Predictors of lower extremity amputation in patients with diabetic foot ulcer: findings from MEDFUN, a multi-center observational study

Atherogenic markers and 1-year amputation risk in adults with diabetic foot in a tertiary level hospital: A retrospective cohort study

AIM

To determine the association between atherogenic markers, such as total cholesterol/high density lipoprotein cholesterol ratio (TC/HDL-C), triglycerides/HDL-C ratio (TG/HDL-C), and triglycerides-glucose index (TyG), and the risk of 1-year amputation in adults with diabetic foot in a tertiary level hospital.

METHODS

Retrospective cohort study conducted in 162 adult patients with diabetic foot. The outcome was amputation, defined as "primary amputation in patients' clinical history after their first hospitalization due to foot ulcer.". The cutoff point was determined using Youden's J statistic. The relative risk (RR) was presented as an association measure.

RESULTS

A TyG index of >9.4 [RR: 1.64 (1.10-2.45)] was associated with a high risk of amputation after 1-year in adults with diabetic foot. However, while a TC/HDL ratio of >4.69 [RR: 1.38 (0.94-2.03)] and a TG/HDL-C ratio > 3.57 [RR: 1.35 (0.89-2.06)] did not show associations with risk of amputation after 1-year.

CONCLUSIONS

Only a TyG index of >9.4 was associated with an increased risk of 1-year amputation in adults with diabetic foot. Future studies with larger samples and a longitudinal design may provide more robust evidence and a better understanding of clinical implications.

A Machine Learning Model for Prediction of Amputation in Diabetics

BACKGROUND

Diabetic foot ulcer (DFU) and the resulting lower extremity amputation are associated with a poor survival prognosis. The objective of this study is to generate a model for predicting the probability of major amputation in hospitalized patients with DFU.

METHODS

The National Inpatient Sample (NIS) database from 2008 to 2014 was used to select patients with DFU, who were then further divided by major amputation status. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and Agency for Healthcare Research and Quality (AHRQ) comorbidity codes were used to compare patient characteristics. For the descriptive statistics, the Student t test, the χ2 test, and the Spearman correlation were utilized. The five most predictive variables were identified. A decision tree model (CTREE) based on conditional inference framework algorithm and a random forest model were used to develop the algorithm.

RESULTS

A total of 326 853 inpatients with DFU were identified, and 5.9% underwent major amputation. The top five contributory variables (all with P < .001) were gangrene (odds ratio [OR] = 11.8, 95% confidence interval [CI] = 11.5-12.2), peripheral vascular disease (OR = 2.9, 95% CI = 2.8-3.0), weight loss (OR = 2.6, 95% CI = 2.5-2.8), systemic infection (OR = 2.5, 95% CI = 2.4-2.53), and osteomyelitis (OR = 1.7, 95% CI = 1.6-1.73). The model performance of the training data was 77.7% (76.1% sensitivity and 79.3% specificity) and of the testing data was 77.8% (76.2% sensitivity and 79.4% specificity). The model was further validated with boosting and random forest models which demonstrated similar performance and area under the curve (AUC) (0.84, 95% CI = 0.83-0.85).

CONCLUSION

Utilizing machine learning methods, we have developed a clinical algorithm that predicts the risk of major lower extremity amputation for inpatients with diabetes with 77.8% accuracy.

Diabetic Foot Osteomyelitis Undergoing Amputation: Epidemiology and Prognostic Factors for Treatment Failure

Background

When treating diabetic foot osteomyelitis (DFO), it remains difficult to determine the presence of residual infection and the optimal treatment after bone resection. In this study, we aimed to investigate the clinical characteristics of and prognostic factors in patients with DFO undergoing amputation.

Methods

This retrospective study involved 101 patients with DFO who underwent amputation. Data on their demographics, clinical characteristics, tissue culture, and surgery type were collected. Patients were grouped according to primary closure status and clinical outcome postamputation. A good outcome was defined as a successful complete remission, characterized by the maintenance of complete wound healing with no sign of infection at 6 months postamputation. Multivariate logistic regression analysis was performed. Outcomes according to surgery type were also analyzed.

Results

Staphylococcus aureus (17%) and Pseudomonas species (14%) were the most prevalent pathogens. Gram-negative bacteria were isolated from 62% of patients. In patients with primary closure, hemodialysis and ankle brachial index (ABI) <0.6 were associated with poor outcomes. In patients with DFO, ABI <0.6 was the only prognostic factor associated with treatment failure. Antimicrobial stewardship allows patients who underwent major amputation to reduce the duration of antibiotic therapy compared to those after minor amputation, although it did not contribute to reducing mortality.

Conclusions

Peripheral artery disease and hemodialysis were associated with poor outcomes despite radical resection of the infected bone. Vigilant monitoring after amputation and antimicrobial stewardship implemented based on microbiological epidemiology, prognostic factors, and the type of surgery are important. A multidisciplinary team could assist in these activities to ensure treatment success.

Neutrophil Extracellular Traps (NETs) Are Associated with Type 2 Diabetes and Diabetic Foot Ulcer Related Amputation: A Prospective Cohort Study

INTRODUCTION

The prevalence of diabetes mellitus and its sequelae has been on the rise, and diabetic foot ulcer (DFU) is the leading cause of non-traumatic lower limb amputation globally. The rising occurrence and financial burden associated with DFU necessitate improved clinical assessment and treatment. Diabetes has been found to enhance the formation of neutrophil extracellular traps (NETs) by neutrophils, and excessive NETs have been implicated in tissue damage and impaired wound healing. However, there is as yet insufficient evidence to clarify the value of NETs in assessing and predicting outcomes of DFU.

METHODS

We designed this prospective study with three cohorts formed from type 2 diabetes mellitus (T2DM) patients with DFU (n = 200), newly diagnosed T2DM patients (n = 42), and healthy donors (n = 38). Serum levels of NETs were detected for all groups, and the prognostic value for DFU-related amputation was analyzed.

RESULTS

The results showed that serum NET levels of the DFU group were significantly higher than in the T2DM group (P < 0.05), which also had significantly elevated serum NET levels compared to healthy donors (P < 0.05). Multivariate Cox regression showed that serum NET levels, diabetic foot surgical history, and Wagner grade were the risk factors for amputation (P < 0.05), and these three variables also exhibited the highest coefficient values in additional Lasso Cox regression. For patients with DFU, Kaplan-Meier curves showed that high serum NET levels associated with higher amputation probability (HR = 0.19, P < 0.01) and ROC curve based on NET value showed good validity for amputation (AUC: 0.727, CI 0.651-0.803).

CONCLUSION

Elevated serum NET levels serve as an easily accessible serological prognostic marker for assessing the risk of DFU-related amputation, thereby offering evaluation metrics for healthcare providers. Further investigations are necessary to understand the mechanisms driving this relationship.

Superficial Tissue Swabs Versus Deep Tissue Samples in the Detection of Microbiological Profile of Infected Diabetic Foot Ulcerations

This study aimed to determine the most accurate microbiological test for the detection of micro-organisms in infected diabetic foot ulcerations in people living with type-2 Diabetes. For 20 eligible patients, a superficial tissue swab and a deep tissue sample were taken during a regular appointment at a Diabetes out-patient's Podiatry Clinic. Two specimens were collected from each wound for microbial culturing after debridement. Infected foot ulcerations were graded according to the Wagner's classification as per clinical protocol. This study found a significant difference [p = 0.028] between the two different samples. The deep tissue sample was found to be more accurate in identifying micro-organisms than the superficial swabs, although the latter is more widely used in clinical practice. Further studies are warranted to provide more evidence to clinicians on the best method to adopt when swabbing different types of diabetic foot ulcerations with different wound classification since, it is clearly still a matter of debate how to detect wound infection.

Early intervention and care for Diabetic Foot Ulcers in Low and Middle Income Countries: Addressing challenges and exploring future strategies: A narrative review

Background and Aims

Diabetic Foot Ulcers (DFUs) are a significant health concern, particularly in Low- and Middle-Income Countries (LMICs). This review explores key strategies for managing DFUs in LMICs, including integrating podiatry, endocrinology, and wound care services, educating patients, promoting self-care, and preventive measures to reduce amputation rates.

Methods

A comprehensive literature review was conducted, focusing on studies conducted in Low and Middle Income Countries to facilitate a qualitative analysis. The review examined the aetiology and risk factors to developing DFUs, clinical presentation, multidisciplinary management and evidence based interventions, challenges to the provision of care and future directions, all pertaining to DFUs in low and middle income countries.

Results

The aetiology and risk factors contributing to the development of DFUs are complex and multifaceted. Factors such as limited access to health care, inadequate diabetes management, and socioeconomic disparities significantly influence the incidence of DFUs. Clinical presentation varies, with patients often presenting at advanced stages of the disease due to delayed or missed diagnoses. Multidisciplinary management, incorporating podiatry, endocrinology, and wound care services, has exhibited substantial promise in enhancing patient outcomes. Evidence-based interventions, including offloading techniques, wound debridement, and the use of advanced wound dressings, have proven effective in promoting ulcer healing.

Conclusion

The burden of DFUs in LMICs requires comprehensive strategies. Integrating podiatry, endocrinology, and wound care services, along with patient education and self-care practices, is essential for reducing amputations and improving patients' quality of life. Regular follow-up and early detection are vital for effective DFU management, emphasizing the need for ongoing research and investment in LMIC health care infrastructure. Embracing these multidisciplinary, patient-centered approaches can effectively address the challenge of DFUs in LMICs, leading to better patient outcomes and improved quality of life.

Identification, influencing factors and outcomes of time delays in the management pathway of diabetic foot: A systematic review

OBJECTIVE

A systematic review was conducted to evaluate the time delays in the management of diabetic foot and explore influencing factors of these delays and potential outcomes.

METHODS

The researchers searched several electronic databases (Pubmed, Web of Science, Cochrane Library, EMbase, CNKI, WanFang, CBM and VIP) for English and Chinese studies that examined time delays in the management pathway of diabetic foot. Two authors independently screened and extracted data, and assessed the quality of the included studies using the Newcastle-Ottawa Scale and the Agency for Health Research and Quality checklist. Due to heterogeneity among the studies, descriptive analysis was performed.

RESULTS

The review included 28 articles, comprising 20 cohort studies and 8 cross-sectional studies, that met the inclusion criteria. Among these, 14 were deemed of high quality. The median times from symptom onset to primary health care or specialist care varied from 3 to 46.69 days. The median delay in referral by primary care specialists ranged from 7 to 31 days, and subsequent median times to definitive treatment ranged from 6.2 to 56 days. Multiple complex factors were found to contribute to these delays, including patient demographics (older age, lower education level and income level) and poor patient health-seeking behaviors (inaccurate self-treatment, incorrect recognition and interpretation of symptoms), inaccurate assessment or initial treatment by health primary professionals, complex referral pathways and clinical characteristics of diabetic foot (number of foot ulcers, Wagner grade scale, and hemoglobin A1c index). Negative outcomes associated with these delays included increased risk of major amputation and mortality, decreased wound healing rate, prolonged hospital stay, and increased hospital costs.

CONCLUSIONS

Time delays in the diabetic foot management pathway were both common and serious, contributing to negative health outcomes for patients with diabetic foot. Many complex factors related to patient's poor patient health-seeking behaviors, health system, and clinical characteristics of diabetic foot are responsible for these delays. Therefore, it is necessary to develop new strategies for standard referral practices and strengthen patient awareness of seeking care.

Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections

BACKGROUND

Diabetes is a well-established risk factor for severe digital infection, and patients are more likely to require digital amputation for adequate source control. This study aims to identify factors predictive of digital amputation compared with preservation in patients with diabetes who present with surgically treated finger infections.

METHODS

Current Procedural Terminology (CPT) and International Classification of Diseases Versions 9 and 10 (ICD-9/10) databases from a single academic medical center were queried to identify patients with type 1 or type 2 diabetes mellitus who underwent surgical treatment in the operating room for treatment of a digital infection from 2010 to 2020. Electronic medical records were reviewed to obtain historical and acute clinical variables at the time of hospital presentation. Bivariate and multivariable regression were used to identify factors associated with amputation.

RESULTS

In total, 145 patients (61 digital amputation, 84 digital preservation) met inclusion criteria for this retrospective cohort study. Mean hospital stay was 6 days, and the average patient underwent 2 operations. Multivariable analysis revealed that the presence of osteomyelitis, ipsilateral upper extremity dialysis fistula, end-stage renal disease, and vascular disease each had significant independent predictive value for amputation rather than digital preservation.

CONCLUSIONS

Digital amputation is common in the setting of diabetic finger infection. The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. Further study should focus on clinical factors affecting surgical decision making and how the treatment rendered affects patient outcomes.

Targeted muscle reinnervation: A narrative review of a novel tool for the management of neuropathic pathology in major lower extremity amputations

OBJECTIVE

The purpose of this narrative review is to provide the vascular surgery community with updated recommendations and information regarding the use of Targeted Muscle Reinnervation (TMR) for both the prevention and treatment of chronic pain and phantom limb pain occurring in patients after undergoing lower extremity amputation for peripheral artery disease.

METHODS

Current available literature discussing TMR is reviewed and included in the article in order to provide a succinct overview on the indications, clinical applications, and surgical technique for TMR. Additionally, early studies showing favorable long-term results after TMR are discussed. Patient consent for publication was obtained for this investigation.

RESULTS

TMR has been demonstrated to be an effective means of both treating and preventing neuroma-related symptoms including chronic pain and phantom limb pain. It has been proven to be technically feasible, and can help patients to have improved utilization of prostheses for ambulation, which can conceivably lead to a reduction in mortality.

CONCLUSIONS

TMR is an important tool to consider for any patient undergoing lower extremity amputation for a vascular-related indication. A vascular-plastic surgeon dual team approach is an effective means to prevent and reduce neuromas and associated chronic pain in this patient population.

Dilute Povidone-Iodine Solution Soaking Is Ineffective in Improving Outcomes of Necrotizing Fasciitis Caused by Diabetic Foot

ABSTRACT

Wound soaking is a physical debridement method that helps reduce bacterial colonization and consequently promotes wound healing. Although soaking in povidone-iodine solution was ineffective in reducing bacterial colonization in acute trauma wounds, there is still a lack of evidence supporting the efficacy of this method in treating severe soft tissue infection. This study aimed to explore the effects of wound soaking in 1% dilute povidone-iodine solution on necrotizing fasciitis caused by diabetic foot ulcers. We retrospectively reviewed and finally included 153 patients who were admitted because of diabetic foot ulcers after undergoing fasciotomy for necrotizing infection from January 2018 to December 2021. Results showed no statistical difference in the outcomes between patients in the soaking and nonsoaking groups. End-stage renal disease (P = 0.029) and high serum C-reactive protein level (P = 0.007) were the only independent factors for below-knee amputation in the univariate and multivariate logistic regression analyses. Therefore, soaking diabetic wounds with severe infection in 1% dilute povidone-iodine solution may not reduce the hospital length of stay, risk of below-knee amputation, and readmission rate.

Risk factor analysis for diabetic foot ulcer-related amputation including Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio

Diabetic foot ulcer often leads to amputation, and both nutritional status and immune function have been associated with this process. We aimed to investigate the risk factors of diabetic ulcer-related amputation including the Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio biomarker. We evaluated data from hospital in patients with diabetic foot ulcer, performing univariate and multivariate analyses to screen for high-risk factors and Kaplan-Meier analysis to correlate high-risk factors with amputation-free survival. Overall, 389 patients underwent 247 amputations over the follow-up period. After correction to relevant variables, we identified five independent risk factors for diabetic ulcer-related amputation: ulcer severity, ulcer site, peripheral arterial disease, neutrophil-to-lymphocyte ratio and nutritional status. Amputation-free survival was lower for the moderate-to-severe versus mild cases, for the plantar forefoot versus hindfoot location, for the concomitant peripheral artery disease versus without and in the high versus low neutrophil-to-lymphocyte ratio (all p < 0.01). The results showed that ulcer severity (p < 0.01), ulcer site (p < 0.01), peripheral artery disease (p < 0.01), neutrophil-to-lymphocyte ratio (p < 0.01) and Controlling Nutritional Status score (p < 0.05) were independent risk factors for amputation in diabetic foot ulcer patients and have predictive values for diabetic foot ulcer progression to amputation.

A novel PPARβ/FFA1 dual agonist Y8 promotes diabetic wound healing

BACKGROUND

Diabetes ulcer is one of the leading causes of disability and death in diabetics. Y8 [(2-(2-fluoro-4-((4-methyl-2-(4-(trifluoromethyl)phenyl)thiazol-5-yl)methoxy) phenoxy)acetic acid)], a dual agonist of peroxisome proliferation activated receptorβ (PPARβ) and free fatty acid receptor 1 (FFA1/FFAR1/GPR40), a new compound molecule with the potential for diabetes ulcer treatment.

OBJECTIVE

To research the effect of the dual target agonist Y8 and its mechanism of action in the treatment of diabetic ulcers.

METHODS

We have established a wound model in diabetic mice. After treatment with Y8, wound healing was evaluated by tissue pathology, reactive oxygen species (ROS) levels, and gene expression testing. Under high sugar conditions, the mechanism of Y8 affecting fibroblasts' proliferation and keratinocytes' migration is further studied.

RESULTS

We found that Y8 accelerated wound healing and shortened healing time in diabetic mice. Granulation tissue generation and extracellular matrix (ECM) deposition were significantly increased in Y8-treated mice. Mechanistically, Y8 promotes keratinocyte proliferation by activating PPARβ and migration of keratinocytes by triggering FFA1 in vitro. In addition, Y8 also decreased ROS levels in fibroblasts in vitro and in vivo by activating PPARβ, reducing their release of superoxide anions.

CONCLUSION

Our results suggest that PPARβ/FFA1 dual agonist Y8 has the effect of promoting the healing of diabetic ulcer wounds in vivo and in vitro, and its therapeutic effect is better than that of single-target agonists.

Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan

BACKGROUND

Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries.

METHODOLOGY

This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics.

RESULTS

The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330).

CONCLUSION

Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

P-MSC-derived extracellular vesicles facilitate diabetic wound healing via miR-145-5p/ CDKN1A-mediated functional improvements of high glucose-induced senescent fibroblasts

Background

Persistent hyperglycaemia in diabetes causes functional abnormalities of human dermal fibroblasts (HDFs), partially leading to delayed skin wound healing. Extracellular vesicles (EVs) containing multiple pro-healing microRNAs (miRNAs) have been shown to exert therapeutic effects on diabetic wound healing. The present study aimed to observe the effects of EVs derived from placental mesenchymal stem cells (P-MSC-EVs) on diabetic wound healing and high glucose (HG)-induced senescent fibroblasts and to explore the underlying mechanisms.

Methods

P-MSC-EVs were isolated by differential ultracentrifugation and locally injected into the full-thickness skin wounds of diabetic mice, to observe the beneficial effects on wound healing in vivo by measuring wound closure rates and histological analysis. Next, a series of assays were conducted to evaluate the effects of low (2.28 x 1010 particles/ml) and high (4.56 x 1010 particles/ml) concentrations of P-MSC-EVs on the senescence, proliferation, migration, and apoptosis of HG-induced senescent HDFs in vitro. Then, miRNA microarrays and real-time quantitative PCR (RT-qPCR) were carried out to detect the differentially expressed miRNAs in HDFs after EVs treatment. Specific RNA inhibitors, miRNA mimics, and small interfering RNA (siRNA) were used to evaluate the role of a candidate miRNA and its target genes in P-MSC-EV-induced improvements in the function of HG-induced senescent HDFs.

Results

Local injection of P-MSC-EVs into diabetic wounds accelerated wound closure and reduced scar widths, with better-organized collagen deposition and decreased p16INK4a expression. In vitro, P-MSC-EVs enhanced the antisenescence, proliferation, migration, and antiapoptotic abilities of HG-induced senescent fibroblasts in a dose-dependent manner. MiR-145-5p was found to be highly enriched in P-MSC-EVs. MiR-145-5p inhibitors effectively attenuated the P-MSC-EV-induced functional improvements of senescent fibroblasts. MiR-145-5p mimics simulated the effects of P-MSC-EVs on functional improvements of fibroblasts by suppressing the expression of cyclin-dependent kinase inhibitor 1A and activating the extracellular signal regulated kinase (Erk)/protein kinase B (Akt) signaling pathway. Furthermore, local application of miR-145-5p agomir mimicked the effects of P-MSC-EVs on wound healing.

Conclusions

These results suggest that P-MSC-EVs accelerate diabetic wound healing by improving the function of senescent fibroblasts through the transfer of miR-145-5p, which targets cyclin-dependent kinase inhibitor 1A to activate the Erk/Akt signaling pathway. P-MSC-EVs are promising therapeutic candidates for diabetic wound treatment.

Effect of hyperbaric oxygen treatment on diabetic foot ulcers: A meta-analysis

The meta-analysis aimed to assess the effect of hyperbaric oxygen treatment on diabetic foot ulcers. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 17 examinations from 1992 to 2022 were enrolled for the present meta-analysis, including 7219 people with diabetic foot ulcers. Hyperbaric oxygen treatment had a significantly higher healed ulcer (OR, 14.39; 95% CI, 4.02-51.52, p < 0.001), higher adverse event (OR, 2.14; 95% CI, 1.11-4.11, p = 0.02), lower mortality (OR, 0.22; 95% CI, 0.07-0.71, p = 0.01) and higher ulcer area reduction (MD, 23.39; 95% CI, 11.79-34.99, p < 0.001) compared to standard treatment in patients with diabetic foot ulcers. However, hyperbaric oxygen treatment and standard treatment had no significant difference in amputation (OR, 0.62; 95% CI, 0.22-1.75, p = 0.37), major amputation (OR, 0.59; 95% CI, 0.18-1.92, p = 0.38), minor amputation (OR, 0.64; 95% CI, 0.15-2.66, p = 0.54) and healing time (MD, -0.001; 95% CI, -0.76 to 0.75, p = 0.99) in patients with diabetic foot ulcers. The examined data revealed that hyperbaric oxygen treatment had a significantly higher healed ulcer, adverse event, and ulcer area reduction and lower mortality, however, there was no significant difference in amputation and healing time compared to standard treatment in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size and some of the comparisons had a low number of selected studies.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Multicomponent prediction of 2-year mortality and amputation in patients with diabetic foot using a random survival forest model: Uric acid, alanine transaminase, urine protein and platelet as important predictors

The current methods for the prediction of mortality and amputation for inpatients with diabetic foot (DF) use only conventional, simple variables, which limits their performance. Here, we used a random survival forest (RSF) model and multicomponent variables to improve the prediction of mortality and amputation for these patients. We performed a retrospective cohort study of 175 inpatients with DF who were recruited between 2014 and 2021. Thirty-one predictors in six categories were considered as potential covariates. Seventy percent (n = 122) of the participants were randomly selected to constitute a training set, and 30% (n = 53) were assigned to a testing set. The RSF model was used to screen appropriate variables for their value as predictors of 2-year all-cause mortality and amputation, and a multicomponent prediction model was established. Model performance was evaluated using the area under the curve (AUC) and the Hosmer-Lemeshow test. The AUCs were compared using the Delong test. Seventeen variables were selected to predict mortality and 23 were selected to predict amputation. Uric acid and alanine transaminase were the top two most useful variables for the prediction of mortality, whereas urine protein and platelet were the top variables for the prediction of amputation. The AUCs were 0.913 and 0.851 for the prediction of mortality for the training and testing sets, respectively; and the equivalent AUCs were 0.963 and 0.893 for the prediction of amputation. There were no significant differences between the AUCs for the training and testing sets for both the mortality and amputation models. These models showed a good degree of fit. Thus, the RSF model can predict mortality and amputation in inpatients with DF. This multicomponent prediction model could help clinicians consider predictors of different dimensions to effectively prevent DF from clinical outcomes .

Enhancing Self-Management Skills of Patients With Existing Diabetic Foot Ulcerations: A Quality Improvement Project

PURPOSE

The purpose of this quality improvement initiative was to determine the impact of a nurse-administered foot care intervention bundle (NA-FCIB) upon self-management knowledge, skills, and outcomes in patients with diabetic foot ulcerations.

PARTICIPANTS AND SETTING

The sample comprised 39 patients being treated for diabetic foot ulceration at a wound care clinic in a tertiary care hospital in Arlington, Virginia. The project was conducted from August 2017 to February 2018.

APPROACH

This quality improvement project used the Johns Hopkins Plan-Do-Study-Act Method supplemented by self-regulation theory for diabetic patient education and evidence in clinical literature. The 12-week-long intervention included one-on-one teaching in the prevention of ulcerations and optimal care of the diabetic foot, blood glucose level tracking logs, patient "teach-back" and skills demonstration, and free foot care tools.

OUTCOMES

From baseline to post-NA-FCIB, the number of participants knowing the reasons for temperature foot protection increased by 92%, those knowing major factors leading to diabetic foot ulceration by 85%, those knowing what to look for in the foot self-exam by 85%, and those able to demonstrate correct foot self-exam by 84%. The number of participants understanding proper footwear increased by 74%, and those identifying ways to avoid/decrease the likelihood of diabetic foot ulcers by 72%. Mean serum hemoglobin A1c (HgbA1c) levels decreased from baseline to postintervention (8.27%; SD 2.05% vs 7.46%; SD 1.58%; P = .002).

IMPLICATIONS FOR PRACTICE

The NA-FCIB intervention was successfully incorporated into routine clinic care as the standard of care. Our experience suggests that the NA-FCIB may be feasible and effective for use at comparable wound care clinics and may have secondary benefits for HgbA1c regulation.

An Overview of Risk Factors for Diabetic Foot Amputation: An Observational, Single-centre, Retrospective Cohort Study

INTRODUCTION

Not only are early detection and treatment of diabetic foot ulcers important, but also acknowledging potential risk factors for amputation gives clinicians a considerable advantage in preventing amputations. Amputations impact both healthcare services and the physical and mental health of patients. This study aimed to investigate the risk factors for amputation in patients with diabetic foot ulcers.

METHODS

The sample for this study was patients with diabetic foot ulcers who were treated by the diabetic foot council at our hospital between 2005 and 2020. A total of 32 risk factors for amputation were identified and investigated among 518 patients.

RESULTS

Our univariate analysis showed that 24 of 32 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, seven risk factors remained statistically significant. The risk factors most significantly associated with amputation were Wagner grading, abnormal peripheral arteries, hypertension, high thrombocyte levels, low haematocrit levels, hypercholesterolaemia and male sex, respectively. The most common cause of death in patients with diabetes who have undergone amputation is cardiovascular disease, followed by sepsis.

CONCLUSION

To enable optimum treatment of patients with diabetic foot ulcers it is important for physicians to be aware of the amputation risk factors, and thus avoid amputations. Correcting risk factors, using suitable footwear and routinely inspecting feet are crucial factors for preventing amputations in patients with diabetic foot ulcers.

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.

Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects

BACKGROUND

We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.

METHODS

Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

RESULTS

We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001.

CONCLUSIONS

Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications.

Does Metabolic Control Have Any Influence on the Clinical Presentation and Short-Term Outcomes of Diabetic Foot Infections?

Objective: We hypothesized that patients with poor glycemic control undergoing treatment for diabetic foot infections (DFIs) would have a poorer prognosis than those with better metabolic control assessed by glycated hemoglobin (HbA1c). Approach: We analyzed a retrospective cohort of 245 patients with moderate and severe DFIs. HbA1c values were dichotomized (<7% or ≥7% and ≤75th percentile (P75) and >P75) to analyze patient outcomes regarding metabolic control. The present study adhered to the STROBE guidelines for cohort studies. Results: One hundred sixty-nine patients (69%) were men. Their mean age was 60.7 years (10.8). HbA1c ≥7% was detected in 203 patients (82.9%). P75 HbA1c was 10.9%. After performing univariate analysis, we found an association of HbA1c <7% with major amputations and mortality. However, after applying the logistic regression model, we did not find HbA1c <7% to be a predictive factor of major amputation. The risk factors for mortality following application of Cox's proportional hazards model were osteomyelitis (HR: 0.2, 95% CI: 0.07-0.62, p < 0.01), eGFR <60 mL/min/1.73 m² (HR: 2.7, 95% CI: 1.0-7.5, p = 0.04), and HbA1c <7% (HR: 4.9, 95% CI: 1.8-13.2, p < 0.01). Innovation: The group with optimal glycemic control (HbA1c <7%) had a shorter survival time than those with worse metabolic control. Conclusions: We did not find a longer duration of hospitalization, a higher rate of amputations, or longer healing times in the groups with worse metabolic control. HbA1c <7% was a risk factor for mid-term mortality.

Clinical Features, Inflammatory Markers, and Limb Salvage in Older Adults with Diabetes-Related Foot Infections

Little information exists about diabetic foot infections (DFIs) in older patients. We hypothesize that older patients with DFIs have different clinical features and worse outcomes than younger patients. We conducted a prospective observational study consisting of a cohort of patients with diabetes and moderate to severe DFIs. Patients included in the cohort were dichotomized into two groups using percentile 75 (P75) of age as the cut-off value. Patients aged > P75 presented with more comorbidities and foot-related complications, a higher rate of peripheral arterial disease (PAD), worse renal function (higher values of blood urea nitrogen and creatinine, and lower values of estimated glomerular filtration rate), and lower values of HbA1c compared with younger patients. Infection severity, microbiological features, and inflammatory markers were similar in both groups. In the multivariate analysis, minor amputations were associated with age > P75 (OR = 2.8, 95% CI 1.3-5.9, p <0.01), necrosis (OR = 4.2, 95% CI 1.8-10.1, p < 0.01), and CRP values (OR = 1.045, 95% CI 1.018-1.073, p < 0.01). Major amputations were associated with a history of amputation (OR = 4.7, 95% CI 1.3-16.7, p = 0.01), PAD (OR = 4.3, 95% CI 1.2-14.6, p = 0.01), and albumin values (OR = 0.344, 95% CI 0.130-0.913, p = 0.03). In conclusion, limb salvage can be achieved in older patients with diabetes-related foot infections at the same rate as in younger patients, despite the fact that they have more comorbidities and foot-related complications, a higher rate of PAD, and worse renal function.

Annual Foot Exams are Associated with Reduced Incident Amputation among Older Veterans with Diabetes

We conducted a secondary data analysis to evaluate the association between annual foot exams and incident lower extremity amputations (LEA) among older veterans with diabetes during FY2007-FY2014. Older Veterans with at least one primary care provider visit each year (N = 664,162) and at least one foot exam each year (N = 72,892) and the overlap were identified from the 5 years prior to the study period of interest (FY2002-FY2006 (N = 71,122)). After excluding incident LEA related to cancer and trauma, 71,018 veterans (mean age +/- SD, % male) were included in the final cohort, which was followed from FY2007-FY2014 to evaluate the influence of subsequent annual foot exams and incident LEA. Consistent annual foot exams were protective for incident LEA in older veterans with diabetes, adjusted OR was 0.85 (97% CI: 0.74-0.96). Results indicate that adherence to annual foot exam guidelines can reduce incident LEA in older veterans with diabetes.

Adverse cardiovascular, limb, and renal outcomes in patients with diabetes after peripheral artery disease revascularization treated with sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors

AIMS

The effectiveness and limb safety of sodium glucose co-transporter 2 inhibitors (SGLT2i) for patients with type-2 diabetes (T2D) who have received peripheral artery disease (PAD) revascularization are unknown.

METHODS AND RESULTS

In this nationwide retrospective cohort study, we identified a total of 2,455 and 8,695 patients with T2D who had undergone PAD revascularization and received first prescriptions for SGLT2i and dipeptidyl peptidase-4 inhibitors (DPP4i), respectively, between May 1, 2016, and December 31, 2019. We used 1:1 propensity score matching (PSM) to balance covariates between the two study groups. Patients were followed up from the drug index date until the occurrence of specified outcomes, death, discontinuation of the index drug, or the end of the study period, whichever occurred first. After PSM, we observed that compared with DPP4i, SGLT2i were associated with comparable risks of ischemic stroke, acute myocardial infarction, and heart failure hospitalization but were associated with a lower risk of cardiac death (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.40-0.90]; p = 0.0126). Regarding major limb outcomes, SGLT2i were associated with comparable risks of repeated revascularization and lower limb amputation compared with DPP4i. SGLT2i were associated with a lower risk of composite renal outcomes (HR: 0.40; 95% CI: 0.27-0.59; p < 0.0001) compared with DPP4i.

CONCLUSION

In a real-world study of patients with T2D who had undergone PAD revascularization, SGLT2i were associated with lower risks of cardiac death and composite renal outcomes but not associated with increased risks of adverse limb events compared with DPP4i.

The Influence of 6-Month Interdisciplinary Accompaniment on Family Caregivers’ Knowledge and Self-Efficacy Regarding Diabetic Wound Care

Introduction

Diabetes mellitus (DM) is a global health issue. Diabetic wounds have become a severe health complication. Interdisciplinary education and the use of homecare have led to improvements in the health of patients with chronic disease. The family caregiver's knowledge and self-efficacy positively impact the DM patient's self-care in the physical and psychological dimensions. There is still a need for interdisciplinary education to enhance family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Objective

To determine the effect of 6 months of interdisciplinary education on family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Methods

A quantitative longitudinal study with a quasi-experimental, one-group, pretest–posttest design was conducted. Family caregivers received 6 months of interdisciplinary education regarding diabetic wound care. The Foot Care Confidence Scale (FCCS) was used to measure the family caregivers’ knowledge and self-efficacy regarding diabetic wound care. The dependent samples t test and the Wilcoxon signed-rank test were used for statistical analysis.

Results

Sixteen caregivers of patients with diabetic ulcer wounds in the homecare unit participated in this intervention with a 6-month follow-up. Six months of interdisciplinary education significantly increased the family caregivers’ knowledge ( p = 0.001) and self-efficacy ( p = 0.001). However, there was no significant correlation between self-efficacy and gender, age, education level, or duration of wound care ( p = 0.91; 0.93; 0.38; 0.40, respectively). Long-term interdisciplinary education improved caregiver performance across genders, ages, education levels, and wound care experience durations.

Conclusion

Long-term interdisciplinary education of family caregivers is recommended as one method to enhance the family support system with respect to diabetic ulcer care management. In addition, interprofessional collaboration could be performed to enhance the understanding of healthcare, especially diabetic ulcer care.

Machine learning for the prediction of minor amputation in University of Texas grade 3 diabetic foot ulcers

Minor amputations are performed in a large proportion of patients with diabetic foot ulcers (DFU) and early identification of the outcome of minor amputations facilitates medical decision-making and ultimately reduces major amputations and deaths. However, there are currently no clinical predictive tools for minor amputations in patients with DFU. We aim to establish a predictive model based on machine learning to quickly identify patients requiring minor amputation among newly admitted patients with DFU. Overall, 362 cases with University of Texas grade (UT) 3 DFU were screened from tertiary care hospitals in East China. We utilized the synthetic minority oversampling strategy to compensate for the disparity in the initial dataset. A univariable analysis revealed nine variables to be included in the model: random blood glucose, years with diabetes, cardiovascular diseases, peripheral arterial diseases, DFU history, smoking history, albumin, creatinine, and C-reactive protein. Then, risk prediction models based on five machine learning algorithms: decision tree, random forest, logistic regression, support vector machine, and extreme gradient boosting (XGBoost) were independently developed with these variables. After evaluation, XGBoost earned the highest score (accuracy 0.814, precision 0.846, recall 0.767, F1-score 0.805, and AUC 0.881). For convenience, a web-based calculator based on our data and the XGBoost algorithm was established (https://dfuprediction.azurewebsites.net/). These findings imply that XGBoost can be used to develop a reliable prediction model for minor amputations in patients with UT3 DFU, and that our online calculator will make it easier for clinicians to assess the risk of minor amputations and make proactive decisions.

Knowledge, Awareness, and Practice Related to Diabetic Foot Ulcer Among Healthcare Workers and Diabetic Patients and Their Relatives in Saudi Arabia: A Cross-Sectional Study

Background Diabetes mellitus is a chronic progressive metabolic disorder characterized by high blood sugar affecting the whole body resulting in a significant impact on the quality of life for the patients and their families. Diabetes mellitus complications lead to morbidity, disability, and mortality and represent a serious global health issue threatening the health system worldwide and resulting in a critical economic impact for all countries, especially epidemic ones. Objective The objective of this study was to assess the level of knowledge and awareness regarding diabetic foot and related behaviour among diabetic patients and their relatives, as well as healthcare workers in Saudi Arabia. Methods A cross-sectional analytic study was conducted in 2022 on healthcare workers, diabetic patients, and their relatives above the age of 18 in Saudi Arabia by using a valid, pretested structured questionnaire. The collected data were analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). Results In this study, there was no correlation between the healthcare workers' attitude and knowledge. A total of 131 healthcare workers were involved, and a majority of them had good knowledge regarding the predisposing factors of diabetic foot ulcers, and 63 (48.1%) had good knowledge regarding diabetes foot care. On the other hand, there was poor knowledge regarding the characteristics and complications of diabetes ulcers. This study showed various attitudes among healthcare workers regarding diabetic ulcer care. For example, they prioritized the prevention of ulcers over treatment (N=67, 51.1%), the majority of healthcare workers were very keen to wound care (N=77, 58.8%), and they believed that it was their responsibility to educate their patients about reducing re-ulceration (N=86; 65.7%). However, 52 participants (39.7%) considered management of diabetic foot ulcer time-consuming, 54 (41.2%) mentioned that if they had the opportunity, they would like to avoid taking care of the diabetic wound, and 51 (38.9%) reported non-satisfaction with diabetic wound care.  One hundred diabetic patients and 117 relatives also were involved, and only 41.3% of participants (patients and relatives) had good knowledge regarding diabetes mellitus. However, our findings also revealed that 91.65% of the participants had good knowledge and a favourable attitude towards diabetes mellitus and diabetic foot care. Nevertheless, even though the participants had good knowledge regarding foot care, they had poor practice, with 56.55% scoring poor on the assessment questionnaire.  Conclusion Our study shows that most of the participants had good knowledge and attitudes but poor practices. This highlights the need for more efforts to educate the Saudi population about diabetes and its complications.

Translational development of ABCB5+ dermal mesenchymal stem cells for therapeutic induction of angiogenesis in non-healing diabetic foot ulcers

Background

While rapid healing of diabetic foot ulcers (DFUs) is highly desirable to avoid infections, amputations and life-threatening complications, DFUs often respond poorly to standard treatment. GMP-manufactured skin-derived ABCB5⁺ mesenchymal stem cells (MSCs) might provide a new adjunctive DFU treatment, based on their remarkable skin wound homing and engraftment potential, their ability to adaptively respond to inflammatory signals, and their wound healing-promoting efficacy in mouse wound models and human chronic venous ulcers.

Methods

The angiogenic potential of ABCB5⁺ MSCs was characterized with respect to angiogenic factor expression at the mRNA and protein level, in vitro endothelial trans-differentiation and tube formation potential, and perfusion-restoring capacity in a mouse hindlimb ischemia model. Finally, the efficacy and safety of ABCB5⁺ MSCs for topical adjunctive treatment of chronic, standard therapy-refractory, neuropathic plantar DFUs were assessed in an open-label single-arm clinical trial.

Results

Hypoxic incubation of ABCB5⁺ MSCs led to posttranslational stabilization of the hypoxia-inducible transcription factor 1α (HIF-1α) and upregulation of HIF-1α mRNA levels. HIF-1α pathway activation was accompanied by upregulation of vascular endothelial growth factor (VEGF) transcription and increase in VEGF protein secretion. Upon culture in growth factor-supplemented medium, ABCB5⁺ MSCs expressed the endothelial-lineage marker CD31, and after seeding on gel matrix, ABCB5⁺ MSCs demonstrated formation of capillary-like structures comparable with human umbilical vein endothelial cells. Intramuscularly injected ABCB5⁺ MSCs to mice with surgically induced hindlimb ischemia accelerated perfusion recovery as measured by laser Doppler blood perfusion imaging and enhanced capillary proliferation and vascularization in the ischemic muscles. Adjunctive topical application of ABCB5⁺ MSCs onto therapy-refractory DFUs elicited median wound surface area reductions from baseline of 59% (full analysis set, n = 23), 64% (per-protocol set, n = 20) and 67% (subgroup of responders, n = 17) at week 12, while no treatment-related adverse events were observed.

Conclusions

The present observations identify GMP-manufactured ABCB5⁺ dermal MSCs as a potential, safe candidate for adjunctive therapy of otherwise incurable DFUs and justify the conduct of a larger, randomized controlled trial to validate the clinical efficacy.

Trial registration: ClinicalTrials.gov, NCT03267784, Registered 30 August 2017, https://clinicaltrials.gov/ct2/show/NCT03267784

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-03156-9.

Sequelae of Hospitalization for Diabetic Foot Ulcers at LASUTH Ikeja Lagos: A Prospective Observational Study

Abstract

Diabetic foot ulcers (DFUs) remain important sequelae of diabetes (DM) which cause debilitating effects on the sufferer. The evolution of some aspects of epidemiology and the current clinical impact of DFUs was examined.

Methods

A single-center prospective observational study. Study subjects were consecutively recruited.

Results

Total medical admissions during the study period were 2288, 350 were DM related, out of these 112 were admitted for DFU. 32% of total DM admissions were for DFU. The mean age of the study subjects is 58 ± 11.0 range is from 35 years to 87 years. Males were slightly predominant (51.8%). Most of them were actively employed (92%), and the majority were in the 55 to 64 years age category. Most of them had not been diabetic for longer than 8 years (61%). The mean duration of DM is 8.32±7.27 years. The mean duration of ulcer at presentation was 72.0±138.13 days. The majority of the patients (80.3%) presented with severe (grades 3 to 5) ulcers, Wagner grade four was the most predominant. Regarding clinical outcome, 24 (24.7%) had an amputation, 3 of which were minor. The factor that was associated with amputation was concomitant heart failure – OR 6.00 CI 0.589-61.07, 0.498-4.856. Death occurred in 16 (18.4%). The factors associated with mortality were severe anemia OR 2.00 CI 0.65 – 6.113, severe renal impairment requiring dialysis OR 3.93 CI 0.232-66.5, concomitant stroke OR 8.42 CI 0.71-99.6, and peripheral arterial disease- OR 18.33 CI 2.27 -147 p-value- 0.006.

Conclusion

The hallmark of DFU in this report is late presentation, it accounted for a significant proportion of the total medical admissions, although the case fatality of DFU reduced from previous reports from the center, mortality, and amputation rates are still unacceptably high. Concomittant heart failure was a factor of amputation. Mortality was associated with severe anemia, renal impairment and peripheral arterial disease.

Predicting Amputation in Patients With Diabetic Foot Ulcers: A Systematic Review

Foot ulcers are a leading cause of morbidity in diabetics. One of the known complications of diabetic foot ulcers is lower limb amputation which makes it a major socioeconomic problem. Currently, there’s a lack of knowledge on the predictors of amputations in diabetics with foot ulcers. We performed a systematic review of studies that identified risk factors of amputation in patients with diabetic foot ulcers. This systematic review aims to identify the predictors of amputation in order to optimize the management strategy and care plan. Medline database was searched and inclusion criteria were implemented for the selection of studies. The risk factors extracted were part of four categories: (i) history and physical examination, (ii) ulcer characteristics, (iii) lab results, and (iv) co-morbidities. The data extracted were in the form of odds ratios, 95% confidence intervals, and predictive values. The mean values with standard deviations of the included risk factors were recorded, and the incidence of risk factors among the amputation groups was identified or calculated when the data were sufficient. Seven articles were selected reporting on 3481 patients. This review identified peripheral arterial disease, neuropathy, high Wagner’s grade, osteomyelitis, postprandial glucose level, white cell count, c-reactive protein, erythrocyte sedimentation rate, low hemoglobin, and albumin as the most significant predictors of amputation.

Quality of life in diabetic foot ulcer, grade 3: associated demographic factors

Abstract

Introduction: Patients with diabetic foot ulcer grade 3 experience some limitations that adversely affect their quality of life (QoL).

Aim: The aim of the study was to explore demographic characteristics associated with the quality of life of diabetic foot ulcer patients, grade 3.

Materials and methods: The present study recruited 120 diabetic foot ulcer patients. Data collected by completion of SF-36 Health Survey (SF-36).

Results: Of the 120 participants, 65.8% were men and 73% were more than 60 years of age. Patients showed moderate to high levels of quality of life in social functionality, energy/fatigue, emotional well-being, and physical pain (medians: 50, 60, 72, and 67.5, respectively) and poor levels in physical functioning, role physical, and role emotional (medians: 22, 0 and 0, respectively). In addition, patients had moderate levels of quality of life in general health (median: 48.5). It was observed that physical functioning was significantly associated with place of residence (p=0.005). Moreover, physical role was significantly associated with age (p=0.020) and occupation (p=0.018), while emotional role was significantly associated with age (p=0.012), marital status (p=0.016), and occupation (p=0.012). Energy/fatigue was significantly associated with age (p=0.026), marital status (p=0.018), and occupation (p=0.009). Emotional well-being was significantly associated with gender (p=0.009), level of education (p=0.001), and occupation (p=0.007). Social functionality was significantly associated with marital status (p=0.001) while pain was significantly associated with education level (p=0.010). General health was significantly associated with marital status (p=0.037), and place of residence (p=0.024).

Conclusions: The findings of the present study may adequately inform stakeholders in the field of diabetic foot ulcer grade 3 when planning effective care.

The efficacy of inflammatory markers in diagnosing infected diabetic foot ulcers and diabetic foot osteomyelitis: Systematic review and meta-analysis

Background

Diabetes foot ulcer (DFU) is a complication of diabetes mellitus. Accurate diagnosis of DFU severity through inflammatory markers will assist in reducing impact on quality of life. We aimed to ascertain the diagnostic test accuracy of commonly used inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and white cell count (WCC) for the diagnosis and differentiation between DFU grades based on the International Working Group on the Diabetic Foot classification system.

Methods

This systematic review explored studies that investigated one or more of the above-listed index tests aiding in diagnosing infected DFU. This review was registered on PROSPERO database (ID = CRD42021255618) and searched 5 databases including an assessment of the references of included studies. Records were manually screened as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 16 studies were included which were assessed for quality using QUADAS-2 tool and meta-analysed using Meta-Disc v1.4.

Results

CRP had the greatest area under the curve (AUC) of 0.893 for diagnosing grade 2 DFU. This returned a pooled sensitivity and specificity of 77.4% (95% CI: 72% to 82%) and 84.3% (95% CI: 79% to 89%) respectively. In terms of diagnosing grade 3 DFU, procalcitonin had the highest AUC value of 0.844 when compared with other markers. The pooled sensitivity of PCT was calculated as 85.5% (95% CI: 79% to 90%) and specificity as 68.9% (95% CI: 63% to 75%).

Conclusion

CRP and PCT are the best markers for diagnosing grade 2 and grade 3 DFU respectively. Other markers are also valuable when used in conjunction with clinical judgement. The findings accentuate the necessity of further research to establish standardised cut-off values for these inflammatory markers in diagnosing diabetic foot ulcers.

Pattern and type of amputation and mortality rate associated with diabetic foot in Jeddah, Saudi Arabia: A retrospective Cohort Study

Background

Diabetic foot complications constitute a major public health problem worldwide, especially in Jeddah, Saudi Arabia, where the prevalence of diabetes is high. Our study was designed to determine the pattern and type of amputations performed on patients with diabetic foot admitted to a tertiary center in Jeddah, Saudi Arabia; we also aimed to determine the 7-year mortality rate of patients with diabetic foot at the same institution.

Materials and methods

This retrospective study was conducted between January 2013 and September 2020 at a tertiary center in Jeddah, Saudi Arabia. It included all patients previously diagnosed with diabetes mellitus who presented to the hospital with either diabetic foot ulcers or foot gangrene (dry/wet/gas). The medical records of 358 patients were reviewed to acquire information regarding demographics, admission history regarding diabetes and its outcome, medical and surgical history, the level of amputation, and the presence of infection.

Results

Among the participants, 84.9% underwent amputation, 38.2% underwent minor amputations, 40.1% underwent major amputations, and 21.7% underwent both types of amputation. The most common cause of amputation was infection (50.3%). There were 75 deaths and a 7-year mortality rate of 20%. Low mean hemoglobin and high mean creatinine levels were significantly associated with mortality (p < 0.05).

Conclusion

Efforts to decrease the risk of amputation and mortality among patients with diabetic foot complications are required. Early detection of the risk factors and intervention in specialist centers with a multidisciplinary approach is essential.

•

Diabetic foot complications are a serious health problem, especially in our society.

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The risk for lower limb amputation increased significantly with a high hemoglobin A_1c.

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Once infection occurs, the risk of diabetic foot–related amputation significantly increases.

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Premature death was identified among patients underwent amputation.

Cross-Sectional Study Concerning the Knowledge, Attitude, and Practice of People With Diabetes Regarding the Prevention of Foot Ulcers in a Community

Foot ulceration is a serious problem among people with diabetes. This study assessed the knowledge, attitude, and practice of 483 people with diabetes with regard to the prevention of diabetic foot ulcers (DFUs). Data were collected using a valid and reliable questionnaire, and logistic regression was carried out to predict the effect of statistically significant independent variables on the scores of dependent variables. A significant association was found between knowledge and attitude about DFU prevention. Individuals who were unmarried were more likely to have higher knowledge scores than those who were married, and those who had university and secondary education were more likely to have higher attitude and practice scores than other groups. Overall, however, only a small percentage of study participants achieved high scores for knowledge, practice, and attitude in this study.

Machine Learning Models for Predicting the Risk of Hard-to-Heal Diabetic Foot Ulcers in a Chinese Population

BACKGROUND

Early detection of hard-to-heal diabetic foot ulcers (DFUs) is vital to prevent a poor prognosis. The purpose of this work was to employ clinical characteristics to create an optimal predictive model of hard-to-heal DFUs (failing to decrease by >50% at 4 weeks) based on machine learning algorithms.

METHODS

A total of 362 DFU patients hospitalized in two tertiary hospitals in eastern China were enrolled in this study. The training dataset and validation dataset were split at a ratio of 7:3. Univariate logistic analysis and clinical experience were utilized to screen clinical characteristics as predictive features. The following six machine learning algorithms were used to build prediction models for differentiating hard-to-heal DFUs: support vector machine, the naïve Bayesian (NB) model, k-nearest neighbor, general linear regression, adaptive boosting, and random forest. Five cross-validations were employed to realize the model's parameters. Accuracy, precision, recall, F1-scores, and AUCs were utilized to compare and evaluate the models' efficacy. On the basis of the best model identified, the significance of each characteristic was evaluated, and then an online calculator was developed.

RESULTS

Independent predictors for model establishment included sex, insulin use, random blood glucose, wound area, diabetic retinopathy, peripheral arterial disease, smoking history, serum albumin, serum creatinine, and C-reactive protein. After evaluation, the NB model was identified as the most generalizable model, with an AUC of 0.864, a recall of 0.907, and an F1-score of 0.744. Random blood glucose, C-reactive protein, and wound area were determined to be the three most important influencing factors. A corresponding online calculator was created (https://predicthardtoheal.azurewebsites.net/).

CONCLUSION

Based on clinical characteristics, machine learning algorithms can achieve acceptable predictions of hard-to-heal DFUs, with the NB model performing the best. Our online calculator can assist doctors in identifying the possibility of hard-to-heal DFUs at the time of admission to reduce the likelihood of a dismal prognosis.

Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review

Background and aims

The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease.

Methods

Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors.

Results

In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease.

Conclusion

We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.

Predictors and outcomes of diabetic foot ulcer infection with ESBL-producing bacteria in a large tertiary center

OBJECTIVES

The aim of this study was to describe the predictors and outcomes of infection with extended-spectrum beta-lactamase (ESBL)-producing bacteria in patients with an acute diabetic foot infection (DFI).

METHODS

The records of patients admitted with acute DFI to a large tertiary hospital during the years 2014-2018 were reviewed. Demographic, clinical, and laboratory data were collected, as well as outcomes regarding amputations and mortality. Only cultures obtained during the first 2 weeks following admission were considered.

RESULTS

Cultures were available for 493 patients; 121 (24.5%) included bacteria suspected of being ESBL producers. Patients infected with ESBL-producing bacteria were older, more likely to have peripheral vascular disease (PVD), and had higher SINBAD and Wagner scores upon admission. They were also more likely to have been hospitalized in the recent 6 months. Major amputations were more prevalent in patients with versus without an ESBL-producing bacterial infection (30.6% vs 19.4%; P = 0.010), yet overall amputations and mortality rates were similar.

CONCLUSIONS

ESBL-producing bacteria are common pathogens in DFI, more prevalent in older patients with PVD, advanced ulcers, and recent hospitalization. They are associated with higher rates of major amputation. These considerations may support the choice of empirical antibiotic therapy in patients admitted with an acute DFI.

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.

Profile of Diabetic Foot Ulcer Patients at Tertiary Care Hospital in Surabaya, Indonesia

Background: Diabetic Foot Ulcer (DFU) has been associated with a high mortality rate of Diabetes Mellitus (DM) patients. Both behavioral and biological factors cause predisposition to DFU. Purpose: This research describes the profile of hospitalized DFU patients at a tertiary care hospital in Surabaya. Methods: A retrospective descriptive study that analyzed medical records of hospitalized T2DM patients with DFU in Dr. Soetomo General Hospital. Sampled respondents were patients ≥ 21 years old who were hospitalized between 2016–2018. Demographic data, clinical characteristics, medical histories, length of hospital stay, laboratory results, precipitating factors, microorganism culture results, treatment, and outcome were analyzed. Descriptive analysis is presented in the form of narratives, tables, and diagrams. Results: 9.08% of hospitalized Type 2 DM (T2DM) cases were related to foot ulcers. The average patient age was 57.00 ± 9.83 years with no gender predominance. DM was poorly controlled (Mean HbA1C 9.78±2.83%; RBG 251.83 ± 158.15 mg/dL). The majority of patients had sepsis (68.26%) and renal function impairment (62.72%). Ulcers with Wagner grades of 4–5 were frequent (41.31%). The highest percentage of sepsis (80.49%) and the average leukocyte level (22.60±11.95 x109/L) were found in gangrenous feet. Anemia was more predominant and severe in ulcers with higher Wagner grades. Trauma and Escherichia coli were the most common precipitating factors and microorganisms isolated, respectively. Amputation was performed for 82.36% of patients who were admitted to hospital with gangrene. The Lower Extremity Amputation (LEA) and mortality rates were 14.11% and 40.93%, respectively. Conclusion: DFUs were found to have a relatively high prevalence among T2DM patients, and must never be neglected due to the high associated mortality rate.

Clinical outcomes among patients with chronic kidney disease hospitalized with diabetic foot disorders: A nationwide retrospective study

INTRODUCTION

Diabetic foot ulcerations or infections (DFUs/DFIs) are common complications of patients with diabetes. This study aimed to explore the impact of non-dialysis and dialysis CKD on hospitalized patients with DFUs/DFIs.

METHODS

A retrospective cohort study was conducted using the National Inpatient Sample database for the years 2017 and 2018. Patients hospitalized for DFUs/DFIs were included in the study. The primary outcome was lower limb amputations. The secondary outcomes were inpatient mortality, sepsis, length of stay (LOS), total hospitalization charges (THC) and disposition.

RESULTS

A total of 121,815 hospitalizations were included (26.1% non-dialysis CKD; 8.4% dialysis CKD). There was no significant difference in amputation rates between those on non-dialysis CKD (adjusted odds ratio [aOR]: 0.96; 95% confidence interval [CI]: 0.87-1.06) and dialysis CKD (aOR: 1.04, [95% CI: 0.91-1.12]) when compared to non-CKD group. Dialysis CKD group had increased odds of undergoing major amputation (aOR: 1.74, [95% CI: 1.32-2.29]), in-hospital mortality (aOR: 3.77 [95% CI: 1.94-7.31]), sepsis (aOR: 1.83 [95% CI: 1.27-2.62]), longer LOS (adjusted mean difference [aMD]: 1.46 [95 CI: 1.12-1.80) and higher THC (adjusted mean difference [aMD]: $20,148 [95% CI: $15,968-$24,327]). Non-dialysis CKD group had increased odds of sepsis (aOR: 1.36 [95% CI: 1.02-1.82]), less likely to be discharged home (aOR: 0.87 [95% CI: 0.80-0.95]), longer LOS (aMD: 0.91 [95% CI 0.69-1.13]) and higher THC (aMD: $20,148 [95% CI: $15,968-$24,327]).

CONCLUSION

Patients with CKD on dialysis had higher odds of undergoing major amputation. CKD increased the odds of in-hospital morbidity and resource utilization, with the most significant is for those on dialysis.

The Neuro-Vascular Consequence of Diabetes: Foot Amputation and Evaluation of its Risk Factors and Health-Related Economic Impact

BACKGROUND

The rising prevalence of type 2 diabetes mellitus (T2DM) with the huge burden of diabetic foot amputation is a challenge to the health economy of Pakistan and other countries. Identification of various risk factors for amputation, along with its financial burden, is needed to address this problem.

OBJECTIVES

This study aimed to determine the financial burden and risk factors associated with T2DMrelated foot amputation.

METHODS

Retrospective hospital-based study from January 2017 to December 2018. Patients with T2DM with and without amputation were enrolled. The direct medical costs of amputation along with various risk factors, were determined. Risk factors were evaluated by logistic regression analysis.

RESULTS

A total of 1460 patients with T2DM were included; 484 (33%) patients had an amputation. The mean total cost of below knee, fingers and toe amputation was 886.63±23.91, 263.35 ±19.58 and 166.68 ± 8.47 US$, respectively. This difference among groups was significant (p<0.0001). Male gender (odds ratio, OR: 1.29, 1.01-1.63, p=0.037), peripheral artery disease (OR: 1.93, 1.52-2.46, p=0.000), peripheral neuropathy (OR: 1.31, 1.40-1.63, p=0.000), prior diabetic foot ulcer (OR: 2.02, 1.56- 2.56, p=0.000) and raised glycated haemoglobin (HbA1c) (OR: 3.50, 2.75-4.4, p=0.000) were risk factors for amputation.

CONCLUSION

The health-related financial impact of amputations is high. Peripheral artery disease, peripheral neuropathy, prior diabetic foot ulcer and raised HbA1c were risk factors for amputation.

Serum exosomes accelerate diabetic wound healing by promoting angiogenesis and ECM formation

Nonhealing wounds in diabetes remain a global clinical and research challenge. Exosomes are primary mediators of cell paracrine action, which are shown to promote tissue repair and regeneration. In this study, we investigated the effects of serum derived exosomes (Serum-Exos) on diabetic wound healing and its possible mechanisms. Serum-Exos were isolated from blood serum of normal healthy mice and identified by transmission electron microscopy and western blot. The effects of Serum-Exos on diabetic wound healing, fibroblast growth and migration, angiogenesis and extracellular matrix (ECM) formation were investigated. Our results showed that the isolated Serum-Exos exhibited a sphere-shaped morphology with a mean diameter at 150 nm, and expressed classical markers of exosomes including HSP70, TSG101, and CD63. Treatment with Serum-Exos elevated the percentage of wound closure and shortened the time of healing in diabetic mice. Mechanistically, Serum-Exos promoted granulation tissue formation and increased the expression of CD31, fibronectin and collagen-ɑ in diabetic mice. Serum-Exos also promoted the migration of NIH/3T3 cells, which was associated with increased expression levels of PCNA, Ki67, collagen-α and fibronectin. In addition, Serum-Exos enhanced tube formation in human umbilical vein endothelial cells and induced the expression of CD31 at both protein and messenger RNA levels. Collectively, our results suggest that Serum-Exos may facilitate the wound healing in diabetic mice by promoting angiogenesis and ECM formation, and show the potential application in treating diabetic wounds.

Negative-Pressure Wound Therapy With Instillation: A Tool in the Multidisciplinary Approach to Limb Function Preservation

SUMMARY

The multidisciplinary approach to lower extremity function preservation is well established and is globally considered the standard of care. Every member of the team contributes their unique skills and knowledge to patient care. The effective integration of negative-pressure wound therapy with instillation (NPWTi) has fundamentally changed the approach to the infected or contaminated wound. Initially, in conjunction with excisional debridement, NPWTi has demonstrated its utility of expediting wound bed preparation for closure or coverage. With the introduction of a novel foam design, the effectiveness has increased and provided an option in cases where surgical intervention is not available or recommended. The successful implementation and continued monitoring of NPWTi provides an efficient tool to expedite ultimate wound healing and involves all members of the team.

The Effects of Antimicrobial Resistance and the Compatibility of Initial Antibiotic Treatment on Clinical Outcomes in Patients With Diabetic Foot Infection

We aimed to determine pathogen microorganisms, their antimicrobial resistance patterns, and the effect of initial treatment on clinical outcomes in patients with diabetic foot infection (DFI). Patients with DFI from 5 centers were included in this multicenter observational prospective study between June 2018 and June 2019. Multivariate analysis was performed for the predictors of reinfection/death and major amputation. A total of 284 patients were recorded. Of whom, 193 (68%) were male and the median age was 59.9 ± 11.3 years. One hundred nineteen (41.9%) patients had amputations, as the minor (n = 83, 29.2%) or major (n = 36, 12.7%). The mortality rate was 1.7% with 4 deaths. A total of 247 microorganisms were isolated from 200 patients. The most common microorganisms were Staphylococcus aureus (n = 36, 14.6%) and Escherichia coli (n = 32, 13.0%). Methicillin resistance rates were 19.4% and 69.6% in S aureus and coagulase-negative Staphylococcus spp., respectively. Multidrug-resistant Pseudomonas aeruginosa was detected in 4 of 22 (18.2%) isolates. Extended-spectrum beta-lactamase-producing Gram-negative bacteria were detected in 20 (38.5%) isolates of E coli (14 of 32) and Klebsiella spp. (6 of 20). When the initial treatment was inappropriate, Klebsiella spp. related reinfection within 1 to 3 months was observed more frequently. Polymicrobial infection (p = .043) and vancomycin treatment (p = .007) were independent predictors of reinfection/death. Multivariate analysis revealed vascular insufficiency (p = .004), hospital readmission (p = .009), C-reactive protein > 130 mg/dL (p = .007), and receiving carbapenems (p = .005) as independent predictors of major amputation. Our results justify the importance of using appropriate narrow-spectrum empirical antimicrobials because higher rates of reinfection and major amputation were found even in the use of broad-spectrum antimicrobials.

A Rule of Thumb for Evaluating Surface Areas of Chronic Wounds

BACKGROUND

Rapid estimation of the area of chronic wounds is clinically important. A simple method using the thumb was investigated for universal physical measurement, particularly of small and multiple wounds; the thumb surface area (TSA) was then compared with the total body surface area (TBSA).

METHODS

A cross-sectional observational study and random sampling were used to obtain the characteristics of 343 participants. Data related to handprint surface area of the thumb and palm were collected using a scanner and laptop and assessed using image software. The TSA as a percentage of TBSA was confirmed based on the traditional rule that regards palmar surface area as 1% of TBSA. Information on factors potentially influencing measurement was gathered with questionnaires to analyze correlations.

RESULTS

The left and right TSAs were on average 4.27% and 4.28%, respectively, of the palmar surface area for all participants. Multiple linear regression analysis found that male and older participants had higher TSA:TBSA proportions (sex, P = .0020; age, P < .0001). The TSA:TBSA proportion increased by age for both males (by age group, 0.0418%, 0.0426%, 0.0432%, and 0.0460%, respectively) and females (0.0400%, 0.0409%, 0.0427%, and 0.0430%, respectively).

CONCLUSIONS

Thumb size is relatively stable in relation to TBSA, lending itself to a universal method for estimating the size of chronic wounds as a percentage of TBSA. It therefore represents a convenient physical measurement for assessing the area of burns and other wounds.

Sex difference for the risk of amputation in diabetic patients: A systematic review and meta-analysis

The risk of amputation is a sequelae of diabetic foot ulceration, which are significantly increased in diabetic patients and caused huge morbidly and mortality. However, whether the risk amputation in diabetic patients are differing in male and female remains inconclusive. We therefore conducted a systematic review and meta-analysis to assess the sex difference for the risk of amputation in diabetic patients. We systematically searched PubMed, EmBase, and the Cochrane library to identify eligible study from their inception up to November 2020. The diagnostic value of male patients on subsequent amputation risk were assessed by using sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC). Twenty-two studies recruited a total of 33,686,171 diabetic patients were selected for quantitative analysis. The risk of amputation in male diabetic patients was greater than female diabetic patients (DOR: 1.38; 95%CI: 1.13–1.70; P<0.001). The sensitivity and specificity for male diabetic patients on the risk of amputation were 0.72 (95%CI: 0.72–0.73), and 0.51 (95%CI: 0.51–0.51), respectively. Moreover, the PLR and NLR of male diabetic patients for predicting amputation were 1.13 (95%CI: 1.05–1.22), and 0.82 (0.72–0.94), respectively. Furthermore, the AUC for male diabetic patients on amputation risk was 0.56 (95%CI: 0.48–0.63). This study found male diabetic patients was associated with an increased risk of amputation than female diabetic patients, and the predictive value of sex difference on amputation risk in diabetic patients was mild.

Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials

Studies have suggested that hyperbaric oxygen therapy (HBOT) is effective in the healing of diabetic foot ulcer (DFU); however, there is a lack of consensus. Therefore, to assess the efficacy of HBOT on diabetic foot ulcer among diabetic patients, controlled clinical trials were searched through PubMed, EMBASE, Clinical key, Ovid Discovery, ERMED, Clinical Trials.gov databases for randomized controlled trials (RCTs) and other sources until 15 September 2020. Studies that evaluated the effect of HBOT on diabetic foot ulcer, complete healing, amputation, adverse events, ulcer reduction area, and mortality rate were included. Of 1984 study records screened, 14 studies (768 participants) including twelve RCTs, and two CCTs were included as per inclusion criteria. The results with pooled analysis have shown that HBOT was significantly effective in complete healing of diabetic foot ulcer (OR = 0.29; 95% CI 0.14-0.61; I² = 62%) and reduction of major amputation (RR = 0.60; 95% CI 0.39-0.92; I² = 24%). Although, it was not effective for minor amputations (RR = 0.82; 95% CI 0.34-1.97; I² = 79%); however, less adverse events were reported in standard treatment group (RR = 1.68; 95% CI 1.07-2.65; I² = 0%). Nevertheless, reduction in mean percentage of ulcer area and mortality rate did not differ in HBOT and control groups. This review provides an evidence that hyperbaric oxygen therapy is effective as an adjunct treatment measure for the diabetes foot ulcers. These findings could be generalized cautiously by considering methodological flaws within all studies.

Development of Predictive Nomograms for Clinical Use to Quantify the Risk of Amputation in Patients with Diabetic Foot Ulcer

OBJECTIVE

To determine the novel proposed nomogram model accuracy in the prediction of the lower-extremity amputations (LEA) risk in diabetic foot ulcer (DFU).

METHODS AND MATERIALS

In this retrospective study, data of 125 patients with diabetic foot ulcer who met the research criteria in Zhongnan Hospital of Wuhan University from January 2015 to December 2019 were collected by filling in the clinical investigation case report form. Firstly, univariate analysis was used to find the primary predictive factors of amputation in patients with diabetic foot ulcer. Secondly, single factor and multiple factor logistic regression analysis were employed to screen the independent influencing factors of amputation introducing the primary predictive factors selected from the univariate analysis. Thirdly, the independent influencing factors were applied to build a prediction model of amputation risk in patients with diabetic foot ulcer by using R4.3; then, the nomogram was established according to the selected variables visually. Finally, the performance of the prediction model was evaluated and verified by receiver working characteristic (ROC) curve, corrected calibration curve, and clinical decision curve.

RESULTS

7 primary predictive factors were selected by univariate analysis from 21 variables, including the course of diabetes, peripheral angiopathy of diabetic (PAD), glycosylated hemoglobin A1c (HbA1c), white blood cells (WBC), albumin (ALB), blood uric acid (BUA), and fibrinogen (FIB); single factor logistic regression analysis showed that albumin was a protective factor for amputation in patients with diabetic foot ulcer, and the other six factors were risk factors. Multivariate logical regression analysis illustrated that only five factors (the course of diabetes, PAD, HbA1c, WBC, and FIB) were independent risk factors for amputation in patients with diabetic foot ulcer. According to the area under curve (AUC) of ROC was 0.876 and corrected calibration curve of the nomogram displayed good fitting ability, the model established by these 5 independent risk factors exhibited good ability to predict the risk of amputation. The decision analysis curve (DCA) indicated that the nomogram model was more practical and accurate when the risk threshold was between 6% and 91%.

CONCLUSION

Our novel proposed nomogram showed that the course of diabetes, PAD, HbA1c, WBC, and FIB are the independent risk factors of amputation in patients with DFU. This prediction model was well developed and behaved a great accurate value for LEA so as to provide a useful tool for screening LEA risk and preventing DFU from developing into amputation.