Prevalence and Risk Factors for Diabetic Lower Limb Amputation: A Clinic-Based Case Control Study

HbA1c and the Risk of Lower Limb Ulcers Among Diabetic Patients: An Observational and Genetics Study

Aims: A lower limb ulcer is a serious complication of diabetes. The association between glycated hemoglobin (HbA1c) and lower limb ulcers needs further clarification. We aimed to comprehensively evaluate the relationship between HbA1c and lower limb ulcer risk in diabetic patients through multivariable-adjusted observational analyses and Mendelian randomization (MR) approaches. Methods: This prospective cohort study included 23,434 individuals with prevalent diabetes in the UK Biobank. The Cox proportional hazard model was used to evaluate the association between HbA1c levels and lower limb ulcer risk. Furthermore, a one-sample MR analysis was conducted to explore the potential causal effect. Results:Over a follow-up period of 290,677 person-years (median length: 13.3 years), 1101 lower limb ulcers cases were documented. The multivariable-adjusted hazard ratios across categories of HbA1c of ≤ 42, 42-53, 53-64, 64-75, 75-86, and > 86 mmol/mol were 0.93 (0.76-1.15), 1.00, 1.24 (1.05-1.46), 1.98 (1.65-2.39), 2.68 (2.13-3.37), and 4.52 (3.62-5.65), respectively. The restrictive cubic spline model showed that lower limb ulcer risk increased steeply when HbA1c concentration exceeded 53 mmol/mol. One-sample linear and nonlinear MR analyses provided a positive but not significant association between genetically proxied HbA1c and lower limb ulcer risk among diabetic patients. Conclusions: High HbA1c levels increase the risk of lower limb ulcers in diabetic patients. MR analyses validated the positive but not significant association between genetically proxied HbA1c levels and lower limb ulcer risk. The results recommended an HbA1c goal of < 53 mmol/mol to decrease the incidence of diabetic ulcers.

Predictive Factors of Wound Healing and Limb Salvage After Successful Below-the-Knee Endovascular Angioplasty in Patients with Diabetic Foot Ulcer: A Retrospective Study

Background and Objectives: The primary objective of this study was to determine the predictive factors of limb salvage and wound healing in patients presenting with diabetic foot ulcers (DFUs) following successful below-the-knee endovascular angioplasty. Materials and Methods: Between January 2014 and January 2019, we retrospectively analyzed the wound healing and limb salvage rates of 85 patients (88 limbs) who underwent infra-popliteal endovascular treatment (EVT) for DFUs. Numerous variables were explored, including age, sex, comorbidities, and the scores from three DFU grading systems (Wagner grade, University of Texas (UT) grade and stage, and Wound, Ischemia, and foot Infection (WIfI) stage). Univariate and multivariate Cox proportional hazards analyses were conducted to determine the associations between adverse events and these variables. Results: During follow-up, 44 wounds healed completely, 47 limb amputations (major, 25; minor, 22) were required, and 17 limbs needed reintervention for wound healing. Nine patients who received treatment died of cardiovascular and cerebrovascular diseases, pneumonia, and other causes. At 1, 3, 6, 9, and 12 months, total wound healing rates were 4.6%, 16.9%, 27.5%, 34.5%, and 64.5%, respectively. At 6 months, 1 year, 2 years, and 5 years, amputation-free survival rates were 77.6%, 72.4%, 63.3%, and 63.3%, respectively. In multivariate Cox analyses, the UT grade and stage were associated with increased wound non-healing, while the UT grade and Wagner grade were associated with increased major lower-extremity amputation rates. Importantly, the UT grade was the only simultaneous risk factor predicting both wound healing and limb salvage. Conclusions: Despite successful below-the-knee angioplasty, a significant proportion of patients experienced wound non-healing and major amputation. The UT grade may serve as a predictor for both wound healing and limb salvage outcomes.

Predictive Factors of Amputation in Diabetic Foot

Background: Diabetic foot ulcers are a common complication of diabetes mellitus, often leading to progressive sensory deficits, impaired vascularization, and a predisposition to ulceration and gangrene. Untreated ulcers may cause recurrent infections that endanger a patient's life. Amputation of part of the limb up to a well-vascularized level is one of the treatments employed for untreated ulcers. Objectives: Laboratory data were analyzed with the aim of identifying risk factors related to surgical amputation treatment of diabetic foot. We believe it is useful to identify risk factors that can be altered from a reversible condition in the clinical decision-making of treatment, thus manifesting themselves in a timely manner to provide the patient with an alternative to surgical amputation of the lower limb. Methods: Our retrospective study was conducted by the Department of Orthopedics and Traumatology at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome. We recruited 200 patients who underwent lower limb amputation for diabetic foot between 2017 and 2021 and had blood tests both 30 days and within 5 days before the first surgery. Results: This case-control study revealed a significant negative correlation between hemoglobin (Hb) levels and the occurrence of leg amputations. In contrast, C-reactive protein (CRP) levels, the neutrophil-to-lymphocyte ratio (NLR), and the platelet-to-lymphocyte ratio (PLR) showed significant positive correlations with leg amputations. A 3-year follow-up of the cases also revealed a significative positive correlation between age, white blood cells (WBC) count, NLR, PLR, and death at 3 years. Conclusions: Our findings suggested that lower Hb levels and elevated CRP, NLR, and PLR levels in patients with diabetic foot disease may be associated with a higher risk of lower-limb amputation. Unexpectedly, this study also demonstrated that elderly age, WBC, CRP, NLR and PLR levels may be associated with a negative prognosis for these patients. These findings highlighted the importance of monitoring these laboratory values in diabetic patients to identify individuals at higher risk of leg amputations and implement appropriate interventions to prevent or minimize the occurrence of this severe complication.

Geographic Variation in First Lower Extremity Amputations Related to Diabetes and/or Peripheral Arterial Disease

BACKGROUND

To assess trends of first cases of lower extremity amputation (LEA) related to diabetes and/or peripheral arterial disease (PAD), according to areas of residency and neighbourhood material and social deprivation quintiles, in the province of Quebec, Canada.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of first LEA (total, minor, and major) among adults 40 years of age and older with diabetes and/or PAD in fiscal years 2006 and 2019. Area of residency was compiled in 3 categories: (1) Montreal and other census metropolitan areas; (2) midsize agglomerations (10,000-100,000 inhabitants); and (3) small towns and rural areas (< 10,000 inhabitants). We also stratified according to neighbourhood material and social deprivation quintiles. One-year and 5-year all-cause mortality after first LEA were compared according to area of residency.

RESULTS

Among the 10,275 individuals who had a first LEA, age-standardized LEA rates remained stable between 2006 and 2019, whereas major LEA rates declined in all geographical areas and minor LEA rates increased (31.6%) in small towns and rural areas. In 2019, age-standardized LEA rates were higher in midsize agglomerations and small towns and rural areas compared with census metropolitan areas. Age-standardized LEA rates in 2019 were higher among the most deprived quintile compared with the most privileged quintile for material and social deprivation. No difference was observed in mortality after first LEA according to area of residency.

CONCLUSIONS

There are health disparities in the burden of diabetes and PAD related to first LEA in the province of Quebec. To improve preventive care and reduce the burden of LEA, targeted actions should be taken among the most deprived groups and rural settings.

Risk Factors for Early Lower Limb Re-Amputation in Vascular Diseases

BACKGROUND

Numerous risk factors for lower limb amputations are known; however, this study aimed to identify risk factors for re-amputation in patients within 6 months from an initial lower limb amputation procedure.

METHODS

This single-center retrospective cohort study was performed at the Hospital Regional Hans Dieter Schmidt in Brazil. The study included patients who were aged at least 18 years and had undergone lower limb amputation between 2013 and 2022. Patients who died while hospitalized and patients who were lost to follow-up after hospital discharge were excluded from the study. Patient age, sex, number of amputations, revision time, comorbidities, and potential risk factors were extracted from the physical therapy service database and electronic medical records of the hospital. Chi-squared test and student's t-test were used to identify statistical significance.

RESULTS

A total of 652 patients were included, of which 35.2% (230) patients underwent re-amputation within 6 months of the first operation. We found that dialysis (P = 0.004; odds ratio [OR] 8.36, 95% confidence interval [CI] 3.09-20.5), smoking (P = 0.004; OR 1.67, 95% CI 1.18-2.35), and hypertension (P = 0.02; OR 1.55, 95% CI 1.09-2.19) were predictive factors for re-amputation within 6 months of lower limb amputation.

CONCLUSIONS

Therefore, it is important to intervene early and provide additional support to patients undergoing lower limb amputation with these risk factors to reduce the potential for re-amputation in the future.

Use of hypothermically stored amniotic membrane on diabetic foot ulcers: a multicentre retrospective case series

OBJECTIVE

The aim of this retrospective case series was to report on the outcomes of diabetic foot ulcers (DFUs) managed with hypothermically stored amniotic membrane (HSAM).

METHOD

Deidentified case data of patients who received HSAM were obtained from wound care sites across the US. Data were collected, beginning at the first patient visit to the wound care site (first presentation), at the visit in which the first HSAM application occurred (baseline), and at each subsequent visit over 12 weeks of treatment (follow-up). All patients received standard of care (SoC) between first presentation and baseline.

RESULTS

Of the 50 patients in the study, 68% were male. Mean age of the entire cohort was 66.7 years. Of the DFUs, 88% were present for <6 months at first presentation. Mean wound area was 3.5cm2, and mean percentage area reduction was -68.3% from first presentation to baseline. The mean number of HSAM applications was 5.5, and mean number of days between applications was 7.5. A >60% area reduction was attained in 96.0% of DFUs, and 78% attained complete wound closure (CWC) by week 12. The median time to CWC was 55 days.

CONCLUSION

The results of this retrospective case series suggest positive outcomes for DFUs managed with HSAM. A reduction in time to CWC may lead to lesser financial burden and improved quality of life for DFU patients.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Reliability and validity of the Diabetic foot self-care questionnaire in Turkish patients

AIM

This study was conducted to examine the psychometric, properties of the Turkish version of the Diabetic, Foot Self-Care, Questionnaire.

METHODS

This was a descriptive- methodological study conducted on 193 diabetes patients. Data were collected, using Descriptive, Information Form and Diabetic Foot Self-Care Questionnaire. Data were analyzed using exploratory factor analysis, item-total score correlation, Cronbach's alpha, and test-retest analysis.

RESULTS

The Diabetic, Foot Self-Care, Questionnaire consists of 16 items and three sub-dimensions. The three sub-dimensions recorded a variance of 58.137%. The total Cronbach's alpha coefficient of the Turkish version of the Diabetic, Foot Self-Care, Questionnaire was 0.87, and Cronbach's alpha values of its sub-dimensions were 0.71 and 0.88. The two-month test-retest credibility interpreted with intra-class correlation was 0.97.

CONCLUSIONS

It has been shown that the questionnaire is a valid and reliable tool for assessing foot self-care behavior in diabetic patients.

Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens

Introduction

Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens.

Methods

A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR).

Results

Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA.

Discussion

This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare.

Conclusion

Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting.

Systematic review registration

Open Science Framework https://osf.io/j9pu7, identifier j9pu7.

Prevalence and determinants of lower extremity amputations among type I and type II diabetic patients: A multicenter-based study

The incidence of diabetes-related lower-extremity complications is increasing globally, yet the condition in developing countries, particularly those in sub-Saharan Africa, is unclear. This study determined the prevalence and determinants of lower extremity amputations among type I and type II diabetic patients at health facilities in the Volta Region, Ghana. This was a multicenter-based study involving 473 diabetic patients. Sociodemographic, lifestyle, medical, biochemical, and anthropometric data were obtained systematically with a pretested structured questionnaire. The prevalence rate of lower extremity amputations (LEAs) was 1.9%. LEAs were linked to the male gender (unadjusted odds ratio [UOR] = 5.86; 95% confidence interval [CI] = 1.44-23.82; P = 0.013), smokers (UOR = 10.12; 95% CI = 2.63-38.91; P = .001), type I diabetic patients (UOR = 4.74; 95% CI = 1.24-18.10; P = .023), family history of diabetes mellitus (UOR = 9.18; 95% CI = 2.25-37.46; P = .002), diabetic foot ulcers (adjusted odds ratio [AOR] = 8.62; 95% CI = 1.58-47.62; P = .013) and obesity (AOR = 6.20; 95% CI = 1.00-38.04; P = .049). This study showed a relatively low prevalence rate compared to previous studies within Ghana. However, it is a major concern in public health that needs to be addressed since diabetes-related LEAs are connected to global major morbidity and mortality.

Effects of Implementing a Self-Care Program for Adults With Lower Limb Prostheses

An artificial replacement for a lost limb or portion of a limb, known as a prosthesis, is a tool that can assist a person to regain their independence. The aim of this project was to evaluate the effect of a self-care program for adults with lower limb prostheses. We used a quasi-experimental research design. We conducted our study at the Physical Medicine and Rehabilitation and Rheumatology Center affiliated with the Armed Forces, located in the Al-Geza Governorate of Egypt using a purposeful sample of 81 adults with lower limb prostheses. We used two tools for data collection: a structured interviewing questionnaire and the Trinity Amputation and Prosthesis Experience Scales (TAPES). The mean age of adults with lower limb prosthesis in our study was 38.91 years (10.53). A total of 64.2% of the study participants (n = 51) were men. We found that before the self-care program, 22.2% of the participants (n = 18) had a satisfactory level of knowledge about self-care, which increased to 88.9% (n = 72) after the program. Before the self-care program, the number of participants with adequate practice levels was 13.6% (n = 11), which increased to 100.0% (n = 81) after the program. We concluded that implementing the self-care program provided a significant improvement in the attendee's total satisfactory knowledge (χ2[79,81] = 72.90, p < .000) and adequate practice levels (p < .001).

Poly(l-lactic acid) Scaffold Releasing an α4β1 Integrin Agonist Promotes Nonfibrotic Skin Wound Healing in Diabetic Mice

Skin wound healing is a highly complex process that continues to represent a major medical problem, due to chronic nonhealing wounds in several classes of patients and to possible fibrotic complications, which compromise the function of the dermis. Integrins are transmembrane receptors that play key roles in this process and that offer a recognized druggable target. Our group recently synthesized GM18, a specific agonist for α4β1, an integrin that plays a role in skin immunity and in the migration of neutrophils, also regulating the differentiated state of fibroblasts. GM18 can be combined with poly(l-lactic acid) (PLLA) nanofibers to provide a controlled release of this agonist, resulting in a medication particularly suitable for skin wounds. In this study, we first optimized a GM18-PLLA nanofiber combination with a 7-day sustained release for use as skin wound medication. When tested in an experimental pressure ulcer in diabetic mice, a model for chronic nonhealing wounds, both soluble and GM18-PLLA formulations accelerated wound healing, as well as regulated extracellular matrix synthesis toward a nonfibrotic molecular signature. In vitro experiments using the adhesion test showed fibroblasts to be a principal GM18 cellular target, which we then used as an in vitro model to explore possible mechanisms of GM18 action. Our results suggest that the observed antifibrotic behavior of GM18 may exert a dual action on fibroblasts at the α4β1 binding site and that GM18 may prevent profibrotic EDA-fibronectin-α4β1 binding and activate outside-in signaling of the ERK1/2 pathways, a critical component of the wound healing process.

Understanding amputation care in England and Scotland: a qualitative exploration of patient stories posted on an online patient feedback site

PURPOSE

Undergoing an amputation is a life-altering experience that can involve a protracted and intensive period of care from a range of healthcare professionals. Amputation care within the NHS has historically been criticised. Here we seek to understand how patients are experiencing care by exploring their stories and identifying features of both high- and low-quality care.

MATERIALS AND METHODS

We analysed patient stories posted on the patient feedback site Care Opinion during the period 2018-2020 to examine how amputee patients (and their families) experience NHS care. Using thematic analysis, we identified four key themes.

RESULTS

We found that patients' stories of undergoing an amputation as posted on Care Opinion give overwhelmingly positive feedback on their experiences. Patients report feeling well-supported by empathetic staff, and that the outcomes, in terms of quality of life and restoration of mobility, are beneficial. Time was a common feature within the posts we examined and negative experiences of care often related to untimeliness in a variety of ways.

CONCLUSIONS

Care Opinion provides a useful and accessible resource for understanding how patients experience amputation care; analysis of stories posted there provides preliminary ideas of the features of "good care" from a patient-centred perspective.IMPLICATIONS FOR REHABILITATIONPatients undergoing amputations view professionalism of staff as important for good care.Timeliness is important to patients in seeing care in positive terms, ensuring patients are supported in their care during and after amputation in a timely manner is therefore important for achieving good rehabilitation care.Rehabilitation and related services supporting patients who have undergone amputations could usefully patient feedback sites as a means for further understanding the experiences of their patients and for improving services where necessary.

Predictive factors and nomogram to evaluate the risk of below-ankle re-amputation in patients with diabetic foot

BACKGROUND

Diabetes mellitus, as the most common metabolic disease, is common worldwide and represents a crucial global health concern. The purpose of this research was to investigate the related risk factors and to develop a re-amputation risk nomogram in diabetic patients who have undergone an amputation.

METHODS

A observational analysis was performed on 459 patients who have underwent amputation for diabetic foot from January 2014 through December 2019 at the First Affiliated Hospital of Wenzhou Medical University. The least absolute shrinkage and selection operator regression and stepwise regression methods were implemented to determine risk selection for the re-amputation risk model, and the predictive nomogram was established with these features. Calibration curve, receiver operating characteristic curve, and decision curve analysis of this re-amputation nomogram were assessed.

RESULTS

Predictors contained in this predictive model included smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI) and C-reactive protein (CRP). Good discrimination with a C-index of 0.725 (95% CI, 0.6624-0.7876) and good calibration were displayed with this predictive model. The decision curve analysis showed that this re-amputation nomogram predicting risk adds more benefit than none strategy if the threshold probability of a patient was >6% and <59%.

CONCLUSIONS

This novel re-amputation nomogram incorporating smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI), C-reactive protein (CRP), and smoking could be easily used to predict individual re-amputation risk prediction in diabetic foot patients who have undergone an amputation. In the future, further analysis and external testing will be needed as much as possible to reconfirm that this new Nomogram can accurately predict the risk of toe re-amputation.

Molecular mechanisms of skin wound healing in non-diabetic and diabetic mice in excision and pressure experimental wounds

Experimental models for chronic skin lesions are excision and pressure ulcer, defined as “open” and “closed” lesions, respectively, only the latter characterized by tissue hypoxia. Moreover, systemic diseases, such as diabetes mellitus, affect wound repair. Thus, models for testing new therapies should be carefully selected according to the expected targets. In this study, we present an extensive and comparative histological, immunohistochemical, and molecular characterization of these two lesions in diabetic (db/db) and non-diabetic (C57BL/6 J) mice. In db/db mice, we found significant reduction in PGP9.5-IR innervation, reduction of capillary network, and reduced expression of NGF receptors. We found an increase in VEGF receptor Kdr expression, and the PI3K-Akt signaling pathway at the core of the altered molecular network. Db/db mice with pressure ulcers showed an impairment in the molecular regulation of hypoxia-related genes (Hif1a, Flt1, and Kdr), while extracellular matrix encoding genes (Itgb3, Timp1, Fn1, Col4a1) were upregulated by hyperglycemia and lesions. Overall, the molecular analysis suggests that db/db mice have a longer inflammatory phase of the wound repair process, delaying the progression toward the proliferation and remodeling phases.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Clinical Effect of Revascularization Strategies and Pharmacologic Treatment on Long-Term Results in Patients with Advanced Peripheral Artery Disease with TASC C and D Femoropopliteal Lesions

Background

This study was to assess the clinical outcome and associated parameters of endovascular therapy (EVT group) and bypass surgery (bypass group) in patients with long femoropopliteal TransAtlantic Inter-Society Consensus II (TASC II) C and D peripheral artery disease (PAD).

Methods

187 patients who underwent successful EVT or bypass surgery were assessed. The endpoints included the events of cardiovascular disease (CVD) and lower-extremity amputation (LEA), 3-year primary patency, and 3-year amputation-free survival (AFS).

Results

The 3-year primary and secondary patency rates were better in the bypass group (P=0.007 and P=0.039, respectively), while the incidences of LEA, new CVD events, and mortality were comparable between groups. Weighted multivariate Cox analyses showed that cilostazol treatment (hazard ratio (HR): 0.46, 95% confidence interval (CI): 0.3–0.72, P=0.001), statin treatment (HR: 0.54, 95% CI: 0.33–0.9, P=0.014), and direct revascularization (DR) (HR: 0.47, 95% CI: 0.29–0.74, P=0.001) were predictive factors of 3-year primary patency. Kaplan–Meier curve analyses of time-to-primary cumulative AFS showed that nondiabetes mellitus, mild PAD, and cilostazol and statin treatment were correlated with a superior 3-year AFS (log rank test, P=0.001, P < 0.001, P=0.009, and P=0.044, respectively).

Conclusions

Endovascular stenting based on the angiosome concept and bypass surgery provide comparable benefits for the treatment of long, advanced femoropopliteal lesions after a short follow-up period, whereas cilostazol therapy for more than 3 months, aggressive treatment of dyslipidemia, and surgical revascularization were associated with higher primary patency.

Risk factors that predict major amputations and amputation time intervals for hospitalised diabetic patients with foot complications

Diabetes‐related lower extremity amputations are an enormous burden on global health care and social resources because of the rapid worldwide growth of the diabetic population. This research aimed to determine risk factors that predict major amputation and analyse the time interval from first hospitalisation to amputation by using standard management protocols and Kaplan–Meier survival curves. Data from 246 patients with diabetes mellitus and diabetic foot ulcers from the Division of Plastic and Reconstructive Surgery of the Department of Surgery at XXX Hospital between January 2016 and May 2020 were analysed. Univariate and multivariate analyses of 44 potential risk factors, including invasive ulcer depth and C‐reactive protein levels, showed statistically significant differences for those at increased risk for major amputation. The median time from hospitalisation to lower extremity amputation was approximately 35 days. Most patients with abnormal C‐reactive protein levels and approximately 70% of patients with ulcers invading the bone were at risk for lower extremity amputations within 35 days. Therefore, invasive ulcer depth and C‐reactive protein levels are significant risk factors. Other potential risk factors for major amputation and the time intervals from first hospitalisation to amputation should be analysed to establish further prediction strategies.

Walking while talking: validation in older adults with lower-limb amputation

BACKGROUND

Walking while talking (WWT) is a dual-task (cognitive and motor) performance test that has not yet been validated in older adults with lower-limb amputation (LLA). WWT is composed of two sections: WWT-simple (walking while reciting every letter of the alphabet) and WWT-complex (walking while reciting every other letter of the alphabet).

OBJECTIVE

To determine the validity, and provide normative data and a new scoring system for the WWT test in older adults with LLA.

STUDY DESIGN

Baseline cross-sectional data were collected from 56 community-living older adults (≥50 years old) with LLA at rehabilitation hospitals in Vancouver, BC, London, ON, and Edmonton, AB, Canada.

METHODS

Time and number of recited letters and errors during both sections were recorded. A new score was developed based on all these variables. Correlations of the recorded times with the Activities-specific Balance Confidence (ABC) scale and the 2-Minute Walk Test (2MWT) score were used to evaluate the validity of the WWT test.

RESULTS

As hypothesized, the times for both sections of the WWT were negatively correlated with both the ABC and 2MWT scores. Positive correlations were observed between the scores developed for both WWT sections with the 2MWT score.

CONCLUSION

Times taken to complete each section of the WWT test were correlated with the 2MWT and the ABC scale scores, providing evidence for the validity of the WWT test. We also provided a scoring method that is more objective and in line with the dual-task nature of the test.

Racial differences in all-cause mortality and future complications among people with diabetes: a systematic review and meta-analysis of data from more than 2.4 million individuals

AIMS/HYPOTHESIS

The aim of this work was to quantify racial/ethnic differences in risk for future diabetic complications and all-cause mortality by performing a meta-analysis of prospective studies.

METHODS

A systematic search in PubMed and EMBASE was performed from inception to May 2021. Prospective cohort studies that reported HRs and associated 95% CIs of diabetes complications and all-cause mortality among racial/ethnic groups, with White people as the reference group, were included. Study characteristics and HR estimates were extracted from each study. Estimates were pooled using random-effects inverse-variance model with the Hartung-Knapp-Sidik-Jonkman variance estimator.

RESULTS

A total of 23 studies were included, comprising 2,416,516 individuals diagnosed with diabetes (White 59.3%, Black 11.2%, Asian 1.3%, Hispanic-American 2.4%, Native American 0.2%, East Asian 1.9%, South Asian 0.8%, Pacific Islander 2.3%, Māori 2.4% and others 18.2%). Compared with White individuals with diabetes, individuals of Māori ethnicity were at higher risk for all-cause mortality (HR 1.88 [95% CI 1.61, 2.21]; I² = 7.1%), Hispanic-American individuals had a significantly lower risk for CVD (HR 0.66 [95% CI 0.53, 0.81]; I² = 0%) and Black individuals had higher risk for end-stage renal disease (HR 1.54 [95% CI 1.05, 2.24]; I² = 95.4%). No significant higher risk for diabetes complications was found in other racial/ethnic groups relative to White people.

CONCLUSIONS/INTERPRETATION

Racial/ethnic differences exist in the risk for future diabetic complications and all-cause mortality. Our results support the use of such categories for international diabetes clinical guideline recommendations until better predictors become available. Efforts to identify high-risk groups and to better control cardiovascular risk factors across ethnically diverse populations are therefore needed.

REGISTRATION

PROSPERO registration ID CRD42021239274.

Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations

BACKGROUND

Aboriginal people have higher prevalence rates of diabetes than non-Aboriginal people in the same geographic locations, and diabetic foot ulcer (DFU) complication rates are also presumed to be higher. The aim of this systematic review and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal populations.

METHODS

We searched PubMed, Embase, CINAHL and the Cochrane Library from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other than English. The primary outcome was the major amputation rate. We assessed the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool. Effect measures were reported as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

Six cohort studies with a total of 244 792 patients (2609 Aboriginal, 242 183 non-Aboriginal) with DFUs were included. The Aboriginal population was found to have a higher rate of major amputation than the non-Aboriginal population (OR 1.85, 95% CI 1.04-3.31). Four studies were deemed to have moderate risk of bias, and 2 were deemed to have serious risk of bias.

CONCLUSION

Our analysis of the available studies supports the conclusion that DFU outcomes, particularly the major amputation rate, are worse in Aboriginal populations than in non-Aboriginal populations in the same geographic locations. Rurality was not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined with ethnicity, resulting in worse outcomes.

Prevalence of diabetic foot ulcers and their associated factors in patients from public hospitals in manaus-am

AIM

The purpose of this study was to identify and analyze the prevalence of diabetic foot ulcers (DFU) as well as associating factors in the city of Manaus, Amazonas State, Brazil.

METHODS

This was an observational, epidemiological, cross-sectional study, point prevalence, with 229 adults' diabetic inpatients from seven hospitals. Written signed consent was obtained from all participants or their legal representative if they had a cognitive impairment. Sociodemographic and clinical data were collected through interviews and medical records. Each participant was examined by the research team to evaluate for foot deformity.

RESULTS

Of the 229 patients diagnosed with DM, 60 presented DFU, resulting in a prevalence of 26.2 %. The logistic regression model that included all variables with a significance level of 5 % (p ≤ 0.05) shows: Patients with PAD were more likely to have DFU (OR = 2956; p = 0,01). The use of emollients (OR = 0.097; p < 0.001) and anticoagulants (OR = 0.149; p = 0.002) were related to reduced likelihood for developing DFU.

CONCLUSION

This study contributes to a better understanding of DFU epidemiology in hospitalized patients, as well as the factors associated with them. The results are important for nursing in order to develop early prevention and intervention strategies.

Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019

BACKGROUND

There is conflicting evidence whether limb amputation (LA) disproportionately affects indigenous populations. To better understand this disparity, we compared the LA incidence rate between First Nations persons registered under the Indian Act of Canada (RI) and the general population (GP) in Saskatchewan.

METHODS

We used Saskatchewan's retrospective administrative data containing hospital discharge LA cases, demographic characteristics (age and sex), and residents population reported in the database stratified by RI and GP from 2006-2019. The LA cases for each stratified group were first disaggregated into three broad categories: overall LA (all reported LA), primary LA (first reported LA), and subsequent LA (revision or contralateral LA), with each category further split into the level of amputation defined as major amputation (through/above the ankle/wrist joint) and minor amputation (below the ankle/wrist joint). LA rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial regressions were performed to explore the trends further.

RESULTS

Overall, there were 1347 RI and 4520 GP LA cases reported in Saskatchewan from 2006-2019. Primary LA made up approximately 64.5% (869) of RI and 74.5% (3369) of GP cases, while subsequent LA constituted 35.5% (478) of RI and 25.5% (1151) of GP cases. The average age-adjusted LA rate was 153.9 ± 17.3 per 100,000 in the RI cohort and 31.1 ± 2.3 per 100,000 in the GP cohort. Overall and primary LA rates for the GP Group declined 0.7% and 1.0%, while subsequent LA increased 0.1%. An increased LA rate for all categories (overall 4.9%, primary 5.1%, and subsequent 4.6%) was identified in the RI group. Overall, minor and major LA increased by 6.2% and 3.3%, respectively, in the RI group compared to a 0.8% rise in minor LA and a 6.3% decline in major LA in the GP group. RI females and males were 1.98-1.66 times higher risk of LA than their GP counterparts likewise, RI aged 0-49 years and 50+ years were 2.04-5.33 times higher risk of LA than their GP cohort. Diabetes mellitus (DM) was the most prevalent amputation predisposing factor in both groups with 81.5% of RI and 54.1% of GP diagnosed with DM. Also, the highest proportion of LA was found in the lowest income quintile for both groups (68.7% for RI and 45.3% for GP).

CONCLUSION

Saskatchewan's indigenous individuals, specifically First Nations persons registered under the Indian Act of Canada, experience LA at a higher rate than the general population. This disparity exists for all variables examined, including overall, primary, and subsequent LA rates, level of amputation, sex, and age. Amplification of the disparities will continue if the rates of change maintain their current trajectories. These results underscore the need for a better understanding of underlying causes to develop a targeted intervention in these groups.

Incidence and Predictive Factors for Amputations Derived From Charcot's Neuroarthropathy in Persons With Diabetes

Charcot's neuroarthropathy (CN) is the progressive destruction of the bones and joints of the feet, as a consequence of severe peripheral neuropathy, which predisposes patients to amputations. The purpose of this study was to measure the cumulative incidence of amputations resulting from CN and risk factors among amputated people with diabetes mellitus (DM). This was an epidemiological, observational, and retrospective study of 114 patients with DM who had an amputation involving the lower limbs. Data were collected from 2 specialized outpatient clinics between 2015 and 2019, including socio-demographic and clinical variables (cause of amputation: CN, peripheral arterial disease [PAD], infected ulcers, fracture, osteomyelitis, and others; body mass index [BMI]; 1 or 2 DM, time since DM diagnosis, insulin treatment, glycated hemoglobin; creatinine; smoking and drinking; systemic arterial hypertension, diabetic retinopathy, diabetic kidney disease, diabetic peripheral neuropathy, acute myocardial infarction, PAD, and stroke; characteristics of amputation [level and laterality], in addition to the specific variables related to CN [time of amputation in relation to the diagnosis of CN, diagnosis of CN in the acute phase, and treatment implemented in the acute phase]). We compared socio-demographic and clinical characteristics, including types of amputation, between patients with and without CN. Statistical analyses were performed using the 2 sample t-test or Wilcoxon-Mann-Whitney test, for quantitative variables, and the Pearson's χ² test or Fisher's exact test for categorical variables. The investigation of the possible association of predictive factors for a CN amputation was carried out through logistic regression. The amputation caused by CN was present in 27 patients with a cumulative incidence of 23.7% in 5 years. There was a statistically significant association between BMI and the occurrence of CN (odds ratio: 1.083; 95% confidence interval: 1.001-1.173; P = .048); higher values of BMI were associated with a higher occurrence of amputations secondary from CN.

A Bittersweet Response to Infection in Diabetes; Targeting Neutrophils to Modify Inflammation and Improve Host Immunity

Chronic and recurrent infections occur commonly in both type 1 and type 2 diabetes (T1D, T2D) and increase patient morbidity and mortality. Neutrophils are professional phagocytes of the innate immune system that are critical in pathogen handling. Neutrophil responses to infection are dysregulated in diabetes, predominantly mediated by persistent hyperglycaemia; the chief biochemical abnormality in T1D and T2D. Therapeutically enhancing host immunity in diabetes to improve infection resolution is an expanding area of research. Individuals with diabetes are also at an increased risk of severe coronavirus disease 2019 (COVID-19), highlighting the need for re-invigorated and urgent focus on this field. The aim of this review is to explore the breadth of previous literature investigating neutrophil function in both T1D and T2D, in order to understand the complex neutrophil phenotype present in this disease and also to focus on the development of new therapies to improve aberrant neutrophil function in diabetes. Existing literature illustrates a dual neutrophil dysfunction in diabetes. Key pathogen handling mechanisms of neutrophil recruitment, chemotaxis, phagocytosis and intracellular reactive oxygen species (ROS) production are decreased in diabetes, weakening the immune response to infection. However, pro-inflammatory neutrophil pathways, mainly neutrophil extracellular trap (NET) formation, extracellular ROS generation and pro-inflammatory cytokine generation, are significantly upregulated, causing damage to the host and perpetuating inflammation. Reducing these proinflammatory outputs therapeutically is emerging as a credible strategy to improve infection resolution in diabetes, and also more recently COVID-19. Future research needs to drive forward the exploration of novel treatments to improve infection resolution in T1D and T2D to improve patient morbidity and mortality.

Polymeric Composite Dressings Containing Calcium-Releasing Nanoparticles Accelerate Wound Healing in Diabetic Mice

Objective: Wound healing is a complex process that involves the interaction between different cell types and bioactive factors. Impaired wound healing is characterized by a loss in synchronization of these interactions, resulting in nonhealing chronic wounds. Chronic wounds are a socioeconomic burden, one of the most prominent clinical manifestations of diabetes, however, they lack satisfactory treatment options. The objective of this study was to develop polymeric composites that deliver ions having wound healing properties and evaluate its performance using a pressure ulcer model in diabetic mice. Approach: To develop a polymeric composite wound dressing containing ion-releasing nanoparticles for chronic wound healing. This composite was chemically and physically characterized and evaluated using a pressure ulcer wound model in diabetic (db/db) mice to explore their potential as novel wound dressing. Results: This dressing exhibits a controlled ion release and a good in vitro bioactivity. The polymeric composite dressing treatment stimulates angiogenesis, collagen synthesis, granulation tissue formation, and accelerates wound closure of ischemic wounds created in diabetic mice. In addition, the performance of the newly designed composite is remarkably better than a commercially available dressing frequently used for the treatment of low-exuding chronic wounds. Innovation: The developed nanoplatforms are cell- and growth factor free and control the host microenvironment resulting in enhanced wound healing. These nanoplatforms are available by cost-effective synthesis with a defined composition, offering an additional advantage in potential clinical application. Conclusion: Based on the obtained results, these polymeric composites offer an optimum approach for chronic wound healing without adding cells or external biological factors.

Virus-like mesoporous silica-coated plasmonic Ag nanocube with strong bacteria adhesion for diabetic wound ulcer healing

The Gram-positive bacterium Staphylococcus aureus (MRSA) and the Gram-negative bacillus Escherichia coli (E. coli) can be commonly found in diabetic foot ulcers. However, the multi-drug resistant pathogenic bacteria infection is often difficult to eradicate by the conventional antibiotics and easy to spread which can lead to complications such as gangrene or sepsis. In this work, in order to pull through the low cell wall adhesion capability of typical antibacterial Ag nanoparticles, we fabricated biomimic virus-like mesoporous silica coated Ag nanocubes with gentamicin loading, and then the core-shell nanostructure was entrapped in the FDA approved hydrogel dressing. Interestingly, the Ag nanocubes with virus-like mesoporous silica coating are capable of effectively adsorbing on the rigid cell wall of both E. coli and MRSA. The intracellular H₂S in natural bacterial environment can induce generation of small Ag nanospheres, which are the ideal antibacterial nanoagents. Combined with the gentamicin delivery, the pathogenic bacteria in diabetic wound can be completely eradicated by our dressing to improve the wound healing procedure. This virus-like core-shell nanostructure sheds light for the future wound healing dressing design to promote the clinical applications on antibacterial eradication.

Different Levels of Physical Activity, Physical Health, Happiness, and Depression among Older Adults with Diabetes

The purpose of this study was to investigate the relationship between different levels of physical activity (light, moderate, and vigorous), physical health, happiness, and depression among older adults with diabetes. Using data from the National Social Life, Health and Aging Project (NSHAP) Wave 3, the results indicate that moderate and/or vigorous physical activity is more effective than light physical activity for promoting physical health and happiness and lowering depression of older adults with diabetes. This study suggests that activity professionals and therapists working with older adults with diabetes need to encourage their participation in physical activity as well as adjust a level of physical activity intensity that is tailored to participants’ needs and expectations.

Risk factors associated with lower extremity amputation in Sudanese individuals with diabetes: The need for improvement in primary health care system

Background:

Lower extremity amputation (LEA) in individuals with diabetes is a serious health issue with a considerable physical and social burden. The aim of this study was to assess the prevalence and risk factors associated with LEA in diabetic foot ulcer (DFU) patients.

Materials and Methods:

This was a cross-sectional health facility-based study that recruited 315 diabetes individuals with foot ulcers from the diabetes center in Khartoum, Sudan. Direct interviewing of subjects was used to obtain data, using a standardized validated questionnaire. Chi-square and logistic regression analysis were used in data analysis.

Results:

69.5% of the diabetic participants were aged 50 years old or more, and 71.1% were males. Most of the subjects (48.2%) were diabetics for a duration of >10 years, while more than one third (37.5%) of them were diabetic for 5–10 years. The majority (89.5%) had type 2 DM, while only 10.5% were type 1 DM. Two hundred forty-five patients had a left lower foot ulcer; 55.1% of the patients' ulcers were present in the toes, while 21.6% were in the foot sole. The overall prevalence of lower limb amputation was 17.1%. Individuals with diabetes patients with LEA had a higher incidence of hypertension (P = 0.000), retinopathy (P = 0.000), nephropathy (P = 0.002), ulcer size >2.5 cm (P = 0.000), and neuropathy (P = 0.000) through Chi-square analysis. Furthermore, logistic regression analysis showed that amputation was significantly associated with retinopathy (P = 0.000), size of ulcer (P = 0.000), and neuropathy (P = 0.016).

Conclusion:

The overall prevalence of LEA was 17.1%. The primary risks factors associated with amputation were presence of neuropathy and ulcer size >2.5 cm. Presence of retinopathy predispose diabetic individuals to amputation. Amputation is associated with disability and psychological problems; therefore, there is an urgent need for more improvement in preventative measures and primary health care system in low resource setting country like Sudan in order to decrease diabetes complications, especially patient's education about diabetes management by primary care physicians.

Diabetic foot and peripheral arterial disease. Single centre experience

OBJECTIVES

To determine the prevalence of vasculopathic diabetic foot and the associated factors in a Saudi tertiary center. Methods: This retrospective chart review included adult patients (≥18 years) diagnosed with diabetic foot between May 2015 and July 2019 in King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. Based on clinical presentation and laboratory results, the patients were categorized into 2 groups namely, "vascular induced diabetic foot group" and "non-vascular induced diabetic foot group".

RESULTS

A total of 404 diabetic patients were enrolled in the study. The mean age of the patients was 62.03±12.30 years; 61.9% were males. Most of the diabetic foot cases had a non-vascular etiology (n=327, 80.9%), while 77 cases (19.1%) were due to vasculopathy. Patient in the vascular group had a significantly higher incidence of coronary artery disease (32.5% versus 14.4%; p greater than 0.001), and a higher incidence of peripheral artery disease (PAD) in the unaffected limb (22.1% versus 2.1%; p less than 0.001). Conclusion: Most cases of diabetic foot were due to non-vascular causes. Old age, history of coronary artery disease, or PAD in the unaffected limb were factors that were significantly associated with diabetic foot due to arterial disease.

Effects of Topical Application of CHF6467, a Mutated Form of Human Nerve Growth Factor, on Skin Wound Healing in Diabetic Mice

Nerve growth factor (NGF) is the protein responsible for the development and maintenance of sensory skin innervation. Given the role of appropriate innervation in skin healing, NGF has been indicated as a possible prohealing treatment in pathologic conditions characterized by nerve-ending loss, such as chronic ulcers in diabetes; however, its use as a therapeutic agent is limited by its hyperalgesic effect. We tested the effect of topical application of the nonalgogenic NGF derivative hNGFP61S/R100E in two models of skin ulcer induced in dbdb diabetic mice, investigating healing time, skin histology, reinnervation, and angiogenesis using morphologic and molecular approaches. We showed that the topical administration of CHF6467, a recombinant human NGF in which an amino acid substitution (R100E) abolished the hyperalgesic effect usually associated with NGF, accelerated skin repair in experimental wounds (full-excision and pressure-ulcer) induced in diabetic mice (dbdb). CHF6467-induced acceleration of wound healing was accompanied by increased re-epithelization, reinnervation, and revascularization as assessed by histology, immunohistochemistry, and image analysis. Bioinformatic analysis of differentially expressed genes and signaling pathways in the wound tissues showed that protein kinase B-mammalian target of rapamycin was the most regulated pathway. In spite of the transdermal absorption leading to measurable, dose-dependent increases in CHF6467 plasma levels, no systemic thermal or local mechanical hyperalgesia was observed in treated mice. When tested in vitro in human cell lines, CHF6467 stimulated keratinocyte and fibroblast proliferation and tube formation by endothelial cells. Collectively, these results support a possible use of CHF6467 as a prohealing agent in skin lesions in diabetes. SIGNIFICANCE STATEMENT: Topical application of CHF6467 accelerates reinnervation, neoangiogenesis, and wound healing in diabetic mice in both full-thickness skin-excision and pressure-ulcer models through the protein kinase B/mammalian target of rapamycin pathway and does not induce hyperalgesia.

Patient-level predictors of diabetes-related lower extremity amputations at a quaternary hospital in South Africa

INTRODUCTION

Diabetes-related lower extremity amputation has a major psycho-social and economic cost on the patient as well as a direct impact on financial expenditure within health facilities.

AIM

This study aimed to determine the incidence and patient-related factors related to diabetes-related amputations amongst patients that were referred to the quaternary hospital between 1 January 2014 and 31 December 2015.

METHODS

A retrospective cohort study. Data were retrieved from the medical record for each diabetes patient that was managed at IALCH during the study period. The following variables were collected: sociodemographic parameters (age, gender, and ethnicity) and diabetes-related parameters (type of diabetes) and additional complications.

RESULTS

Ninety-nine patients (0, 73%) of all diabetes patients managed were new diabetes-related lower-extremity amputations. There were statistically significant increased odds of female patients (OR: 1, 7) and patients with non-insulin dependent diabetes (OR: 1, 64) to have new diabetes-related amputations. Patients older than 60 years (OR: 1, 31); African patients (OR: 1, 35) patients with cardiovascular complications (OR: 1, 04) and patients with retinopathy (OR: 1, 48) were more likely to have diabetes-related amputations but not statistically significant.

CONCLUSIONS

A combination of primary preventive strategies, early detection and appropriate management of patients with diabetes and specific guidelines on the frequency, clinical and laboratory tests required for early diagnosis and referrals with early signs of diabetes-related complicationsat primary care level will assist in reducing the long term adverse outcomes including amputations.

Leg dominance as a determinant in laterality of lower extremity amputation in diabetic patients: retrospective study and literature review

Background/Aims

Diabetic patients with peripheral vascular manifestations often develop foot ulcers and sometimes have to undergo lower extremity amputation. This retrospective study investigated leg dominance and laterality of lower extremity amputation in diabetic, dysvascular amputees.

Methods

All patients who met the inclusion criteria had their medical records reviewed for their dominant side and a correlation with a side of amputation was analysed. This information is routinely obtained as part of the admission history. For the literature review, PubMed, Google Scholar, ScienceDirect and Cochrane Library were searched with no date restriction until February 2018. Relevant studies were included and analysed.

Results

Of all the patients (n=27), 16 had diabetes and of these, 12 (75%) had their dominant leg amputated.

Conclusions

The data and literature analysis suggest that diabetic, dysvascular patients' dominant legs may be at higher risk for amputation than the non-dominant side. Larger studies are needed to clarify the relationship between leg dominance and laterality of lower extremity amputation.

Curcumin preconditioned human adipose derived stem cells co-transplanted with platelet rich plasma improve wound healing in diabetic rats

AIM

Inflammatory and oxidative microenvironment at diabetic' wound site hinder the therapeutic efficacy of cell-based therapies in diabetic patients. The purpose of this study is to explore the competence of curcumin preconditioned human adipose derived cells (hASCs) in combination with platelet rich plasma (PRP) for the repair of wounds in diabetic rats.

MAIN METHODS

The cytoprotective effect of curcumin preconditioning for hASCs against hyperglycemic stress was evaluated through analysis of cell morphology, viability, cytotoxicity, senescence, and scratch wound healing assays. Subsequently, the healing capacity of curcumin preconditioned hASCs (Cur-hASCs) added to PRP was examined in excisional wounded diabetic rat model. Healed skin biopsies were excised to analyze gene and protein expression of wound healing markers by qPCR and western blotting. Histopathological changes were observed through hematoxylin and eosin staining.

KEY FINDINGS

We found that Cur-hASCs counteract the glucose stress much better than non-preconditioned hASCs by maintaining their cellular morphology and viability as well as metabolic potential. Further in vivo results revealed that, Cur-hASCs co-injected with PRP resulted in faster wound closure, improved fibroblast proliferation, increased neovascularization, marked reduction in inflammatory cells, and compact extracellular matrix with completely covered thick epithelium. Moreover, Cur-hASCs + PRP treatment significantly improved the expression of key healing markers such as pro-angiogenic (Vegf), dermal matrix deposition (Col1α1), cell migration (bFgf) and cell proliferation (Pcna) at wound site.

SIGNIFICANCE

Our findings propose a combinatorial therapy (Cur-hASCs + PRP) as a novel modality to improve the efficacy of hASCs-based therapy for diabetic wounds.

The Relationship Between Blood Hypoxia-Inducible Factor-1α, Fetuin-A, Fibrinogen, Homocysteine, and Amputation Level

Reduced life expectancy has resulted from an increased incidence of chronic complications in patients with diabetes. The diabetic foot is one of these complications and generally presents together with diabetic neuropathy and vascular insufficiency. Hypoxia-inducible factor-1α (HIF-1α) is important in developing the adaptation response to hypoxia and facilitates healing through regulation of keratinocyte migration and epithelium restoration in wounds. Fetuin-A is a transporter protein that is synthesized in the liver and inhibits vascular and ectopic calcifications. It has been observed that altered fetuin-A is associated with peripheral artery disease through vascular calcification and is associated with inflammation and metabolic syndrome occurrence in diabetic patients. Fibrinogen is an acute-phase reactant and has a major role in homeostasis, tissue repair, and wound healing. Increased fibrinogen blood level is one of the factors that facilitates the hypercoagulability in diabetics. Homocysteine has atherogenic features and causes vascular toxicity by enhancing low-density lipoprotein oxidation. We evaluated the association of serum HIF-1α, fetuin-A, fibrinogen, and homocysteine levels with amputation in 31 patients diagnosed with diabetes mellitus. According to our evaluation, a negative correlation was determined between fetuin-A and amputation level (P = .012, r = -0.450), which was statistically significant. Unfortunately, there was no significant correlation between HIF-1α, fibrinogen, homocysteine, and amputation level (P > .05). As a result, it was suggested that vascular calcification due to fetuin-A deficiency may be important in the diabetic foot pathogenesis and that fetuin-A levels may be a predictor for amputation level.

Long-Term Cilostazol Treatment and Predictive Factors on Outcomes of Endovascular Intervention in Patients with Diabetes Mellitus and Critical Limb Ischemia

INTRODUCTION

Despite improvements in endovascular interventions and multidisciplinary approaches, improving clinical outcomes and increasing limb salvage have become increasingly challenging. This prospective study investigated the associations of cilostazol treatment with clinical outcomes and predictive factors in patients with diabetes mellitus (DM) and critical limb ischemia (CLI) after endovascular revascularization of the affected angiosome.

METHODS

In this study, 172 consecutive patients with CLI (Fontaine levels III-IV) received cilostazol treatment after successful endovascular intervention according to the angiosome concept, and their primary patency rates and cardiovascular and amputation events during a 24-month follow-up period were assessed.

RESULT

The 24-month primary patency rate, mortality rate, and amputation rate were better in the patients under long-term cilostazol treatment (P < 0.001, P = 0.029, and P = 0.014). Weighted multivariate Cox analyses with a propensity scoring-based method showed that long-term cilostazol treatment [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.11-0.36, P < 0.001], direct revascularization (DR) (HR 0.46, 95% CI 0.28-0.74, P = 0.002), and supervised exercise (HR 0.4, 95% CI 0.24-0.66, P < 0.001) were independently associated with primary patency. Patients with lower-extremity amputation (LEA) had a higher risk of coronary artery disease (CAD) and mortality. Cellulitis and neuropathy were independently associated with LEA events (cellulitis: HR 2.89, 95% CI 1.66-5.05, P < 0.001; neuropathy: HR 2.2, 95% CI 1.31-3.7, P = 0.003).

CONCLUSION

Our results showed that patients with DM who received cilostazol treatment for more than 3 months had significantly better outcomes and decreased amputation and mortality rates after DR, and cellulitis and neuropathy were highly associated with the risk of limb loss. A large-scale randomized trial should be conducted in the future to confirm these results.

TRIAL REGISTRATION

Taipei Veterans General Hospital (TVGH) IRB no. 2013-08-020B. Registered 30 August 2013.

Prevalence and factors associated with lower limb amputation in individuals with type II diabetes mellitus in a referral hospital in Fortaleza, Ceará, Brazil: A hospital-based cross-sectional study

AIMS

To analyze the association between demographic, socioeconomic, clinical, epidemiological, and primary healthcare factors with the severity of lower limb amputations (LLAs) in individuals with type II diabetes mellitus (DM-II) at a reference hospital in Fortaleza, Ceará, in Northeast Brazil.

METHODS

A cross-sectional study was performed with a representative sample of individuals hospitalized with DM-II and the degree of LLA severity: (1) toes; (2) transmetatarsal or infrapatellar; (3) suprapatellar; (4) disarticulation or bilateral. Potentially associated factors with the outcome degree of amputation severity were identified in a semi-structured evaluation during hospitalization. The prevalence ratios of the degree of amputation severity as a function of associated factors were calculated with robust variance Poisson regression models.

RESULTS

The prevalence of high degree of severity in amputations (suprapatellar, with disarticulation or bilateral) was high in the total sample of 385 patients, revealing to be 49% (187/385). Prevalence ratios (PR) indicated a higher prevalence of DM-II amputation severity in patients who lacked of specific guidance on DM-II amputation in primary care (PR = 1.52, 95% CI: 1.05-2.21).

CONCLUSIONS

LLAs in DM-II were associated with age above 67 years, male gender, cardiovascular disease, and low support for guidance at the primary healthcare level.

A randomized controlled clinical trial of a hypothermically stored amniotic membrane for use in diabetic foot ulcers

Aim: Determine the effectiveness of hypothermically stored amniotic membrane (HSAM) versus standard of care (SOC) in diabetic foot ulcers (DFUs). Methods: A randomized controlled trial was conducted on 76 DFUs analyzed digitally. Results: Cox wound closure for HSAM (38 wounds) was significantly greater (p = 0.04) at weeks 12 (60 vs 38%), and 16 (63 vs 38%). The probability of wound closure increased by 75% (Hazard Ratio = 1.75; 95% CI: 1.16–2.70). HSAM showed >60% reductions in area (82 vs 58%; p = 0.02) and depth (65 vs 39%; p = 0.04) versus SOC. Conclusion: HSAM increased frequency and probability of wound closure in DFUs versus SOC.

Treatment of experimentally induced diabetic wound infected with methicillin-resistant Staphylococcus aureus using Aloe vera, Apium graveolens, and Sauropus androgynus extracts in rats

Background and Aim: One of the complications of diabetes mellitus is diabetic ulcer. Diabetic ulcer is commonly infected by infectious agents, especially methicillin-resistant Staphylococcus aureus (MRSA). This study aimed to evaluate the potential effects of alcoholic extracts of Aloe vera, Apium graveolens, and Sauropus androgynus on promoting wound healing in a diabetic wound infected with MRSA. Materials and Methods: A total of 60 male Sprague-Dawley rats (6 months old, weighing 250-300 g) were injected with 65 mg/kg body weight of streptozotocin to induce diabetes. On day 7, the backs of the rats were shaved, and two circular wounds (4 mm in diameter) were created on their back, which were infected with MRSA. The rats were divided into six groups: Group I = control, Group II = treated with cream base without extract, Group III = treated with 2% A. vera cream, Group IV = treated with 2% A. graveolens cream, Group V = treated with 2% S. androgynus cream, and Group VI = treated with 2% A. vera + 2% A. graveolens + 2% S. androgynus cream. The wounds were treated twice a day for 14 days. The data were collected on days 7 and 14. Results: The results showed that all three herbal extracts and their combination decreased wound area and percentage of the wound, increased tensile strength of skin, collagen deposition, vascular endothelial growth factor expression, and skin thickness, and depressed the C-reactive protein profile and cyclooxygenase-2 expression. Conclusion: A. vera, A. graveolens, and S. androgynus creams can be used as herbal therapies against diabetic wounds infected with MRSA, both as a single and combination treatment.

Amputations in patients with diabetic foot ulcer: a retrospective study from a single centre in the Northern Territory of Australia

BACKGROUND

Lower extremity amputations (LEAs) in diabetic patients are common in the indigenous population. There is no published data from the Northern Territory.

METHODS

All patients with diabetic foot ulcer, presenting for the first time to the multi-disciplinary foot clinic at Royal Darwin Hospital, between January 2003 and June 2015, were included. These patients were followed until 2017, or death. LEA rates over the follow-up period and the risk factors were studied.

RESULTS

Of the 513 included patients, 62.8% were males and 48.2% were indigenous. The majority (93.6%) had type 2 diabetes with median diabetes duration of 7.0 years (interquartile range 3-12). During the follow-up period of 5.8 years (interquartile range 3.1-9.8), a total of 435 LEAs (16.6% major; 34.7% minor) occurred in 263 patients (mean age 57.0 ± 11.8 years). In multivariate analysis, the following variables were associated with LEAs (adjusted odds ratio (95% confidence interval)): prior LEA (4.49 (1.69-11.9)); peripheral vascular disease (2.67 (1.27-5.59)); forefoot ulcer (7.72 (2.61-22.7)); Wagner grade 2 (3.71 (1.87-7.36)); and Wagner grade 3 (17.02 (3.77-76.72)). Indigenous patients were 1.8 times more likely to have LEAs than non-indigenous patients. Indigenous amputees were approximately 9 years younger than their non-indigenous counterparts.

CONCLUSION

Half of patients presenting with diabetic foot ulcer had LEA during follow-up. Prior LEAs, peripheral vascular disease, forefoot ulcers and higher Wagner grades were independent risk factors for LEA. Indigenous patients were at higher risk for LEAs and were younger at the time of amputation.

Patients' clinical charecteristics and predictors for diabetic foot amputation

INTRODUCTION

Medical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients.

METHODS

In this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed.

RESULTS

Of the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p<0,05). Amputees also exhibited significantly longer smoking histories (p<0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p=0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision.

CONCLUSION

The following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4-5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.

Regional variation in the risk of lower-limb amputation among patients with diabetes in New Zealand

BACKGROUND

Lower-limb amputation is one of the most substantial and debilitating consequences of diabetes mellitus; however, the risk of lower-limb amputation is not equally shared across the diabetic population. The aims of this study were to (i) describe regional variation in the rate of lower-limb amputation in New Zealand among a national prevalent cohort of patients with diabetes; and (ii) explore the plausible factors that could be contributing to this variation.

METHODS

Our cohort were the national prevalent cohort of individuals with diabetes in New Zealand in 2011, according to the Virtual Diabetes Register (n = 215 676). Using descriptive analysis and Poisson regression, we compared the rate of lower-limb amputation within each of New Zealand's 20 District Health Boards with the national rate of amputation, adjusting for demographic, health care access and patient-level factors.

RESULTS

We observed nearly four-fold variation in the rate of major lower-limb amputation between regions in New Zealand, as well as nearly two-fold variation in the rate of minor lower-limb amputation. Adjustment for differences between regions in terms of ethnicity reduced this variation substantially for many District Health Boards. Despite adjustment for sex, age, ethnicity, deprivation, rurality, comorbidity and prior amputation, the rate of lower-limb amputation in a number of District Health Boards remained substantially higher than the national rate.

CONCLUSIONS

These observations could help to inform the funding and provision of diabetic foot care services across New Zealand; however, more work is required to further untangle the drivers of national variation in rates of lower-limb amputation.

Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review

The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.

Chronic wounds in Australia: A systematic review of key epidemiological and clinical parameters

Chronic wounds are a significant problem in Australia. The health care-related costs of chronic wounds in Australia are considerable, equivalent to more than AUD $3.5 billion, approximately 2% of national health care expenditure. Chronic wounds can also have a significant negative impact on the health-related quality of life of affected individuals. Studies have demonstrated that evidence-based care for chronic wounds improves clinical outcomes. Decision analytical modelling is important in confirming and applying these findings in the Australian context. Epidemiological and clinical data on chronic wounds are required to populate decision analytical models. Although epidemiological and clinical data on chronic wounds in Australia are available, these data have yet to be systematically summarised. To address these omissions and clarify the state of existing evidence, we conducted a systematic review of the literature on key epidemiological and clinical parameters of chronic wounds in Australia. A total of 90 studies were selected for inclusion. This paper presents a synthesis of the evidence on the prevalence and incidence of chronic wounds in Australia, as well as rates of infection, hospitalisation, amputation, healing, and recurrence.

Risk of lower limb amputation in a national prevalent cohort of patients with diabetes

AIMS/HYPOTHESIS

Lower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand.

METHODS

A national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period.

RESULTS

A total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3 years of their procedure (57%).

CONCLUSIONS/INTERPRETATION

Using a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.

Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians

BACKGROUND

The Aboriginal and Torres Strait Islander community has an increased risk of developing chronic illnesses including diabetes. Among people with diabetes, foot complications are common and make a significant contribution to the morbidity and mortality associated with this disease. The aim of this review was to systematically evaluate the literature comparing the rates of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians to non-Indigenous Australians.

METHODS

MEDLINE, EMBASE, The Cochrane Library; PUBMED and CINAHL were searched from inception until August 2016. Inclusion criteria were: published cross-sectional or longitudinal studies reporting the prevalence of diabetes related foot complications in both a cohort of Aboriginal and Torres Strait Islander Australians and a cohort of one other Australian population of any age with diabetes. Risk of bias was assessed using the STROBE tool.

RESULTS

Eleven studies including a total of 157,892 participants were included. Studies were set in Queensland, the Northern Territory and Western Australia, primarily in rural and remote areas. Aboriginal and Torres Strait Islander Australians experienced substantially more diabetes related foot complications with the mean age up to 14 years younger than non-Indigenous Australians. Aboriginality was associated with increased risk of peripheral neuropathy, foot ulceration and amputation. In several studies, Aboriginal and Torres Strait Islander Australians accounted for the vast majority of diabetes related foot complications (up to 91%) while comprising only a small proportion of the regional population. Reporting quality as assessed with the STROBE tool showed underreporting of: methods, sample description and potential sources of bias. There are no data available for some Australian states and for specific types of diabetes related foot complications.

CONCLUSIONS

Aboriginal and Torres Strait Islander Australians have a 3-6 fold increased likelihood of experiencing a diabetes related foot complication compared to non-Indigenous Australians. Evidence-based, culturally appropriate screening and intervention programs and improved access to effective health care services are required to prevent a widening of the gap in diabetes related foot complications between Aboriginal and Torres Strait Islander and non-Indigenous Australians.