Repeatability, Completion Time, and Predictive Ability of Four Diabetes-Related Foot Ulcer Classification Systems

A Review of WIfI Clinical Staging to Predict Outcomes in Patients With Threatened Limbs

The Society for Vascular Surgery Wound, Ischemia, and foot Infection's (WIfI's) threatened limb classification system serves to comprehensively assess the severity of disease in patients with chronic limb-threatening ischemia by identifying and grading the main factors that place the threatened limb at greatest risk: wound severity, ischemic burden, and presence of infection. Each of these 3 factors is graded and the limb placed into a clinical stage, with increasing stage associated with severity of limb threat and predicted risk of major limb amputation at 1 year. Globally, there is a growing body of evidence reported from multiple institutions that has assessed amputation rates and wound-healing outcomes following revascularization in patients with WIfI clinical staging. Risk of major amputation at 1 year is low in clinical stage 1, moderate in stages 2 and 3, and high in stage 4. Higher clinical stages are associated with prolonged time to wound healing, while 1-year wound healing rates consistently decrease with increasing clinical stage. Additional avenues of investigation utilizing WIfI as an objective clinical staging tool have yielded new insights into which patients benefit from revascularization, complexity of care, hospital length of stay, quality of life, ethnic and socioeconomic disparities, as well as spurred interest in other modalities of assessing limb perfusion and their possible clinical utility. Ongoing study and refinement of WIfI grading and clinical staging will continue to improve its prognostic utility.

The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers

ABSTRACT

Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.

Risk Factors for Hospital Re-admission for Diabetes Related Foot Disease: A Prospective Cohort Study

OBJECTIVE

Diabetes related foot disease (DFD) is a common reason for admission to hospital, but the predictive factors for repeat admission are poorly defined. The primary aim of this study was to identify rates and predictive factors for DFD related hospital re-admission.

METHODS

Patients admitted to hospital for treatment of DFD at a single regional centre were recruited prospectively between January 2020 and December 2020. Participants were followed for 12 months to evaluate the primary outcome of hospital re-admission. The relationship between predictive factors and re-admission were examined using non-parametric statistical tests and Cox proportional hazard analyses.

RESULTS

The median age of the 190 participants was 64.9 (standard deviation 13.3) years and 68.4% were male. Forty-one participants (21.6%) identified themselves as Aboriginal or Torres Strait Islander people. One hundred participants (52.6%) were re-admitted to hospital at least once over 12 months. The commonest reason for re-admission was for treatment of foot infection (84.0% of first re-admission). Absent pedal pulses (unadjusted hazard ratio [HR] 1.90; 95% confidence interval [CI] 1.26 - 2.85), loss of protective sensation (LOPS) (unadjusted HR 1.98; 95% CI 1.08 - 3.62), and male sex (unadjusted HR 1.62; 95% CI 1.03 - 2.54) increased the risk of re-admission. After risk adjustment, only absence of pedal pulses (HR 1.92, 95% CI 1.27 - 2.91) and LOPS (HR 2.02, 95% CI 1.09 - 3.74) significantly increased the risk of re-admission.

CONCLUSION

Over 50% of patients admitted to hospital for treatment of DFD are re-admitted within one year. Patients with absent pedal pulses and those with LOPS are twice as likely to be re-admitted.

ENERGI-F703 gel, as a new topical treatment for diabetic foot and leg ulcers: A multicenter, randomized, double-blind, phase II trial

BACKGROUND

Diabetic foot and leg ulcers are a major cause of disability among patients with diabetes mellitus. A topical gel called ENERGI-F703, applied twice daily and with adenine as its active pharmaceutical ingredient, accelerated wound healing in diabetic mice. The current study evaluated the safety and efficacy of ENERGI-F703 for patients with diabetic foot and leg ulcers.

METHODS

This randomized, double-blind, multicenter, phase II trial recruited patients from eight medical centers in Taiwan. Patients with intractable diabetic foot and leg ulcers (Wagner Grade 1-3 without active osteomyelitis) were randomly assigned (2:1) to receive topical ENERGI-F703 gel or vehicle gel twice daily for 12 weeks or until complete ulcer closure. The investigator, enrolled patients and site personnel were masked to treatment allocation. Intention to treat (ITT) population and safety population were patient to primary analyses and safety analyses, respectively. Primary outcome was complete ulcer closure rate at the end of treatment. This trial is registered with ClinicalTrials.gov, number NCT02672436.

FINDINGS

Starting from March 15^th, 2017 to December 26^th, 2019, 141 patients were enrolled as safety population and randomized into ENERGI-F703 gel (n = 95) group or vehicle gel (n = 46) group. In ITT population, ENERGI-F703 (n = 90) and vehicle group showed ulcer closure rates of 36.7% (95% CI = 26.75% - 47.49%) and 26.2% (95% CI = 13.86% - 42.04%) with difference of 9.74 % (95 % CI = -6.74% - 26.23%) and 25% quartiles of the time to complete ulcer closure of 69 days and 84 days, respectively. There were 25 (26.3%) patients in ENERGI-F703 group and 11 (23.9%) patients in vehicle group experiencing serious adverse events and five deaths occurred during the study period, none of them related to the treatment.

INTERPRETATION

Our study suggests that ENERGI-F703 gel is a safe and well-tolerated treatment for chronic diabetic foot and leg ulcers. Further studies are needed to corroborate our findings in light of limitations.

FUNDING

Energenesis Biomedical Co., Ltd.