFU) in six French hospitals were included between 1 February 2019 and 17 March 2019, and between 1 February 2020 and 17 March 2020. The SINBAD score was assessed at inclusion. The frequency of a composite outcome consisting of eight major adverse foot events (MAFE) was assessed after 5-6 months of follow-up: hospitalisation for DFU, septic surgery, revascularisation, minor amputation, major amputation, death, secondary infection and ulcer recurrence. A logistical regression explored the link between the SINBAD score and MAFE and each of its component. RESULTS A low SINBAD score (from 0 to 3) was observed in 61% of patients and a high (from 4 to 6) in 39%. MAFE occurred in, respectively, 24% and 28% of these patients. Multivariate analyses showed a significant relationship between the SINBAD score and MAFE, with the continuous SINBAD score: odds ratio (OR) 1.72 [95% CI (1.51-1.97)] or dichotomic SINBAD score (values: 0-3 and 4-6): OR 3.71 [95% CI (2.54-5.42)]. The SINBAD score (continuous or dichotomic) at inclusion was also significantly associated with six out of the eight components of the MAFE. CONCLUSIONS The SINBAD score is a useful tool for predicting major adverse foot events.
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Affiliation(s)
- Georges Ha Van
- Diabetes Department, APHP, Hospital Pitie Salpetriere, Paris, France
| | | | - Ariane Sultan
- Nutrition-Diabetes Department, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, Montpellier, France
| | - Benjamin Bouillet
- Endocrinology and Diabetology Department, University Hospital Center, Dijon, France
- INSERM, Dijon, France
- University of Bourgogne Franche-Comté, LNC UMR1231, Dijon, France
| | - Jacques Martini
- Endocrinology Department, University Hospital Center, Toulouse, France
| | | | - Medhi Menai
- IHU ICAN, Foundation for Innovation in Cardio Metabolism and Nutrition, Paris, France
| | - Aurélie Foucher
- IHU ICAN, Foundation for Innovation in Cardio Metabolism and Nutrition, Paris, France
| | - Olivier Bourron
- Diabetes Department, Sorbonne University, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Agnes Hartemann
- Diabetes Department, Sorbonne University, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Perrier
- Diabetes Department, APHP, Hospital Pitie Salpetriere, Paris, France
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17
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Brocklehurst JD. The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers. Adv Skin Wound Care 2023; 36:1-5. [PMID: 37861669 DOI: 10.1097/asw.0000000000000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
ABSTRACT Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.
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Affiliation(s)
- Jonathan D Brocklehurst
- Jonathan D. Brocklehurst, BSc, is Lecturer and Podiatrist, The SMAE Institute, Maidenhead, Berkshire, UK. The author has disclosed no financial relationships related to this article. Submitted September 21, 2022; accepted in revised form December 9, 2022
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18
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Zhang H, Huang C, Bai J, Wang J. Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis. Int Wound J 2023; 20:3035-3047. [PMID: 37095728 PMCID: PMC10502264 DOI: 10.1111/iwj.14179] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/26/2023] Open
Abstract
A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.
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Affiliation(s)
- Huiling Zhang
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
| | - Chuanwang Huang
- Department of Orthopedic SurgeryLiaocheng People's HospitalShandongChina
| | - Jie Bai
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
| | - Jing Wang
- Department of Endocrinology and MetabologyLiaocheng People's HospitalShandongChina
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Schönborn M, Gregorczyk-Maga I, Batko K, Maga M, Bogucka K, Gawlik K, Pawlica-Gosiewska D, Maga P. Angiogenic and Microvascular Status Alterations after Endovascular Revascularization of Lower Limb Arteries among Patients with Diabetic Foot Syndrome: A Prospective 12-Month Follow-Up Study. J Clin Med 2023; 12:5581. [PMID: 37685648 PMCID: PMC10488381 DOI: 10.3390/jcm12175581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 07/31/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Peripheral arterial disease (PAD)-induced ischemia is an important component of diabetic foot syndrome (DFS). The results of revascularization of the lower extremity arteries (including percutaneous transluminal angioplasty [PTA]) do not always give satisfactory long-term results, which is due to many factors. The aim of the study was to investigate the alterations in selected circulating angiogenic factors and microcirculation parameters in 41 patients with DFS following PTA and analyze their relationships with clinical outcomes during 1-year follow-up. Our study revealed a general decrease in pro-angiogenic factor levels after PTA and their subsequent stabilization during subsequent observation. The results indicated a significant association between plasma circulating FGF-2 level and poor outcomes (including the incidence of restenosis/reocclusion of treated arteries) during 12 months of observation. The perioperative changes in FGF-2 showed a significant association with LDF alterations after PTA. Follow-up 1-3 months post-intervention showed a tendency towards elevated TcpO2, VEGF-A, and VEGF-R2 levels in patients free from adverse events. These results may provide a basis for further research on the potential use of selected circulating angiogenic factors for monitoring the treatment of patients with DFS following PTA.
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Affiliation(s)
- Martyna Schönborn
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Doctoral School of Medical and Health Sciences, Jagiellonian University, 31-007 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Iwona Gregorczyk-Maga
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, 31-008 Kraków, Poland;
| | - Krzysztof Batko
- Department of Research and Development, Medicine Economy Law Society (MELS) Foundation, 30-040 Krakow, Poland;
| | - Mikołaj Maga
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Katarzyna Bogucka
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
| | - Katarzyna Gawlik
- Department of Clinical Biochemistry, Jagiellonian University Medical College, 31-008 Krakow, Poland; (K.G.); (D.P.-G.)
| | - Dorota Pawlica-Gosiewska
- Department of Clinical Biochemistry, Jagiellonian University Medical College, 31-008 Krakow, Poland; (K.G.); (D.P.-G.)
| | - Paweł Maga
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland; (M.M.); (P.M.)
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Kraków, Poland;
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20
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Jiang P, Li Q, Luo Y, Luo F, Che Q, Lu Z, Yang S, Yang Y, Chen X, Cai Y. Current status and progress in research on dressing management for diabetic foot ulcer. Front Endocrinol (Lausanne) 2023; 14:1221705. [PMID: 37664860 PMCID: PMC10470649 DOI: 10.3389/fendo.2023.1221705] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Diabetic foot ulcer (DFU) is a major complication of diabetes and is associated with a high risk of lower limb amputation and mortality. During their lifetime, 19%-34% of patients with diabetes can develop DFU. It is estimated that 61% of DFU become infected and 15% of those with DFU require amputation. Furthermore, developing a DFU increases the risk of mortality by 50%-68% at 5 years, higher than some cancers. Current standard management of DFU includes surgical debridement, the use of topical dressings and wound decompression, vascular assessment, and glycemic control. Among these methods, local treatment with dressings builds a protective physical barrier, maintains a moist environment, and drains the exudate from DFU wounds. This review summarizes the development, pathophysiology, and healing mechanisms of DFU. The latest research progress and the main application of dressings in laboratory and clinical stage are also summarized. The dressings discussed in this review include traditional dressings (gauze, oil yarn, traditional Chinese medicine, and others), basic dressings (hydrogel, hydrocolloid, sponge, foam, film agents, and others), bacteriostatic dressings, composite dressings (collagen, nanomaterials, chitosan dressings, and others), bioactive dressings (scaffold dressings with stem cells, decellularized wound matrix, autologous platelet enrichment plasma, and others), and dressings that use modern technology (3D bioprinting, photothermal effects, bioelectric dressings, microneedle dressings, smart bandages, orthopedic prosthetics and regenerative medicine). The dressing management challenges and limitations are also summarized. The purpose of this review is to help readers understand the pathogenesis and healing mechanism of DFU, help physicians select dressings correctly, provide an updated overview of the potential of biomaterials and devices and their application in DFU management, and provide ideas for further exploration and development of dressings. Proper use of dressings can promote DFU healing, reduce the cost of treating DFU, and reduce patient pain.
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Affiliation(s)
- Pingnan Jiang
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qianhang Li
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yanhong Luo
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Feng Luo
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Qingya Che
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhaoyu Lu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shuxiang Yang
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yan Yang
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Endocrinology and Metabolism, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Xia Chen
- Department of Endocrinology, Kweichow Moutai Hospital, Renhuai, Guizhou, China
| | - Yulan Cai
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Endocrinology and Metabolism, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
- Department of Endocrinology, Kweichow Moutai Hospital, Renhuai, Guizhou, China
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Niță O, Arhire LI, Mihalache L, Popa AD, Niță G, Gherasim A, Graur M. Evaluating Classification Systems of Diabetic Foot Ulcer Severity: A 12-Year Retrospective Study on Factors Impacting Survival. Healthcare (Basel) 2023; 11:2077. [PMID: 37510519 PMCID: PMC10379067 DOI: 10.3390/healthcare11142077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: This study examines the survival of patients after their first presentation with diabetic foot ulcers (DFUs) to the regional Diabetes, Nutrition, and Metabolic Diseases Clinic within the Emergency Clinical Hospital "Sf. Spiridon", Iaşi, and analyzes the factors associated with this outcome. (2) Methods: In this retrospective study, patients with DFUs consecutively referred between 1 January 2007 and 31 December 2017 were followed up until 31 December 2020 (for 13 years). The study group included 659 subjects. (3) Results: During the study period, there were 278 deaths (42.2%) and the average survival time was 9 years. The length of hospitalization, diabetic nephropathy, chronic kidney disease, glomerular filtration rate, cardiovascular disease, hypertension, anemia, and DFU severity were the most significant contributors to the increase in mortality. Patients with severe ulcers, meaning DFUs involving the tendon, joint, or bone, had a higher mortality risk than those with superficial or pre-ulcerative lesions on initial presentation (Texas classification HR = 1.963, 95% CI: 1.063-3.617; Wagner-Meggitt classification HR = 1.889, 95% CI: 1.024-3.417, SINBAD Classification System and Score HR = 2.333, 95% CI: 1.258-4.326) after adjusting for confounding factors. (4) Conclusions: The findings of this study suggested that patients presenting with severe ulcers involving the tendon, joint, or bone exhibited a significantly higher risk of mortality, even when potential confounders were taken into consideration.
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Affiliation(s)
- Otilia Niță
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Lidia Iuliana Arhire
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Laura Mihalache
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Alina Delia Popa
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - George Niță
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Andreea Gherasim
- Faculty of Medicine, University of Medicine and Pharmacy "Grigore T Popa", 700115 Iasi, Romania
| | - Mariana Graur
- Faculty of Medicine and Biological Sciences, University "Ștefan cel Mare" of Suceava, 720229 Suceava, Romania
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22
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Correa CAS, Vargas-Hernández JS, García LF, Jaimes J, Caicedo M, Niño ME, Quijano JR. Risk factors for reamputation in patients with diabetic foot: A case-control study. Foot Ankle Surg 2023:S1268-7731(23)00100-5. [PMID: 37301675 DOI: 10.1016/j.fas.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/25/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals. METHODS Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors. RESULTS Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound >50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound >50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR. CONCLUSION Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Luisa Fernanda García
- Resident in Orthopedics and Traumatology, Pontificia Universidad Javeriana, Colombia
| | | | - Martha Caicedo
- Hospital Universitario de La Samaritana, Universidad de la Sabana, Colombia
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Schönborn M, Gregorczyk-Maga I, Batko K, Bogucka K, Maga M, Płotek A, Pasieka P, Słowińska-Solnica K, Maga P. Circulating Angiogenic Factors and Ischemic Diabetic Foot Syndrome Advancement-A Pilot Study. Biomedicines 2023; 11:1559. [PMID: 37371653 DOI: 10.3390/biomedicines11061559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Despite clear evidence of inadequate angiogenesis in ischemic diabetic foot syndrome (DFS) pathogenesis, angiogenic factor level changes in patients with ischemic DFS remain inconsistent. This study aimed to assess circulating angiogenic factors concerning ischemic DFS advancement and describe their relationships with patients' clinical characteristics, microvascular parameters, and diabetic control. The study included 41 patients with ischemic DFS (67.3 (8.84) years; 82.9% males). Angiogenic processes were assessed by identifying circulating concentrations of five pro- and two anti-angiogenic factors. We found that penetrating ulcers were related to a significantly higher FGF-2 level (8.86 (5.29) vs. 5.23 (4.17) pg/mL, p = 0.02). Moreover, plasma FGF-2 showed a significant correlation with the SINBAD score (r = 0.32, p = 0.04), platelet count (r = 0.43, p < 0.01), white cell count (r = 0.42, p < 0.01), and age (r = -0.35, p = 0.03). We did not observe any significant linear relationship between the studied biomarkers and microcirculatory parameters, nor for glycemic control. In a univariate analysis using logistic regression, an increase in plasma FGF-2 was tied to greater odds of high-grade ulcers (OR 1.16; 95% CI 1.02-1.38, p = 0.043). This suggests that circulating FGF-2 may serve as a potential biomarker for predicting DFU advancement and progression. It is necessary to conduct further studies with follow-up observations to confirm this hypothesis.
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Affiliation(s)
- Martyna Schönborn
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Krakow, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University, 31-007 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Iwona Gregorczyk-Maga
- Faculty of Medicine, Institute of Dentistry, Jagiellonian University Medical College, 30-663 Krakow, Poland
| | - Krzysztof Batko
- Department of Research and Development, Medicine Economy Law Society (MELS) Foundation, 30-040 Krakow, Poland
| | - Katarzyna Bogucka
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Mikołaj Maga
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Department of Rehabilitation in Internal Medicine, Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Anna Płotek
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Patrycja Pasieka
- Department of Dermatology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | | | - Paweł Maga
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
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Yuzuguldu B, Zengin B, Simsir IY, Cetinkalp S. An Overview of Risk Factors for Diabetic Foot Amputation: An Observational, Single-centre, Retrospective Cohort Study. TOUCHREVIEWS IN ENDOCRINOLOGY 2023; 19:85-93. [PMID: 37313238 PMCID: PMC10258617 DOI: 10.17925/ee.2023.19.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/13/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Not only are early detection and treatment of diabetic foot ulcers important, but also acknowledging potential risk factors for amputation gives clinicians a considerable advantage in preventing amputations. Amputations impact both healthcare services and the physical and mental health of patients. This study aimed to investigate the risk factors for amputation in patients with diabetic foot ulcers. METHODS The sample for this study was patients with diabetic foot ulcers who were treated by the diabetic foot council at our hospital between 2005 and 2020. A total of 32 risk factors for amputation were identified and investigated among 518 patients. RESULTS Our univariate analysis showed that 24 of 32 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, seven risk factors remained statistically significant. The risk factors most significantly associated with amputation were Wagner grading, abnormal peripheral arteries, hypertension, high thrombocyte levels, low haematocrit levels, hypercholesterolaemia and male sex, respectively. The most common cause of death in patients with diabetes who have undergone amputation is cardiovascular disease, followed by sepsis. CONCLUSION To enable optimum treatment of patients with diabetic foot ulcers it is important for physicians to be aware of the amputation risk factors, and thus avoid amputations. Correcting risk factors, using suitable footwear and routinely inspecting feet are crucial factors for preventing amputations in patients with diabetic foot ulcers.
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Affiliation(s)
- Burak Yuzuguldu
- Division of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Bugra Zengin
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ilgin Yildirim Simsir
- Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sevki Cetinkalp
- Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, Izmir, Turkey
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25
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Hu X, Zhang Y, Chen Y, Zhang YP. Validation and application of the 2019 International Working Group on the Diabetic Foot risk stratification for diabetic foot in Chinese patients. J Diabetes Investig 2023. [PMID: 37060582 DOI: 10.1111/jdi.14014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 04/17/2023] Open
Abstract
AIMS/INTRODUCTION The purpose of the present study was to evaluate the validation and application of the 2019 International Working Group on the Diabetic Foot (IWGDF) risk stratification system among Chinese patients with diabetes. MATERIALS AND METHODS A retrospective cohort study was carried out with 254 patients with diabetes, but without an active diabetic foot (DF) ulcer. Patients hospitalized from January to May 2017 were enrolled, and the follow-up period was from January to May 2020. Patients were stratified into four risk groups based on the 2019 IWGDF risk stratification system. RESULTS Of the 254 patients, four of 31 patients at risk 1 were diagnosed with DF within 3 years, whereas 12 of 26 patients at risk 2 and 16 of 20 patients at risk 3 developed DF. The area under the curve was 0.919 (P < 0.01, 95% confidence interval 0.893-0.945). Because DF risk 2 and greater (risk 2 + risk 3) was the optimal cut-off point, we simplified the risk stratification system by using two tiers, namely, low risk (risk 0 + 1) and high risk (risk 2 + 3). For the simplified risk stratification system, the sensitivity, specificity, positive likelihood ratio, percent agreement, positive predictive value and negative predictive value were 87.5%, 91.8%, 10.607, 91.3%, 60.8% and 98.1%, respectively. The χ2 -test showed that the odds ratio of the high-risk group (risk 2 + 3) was 29.33-fold that of the low-risk group (risk 0 + 1). CONCLUSIONS The 2019 IWGDF risk stratification system showed high validity and primary screening value in Chinese patients with diabetes. Thus, a simplified, two-tiered IWGDF stratification might be more efficient and cost-effective for predicting DF ulcers.
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Affiliation(s)
- Xiling Hu
- School of Nursing, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yao Zhang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanming Chen
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yin-Ping Zhang
- School of Nursing, Xi'an Jiaotong University Health Science Center, Xi'an, China
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26
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Vahwere BM, Ssebuufu R, Namatovu A, Kyamanywa P, Ntulume I, Mugwano I, Pius T, Sikakulya FK, Xaviour OF, Mulumba Y, Jorge S, Agaba G, Nasinyama GW. Factors associated with severity and anatomical distribution of diabetic foot ulcer in Uganda: a multicenter cross-sectional study. BMC Public Health 2023; 23:463. [PMID: 36899359 PMCID: PMC9999659 DOI: 10.1186/s12889-023-15383-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Diabetic foot ulcer (DFU) is a devastating complication of diabetes mellitus (DM) that is associated with increased mortality, morbidity, amputation rate and economic burden. This study aimed at identifying the anatomical distribution and factors associated with severity of DFU in Uganda. METHODOLOGY This was a multicenter cross-sectional study conducted in seven selected referral hospitals in Uganda. A total of 117 patients with DFU were enrolled in this study between November 2021 and January 2022. Descriptive analysis and modified Poisson regression analysis were performed at 95% confidence interval; factors with p-value < 0.2 at bivariate analysis were considered for multivariate analysis. RESULTS The right foot was affected in 47.9% (n = 56) of patients, 44.4% (n = 52) had the DFU on the plantar region of the foot and 47.9% (n = 56) had an ulcer of > 5 cm in diameter. The majority (50.4%, n = 59) of patients had one ulcer. 59.8% (n = 69) had severe DFU, 61.5% (n = 72) were female and 76.9% had uncontrolled blood sugar. The mean age in years was 57.5 (standard deviation 15.2 years). Primary (p = 0.011) and secondary (p < 0.001) school educational levels, moderate (p = 0.003) and severe visual loss (p = 0.011), 2 ulcers on one foot (p = 0.011), and eating vegetables regularly were protective against developing severe DFU (p = 0.03). Severity of DFU was 3.4 and 2.7 times more prevalent in patients with mild and moderate neuropathies (p < 0.01), respectively. Also, severity was 1.5 and 2.5 higher in patients with DFU of 5-10 cm (p = 0.047) and in those with > 10 cm diameter (p = 0.002), respectively. CONCLUSION Most DFU were located on the right foot and on the plantar region of the foot. The anatomical location was not associated with DFU severity. Neuropathies and ulcers of > 5 cm diameter were associated with severe DFU but primary and secondary school education level and eating vegetables were protective. Early management of the precipitating factors is important to reduce the burden of DFU.
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Affiliation(s)
| | | | - Alice Namatovu
- College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, Kampala, Uganda
| | | | - Ibrahim Ntulume
- Kampala International University, Western Campus, Kampala, Uganda.,College of Veterinary Medicine, Animal Resources and Biosecurity, Makerere University, Kampala, Uganda
| | - Isaac Mugwano
- Fortportal Regional Referral Hospital, Fort portal, Uganda
| | - Theophilus Pius
- Kampala International University, Western Campus, Kampala, Uganda
| | - Franck Katembo Sikakulya
- Kampala International University, Western Campus, Kampala, Uganda.,Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo
| | | | | | - Soria Jorge
- Kampala International University, Western Campus, Kampala, Uganda
| | - Gidio Agaba
- Kiruddu National Referral Hospital, Kampala, Uganda
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Liu Y, Jiang C, Zhang X, Ma B, Ding Y, Jin Y, Liu Y, Li L, Zhao C. Anterior superior iliac spine distraction for severe and recalcitrant diabetic foot ulcers. Injury 2023; 54:778-783. [PMID: 36481053 DOI: 10.1016/j.injury.2022.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE The study aimed to introduce anterior superior iliac spine distraction to treat severe and recalcitrant diabetic foot ulcers. For comparison, we also included another group of diabetic foot ulcers treated with proximal tibial cortex transverse distraction. METHODS From February 1998 to February 2020, 87 patients (87 feet) with severe and recalcitrant diabetic foot ulcers were treated. The mean age of patients at surgery was 64 years (range, 47 to 87 years). The severity of the narrowed artery was assessed using the ankle-brachial index test. For comparison, another group of 91 patients (91 diabetic foot ulcers) treated with proximal tibial cortex transverse distraction was included. RESULTS The mean preoperative ankle-brachial indexes of the two groups were 0.41±0.07 and 0.39±0.05 (OR 0.65 [95% CI -0.77 to 1.58]; P=0.62), respectively. The mean preoperative limb pain was 3.42±2.84 cm and 3.52±3.11 cm (OR 1.54 [95% CI -077 to 1.35]; P=0.083), respectively. At the 2-year follow-up visit, ulcers healed in 72 (83%) and 74 (81%) patients, respectively (P=0.188). The mean postoperative limb pain was 0.52±0.23 cm and 0.49±0.41 cm (OR 2.32 [95% CI -0.27 to 1.66]; P=0.078), respectively. Pin-site infection occurred in 2 patients and 8 patients (P=0.09), respectively. Ulcer recurrence occurred in 13 (15%) patients and 15 (16%) patients (P=0.205), respectively. CONCLUSIONS Anterior superior iliac spine transverse distraction may be an effective alternative treatment for severe and recalcitrant diabetic foot ulcers. It may be associated with fewer distraction-site complications than proximal tibial cortex transverse distraction. LEVEL OF EVIDENCE Therapeutic study, Level IIa.
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Affiliation(s)
- Yingliang Liu
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China
| | - Changhai Jiang
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China.
| | - Xu Zhang
- Department of Hand Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Bingshu Ma
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China
| | - Yanfen Ding
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China
| | - Yanhong Jin
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China
| | - Yanjun Liu
- Department of Orthopaedics, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan 675000, China
| | - Linhong Li
- Department of Orthopaedics, People's Hospital of Xishuangbanna State, Yunnan, China
| | - Chenglong Zhao
- Department of Orthopaedics, People's Hospital of Mile City of Honghe State, Yunnan, China
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28
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Brekelmans W, van Laar W, Tolen NJ, Hoencamp R, Borger van der Burg BLS. Recurrent diabetic foot ulcers: Results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery. Int Wound J 2023. [PMID: 36606312 DOI: 10.1111/iwj.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 01/07/2023] Open
Abstract
The diabetic foot ulcer (DFU) and Charcot Neuroarthropathy (CN) are serious complications of diabetes mellitus in which wound closure is complex to achieve. Treating recurrent DFU in patients with a combination of infection, ischemia, and deformities is extremely challenging and this group of patients has a very poor outcome. This case series describes the outcomes of patients with a recurrent DFU and CN, with a mean SINBAD score of 4 and of which 40% had a TCS of D3, using a multidisciplinary protocol that includes reconstructive foot and ankle surgery. In 24/35 (69%) of patients, wound closure was achieved after a mean of 75 days postoperatively. The mean ulcer-free period was 358 days. The mean number of interventions was 6.7 (range 3-9). Post treatment 27/35 (77%) of patients was mobile, without additional amputation or ulcer recurrence. This study shows that wound closure and a long ulcer-free period can be achieved in patients with a DFU and CN and its multifactorial underlying diseases when treated in a multidisciplinary team, including reconstructive foot and ankle surgery.
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Affiliation(s)
- Wouter Brekelmans
- Alrijne Wound Centre, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Wilbert van Laar
- Alrijne Wound Centre, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Orthopaedic Surgery, Alrijne Ziekenhuis, Leiderdorp, The Netherlands
| | - Nicole J Tolen
- Alrijne Wound Centre, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Alrijne Ziekenhuis, Leiderdorp, The Netherlands
| | - Rigo Hoencamp
- Alrijne Wound Centre, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.,Defence Healthcare Organization, Ministry of Defence, Utrecht, The Netherlands.,Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Boudewijn L S Borger van der Burg
- Alrijne Wound Centre, Alrijne Ziekenhuis, Leiderdorp, The Netherlands.,Department of Surgery, Alrijne Ziekenhuis, Leiderdorp, The Netherlands
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29
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Alahakoon C, Fernando M, Galappaththy C, Lazzarini P, Moxon JV, Jones R, Golledge J. Repeatability, Completion Time, and Predictive Ability of Four Diabetes-Related Foot Ulcer Classification Systems. J Diabetes Sci Technol 2023; 17:35-41. [PMID: 33451251 PMCID: PMC9846411 DOI: 10.1177/1932296820986548] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The inter and intra-observer reproducibility of measuring the Wound Ischemia foot Infection (WIfI) score is unknown. The aims of this study were to compare the reproducibility, completion times and ability to predict 30-day amputation of the WIfI, University of Texas Wound Classification System (UTWCS), Site, Ischemia, Neuropathy, Bacterial Infection and Depth (SINBAD) and Wagner classifications systems using photographs of diabetes-related foot ulcers. METHODS Three trained observers independently scored the diabetes-related foot ulcers of 45 participants on two separate occasions using photographs. The inter- and intra-observer reproducibility were calculated using Krippendorff's α. The completion times were compared with Kruskal-Wallis and Dunn's post-hoc tests. The ability of the scores to predict 30-day amputation rates were assessed using receiver operator characteristic curves and area under the curves. RESULTS There was excellent intra-observer agreement (α >0.900) and substantial agreement between observers (α=0.788) in WIfI scoring. There was moderate, substantial, or excellent agreement within the three observers (α>0.599 in all instances except one) and fair or moderate agreement between observers (α of UTWCS=0.306, α of SINBAD=0.516, α of Wagner=0.374) for the other three classification systems. The WIfI score took significantly longer (P<.001) to complete compared to the other three scores (medians and inter quartile ranges of the WIfI, UTWCS, SINBAD, and Wagner being 1.00 [0.88-1.00], 0.75 [0.50-0.75], 0.50 [0.50-0.50], and 0.25 [0.25-0.50] minutes). None of the classifications were predictive of 30-day amputation (P>.05 in all instances). CONCLUSION The WIfI score can be completed with substantial agreement between trained observers but was not predictive of 30-day amputation.
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Affiliation(s)
- Chanika Alahakoon
- Ulcer and Wound Healing Consortium
(UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of
Medicine and Dentistry, James Cook University, Townsville, Queensland,
Australia
- Faculty of Medicine, University of
Peradeniya, Peradeniya, Sri Lanka
| | - Malindu Fernando
- Ulcer and Wound Healing Consortium
(UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of
Medicine and Dentistry, James Cook University, Townsville, Queensland,
Australia
- School of Public Health and Social Work,
Queensland University of Technology, Brisbane, Queensland, Australia
| | - Charith Galappaththy
- Faculty of Medicine, University of
Peradeniya, Peradeniya, Sri Lanka
- The Department of Vascular and
Endovascular Surgery, Townsville University Hospital, Townsville, Queensland,
Australia
| | - Peter Lazzarini
- School of Public Health and Social Work,
Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative,
Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Joseph V. Moxon
- Ulcer and Wound Healing Consortium
(UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of
Medicine and Dentistry, James Cook University, Townsville, Queensland,
Australia
- The Australian Institute of Tropical
Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Rhondda Jones
- The Australian Institute of Tropical
Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Ulcer and Wound Healing Consortium
(UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of
Medicine and Dentistry, James Cook University, Townsville, Queensland,
Australia
- The Department of Vascular and
Endovascular Surgery, Townsville University Hospital, Townsville, Queensland,
Australia
- The Australian Institute of Tropical
Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Jonathan Golledge, MChir, FRACS, Queensland
Research Centre for Peripheral Vascular Disease, College of Medicine and
Dentistry, James Cook University, 1 University Drive, Townsville, Queensland
4811, Australia.
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Wang S, Wang J, Zhu MX, Tan Q. Machine learning for the prediction of minor amputation in University of Texas grade 3 diabetic foot ulcers. PLoS One 2022; 17:e0278445. [PMID: 36472981 PMCID: PMC9725167 DOI: 10.1371/journal.pone.0278445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
Minor amputations are performed in a large proportion of patients with diabetic foot ulcers (DFU) and early identification of the outcome of minor amputations facilitates medical decision-making and ultimately reduces major amputations and deaths. However, there are currently no clinical predictive tools for minor amputations in patients with DFU. We aim to establish a predictive model based on machine learning to quickly identify patients requiring minor amputation among newly admitted patients with DFU. Overall, 362 cases with University of Texas grade (UT) 3 DFU were screened from tertiary care hospitals in East China. We utilized the synthetic minority oversampling strategy to compensate for the disparity in the initial dataset. A univariable analysis revealed nine variables to be included in the model: random blood glucose, years with diabetes, cardiovascular diseases, peripheral arterial diseases, DFU history, smoking history, albumin, creatinine, and C-reactive protein. Then, risk prediction models based on five machine learning algorithms: decision tree, random forest, logistic regression, support vector machine, and extreme gradient boosting (XGBoost) were independently developed with these variables. After evaluation, XGBoost earned the highest score (accuracy 0.814, precision 0.846, recall 0.767, F1-score 0.805, and AUC 0.881). For convenience, a web-based calculator based on our data and the XGBoost algorithm was established (https://dfuprediction.azurewebsites.net/). These findings imply that XGBoost can be used to develop a reliable prediction model for minor amputations in patients with UT3 DFU, and that our online calculator will make it easier for clinicians to assess the risk of minor amputations and make proactive decisions.
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Affiliation(s)
- Shiqi Wang
- Department of Burns and Plastic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jinwan Wang
- School of Information Management, Nanjing University, Nanjing, China
| | - Mark Xuefang Zhu
- School of Information Management, Nanjing University, Nanjing, China
- * E-mail: (MXZ); (QT)
| | - Qian Tan
- Department of Burns and Plastic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
- * E-mail: (MXZ); (QT)
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Prognostic Value of Histological and Immunohistochemical Data in Diabetic Foot Ulcers. J Clin Med 2022; 11:jcm11237202. [PMID: 36498776 PMCID: PMC9737256 DOI: 10.3390/jcm11237202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/07/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Diabetic foot ulcers are an extremely urgent medical and social problem throughout the world. The purpose of this study was to analyse the histological and immunohistochemical features of tissues and cells of different sections of wounds taken during the primary surgical treatment of chronic wounds in patients with diabetic foot syndrome with favourable and unfavourable outcomes. MATERIAL AND METHODS A clinical prospective observational study of the treatment outcomes of fifty-three patients with diabetic foot ulcers hospitalized twice in one specialized centre over the course of the year was conducted. The analysis of histological and immunohistochemical data of the tissues of the edges and the centre of the ulcer taken during the primary surgical treatment was performed. While performing histological analyses of wound tissues, special attention was given to the determination of cellular characteristics of leukocyte-necrotic masses, granulation tissue, and loose and dense connective tissue. Immunohistochemistry was performed using a set of monoclonal antibodies, allowing verification of neutrophilic leukocytes, fibroblasts, and endothelial cells. RESULTS Unfavourable outcomes (amputation, reamputation, death from cardiovascular diseases, nonhealing ulcer within a year) were registered in 52.8% of cases. Uniform distribution of neutrophils and endothelial cell fibroblasts in all parts of the wound was recorded in patients with a favourable outcome. An unfavourable outcome was predetermined by the uneven content of these cells with a significant increase in neutrophilic leukocytosis in the bottom of the wounds, as well as a significant decrease in the number of fibroblasts and endotheliocytes in the centre of the wounds. CONCLUSIONS The datasets obtained during primary surgical treatment are extremely informative to predict the outcome of the treatment of diabetic foot ulcers and indicate more active surgical strategies with the potential to reduce the treatment time, increase its effectiveness, and eventually make the treatment cost-effective.
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Byeon JY, Hwang YS, Choi HJ, Kim JH, Lee DW. A long‐term follow‐up study of diabetic foot ulcer using micronized acellular dermal matrix. Int Wound J 2022; 20:1622-1637. [PMID: 36377547 PMCID: PMC10088852 DOI: 10.1111/iwj.14018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022] Open
Abstract
Treating a diabetic foot ulcer (DFU) extending to the tendon or bone can be a challenge for physicians. Recent studies have shown positive results of micronized acellular dermal matrix (ADM) treatment for treating DFU. However, studies on such ADM with a long-term follow-up are rare. Thus, the objective of this study was to retrospectively analyse patients treated with micronized ADM with a long-term follow-up to assess the effectiveness of the treatment and determine the recurrence rate. The rate of success of complete healing was 62.96% and the time of complete healing was 86.96 days in this study. The recurrence rate of DFUs was 41.17% in the overall group. However, it was only 23.52% in the micronized ADM group. The average duration of recurrence was 720.50 ± 505.12 days. The recurrence rate was 50% in weight bearing areas such as the plantar and heel. It was 12.5% in toes and non-weight bearing areas. In conclusion, micronized ADM can be used to effectively treat DFUs that have invaded ligaments or bones. A close follow-up of weight bearing area wounds will allow us to identify and treat recurrence early.
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Affiliation(s)
- Je Yeon Byeon
- Department of Plastic and Reconstructive Surgery Soonchunhyang University Cheonan Hospital Cheonan South Korea
| | - Yong Seon Hwang
- Department of Plastic and Reconstructive Surgery Soonchunhyang University Cheonan Hospital Cheonan South Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery Soonchunhyang University Cheonan Hospital Cheonan South Korea
- Institute of Tissue Regeneration, College of Medicine Soonchunhyang University Cheonan South Korea
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery Soonchunhyang University Cheonan Hospital Cheonan South Korea
| | - Da Woon Lee
- Department of Plastic and Reconstructive Surgery Soonchunhyang University Cheonan Hospital Cheonan South Korea
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Wang Y, Zhu J, Chen J, Xu R, Groth T, Wan H, Zhou G. The Signaling Pathways Induced by Exosomes in Promoting Diabetic Wound Healing: A Mini-Review. Curr Issues Mol Biol 2022; 44:4960-4976. [PMID: 36286052 PMCID: PMC9600352 DOI: 10.3390/cimb44100337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/08/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022] Open
Abstract
Impaired healing of diabetic wounds harms patients' quality of life and even leads to disability and death, which is an urgent issue to be solved clinically. Despite the great progress that has been achieved, it remains a worldwide challenge to develop effective therapeutic treatments for diabetic wounds. Recently, exosomes have attracted special attention because they can be involved in immune response, antigen presentation, cell migration, cell differentiation, tumor invasion and other processes. Meanwhile, exosomes have been proven to hold great potential in the treatment of diabetic wounds. Mechanistic studies of exosomes based on signaling pathways could not only help to uncover the mechanisms by which exosomes promote diabetic wound healing but could also provide a theoretical basis for the clinical application of exosomes. Herein, our mini-review aims to summarize the progress of research on the use of various exosomes derived from different cell types to promote diabetic wound healing, with a focus on the classical signaling pathways, including PI3K/Akt, Wnt, NF-κB, MAPK, Notch, Nrf2, HIF-1α/VEGF and TGF-β/Smad. The results show that exosomes could regulate these signaling pathways to down-regulate inflammation, reduce oxidative stress, increase angiogenesis, promote fibroblast proliferation, induce re-epithelization and inhibit scar formation, making exosomes attractive candidates for the treatment of diabetic wounds.
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Affiliation(s)
- Yanying Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
| | - Jiayan Zhu
- College of Life Science, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
| | - Jing Chen
- College of Life Science, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
| | - Ruojiao Xu
- College of Life Science, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
| | - Thomas Groth
- Department Biomedical Materials, Institute of Pharmacy, Martin Luther University Halle-Wittenberg, D-06099 Halle (Saale), Germany
| | - Haitong Wan
- College of Life Science, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
- Correspondence: (H.W.); (G.Z.)
| | - Guoying Zhou
- The Second Clinical Medical College, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
- College of Life Science, Zhejiang Chinese Medical University, 548 Binwen Road, Hangzhou 310053, China
- Correspondence: (H.W.); (G.Z.)
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Byeon JY, Kwak SH, Choi HJ, Kim JH, Lee DW. Clinical significance of early venous enhancement on CT angiography of the ischemic lower limbs. Medicine (Baltimore) 2022; 101:e30560. [PMID: 36181004 PMCID: PMC9524914 DOI: 10.1097/md.0000000000030560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.
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Affiliation(s)
- Je Yeon Byeon
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
- Institute of Tissue Regeneration, College of Medicine, Soonchunhyang University, Cheonan, Korea
- * Correspondence: Hwan Jun Choi, Department of Plastic & Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Bongmyeong-dong, Dongnam-gu, Cheonan-si, Chungcheongnam-do 330-721, Korea (e-mail: )
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Da Woon Lee
- Department of Plastic and Reconstructive Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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The implications of diabetic foot health-related with quality of life: A retrospective case control investigation. J Tissue Viability 2022; 31:790-793. [PMID: 35853797 DOI: 10.1016/j.jtv.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 07/02/2022] [Accepted: 07/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The diabetes people show a significant presence of foot health problems are usually all over the world, causing in big economic effects for these persons, their families and world population OBJECTIVE: The purpose of this research is to evaluate and relate the impact of foot health associated with the quality of life (QoL) in a group of people with and without diabetes MATERIAL AND METHODS: A total of 150 persons of a mean age of 71.45 ± 11.93 years came to a foot and ankle specialist outpatient center. Self-reported data were medical records where persons'with and without diabetes was evaluated. All findings obtained was compared with scores quality of life using the tool Foot Health Status Questionnaire, spanish version RESULTS: The diabetes group revealed a reduction of QoL linked to overall health and to foot health in particular. Differences among both groups were analyzed by means of a independent Student's t-test samples, displaying a p-value lower than 0.05 statistically significant for the domains of foot pain, foot function footwear and social capacity CONCLUSIONS: Diabetes people recorded a negative influence on the QoL related with foot health, that seems to be linked with the presence of chronic disease in diabetes people.
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Lee DW, Kwak SH, Kim JH, Choi HJ. Prediction of diabetic foot amputation using newly revised DIRECT coding system: Comparison of accuracy with that of five existing classification systems. Int Wound J 2022; 20:359-371. [PMID: 35811359 PMCID: PMC9885474 DOI: 10.1111/iwj.13884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Diabetes mellitus (DM) causes various complications over time, one such complication is diabetic foot ulcers (DFU), which are challenging to treat and can lead to amputation. Additionally, a system for accurate prediction of amputation has yet to be developed. In total, 131 patients were included in the study after retrospectively collecting data from 2016 to 2020 about DFU. The collected data were used for comparison of the accuracy between five existing classification systems and the newly revised DIRECT coding system, and investigation of risk factors for lower extremity amputation (LEA). The existing five classification systems and DIRECT system can effectively predict LEA. The DIRECT3 system has three elements, C-reactive protein (CRP), ulcer history (UH), and hypertension (HTN) in addition to those of the DIRECT system. It had a high predictive value and accuracy similar to that of Wagner and University of Texas (UT) on depth among the five classification systems. Among the statistically significant risk factors, duration of DM and HTN, haemoglobin (Hb), CRP, and UH showed an association with LEA. The DIRECT coding system is effective for predicting LEA and explaining appropriate treatment methods for DFU, and is widely applicable because of its user accessibility and convenience.
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Affiliation(s)
- Da Woon Lee
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea,Institute of Tissue Regeneration, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
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Jaber D, Younes N, Khalil E, Albsoul-Younes A, Mismar A, Nassar M, Al-Bakri AG. Effect of Diluted Dakin's Solution Versus Standard Care on Diabetic Foot Ulcer Management: A Randomized Controlled Trial. J Am Podiatr Med Assoc 2022; 112:20-213. [PMID: 34233350 DOI: 10.7547/20-213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) are the main cause of hospitalizations and amputations in diabetic patients. Failure of standard foot care is the most important cause of impaired DFU healing. Dakin's solution (DS) is a promising broad-spectrum bactericidal antiseptic for management of DFUs. Studies investigating the efficacy of using DS on the healing process of DFUs are scarce. Accordingly, this is the first evidence-based, randomized, controlled trial conducted to evaluate the effect of using diluted DS compared with the standard care in the management of infected DFUs. METHODS A randomized controlled trial was conducted to assess the efficacy of DS in the management of infected DFUs. Patients were distributed randomly to the control group (DFUs irrigated with normal saline) or the intervention group (DFUs irrigated with 0.1% DS). Patients were followed for at least 24 weeks for healing, reinfection, or amputations. In vitro antimicrobial testing on DS was performed, including determination of its minimum inhibitory concentration, minimum bactericidal concentration, minimum biofilm inhibitory concentration, minimum biofilm eradication concentration, and suspension test. RESULTS Replacing normal saline irrigation in DFU standard care with 0.1% DS followed by soaking the ulcer with commercial sodium hypochlorite (0.08%) after patient discharge significantly improved ulcer healing (P < .001) and decreased the number of amputations and hospitalizations (P < .001). The endpoint of death from any cause (risk ratio, 0.13; P = .029) and the amputation rate (risk ratio, 0.27; P < .001) were also significantly reduced. The effect on ulcer closure (OR, 11.9; P < .001) was significantly enhanced in comparison with the control group. Moreover, DS irrigation for inpatients significantly decreased bacterial load (P < .001). The highest values for the in-vitro analysis of DS were as follows: minimum inhibitory concentration (MIC), 1.44%; minimum bactericidal concentration (MBC), 1.44%; minimum biofilm inhibitory concentration (MBIC), 2.16%; and minimum biofilm eradication concentration (MBEC), 2.87%. CONCLUSIONS Compared with standard care, diluted DS (0.1%) was more effective in the management of infected DFUs. Dakin's solution (0.1%) irrigation with debridement followed by standard care is a promising method in the management of infected DFUs.
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Affiliation(s)
- Deema Jaber
- *Department of Clinical Pharmacy, School of Pharmacy, Zarqa University, Zarqa, Jordan.,†School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Nidal Younes
- ‡School of Medicine, The University of Jordan, Amman, Jordan
| | - Enam Khalil
- †School of Pharmacy, The University of Jordan, Amman, Jordan
| | | | - Ayman Mismar
- ‡School of Medicine, The University of Jordan, Amman, Jordan
| | - Moayyad Nassar
- †School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Amal G Al-Bakri
- †School of Pharmacy, The University of Jordan, Amman, Jordan
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Shabib S, Soltani R, Khorvash F, Taheri A, Shahbazi Azad M. The Effect of Topical Cow's Milk on the Healing of Diabetic Foot Ulcers: A Randomized Controlled Pilot Clinical Trial. INT J LOW EXTR WOUND 2022:15347346221084788. [PMID: 35287509 DOI: 10.1177/15347346221084788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetic foot ulcer (DFU) is a very serious side effect among the diabetic patients with substantial clinical and economic consequences. The aim of this study was to investigate the efficacy of cows' milk topical ointment, as an available and cost-effective natural product, on accelerating the healing of DFU. In this randomized controlled clinical trial, patients with grade 1 or 2 DFU were randomly divided into two groups of intervention (n = 50) and control (n = 49). For patients of intervention group, cows' milk 20% topical ointment was applied on the ulcer once daily for two weeks, while a type of novel dressing was used for control group with the same frequency and duration. Both groups received usual standard wound care measures. The percentage of change in the ulcer size and the number of cases with complete wound healing (>90% reduction in the ulcer size) were recorded in the both groups. The ulcer size significantly reduced in both groups on the seventh and 14th days of intervention; however, the percentage of reduction was significantly higher in the intervention (milk) group compared to control at both time points (44.64 ± 15.98 vs. 24.95 ± 12.78, P < .001; 67.67 ± 22.15 vs. 42.87 ± 19.74, P < .001). Furthermore, although more patients in the intervention group (n = 4, 8%) showed complete healing of the ulcer compared to control (n = 0), the difference was not statistically significant (P = .117). Cow's milk 20% topical ointment improves and accelerates the healing of diabetic foot ulcers. However, more clinical studies are required to confirm these effects.
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Affiliation(s)
- Somayeh Shabib
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Rasool Soltani
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, 48455Isfahan University of Medical Sciences, Isfahan, Iran
- Pharmaceutical Sciences Research Center, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzin Khorvash
- Nosocomial Infection Research Center, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azade Taheri
- Department of Pharmaceutics, School of Pharmacy and Novel Drug Delivery System Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Shahbazi Azad
- Nosocomial Infection Research Center, 48455Isfahan University of Medical Sciences, Isfahan, Iran
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Seçkin MF, Özcan Ç, Çamur S, Polat Ö, Batar S. Predictive Factors and Amputation Level for Reamputation in Patients With Diabetic Foot: A Retrospective Case-Control Study. J Foot Ankle Surg 2022; 61:43-47. [PMID: 34253432 DOI: 10.1053/j.jfas.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/12/2020] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
The aim of this study was to assess the rate and level of reamputation in patients who had a previous amputation from diabetic foot. We retrospectively analyzed patients who underwent amputation and reamputation due to diabetic foot in our clinic between 2011 and 2019. Fifty-nine were evaluated as the healed group after the first amputation and 55 were evaluated as the reamputation group. Given 55 patients who needed reamputation: there were 13 finger or ray, 23 transmetatarsal or syme, 18 transtibial, and 1 transfemoral in the first operation. We found the reamputation rate was 65.4% in distal amputations. When serum parameters were examined before the first amputation in each group, there was no statistically significant difference in white blood cells, neutrophils, lymphocytes, platelets, sedimentation, C-reactive protein, total protein, hematocrit, urea, creatinine, and HgA1c values. There was, however, a significant difference between groups in albumin levels. When comorbidities were assessed for smoking, hypertension, duration of diabetes, and number of debridements after the first surgery, a significant difference between groups was found. When peripheral artery disease and chronic renal failure were examined, no significant difference was observed. In our study, it was observed that the rate of reamputation was higher in distal level amputations for diabetic foot patients. Accordingly, albumin values, smoking, hypertension, duration of diabetes, number of debridements after surgery, were seen as risk factors for reamputation patients.
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Affiliation(s)
- Mustafa Faik Seçkin
- Department of Orthopaedics and Traumatology, Florance Nightingale Hospital, Istanbul, Turkey.
| | - Çağrı Özcan
- Department of Orthopeadics and Traumatology, University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Savaş Çamur
- Department of Orthopeadics and Traumatology, University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Ömer Polat
- Department of Orthopeadics and Traumatology, University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Suat Batar
- Department of Orthopeadics and Traumatology, University of Health Sciences, Umraniye Education and Research Hospital, Istanbul, Turkey
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Bedriñana-Marañón B, Rubio-Rodríguez M, Yovera-Aldana M, Garcia-Villasante E, Pinedo-Torres I. Association Between the Diabetes mellitus Duration and the Severity of Diabetic Foot Disease in Hospitalized Patients in Latin America. INT J LOW EXTR WOUND 2021:15347346211063266. [PMID: 34889665 DOI: 10.1177/15347346211063266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The objective was to determine the association between a diabetes mellitus duration greater than 10 years and the severity of diabetic foot in hospitalized patients in Latin America.Analytical, observational, and retrospective study based in secondary databases. Patients older than 18 years with diagnosis of diabetes mellitus (DM) and hospitalized for any causes were included. The independent and dependent variables were having more than 10 years of diagnosis of DM and the severity of the diabetic foot disease (Wagner> = 2), respectively. A crude Poisson regression analysis was performed to obtain prevalence rates adjusted to confounders.Male gender was 54.8% and the median age was 62 years. In the group with more than10 years of disease (n = 903) 18% (n = 162) had severe injuries. We performed two Poisson regression analyzes, one of which included the entire sample; and in the other, only patients with some degree of ulcer were included at the time of evaluation (Wagner > = 1). In the first analysis the PR was 1.95 (p < 0.01) adjusted for the significant variables in the bivariate analysis and in the second analysis the PR was 1.18 (p < 0.01) adding to the adjustment the days of injury prior to hospitalization and the location of the ulcer.We conclude that in patients with more than 10 years of diabetes mellitus, diabetic foot injuries are more severe, regardless type of diabetes, gender, age, history of amputation and days of injury prior to hospitalization for inpatients in Latin America.
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Affiliation(s)
| | | | - Marlon Yovera-Aldana
- Grupo de Investigación Neurociencia, Efectividad y Salud Pública, Universidad Científica del Sur, Lima, Perú
- 33209Red de Eficacia Clinica y Sanitaria, REDECS, Lima, Perú
| | - Eilhart Garcia-Villasante
- 33209Red de Eficacia Clinica y Sanitaria, REDECS, Lima, Perú
- 269034Hospital Nacional Daniel Alcides Carrion, Callao, Perú
| | - Isabel Pinedo-Torres
- Grupo de Investigación Neurociencia, Efectividad y Salud Pública, Universidad Científica del Sur, Lima, Perú
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Chou YY, Hou CC, Wu CW, Huang DW, Tsai SL, Liu TH, Ding LM, Chang CK, Ou KL, Chiu YL, Tzeng YS. Risk factors that predict major amputations and amputation time intervals for hospitalised diabetic patients with foot complications. Int Wound J 2021; 19:1329-1338. [PMID: 34879446 PMCID: PMC9493235 DOI: 10.1111/iwj.13727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/20/2021] [Accepted: 12/01/2021] [Indexed: 12/05/2022] Open
Abstract
Diabetes‐related lower extremity amputations are an enormous burden on global health care and social resources because of the rapid worldwide growth of the diabetic population. This research aimed to determine risk factors that predict major amputation and analyse the time interval from first hospitalisation to amputation by using standard management protocols and Kaplan–Meier survival curves. Data from 246 patients with diabetes mellitus and diabetic foot ulcers from the Division of Plastic and Reconstructive Surgery of the Department of Surgery at XXX Hospital between January 2016 and May 2020 were analysed. Univariate and multivariate analyses of 44 potential risk factors, including invasive ulcer depth and C‐reactive protein levels, showed statistically significant differences for those at increased risk for major amputation. The median time from hospitalisation to lower extremity amputation was approximately 35 days. Most patients with abnormal C‐reactive protein levels and approximately 70% of patients with ulcers invading the bone were at risk for lower extremity amputations within 35 days. Therefore, invasive ulcer depth and C‐reactive protein levels are significant risk factors. Other potential risk factors for major amputation and the time intervals from first hospitalisation to amputation should be analysed to establish further prediction strategies.
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Affiliation(s)
- Yu-Yu Chou
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Chun Hou
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Wei Wu
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Dun-Wei Huang
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sheng-Lin Tsai
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ting-Hsuan Liu
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Lu-Ming Ding
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Kai Chang
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Ling Ou
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Lung Chiu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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42
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Ozkan S, Adanas C, Alp HH. Is ischaemia-modified albumin a biomarker in wagner classification in diabetic foot ulcers? Int J Clin Pract 2021; 75:e14830. [PMID: 34510669 DOI: 10.1111/ijcp.14830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND We aimed to determine the relationship of ischaemia-modified albumin (IMA) with diabetic foot ulcers and its predictive value in the Wagner classification. METHODS Our cross-sectional study was conducted in 120 diabetic foot patients and 60 healthy individuals with similar body mass index (BMI) and age. Patients with a diabetic foot were classified according to the Wagner classification. Biochemical parameters, C-reactive protein (CRP) and IMA levels were measured in all patients and healthy volunteers. Screening performance characteristics of CRP and IMA were calculated according to Wagner classes and the presence of osteomyelitis. RESULTS The levels of BMI, CRP and IMA in diabetic foot patients were significantly higher than the healthy controls. When we grouped the patients according to the Wagner classification, there were no significant differences between the Wagner groups in terms of BMI. The highest IMA levels were detected in Wagner grade 5. CRP had higher sensitivity and specificity than IMA in the discrimination of other grades, except for grade 4-5 separation. For Wagner grade 4-5 distinction, IMA had 84.6% sensitivity and 94.7% specificity. CONCLUSION IMA had a higher predictive value in discrimination of the Wagner grade 4-5. In the management of diabetic foot patients, it may be recommended that IMA is evaluated by clinicians.
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Affiliation(s)
- Sezai Ozkan
- Department of Orthopaedics and Traumatology, Medicine Faculty, Van Yuzuncu Yil University, Van, Turkey
| | - Cihan Adanas
- Department of Orthopaedics and Traumatology, Medicine Faculty, Van Yuzuncu Yil University, Van, Turkey
| | - Hamit Hakan Alp
- Department of Biochemistry, Medicine Faculty, Van Yuzuncu Yil University, Van, Turkey
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43
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Gracia-Sánchez A, López-Pineda A, Chicharro-Luna E, Gil-Guillén VF. A Delphi Study Protocol to Identify Recommendations on Physical Activity and Exercise in Patients with Diabetes and Risk of Foot Ulcerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10988. [PMID: 34682736 PMCID: PMC8536116 DOI: 10.3390/ijerph182010988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 01/05/2023]
Abstract
Patients with diabetes mellitus are exposed to important complications, such as diabetic neuropathy or peripheral vascular disease. The evidence on the guidelines that these patients, with a certain risk of suffering foot ulcerations, should follow before, during and after physical exercise is scarce. The objective of this study is to identify the physical exercise guidelines to recommend based on the risk of the foot of the patient with diabetes through a consensus of experts. A three-round Delphi study will be conducted. A scientific committee (multidisciplinary group of four national experts) will review the proposal of experts and the Delphi questionnaire before submitting. A group of experts in the management and approach of the diabetic foot of an international and multidisciplinary nature will form the panel of experts, who must express their degree of (dis)agreement with each of the statements contained in the Delphi questionnaire. The percentage will be calculated in response categories, and a cut-off point of 80% will be set to define the consensus of (dis)agreement of the panelists. The results of the study could provide a series of recommendations on the realization of physical exercise in diabetic patients at risk of suffering foot ulcerations.
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Affiliation(s)
- Alba Gracia-Sánchez
- Department of Behavioral and Health Sciences, Miguel Hernández University, 03550 San Juan de Alicante, Spain; (A.G.-S.); (E.C.-L.)
| | - Adriana López-Pineda
- Clinical Medicine Department, Miguel Hernandez University, 03550 San Juan de Alicante, Spain;
| | - Esther Chicharro-Luna
- Department of Behavioral and Health Sciences, Miguel Hernández University, 03550 San Juan de Alicante, Spain; (A.G.-S.); (E.C.-L.)
| | - Vicente F. Gil-Guillén
- Clinical Medicine Department, Miguel Hernandez University, 03550 San Juan de Alicante, Spain;
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44
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Xie P, Li Y, Deng B, Du C, Rui S, Deng W, Wang M, Boey J, Armstrong DG, Ma Y, Deng W. An explainable machine learning model for predicting in-hospital amputation rate of patients with diabetic foot ulcer. Int Wound J 2021; 19:910-918. [PMID: 34520110 PMCID: PMC9013600 DOI: 10.1111/iwj.13691] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot ulcer (DFU) is one of the most serious and alarming diabetic complications, which often leads to high amputation rates in diabetic patients. Machine learning is a part of the field of artificial intelligence, which can automatically learn models from data and better inform clinical decision‐making. We aimed to develop an accurate and explainable prediction model to estimate the risk of in‐hospital amputation in patients with DFU. A total of 618 hospitalised patients with DFU were included in this study. The patients were divided into non‐amputation, minor amputation or major amputation group. Light Gradient Boosting Machine (LightGBM) and 5‐fold cross‐validation tools were used to construct a multi‐class classification model to predict the three outcomes of interest. In addition, we used the SHapley Additive exPlanations (SHAP) algorithm to interpret the predictions of the model. Our area under the receiver‐operating‐characteristic curve (AUC) demonstrated a 0.90, 0.85 and 0.86 predictive ability for non‐amputation, minor amputation and major amputation outcomes, respectively. Taken together, our data demonstrated that the developed explainable machine learning model provided accurate estimates of the amputation rate in patients with DFU during hospitalisation. Besides, the model could inform individualised analyses of the patients' risk factors.
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Affiliation(s)
- Puguang Xie
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
| | - Yuyao Li
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
| | - Bo Deng
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Chenzhen Du
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
| | - Shunli Rui
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China
| | - Wu Deng
- College of Electronic Information and Automation, Civil Aviation University of China, Tianjin, China
| | - Min Wang
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
| | - Johnson Boey
- Department of Podiatry, National University Hospital, Singapore
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Yu Ma
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
| | - Wuquan Deng
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Key Laboratory of Emergency Medicine, Chongqing University Central Hospital, Chongqing University, Chongqing, China.,College of Bioengineering, Chongqing University of China, Chongqing, China
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45
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Armstrong DG, Orgill DP, Galiano RD, Glat PM, DiDomenico LA, Carter MJ, Zelen CM. A multi-centre, single-blinded randomised controlled clinical trial evaluating the effect of resorbable glass fibre matrix in the treatment of diabetic foot ulcers. Int Wound J 2021; 19:791-801. [PMID: 34418302 PMCID: PMC9013587 DOI: 10.1111/iwj.13675] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/25/2021] [Indexed: 12/28/2022] Open
Abstract
Diabetic foot ulcers (DFUs) are at risk for detrimental complications even with current, standard of care (SOC) treatments. The primary objective of this randomised controlled trial was to compare a unique resorbable glass microfiber matrix (Mirragen; Advanced Wound Matrix [BBGFM]; ETS Wound Care, Rolla, Missouri) compared with a standard of care group (SOC, collagen alginate dressing) at 12 weeks. Both groups received standard diabetic foot care including glucose monitoring, weekly debridements when needed and an offloading device. The primary endpoint was proportion of full‐thickness, non‐infected, non‐ischaemic wounds healed at 12 weeks, with secondary endpoints including percent area reduction (PAR) and changes in Semmes‐Weinstein monofilament testing. The result illustrated in the intent‐to‐treat analysis at 12 weeks showed that 70% (14/20) of the BBGFM‐treated DFUs healed compared with 25% (5/20) treated with SOC alone (adjusted P = .006). Mean PAR at 12 weeks was 79% in the BBGFM group compared with 37% in the SOC group (adjusted P = .027). Mean change in neuropathic score between baseline and up to 12 weeks of treatment was 2.0 in the BBGFM group compared with −0.6 in the SOC group where positive improvement in scores are better (adjusted P = .008). The mean number of BBGFM applications was 6.0. In conclusion, adding BBGFM to SOC significantly improved wound healing with no adverse events related to treatment compared with SOC alone.
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Affiliation(s)
- David G Armstrong
- Department of Surgery Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Dennis P Orgill
- Professional Education and Research Institute, Roanoke, Virginia, USA
| | - Robert D Galiano
- Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Paul M Glat
- Department of Surgery, Drexel University School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Charles M Zelen
- Professional Education and Research Institute, Roanoke, Virginia, USA
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46
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Jangir SK, Joshi N, Kumar M, Choubey DK, Singh S, Verma M. Functional link convolutional neural network for the classification of diabetes mellitus. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3496. [PMID: 33964103 DOI: 10.1002/cnm.3496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 06/12/2023]
Abstract
Diabetes is a faction of metabolic ailments distinguished by hyperglycemia which is the consequence of a defect, in the action of insulin, insulin secretion, or both and producing various abnormalities in the human body. In recent years, the utilization of intelligent systems has been expanded in disease classification and numerous researches have been proposed. In this research article, a variant of Convolutional Neural Network (CNN) that is, Functional Link Convolutional Neural Network (FLCNN) is proposed for the diabetes classification. The main goal of this article is to find the potential of a computationally less complex deep learning network like FLCNN and applied the proposed technique on a real dataset of diabetes for classification. This article also presents the comparative studies where various other machine learning techniques are implemented and outcomes are compared with the proposed FLCNN network. The performance of each classification techniques have been evaluated based on standard measures and also validated with a non-parametric statistical test such as Friedman. Data for modeling diabetes classification is collected from Bombay Medical Hall, Upper Bazar, Ranchi, India. Accuracy achieve by the proposed classifier is more than 90% which is closer to the other state-of-the-art implemented classifiers.
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Affiliation(s)
- Sunil Kumar Jangir
- Department of Computer Science & Engineering, Mody University of Science and Technology, Sikar, India
| | | | - Manish Kumar
- Department of Biomedical Engineering, Mody University of Science and Technology, Sikar, India
| | - Dilip Kumar Choubey
- Department of Computer Science & Engineering, Indian Institute of Information Technology Bhagalpur, Bhagalpur, India
| | - Shatakshi Singh
- Department of Computer Science & Engineering, Mody University of Science and Technology, Sikar, India
| | - Madhushi Verma
- Department of Computer Science and Engineering, Bennett University, Noida, India
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47
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Leese GP, Soto-Pedre E, Schofield C. Independent Observational Analysis of Ulcer Outcomes for SINBAD and University of Texas Ulcer Scoring Systems. Diabetes Care 2021; 44:326-331. [PMID: 33288650 DOI: 10.2337/dc20-1817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/02/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to compare the University of Texas (UT) and Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) foot ulcer scores in predicting ulcer outcome within a routine diabetes foot clinic. RESEARCH DESIGN AND METHODS From 2006 to 2018, data were collected from all patients attending an outpatient diabetes foot clinic with an active ulcer not healed within 4 weeks. UT and SINBAD were compared in predicting ulcer outcome. A unified numerical score for UT was constructed and compared with UT grade (depth) and stage scores. Outcomes included death, a healed ulcer, or a nonhealed ulcer, which included major or minor amputation and nonhealing chronic ulcers. RESULTS Outcomes were available from 1,645 ulcer outcomes in 1,068 patients (mean [SD] age 65.4 [4] years, 72% male), of which 1,108 (67%) healed. With exclusion of death as an adverse outcome, the c-statistic (area under operator curve) was 0.67 (95% CI 0.65-0.71) for UT grade/depth and 0.64 (0.61-0.67) for UT stage. The new unified UT score had an improved c-statistic of 0.71 (0.68-0.74). The c-statistic was 0.72 (0.69-0.75) for SINBAD. There was a stepwise decrease in the proportion of ulcers healed for each increased score on ulcer grading for both grading schemes. CONCLUSIONS This large and independent observational comparison, in a real-world clinical setting, demonstrated that the UT and SINBAD diabetes foot ulcer grading schemes had similar prognostic ability for predicting foot ulcer outcomes. We have devised and validated a unified numerical scoring system for UT.
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Affiliation(s)
- Graham P Leese
- Strathmore Diabetes Centre, Ninewells Hospital, Dundee, U.K.
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48
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Vera-Cruz PN, Palmes PP, Tonogan L, Troncillo AH. Comparison of WIFi, University of Texas and Wagner Classification Systems as Major Amputation Predictors for Admitted Diabetic Foot Patients: A Prospective Cohort Study. Malays Orthop J 2021; 14:114-123. [PMID: 33403071 PMCID: PMC7751999 DOI: 10.5704/moj.2011.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Classifications systems are powerful tools that could reduce the length of hospital stay and economic burden. The Would, Ischemia, and Foot Infection (WIFi) classification system was created as a comprehensive system for predicting major amputation but is yet to be compared with other systems. Thus, the objective of this study is to compare the predictive abilities for major lower limb amputation of WIFi, Wagner and the University of Texas Classification Systems among diabetic foot patients admitted in a tertiary hospital through a prospective cohort design. Materials and Methods: Sixty-three diabetic foot patients admitted from June 15, 2019 to February 15, 2020. Methods included one-on-one interview for clinico-demographic data, physical examination to determine the classification. Patients were followed-up and outcomes were determined. Pearson Chi-square or Fisher’s Exact determined association between clinico-demographic data, the classifications, and outcomes. The receiver operating characteristic (ROC) curve determined predictive abilities of classification systems and paired analysis compared the curves. Area Under the Receiver Operating Characteristic Curve (AUC) values used to compare the prediction accuracy. Analysis was set at 95% CI. Results: Results showed hypertension, duration of diabetes, and ambulation status were significantly associated with major amputation. WIFi showed the highest AUC of 0.899 (p = 0.000). However, paired analysis showed AUC differences between WIFi, Wagner, and University of Texas classifications by grade were not significantly different from each other. Conclusion: The WIFi, Wagner, and University of Texas classification systems are good predictors of major amputation with WIFi as the most predictive.
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Affiliation(s)
- P N Vera-Cruz
- Department of Internal Medicine, West Visayas State University Medical Center, Iloilo City, Philippines
| | - P P Palmes
- Department of Internal Medicine, West Visayas State University Medical Center, Iloilo City, Philippines
| | - Ljm Tonogan
- Department of Orthopaedics, West Visayas State University Medical Center, Iloilo City, Philippines
| | - A H Troncillo
- Department of Orthopaedics, West Visayas State University Medical Center, Iloilo City, Philippines
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49
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Reis JMCD, Wanzeller RRM, Meireles WM, Andrade MCDE, Gomes VHGA, Arrais JAA, Ishak G. Demographic and socioeconomic profiles of patients admitted with diabetic foot complications in a tertiary hospital in Belem - Para. Rev Col Bras Cir 2020; 47:e20202606. [PMID: 33263651 DOI: 10.1590/0100-6991e-20202606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/28/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE to assess the socioeconomic and demographic profiles of patients hospitalized with a diagnosis of diabetic foot in a tertiary hospital in Belem-PA, Brazil, as well as to evaluate risk factors for lower limb amputations in such patients, classifying them according to the Wagner and PEDIS classifications. METHODS we conducted a descriptive, cross-sectional, unicentric, and analytical study carried out through a structured questionnaire. RESULTS the study consisted of 57 patients, aged between 48 and 84 years old, 66.7% being male. The average income ranged between one and three (61.4%) minimum wages and below one minimum wage (31.6%). Type II Diabetes Mellitus was predominant (86.0%). Concerning comorbidities, arterial hypertension displayed the highest proportion (62.3%), followed by dyslipidemia (52.8%). Smokers comprised 35.1% of the sample. Infectious diabetic foot (50.9%) and mixed diabetic foot (49.1%) were the most common. Of the 20 patients with previous amputation, 90% had undergone minor amputation, and 10%, major ones. Callosity (92.6%) was the most prevalent deformity. Fifty-four (94.7%) patients underwent surgery, those being debridement (24.1%), minor amputation (37.0%) and major amputation (38.9%). During hospitalization, 78.9% of individuals did not require ICU stay. Hospitalization time varied between three and 59 days, and 78.9% of hospitalized patients did not progress to death, but 43.1% of patients submitted to major amputations died. CONCLUSION patients with diabetic foot followed-up have a low socioeconomic profile; most of them underwent surgical procedures, whether major or minor, due to the higher prevalence of infectious diabetic foot and/or non-adherence to non-operative treatment.
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Affiliation(s)
- JosÉ Maciel Caldas Dos Reis
- - Centro Universitário Metropolitano da Amazônia (UNIFAMAZ), Cirurgia Vascular, Disciplina de Habilidades Cirúrgicas - Belém - PA - Brasil
| | - Robson Roberto Melo Wanzeller
- - Hospital Universitário João de Barros Barreto, Departamento de Cirurgia Geral e do Aparelho Digestivo - Belém - PA - Brasil
| | - Wilame Melo Meireles
- - Hospital Universitário João de Barros Barreto, Departamento de Cirurgia Geral e do Aparelho Digestivo - Belém - PA - Brasil
| | | | | | - JosÉ Aroldo Alves Arrais
- - Hospital Universitário João de Barros Barreto, Departamento de Cirurgia Geral e do Aparelho Digestivo - Belém - PA - Brasil
| | - Geraldo Ishak
- - Hospital Universitário João de Barros Barreto, Departamento de Cirurgia Geral e do Aparelho Digestivo - Belém - PA - Brasil
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50
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Diabetic Foot Ulcer Assessment and Management: Use of Classification Systems for Healing Progress. Adv Skin Wound Care 2020; 33:670-671. [DOI: 10.1097/01.asw.0000722268.83883.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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