Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cardiometabolic risk factors and electrocardiogram results in type 2 diabetes patients with or without non-infected foot ulcers: A comparative study

BACKGROUND: Numerous investigations have demonstrated that type-2 diabetes (T2D) causes electrocardiographic alterations, whether or not there are microvascular or macrovascular problems.

AIM: With respect to glycemic control and the accompanying cardio-metabolic risk factors, the goal of this study was to demonstrate the variations in electrocardiogram records between T2D patients with non-infected diabetic foot ulcers (DFUs) and those without ulcers.

METHODS: This study was performed in the Shar Teaching Hospital in the Sulaimani Governorate-Iraq from July 2018 to June 2019. 167 participants were grouped into Group I (T2D, n=72); Group II (T2D with non-infected diabetic foot ulcers, n=65) and Group III (healthy subjects, n= 30). Blood pressure, electrocardiography, and anthropometric measurements were taken. Fasting serum glucose and lipid profiles were assessed as part of laboratory tests.

RESULTS: Group II patients significantly differed from Group I by having lower diastolic blood pressure, a higher pulse pressure index, and a higher fasting serum glucose. The Group I patients had a significantly higher heart rate, a shortening of TQ-interval and widening of QRS dispersion. Group II patients had a significantly shorter TQ-interval compared with the corresponding value of Group I patients (523.6±136.4ms versus 579.2±110.0ms, respectively). These changes in the electrocardiograms are not related to the cardiometabolic risk factors.

CONCLUSION: In the non-infected diabetic foot, the TQ-interval, a measure of ventricular repolarization impairment, is much shorter and is linked to a broad pulse pressure. According to this finding, the electrocardiographic abnormalities are a result of cardiovascular autonomic dysfunction.

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.

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.

Risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis and diabetic nephropathy: A 3-year follow-up study

This study aimed to explore the risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis (DFO) and diabetic nephropathy (DN). This is a prospective cohort study. Between May 2018 and May 2021, we selected 120 inpatients with comorbid severe diabetic foot infection (PEDIS Grade 3 or above) and DN for inclusion in our study. All cases were followed up for 36 months. The study outcomes were whether foot ulcer recurred and the time to recurrence. The risk factors of ulcer recurrence were analysed by comparing the data of the three groups. According to the recurrence of foot ulcer, the participants were divided into three groups: Group A (no foot ulcer recurrence, n = 89), Group B (foot ulcer recurrence within 12-36 months, n = 19) and Group C (foot ulcer recurrence within 6-12 months, n = 12). The multivariate Cox regression analysis showed that urine albumin-creatinine ratio (UACR) (HR: 1.008, 95% CI: 1.005-1.011, P < .001) and vibration perception threshold (VPT) (HR: 1.064, 95% CI: 1.032-1.096, P < .001) were identified as independent risk factors. Kaplan-Meier curves showed a significant positive association between UACR or VPT and the risk of foot ulcer recurrence (log rank, all P < .05). Areas under the ROC curves for UACR, VPT and the combination of UACR and VPT were 0.802, 0.799 and 0.842, respectively. The best cut-off values of UACR and VPT were 281.51 mg/g and 25.12 V, respectively. In summary, elevated UACR and VPT were independent risk factors. The best clinical cut-off values of UACR and VPT for prediction of foot ulcer recurrence were 281.51 mg/g and 25.12 V, respectively. Besides, our results suggested that microcirculation disorders rather than macrovascular complications play a major role in the recurrence of foot ulcer in patients with comorbid DFO and DN.

Predictors of healing, ulcer recurrence and persistence, amputation and mortality in type 2 diabetic patients with diabetic foot: a 10-year retrospective cohort study

PURPOSE

Predictors of outcome of diabetic foot ulcer (DFU) are important to improve the management of patients. Aim of the study was to find these predictors in type 2 diabetic patients with DFU.

METHODS

We recruited 583 patients. They were followed-up by a multidisciplinary team. A holistic and conservative approach was used and all risk factors and co-morbidities were aggressively treated.

RESULTS

During the follow-up period, 79.6% of patients healed in a mean time of 7.6 ± 3.8 months, 6.9% showed DFU persistence, 9.9% had minor amputations, and 3.6% experienced major amputation. Seventeen percent of the patients died. Among patients who healed, 37.1% of them showed DFU recurrence. Impairment of renal function was associated to DFU persistence, amputation, and mortality. Previous cardiovascular disease predicted DFU persistence, DFU recurrence, and mortality. Lower BMI predicted DFU persistence and mortality. Osteomyelitis was a predictor of amputation and death. Markers of peripheral artery disease (PAD) predicted minor amputation and DFU recurrence. Our study shows a relatively low incidence of complications of DFU.

CONCLUSIONS

Some predictors of outcome of DFU were confirmed and new predictors, like BMI and markers of PAD, were found. Our new findings suggest future strategies for nutrition support and revascularization. In addition, a holistic and conservative approach may improve the prognosis.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Predict Mortality in Patients with Diabetic Foot Ulcers Undergoing Amputations

PURPOSE

Elevated platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are associated with poor outcomes in various diseases. The objectives of this study were to explore the utility of PLR and NLR in predicting all-cause mortality in patients with diabetic foot ulcers (DFU) undergoing amputations.

PATIENTS AND METHODS

A retrospective observational study was performed that included a total of 348 DFU patients undergoing amputations. The primary end-point was all-cause death. According to the PLR and NLR cut-off values, patients were divided into two groups and Kaplan-Meier survival curves were constructed. Multivariable Cox regression was conducted to test the independent predictors of mortality in the study cohort.

RESULTS

All-cause mortality was significantly higher in patients with a high PLR/NLR compared to those with a low PLR/NLR. In the low NLR group, the overall survival (OS) rates at 1, 3, and 5 years after amputation were 96.8%, 84% and 80.1%, respectively (p=0.001). In the high NLR group the corresponding OS rates at 1, 3, and 5 years were 85.2%, 58.6% and 23.9% (p<0.001). According to the multivariate analysis, age (HR 1.074, 95% CI 1.045-1.104, p<0.001), Wagner classification (HR 2.274, 95% CI 1.351-3.828, p=0.002), PLR (HR 1.794, 95% CI 1.014-3.174, p=0.045), NLR (HR 2.029, 95% CI 1.177-3.499, p=0.011), creatinine (HR 1.003, 95% CI 1.001-1.004, p<0.001) and direct bilirubin (HR 1.154, 95% CI 1.081-1.232, p<0.001) were independent predictors of mortality following amputation.

CONCLUSION

Postoperative PLR and NLR values may be reliable predictive biomarkers of mortality in patients following amputation for DFU. Considering the high mortality in those patients, the patients with elevated PLR/NLR should be given more intensive in clinical practice.

Joint Initiative Between Infectious Diseases and Podiatry in Outpatient Settings Improves Outcomes and Adherence to Treatment

BACKGROUND

A joint infectious disease-podiatry clinic (JIDPC) in which an infectious diseases physician and a podiatrist see patients with diabetic foot infections together once a week was initiated in January 2017. This study was designed to investigate if the JIDPC can improve patient adherence and reduce recurrent infections.

METHODS

A retrospective analysis of patients with diabetic foot infection admitted to Wheeling Hospital from March 2013 to December 2018 was performed. Initially, the patients were followed by infectious diseases and podiatry in their clinics separately (preintervention group). Beginning January 2017, they were followed together at the JIDPC (postintervention group). Recurrent infection, mortality, and loss to follow-up were compared using logistic regression models.

RESULTS

Surgeries were performed in 52.5% of preintervention group participants (n = 99) and 81.9% of postintervention group participants (n = 55; P < .001). The preintervention group was more likely to be lost to follow-up (30.3% vs 9.1%; odds ratio [OR], 4.35 [confidence interval (CI), 1.58-11.99]), but the association was attenuated with further adjustment for surgery (OR 3.35 [CI, 1.17-9.62]). The risk of infection recurrence in 6 months was significantly higher in the preintervention group (36.1% vs 20.8%; OR, 2.16 [CI, 0.99-4.71]), but with further adjustment for surgery, this was not significant (P = .067; OR, 2.17 [CI, 0.95-4.94]). Mortality and 90-day readmission were not significantly different.

CONCLUSIONS

Implementation of JIDPCs may decrease the incidence of recurrent infections among patients with diabetic foot infections.

Amputation rate of diabetic foot ulcer and associated factors in diabetes mellitus patients admitted to Nekemte referral hospital, western Ethiopia: prospective observational study

BACKGROUND

Diabetes foot ulcer is a devastating and much-feared complication of diabetes. Diabetes foot ulcerations which developed gangrene can take weeks or months to heal and can sometimes not heal at all so that amputation for non-traumatic causes is a frequent outcome in the diabetic foot. Despite this, there is no finding on predictors of the amputation rate of diabetes foot ulcers in Ethiopia. Hence this study was aimed to identify factors associated with the amputation rate of diabetes foot ulcer patients in Nekemte referral hospital.

PATIENTS AND METHODS

A prospective observational study was conducted among adult diabetes foot ulcer patients admitted to Nekemte referral hospital from March 15 to June 15, 2018. A pus swab was obtained from the ulcers before any ulcer cleaning to conduct gram staining. The primary outcome was the amputation rate. Cox regression analysis was used to estimate the hazard ratios and time from study entry to healing was evaluated as censored event times by Kaplan-Meier curves.

RESULT

Over the study period, 115 diabetes foot ulcer patients were admitted to the NRH; of these patients, 64(55.65%) were males while the mean age of participants was 44.4 ± 14.7. A total of 34(29.57%) of the diabetes foot ulcer were overweight and 16(13.91%) were obese while the mean ± standard deviation of body mass index (BMI) was 24.94 ± 3.69 kg/m2 and a total of 56(48.69%) diabetic foot ulcer had a diabetic complication. Of patients with diabetic foot ulcer, 35(30.43%) were undergone lower extremity amputations (LEA). Patients who were prescribed with inappropriate antibiotics were unlikely to heal. A total of 18(46.15%) of the patients who were taken inappropriate antibiotics were healed whereas 21(53.85%) were not healed (P = 0.017). Besides, the higher the Wagner grade, the worse the outcome of healing. A total of 19(21.84%) and 16(57.14%) of patients with grade < 4 and grade ≥ 4, respectively, did not heal (P = 0.005).

CONCLUSION

The amputation rate of diabetes foot ulcers was rapid for patients prescribed inappropriate antibiotics and higher grades of the foot ulcer. Therefore, the presence of clinical pharmacists plays a pivotal role to promote the appropriate use of antibiotics and besides the daily care, special attention should be given for patients having an advanced grade of diabetes foot ulcer.

Auto-Administered Photobiomodulation on Diabetic Leg Ulcers Treatment: A New Way to Manage It?

Background

Peripheral arterial disease is a dramatic consequence of an uncontrolled diabetic condition causing an increase of morbidity and mortality and its treatment is currently medical or surgical, finally requiring, in the 7–20% of cases, major or minor amputation. Photobiomodulation therapy (PBM) is a laser treatment used in medicine, thanks to its ability to stimulate the wound healing, the acceleration of inflammatory process, and the modulation of pain. Recently, the self-administration of the treatment has been suggested for different purposes in medicine and dentistry with a great number of advantages and no side effects.

Methods

A 84-year-old woman affected by diabetes type 2 and positive for diabetes complications had diagnosis for an ulcerative lesion of 1 cm diameter on her right leg and started a treatment of the lesion applying the B-Cure Laser Pro (Erika Carmel, Haifa, Israel) on her own with a fluence per minute of 3.2 J/cm² for 2 sessions of 15 minutes by cutaneous application.

Results

After a week of treatment, the ulcer dried and crusted, finally providing complete healing after 30 days of treatment.

Conclusion

With this short case report, we think to add a further contribution by suggesting this kind of treatment for successful management of the leg ulcers in diabetic patients.

Pilot Experience on the Use of S54P4 Bioactive Glass in the Surgical Management of Diabetic Foot Osteomyelitis

To test safety and efficacy of bioactive glass, a novel material used to replace bone, able to completely bond itself to the host tissues on patients treated for osteomyelitis (OM) complicating a diabetic foot (DF). We evaluated a group of patients consecutively admitted in our department between September and December 2018, who underwent surgical DF procedures for OM and in whom the use of bioactive glass could limit the demolition phase of surgical procedure. Patients were treated with bioactive glass S53P4 on top of standard treatment directly in operating room. The patients were weekly controlled for 6 months or until complete healing. During follow-up, we analyzed primarily healing rate and secondarily time of healing, need for further debridement procedures, recurrences, and adverse or hypersensitivity reactions to study treatment. Ten DF patients were enrolled (male/female 6/4; mean age 56 ± 11 years; mean duration of diabetes 10.5 ± 4.7 years, mean hemoglobin A1c 7.2 ± 0.9%). Patients underwent surgical procedure during which, after an accurate debridement, bioactive glass was applied. A healing rate of 80% in a mean time of 34 ± 2 days, with only 1 patient who needed a second surgical look, was observed. Neither recurrences nor adverse events during follow-up were observed in treated patients. This pilot experience demonstrated that bioactive glass can be considered a useful tool for the surgical treatment of DF-related OM.