Prevalence of Peripheral Arterial Disease in Diabetic Foot Ulcer Patients and its Impact in Limb Salvage

The impact of lower extremity peripheral arterial disease on activities of daily living in home care patients

Peripheral arterial disease (PAD) causes narrowing of the lower extremity arteries and impacts daily living activities. This retrospective study (April 2023 - April 2024) examined 171 home care patients, with 31.6% diagnosed with PAD. Of these, 37.4% were fully dependent, 36.3% (n = 62) were severely dependent, 16.4% (n = 28) were moderately dependent, 7.0% (n = 12) were mildly dependent, 2.9% (n = 5) were independent, and PAD prevalence was higher among severely dependent patients. Dementia was identified as a significant risk factor for PAD. The high prevalence of PAD among severely dependent individuals suggests a potential link between lifestyle factors and PAD risk. The study highlights the need for further research on whether modifying PAD risk factors can enhance patient independence.

Optimising wound monitoring: Can digital tools improve healing outcomes and clinic efficiency

BACKGROUND

Chronic wounds present significant challenges for patients and nursing care teams worldwide. Digital health tools offer potential for more standardised and efficient nursing care pathways but require further rigorous evaluation.

OBJECTIVE

This retrospective matched cohort study aimed to compare the impacts of a digital tracking application for wound documentation versus traditional manual nursing assessments.

METHODS

Data from 5236 patients with various wound types were analysed. Propensity score matching balanced groups, and bivariate tests, correlation analyses, linear regression, and Hayes' Process Macro Model 15 were utilised for a mediation-moderation model.

RESULTS

Digital wound tracking was associated with significantly shorter healing durations (15 vs. 35 days) and fewer clinic nursing visits (3 vs. 5.8 visits) compared to standard nursing monitoring. Digital tracking demonstrated improved wound size reduction over time. Laboratory values tested did not consistently predict healing outcomes. Digital tracking exhibited moderate negative correlations with the total number of nursing visits. Regression analysis identified wound complexity, hospitalizations, and initial wound size as clinical predictors for more nursing visits in patients with diabetes mellitus (p < .01). Digital tracking significantly reduced the number of associated nursing visits for patients with peripheral vascular disease.

CONCLUSION

These findings suggest that digital wound management may streamline nursing care and provide advantages, particularly for comorbid populations facing treatment burdens.

REPORTING METHOD

This study adhered to STROBE guidelines in reporting this observational research.

RELEVANCE TO CLINICAL PRACTICE

By streamlining documentation and potentially shortening healing times, digital wound tracking could help optimise nursing resources, enhance wound care standards, and improve patient experiences. This supports further exploration of digital health innovations to advance evidence-based nursing practice.

PATIENT OR PUBLIC CONTRIBUTION

This study involved retrospective analysis of existing patient records and did not directly include patients or the public in the design, conduct, or reporting of the research.

The efficacy of custom-made offloading devices for diabetic foot ulcer prevention: a systematic review

INTRODUCTION

Therapeutic offloading devices, including insoles, shoes, and other orthoses, are some of the most commonly used interventions to treat or prevent diabetic foot ulceration. Custom-made offloading devices are increasingly used to offset the development of foot ulcers. However, whether these devices are more effective than prefabricated standard offloading devices is uncertain. Therefore, this systematic review collates and examines evidence on the efficacy of custom-made offloading devices in preventing foot ulcer incidence and recurrence in people diagnosed with diabetes.

METHODS

Five scientific databases were searched, covering 2011-2023. Initial searches and screening were carried out independently by two researchers. Studies meeting the inclusion criteria were further examined through additional screenings, and critical appraisal. Data relevant to the review aims were extracted and analysed within a narrative synthesis.

RESULTS

Of the 1,715 articles found in the initial searches, nine papers were found to meet inclusion criteria and were included in the review. The evidence shows that custom-made offloading devices are likely to be more effective for reducing or preventing diabetic foot ulcers than standard offloading devices. However, due to a lack of data it remains uncertain whether custom-made offloading devices are more cost-effective for preventing ulceration compared to standard insoles. Likewise, due to measurement heterogeneity between studies and lack of data, it is unclear whether adherence is higher in users of custom-made offloading devices, and whether such devices deliver significantly greater reductions in peak pressure as compared to standard offloading devices.

CONCLUSION

Custom-made offloading devices are more effective than standard devices for preventing diabetic foot ulceration, and we recommended their use when feasible; however, there remains uncertainty regarding their cost-effectiveness compared to standard insoles and offloading devices.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Association Between the Society for Vascular Surgery (SVS)-WIfI (Wound, Ischemia, Foot Infection) Classification, Wagner-Meggitt Classification, and Amputation Rate in Patients With Diabetic Foot Infection

Diabetic foot infection (DFI) is a common problem in patients with diabetic foot disease. Amputations and other complications of DFI lead to significant morbidity and mortality. The Society for Vascular Surgery (SVS)-WIfI (wound, ischemia, and foot infection) classification system can evaluate the benefit from revascularization and the risk of amputation in 1 and 3 years. We aimed to evaluate SVS-WIfI and Wagner-Meggitt (WM) prediction of DFI outcome, and to determine factors associated with major amputation and mortality rate. The patients with diabetes who presented between June 2018 and May 2020 with characteristics suggesting a more serious DFI or potential indications for hospitalization were reviewed in this cohort study. Demographic data, clinical characteristics, and type of revascularization were evaluated. One-year and 3-year amputation and mortality rates were the main outcomes. The grading of WM classification and the SVS-WIfI score were compared between amputation and nonamputation groups. Association between mortality and comorbidity were analyzed. One hundred and thirty-one patients admitted with DFI were included in study. And 73.28% had peripheral arterial disease (PAD). The 1-year and 3-year major amputation rates were 16.03% and 26.23%, respectively. Seventy-eight (59.54%) patients required minor amputation to control infection before revascularization. PAD (risk ratio [RR] 1.47: 95% confidence interval [CI] 1.29-1.67, P = .032), benefit from revascularization clinical stage 3 on SVS-WIfI score (RR 4.56: 95%CI 1.21-17.21, P = 0.007), and high WM classification score (RR 9.46: 95% CI 5.65-15.82, P < 0.001) were associated by multivariate analysis with high amputation rates. 1-year & 3-year amputation risk on SVS-WIfI score were not associated with amputation rates in DFI (P = .263 and .496). Only 9 (6.8%) patients were lost to follow up during the 3-year period. WM classification score, SVS-WIfI score on benefit from revascularization, and PAD were strongly associated with major amputation rates in patients with DFI.

Current knowledge of morbidities and direct costs related to diabetic foot disorders: a literature review

Diabetes is a chronic disease associated with numerous complications including diabetic foot disorders, which are associated with significant morbidity and mortality as well as high costs. The costs associated with diabetic foot disorders comprise those linked to care (direct) and loss of productivity and poor quality of life (indirect). Due to the constant increase in diabetes prevalence, it is expected that diabetic foot disorder will require more resources, both in terms of caregivers and economically. We reviewed findings on management, morbidity, mortality, and costs related to diabetic foot disorder.

Stem Cell-Based Tissue Engineering Approaches for Diabetic Foot Ulcer: a Review from Mechanism to Clinical Trial

Diabetic foot ulcer (DFU) is a complication from incomplete or prolonged wound healing, at times requires amputation, putting substantial health and socioeconomic burden. Wound healing is a dynamic overlapping process that can be regulated by arrays of molecular factors showing redundancy in function. However, dysregulation in the mechanism of angiogenesis, extra cellular matrix (ECM) formation and immune modulation are the major causes for impair wound healing in hyperglycaemic patients. Despite development of wound care research, there is a lack of well-accepted targeted therapy with multidisciplinary approach for DFU treatment. Stem cell therapy holds a promising outcome both in preclinical and clinical trials because of its ability to promote healing via regeneration and specialized tissue differentiation. Among different types of stem cells, regenerative potential of mesenchymal stem cell (MSC) is well demonstrated in both experimental and clinical trial. Still there is a huge knowledge gap among medical practitioners for deciding the best stem cell source, administration route, and safety. This review strengthens the fact that why stem cell therapy is a promising candidate to treat DFU and cited multiple tissue engineering and biomaterial-based approaches for delivering stem cells and their aftermath paracrine events. Based on the pre-clinical and clinical studies, the review tried to come up with optimum stem cell source and delivery route for the treatment of DFU. At last, the review glances on possible direction to enhance therapeutics strategy for the same, including different approaches like: phytocompounds, exosomes, scaffold geometry, cell preconditioning and licensing etc.

Sodium Glucose Transporter-2 Inhibitors (SGLT2Is)-TLRs Axis Modulates Diabetes

Diabetes affects millions of people worldwide and is mainly associated with impaired insulin function. To date, various oral anti-diabetic drugs have been developed, of which, the sodium glucose transporter-2 inhibitors (SGLT2Is) are of the most recent classes that have been introduced. They differ from other classes in terms of their novel mechanism of actions and unique beneficial effects rather than just lowering glucose levels. SGLT2Is can protect body against cardiovascular events and kidney diseases even in non-diabetic individuals. SGLT2Is participate in immune cell activation, oxidative stress reduction, and inflammation mediation, thereby, moderating diabetic complications. In addition, toll like receptors (TLRs) are the intermediators of the immune system and inflammatory process, thus it's believed to play crucial roles in diabetic complications, particularly the ones that are related to inflammatory reactions. SGLT2Is are also effective against diabetic complications via their anti-inflammatory and oxidative properties. Given the anti-inflammatory properties of TLRs and SGLT2Is, this review investigates how SGLT2Is can affect the TLR pathway, and whether this could be favorable toward diabetes.

Therapeutic Potential for Beta-3 Adrenoreceptor Agonists in Peripheral Arterial Disease and Diabetic Foot Ulcers

Annually, peripheral arterial disease is estimated to cost over USD 21 billion and diabetic foot disease an estimated at USD 9-13 billion. Mirabegron is a TGA-approved beta-3 adrenoreceptor agonist, shown to be safe and effective in the treatment of overactive bladder syndrome by stimulating bladder smooth muscle relaxation. In this review, we discuss the potential use of beta-3 adrenoreceptor agonists as therapeutic agents repurposed for peripheral arterial disease and diabetic foot ulcers. The development of both conditions is underpinned by the upregulation of oxidative stress pathways and consequential inflammation and hypoxia. In oxidative stress, there is an imbalance of reactive oxygen species and nitric oxide. Endothelial nitric oxide synthase becomes uncoupled in disease states, producing superoxide and worsening oxidative stress. Agonist stimulation of the beta-3 adrenoreceptor recouples and activates endothelial nitric oxide synthase, increasing the production of nitric oxide. This reduces circulating reactive oxygen species, thus decreasing redox modification and dysregulation of cellular proteins, causing downstream smooth muscle relaxation, improved endothelial function and increased angiogenesis. These mechanisms lead to endothelial repair in peripheral arterial disease and an enhanced perfusion in hypoxic tissue, which will likely improve the healing of chronic ulcers.

Advanced polymer hydrogels that promote diabetic ulcer healing: mechanisms, classifications, and medical applications

Diabetic ulcers (DUs) are one of the most serious complications of diabetes mellitus. The application of a functional dressing is a crucial step in DU treatment and is associated with the patient's recovery and prognosis. However, traditional dressings with a simple structure and a single function cannot meet clinical requirements. Therefore, researchers have turned their attention to advanced polymer dressings and hydrogels to solve the therapeutic bottleneck of DU treatment. Hydrogels are a class of gels with a three-dimensional network structure that have good moisturizing properties and permeability and promote autolytic debridement and material exchange. Moreover, hydrogels mimic the natural environment of the extracellular matrix, providing suitable surroundings for cell proliferation. Thus, hydrogels with different mechanical strengths and biological properties have been extensively explored as DU dressing platforms. In this review, we define different types of hydrogels and elaborate the mechanisms by which they repair DUs. Moreover, we summarize the pathological process of DUs and review various additives used for their treatment. Finally, we examine the limitations and obstacles that exist in the development of the clinically relevant applications of these appealing technologies. This review defines different types of hydrogels and carefully elaborate the mechanisms by which they repair diabetic ulcers (DUs), summarizes the pathological process of DUs, and reviews various bioactivators used for their treatment.

Therapeutic role of growth factors in treating diabetic wound

Wounds in diabetic patients, especially diabetic foot ulcers, are more difficult to heal compared with normal wounds and can easily deteriorate, leading to amputation. Common treatments cannot heal diabetic wounds or control their many complications. Growth factors are found to play important roles in regulating complex diabetic wound healing. Different growth factors such as transforming growth factor beta 1, insulin-like growth factor, and vascular endothelial growth factor play different roles in diabetic wound healing. This implies that a therapeutic modality modulating different growth factors to suit wound healing can significantly improve the treatment of diabetic wounds. Further, some current treatments have been shown to promote the healing of diabetic wounds by modulating specific growth factors. The purpose of this study was to discuss the role played by each growth factor in therapeutic approaches so as to stimulate further therapeutic thinking.

Effect of Percutaneous Endovascular Angioplasty Combined with Negative Pressure Drainage on the "One-Stop" Treatment of Ischemic Diabetic Foot Ulcer

BACKGROUND

To explore the therapeutic effect, safety, and economic benefit of a "one-stop" diagnosis and treatment mode of vascular surgery for ischemic diabetic foot (DF) ulcer and to analyze the associated and independent factors that affect ulcer healing.

METHODS

In a prospective, single-center study, patients with ischemic DF ulcers from January 2017 to July 2021 were treated with either percutaneous endovascular angioplasty combined with negative pressure closed drainage (PTA-VSD) or percutaneous endovascular angioplasty combined with depuration (PTA-UD). The effectiveness and economic benefits of the 2 measures were compared, and independent factors affecting ulcer healing were explored via univariate and logistic regression analyses.

RESULTS

Fifty patients with ischemic DF ulcer (25 patients in the PTA-VSD group and 25 patients in the PTA-UD group; 40 males and 10 females) were included, with an average age of 67.74 ± 10.71 years. No difference was observed in the demographic data. The findings showed that the ulcer healing time in the PTA-VSD group was significantly shorter than that in the PTA-UD group (154.79 vs. 238.31 days), and the ulcer healing rate at 180 days post surgery was significantly greater in the PTA-VSD group (52% vs. 12%) (P = 0.002, < 0.05). The ulcer score in the PTA-VSD group decreased significantly at 3, 6, and 12 months post surgery. The duration of hospitalization in the PTA-VSD group was greater (P = 0.002, <0.05), but no significant difference in hospitalization frequency and cost was observed between the 2 groups. During follow-up, there was 1 death and 1 amputation in the PTA-UD group, but no death or amputation in the PTA-VSD group. Arterial occlusion was primarily located in the femoral-popliteal artery and the inferior knee artery in the 2 groups, and PTA intervention effectively opened the outflow tract of the affected limb. Two to three outflow tracts were opened in 41 patients. The ankle-brachial index (ABI) after surgery was significantly higher in both groups than before. Univariate and multivariate logistic regression analyses revealed that the Wagner grade and number of outflow channels and therapies (PTA-VSD) could be independent factors affecting ulcer healing.

CONCLUSIONS

The severity of DF ulcers is an important factor affecting the quality of life of patients. A multidisciplinary "one-stop" treatment strategy based on percutaneous endovascular angioplasty combined with negative pressure-sealing drainage can rapidly and effectively restore the blood flow to the affected limb and promote ulcer healing without increasing medical costs.

Association of Non-Dipping Blood Pressure Patterns with Diabetic Peripheral Neuropathy: A Cross-Sectional Study among a Population with Diabetes in Greece

Diabetic peripheral neuropathy (DPN) is present in 20-50% of cases with diabetes. The pathophysiology of DPN is not yet clear regarding hypertension (HTN). The aim of this study was to assess the association between the stages of DPN and HTN in a Greek population with diabetes. We examined 102 adults for diabetic neuropathy (DPN) from November 2020 to December 2021, using the Toronto Clinical Neuropathy Scale System (TCNSS) to categorize them into two groups (no/mild DPN versus medium/severe DPN). Ambulatory blood pressure monitoring was performed to evaluate their hypertensive status. Univariate and multivariate logistic regression analyses were performed to assess the association between the stage of DPN and HTN. The multivariate analysis, considering sex, age, and dipping status, did not show statistically significant associations between stages of HTN and DPN. However, in contrast to dippers, non-dippers had an almost four-times higher risk of developing medium-to-severe DPN (odds ratio (OR) 3.93; 95% confidence interval (CI) [1.33-11.64]); females, in contrast to males, had a 65% lower risk of developing moderate/severe DPN (OR 0.35; 95%CI [0.14-0.92]). In conclusion, our findings showed no statistically significant associations between DPN and HTN; however, dipping status, hyperglycemia, and female sex were shown to play a role in the pathophysiology of DPN.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diabetic Wound-Healing Science

Diabetes mellitus is an increasingly prevalent chronic metabolic disease characterized by prolonged hyperglycemia that leads to long-term health consequences. It is estimated that impaired healing of diabetic wounds affects approximately 25% of all patients with diabetes mellitus, often resulting in lower limb amputation, with subsequent high economic and psychosocial costs. The hyperglycemic environment promotes the formation of biofilms and makes diabetic wounds difficult to treat. In this review, we present updates regarding recent advances in our understanding of the pathophysiology of diabetic wounds focusing on impaired angiogenesis, neuropathy, sub-optimal chronic inflammatory response, barrier disruption, and subsequent polymicrobial infection, followed by current and future treatment strategies designed to tackle the various pathologies associated with diabetic wounds. Given the alarming increase in the prevalence of diabetes, and subsequently diabetic wounds, it is imperative that future treatment strategies target multiple causes of impaired healing in diabetic wounds.