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Ponukumati AS, Krafcik BM, Newton L, Baribeau V, Mao J, Zhou W, Goodney EJ, Fowler XP, Eid MA, Moore KO, Armstrong DG, Feinberg MW, Bonaca MP, Creager MA, Goodney PP. Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease. J Vasc Surg 2024:S0741-5214(24)01279-5. [PMID: 38880181 DOI: 10.1016/j.jvs.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/05/2024] [Accepted: 06/09/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Prior studies have described risk factors associated with amputation in patients with concomitant diabetes and peripheral arterial disease(DM/PAD). However, the association between the severity and extent of tissue loss type and amputation risk remains less well-described. We aimed to quantify the role of different tissue loss types in amputation risk among patients with DM/PAD, in the context of demographic, preventive, and socioeconomic factors. METHODS Applying ICD-9 and ICD-10 codes to Medicare claims data(2007-2019), we identified all patients with continuous fee-for-service Medicare coverage diagnosed with DM/PAD. Eight tissue loss categories were established using ICD-9 and ICD-10 diagnosis codes, ranging from lymphadenitis(least severe) to gangrene(most severe). We created a Cox proportional hazards model to quantify associations between tissue loss type and one- and five-year amputation risk, adjusting for age, race/ethnicity, sex, rurality, income, comorbidities, and preventive factors. Regional variation in DM/PAD rates and risk-adjusted amputation rates was examined at the hospital referral region(HRR) level. RESULTS We identified 12,257,174 patients with DM/PAD(48% male, 76% White, 10% prior myocardial infarction, 30% chronic kidney disease). While 2.2 million patients(18%) had some form of tissue loss, 10.0 million patients(82%) did not. The one-year crude amputation rate(major and minor) was 6.4% in patients with tissue loss, and 0.4% in patients without tissue loss. Among patients with tissue loss, one-year any amputation rate varied from 0.89% for patients with lymphadenitis to 26% for patients with gangrene. One-year amputation risk varied from two-fold for patients with lymphadenitis(aHR 1.96, 95%CI 1.43-2.69) to 29-fold for patients with gangrene(aHR 28.7, 95%CI 28.1-29.3), compared to patients without tissue loss. No other demographic variable including age, sex, race, or region incurred a hazard ratio for one- or five-year amputation risk higher than the least severe tissue loss category. Results were similar across minor and major amputation, and one- and five-year amputation outcomes. At a regional level, higher DM/PAD rates were inversely correlated with risk-adjusted five-year amputation rates(R2=0.43). CONCLUSION Among 12 million patients with DM/PAD, the most significant predictor of amputation was presence and extent of tissue loss, with an association greater in effect size than any other factor studied. Tissue loss could be used in awareness campaigns as a simple marker of high-risk patients. Patients with any type of tissue loss require expedited wound care, revascularization as appropriate, and infection management to avoid amputation. Establishing systems of care to provide these interventions in regions with high amputation rates may prove beneficial for these populations.
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Affiliation(s)
- Aravind S Ponukumati
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; VA Medical Center, White River Junction, VT, USA.
| | - Brianna M Krafcik
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Laura Newton
- VA Medical Center, White River Junction, VT, USA; Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Jialin Mao
- Weill Cornell Medical Center, New York, NY, USA
| | - Weiping Zhou
- The Dartmouth Institute, Dartmouth College, Hanover, NH, USA
| | - Eric J Goodney
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Xavier P Fowler
- Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark A Eid
- Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Kayla O Moore
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | | | - Marc P Bonaca
- Colorado Prevention Center, University of Colorado, Denver, CO, USA
| | - Mark A Creager
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA; VA Medical Center, White River Junction, VT, USA; The Dartmouth Institute, Dartmouth College, Hanover, NH, USA
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Nguyen ML, Wong D, Barson E, Staunton E, Fisher CA. Cognitive dysfunction in diabetes-related foot complications: A cohort study. J Diabetes Metab Disord 2024; 23:1017-1038. [PMID: 38932904 PMCID: PMC11196439 DOI: 10.1007/s40200-023-01381-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/21/2023] [Indexed: 06/28/2024]
Abstract
Objective Mild-moderate cognitive impairment has been identified in general diabetes, and early evidence indicates cognitive reductions may be more pronounced in those with diabetes-related foot complications (DRFC). Cognitive difficulties may impede treatment engagement and self-management. This requires further explication to optimise patient care and outcomes. The current study aimed to characterise cognitive function in people with DRFC using comprehensive cognitive measures. Method This cross-sectional cohort study recruited 80 adult participants (M age = 63.38, SD = 11.40, range = 30 - 89) from the Royal Melbourne Hospital Diabetic Foot Unit in Victoria, Australia, all with DRFC. Each completed a comprehensive cognitive battery (memory, attention, executive functions) and scores were calculated using age-matched population norms, where available. Results On the majority of tasks, DRFC participants performed significantly worse than age-matched norms, with the largest decrements seen in inhibition control, verbal memory, verbal abstract reasoning and working memory. Small to moderate reductions were also seen in visual learning, verbal fluency, processing speed and premorbid functioning. Demographic (lower education, male gender) and clinical factors (higher HbA1c, macrovascular and microvascular disease, longer diabetes duration) were associated with poorer cognitive functioning. Conclusions Marked reductions in cognitive functioning were found in individuals with DRFC, predominantly in the domains of verbal memory and executive functioning. Lower education, male gender and indicators of diabetes severity, such as vascular disease, are associated with heightened risk for poorer cognitive functioning. As DRFCs are a serious complication with devastating outcomes if not successfully managed, cognitive barriers to self-management must be addressed to optimise treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-023-01381-4.
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Affiliation(s)
- Mai Loan Nguyen
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086 Australia
| | - Dana Wong
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086 Australia
| | - Elizabeth Barson
- Psychosocial Oncology Program, Peter MacCallum Cancer Centre, Grattan Street, Parkville Victoria, 3052 Australia
| | - Eva Staunton
- Allied Health – Podiatry, The Royal Melbourne Hospital, Grattan Street, Parkville Victoria, 3052 Australia
| | - Caroline A. Fisher
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086 Australia
- Allied Health – Psychology, 4 North, The Royal Melbourne Hospital, 300 Grattan Street, Parkville Victoria, 3052 Australia
- The Melbourne Clinic, 130 Church St, Richmond Victorian, 3121 Australia
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Swaminathan N, Awuah WA, Bharadwaj HR, Roy S, Ferreira T, Adebusoye FT, Ismail IFNB, Azeem S, Abdul-Rahman T, Papadakis M. Early intervention and care for Diabetic Foot Ulcers in Low and Middle Income Countries: Addressing challenges and exploring future strategies: A narrative review. Health Sci Rep 2024; 7:e2075. [PMID: 38690005 PMCID: PMC11058085 DOI: 10.1002/hsr2.2075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 12/13/2023] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Sakshi Roy
- School of Medicine Queen's University Belfast Belfast UK
| | - Tomas Ferreira
- School of Clinical Medicine University of Cambridge Cambridge UK
| | | | | | - Saleha Azeem
- Faculty of Medicine King Edward Medical University Lahore Pakistan
| | | | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, Heusnerstrasse 40 University of Witten-Herdecke Wuppertal Germany
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Classification of foot ulcers in people with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3645. [PMID: 37132179 DOI: 10.1002/dmrr.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Che D, Jiang Z, Xiang X, Zhao L, Liu X, Zhou B, Xie J, Li H, Lv Y, Cao D. Predictors of amputation in patients with diabetic foot ulcers: a multi-centre retrospective cohort study. Endocrine 2024:10.1007/s12020-024-03704-8. [PMID: 38332209 DOI: 10.1007/s12020-024-03704-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/15/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE Investigating risk factors for amputation in patients with diabetic foot ulcer (DFU) and developing a nomogram prediction model. METHODS We gathered case data of DFU patients from five medical institutions in Anhui Province, China. Following eligibility criteria, a retrospective case-control study was performed on data from 526 patients. RESULTS Among the 526 patients (mean age: 63.32 ± 12.14), 179 were female, and 347 were male; 264 underwent amputation. Univariate analysis identified several predictors for amputation, including Blood type-B, Ambulation, history of amputation (Hx. Of amputation), Bacterial culture-positive, Wagner grade, peripheral arterial disease (PAD), and laboratory parameters (HbA1c, Hb, CRP, ALB, FIB, PLT, Protein). In the multivariate regression, six variables emerged as independent predictors: Blood type-B (OR = 2.332, 95%CI [1.488-3.657], p < 0.001), Hx. Of amputation (2.298 [1.348-3.917], p = 0.002), Bacterial culture-positive (2.490 [1.618-3.830], p <0.001), Wagner 3 (1.787 [1.049-3.046], p = 0.033), Wagner 4-5 (4.272 [2.444-7.468], p <0.001), PAD (1.554 [1.030-2.345], p = 0.036). We developed a nomogram prediction model utilizing the aforementioned independent risk factors. The model demonstrated a favorable predictive ability for amputation risk, as evidenced by its area under the receiver operating characteristics (ROC) curve of 0.756 and the well-fitted corrected nomogram calibration curve. CONCLUSION Our findings underscore Blood type-B, Hx. Of amputation, Bacterial culture-positive, Wagner 3-5, and PAD as independent risk factors for amputation in DFU patients. The resultant nomogram exhibits substantial accuracy in predicting amputation occurrence. Timely identification of these risk factors can reduce DFU-related amputation rates.
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Affiliation(s)
- Dehui Che
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhengwan Jiang
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xinjian Xiang
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | | | - Xie Liu
- Taihe Hospital of Wannan Medical College, Shiyan, China
| | - Bingru Zhou
- The Affiliated Hospital of North Anhui College of Health Professions, Hefei, China
| | - Juan Xie
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Honghong Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yang Lv
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dongsheng Cao
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China.
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Eckert AJ, Zimny S, Altmeier M, Dugic A, Gillessen A, Bozkurt L, Götz G, Karges W, Wosch FJ, Kress S, Holl RW. Factors associated with diabetic foot ulcers and lower limb amputations in type 1 and type 2 diabetes supported by real-world data from the German/Austrian DPV registry. J Diabetes 2024; 16:e13531. [PMID: 38403299 PMCID: PMC10894714 DOI: 10.1111/1753-0407.13531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/09/2023] [Accepted: 12/27/2023] [Indexed: 02/27/2024] Open
Abstract
AIMS Diabetic foot ulcer (DFU) is a leading cause of lower limb amputations in people with diabetes. This study was aimed to retrospectively analyze factors affecting DFU using real-world data from a large, prospective central-European diabetes registry (DPV [Diabetes-Patienten-Verlaufsdokumentation]). MATERIALS AND METHODS We matched adults with type 1 (T1D) or type 2 diabetes (T2D) and DFU to controls without DFU by diabetes type, age, sex, diabetes duration, and treatment year to compare possible risk factors. Cox regression was used to calculate hazard ratios for amputation among those with DFU. RESULTS In our cohort (N = 63 464), male sex, taller height, and diabetes complications such as neuropathy, peripheral artery disease, nephropathy, and retinopathy were associated with DFU (all p < .001). Glycated hemoglobin (HbA1c) was related to DFU only in T1D (mean with 95% confidence interval [CI]: 7.8 [6.9-9.0] % vs 7.5 [6.8-8.5] %, p < .001). High triglycerides and worse low-density lipoprotein/high-density lipoprotein ratio were also associated with DFU in T1D, whereas smoking (14.7% vs 13.1%) and alcohol abuse (6.4% vs 3.8%, both p < .001) were associated with DFU in T2D. Male sex, higher Wagner grades, and high HbA1c in both diabetes types and insulin use in T2D were associated with increased hazard ratios for amputations. CONCLUSIONS Sex, body height, and diabetes complications were associated DFU risk in adults with T1D and T2D. Improvement in glycemic control and lipid levels in T1D and reduction of smoking and drinking in T2D may be appropriate interventions to reduce the risk for DFU or amputations.
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Affiliation(s)
- Alexander J Eckert
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
| | - Stefan Zimny
- Department of General Internal Medicine, Endocrinology and Diabetology, Helios Clinic Schwerin, Schwerin, Germany
| | - Marcus Altmeier
- Klinik für Diabetologie, Klinikum Dortmund, Dortmund, Deutschland
| | - Ana Dugic
- Medical Clinic I, Klinikum Bayreuth Friedrich-Alexander-University Erlangen-Nürnberg, Bayreuth, Germany
| | - Anton Gillessen
- Department of Internal Medicine, Herz-Jesu-Hospital, Muenster, Germany
| | - Latife Bozkurt
- Department of Internal Medicine III and Karl Landsteiner Institute for Metabolic Disorders and Nephrology, Clinic Hietzing, Vienna Health Care Group, Vienna, Austria
| | - Gabriele Götz
- Department of Internal Medicine, Diabetes, Gastroenterology, Tumor Medicine, and Palliative Care, Academic Teaching Hospital Nürtingen, Tübingen, Germany
| | - Wolfram Karges
- Clinic for Gastroenterology, Metabolic Disorders and Internal Intensive Medicine (Medical Clinic III), Department of Endocrinology and Diabetology, University Hospital Aachen, Aachen, Germany
| | | | - Stephan Kress
- Diabetes, Sport and Physical Activity Working Group of the DDG, Unna, Germany
- Department of Internal Medicine I, Vinzentius Hospital Landau, Landau, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
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Chen YJ, Hsu CY, Lin CH. Chronic Leg Ulcer Associated with Cutaneous IgG4-Related Disease. INT J LOW EXTR WOUND 2023; 22:792-797. [PMID: 35068233 DOI: 10.1177/15347346221075873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Chronic leg ulcer occurs in up to 13% of the general population and leads to economic and health care burdens. Approximately 20% of chronic nonhealing wounds are related to autoimmune diseases or vasculitis. Of these, chronic wounds associated with IgG4-related disease, a group of fibroinflammatory disorders that can have cutaneous and systemic involvement, are rarely reported. This case report describes a chronic leg ulcer associated with cutaneous IgG4-related disease. In addition to disease control with anti-inflammatory agents, following the principles of wound management and providing adjuvant wound treatment (eg, debridement, dressing, photobiomodulation therapy, or hyperbaric oxygen therapy) can promote the wound healing process.
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Affiliation(s)
- Yi-Jye Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Yi Hsu
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chih-Hsun Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Akyüz S, Mutlu ABB, Erhan Güven H, Murat Başak A, Yılmaz KB. Elevated HbA1c level associated with disease severity and surgical extension in diabetic foot patients. ULUS TRAVMA ACIL CER 2023; 29:1013-1018. [PMID: 37681727 PMCID: PMC10560815 DOI: 10.14744/tjtes.2023.08939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/22/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Diabetic foot is a complex syndrome that is associated with other diabetic complications, such as peripheral arte-rial disease and peripheral neuropathy. Optimization of plasma glucose and glycated hemoglobin (HbA1c) is one of the main principles of standard care and treatment approaches in individuals with diabetes mellitus (DM). In this study, the relationship of HbA1c level at the time of diagnosis was evaluated with diabetic foot disease severity score and surgical extension in patients with Type 2 DM. METHODS This study included 301 consecutive patients who were diagnosed with diabetic foot in the general surgery diabetic foot clinic and were hospitalized for surgery. The relationships between the HbA1c levels of the patients with the Wagner and PEDIS (Perfusion, Extent, Dept, Infection, Sensation) classification system grades, and the surgical procedures performed were analyzed and the treatment outcomes were evaluated. RESULTS It was determined that there was a 90% statistically significant relationship between HbA1c values of ≥10.1% and the de-velopment of Wagner Grade 4 diabetic foot ulcer (DFU) (P=0.037). A strong statistically significant relationship at the rate of 85% was determined between HbA1c values of ≥10.1% and the development of PEDIS Grade 3 ulcers. As the HbA1c values increased, so there was determined to be a statistically significant relationship with the development of PEDIS Grade 3 ulcer (P=0.003). In the comparison of the HbA1c values according to the type of surgery performed, a weak relationship was determined at the rate of 26%, and it was determined that as the HbA1c values increased, so there could be an increase in the amputation level. CONCLUSION The results of this study showed that as HbA1c values at diagnosis increased in patients with diabetic foot; Wagner/PEDIS grades, disease severity, surgical extension, amputation level, and tissue loss increased. To reduce the severity of diabetic foot disease and prevent amputation, compliance with diabetic treatment and glycemic control should be increased.
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Affiliation(s)
- Simay Akyüz
- Department of General Surgery Diabetic Foot, University of Health Sciences, Gulhane Research and Training Hospital, Ankara-Türkiye
| | - Adile Begüm Bahçecioğlu Mutlu
- Department of Endocrinology and Metabolism, University of Health Sciences, Gulhane Research and Training Hospital, Ankara-Türkiye
| | - Hikmet Erhan Güven
- Department of General Surgery Diabetic Foot, University of Health Sciences, Gulhane Research and Training Hospital, Ankara-Türkiye
| | - Ali Murat Başak
- Department of Orthopedics and Traumatology, University of Health Sciences, Gulhane Research And Training Hospital, Ankara-Türkiye
| | - Kerim Bora Yılmaz
- Department of General Surgery Diabetic Foot, University of Health Sciences, Gulhane Research and Training Hospital, Ankara-Türkiye
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Anwander H, Vonwyl D, Hecht V, Tannast M, Kurze C, Krause F. Risk Factors for Failure After Surgery in Patients With Diabetic Foot Syndrome. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231182656. [PMID: 37435393 PMCID: PMC10331347 DOI: 10.1177/24730114231182656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background In the present study, we aimed to identify risk factors for failure (defined as reoperation within 60 days) after debridement or amputation at the lower extremity in patients with diabetic foot syndrome and to develop a model using the significant risk factors to predict the success rate at different levels of amputation. Methods Between September 2012 and November 2016, we performed a prospective observational cohort study of 174 surgeries in 105 patients with diabetic foot syndrome. In all patients, debridement or the level of amputation, need for reoperation, time to reoperation, and potential risk factors were assessed. A cox regression analysis, dependent on the level of amputation, with the endpoint reoperation within 60 days defined as failure and a predictive model for the significant risk factors were conducted. Results We identified the following 5 independent risk factors: More than 1 ulcer (hazard ratio [HR] 3.8), peripheral artery disease (PAD, HR 3.1), C-reactive protein >100 mg/L (HR 2.9), diabetic peripheral neuropathy (HR 2.9), and nonpalpable foot pulses (HR 2.7) are the 5 independent risk factors for failure, which were identified. Patients with no or 1 risk factor have a high success rate independent of the level of amputation. A patient with up to 2 risk factors undergoing debridement will achieve a success rate of <60%. However, a patient with 3 risk factors undergoing debridement will need further surgery in >80%. In patients with 4 risk factors a transmetatarsal amputation and in patients with 5 risk factors a lower leg amputation is needed for a success rate >50%. Conclusion Reoperation for diabetic foot syndrome occurs in 1 of 4 patients. Risk factors include presence of more than 1 ulcer, PAD, CRP > 100, peripheral neuropathy, and nonpalpable foot pulses. The more risk factors are present, the lower the success rate at a certain level of amputation. Level of Evidence Level II, prospective observational cohort study.
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Affiliation(s)
- Helen Anwander
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Vonwyl
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verena Hecht
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Christophe Kurze
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Krause
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Waldman OV, Dexter BJ, Sulovari A, Oh IC. Clinical presentation of group B Streptococcus-infected diabetic foot ulcers. J Wound Care 2023; 32:S19-S25. [PMID: 37405964 DOI: 10.12968/jowc.2023.32.sup7.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Group B Streptococcus (GBS) is a common pathogen in diabetic foot ulcers (DFUs), where it has been found to result in higher rates of soft tissue infection and amputation despite appropriate treatment. In this study, we aim to investigate clinical characteristics and prognosis of GBS DFU infections, especially those with tenosynovial involvement. We hypothesise that GBS-infected DFUs with tenosynovial involvement leads to an increased number of recurrent infections and unexpected returns to the operating room. METHOD Data were retrospectively collected from GBS-infected DFU patients surgically treated by an orthopaedic foot and ankle surgeon over a four-year period. Demographics, comorbidities, initial laboratory values and culture results from infected bone samples were recorded. Clinical outcome was assessed by recurrent infection and unplanned reoperation(s) within 3 months following the initial surgery. RESULTS In total, 72 patients were treated for GBS-infected DFUs. Intra-operative culture of infected bone identified GBS in 16 patients (22.2%). Significantly more black patients (p=0.017) were afflicted by GBS DFUs. Patients with GBS DFUs had higher initial haemoglobin A1C levels (p=0.019), and those with tenosynovial involvement were likely to require reoperation (p=0.036) and had a greater total number of surgeries (p=0.015) than those without. CONCLUSION GBS-infected DFUs are more common in black patients and those with elevated haemoglobin A1Cs. GBS infections with tenosynovial involvement are particularly destructive and require aggressive treatment by surgeons.
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Affiliation(s)
- Olivia V Waldman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, US
| | - Brandon J Dexter
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
| | - Aron Sulovari
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
| | - Irvin C Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, US
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11
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Tuglo LS. Prevalence and determinants of lower extremity amputations among type I and type II diabetic patients: A multicenter-based study. Int Wound J 2023; 20:903-909. [PMID: 36054437 PMCID: PMC10031208 DOI: 10.1111/iwj.13935] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Lawrence Sena Tuglo
- Department of Nutrition and Dietetics, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
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12
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Gong H, Ren Y, Li Z, Zha P, Bista R, Li Y, Chen D, Gao Y, Chen L, Ran X, Wang C. Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers. Front Endocrinol (Lausanne) 2023; 14:1144806. [PMID: 37065766 PMCID: PMC10102466 DOI: 10.3389/fendo.2023.1144806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
OBJECTIVES To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University. METHODS A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA. RESULTS 992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs. CONCLUSIONS The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.
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Affiliation(s)
- Hongping Gong
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- International Medical Center Ward, Department of General Practice, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Ren
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhenyi Li
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Panpan Zha
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Raju Bista
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Li
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dawei Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yun Gao
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lihong Chen
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xingwu Ran
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chun Wang
- Department of Endocrinology and Metabolism, Diabetic Foot Care Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- *Correspondence: Chun Wang, ,
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13
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Winkler E, Schöni M, Krähenbühl N, Uçkay I, Waibel FWA. Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes. Foot Ankle Int 2022; 43:957-967. [PMID: 35582923 PMCID: PMC9260474 DOI: 10.1177/10711007221088552] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited. METHODS In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed. RESULTS Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors. CONCLUSION In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Elin Winkler
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland,Elin Winkler, MD, Department of
Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich, 8008,
Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and
Applied Research and Infectiology, Balgrist University Hospital, Zurich,
Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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14
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Mudrik-Zohar H, Carasso S, Gefen T, Zalmanovich A, Katzir M, Cohen Y, Paitan Y, Geva-Zatorsky N, Chowers M. Microbiome Characterization of Infected Diabetic Foot Ulcers in Association With Clinical Outcomes: Traditional Cultures Versus Molecular Sequencing Methods. Front Cell Infect Microbiol 2022; 12:836699. [PMID: 35402307 PMCID: PMC8987016 DOI: 10.3389/fcimb.2022.836699] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/01/2022] [Indexed: 12/19/2022] Open
Abstract
Background Infected diabetic foot ulcers (IDFU) are a major complication of diabetes mellitus. These potentially limb-threatening ulcers are challenging to treat due to impaired wound healing characterizing diabetic patients and the complex microbial environment of these ulcers. Aim To analyze the microbiome of IDFU in association with clinical outcomes. Methods Wound biopsies from IDFU were obtained from hospitalized patients and were analyzed using traditional microbiology cultures, 16S rRNA sequencing and metagenomic sequencing. Patients’ characteristics, culture-based results and sequencing data were analyzed in association with clinical outcomes. Results A total of 31 patients were enrolled. Gram-negative bacteria dominated the IDFU samples (79%, 59% and 54% of metagenomics, 16S rRNA and cultures results, respectively, p<0.001). 16S rRNA and metagenomic sequencing detected significantly more anaerobic bacteria, as compared to conventional cultures (59% and 76%, respectively vs. 26% in cultures, p=0.001). Culture-based results showed that Staphylococcus aureus was more prevalent among patients who were treated conservatively (p=0.048). In metagenomic analysis, the Bacteroides genus was more prevalent among patients who underwent amputation (p<0.001). Analysis of metagenomic-based functional data showed that antibiotic resistance genes and genes related to biofilm production and to bacterial virulent factors were more prevalent in IDFU that resulted in amputation (p<0.001). Conclusion Sequencing tools uncover the complex biodiversity of IDFU and emphasize the high prevalence of anaerobes and Gram-negative bacteria in these ulcers. Furthermore, sequencing results highlight possible associations among certain genera, species, and bacterial functional genes to clinical outcomes.
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Affiliation(s)
- Hadar Mudrik-Zohar
- Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- *Correspondence: Naama Geva-Zatorsky, ; Hadar Mudrik-Zohar,
| | - Shaqed Carasso
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
| | - Tal Gefen
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
| | - Anat Zalmanovich
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Michal Katzir
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Yael Cohen
- Department of Orthopedics B, Meir Medical Center, Kfar Saba, Israel
| | - Yossi Paitan
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Clinical Microbiology Laboratory, Meir Medical Center, Kfar Saba, Israel
| | - Naama Geva-Zatorsky
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
- Canadian Institute for Advanced Research (CIFAR), Toronto, ON, Canada
- *Correspondence: Naama Geva-Zatorsky, ; Hadar Mudrik-Zohar,
| | - Michal Chowers
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
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15
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Rai V, Moellmer R, Agrawal DK. The role of CXCL8 in chronic nonhealing diabetic foot ulcers and phenotypic changes in fibroblasts: a molecular perspective. Mol Biol Rep 2022; 49:1565-1572. [PMID: 35044539 DOI: 10.1007/s11033-022-07144-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION A persistent inflammation is perpetuated by infiltrating immune cells and cytokines secreted from these immune cells. Additionally, apoptotic keratinocytes and adipocytes in diabetes causes diabetic foot ulcer (DFU) to arrest in an inflammatory phase without progressing to the resolution phase. This leads to a nonhealing DFU and, despite advanced treatments consisting of wound debridement, off-loading the ulcer of necrotic tissue, wound dressings to keep it moist and control exudate, medication, and preventing infection, DFUs remain a clinical problem. Nonhealing DFUs pose not only an economic burden but also increased morbidity and mortality in the form of psychological stress with and increased chance of amputation, and even death. Thus, investigating the complicated underlying molecular mechanism responsible for nonhealing patterns and designing better therapeutics is warranted. This review article focuses on the role of IL-8-mediated persistent inflammation and phenotypic change of fibroblasts due to this inflammatory cascade. We have discussed various sources of interleukin (IL)-8 secretion and the possible association of IL8-fibroblast plasticity as a cause of nonhealing DFUs. MATERIAL AND METHODS A literature search on PubMed, Google Scholar, and PMC was done including the terms diabetic foot ulcer, diabetes, diabetic ulcer, chronic inflammation, interleukin 8, diabetic wound, and nonhealing diabetic foot ulcers. The articles in the English language and published in last 10 years were selected. From the pool of these, the articles describing the relationship between IL-8 and nonhealing diabetic foot ulcer and diabetic ulcer were used sorted out and used for this review article following PRISMA guidelines. CONCLUSION Increased infiltration of inflammatory immune cells, secretion of pro-inflammatory cytokines, altered keratinocyte-fibroblast function, and phenotypic changes of fibroblasts in DFUs seem to be critical to the nonhealing of DFUs. Thus, inhibiting IL-8 secretion and downstream signaling seems to be a goal of potential therapeutics.
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Affiliation(s)
- Vikrant Rai
- Department of Translational Research, Western University of Health Sciences, 309 E. Second Street, Pomona, CA, 91766-1854, USA.
| | - Rebecca Moellmer
- Western University College of Podiatric Medicine, Pomona, CA, 91766, USA
| | - Devendra K Agrawal
- Department of Translational Research, Western University of Health Sciences, 309 E. Second Street, Pomona, CA, 91766-1854, USA
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16
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Yin X, Zhu W, Liu C, Yao H, You J, Chen Y, Ying X, Li L. Association of continuous glucose monitoring-derived time in range with major amputation risk in diabetic foot osteomyelitis patients undergoing amputation. Ther Adv Endocrinol Metab 2022; 13:20420188221099337. [PMID: 35602463 PMCID: PMC9121454 DOI: 10.1177/20420188221099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 04/21/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The metrics generated from continuous glucose monitoring (CGM), such as time in range (TIR), are strongly correlated with diabetes complications. This study explored the association of perioperative CGM-derived metrics with major amputation risk in patients with diabetic foot osteomyelitis (DFO). METHODS This study recruited 55 DFO patients with grade 3-4 wounds according to the Wagner Diabetic Foot Ulcer Classification System, all of whom underwent CGM for 5 days during the perioperative period. The CGM-derived metrics were defined in accordance with the most recent international consensus recommendations. RESULTS Patients with major amputation had significantly less TIR and higher time below range (TBR) (all p < 0.05). In binary logistic regression analyses, a lower TIR was associated with the risk of major amputation (odds ratio: 0.83 (95% confidence interval: 0.71-0.99), p = 0.039). This association remained statistically significant after adjustments for age, sex, body mass index, type of diabetes, smoking, drinking, durations of diabetes and DFU, ankle-brachial index, albumin, estimated-glomerular filtration rate, Society for Vascular Surgery wound, ischemia, and foot infection (WIfi) stage, multidrug-resistant organisms, and hemoglobin A1c. Further adjustment for the mean amplitude of glycemic excursion (MAGE) reduced this association. TBR was also independently associated with the risk of major amputation (odds ratio: 1.60 (95% confidence interval: 1.17-2.18), p = 0.003); this association persisted after adjustment for MAGE. CONCLUSION Perioperative TIR (3.9-10.0 mmol/L) and TBR (<3.9 mmol/L) were significantly associated with major amputation in hospitalized patients with DFO.
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Affiliation(s)
| | | | - Chao Liu
- Department of Orthopedics, Zhejiang University
School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Huilan Yao
- Department of Nursing Education, Zhejiang
University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou,
China
| | - Jiaxing You
- Department of Orthopedics, Zhejiang University
School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Yixin Chen
- Department of Endocrinology, Zhejiang
University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou,
China
| | - Xiaofang Ying
- Department of Endocrinology, Jiangshan People’s
Hospital, Quzhou, China
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17
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Waibel FW, Schöni M, Kronberger L, Flury A, Berli MC, Lipsky BA, Uçkay I, Jud L. Treatment Failures in Diabetic Foot Osteomyelitis Associated with Concomitant Charcot Arthropathy: The Role of Underlying Arteriopathy. Int J Infect Dis 2021; 114:15-20. [PMID: 34715357 DOI: 10.1016/j.ijid.2021.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Therapy for diabetic foot osteomyelitis (DFO) with Charcot neuroosteoarthropathy is challenging. In patients with diabetic Charcot osteomyelitis (DCO), both the anatomic deformity and infection must be addressed. This study assessed the outcomes of DCO therapy and variables associated with treatment failure and compared them with outcomes of DFO cases. METHODS A single-center, retrospective, case-control study was performed to compare 93 DCO episodes with 530 DFO episodes, using Kaplan-Meier survival curves and multivariate Cox regression analyses. RESULTS Clinical failure occurred in 21.5% of DCO compared with 22.3% in DFO episodes (p=0.89) and was associated with peripheral arterial disease (PAD) stages 3 or 4 (HR 6.1; CI 2.0-18.1) and chronic treatment with immunosuppressives (HR 7.4; CI 2.0-27.1). Major amputations were significantly more frequent in DCO (28% versus 13.6%; p<0.01) and associated with PAD stages 3 and 4 (HR 8.0; CI 2.2-29.4), smoking (HR 5.4; CI 1.2-24.6), alcohol abuse (HR 3.5; CI 1.1-10.6), and renal dialysis (HR 4.9; CI 1.3-18.9). CONCLUSIONS Clinical treatment failures did not differ between DCO and DFO. However, patients with DCO underwent major amputation twice as often as those with DFO. Unlike widespread belief, treatment failure in DCO patients may, similar to DFO, be associated with a striking epidemiological link to severe PAD.
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Affiliation(s)
- Felix Wa Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Leo Kronberger
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Andreas Flury
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Martin C Berli
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | | | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Switzerland; Infectiology, Balgrist University Hospital, University of Zurich, Switzerland
| | - Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
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