The Investigation of Demographic Characteristics and the Health-Related Quality of Life in Patients With Diabetic Foot Ulcers at First Presentation

Classification of foot ulcers in people with diabetes: A systematic review

BACKGROUND

Classification and scoring systems can help both clinical management and audit the outcomes of routine care.

AIM

This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot.

METHODS

We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer.

RESULTS

We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost.

CONCLUSION

Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.

The health-related quality of life in patients with diabetic foot ulcers in the Kingdom of Bahrain

AIMS

The aims of this study were to assess the health-related quality of life (HRQoL) of adult Bahraini patients with diabetic foot ulcers (DFU) and to explore factors associated with poor HRQoL.

METHODS

Cross-sectional HRQoL data were obtained from a sample of patients in active treatment for DFU at a large public hospital in Bahrain. Patient-reported HRQOL was measured using the following instruments: DFS-SF, CWIS and EQ-5D.

RESULTS

The patient sample included 94 patients, with a mean age of 61.8 (SD: 9.9) years, 54 (57.5%) were males, and 68 (72.3%) were native Bahrainis. Poorer HRQoL was found among patients who were unemployed, divorced/widowed, and those with a shorter duration of formal education. Additionally, patients with severe DFUs, persisting ulcers, and a longer duration of diabetes reported statistically significantly poorer HRQoL.

CONCLUSIONS

Findings from this study demonstrate a low level of HRQoL among Bahraini patients with DFUs. A longer duration of diabetes, in addition to ulcer severity and status statistically significantly influence HRQoL.

Healing profiles in patients with a chronic diabetic foot ulcer: An exploratory study with machine learning

Diabetic foot ulcers (DFU) are one of the most frequent and debilitating complications of diabetes. DFU wound healing is a highly complex process, resulting in significant medical, economic and social challenges. Therefore, early identification of patients with a high-risk profile would be important to adequate treatment and more successful health outcomes. This study explores risk assessment profiles for DFU healing and healing prognosis, using machine learning predictive approaches and decision tree algorithms. Patients were evaluated at baseline (T0; N = 158) and 2 months later (T1; N = 108) on sociodemographic, clinical, biochemical and psychological variables. The performance evaluation of the models comprised F1-score, accuracy, precision and recall. Only profiles with F1-score >0.7 were selected for analysis. According to the two profiles generated for DFU healing, the most important predictive factors were illness representations on T1 IPQ-B (IPQ-B ≤ 9.5 and < 10.5) and the DFU duration (≤ 13 weeks). The two predictive models for DFU healing prognosis suggest that biochemical factors are the best predictors of a favorable healing prognosis, namely IL-6, microRNA-146a-5p and PECAM-1 at T0 and angiopoietin-2 at T1. Illness perception at T0 (IPQ-B ≤ 39.5) also emerged as a relevant predictor for healing prognosis. The results emphasize the importance of DFU duration, illness perception and biochemical markers as predictors of  healing in chronic DFUs. Future research is needed to confirm and test the obtained predictive models.

Factors Affecting the Quality of Life of Hospitalized Persons with Chronic Foot and Lower Leg Wounds

OBJECTIVE

To determine the factors affecting the quality of life of patients with chronic wounds.

METHODS

This descriptive cross-sectional study was conducted in a university hospital wound care unit in western Turkey with 134 patients. The data were collected via personal information form, Barthel Index for activities of daily living, visual analog scale, and Short Form-12 questionnaire. Descriptive statistics and Spearman correlation were used for data analysis.

RESULTS

The mean age of the participants was 60.4 ± 10.7 years; 79.9% of the research group had diabetic foot wounds, and 56.7% had wounds on their right/left big toe. The mean duration of wounds was 9.4 ± 11.4 months, and 68.7% had previously been hospitalized because of wounds. The average visual analog scale pain level was 3.5 ± 2.5, and 45.5% of the patients were PEDIS (perfusion, extent, depth, infection, and sensation) classification grade II. A positive correlation was detected between Short Form-12 physical summary score and activities of daily living score.

CONCLUSIONS

Patients with chronic wounds have a poor quality of life. Patient quality of life decreases as pain and PEDIS score increase and increases with their level of independence.

Effect of an Educational Intervention Based on Bandura's Theory on Foot Care Self-Efficacy in Diabetes: A Prospective Quasi-Experimental Study

The purpose of this study is to evaluate the foot care self-efficacy of diabetic foot patients and the effect of an educational intervention for improving it. This study was of a semi-experimental design and was conducted between January and December 2019 in a diabetic foot council of a university hospital. After power analysis to determine sample size, 33 participants meeting the inclusion criteria were included in the study. A Patient Identification Form and Diabetic Foot Care Self-Efficacy Scale (DFCSES) were used to collect data. Of the patients, 51.5% were male and the mean age was 54.91 ± 16.61 years. The mean score of DFCSES was 50.18 ± 20.88 before education and 72.67 ± 20.74 after education. The educational intervention has large effects on self-efficacy (d = 1.233), perceived knowledge level on diabetic foot (d = 1.102), perceived health status (d = 0.859), and perceived quality of life (d = 0.807). Educational intervention was found to be an effective way to improve foot care self-efficacy, perceived knowledge level on diabetic foot, perceived health status, and perceived quality of life.

Demographic and clinical predictors of health-related quality of life among people with type 2 diabetes mellitus living in northern Thailand: A cross-sectional study

Background

Type 2 Diabetes Mellitus (T2DM) is a chronic disease which is growing global health problems. However, research on such prediction of health-related quality of life (HRQOL) in Thailand is limited, in particular on the demographic and clinical characteristic in each HRQOL domains. Therefore, the aim of the present study was to determine the demographic and clinical predictors of health-related quality of life among people with type 2 diabetes mellitus (T2DM) in Northern Thailand.

Methods

A cross-sectional study of people with T2DM at a large teaching hospital in Northern Thailand was conducted. The HRQOL was evaluated using the Thai version of Diabetes-39. Descriptive analysis was used to summarize the demographic and HRQOL scores. Multiple regression analysis was used to determine the predictors of overall HRQOL and the predictors of each D-39 dimension.

Results

A total of 502 people with T2DM were recruited. Forty-one were identified as having diabetic foot ulcers. The mean score for perception of overall HRQOL was 61.18 (SD 18.74). Scores in the D-39 questionnaire showed a poor HRQOL among people with T2DM. The predictors of demographic and clinical characteristics of people with T2DM were calculated for overall HRQOL and all six domains.

Conclusion

These results demonstrate that people with T2DM have a poor HRQOL. The presence of diabetic foot ulcers and smoking status were identified as significant predictors of low HRQOL in the domains relating to diabetes control, social burden and energy and mobility presence of obesity, receiving insulin injection or a combination of insulin and oral medication were predictors of poor HRQOL in the domain of other health problems and diabetes complications. These findings allow for a nursing care plan for diabetes management to achieve optimal glycaemic control and improve their HRQOL.

Health-Related Quality of Life and Self-Care Management Among People With Diabetic Foot Ulcers in Northern Thailand

Diabetic foot ulcers (DFUs) are a common complication of diabetes that impacts on the health-related quality of life (HRQOL). Foot care is an important factor in the self-care management of patients with DFUs. The objective of this study was to investigate the HRQOL and foot care management of people with DFUs. A cross-sectional study involving 41 people with DFUs was conducted at a large tertiary hospital in Northern Thailand. The Diabetic Foot Ulcer Scale-Short Form and the VA-Diabetes Foot Care Survey were used to assess the HRQOL and foot care management among people with DFUs. The majority of the participants were female (n = 24, 58.5%), and the mean age was 62.13 years. The scores for HRQOL in the six domains were as follows: leisure (66.95 ± 28.03), physical health (68.93 ± 28.51), dependence or daily life (80.08 ± 25.23), negative emotions (71.23 ± 29.48), worried about ulcers (62.20 ± 31.97), and bothered by ulcer care (69.36 ± 25.20). High scores indicate a high (good) HRQOL. Less than a third of the participants reported that they had received education about foot care management. Almost all participants reported that they washed their feet daily; however, a large proportion did not test the water temperature or use lubricants on their feet. Most of the participants did not have a mirror for checking under their feet (48.8%), and there was a lack of knowledge about how to use a mirror for foot inspections (51.2%). This study provides guidance for clinicians on the content and delivery of diabetes education programs for people with diabetes (and DFUs) in Northern Thailand. The findings provide guidance on existing knowledge and the need for programs to address barriers to foot self-care management both in terms of skills and attitudes.

Health-related quality of life among adults living with diabetic foot ulcers: a meta-analysis

PURPOSE

To undertake a systematic review of the literature to investigate the HRQOL among adults living with DFUs.

METHODS

A systematic search of the medical and nursing/health content databases including MEDLINE, CINAHL, and PsycINFO was conducted up to November 2018. The methodological quality of each study was assessed independently by all authors using the Joanna Briggs Institute checklist. Data analysis was conducted using the Comprehensive Meta-analysis software. All analyses were performed using random-effects models and heterogeneity was quantified.

RESULTS

A total of 12 studies were included in the review. Overall, the HRQOL of participants in the studies was poor on four of eight subscales in the SF-36: physical functioning (mean = 42.75, SE 1.5); role physical (mean = 20.61, SE 3.4); general health (mean = 39.52, SE 1.7); and vitality (mean = 45.73, SE 2.8). In addition, presence of pain, high levels of C-reactive protein (> 10 mg/L), ulcer size > 5 cm², Ankle Brachial Index < 0.9, high glycosylated haemoglobin and body mass index > 25 kg/m² were associated with poorer HRQOL in people with DFUs.

CONCLUSIONS

This review has provided evidence indicating that people with DFUs have a significantly lower HRQOL. Evidence-based interventions to improve the HRQOL in this group of people is needed.

Translation and validation of the Chinese powerlessness assessment tool

The objectives of this study were to translate the powerlessness assessment tool (PAT) into Chinese, and to evaluate its psychometric performance. The PAT was translated into Chinese and was evaluated in patients with chronic wounds. Mean PAT scores were compared between various wound types to evaluate the scale's power to differentiate wound severity (PUSH score). There were 154 consecutive patients included in this study. All items were included, and the results of item-domain correlation (r ranged from 0.838 to 0.967) and small-group analysis (critical ratio, p < 0.05) were satisfactory. Furthermore, the Chinese PAT also showed good criterion validity when correlated with the Cardiff wound impact schedule (r = 0.726, p < 0.01). Exploratory factor analysis of these items extracted only two domains instead of the hypothesized three domains: self-perception of behavioral control and decision making (9 items) and emotional responses to perceived control (3 items), explained 82.045% of the variance. Sensitivity was demonstrated between patients with different activity of daily living, wound severity (PUSH score) and wound types. The internal consistency of all scales of the Chinese PAT was consistently high (Cronbach's alpha ranged from 0.939 to 0. 965) and split-half reliability was 0.901. In conclusion, the validated Chinese PAT has good psychometric properties, and may be used to objectively evaluate the powerlessness experience of Chinese patients with chronic wounds.

Clinical and surgical characteristics of infected diabetic foot ulcers in a tertiary hospital of Mexico

Background: The objective of this study was to determine the clinical and surgical characteristics of diabetic foot ulcers in a tertiary level hospital in Mexico. Methods: We performed a longitudinal, descriptive study from July, 2012 to August, 2015 on a sample composed of 100 patients with type 2 diabetes mellitus and infected diabetic foot ulcers. We analyzed socio-demographic variables, comorbidities, characteristics of ulcers, and the applied treatment. Results: We found that the most affected areas were the forefoot (48%) and the plantar region (55%) of the foot. Also, most of the patients arrived with advanced stages of diabetic foot ulcers, since 93% of the lesions were of grades III-V according to the Wagner classification. Moreover, lesions usually present with advanced states of infection, since 60% of the lesions were of grades 3-4 in the PEDIS scale. In addition, the great majority of the patients are prone to complications because we found that 43% of the patients suffered from hypertension, 47% of the patients had chronic kidney disease, and 45% reported smoking. In fact, 45% of the patients eventually suffered an amputation. We also found that the situation is more difficult because the great majority of the patients (96%) have a low level of education and very low income and they do not have any health insurance. Nevertheless, we also found that an efficient treatment can help in avoiding amputations, since 53% of grade IV and 25% of grade V lesions according to the Wagner system did not suffer an amputation. Conclusions: Therefore, an effective antibiotic treatment and an education of the patient on the adequate care of their lesions are essential in increasing the welfare of patients, especially when they have a low level of education.

A large Italian observational multicentre study on vascular ulcers of the lower limbs (Studio Ulcere Vascolari)

An observational study of 2 years was promoted by the Italian Association for Cutaneous Ulcers (AIUC) in order to monitor the epidemiology of leg ulcers, the trend of healing and the more frequent therapeutic approaches in lower limb ulcers. Fifty-nine sites in 14 different Italian regions involved in the study, with 1333 enrolled patients (1163 patients fully evaluated and followed up for 9 months). A prevalence of females (62%) was observed with a mean age of 70 years and a high rate of hypertension (62%), diabetes (38%) and obesity (29%). Venous ulcer was most frequent (55%), followed by mixed (25%) and diabetic (8·3%) ulcers. Basically, all patients received a local therapy (LT) (compression and advanced local therapies), while 63% of patients have an associated systemic pharmaceutical treatment. Ulcer healing rates progressively increased throughout the study and despite the type of observational study does not allow conclusions on the treatment, it was observed that the patients receiving additional systemic drugs were associated with a more rapid acceleration of healing rates of ulcers compared to LT alone (3 months: 39·7% versus 29·2%; 6 months: 62·0% versus 47·0%; 9 months: 74·7% versus 63·8%). In particular, the Studio Ulcere Vascolari (SUV) study showed that a combination treatment with sulodexide and compression therapy allows for a greater increase in the healing rates in venous ulcers.

Impact of diabetic foot ulcer on health-related quality of life: A cross-sectional study

Studies have reported that health-related quality of life (HRQoL) is adversely affected by diabetic foot ulcer (DFU). There is a paucity of data on the effects of foot ulcers on HRQoL of diabetes patients in our population. Because South-Asians, especially Indians, have unique features related to diabetes and its complications, generalizing the data about their effect on HRQoL from any other part of the world is not a pragmatic approach. This study evaluated the impact of foot ulcers on HRQoL of diabetes patients. This cross-sectional study, conducted in Kasturba Hospital, Manipal (coastal South India), included 200 DFU patients in a study group (SG) and 200 diabetes patients in a control group (CG). The RAND-36 questionnaire was employed for evaluating HRQoL scores for the patients in both groups. DFU patients also completed the Diabetic Foot Ulcer Scale-Short Form questionnaire. Independent t-test was used to test the differences in mean scores. Results found that both CG and SG have "poor" HRQoL (mean score <50) on all the subscales except for two in CG. There is a statistically significant difference between groups (P < 0.05) on all eight of the subscales of HRQoL. For both CG and SG, the Physical Component Summary domain score (44.9 ± 6.3 v 28.4 ± 3.4) and Mental Component Summary domain score (42.5 ± 3.8 v 29.5 ± 7.1) were poor. There were significant differences between CG and SG for both mean Physical Component Summary score and Mental Component Summary score of HRQoL (p < 0.05). The Diabetic Foot Ulcer Scale-Short Form found that HRQoL is very poor for DFU patients on all six domains. The study concludes that DFU patients have very poor HRQoL compared with diabetic patients. Likewise, the diabetic foot is associated with severely impaired HRQoL in both physical and mental health aspects. This study will help to develop a patient education model for DFU patients by looking at the various HRQoL domains that are adversely affected by the presence of foot ulcer.