Review of the role of cigarette smoking in diabetic foot

Predicting the diabetic foot in the population of type 2 diabetes mellitus from tongue images and clinical information using multi-modal deep learning

Aims

Based on the quantitative and qualitative fusion data of traditional Chinese medicine (TCM) and Western medicine, a diabetic foot (DF) prediction model was established through combining the objectified parameters of TCM and Western medicine.

Methods

The ResNet-50 deep neural network (DNN) was used to extract depth features of tongue demonstration, and then a fully connected layer (FCL) was used for feature extraction to obtain aggregate features. Finally, a non-invasive DF prediction model based on tongue features was realized.

Results

Among the 391 patients included, there were 267 DF patients, with their BMI (25.2 vs. 24.2) and waist-to-hip ratio (0.953 vs. 0.941) higher than those of type 2 diabetes mellitus (T2DM) group. The diabetes (15 years vs. 8 years) and hypertension durations (10 years vs. 7.5 years) in DF patients were significantly higher than those in T2DM group. Moreover, the plantar hardness in DF patients was higher than that in T2DM patients. The accuracy and sensitivity of the multi-mode DF prediction model reached 0.95 and 0.9286, respectively.

Conclusion

We established a DF prediction model based on clinical features and objectified tongue color, which showed the unique advantages and important role of objectified tongue demonstration in the DF risk prediction, thus further proving the scientific nature of TCM tongue diagnosis. Based on the qualitative and quantitative fusion data, we combined tongue images with DF indicators to establish a multi-mode DF prediction model, in which tongue demonstration and objectified foot data can correct the subjectivity of prior knowledge. The successful establishment of the feature fusion diagnosis model can demonstrate the clinical practical value of objectified tongue demonstration. According to the results, the model had better performance to distinguish between T2DM and DF, and by comparing the performance of the model with and without tongue images, it was found that the model with tongue images performed better.

Gene Expression Analysis in T2DM and Its Associated Microvascular Diabetic Complications: Focus on Risk Factor and RAAS Pathway

Prolonged hyperglycemic conditions in type 2 diabetes mellitus (T2DM) cause pathological and functional damage to many organs and tissues, including the kidneys, retina, skin, and neuronal tissues, resulting in the development of microvascular diabetic complications. The altered renin angiotensin aldosterone system (RAAS) pathway has been reported to play an important role in the development of insulin resistance in T2DM and associated complications. The current study was carried out to evaluate the association of risk factors and altered expression of RAAS genes in T2DM patients without complications and T2DM patients with complications (retinopathy, nephropathy, and neuropathy). Four hundred and twenty subjects including 140 healthy controls, 140 T2DM patients with diabetic complications, and 140 T2DM patients without diabetic complications were included in the study. Risk factors associated with the development of T2DM and diabetic complications were evaluated. Further, expression analysis of RAAS genes (AGT, ACE, ACE2, and AGT1R) was carried out using qRTPCR in healthy controls, T2DM patients with complications, and T2DM patients without complications. Various risk factors like urban background, higher BMI, alcoholism, smoking, and family history of diabetes among others were found to be associated with the development of T2DM as well as diabetic complications. The expression level of AGT, ACE, and AGT1R was found to be upregulated whereas ACE2 was found to be downregulated in T2DM patients with complications and T2DM patients without complications as compared to controls. Altered expression of the studied genes of RAAS pathway is associated with the development of microvascular diabetic complications.

Patients with diabetic foot ulcers: A qualitative study of patient knowledge, experience, and encountered obstacles

BACKGROUND

Patients with diabetes may experience diabetic foot ulcers, which are long-term complications of the disease and can occur due to uncontrolled hyperglycemia. Foot ulcer development is accelerated due to the negligence of the patient and the healthcare professional.

OBJECTIVE

To determine patient knowledge, experiences, and barriers associated with diabetic foot ulcers.

METHODS

This was a qualitative descriptive study based on content analysis. The study was conducted with patients admitted to a wound care outpatient clinic in a public hospital in Turkey. The data were collected through detailed telephone interviews. Data saturation was achieved for 11 patients. MAXQDA 20 software was used for the data analysis. The COREQ checklist was utilized to guide the reporting of the studies.

RESULTS

Five themes and 14 subthemes were identified. Themes: etiology; impact; treatment process; barriers; recommendations. According to Theme 1, neglect, pressure, trauma and chronic diseases can lead to diabetic foot wounds. According to Theme 2, physical and psychological effects were observed in the participants. According to Theme 3, participants' treatment management and compliance with treatment affected the diabetic foot recovery process. In Theme 4, it was observed that participants with diabetic foot wounds had difficulties performing daily living activities and physical activities. In Theme 5, the participants' recommendations for individuals with diabetic foot ulcers included regulating blood sugar, maintaining a healthy lifestyle, providing foot protection and care, and providing professional health support.

CONCLUSION

Diabetic foot ulcers developed due to the negligence of patients and physicians. Patients were also afraid of foot amputation. The development of foot ulcers is preventable through the provision of training to spread awareness regarding blood sugar control and diabetic foot ulcers. Early self-recognition of diabetic foot ulcers by patients, along with early intervention attempts by healthcare professionals, are important.

Standardized Wound Care: Patchwork Practices?

Standardized care is crucial in health care for ensuring consistent, safe, high-quality, efficient, and evidence-based practices. Care pathways that standardize procedures promote adherence to best practices, reduce variability in treatment, and encourage collaboration among health care teams. This approach ultimately improves patient outcomes, enhances safety, and boosts the overall effectiveness of health care services. However, despite these benefits being widespread across most of the U.S. health care system, wound care stands out as an area where standards can vary significantly. The inconsistency in wound care standards in the United States can be traced to several factors. These include limited structured clinical wound care education, the discretion of health care providers in different business environments, differences in wound care settings, varying access to advanced treatments and technology, patient demographics and socioeconomic status, as well as differences in state laws and regional or institutional practices. Addressing these disparities requires a comprehensive approach that considers the complex interplay of the abovementioned factors. Active measures are needed to improve access, equity, and the quality of wound care services for all patients, regardless of where they live, their socioeconomic status, their health care coverage, or the business interests of providers and their institutions as well as of vendors marketing wound care products inconsistent with evidence-based practice. By understanding and actively addressing these factors, we can work toward achieving more standardized, evidence-based, and patient-centered practices in wound care across the nation.

Protocolized Foot Exercises Help in Improvement of Diabetic Foot Ulcers and Quality of Life When Added to Standard Therapy-A Randomized Clinical Trial

CONTEXT

Diabetic foot disease is the major cause of nontraumatic limb amputations worldwide causing a high socioeconomic and psychological toll and a huge burden to the healthcare system. Currently, standard treatment of diabetic foot ulcer is through multidisciplinary therapy. Foot exercises have been shown to improve healing in diabetic ulcers although evidence is limited and applicability is non-uniform. Our study aimed to generate more evidence regarding the benefit of addition of protocolized foot exercises so that it can be instituted as a standard of care.

METHODS AND MATERIAL

It was an open label Randomized controlled trial with seventy-two patients and study duration of one and half years Patients with diabetic foot ulcers were randomized into two groups. Both groups received standard therapy for diabetic foot ulcer. The intervention group in addition received three months of protocolized foot exercises. At the end of three months ulcer healing and quality of life were m compared among both the groups.

RESULTS

Regular exercises for three months caused significant reduction in ulcer area compared to the non-intervention group [100% versus 45.22%, 95% CI =36.30(16.04-56.56), P-value = 0.001]. Quality of life analyzed by SF-36 score showed significant improvement in components like physical function [69.4 ± 8.9 versus 63.7 ± 11.0, 95% CI = 5.73 (0.97-10.48), P-value = 0.01], emotional well-being [65.2 ± 7.6 versus 60.8 ± 7.9, 95% CI = 4.44 (0.79-8.10), P-value = 0.01], and pain components [55.4 ± 18.5 versus 47.5 ± 14.5, 95% CI = 7.99 (0.16-15.81), P-value = 0.04) at 3 months although change in social functioning, physical health limitation, health change, energy and general health improvement were not significant.

CONCLUSIONS

Addition of protocolized foot exercises are beneficial for patients of diabetic foot ulcers in terms of ulcer healing as well as improvement of quality of life provided compliance to exercises can be ensured.

[Development and Validation of a Risk Prediction Model for Prolonged Hospitalization in Patients With Diabetic Foot Ulcers]

Objective

To investigate the risk factors associated with prolonged hospitalization in patients diagnosed with diabetic foot ulcers (DFU), to develop a predictive model, and to conduct internal validation of the model.

Methods

The clinical data of DFU patients admitted to West China Hospital, Sichuan University between January 2012 and December 2022 were retrospectively collected. The subjects were randomly assigned to a training cohort and a validation cohort at a ratio of 7 to 3. Hospital stays longer than 75th percentile were defined as prolonged length-of-stay. A thorough analysis of the risk factors was conducted using the training cohort, which enabled the development of an accurate risk prediction model. To ensure robustness, the model was internally validated using the validation cohort.

Results

A total of 967 inpatients with DFU were included, among whom 245 patients were identified as having an extended length-of-stay. The training cohort consisted of 622 patients, while the validation cohort comprised 291 patients. Multivariate logistic regression analysis revealed that smoking history (odds ratio [OR]=1.67, 95% confidence interval [CI], 1.13 to 2.48, P=0.010), Wagner grade 3 or higher (OR=7.13, 95% CI, 3.68 to 13.83, P<0.001), midfoot ulcers (OR=1.99, 95% CI, 1.07 to 3.72, P=0.030), posterior foot ulcers (OR=3.68, 95% CI, 1.83 to 7.41, P<0.001), multisite ulcers (OR=2.91, 95% CI, 1.80 to 4.69, P<0.001), wound size≥3 cm2 (OR=2.00, 95% CI, 1.28-3.11, P=0.002), and white blood cell count (OR=1.11, 95% CI, 1.05 to 1.18, P<0.001) were associated with an increased risk of prolonged length of stay. Additionally, a nomogram was constructed based on the identified risk factors. The areas under the receiver operating characteristic (ROC) curves for both the training cohort and the validation cohort were 0.782 (95% CI, 0.745 to 0.820) and 0.756 (95% CI, 0.694 to 0.818), respectively, indicating robust predictive performance. Furthermore, the calibration plot demonstrated optimal concordance between the predicted probabilities and the observed outcomes in both the training and the validation cohorts.

Conclusion

Smoking history, Wagner grade≥3, midfoot ulcers, posterior foot ulcers, multisite ulcers, ulcer area≥3 cm2, and elevated white blood cell count are identified as independent predictors of prolonged hospitalization. Therefore, it is imperative that clinicians conduct a comprehensive patient evaluation and implement appropriate diagnostic and therapeutic strategies to effectively shorten the length of stay for DFU patients.

Performance of risk prediction models for diabetic foot ulcer: a meta-analysis

Background

The number of prediction models for diabetic foot ulcer (DFU) risk is increasing, but their methodological quality and clinical applicability are uncertain. We conducted a systematic review to assess their performance.

Methods

We searched PubMed, Cochrane Library, and Embase databases up to 10 February 2024 and extracted relevant information from selected prediction models. The Prediction model Risk Of Bias ASsessment Tool (PROBAST) checklist was used to assess bias risk and applicability. All statistical analyses were conducted in Stata 14.0.

Results

Initially, 13,562 studies were retrieved, leading to the inclusion of five development and five validation models from eight studies. DFU incidence ranged from 6% to 16.8%, with age and hemoglobin A1C (HbA1c) commonly used as predictive factors. All included studies had a high risk of bias, mainly due to disparities in population characteristics and methodology. In the meta-analysis, we observed area under the curve (AUC) values of 0.78 (95% CI [0.69-0.89]) for development models and 0.84 (95% CI [0.79-0.90]) for validation models.

Conclusion

DFU risk prediction models show good overall accuracy, but there is a risk of bias. Adherence to the PROBAST checklist is crucial for improving their clinical applicability.

Bacteriological analysis and antibiotic resistance in patients with diabetic foot ulcers in Dhaka

The primary objective of this study was to isolate bacteria from diabetic foot ulcers and subsequently assess their antibiotic resistance capabilities. Seventy-five patients diagnosed with diabetic foot ulcers were investigated. A number of these patients (97.33%) had type 2 diabetes, with a significant proportion of them having been diagnosed for 1-5 years (29.33%). Notably, a substantial number of these individuals were on insulin usage (78.66%). Among the patients under examination, 49.33% reported having no use of tobacco products, alcohol, or betel leaf. The ulcers analyzed in this study were classified into grades 1-5 according to the Wagner scale. Wagner grade 2 diabetic foot ulcers had the highest number of culture-positive patients, at 33.33%. Pus samples collected from patients were cultured on selective media, and bacterial identity was confirmed by biochemical tests and polymerase chain reaction. A total of 141 isolates were isolated. Among the isolates, 82.97% gram-negative bacteria and 17.02% gram-positive bacteria were detected. Klebsiella pneumoniae was the most common isolate. Proteus spp., Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus were also detected. Approximately 61.33% of the ulcers exhibited were polybacterial. In this study, it was observed that all bacterial isolates, except for Proteus spp., were primarily detected in patients classified under Wagner's grade 2. Moreover, antibiotic susceptibility was also tested on these 141 isolates. Among them, Escherichia coli showed the highest multidrug resistance, 81.81%. Most of the gram-negative bacteria were resistant to ampicillin. All of the gram-negative isolates exhibited high levels of susceptibility to piperacillin-tazobactam, and these levels were Klebsiella pneumoniae (97.56%), Pseudomonas aeruginosa (95.24%), Escherichia coli (81.82%), and Proteus spp. (80%). On the other hand, gram-positive Staphylococcus aureus mostly showed sensitivity towards vancomycin and norfloxacin (79.17%).

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy

INTRODUCTION

Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes.

METHOD

The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened.

RESULTS

We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated.

CONCLUSION

Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

The association between tobacco smoking and systolic toe pressures in active foot ulceration

Smoking may increase the risk of diabetic foot disease and ulceration. It does so by impairing glycaemic control and promoting the formation of advanced glycated end-products. Additionally, smoking is known to delay surgical wound healing and accelerate peripheral arterial disease. We aimed to determine whether toe pressures differed in smokers with a foot ulcer, when compared to non-smokers and ex-smokers, as well as ulcer outcomes at 12 months, among patients attending Blacktown Hospital High Risk Foot Service (HRFS). This study is a retrospective analysis of our prospectively collected clinic database. Eligible participants were adults attending the HRFS between June 2020 and April 2022. Participants were included if they had an ulcer, at least one systolic toe pressure reading completed at their initial visit and attended at least one follow-up visit. Participants were followed until healing, loss to follow-up or a minimum of 12 months. A total of 195 participants were included; 36 smokers, 82 ex-smokers, and 77 controls who had never smoked. Smoking status was by self-report. Current smokers were significantly younger at initial presentation (p = .002) and tended towards lower socioeconomic status (p = .067). Current smokers were significantly more likely to have ischaemic grade 3 toe pressures (< 30 mmHg) of their left foot (p = .027), suggestive of reduced perfusion. At the end of follow up period, smokers had the numerically highest rates of minor amputations. In conclusion, smokers ulcerate younger and are more likely to have grade 3 ischaemia. Collecting information about the brachial artery pressures and the time since the last cigarette may clarify any relationship between smoking and toe pressures.Trial registration: WSLHD HREC ethics approval 2111-02 and ANZCTR registration 382470. Registered on 15/09/2021.

Gynura divaricata (L.) DC. promotes diabetic wound healing by activating Nrf2 signaling in diabetic rats

THE ETHNOPHARMACOLOGICAL SIGNIFICANCE

Diabetic chronic foot ulcers pose a significant therapeutic challenge as a result of the oxidative stress caused by hyperglycemia. Which impairs angiogenesis and delays wound healing, potentially leading to amputation. Gynura divaricata (L.) DC. (GD), a traditional Chinese herbal medicine with hypoglycemic effects, has been proposed as a potential therapeutic agent for diabetic wound healing. However, the underlying mechanisms of its effects remain unclear.

AIM OF THE STUDY

In this study, we aimed to reveal the effect and potential mechanisms of GD on accelerating diabetic wound healing in vitro and in vivo.

MATERIALS AND METHODS

The effects of GD on cell proliferation, apoptosis, reactive oxygen species (ROS) production, migration, mitochondrial membrane potential (MMP), and potential molecular mechanisms were investigated in high glucose (HG) stimulated human umbilical vein endothelial cells (HUVECs) using CCK-8, flow cytometry assay, wound healing assay, immunofluorescence, DCFH-DA staining, JC-1 staining, and Western blot. Full-thickness skin defects were created in STZ-induced diabetic rats, and wound healing rate was tracked by photographing them every day. HE staining, immunohistochemistry, and Western blot were employed to investigate the effect and molecular mechanism of GD on wound healing in diabetic rats.

RESULTS

GD significantly improved HUVEC survival, decreased apoptosis, lowered ROS production, restored MMP, improved migration ability, and raised VEGF expression. The use of Nrf2-siRNA completely abrogated these effects. Topical application of GD promoted angiogenesis and granulation tissue growth, resulting in faster healing of diabetic wounds. The expression of VEGF, CD31, and VEGFR was elevated in the skin tissue of diabetic rats after GD treatment, which upregulated HO-1, NQO-1, and Bcl-2 expression while downregulating Bax expression via activation of the Nrf2 signaling pathway.

CONCLUSION

The findings of this study indicate that GD has the potential to serve as a viable alternative treatment for diabetic wounds. This potential arises from its ability to mitigate the negative effects of oxidative stress on angiogenesis, which is regulated by the Nrf2 signaling pathway. The results of our study offer valuable insights into the therapeutic efficacy of GD in the treatment of diabetic wounds, emphasizing the significance of directing interventions towards the Nrf2 signaling pathway to mitigate oxidative stress and facilitate the process of angiogenesis.

Potassium permanganate in treatment of diabetic foot ulcer: A randomized clinical trial

Background and Aims

Diabetic foot ulcers (DFU) are a severe complication in diabetes patients, often resulting in significant morbidity and mortality due to non-healing. This study investigated the effectiveness of 5% topical potassium permanganate on these ulcers.

Methods

A clinical trial was conducted on 23 patients with Wagner grade I and II DFU. Patients in the control group received standard treatment, while those in the intervention group also received 5% potassium permanganate topically. Data were recorded at 0, 7, 14, and 21 days for analysis.

Results

Among 23 patients studied, 7 (30.4%) were male and 16 (43.7%) female, with an average age of 59 ± 4 years. Both groups showed a statistically significant decrease in wound size and infection over time (p < 0.001). The intervention group, however, had a more substantial reduction in wound size and infection rate (p < 0.05).

Conclusion

Potassium permanganate, when applied topically, is both well-tolerated and effective in enhancing wound healing and reducing infection in DFU, suggesting its potential as a complementary treatment.

Update on Medical Management of Diabetes: Focus on Relevance for Orthopedic Surgeons

Diabetes mellitus affects more than 30 million US adults and 537 million people worldwide and accounts for major complications, including more than 100,000 lower extremity amputations annually in the United States. Peripheral neuropathy, peripheral vascular disease, and foot ulcers are frequent findings in diabetes patients at risk for amputation. Suboptimal care of early foot lesions increases the risk of amputation. Studies have shown that these complications can be prevented in people with type 1 and type 2 diabetes by optimizing glycemic control and comorbid risk factors. This review focuses on evaluating and managing diabetes, which should interest orthopedic surgeons.

Development of predictive nomograms clinical use to quantify the risk of diabetic foot in patients with type 2 diabetes mellitus

Objective

The aim of the study was to explore the risk factors for diabetic foot disease in patients with type 2 diabetes mellitus and to establish and verify the nomogram model of DF risk in patients with T2DM.

Methods

The clinical data of 705 patients with type 2 diabetes who were hospitalized in our hospital from January 2015 to December 2022 were analyzed retrospectively. According to random sampling, the patients were divided into two groups: the training set (DF = 84; simple T2DM = 410) and the verification set (DF = 41; simple T2DM = 170). Univariate and multivariate logistic regression analysis was used to screen the independent risk factors for DF in patients with T2DM in the training set. According to the independent risk factors, the nomogram risk prediction model is established and verified.

Results

Logistic regression analysis showed age (OR = 1.093, 95% CI 1.062-1.124, P <0.001), smoking history (OR = 3.309, 95% CI 1.849-5.924, P <0.001), glycosylated hemoglobin (OR = 1.328, 95% CI 1.173-1.502, P <0.001), leukocyte (OR = 1.203, 95% CI 1.076-1.345, and LDL-C (OR = 2.002, 95% CI 1.463-2.740), P <0.001) was independent risk factors for T2DM complicated with DF. The area of the nomogram model based on the above indexes under the ROC curve of the training set and the verification set is 0.827 and 0.808, respectively; the correction curve shows that the model has good accuracy; and the DCA results show that when the risk threshold is between 0.10-0.85 (training set) and 0.10-0.75 (verification set), the clinical practical value of the model is higher.

Conclusion

The nomogram model constructed in this study is of high value in predicting the risk of DF in patients with T2DM and is of reference value for clinicians to identify people at high risk of DF and provide them with early diagnosis and individual prevention.

Hyperbaric Oxygen Therapy for Nonhealing Wounds-A Long-term Retrospective Cohort Study

OBJECTIVE

To analyze wound healing results of hyperbaric oxygen therapy (HBOT) for a variety of different wound types.

METHODS

This retrospective cohort study included all patients treated with HBOT and wound care at a single hyperbaric center between January 2017 and December 2020. The primary outcome was wound healing. Secondary outcome measures were quality of life (QoL), number of sessions, adverse effects, and treatment cost. Investigators also examined possible influencing factors, including age, sex, type and duration of wound, socioeconomic status, smoking status, and presence of peripheral vascular disease.

RESULTS

A total of 774 treatment series were recorded, with a median of 39 sessions per patient (interquartile range, 23-51 sessions). In total, 472 wounds (61.0%) healed, 177 (22.9%) partially healed, 41 (5.3%) deteriorated, and 39 (5.0%) minor and 45 (5.8%) major amputations were performed. Following HBOT, median wound surface area decreased from 4.4 cm 2 to 0.2 cm 2 ( P < .01), and patient QoL improved from 60 to 75 on a 100-point scale ( P < .01). The median cost of therapy was €9,188 (interquartile range, €5,947-€12,557). Frequently recorded adverse effects were fatigue, hyperoxic myopia, and middle ear barotrauma. Attending fewer than 30 sessions and having severe arterial disease were both associated with a negative outcome.

CONCLUSIONS

Adding HBOT to standard wound care increases wound healing and QoL in selected wounds. Patients with severe arterial disease should be screened for potential benefits. Most reported adverse effects are mild and transient.

Factors Affecting Platelet-Rich Plasma Success in Patients With Diabetic Foot Ulcer

Introduction Diabetic foot ulcers (DFU) are one of the most common complications of diabetes mellitus (DM). The use of platelet-rich plasma (PRP) in the treatment of DFU has been increasing in recent years. In the current study, we aimed to evaluate the factors affecting the success of PRP in the management of DFU. Methods The present study was planned in a prospective manner, and we enrolled patients with DFU in the study. Patients' characteristics, DFU properties, and treatment outcomes were recorded. Patients with DFU were classified into two groups according to PRP success: healed DFU patients in Group 1 and non-healed DFU patients in Group 2. Groups were compared according to patient characteristics and treatment outcomes, and multivariate regression analysis was performed to clarify factors that predicted PRP success. Results In total, 182 patients were enrolled in the study, and DFU in 141 (77.5%) patients healed with PRP treatment. The mean body mass index (BMI) was significantly higher in the non-healed patients (p= 0.005). The smoking rate was 58.5% in the non-healed group and 39.7% in the healed group (p= 0.016). The duration of DM (17.9 years vs. 22.5 years, p= 0.003) was significantly longer, and patients with glomerular filtration rate (GFR) < 60 (44.0% vs. 63.4, p= 0.028) were significantly more common in the non-healed group. Multivariate regression analysis demonstrated that BMI ≥30 kg/m² and duration of DM ≥20 years were predictive factors for PRP failure in patients with DFU (p= 0.019 and p= 0.005). Smoking and GFR <60 were significantly associated with PRP failure (p= 0.040 and p= 0.044). Conclusion In our study, it was found that PRP was an effective treatment that improved DFU in 141 out of 182 patients. Moreover, the present study demonstrated for the first time that higher BMI, longer duration of DM, smoking, and lower GFR were significantly related to PRP failure in patients with DFU.

Development of an implantable three-dimensional model of a functional pathogenic multispecies biofilm to study infected wounds

Chronic wounds cannot heal due to impairment of regeneration, mainly caused by the persistent infection of multispecies biofilms. Still, the effects of biofilm wound infection and its interaction with the host are not fully described. We aimed to study functional biofilms in physiological conditions in vitro, and their potential effects in health and regeneration in vivo. Therefore, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis were seeded in collagen-based scaffolds for dermal regeneration. After 24 h, scaffolds had bacterial loads depending on the initial inoculum, containing viable biofilms with antibiotic tolerance. Afterwards, scaffolds were implanted onto full skin wounds in mice, together with daily supervision and antibiotic treatment. Although all mice survived their health was affected, displaying fever and weight loss. After ten days, histomorphology of scaffolds showed high heterogeneity in samples and within groups. Wounds were strongly, mildly, or not infected according to colony forming units, and P. aeruginosa had higher identification frequency. Biofilm infection induced leucocyte infiltration and elevated interferon-γ and interleukin-10 in scaffolds, increase of size and weight of spleen and high systemic pro-calcitonin concentrations. This functional and implantable 3D biofilm model allows to study host response during infection, providing a useful tool for infected wounds therapy development.

Diabetic foot ulcer: Challenges and future

Diabetic foot ulcers (DFUs) have become one of the important causes of mortality and morbidity in patients with diabetes, and they are also a common cause of hospitalization, which places a heavy burden on patients and society. The prevention and treatment of DFUs requires multidisciplinary management. By controlling various risk factors, such as blood glucose levels, blood pressure, lipid levels and smoking cessation, local management of DFUs should be strengthened, such as debridement, dressing, revascularization, stem cell decompression and oxygen therapy. If necessary, systemic anti-infection treatment should be administered. We reviewed the progress in the clinical practice of treating DFUs in recent years, such as revascularization, wound repair, offloading, stem cell transplantation, and anti-infection treatment. We also summarized and prospectively analyzed some new technologies and measurements used in the treatment of DFUs and noted the future challenges and directions for the development of DFU treatments.

Risk assessment of amputation in patients with diabetic foot

The prevalence of diabetes has increased dramatically over the past decade, especially in developing countries, reaching pandemic proportions. Although has been the most important factor influencing the prevalence of type 2 diabetes, the prevalence of type 2 diabetes is on the increase among younger adults. The subsequent rate of increase with age is variable, which is more evident in societies where the general prevalence of the disease is higher. Based on clinical and statistical data obtained from the patients who were admitted to The First and Second Surgery Wards in the Sibiu County Emergency University Clinical Hospital (Sibiu, Romania) and the Proctoven Clinic (Sibiu, Romania) between January 2018 and December 2020, the present study attempted to devise a risk score that can be applied for the benefit of patients. The ultimate aim was that this risk score may be eventually applied by diabetologists and surgeons to assess the risk of amputation in patients with diabetic foot lesions. An important part in the therapeutic management of diabetic foot injuries is the assessment of risk factors. Using this risk score system devised, the risk factors that were found to exert influence in aggravating diabetic foot injuries are smoking, obesity, dyslipidaemia, unbalanced diabetes mellitus (glycated haemoglobin ≥7.5%), duration of diabetes >5 years, hepatic steatosis and the co-existence of various heart diseases. To conclude, all these risk factors aforementioned can decrease the effectiveness of treatment and can have a significant impact on the quality of life, if they are not well known.

Metatarsal Protrusion Distance and Its Influence on Recurrent Ulceration Rates After Partial First-Ray Amputations: A Retrospective Study

BACKGROUND

Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.

METHODS

Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.

RESULTS

Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7-47.0).

CONCLUSIONS

Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.

[Clinical characteristics and risk factors of lower extremity arterial disease in patients with diabetic foot ulcer]

OBJECTIVE

To investigate the clinical characteristics of lower extremity arterial disease (LEAD) and its risk factors in patients with diabetic foot ulcer (DFU).

METHODS

We retrospectively collected the clinical and follow-up data of 650 patients with DFU treated in the Department of Endocrinology and Metabolism of Nanfang Hospital between January, 2017 and December, 2019. We compared the data between patients who had LEAD and those without LEAD and used a multivariate logistic regression model to analyze the risk factors of LEAD in DFU patients.

RESULTS

Among the 650 DFU patients, 470 (72.4%) had LEAD. The patients were followed up for a mean of 3.5 months, and the mean healing time of DFU was 2.55 months; healing of DFU occurred in 453 patients and 183 patients received amputation. The patients with LEAD and those without LEAD differed significantly in age, hospitalization costs, diastolic blood pressure (DBP), glycated hemoglobin, blood lipid levels, disease course, ankle brachial index, healing time, smoking history, clinical outcomes, Wagner grade and imaging results (P < 0.05). Multivariate logistic regression analysis identified age (OR=1.070, 95% CI: 1.049-1.091), smoking history (OR= 2.013, 95% CI: 1.268-3.195), and a decreased DBP (OR=0.980, 95% CI: 0.963-0.997) as independent risk factors for LEAD in DFU patients. A prolonged healing time was a prominent clinical feature of DFU complicated by LEAD.

CONCLUSION

DFU patients have a high incidence of LEAD, which leads to high rates of disability and mortality and is associated with an advanced age, high smoking rate and longer healing time. A decreased DBP is also a risk factor for LEAD in DFU patients.

Factors Affecting Mortality of Critical Limb Ischemia 1 Year after Endovascular Revascularization in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Chronic limb ischemia (CLI) is strongly associated with increased mortality in diabetes patients.

OBJECTIVE

The aim of this study was to evaluate factors affecting mortality within 1 year after endovascular revascularization in CLI patients.

METHODS

This retrospective cohort study was based on medical records from the Integrated Cardiovascular Centre of Dr. Cipto Mangunkusumo National General Hospital, a tertiary care hospital in Jakarta, Indonesia. The study included 199 CLI patients with type 2 diabetes mellitus (T2DM) who underwent endovascular revascularization from January 2008 to June 2018. The patients were followed up for 1 year after endovascular revascularization. Kaplan-Meier and Cox proportional hazard analysis was used to analyze the data.

RESULTS

1-year survival probability was 58.8%. Cox proportional hazard analysis showed that duration of diabetes (HR 3.52; 95% CI 1.34-9.22), anemia (HR 2.59; 95% CI 1.47-4.56), and smoking (HR 2.49; 95% CI 1.46-4.27) were significantly associated with mortality within 1 year after endovascular revascularization.

CONCLUSIONS

In T2DM patients with CLI, duration of diabetes, anemia and smoking were associated with a higher risk of mortality within 1 year post endovascular revascularization

Chronic wounds: Treatment consensus

The Wound Healing Foundation (WHF) recognised a need for an unbiased consensus on the best treatment of chronic wounds. A panel of 13 experts were invited to a virtual meeting which took place on 27 March 2021. The proceedings were organised in the sub-sections diagnosis, debridement, infection control, dressings, grafting, pain management, oxygen treatment, outcomes and future needs. Eighty percent or better concurrence among the panellists was considered a consensus. A large number of critical questions were discussed and agreed upon. Important takeaways included that wound care needs to be simplified to a point that it can be delivered by the patient or the patient's family. Another one was that telemonitoring, which has proved very useful during the COVID-19 pandemic, can help reduce the frequency of interventions by a visiting nurse or a wound care center. Defining patient expectations is critical to designing a successful treatment. Patient outcomes might include wound specific outcomes such as time to heal, wound size reduction, as well as improvement in quality of life. For those patients with expectations of healing, an aggressive approach to achieve that goal is recommended. When healing is not an expectation, such as in patients receiving palliative wound care, outcomes might include pain reduction, exudate management, odour management and/or other quality of life benefits to wound care.

Screening for identification of patients at high risk for diabetes-related foot ulcers: a cross-sectional study

OBJECTIVE

Diabetes affected 463 million people globally in 2019, and this number is anticipated to reach 700 million by 2045. Diabetes results in lower limb amputation every 30 seconds. Egypt has a high prevalence of diabetic foot disease among patients with type 2 diabetes mellitus (T2DM). We aimed to identify high-risk patients for diabetic foot ulcers (DFUs) in Egypt.

METHODS

We designed a cross-sectional study among adult patients with diabetes at Asyut University Hospital. Inlow's 60-second diabetic foot screening tool was used to assess the risk of DFU. Neuropathy was assessed using the 10g monofilament test, and laboratory testing was performed to assess glycosylated hemoglobin (HbA1c) and diabetes control levels.

RESULTS

Participants were aged 46.11 ± 9.18 years; 56% had T2DM and HbA1c levels >7%. In total, 47.9% of participants were at risk for DFUs. This risk was higher in patients who were older, male, widowed, working, illiterate, living in rural areas, and patients with diabetes duration >10 years, body mass index >32 kg/m2, uncontrolled blood glucose levels, on an insulin regimen, and smokers.

CONCLUSIONS

Increasing health care providers' awareness and ability to identify high-risk patients is critical to prevent DFUs and reduce the risk of amputation.

Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months

AIMS

To investigate factors independently associated with time-to-(being)-ulcer-free, time-varying effects and predict adjusted ulcer-free probabilities, in a large prospective cohort with diabetes-related foot ulcers (DFU) followed-up for 24 months.

METHODS

Patients presenting with DFU(s) to 65 Diabetic Foot Services across Queensland, Australia, between July-2011 and December-2017 were included. Demographic, comorbidity, limb, ulcer, and treatment factors were captured at presentation. Patients were followed-up until ulcer-free (all DFU(s) healed), amputation, death or two years. Factors associated with time-to-ulcer-free were investigated using both Cox proportional hazards and flexible parametric survival models to explore time-varying effects and plot predicted adjusted ulcer-free probability graphs.

RESULTS

Of 4,709 included patients (median age 63 years, 69.5% male), median time-to-ulcer-free was 112 days (IQR:40->730), with 68.4% ulcer-free within two years. Factors independently associated with longer time-to-ulcer-free were each year of age younger than 60 years, living in a regional or remote area, smoking, neuropathy, peripheral artery disease (PAD), ulcer size >1 cm², deep ulcer and mild infection (all p < 0.05). Time-varying effects were found for PAD and ulcer size limiting their association to six months only. Shorter time-to-ulcer-free was associated with recent DFU treatment by a podiatrist and receiving knee-high offloading treatment (both p < 0.05). Predicted adjusted ulcer-free probability graphs reported largest differences in time-to-ulcer-free over 24-months for geographical remoteness and PAD factors.

CONCLUSIONS

Multiple factors predicted longer and shorter time-to-ulcer-free in people presenting with DFUs. Considering these factors, their time-varying effects and adjusted ulcer-free probability graphs, should aid the prediction of the likely time-to-(being)-ulcer-free for DFU patients.

Cigarette Smoking and Peripheral Vascular Disease are Associated with Increasing Risk of ESKAPE Pathogen Infection in Diabetic Foot Ulcers

OBJECTIVE

Diabetic foot ulcers (DFUs) and ESKAPE pathogens have attracted attention globally, but the role of ESKAPE pathogens in diabetic foot infection is not well described. The purpose of this study was to evaluate the clinical features, antimicrobial resistance, and risk factors for ESKAPE infection in patients with DFUs.

METHODS

A retrospective study was conducted on 180 patients with diabetic foot infection admitted to The Affiliated Hospital of Southwest Medical University (Luzhou, China), from January 2017 to April 2021. Antimicrobial susceptibilities of all isolates were determined. Multivariate logistic regression analysis was performed to analyze the independent risk factors for ESKAPE infection, multidrug-resistant (MDR)-ESKAPE infection, MDR-pathogen infection, and severe group in patients with DFUs.

RESULTS

A total of 206 isolates were collected, of which 42.2% were ESKAPE pathogens. The independent risk factors for ESKAPE infection were cigarette smoking (OR = 1.958; 95% CI, 1.015-3.777) and peripheral vascular disease (OR = 2.096; 95% CI, 1.100-3.992), while alcohol consumption (OR = 2.172; 95% CI, 1.104-4.272) was the independent risk factor for MDR-pathogen infection. Additionally, the independent risk factors for severe DFU group were invasive treatment (OR = 326.642; 95% CI, 76.644-1392.08), the duration of systemic antibiotic treatment (OR = 0.918; 95% CI, 0.849-0.992), and length of hospital stay (OR = 1.145; 95% CI, 1.043-1.256). No independent risk factors for MDR-ESKAPE infection were found.

CONCLUSION

Our data established the microbiological features of ESKAPE pathogens and clinical manifestations of diabetic foot infection, and provide support for monitoring and management of ESKAPE infection in patients with DFUs in southwest China.

Treatment Failures in Diabetic Foot Osteomyelitis Associated with Concomitant Charcot Arthropathy: The Role of Underlying Arteriopathy

OBJECTIVE

Therapy for diabetic foot osteomyelitis (DFO) with Charcot neuroosteoarthropathy is challenging. In patients with diabetic Charcot osteomyelitis (DCO), both the anatomic deformity and infection must be addressed. This study assessed the outcomes of DCO therapy and variables associated with treatment failure and compared them with outcomes of DFO cases.

METHODS

A single-center, retrospective, case-control study was performed to compare 93 DCO episodes with 530 DFO episodes, using Kaplan-Meier survival curves and multivariate Cox regression analyses.

RESULTS

Clinical failure occurred in 21.5% of DCO compared with 22.3% in DFO episodes (p=0.89) and was associated with peripheral arterial disease (PAD) stages 3 or 4 (HR 6.1; CI 2.0-18.1) and chronic treatment with immunosuppressives (HR 7.4; CI 2.0-27.1). Major amputations were significantly more frequent in DCO (28% versus 13.6%; p<0.01) and associated with PAD stages 3 and 4 (HR 8.0; CI 2.2-29.4), smoking (HR 5.4; CI 1.2-24.6), alcohol abuse (HR 3.5; CI 1.1-10.6), and renal dialysis (HR 4.9; CI 1.3-18.9).

CONCLUSIONS

Clinical treatment failures did not differ between DCO and DFO. However, patients with DCO underwent major amputation twice as often as those with DFO. Unlike widespread belief, treatment failure in DCO patients may, similar to DFO, be associated with a striking epidemiological link to severe PAD.

Burning sensation in the feet and glycosylated haemoglobin levels in Swedish- and non-Swedish-born primary healthcare patients

BACKGROUND

A painful burning sensation in the feet is a common problem. The most common cause is small fibre neuropathy, a type of peripheral neuropathy that is often a consequence of diabetes and prediabetes.

AIM

To examine the association between a self-reported burning sensation in the feet and HbA1c levels in primary healthcare patients.

METHODS

This study used data from patients in the 4D diabetes project in Swedish primary healthcare. The study population included 824 patients. Logistic regression was performed to study the association between the outcome and explanatory variables.

RESULTS

A total of 24% of patients reported a burning sensation in the feet. This sensation was not associated with HbA1c levels. However, the probability of reporting a burning sensation was two times higher in non-Swedish-born than Swedish-born patients (OR, 2.31; 95% CI, 1.55-3.44) and higher in smokers than those who had never smoked, regardless of region of birth (OR, 1.69; 95% CI, 1.07-2.65).

CONCLUSIONS

Our results do not support the hypothesis that a self-reported burning sensation in the feet is associated with HbA1c levels. Rather, they indicate a strong relationship between a burning sensation and region of birth, as well as between a burning sensation and smoking.

Association between Osteoprotegerin and Charcot Neuroarthropathy: a systematic review

AIMS

Osteoprotegerin (OPG) has been associated with Charcot Neuroarthropathy (CN); however, three studied OPG polymorphisms (1181C > G, 245A > C and 950 T > C) have yielded conflicting results. Therefore, this meta-analysis was conducted to determine the difference in serum OPG concentrations between healthy controls and diabetics with and without CN and the effect OPG polymorphisms have on CN development.

METHODS

PubMed, LILAC, SCOPUS, and EBSCO databases and retrieved publications' bibliographies were searched for studies that examined for OPG and CN. Depending on the heterogeneity, fixed or random effects were used to calculate the pooled odds ratio (OR) or standard difference in means (SDM) with 95% confidence intervals (95%CI) for 5 genetic models (heterozygous, homozygous, dominant, recessive, and allelic) and serum concentrations, respectively.

RESULTS

Seven publications (12 studies) demonstrated that serum OPG concentrations were more elevated in subjects with CN (SDM = 0.719, 95%CI = 0.555-0.883, p < 0.001). When CN was compared to healthy controls or diabetics, the difference was more prominent for healthy controls (SDM = 1.043, 95%CI = 0.676-1.409, p < 0.001) than diabetics (SDM = 0.639, 95%CI = 0.456-0.821, p < 0.001) and the SDM difference was significant (p = 0.013). Using 6 publications (9 studies), neither the 1181C > G or the 950 T > C polymorphisms showed any significant associations for any genetic model. For the 245A > C polymorphism, only the homozygous genetic model showed a significant association between the polymorphism and CN (OR = 2.850, 95%CI: 1.051-7.729, p = 0.040).

CONCLUSIONS

Here, we determined a potential correlation between the CN and serum OPG concentrations and that only the CC genotype of the 245A > C polymorphism showed an increased risk of developing CN.

For diabetic type 1 patients, the skin autofluorescence predicts ulcers and amputations

We searched whether the accumulation of Advanced Glycation End-products (AGEs), reflected by the skin autofluorescence (SAF), could predict diabetic foot ulcers (DFUs) during the long-term follow-up of people with type 1 diabetes. During year 2009, we measured the SAF with an AGE-Reader in 206 subjects with type 1 diabetes. DFU and amputations were registered during the 10 following years. The relation between the SAF and later DFU was analyzed by Cox model regression, adjusted for vascular risk factors. The 206 participants were mainly men (55.8%), 51 ± 15 years old, with a 22 ± 13 years diabetes duration. Twelve subjects presented a DFU. Their SAF were higher: 2.61 ± 0.89 AU vs 2.11 ± 0.53 for the others (p = 0.003), related to the risk of DFU (OR:3.69; 95% CI: 1.06-12.79) after adjustment for age, gender, diabetes duration, initial HbA1c, arterial hypertension, history of smoking, blood lipids and use of a statin. Five subjects were amputated, also related to the initial SAF: OR: 11.28 (95% CI: 1.76-79.97) after adjustment for age, gender, duration of diabetes, and HbA1c. The SAF has already been related to diabetic neuropathy and peripheral arterial disease. It predicts DFU in type 1 diabetes, which suggests that AGEs play a role in this highly specific and feared complication.

Depression in diabetic foot ulcer: Associated factors and the impact of perceived social support and anxiety on depression

Diabetic foot ulcer (DFU) exerts a heavy physical and emotional burden on patients with diabetes mellitus. The purpose of the present study was to explore the impact of anxiety and perceived social support on depression of DFU patients well as patients' characteristics associated with depression. The sample of the study consisted of 180 DFU patients. Data collected by the completion of "Self-rating Depression/Anxiety Scale- Zung" (SDS/SAS) and the Multidimensional Scale of Perceived Social Support (MSPSS). Patients had moderate levels of anxiety and depression (median: 36, 42, respectively) and high levels of perceived social support from their significant ones, their family and friends (median: 24, 24, 17, respectively). After multiple regression factors that were found to have an impact on depression after taking into account all other factors, were patient's age of above 70 years, patient's anxiety and the social support they received from their significant ones. More specifically, patients aged above 70 years had 9.51 points higher depression than patients aged <50 years of age (β = 9.51, 95% CI: [0.76, 18.25], P = .034). Moreover, one point increase in patient's anxiety score indicated an increase of 0.71 points in patient's depression (β = 0.71, 95% CI: [0.43, 1.00], P = .001). On the contrary, one point increase in patient's social support from their significant ones indicated a decrease of 1.52 points in patient's depression (β = -1.52, 95% CI: [-0.25, -2.79], P = .020). Clinically, a better understanding of factors having an impact on depression on DFU may provide an essential in planning cost effective interventions.