Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis in the Eurodiale subgroup

Plantar pressure measurement in diabetic foot disease: A scoping review

AIMS/INTRODUCTION

Patients with a healed diabetic foot ulcer (DFU) have a 40% risk of ulcer recurrence within a year. New and effective measures to prevent DFU recurrence are essential. We aimed to highlight emerging trends and future research opportunities in the use of plantar pressure measurement to prevent DFU recurrence.

MATERIALS AND METHODS

Our scoping review protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis - Scoping Review protocol. Peer-reviewed, English-language papers were included that addressed both plantar pressure measurement and diabetic foot disease, either as primary studies that have advanced the field or as review papers that provide summaries and/or opinion on the field as a whole, as well as specific papers that provide guidelines for future research and advancement in the field.

RESULTS

A total of 24 eligible publications were identified in a literature search using PubMed. A further 36 eligible studies were included after searching the references sections of these publications, leaving a total of 60 publications included in this scoping review.

CONCLUSIONS

Plantar pressure measurement can and will play a major role in the prevention of DFU. There is already a strong, albeit limited, evidence base in place to prove its benefit in reducing DFU recurrence. More research is required in larger populations, using remote monitoring in real-world settings, and with improved technology.

Relaxation intervention to improve diabetic foot ulcer healing: protocol for a pilot study with a nested qualitative study

OBJECTIVE

A mixed-methods approach nested in a pilot three-arm randomised controlled trial (RCT) was conducted to evaluate the feasibility and acceptability of an intervention of progressive muscle relaxation with guided imagery (experimental group) compared to a neutral guided imagery placebo (active control group) and a group that did not receive any psychological intervention (passive control group). The purpose was to inform a future definitive RCT that will test its effectiveness. Qualitatively, this study examined patients and health professionals' perspectives regarding the relaxation intervention, in order to assess the acceptability and applicability of relaxation as an adjuvant therapy.

METHOD

Participants must have had a diagnosis of diabetes and diabetic foot disease; one or two active hard-to-heal ulcers at the time of the assessment; and clinical levels of stress or anxiety or depression. Participants were randomised and assessed at three timepoints after the first hospital consultation for hard-to-heal diabetic foot ulcer (DFU).

RESULTS

Rates of eligibility, recruitment, refusal, adherence to study protocol, participation in follow-up and dropout, and patients' satisfaction with the relaxation intervention were assessed as primary outcomes. Secondary outcomes were DFU healing; patients' DFU-related quality of life; physical and mental quality of life; perceived stress; emotional distress; adherence to DFU care; perceptions of DFU; as well as arterial systolic/diastolic pressure and heart rate.

CONCLUSION

The results of this pilot study contributed to clarification and better elucidation of the benefits of relaxation techniques regarding patients' HRQoL and DFU healing.

DECLARATION OF INTEREST

Funding: This study was conducted at the Psychology Research Centre (CIPsi/UM) School of Psychology, University of Minho, Portugal and supported by the Foundation for Science and Technology (FCT) through the Portuguese State Budget (UIDB/01662/2020) and by a PhD fellowship from FCT assigned to GF (SFRH/BD/131780/2017) and an FCT grant (PTDC/PSI-GER/28163/2017) assigned to MGP. The authors have no conflicts of interest to declare.

Analysis of factors influencing the recurrence of diabetic foot ulcers

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical characteristics, risk factor analysis and peripheral blood cell changes for early warning of multidrug-resistant bacteria (MDR) infection in elderly patients

OBJECTIVE

To explore peripheral blood indicators that may serve as early indicators for multidrug-resistant bacteria (MDR) infections in this demographic, with the goal of providing reference suggestions for the clinical prevention of MDR infections in elderly inpatients.

METHODS

Clinical data of patients were divided into the MDR-infected group (n = 488) and the MDR-uninfected group (n = 233) according to the results of drug sensitivity experiments, risk factors for MDR infection, and peripheral blood indicators related to MDR infections were analyzed using univariate and multivariate logistic regression in conjunction with the construction of a Chi-squared automatic interaction detector (CHAID) decision tree model, considering statistical significance at p < .05.

RESULTS

Of 721 patients, 488 multidrug-resistant strains were identified. Among them, with Staphylococcus spp. the most prevalent in 148 strains. The most frequent detection of MDR occurred in puncture fluid samples (167 cases). Univariate and multivariate regression analyses revealed that prolonged hospitalization, use of antibiotics preadmission, duration of antibiotics, invasive procedures or recent surgery, and coexisting lung disease were independent risk factors for contracting MDR. Subsequent analysis comparing the aforementioned influences with peripheral blood cells revealed associations between the number of antibiotic treatment days and increased neutrophil-to-lymphocyte ratio (NLR), platelet count-to-lymphocyte ratio (PLR), neutrophils, decreased lymphocytes, and increased eosinophils; preadmission antibiotic use correlated with increased PLR, NLR, neutrophils, and decreased lymphocytes; and invasive manipulation or surgery correlated with increased PLR and NLR.

CONCLUSIONS

Elevated NLR, PLR, neutrophils, lowered lymphocytes, and eosinophils may serve as early indicators of MDR infections in elderly hospitalized patients.

The risk factors in diabetic foot ulcers and predictive value of prognosis of wound tissue vascular endothelium growth factor

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.

Recurrence of Diabetic Foot Complications: A Domino Effect Leading to Lethal Consequences-Insights From a National Longitudinal Study

Background

Foot complications are common in people with diabetes mellitus (DM), leading to increased health care utilization, heightened mortality risk, and notable recurrence rates even after treatment. This retrospective cohort study aimed to investigate the impact of repeated occurrence of DM-related foot complications on the risk of all-cause mortality and to identify the potential risk factors associated with repeated events.

Methods

People with DM admitted with foot complications (ulcer, skin and soft tissue infection, or osteomyelitis) from 2012 to 2014 were identified from Taiwan's National Health Insurance Research Database, with a 3-year follow-up for repeated events. We categorized the study subjects based on their cumulative number of hospital admissions with foot complications. Logistic regression was conducted to explore the potential risk factors associated with repeated diabetic foot events. Kaplan-Meier curves and Cox proportional hazard models were used to examine the associations between repeated diabetic foot events and all-cause mortality.

Results

In this study, 28 754 eligible individuals were enrolled and classified into 3 groups: no repeated diabetic foot events (76.1%), 1 repeated event (16.0%), and 2 or more repeated events (7.9%). Logistic regression revealed that advanced age, male sex, congestive heart failure, dyslipidemia, hypertension, nephropathy, retinopathy, neuropathy, peripheral vascular disease, diabetes-related preventable hospitalizations, and outpatient visits due to diabetic foot were significantly associated with repeated events of diabetic foot complications. Compared with those with no repeated events, the adjusted hazard ratios for all-cause mortality were 1.26 (95% CI, 1.19-1.34) for 1 repeated event and 1.36 (95% CI, 1.26-1.47) for 2 or more repeated events.

Conclusions

The significant association between repeated diabetic foot and elevated mortality risk highlights the critical necessity for proactive and targeted patient care within clinical practice. More research to delve into the predictive factors related to the repeated occurrence of diabetic foot is needed to provide additional insights for prevention strategies.

The potential impact and diagnostic value of inflammatory markers on diabetic foot progression in type II diabetes mellitus: A case-control study

BACKGROUND

The wound-healing process in diabetic foot is affected by pro and anti-inflammatory markers, and any disruption in the inflammatory reaction interferes with tissue homeostasis, leading to chronic non-wound healing.

AIM

This study aimed to determine the diagnostic value and effect of CRP, IL-6, TNF, and HbA1c on initiation the and progression of diabetic foot ulcers.

METHOD

ELISA was used to quantify IL-6, TNF, CRP, and HbA1c in 205 patients with diabetes, and 105 were diabetic foot free. The prevalence and progression of diabetic foot were also evaluated. The area under the curve (AUC) was calculated using the receiver operating characteristic (ROC) curve to analyze the predictive values. Forward stepwise logistic regression analysis was used to compute the odds ratio (OR) and the corresponding 95% confidence intervals (CIs).

RESULTS

CRP, IL-6, and FBS were found to be significant predictors of diabetic foot (OR=1.717, 95% CI=1.250-2.358, P=0.001; OR=1.434, 95% CI=1.142-1.802, P=0.002; and OR=1.040, 95% CI=1.002-1.080, P=0.037), respectively. The AUCs for CRP, IL-6, and HbA1c in predicting diabetic foot were 0.839, 0.728, and 0.834, respectively, demonstrating a good predictive value for each diagnostic marker.

CONCLUSION

The current study demonstrated that IL-6, CRP, and HbA1c may be useful biomarkers to indicate diabetic foot progression. Furthermore, our findings showed a substantial relationship between CRP and HbA1c in individuals with diabetic foot conditions.

Redefining Wound Healing Using Near-Infrared Spectroscopy

OBJECTIVE

No standard definition for a completely healed wound currently exists; it is recommended that providers use a reliable wound assessment tool to determine healing. The objective of this feasibility study was to determine if a point-of-care, noncontact, near-infrared (NIR) imaging device could provide an objective measure of wound resolution and guide clinical decision-making for the optimal time to transition from protective wound dressings and gradual return to full activity.

METHODS

In this single-center feasibility study, adult patients 18 years and older with a lower extremity wound of any size and etiology were seen weekly for wound assessment and standard-of-care treatment. The researchers performed serial imaging with a point-of-care, noncontact, NIR imaging device (Snapshot NIR ; Kent Imaging Inc) to assess the wound and surrounding skin and evaluated the difference in time to 100% reepithelialization on visual inspection and homogeneous tissue oxygen saturation levels at the wound site and surrounding closed skin envelope.

RESULTS

An average time difference of 13.5 ± 10 days (median, 12 days; range, 0-35 days) was observed between 100% reepithelialization on visual wound inspection and imaging assessment. Further, NIR imaging could determine when a patient was at risk for recurrent wound breakdown.

CONCLUSIONS

The addition of point-of-care, noncontact, NIR imaging may help guide clinical decision-making for the optimal time to transition from protective wound dressings with gradual return to full activity and minimize wound recurrence.

The Potential of Autologous Platelet-Rich Plasma Gel for Diabetic Foot Ulcer Care Among Older Adults: A Systematic Review and Meta-Analysis

Introduction

Poorly controlled diabetes mellitus can lead to the development of diabetic foot ulcers (DFU), which is a frequent complication in patients. However, several diabetes management guidelines for older adults do not mention the occurrence of DFUs. Nowadays, Autologous Platelet-Rich Gel (APG) is being used for treating diabetic ulcers. APG is an innovative platelet-derived product with many advantages, such as being low-cost, easy to produce, and readily available materials. Additionally, it does not lead to any rejection reaction.

Objective

This study aims to assess the safety and efficacy of APG as a novel treatment of DFU compared with standard treatment in older adult patients.

Methods

Randomized Controlled Trials (RCTs) were searched using PubMed, Cochrane, Google Scholar, Wiley, and PlosOne. The keywords have been arranged using the Boolean operator, including autologous platelet-rich gel, DFU, and elderly. The data was screened by inclusion and exclusion criteria. The final inclusion study was analyzed and synthesized by tabulation, clusterization, contextual and thematic approach, and assessed for risk of bias using ROB 2.0. Meta-analysis was conducted by using Review Manager 5.4 and the Mantel Haenszel method.

Results

Eight RCTs with 598 patients were eligible for the present analysis. Compared with standard care/conventional treatment, APG could significantly improve the healing wound in patients with diabetic foot ulcers (Relative risk (RR) 1.32, 95% confidence interval (CI) 1.22-1.57, p < 0.0001), shortened the healing time (Mean difference [MD] -16.97 days (95% CI: -32.64 to -1.29; p < 0.00001), shortened the length of hospital stay (MD= -20.11, 95% CI: -38.02, -2.20; p = 0.03), and amputation rate (MD= 0.36, 95% CI: 0.16, 0.84; p = 0.02).

Conclusion

APG treatment can better treat DFU in terms of duration of healing, wound healing, length of hospital stay, and amputation prevention than the standard treatment.

Effect of Early Rehabilitation on Gait, Wound and Home Discharge in Lower Extremity Chronic Wound Patients: A Japanese Multicenter Retrospective Study

This study investigated the effect of early rehabilitation on gait restoration, wound healing, and home discharge in patients with lower extremity (LE) chronic wounds. This multicenter, retrospective cohort study included 233 Japanese inpatients who received treatment for LE chronic wounds from April 2012 to March 2015. A multivariate analysis was conducted using outcomes of gait restoration, wound healing, and home discharge as dependent variables. Other survey items were used as independent variables. Early rehabilitation was extracted as an independent factor with gait restoration (hazard ratio [HR] 1.82, P < .01) and home discharge (HR 1.77, P < .001) as dependent factors by the stepwise method in Cox proportional-hazards regression analysis, but it was not extracted as an independent factor with wound healing as the dependent factor by the stepwise method as well as the forced entry method (P = .44). A significant relationship between the presence of gait restoration and home discharge was observed in the chi-square test (P<.001), and the duration from admission to gait restoration was significantly correlated to the duration from admission to home discharge (Pearson's product-moment correlation coefficient; r=.89, P<.0001). Early rehabilitation was a positive factor for gait restoration and home discharge in chronic LE wound patients.

Comparison of customized vacuum sealing drainage and vacuum sealing drainage in the treatment of diabetic foot ulcers: a retrospective analysis

BACKGROUND

The prevalence of diabetic foot ulcers, a common, more serious chronic diabetes-related complication, is increasing. Vacuum sealing drainage (VSD) constitutes an effective adjunctive treatment for diabetic foot ulcers. Factors, such as poor glycemic control, ischemia, and infection prolong wound healing time, and VSD products are expensive and unaffordable for many patients.

OBJECTIVE

To compare the use of customized VSD and customized VSD in the treatment of diabetic foot ulcer.

METHOD

This retrospective study included 83 patients with diabetic foot ulcers in customized VSD (n = 44) and VSD (n = 39) groups. Baseline data, efficacy after 14 days, total treatment efficiency, final outcome (28 days after treatment, healing rate), average treatment cost, and hospitalization (days) of the two groups were compared. Factors affecting wound healing were analyzed.

RESULTS

No significant intergroup differences in the baseline data were detected (VSD vs. customized VAD, p > 0.05). Treatment efficacy was higher in the customized VSD group than in the VSD group after 14 days (p < 0.05), although total treatment efficiency in both groups reached 100%. The final outcome in the customized VSD group was better (vs. VSD group, p < 0.05), and the wound healing rate was higher than in the VSD group (66.7% vs. 33.3%). The mean treatment cost and hospital days were greater in the VSD group (vs. customized VSD group; p < 0.05). Factors affecting wound healing include age, Wagner classification, HDL-C, and fasting C-peptide. Younger age, low Wagner classification grade, low HDL-C level, and high fasting C-peptide contribute to higher healing rate, CONCLUSION: Efficacy and final outcome of customized VSD were better than that of VSD; the customized VSD device is simple and convenient to operate, and enables cost-effective treatment.

Upregulation of circ_0080968 in diabetic foot ulcer inhibits wound healing via repressing the migration and promoting proliferation of keratinocytes

BACKGROUND

Diabetic foot ulcer (DFU) is a serious chronic complication of diabetes mellitus whose pathogenesis remains unclear. Circular RNA (circRNA) refers to a group of covalently closed non-coding RNAs that are reported to be dysregulated in patients with DFU. However, the mechanism whereby dysregulation in circRNAs contributes to DFU remains unclear. In this study, we investigated the role of dysregulated circRNAs in DFU.

MATERIALS AND METHODS

A gene expression dataset was downloaded from the Gene Expression Omnibus portal and analyzed by the limma package of R. The levels of 24 upregulated circRNAs were detected in two independent cohorts by RT-qPCR. Interactions between miRNAs and circRNAs were predicted through bioinformatics and confirmed using a dual luciferase assay. The circularity and subcellular localization of circRNA-080968 was examined by northern blotting after digestion with RNase-R and in situ hybridization. Cell migration and proliferation were examined using Transwell and MTT assays. The apoptotic cells were detected by flow cytometry.

RESULTS

The level of circRNA-080968 was upregulated in DFU tissues compared to that of non-DFU samples and normal human wounds. CircRNA-080968 was mainly localized in the cytoplasm and its overexpression inhibited the migration and promoted the proliferation of keratinocytes. MiR-326 and miR-766-3p were identified to interact with and be negatively correlated with circRNA-080968 levels. Increased glucose upregulated circRNA-080968, and its overexpression accelerated the degradation of both miR-326 and miR-766-3p. Reduced levels of miR-326 and miR-766-3p upregulated the expression of several genes controlling cell adhesion and proliferation which are related to the pathogenesis of DFU.

CONCLUSIONS

The upregulation of circRNA-080968 in DFU induced the degradation of miR-326 and miR-766-3p, which further repressed the migration and increased the proliferation of keratinocytes.

Effect of hyperbaric oxygen treatment on diabetic foot ulcers: A meta-analysis

The meta-analysis aimed to assess the effect of hyperbaric oxygen treatment on diabetic foot ulcers. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 17 examinations from 1992 to 2022 were enrolled for the present meta-analysis, including 7219 people with diabetic foot ulcers. Hyperbaric oxygen treatment had a significantly higher healed ulcer (OR, 14.39; 95% CI, 4.02-51.52, p < 0.001), higher adverse event (OR, 2.14; 95% CI, 1.11-4.11, p = 0.02), lower mortality (OR, 0.22; 95% CI, 0.07-0.71, p = 0.01) and higher ulcer area reduction (MD, 23.39; 95% CI, 11.79-34.99, p < 0.001) compared to standard treatment in patients with diabetic foot ulcers. However, hyperbaric oxygen treatment and standard treatment had no significant difference in amputation (OR, 0.62; 95% CI, 0.22-1.75, p = 0.37), major amputation (OR, 0.59; 95% CI, 0.18-1.92, p = 0.38), minor amputation (OR, 0.64; 95% CI, 0.15-2.66, p = 0.54) and healing time (MD, -0.001; 95% CI, -0.76 to 0.75, p = 0.99) in patients with diabetic foot ulcers. The examined data revealed that hyperbaric oxygen treatment had a significantly higher healed ulcer, adverse event, and ulcer area reduction and lower mortality, however, there was no significant difference in amputation and healing time compared to standard treatment in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size and some of the comparisons had a low number of selected studies.

Chronic Venous Disease and Its Intersections With Diabetes Mellitus

Chronic venous disease (CVD) is a vascular disorder in which blood return is severely compromised and CVD is usually characterized by venous hypertension. Along with obesity and diabetes mellitus, CVD is one of the most common civilization diseases. In general, the estimated prevalence of CVD ranges from 60-80 %. Early diagnosis and adequate treatment are important for preventing progression to more severe stages of the disease like venous leg ulcers. Clinical manifestations of CVD in initial stages of the disease are often asymptomatic. However, as CVD progresses, symptoms begin to develop. Treatment of CVD could be divided into conservative and surgical. Conservative therapy consists of compression, pharmacological treatment and lifestyle change. In cases where conservative therapy is ineffective, surgical or endovascular treatment may be required. The intersections between diabetes mellitus (DM) and CVD are not to be underestimated. CVD and DM have often the same risk factors. Symptoms of CVD can be modified by late complications of DM, but the incidence of different CVD degrees seems to be the same as in diabetics as in non-diabetics population. We are particularly concerned in diabetics about worse compliance with treatment due to their often-poorer adherence to treatment of DM and lifestyle changes. Moreover, there exist a higher risk of CVD and peripheral arterial disease in diabetics patients. Patients with CVD should always be inspected for the presence of DM, considering its presence can have a bearing on CVD symptoms, diagnostic procedures, and therapeutic strategies.

Glucagon-like peptide-1: a multi-faceted anti-inflammatory agent

Inflammation contributes to many chronic conditions. It is often associated with circulating pro-inflammatory cytokines and immune cells. GLP-1 levels correlate with disease severity. They are often elevated and can serve as markers of inflammation. Previous studies have shown that oxytocin, hCG, ghrelin, alpha-MSH and ACTH have receptor-mediated anti-inflammatory properties that can rescue cells from damage and death. These peptides have been studied well in the past century. In contrast, GLP-1 and its anti-inflammatory properties have been recognized only recently. GLP-1 has been proven to be a useful adjuvant therapy in type-2 diabetes mellitus, metabolic syndrome, and hyperglycemia. It also lowers HbA1C and protects cells of the cardiovascular and nervous systems by reducing inflammation and apoptosis. In this review we have explored the link between GLP-1, inflammation, and sepsis.

The foot in diabetes - a reminder of an ever-present risk

The term 'diabetic foot disease' (DFD) often signifies the presence of foot ulceration and infection, but one must also be wary of the rarer occurrence of Charcot foot disease. The worldwide prevalence of DFD is 6.3% (95%CI: 5.4-7.3%). Foot complications present a major challenge to both patients and healthcare systems, with increased rates of hospitalisation and an almost trebled 5-year mortality. The Charcot foot often occurs in patients with long-standing diabetes, presenting as an inflamed or swollen foot or ankle, following unrecognised minor trauma. This review focuses on the prevention and early identification of the 'at-risk' foot. DFD is best managed by a multi-disciplinary foot clinic team consisting of podiatrists and healthcare professionals. This ensures a combination of expertise and provision of a multi-faceted evidence-based treatment plan. Current research using endothelial progenitor cells (EPC) and mesenchymal stem cells (MSC) offers a new dimension in wound management.

Diabetic Foot Considerations Related to Plantar Pressures and Shear

Diabetic foot ulcers are a complex, multifaceted, and widespread complication of diabetes mellitus. Although there are a multitude of risk factors contributing to diabetic foot ulcer development, pressure and (more recently) shear stresses are two biomechanical metrics that are gaining popularity for monitoring risk factors predisposing skin breakdown. Other areas of diabetic foot ulcers under research include plantar temperature measuring, as well as monitoring wear-time compliance and machine learning/AI algorithms. Charcot arthropathy is another diabetes complication that has a relationship with diabetic foot ulcer development, which should be monitored for development alongside ulcer development. The ability to monitor and prevent diabetic foot ulcer development and Charcot neuroarthropathy will lead to increased patient outcomes and patient quality of life.

A case series of autologous platelet-rich plasma injection in treating chronic ulcers conducted in Saudi Arabia

Objective

This is a case series study of 14 cases of chronic unhealed ulcers involving patients of 19-85 years, aimed to demonstrate the positive therapeutic outcomes of using autologous platelet rich plasma (PRP) in diabetic foot ulcer (DFU) and other chronic wound healing.

Methods

This is a formal consecutive clinical case series. Patients with chronic unhealed ulcers were enrolled from the amputation prevention clinic by an interdisciplinary team includes podiatrist, general surgeon, orthopedic, vascular surgeon, and wound care nurses at Kahel Specialized Centre, a specialized center for managing foot and ankle diseases, located in Riyadh, Saudi Arabia. Those patients who presented with chronic wounds and showed no significant wound reduction despite following the standard wound care protocol were included in the study. There were no specific predetermined exclusion criteria when considering patients for treatment with this modality.

Results

In this case series, majority (80%) of the patients were above 50 years of age, and 10 (66.7%) patients were male and 5 (33.3%) were female. Of all the cases presented to the amputation prevention clinic, majority (73.3%) reported suffering from type 2 diabetes mellitus (DM) and also, one reported type 1 DM [6.7%]). All the cases of DFU received a combination of hydrogel and autologous PRP treatment and were put of suitable offloading devices, except one case received a combination of Cadexomer iodine, hydrogel and PRP treatment. In the present case series involving 3-14 weeks of the treatment duration, only 2-3 doses of autologous PRP provided complete healing and or maximum wound closure.

Conclusion

Autologous PRP therapy is efficacious in facilitating, enhancing wound healing and aids in complete wound closure. This case series was limited in term of the sample size which is the number patients enrolled for the study, hence, the study finding remain inconclusive to some extent and hence, further study is required with greater number of sample size. The strength of this study is that it is the first study in Saudi Arabia and gulf region, to report the beneficial effect of PRP in chronic unhealed ulcers including diabetic ulcers.

Recurrent diabetic foot ulcers: Results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery

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.

The Validity and Efficacy of a Preventative Intervention Model for Reducing Ulcer Recurrence in Diabetic Patients in Indonesia

Introduction

It is important to reduce foot problems by preventing the recurrence of ulcers in diabetes mellitus (DM) patients. In Indonesia, interventions for the prevention of ulcer recurrence remain scarce.

Objective

The present study aimed to evaluate the validity and efficacy of a proposed intervention model for preventing the recurrence of ulcers in DM patients.

Method

Sixty-four DM patients were selected to participate in this quasi-experimental study and divided into two groups: intervention (n  =  32) and control (n  =  32). The intervention group received preventive treatment while the control group received standard care. Two trained nurses supported this study.

Results

Of the 32 participants in the intervention group, 18 (56.20%) were male, 25 (78.10%) were non-smokers, 23 (71.90%) had neuropathy, 14 (43.80%) had foot deformities, four (12.50%) had recurring ulcers, and 20 (62.50%) had a previous ulcer  < 12 months ago. Of the 32 participants in the control group, 17 (53.10%) were male, 26 (81.25%) were non-smokers, 17 (46.90%) had neuropathy, 19 (69.40%) had foot deformities, 12 (37.50%) had recurring ulcers, and 24 (75.00%) had a previous ulcer < 12 months ago. The mean (SD) age [62 (11.28) and 59 (11.11) years], ankle-brachial index [1.19 (0.24) and 1.11 (0.17)], HbA1C [9.18 (2.14%) and 8.91 (2.75%)], and DM duration [10.22 (6.71) and 10.13 (7.54)] of the intervention and control groups did not differ significantly. The content validity of the proposed intervention model was strong (I-CVI > 0.78). When the proposed screening tool for predicting the risk of ulcer recurrence in DM patients (NASFoHSkin) was used in the intervention group, its predictive validity, sensitivity, and specificity were 4, 100%, and 80%, respectively, while in the control group it was 4, 83%, and 80%, respectively.

Conclusion

Inspection/examination, foot care, and blood glucose control can decrease ulcer recurrence in DM patients.

Risk factors for diabetic foot ulcers mortality and novel negative pressure combined with platelet-rich plasma therapy in the treatment of diabetic foot ulcers

The purpose of this study was to assess the risk factors for morbidity and mortality of diabetic foot ulcers (DFUs). For the treatment of diabetic foot ulcers, negative pressure wound therapy (NPWT) combined with platelet-rich plasma-fibrin glue (PRP) was also investigated. There were 653 patients in the diabetic foot ulcer group and 510 patients in the diabetic patients without foot ulceration (NFU) group, for a total of 1163 patients in the study samples after individuals without follow-up were excluded. The patients were randomized into two groups: the negative pressure wound therapy group and the negative pressure wound therapy combined with the PRP group. The findings of the univariate analysis revealed the blood indicators for predicting diabetic foot ulcer morbidity risk factors, such as C-reactive protein, albumin, creatinine, alkaline phosphatase, procalcitonin, platelets, 25-hydroxyvitamin D, β-2-microglobulin, monocyte ratio, low-density protein cholesterol (LDL), triglyceride, alanine aminotransferase (ALT), aminotransferase (AST), creatine kinase (CK) and total cholesterol. Using logistic regression analysis revealed only albumin and age to be independent predictors of diabetic foot ulcer mortality. Our study also revealed that, compared to negative pressure wound therapy alone, negative pressure wound therapy combined with PRP accelerated wound healing and reduced the mortality rate. According to the findings of this pilot study, new risk factors for diabetic foot ulcer morbidity and mortality have been found, and negative pressure wound therapy combined with PRP therapy may provide the first information that it is an effective adjunct treatment for diabetic foot ulcers.

Influencing factors for the recurrence of diabetic foot ulcers: A meta‐analysis

This study aims to systematically review and identify the related influencing factors for the recurrence of diabetic foot ulcers (DFUs)in diabetic patients. We searched PUBMED, EMBASE, Web of Science, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wan Fang and VIP databases to identify eligible studies published before March 31, 2022 to collect case-control studies or cohort studies on the related influencing factors for the recurrence of DFUs. Two reviewers independently screened the literature, and extracted data. Also, they assessed the risk of bias of the included studies using the Newcastle-Ottawa Scale. A meta-analysis was performed using RevMan5.4.1 software. 20 studies were included; 4238 patients were enrolled, in which 1567 were in the DFU recurrence group and 2671 were in the non-recurrent DFU group. Risk factors for the recurrence of DFUs included diabetic peripheral neuropathy (odds ratio [OR] = 4.05, 95% CI, 2.50-6.58, P < 0.00001), peripheral vascular disease (OR = 3.94, 95% CI, 2.65-5.84, P < 0.00001), poor blood glucose control (OR = 3.27, 95% confidence interval [CI], 2.79-3.84, P < 0.00001), plantar ulcer (OR = 3.66, 95% CI, 2.06-6.50, P < 0.00001), osteomyelitis (OR = 7.17, 95% CI, 2.29-22.47, P = 0.0007), smoking (OR = 1.98, 95% CI, 1.65-2.38, P < 0.00001), history of amputation (OR = 11.96, 95%CI, 4.60-31.14, P < 00001), multidrug-resistant bacterial infection (OR = 3.61, 95%CI, 3.13-4.17, P < 0.00001), callus (OR = 5.70, 95%CI, 1.36-23.89, P = 0.02), previous diabetic foot ulcer (OR = 4.10, 95% CI, 2.58-6.50, P < 0.00001), duration of previous diabetic foot ulcer >60d (OR = 1.02, 95% CI, 1.00-1.03, P = 0.004), history of vascular intervention (OR = 3.20, 95% CI, 2.13-4.81, P < 0.00001) and Wagner grade III/IV (OR = 4.40, 95% CI, 2.21-8.78, P < 0.0001). However, no significant differences were found in age, duration of diabetes, body mass index, total cholesterol or foot deformity. Recurrence of diabetic foot ulcers is affected by a variety of factors. Thus, we should focus on high-risk groups and take targeted interventions as soon as possible to reduce the recurrence rate of DFUs, because of the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.

A long‐term follow‐up study of diabetic foot ulcer using micronized acellular dermal matrix

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.

Diabetic foot in primary and tertiary ( DEFINITE ) Care: A health services innovation in coordination of diabetic foot ulcer ( DFU ) Care within a healthcare cluster ‐ 18‐month results from an observational population health cohort study

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.

Clinical Efficacy of a 3D Foot Scanner app for the Fitting of Therapeutic Footwear in Persons with Diabetes in Remission: A Randomized and Controlled Clinical Trial

To evaluate the ability of high-risk patients with diabetes in remission to select proper therapeutic footwear (TF) and validate a novel 3D foot scanner app for selecting the proper fitting TF. We conducted a randomized and controlled clinical trial enrolling 30 patients with a previously healed diabetic foot ulcer carried out in a specialized diabetic foot unit between November 2021 and June 2022. All patients were recommended to TF with extra depth volume and rocker sole. The control group could acquire the TF size and model according to aesthetic preferences, while the experimental group had to acquire a specific size and model according to the result of a novel mobile app 3D feet scan. TF was recommended to change when the ill-fitting reasons were found, excessive length or tightness or compromise with toes. The primary outcome measure was the requirement of TF change after prescription because of ill-fitting. A total of seven patients required TF change, one of them (6.7%) in the experimental group and six patients (40%) in the control group (p = .031, 95% CI [0.011-1.04]). Reasons for ill-fitting were as follows: four patients due to excessive length and three patients due to toe compromise. The relative risk reduction for the need to change the TF via the foot scan compared to the control group was 83%, and the number needed to treat was 20. High-risk patients with diabetes tend to select TF with inadequate fitting (length or capacity), and they should be guided hand to hand to acquire proper TF.

Distal Metatarsal Osteotomies for Chronic Plantar Diabetic Foot Ulcers

In more than 30 years of scientific literature (1986-2021), the few published studies on the management of CPDFUs by DMOs showed satisfactory clinical and radiographic outcomes. Although these reports were all case series, their data suggest that DMOs, performed at a different level of the distal metatarsal bones, are an effective surgical treatment option for achieving rapid healing of CPDFUs and preventing their recurrence after balancing the pressures in diabetic forefeet. Hence, DMOs can be a valid alternative treatment method also for CPDFUs with chronic infection, ulcers penetrating deep structures, and even ulcers with osteomyelitis at the metatarsophalangeal level.

Efficacy and Clinical Value of Negative-Pressure Wound Therapy with Instillation (NPWTi) of Compound Phellodendron Liquid in the Treatment of Diabetic Foot Ulcer: A Prospective Cohort Study

Objective

To evaluate the efficacy and application value of compound Phellodendron liquid (CPL) for negative-pressure wound therapy with instillation (NPWTi) in the treatment of diabetic foot ulcers by observing the improvement of diabetic foot ulcers.

Methods

Sixty patients with diabetic foot ulcers who met the inclusion criteria were admitted to the Department of Peripheral Blood Vessels (Wound Repair) of Chongqing Hospital of Traditional Chinese Medicine from August 2020 to August 2021. The random number table method divided it into the CPL NPWTi group and normal saline NPWTi group, with 30 cases in each group. The experimental group adopted FufangHuangbaiye for NPWTi, and the control group used normal saline for NPWTi. The treatment effect was evaluated by baseline index, wound healing observation index, inflammatory factor index, pain scores during dressing change, and the number of days in hospital.

Results

After 10 days of treatment, the symptom integration, procalcitonin (PCT), and C reactive protein (CRP) of the CPL NPWTi group were significantly reduced compared with the normal saline NPWTi group, while there was no obvious difference between wound area and erythrocyte sedimentation rate (ESR). The wound area, symptom integral, PCT, ESR, and CRP of the CPL NPWTi group were significantly reduced compared with the normal saline NPWTi group after treatment for 20 days and 30 days. The positive proportion of bacterial culture in the CPL NPWTi group was significantly reduced compared with the normal saline NPWTi group after treatment for 10 days, 20 days, and 30 days. After treatment, the pain scores during dressing change and the number of days in hospital in normal saline NPWTi group were significantly lower than those in the CPL NPWTi group.

Conclusion

Compound Phellodendron liquid NPWTi therapy can improve diabetic foot ulcers, providing a safe and effective method for treating diabetic foot ulcers.

Is in-Shoe Microclimate a Neglected Contributor in the Pathway to Diabetic Foot Ulceration?

The identification of the key contributing factors which predispose the foot to ulceration, increasing the risk of recurrence and slow wound healing in diabetes mellitus (DM), has led to some significant research studies over the last 30 years, providing valuable insight into the mechanism leading to diabetic foot ulceration (DFU). Although, these contributory factors are similar to those identified in pressure ulceration occurring in other parts of the body (such as "bed pressure sores') where magnitude and/or duration of mechanical stress in the presence of sensory deficits are key causal factors, research investigating pressure ulceration has also included measurement of temperature and relative humidity at the interface between the skin and supporting surface. The possible influence of these parameters (in-shoe temperature and humidity) does not appear frequently in diabetic foot ulceration research. Referred to as "microclimate", this has an important role in the pathway to tissue breakdown evidenced in pressure ulcer research and may be particularly relevant in countries with warm and humid climates. As the microclimate is influential in the ulceration pathway for other body sites, its role in the DFU causal pathway justifies further investigation.

Effects of wear and tear of therapeutic footwear in patients remission. A 5-year follow-up study

AIMS

To assesses the relationship between the wear and tear of therapeutic footwear (TF) and the risk of recurrence in diabetes remission patients.

METHODS

Remission patients (N = 115) participated in this 5-year prospective study in a specialized Diabetic Foot Unit between October 2016 and January 2022. Patients' TF was assessed in a three-month interval from Day 0 until ulcer recurrence was found. Primary outcome measure was based on the recurrent event in the forefoot.

RESULTS

A total of 82 patients (71.3%) renewed their TF, and 33 patients (28.7%) did not renew their TF during the follow-up period. Patients who failed to renew their TF group experienced more recurrent events (22 vs 14, p <.001, CI [0.04-0.259]) and minor amputations (11 vs 8, p =.002, CI [0.07-0.6]). Both groups showed different recurrence-free survival median times of 205.5 [Interquartile range (IQR) - 188-222] weeks and 89.9 [IQR - 53-126] weeks. Patients who did not renew their TF increased their risk of suffering from a recurrent event in the Cox regression model (p <.001, CI [0.03-0.38], Hazzard Ratio 0.147).

CONCLUSIONS

Patients who renewed their TF because of wear and tear experienced lower recurrences and minor amputations.

Recurrent foot ulcers in patients with diabetes mellitus in out-patient care

OBJECTIVE. Relapses of diabetic foot ulcers are an urgent problem of outpatient surgery, however, risk factors for relapse, as well as the definition of relapse itself remain a subject of discussion. The presented study investigates the frequency of relapses of ulcerative foot defects in diabetes mellitus, the risk factors for their development and treatment outcomes, based on the definition of relapse as the development of a repeated defect in the same place as the healed defect.METHODS AND MATERIALS. The data of 1714 patients with foot ulcers (2213 ulcerative defects) from 01.2012 to 01.2017 were studied. Patients were divided into two groups: with relapses (n=239, 13.9%) and without them (n=1475). Risk factors for relapse, characteristics of patients and ulcerative defects, and treatment outcomes were evaluated.RESULTS. Relative risk for relapse: type 1 diabetes mellitus (1.36); Charcot foot (1.65); history of amputation of the great toe (1.35); severe polyneuropathy (1.25); neuropathic foot (1.37). Relapses/single ulcer (%): superficial lesion 72.8/63.3 (р<0.01); primary healing: 61.1/52.7 (p=0.025); healing after surgery (amputations excluded): 4.2/4.5 (ns); amputations: 7.1/6.6 (ns) of which major 5.9/20.6 (p=0.01); non-healing (%): 11.7/5.5 (р=0.001); loss of follow-up (%): 15.9/30.7 (р=0.0001). Median duration of the treatment (days) of relapses/single ulcer: conservative 147/114; healing after surgery (amputations excluded) 241/170; after amputation 286/182. Revascularization in relapses – 7 (100%), with single ulcers – 66 (59.5% of patients with critical ischemia).CONCLUSION. 5-years relapse rate was 13.9 %. Patients with Charcot foot, postoperative deformities and with neuropathic form of diabetic foot syndrome are more prone for foot reulceration. Recurrent ulcers are characterized with longer duration of the treatment however their primary healing rate is higher compared with single ulcer group. The results of the study were significantly influenced by the high frequency of loss of follow-up in both groups.

Foot deformation analysis with different load-bearing conditions to enhance diabetic footwear designs

In-depth analyses of foot surface measurements upon weight bearing are crucial to understand how the dorsal and plantar surfaces of the foot deform during motion to enhance the fit of footwear, which is particularly important for diabetic patients with stringent fit requirements to redistribute the plantar weight forces. This study analyzes diabetic foot deformations under 3 different weight bearing conditions (no weight bearing, half weight bearing, and 80% weight bearing) by using a novel foot scanning method that enables efficient scanning of the dorsal and plantar surfaces of the foot simultaneously. The feet of 48 patients with diabetes mellitus (DM) are scanned. With increased load on the feet, the width of the forefoot increases by 9.7%-10.4%, height of the midfoot decreases by 15.1%-18.2%, forefoot and midfoot rotate to the medial side by 16.9%-23.9% while the rearfoot rotates to the lateral side by 15.2% simultaneously, and the plantar of the foot increases contact with the floor by 11.4%-23.0%. Gender differences in foot shape are also found between males and females, males have a broader foot than females for the same foot length. Precise anthropometric information of foot changes and deformation therefore enables adequate foot protection, fit and comfort when designing footwear. This research contributes to shoe design considerations that focus on the deformation of the foot under different loads.

Diabetic Foot Ulcer in Malaysia: Consensus on Treatment Patterns, Health Care Utilization and Cost

Healthcare resource utilization for Diabetic foot ulcers (DFUs) in Malaysia needs to be clarified. This modified Delphi panel study aimed to describe the clinical pathways for diabetic foot ulcer in Malaysia and to define the healthcare resources used and their costs. A systematic review of the literature was carried out on the management of diabetic foot ulcer in Malaysia. A modified Delphi panel involving 7 local experts was organized to validate the statements, in order to arrive at a consensus on the resources used for the treatment of DFU patients in Malaysia and their costs. A Markov model was then used to estimate the financial burden of DFU patients in Malaysia.The total cost per patient per annum was MYR 5981 in public and MYR 8581 in private setting. In the public setting, outpatient visits costs represent 50% of the overall cost, followed by medical devices which represent 38% of total costs. In the private setting, as in the public, outpatient visits and devices contribute the most to overall costs with 51% and 21%, respectively. However, hospital inpatient costs are higher in private setting and represent 14% of the total costs versus 5% in public setting.These findings may prove useful for clinicians and decision makers in understanding the economic implications of managing DFUs in Malaysia and the need for innovative therapies to reduce the burden for patients but also for the society.

Role of Dipeptidyl Dipeptidase 4 Inhibitors in the Management of Diabetic Foot

Background: Patients with diabetes mellitus face difficulties in wound healing. It is important to explore therapeutic options for diabetic complications such as ulcers. This study evaluates the role of dipeptidyl dipeptidase 4 inhibitors (DPP4i) in the management of diabetic foot. Methods: Literature search was conducted in electronic databases (Google Scholar, Ovid, PubMed, Science Direct, and Springer) and studies were selected for inclusion if they reported the incidence rate of diabetic foot ulcer during DPP4i treatment or evaluated the effect of DPP4i on wound healing. Incidence rates of foot ulcer, amputation and peripheral vascular disease were pooled to achieve overall estimates. Meta-analyses of odds ratios were performed to evaluate the risk of foot ulcer, amputation, and peripheral vascular disease with DPP4i, and to examine the effect of DPP4i treatment on ulcer healing. Results: Ten studies (532354 DPP4i and 2092010 non-DPP4i treated diabetes patients) were included. Incidence rates of foot ulcer, amputation, and peripheral vascular disease were 3.80 [95% confidence interval (CI): 0.22, 7.39], 0.82 [95%CI: 0.60, 1.05], and 22.33 [95%CI: 9.14, 35.53] per 1000 person-years respectively in patients treated with DPP4i and 3.60 [95%CI: 1.77, 5.39], 0.76 [95%CI: 0.58, 0.94], and 20.9 [95%CI: 16.04, 25.81] per 1000 person-years respectively in patients treated with non-DPP4i drugs. Risk of ulcer or amputation with DPP4i was not consistent across studies. Odds of non-healing of ulcer were significantly lower with DPP4i in comparison with controls (odds ratio: 0.27 [95%CI: 0.10, 0.71]; p = 0.008). Conclusion: Incidence rates of diabetic foot and amputation are found to be similar with DPP4i and non-DPP4i drugs. DPP4i improved wound healing of diabetic foot in 3-month randomized trials.

Analysis of risk factors for multidrug-resistant organisms in diabetic foot infection

BACKGROUND

To study the bacteriological characteristics, risk factors, and treatment of multi-drug resistance (MDR) organisms in patients with diabetic foot infection.

METHODS

Patients with diabetic foot ulcer admitted to hospital from June 2018 to December 2019 (n = 180) were selected as clinical subjects. Demographic information, routine blood test, wound culture and sensitivity were collected. Risk factors of MDR bacteria were analyzed.

RESULTS

Among 180 patients with diabetic foot ulcer, 146 were positive in bacterial culture, with 84 positive in MDR bacteria. A total of 182 strains were isolated, with 104 strains being multi-drug resistant. Body mass index, glycosylated hemoglobin, fasting blood glucose, triglyceride, course of ulcer, size of ulcer, peripheral neuropathy, peripheral vascular disease, osteomyelitis, peripheral blood leukocyte count, percentage of neutrophils, and previous use of antibiotics were the related factors of infection of MDR bacteria in diabetic foot ulcer patients (P < 0.05). The leukocyte count and neutrophil ratio of MDR-bacilli were lower than those of non MDR-bacilli (P < 0.05).

CONCLUSION

The risk of MDR bacteria in diabetic foot infection is high. It is necessary to evaluate the risk of multidrug-resistant bacteria by characterizing the course of disease, metabolic control, local ulcer and other aspects in order to formulate an effective treatment plan. The decrease of leukocyte count and neutrophil ratio may be related to damage of the host immune response.

Association Between Vitamin D Status and Diabetic Foot in Patients With Type 2 Diabetes Mellitus

Aims/Introduction

To assess the association between vitamin D and diabetic foot (DF) in patients with type 2 diabetes mellitus (T2DM), in order to summarize clinical evidence in the prevention and treatment of DF.

Materials and methods

Between January 2012 and December 2019, a total of 1,721 hospitalized patients with type 2 diabetes mellitus were continuously enrolled in West China Hospital, Sichuan University, and divided into DF and non‐DF groups according to whether they had DF, and divided into four subgroups according to the admission season. The 25‐OH‐vitamin D levels were compared between groups and subgroups, and independent risk factors discussed for the occurrence of DF.

Results

The vitamin D insufficiency and deficiency rate were higher in the DF group (77.51%) than in the non‐DF group (59.2%). The 25‐OH‐vitamin D levels were lower in the DF group (35.80 nmol/L) than in the non‐DF group (45.48 nmol/L) (P < 0.001). Patients with poor glycemic control had lower 25‐OH‐vitamin D levels (P = 0.01). The levels of 25‐OH‐vitamin D were lower in winter and spring. In the same season, the levels of 25‐OH‐vitamin D in patients with DF were still lower (P < 0.001). The 25‐OH‐vitamin D levels of patients with Wagner grades 0 to 5 showed a downward trend (P = 0.114). The 25‐OH‐vitamin D level was independently associated with diabetic foot (P < 0.001, OR = 0.986).

Conclusions

The low serum vitamin D level was significantly associated with a higher prevalence of DF among Chinese patients with type 2 diabetes mellitus. Although vitamin D levels vary seasonally, patients with DF were always at higher risk of having vitamin D insufficiency and deficiency.

Higher rates of all-cause mortality and resource utilization during episodes-of-care for diabetic foot ulceration

AIMS

Our primary objective was to determine whether all-cause rates of mortality and resource utilization were higher during periods of diabetic foot ulceration. In support of this objective, a secondary objective was to develop and validate an episode-of-care model for diabetic foot ulceration.

METHODS

We evaluated data from the Medicare Limited Data Set between 2013 and 2019. We defined episodes-of-care by clustering diabetic foot ulcer related claims such that the longest time interval between consecutive claims in any cluster did not exceed a duration which was adjusted to match two aspects of foot ulcer episodes that are well-established in the literature: healing rate at 12 weeks, and reulceration rate following healing. We compared rates of outcomes during periods of ulceration to rates immediately following healing to estimate incidence ratios.

RESULTS

The episode-of-care model had a minimum mean relative error of 4.2% in the two validation criteria using a clustering duration of seven weeks. Compared to periods after healing, all-cause inpatient admissions were 2.8 times more likely during foot ulcer episodes and death was 1.5 times more likely.

CONCLUSIONS

A newly-validated episode-of-care model for diabetic foot ulcers suggests an underappreciated association between foot ulcer episodes and all-cause resource utilization and mortality.

Cost-Effectiveness Analysis for the Treatment of Diabetic Foot Ulcer in France: Platelet-Rich Plasma vs Standard of Care

INTRODUCTION

Diabetic chronic foot ulcers (DFU) lead to pain, reduced quality of life and represent a severe economic burden for patients and health systems. The clinical results of PRP effectiveness in the treatment of DFU are promising; on the other hand, the costs associated with treating DFUs with PRP are higher than those using standard therapy. Therefore, this study aims to determine the cost-effectiveness of platelet-rich plasma (PRP) therapy compared to standard therapy from the French healthcare system perspective.

METHODS

A cost-effectiveness analysis (CEA) was performed using a decision Markov model with a cohort of patients with chronic DFU (duration of >3 weeks) with high orthopaedic risk and with ulcers graded 3A according to University of Texas classification. The effectiveness outcomes are reported in terms of quality adjusted life year (QALY). The costs are reported in euro (€) currency evaluated in 2019. A micro-costing approach alongside a clinical study was used to assess resource use. Deterministic sensibility analyses are reported to evaluate the robustness of the results. The analyses were carried out in the French setting.

RESULTS

The incremental cost-effectiveness ratio (ICER) of PRP treatment is -€613/ QALY, which, being lower than zero, indicates the dominance of the PRP therapy. Deterministic and probabilistic sensitivity analysis underlines the main parameter affecting CE results. Lowest number of standard of care weekly medications (from 5 to 3) leads to a €622/QALY while increasing PRP weekly medication (from 1 to 4) has an ICER of €732/QALY.

DISCUSSION

PRP is a cost-effective or even a cost-saving alternative in the French setting. PRP has higher cost for the complete medication, but, in the absence of wound complications, has the potential to involve lower consumption of resources in the form of routine medication over a 1-year time horizon.

Diabetic Foot Risk Assessment among Patients with Type 2 Diabetes in Kenya

Background

Screening for diabetic foot complications is often neglected, especially during routine and/or annual diabetes check-ups. We assessed the risk of diabetic foot complications among patients with type 2 diabetes in Kenya using the International Working Group on Diabetic Foot risk stratification guidelines to highlight the need for improved foot care.

Methods

We conducted a descriptive cross-sectional study in Mathari National Teaching and Referral Hospital in Kenya between July and October 2015. Seven hundred patients with type 2 diabetes were identified and 147 were systematically sampled. A trained podiatrist examined patients, and urine and blood samples were taken for biochemical tests and assessed by the investigating team.

Results

In total, 44(29.9%) men and 103(70.1%) women were sampled; 75(51.0%) were aged over 55 years, 113(76.9%) were overweight/obese, 117(79.6%) had poor glycaemic control and 125(85%) had never had their feet screened for complications. Thirty participants (20.4%) were categorised as being at high risk for developing diabetic foot complications while 54(36.7%) had moderate risk, 53(36.1%) had low risk and 10(6.8%) had no risk. Compared to other risk groups, those with moderate risk for developing diabetic foot problems had higher mean levels of glycated haemoglobin (9.4%), albumin-creatinine ratio (50.3) and high-density lipoprotein cholesterol (1.4 mmol/L) at presentation. No other differences in clinical and laboratory profiles were noted.

Conclusion

Our results show high rates of obesity, and poor glycaemic control in patients with type 2 diabetes and 56.5% of patients are categorised as being a moderate-to-high risk for foot problems. This highlights the need for healthcare professionals and patients in Kenya to be sensitised regarding the importance of foot screening to prevent lower-extremity complications.

Machine Learning Models for Predicting the Risk of Hard-to-Heal Diabetic Foot Ulcers in a Chinese Population

BACKGROUND

Early detection of hard-to-heal diabetic foot ulcers (DFUs) is vital to prevent a poor prognosis. The purpose of this work was to employ clinical characteristics to create an optimal predictive model of hard-to-heal DFUs (failing to decrease by >50% at 4 weeks) based on machine learning algorithms.

METHODS

A total of 362 DFU patients hospitalized in two tertiary hospitals in eastern China were enrolled in this study. The training dataset and validation dataset were split at a ratio of 7:3. Univariate logistic analysis and clinical experience were utilized to screen clinical characteristics as predictive features. The following six machine learning algorithms were used to build prediction models for differentiating hard-to-heal DFUs: support vector machine, the naïve Bayesian (NB) model, k-nearest neighbor, general linear regression, adaptive boosting, and random forest. Five cross-validations were employed to realize the model's parameters. Accuracy, precision, recall, F1-scores, and AUCs were utilized to compare and evaluate the models' efficacy. On the basis of the best model identified, the significance of each characteristic was evaluated, and then an online calculator was developed.

RESULTS

Independent predictors for model establishment included sex, insulin use, random blood glucose, wound area, diabetic retinopathy, peripheral arterial disease, smoking history, serum albumin, serum creatinine, and C-reactive protein. After evaluation, the NB model was identified as the most generalizable model, with an AUC of 0.864, a recall of 0.907, and an F1-score of 0.744. Random blood glucose, C-reactive protein, and wound area were determined to be the three most important influencing factors. A corresponding online calculator was created (https://predicthardtoheal.azurewebsites.net/).

CONCLUSION

Based on clinical characteristics, machine learning algorithms can achieve acceptable predictions of hard-to-heal DFUs, with the NB model performing the best. Our online calculator can assist doctors in identifying the possibility of hard-to-heal DFUs at the time of admission to reduce the likelihood of a dismal prognosis.

The association of chronic, enhanced immunosuppression with outcomes of diabetic foot infections

We investigated if a chronic, enhanced immunosuppressed condition, beyond the immunodeficiency related to diabetes, is associated with clinical failures after combined surgical and medical treatment for diabetic foot infection (DFI). This is a case-control cohort study in a tertiary centre for diabetic foot problems, using case-mix adjustments with multivariate Cox regression models. Among 1013 DFI episodes in 586 patients (median age 67 years; 882 with osteomyelitis), we identified a chronic, enhanced immune-suppression condition in 388 (38%) cases: dialysis (85), solid organ transplantation (25), immune-suppressive medication (70), cirrhosis (9), cancer chemotherapy (15) and alcohol abuse (243). Overall, 255 treatment episodes failed (25%). By multivariate analysis, the presence (as compared with absence) of chronic, enhanced immune-suppression was associated with a higher rate of clinical failures in DFI cases (hazard ratio 1.5, 95% confidence interval 1.1-2.0). We conclude that a chronic, enhanced immune-suppressed state might be an independent risk factor for treatment failure in DFI. Validation of this hypothesis could be useful information for both affected patients and their treating clinicians.

Nanotechnology-based therapeutic applications: in vitro and in vivo clinical studies for diabetic wound healing

Diabetic wounds often indicate chronic complications that are difficult to treat. Unfortunately, existing conventional treatment modalities often cause unpremeditated side effects, given the need to develop alternative therapeutic phenotypes that are safe or have minimal side effects and risks. Nanotechnology-based platforms, including nanotherapeutics, nanoparticles (NPs), nanofibers, nanohydrogels, and nanoscaffolds, have garnered attention for their groundbreaking potential to decipher the biological environment and offer personalized treatment methods for wound healing. These nanotechnology-based platforms can successfully overcome the impediments posed by drug toxicity, existing treatment modalities, and the physiology and complexity of the wound sites. Furthermore, studies have shown that they play an essential role in influencing angiogenesis, collagen production, and extracellular matrix (ECM) synthesis, which are integral in skin repair mechanisms. In this review, we emphasized the importance of various nanotechnology-based platforms for healing diabetic wounds and report on the innovative preclinical and clinical outcomes of different nanotechnology-based platforms. This review also outlined the limitations of existing conventional treatment modalities and summarized the physiology of acute and chronic diabetic wounds.

Effect of foot-ankle flexibility and resistance exercise in the secondary prevention of plantar foot diabetic ulcer

AIMS

The study aimed to evaluate the effects of foot-ankle flexibility and resistance exercises on the recurrence rate of plantar foot diabetic ulcers, HbA1c levels, diabetic neuropathy examination (DNE) scores, ankle brachial index (ABI), and walking speed within 12 and 24weeks.

METHODS

We conducted a double-blind randomized clinical trial. Fifty patients with recently healed plantar foot diabetic ulcers were randomized to an intervention group that performed foot-ankle flexibility and resistance exercise three times a week in their home (n=25) or a control group (n=25). Both groups were given foot care education. Outcomes were assessed at plantar foot diabetic ulcer recurrence or at 12 and 24weeks whichever came first. Outcome measures included plantar foot diabetic ulcer recurrence, changes of HbA1c levels, DNE scores, ankle brachial index ABI, and walking speed.

RESULTS

There were significant difference between groups in ulcer recurrence at either 12weeks (intervention 8%, control 68%, RR 0.288; 95% CI 0.156-0.534, P=0.000) within 12weeks. or 24weeks (intervention 16%, control 72%, RR 0.222; 95% CI 0.088-0.564, P=0.000).). There were significant differences in the DNE score delta (P=0.000) and walking speed delta (P=0.000), but there were no significant differences in the HbA1c delta and ABI delta between groups at either 12 or 24weeks.

CONCLUSIONS

Foot-ankle flexibility and resistance exercises can reduce the recurrence of plantar foot diabetic ulcer incidence and improve diabetic neuropathy and walking speed. Clinical trial number: NCT04624516.

Sedentary behaviour is an independent predictor of diabetic foot ulcer development: An 8-year prospective study

AIMS

To prospectively explore the association between sedentary time (SED-time) and the development of diabetic foot ulcer (DFU) in people with diabetic peripheral neuropathy (DPN).

METHODS

175 DPN individuals who attended the annual evaluation for the SAMBA Study (2012-2019) were included. Main outcome measure was the first diagnosis of DFU. SED-time was measured by the PAS 2.1 questionnaire. Nerve function was evaluated by nerve conduction studies. Vascular function was assessed by Ankle-brachial index (ABI) and pedal pulses. Foot deformity and skin dryness were examined by visual inspection.

RESULTS

62 participants (35.5%) developed a DFU during the study. SED-time was significantly higher in people who developed DFUs (12.8 ± 3.0 vs 9.4 ± 3.1 h/day). Logistic regression showed that among several nervous (motor amplitude, OR 0.33, 95% CI, 0.18-0.60; sensory amplitude, 0.85, 0.77-0.94) and vascular parameters (ABI, 0.23, 0.1-0.61; pedal pulses, 2.81, 0.12-0.63) and foot characteristics (deformity, 2.63, 1.30-5.32; skin dryness, 2.04, 0.95-4.37), SED-time was one of the strongest variables contributing to the development of DFUs (2.95, 1.45-6.44).

CONCLUSIONS

SED-time is an independent predictor of the risk of DFU in people with DPN. The monitoring of SED-time with strategies aimed at reducing it should be included in the standard care of diabetic patients.

Development of a prediction model for foot ulcer recurrence in people with diabetes using easy-to-obtain clinical variables

INTRODUCTION

We aimed to develop a prediction model for foot ulcer recurrence in people with diabetes using easy-to-obtain clinical variables and to validate its predictive performance in order to help risk assessment in this high-risk group.

RESEARCH DESIGN AND METHODS

We used data from a prospective analysis of 304 people with foot ulcer history who had 18-month follow-up for ulcer outcome. Demographic, disease-related and organization-of-care variables were included as potential predictors. Two logistic regression prediction models were created: model 1 for all recurrent foot ulcers (n=126 events) and model 2 for recurrent plantar foot ulcers (n=70 events). We used 10-fold cross-validation, each including five multiple imputation sets for internal validation. Performance was assessed in terms of discrimination using area under the receiver operating characteristic curve (AUC) (0-1, 1=perfect discrimination), and calibration with the Brier Score (0-1, 0=complete concordance predicted vs observed values) and calibration graphs.

RESULTS

Predictors in model 1 were: a younger age, more severe peripheral sensory neuropathy, fewer months since healing of previous ulcer, presence of a minor lesion, use of a walking aid and not monitoring foot temperatures at home. Mean AUC for model 1 was 0.69 (2SD 0.040) and mean Brier Score was 0.22 (2SD 0.011). Predictors in model 2 were: a younger age, plantar location of previous ulcer, fewer months since healing of previous ulcer, presence of a minor lesion, consumption of alcohol, use of a walking aid, and foot care received in a university medical center. Mean AUC for model 2 was 0.66 (2SD 0.023) and mean Brier Score was 0.16 (2SD 0.0048).

CONCLUSIONS

These internally validated prediction models predict with reasonable to good calibration and fair discrimination who is at highest risk of ulcer recurrence. The people at highest risk should be monitored more carefully and treated more intensively than others.

TRIAL REGISTRATION NUMBER

NTR5403.

Prevalence of leg ulcers in the province of Cuenca: A study in Primary Care

OBJECTIVE

To determine the prevalence of leg ulcers, and to describe the affected patients, wounds, and treatment.

METHOD

Observational, cross-sectional prevalence study. An ad hoc online questionnaire was sent to all nurses attending Primary Care centres of the "Gerencia de Atención Integrada de Cuenca" (Integrated Care Management of Cuenca, Spain). Data regarding patient sociodemographic and clinical variables, lesion characteristics and the type of intervention (concerning prevention and treatment) were collected.

RESULTS

In total, 152 professionals (response rate = 98.1%) completed the questionnaire, collecting data from 131,190 inhabitants. A total of 63 patients (75.5 ± 12.6 years old) with 75 ulcers were identified, finding an overall prevalence of .480‰ (CI 95%: .375-.614), distributed as: venous ulcer .274‰ (n = 36), diabetic foot .145‰ (n = 19), and arterial ulcer .061‰ (n = 8). The prevalence was similar regarding gender (.535‰ vs .426‰, respectively, p = .365), but men exhibited more diabetic foot (.214‰ vs .076‰, p = .037). In all three types of lesions prevalence increased with age, reaching 1.743‰ in 64+ age group. The median of the leg ulcer duration and corrected area were 190.0 ± 340.0 days and 5.0 ± 13.7 cm², respectively, with a recurrence rate of 74.7%.

CONCLUSIONS

The prevalence of chronic leg ulcers was lower than that reported in other studies, although with high recurrence rates. Overall estimators from previous studies may have overestimated the prevalence, especially in regions with a high rural component.

Cooling Intervention (MUSTCOOL) for Prevention of Lower Extremity Ulcer Recurrence: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to test our MUSTCOOL cooling patch intervention on the incidence of venous leg (VLU) and diabetic foot ulcer (DFU) recurrence over a previously healed wound.

DESIGN

A 6-month randomized controlled trial.

SUBJECTS AND SETTING

The target population was individuals with previously healed ulcers receiving care in outpatient wound centers in the Southeastern region of the United States. The sample comprised 140 individuals with recently healed ulcers; their average age was 62.4 years (SD = 12 years); 86 (61.4%) were male; and 47 (33.6%) were Black or African American.

METHODS

Participants were randomized to the MUSTCOOL or placebo patch. Both groups received instructions to apply the patch 3 times per week, and engage in standard of care including compression and leg elevation (VLU) or therapeutic footwear and hygiene (DFU). Demographic data were collected at baseline, and incidence measures taken at 1, 3, and 6 months. We also studied whether new ulcers developed on the adjacent leg or foot. Data were reported in frequencies/percentages.

RESULTS

One hundred seventeen participants (84%) were analyzed who completed 6 months of study participation. Thirteen percent (9/69) and 17% (12/69) developed a recurrent or new VLU, respectively; 29% (14/48) and 13% (6/48) developed a recurrent or new DFU, respectively. One person in the DFU group developed both a recurrent and new ulcer. For 9 recurrent VLUs, 6 (66.7%) recurred in the MUSTCOOL group and 3 (33.3%) receiving the placebo. Of the 15 recurrent DFUs (includes individual who developed both a recurrent and new ulcer), 10 (66.7%) recurred in the MUSTCOOL group and 5 (33.3%) receiving the placebo.

CONCLUSIONS

While the incidence of ulcer recurrent was slightly higher in the MUSTCOOL group, this finding was not considered clinically relevant. Overall ulcer recurrence during the 6-month study period was lower than reports in the literature, the time frame in which recurrence rates are highest.

TRIAL REGISTRATION

The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156)-https://clinicaltrials.gov/ct2/show/NCT02626156.