Lower-extremity amputation in people with diabetes. Epidemiology and prevention

Diabetic foot ulcers, their characteristics, and trends in survival: Real world outcomes at a tertiary care facility in India

AIMS

Characteristics of diabetes-related foot ulcers (DFU), association with recurrence and amputation are poorly described in the Asian Indian population.

METHODS

A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence.

RESULTS

Of 200 patients, 63.5 % were male, the median age was 62 years (Min-Max:40-86), and median BMI was 27.90 kg/m2 (Min-Max:18.5-42.7). Median duration of Diabetes mellitus was 15 years (Min-Max:2-43). Complete healing occurred at a median of three months (Min-Max:0.23-37.62). Amputation for the current ulcer was required in 43.4 % of individuals. Ulcer recurrence was documented in 42.4 % instances, 66.1 % evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation (Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5 %,2.5 %,8.2 % and 30.9 % respectively among those who underwent amputation versus 0 %,0 %,10.1 % and 24.5 % respectively for those who achieved healing.

CONCLUSIONS

Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30 %. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.

Trends of Concomitant Diabetes and Peripheral Artery Disease and Lower Extremity Amputation in US Medicare Patients, 2007 to 2019

BACKGROUND

Previous studies demonstrate geographic and racial/ethnic variation in diagnosis and complications of diabetes and peripheral artery disease (PAD). However, recent trends for patients diagnosed with both PAD and diabetes are lacking. We assessed the period prevalence of concurrent diabetes and PAD across the United States from 2007 to 2019 and regional and racial/ethnic variation in amputations among Medicare patients.

METHODS

Using Medicare claims from 2007 to 2019, we identified patients with both diabetes and PAD. We calculated period prevalence of concomitant diabetes and PAD and incident cases of diabetes and PAD for every year. Patients were followed to identify amputations, and results were stratified by race/ethnicity and hospital referral region.

RESULTS

9 410 785 patients with diabetes and PAD were identified (mean age, 72.8 [SD, 10.94] years; 58.6% women, 74.7% White, 13.2% Black, 7.3% Hispanic, 2.8% Asian/API, and 0.6% Native American). Period prevalence of diabetes and PAD was 23 per 1000 beneficiaries. We observed a 33% relative decrease in annual new diagnoses throughout the study. All racial/ethnic groups experienced a similar decline in new diagnoses. Black and Hispanic patients had on average a 50% greater rate of disease compared with White patients. One- and 5-year amputation rates remained stable at ≈1.5% and 3%, respectively. Native American, Black, and Hispanic patients were at greater risk of amputation compared with White patients at 1- and 5-year time points (5-year rate ratio range, 1.22-3.17). Across US regions, we observed differential amputation rates, with an inverse relationship between the prevalence of concomitant diabetes and PAD and overall amputation rates.

CONCLUSIONS

Significant regional and racial/ethnic variation exists in the incidence of concomitant diabetes and PAD among Medicare patients. Black patients in areas with the lowest rates of PAD and diabetes are at disproportionally higher risk for amputation. Furthermore, areas with higher prevalence of PAD and diabetes have the lowest rates of amputation.

A Prospective Analysis of the SVS WIfI Classification System to Stratify Immediate and 1-Year Patient Outcomes

The purpose of this study was to prospectively enroll patients that presented to the emergency department with a lower extremity infection, stratify risk and record outcomes. Risk stratification was performed based on the Society of Vascular Surgery Wound, foot Infection, and Ischemia (WIfI) classification system. This study aimed to establish the efficacy and validity of this classification in predicting patient outcomes during immediate hospitalization and throughout a 1 year follow up. A total of 152 patients were enrolled in the study and of these, 116 met the inclusion criteria and had at least 1 year of follow up for analysis. Each patient was assigned a WIfI score based on wound, ischemia, and foot infection severity according to the classification guidelines. Patient demographics as well as all podiatric and vascular procedures were recorded. The major end points of the study were rates of proximal amputation, time to wound healing, surgical procedures, surgical dehiscence, readmission rates, and mortality. A difference in rates of healing (p = .04), surgical dehiscence (p < .01), and 1 year mortality (p = .01) with increasing WIfI stage as well as across the individual component scores was noted. This analysis further supports the application of the WIfI classification system early during patient care to stratify risk and identify the need for early intervention and a multispecialty team approach to potentially improve outcomes in the severe multicomorbid patient.

Social Deprivation, Healthcare Access and Diabetic Foot Ulcer: A Narrative Review

The diabetic foot ulcer (DFU) is a common and serious complication of diabetes. There is also a strong relationship between the environment of the person living with a DFU and the prognosis of the wound. Financial insecurity seems to have a major impact, but this effect can be moderated by social protection systems. Socioeconomic and socio-educational deprivations seem to have a more complex relationship with DFU risk and prognosis. The area of residence is a common scale of analysis for DFU as it highlights the effect of access to care. Yet it is important to understand other levels of analysis because some may lead to over-interpretation of the dynamics between social deprivation and DFU. Social deprivation and DFU are both complex and multifactorial notions. Thus, the strength and characteristics of the correlation between the risk and prognosis of DFU and social deprivation greatly depend not only on the way social deprivation is calculated, but also on the way questions about the social deprivation−DFU relationship are framed. This review examines this complex relationship between DFU and social deprivation at the individual level by considering the social context in which the person lives and his or her access to healthcare.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Use of glycated albumin for the identification of diabetes in subjects from northeast China

BACKGROUND

Metabolic memory is important for the diagnosis and treatment of diabetes in the early stage, and in maintaining blood glucose concentrations within the normal range. The clinical diagnosis of diabetes mellitus is currently made using fasting plasma glucose, 2 h-plasma glucose (2h-PG) during a 75 g oral glucose tolerance test, and hemoglobin A1c (HbA1c) level. However, the fasting plasma glucose test requires fasting, which is a barrier to screening, and reproducibility of the 2h-PG level is poor. HbA1c is affected by a shortened red blood cell lifespan. In patients with anemia and hemoglobinopathies, the measured HbA1c levels may be inaccurate. Compared with HbA1c, glycated albumin (GA) is characterized by more rapid and greater changes, and can be used to diagnose new-onset diabetes especially if urgent early treatment is required, for example in gestational diabetes. In this study, we provided cutoff values for GA and evaluated its utility as a screening and diagnostic tool for diabetes in a large high-risk group study.

AIM

To evaluate the utility of GA in identifying subjects with diabetes in northeast China, and to assess the diagnostic accuracy of the proposed GA cutoff in the diagnosis of diabetes mellitus.

METHODS

This cross-sectional study included 1935 subjects, with suspected diabetes or in high-risk groups, from 2014 to 2015 in the Second Affiliated Hospital of Harbin Medical University (Harbin, China). The use of GA to identify diabetes was investigated using the area under the receiver operating characteristic curve (AUC). The GA cutoffs were derived from different 2h-PG values with hemoglobin A1c cutoffs used as a calibration curve.

RESULTS

The GA cutoff for the diagnosis of diabetes mellitus was 15.15% from the receiver operating characteristic (ROC) curve. ROC analysis demonstrated that GA was an efficient marker for detecting diabetes, with an AUC of 90.3%.

CONCLUSION

Our study supports the use of GA as a biomarker for the diagnosis of diabetes.

Gangrene, revascularization, and limb function improved with E-selectin/adeno-associated virus gene therapy

OBJECTIVE

Novel therapeutic angiogenic concepts for critical limb ischemia are still needed for limb salvage. E-selectin, a cell-adhesion molecule, is vital for recruitment of the stem/progenitor cells necessary for neovascularization in ischemic tissues. We hypothesized that priming ischemic limb tissue with E-selectin/adeno-associated virus (AAV) gene therapy, in a murine hindlimb ischemia and gangrene model, would increase therapeutic angiogenesis and improve gangrene.

METHODS

FVB/NJ mice were given intramuscular hindlimb injections of either E-selectin/AAV or LacZ/AAV and then underwent induction of gangrene via femoral artery ligation and concomitant systemic injections of the nitric oxide synthesis inhibitor L-NAME (L-NG-Nitro arginine methyl ester; 40 mg/kg). Gangrene was evaluated via the Faber hindlimb appearance score. The rate of ischemic limb reperfusion and ischemic tissue angiogenesis were evaluated using laser Doppler perfusion imaging and DiI perfusion with confocal laser scanning microscopy of the ischemic footpads, respectively. The treadmill exhaustion test was performed on postoperative day (POD) 8 to determine hindlimb functionality.

RESULTS

The E-selectin/AAV-treated mice (n = 10) had decreased Faber ischemia scores compared with those of the LacZ/AAV-treated mice (n = 7) at both PODs 7 and 14 (P < .05 and P < .01, respectively), improved laser Doppler perfusion imaging reperfusion indexes by POD 14 (P < .01), and greater gangrene footpad capillary density (P < .001). E-selectin/AAV-treated mice also had improved exercise tolerance (P < .05) and lower relative muscular atrophy (P < .01).

CONCLUSION

We surmised that E-selectin/AAV gene therapy would significantly promote hindlimb angiogenesis, reperfusion, and limb functionality in mice with hindlimb ischemia and gangrene. Our findings highlight the reported novel gene therapy approach to critical limb ischemia as a potential therapeutic option for future clinical studies.

The Slipping Slipper Sign: A Poor Man's Test for Severe Diabetic Peripheral Neuropathy

BACKGROUND

Neuropathic feet are at very high risk for infection and amputation. The slipping slipper sign (SSS) is elicited by a simple questionnaire test reported to detect the presence of severe diabetic peripheral neuropathy. This test can be administered by non-medical staff. In this study, subjects with and without the SSS were evaluated by nerve conduction studies (NCS) and ultrasound measurements of the right sural nerve diameters as well as with traditional scoring systems for peripheral and autonomic neuropathy.

OBJECTIVE

To demonstrate that the Slipping Slipper Sign can be used as an index of severe diabetic peripheral neuropathyMethod:This was a prospective cross sectional study in which 74 patients with diabetes (38 positive and 36 negative for SSS) underwent ultrasonography and NCS of the right sural nerve by an examiner blinded to SSS status. Findings were evaluated against demography, clinical history, anthropometry as well as traditional clinical and autonomic neuropathic scores.

RESULTS

Patients without the SSS [median (IQR) = 10.0 years (4.0-20.3)] had a significantly shorter duration of diabetes compared with those with the SSS [median (IQR) = 15.0 years (8.5-25.0)], p = 0.028. The frequencies of retinopathy (36.8% vs 2.8%, p <  0.05) and cerebrovascular accidents (18.4% vs 13.9 %, p <  0.05) were higher among those with SSS compared with those without. Differences in nerve conduction characteristics were markedly significant. The amplitude of the sural sensory nerve action potential (SNAP) was ([median (IQR)] 0 microvolts vs 4.0 microvolts (0.0-10.8) p <  0.002) between those with and without SSS, respectively whilst none of patients with SSS had a recordable SNAP vs 78% without a SSS. Similarly, maximal thickness of the right sural nerve at the ankle 3.0 mm (2.3-3.4) vs 3.5 mm (3.0-3.9), and leg 3.4 mm (2.7-3.8) vs 3.9 mm (3.3-4.2) was reduced, p <  0.01 in patients with the SSS compared with those with a negative SSS.

CONCLUSION

The SSS identifies feet with objective neurophysiological and imaging characteristics of severe neuropathy.

Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease

Peripheral artery disease (PAD) stems from atherosclerosis of lower extremity arteries with resultant arterial narrowing or occlusion. The most severe form of PAD is termed chronic limb-threatening ischemia and carries a significant risk of limb loss and cardiovascular mortality. Diabetes mellitus is known to increase the incidence of PAD, accelerate disease progression, and increase disease severity. Patients with concomitant diabetes mellitus and PAD are at high risk for major complications, such as amputation. Despite a decrease in the overall number of amputations performed annually in the United States, amputation rates among those with both diabetes mellitus and PAD have remained stable or even increased in high-risk subgroups. Within this cohort, there is significant regional, racial/ethnic, and socioeconomic variation in amputation risk. Specifically, residents of rural areas, African-American and Native American patients, and those of low socioeconomic status carry the highest risk of amputation. The burden of amputation is severe, with 5-year mortality rates exceeding those of many malignancies. Furthermore, caring for patients with PAD and diabetes mellitus imposes a significant cost to the healthcare system-estimated to range from $84 billion to $380 billion annually. Efforts to improve the quality of care for those with PAD and diabetes mellitus must focus on the subgroups at high risk for amputation and the disparities they face in the receipt of both preventive and interventional cardiovascular care. Better understanding of these social, economic, and structural barriers will prove to be crucial for cardiovascular physicians striving to better care for patients facing this challenging combination of chronic diseases.

Management of Foot Problems in Diabetes

Many diabetic foot complications are preventable. This requires a team approach, aiming to identify the high-risk patient and provide appropriate education and foot care. An established ulcer needs careful management with the emphasis on pressure relief and establishing a good blood supply.

Prevalence of Diabetic Foot Ulcer and Associated Factors among Adult Diabetic Patients on Follow-Up Clinic at Jimma Medical Center, Southwest Ethiopia, 2019: An Institutional-Based Cross-Sectional Study

BACKGROUND

Diabetic foot ulceration is a devastating complication of diabetes mellitus and is a major source of morbidity and mortality. So far, there are few published data on diabetic foot ulcers and its determinants among diabetic patients on follow-up at Jimma Medical Center. Hence, the aim of this study was to assess the prevalence of diabetic foot ulcer and its determinants among patients with diabetes mellitus at Jimma Medical Center.

METHODS

A hospital-based cross-sectional study was conducted from June 1 to August 30, 2019, and systematic random sampling technique was applied. The total number of study subjects who participated in the study was 277. Data were collected using an interview-administered structured questionnaire. Data were entered into EpiData version 3.1 and exported to SPSS version 20 software for analysis. Analysis was done using descriptive statistics and logistic regression. A variable having a p value of <0.25 in the bivariate model was subjected to multivariate analysis to avoid confounding the variable's effect. Adjusted odds ratios (AOR) were calculated at 95% confidence interval and considered significant with a p value of <0.25 in the bivariate model was subjected to multivariate analysis to avoid confounding the variable's effect. Adjusted odds ratios (AOR) were calculated at 95% confidence interval and considered significant with a.

RESULT

The mean of age of participants was 50.1 ± 14.19 years. More than three-fourths of participants (82.7%) were type 2 DM. The mean duration of diabetic patients was 6.00 ± 5.07 years. The prevalence of diabetic foot ulcer was 11.6% among study participants. According to multivariate logistic regression analysis, previous history of ulceration (AOR = 5.77; 95% CI: 2.37, 14.0) and peripheral neuropathy (AOR = 11.2; 95% CI: 2.8, 44.4) were independent predictors of diabetic foot ulcer.

CONCLUSION

The prevalence of diabetic foot ulcer was 11.6%. Previous history of ulceration and peripheral neuropathy were associated with diabetic foot ulcer. The health care providers are recommended to thoroughly give emphasis during follow-up of patients who had previous history of ulceration and peripheral neuropathy in order to decrease the occurrence of diabetic foot ulcer.

Laser therapy for onychomycosis in patients with diabetes at risk for foot ulcers: a randomized, quadruple-blind, sham-controlled trial (LASER-1)

BACKGROUND

Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy.

METHODS

In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up.

RESULTS

From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe.

CONCLUSION

At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.

The role of reconstructive microsurgery in treating lower-extremity chronic wounds

Frequently considered chronic wounds for reconstruction are wounds lacking healing progress despite good wound care. And those needing microsurgical reconstruction are chronic wounds that are unable to close by local flap or skin grafts, wounds with exposed vital structure such as tendon and bones, and wounds that have prolonged infections such as osteomyelitis and skin necrosis. The reconstruction for soft tissue defects not only aims to provide coverage but to restore function and acceptable form as well. Wound preparation prior to microsurgical reconstruction consists of improving or restoring vascular supply, stabilising skeletal structures, and obtaining clinically clean wounds. Microsurgery is a surgical discipline that combines magnification with a advanced microscope, specialised precision tools, and various operating techniques. Thus microsurgery allows flap to be transferred far from the donor site restoring form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support. Microsurgery has expanded reconstructive surgery's elements and strategies and is still evolving. Along with the multidisciplinary approach and good principle of wound care, the repair and restoration strategies using microsurgery have widened the possibilities for limb salvage from complex chronic wounds.

Painful diabetic peripheral neuropathy: Health care costs and complications from 2010 to 2015

Objective

To quantify health care resource utilization and risk of complications in painful diabetic peripheral neuropathy (pDPN).

Methods

Adult patients diagnosed with diabetes mellitus or diabetic peripheral neuropathy (DPN) were identified in MarketScan from January 2010 to December 2015. Subgroups (pDPN and nonpainful DPN) were based on the use of pain medications 6 months before a new indexed diagnosis and 1 year thereafter. Health care costs were collected for up to 5 years, and complications charted for those with at least 1 and 2 years of follow-up. Complication comparisons were made using χ² or Fisher exact tests, and a multivariable regression cost model was fit with log link function using generalized estimating equations.

Results

Among 360,559 patients with diabetes (62 ± 14 years; 54.3% female), 84,069 (23.3%) developed pDPN, 17,267 (4.8%) experienced nonpainful DPN, and the majority (259,223, 71.9%) were controls with diabetes without neuropathy. At baseline, costs associated with pDPN patients were 20% higher than diabetic controls (95% confidence interval [CI] [1.19, 1.21], p < 0.001), which increased to 31% in the 5th year (95% CI [1.27, 1.34], p < 0.001). Patients with pDPN had 200%, 356%, and 224% of the odds of using opioids, anticonvulsants, and antidepressants, respectively, compared with diabetic controls. The amputation risk in the pDPN subgroup was 16.24 times that of diabetic controls (95% CI [2.15, 122.72], p = 0.0003), and 87% more patients with pDPN experienced lower extremity infections (95% CI [1.43, 2.46], p < 0.0001) within a year. Within 2 years, 2.2% of patients with pDPN had falls and fall-related injuries compared with 1.1% of diabetic controls (p < 0.0001).

Conclusions

Our study characterizes a substantial pDPN cohort in the United States, demonstrating considerable morbidity and economic costs.

FGF23 and Klotho Levels are Independently Associated with Diabetic Foot Syndrome in Type 2 Diabetes Mellitus

Background: Diabetic foot syndrome (DFS) is a prevalent complication in the diabetic population and a major cause of hospitalizations. Diverse clinical studies have related alterations in the system formed by fibroblast growth factor (FGF)-23 and Klotho (KL) with vascular damage. In this proof-of-concept study, we hypothesize that the levels of FGF23 and Klotho are altered in DFS patients. Methods: Twenty patients with limb amputation due to DFS, 37 diabetic patients without DFS, and 12 non-diabetic cadaveric organ donors were included in the study. Serum FGF23/Klotho and inflammatory markers were measured by enzyme-linked immunosorbent assay (ELISA). Protein and gene expression levels in the vascular samples were determined by immunohistochemistry and quantitative real-time PCR, respectively. Results: Serum Klotho is significantly reduced and FGF23 is significantly increased in patients with DFS (p < 0.01). Vascular immunoreactivity and gene expression levels for Klotho were decreased in patients with DFS (p < 0.01). Soluble Klotho was inversely related to serum C-reactive protein (r = −0.30, p < 0.05). Vascular immunoreactivities for Klotho and IL6 showed an inverse association (r = −0.29, p < 0.04). Similarly, vascular gene expression of KL and IL6 were inversely associated (r = −0.31, p < 0.05). Logistic regression analysis showed that higher Klotho serum concentrations and vascular gene expression levels were related to a lower risk of DFS, while higher serum FGF23 was associated with a higher risk for this complication. Conclusion: FGF23/Klotho system is associated with DFS, pointing to a new pathophysiological pathway involved in the development and progression of this complication.

Efficacy and Safety of Low-Frequency, Noncontact Airborne Ultrasound Therapy (Glybetac) For Neuropathic Diabetic Foot Ulcers: A Randomized, Double-Blind, Sham-Control Study

The diabetic foot ulcer (DFU) healing rates remain dismally low. Therefore, many adjunctive therapies have been evaluated including ultrasound therapy. The prior studies with noncontact, low-frequency ultrasound were retrospective, single arm, unblinded, or with historical controls. The aim of the present study was to compare the efficacy of noncontact, low-frequency airborne ultrasound (Glybetac) therapy with sham therapy added to standard treatment in patients with neuropathic, clinically infected, or noninfected DFU (wound size >2 cm²), Wagner grades 2 and 3. Patients received ultrasound or sham therapy for 28 days dosed daily for first 6 days followed by twice a week for next 3 weeks along with standard of care. The primary outcome was percentage of patients with at least >50% decrease in wound area at 4 week of intervention. Fifty-eight patients completed the study protocol. The duration of wound was 15.8 ± 11.2 weeks and 12.1 ± 10.9 weeks and wound area of 11.3 ± 8.2 cm² and 14.8 ± 13.8 cm² ( P = .507) in the ultrasound and sham groups, respectively. A >50% reduction in wound area was observed in 97.1% and 73.1% subjects ( P = .042) in ultrasound and sham groups, respectively. Wound contraction was faster in the first 2 weeks with ultrasound therapy, 5.3 cm², compared with 3.0 cm² ( P = .025) with sham treatment. Overall, wound area reduction of 69.4 ± 23.2% and 59.6 ± 24.9% ( P = .126) was observed at 4 weeks in the ultrasound and sham groups, respectively. We conclude that the airborne low-frequency ultrasound therapy improves and hastens the healing of chronic neuropathic DFU when combined with standard wound care.

Hospitalisation Cost of Patients with Diabetic Foot Ulcers in Valencia (Spain) in the Period 2009⁻2013: A Retrospective Descriptive Analysis

Ulcers are the main cause of hospitalisation and clinical complications in patients with diabetes. We analyse the length and cost of hospital stay of patients with diabetic foot ulcers, taking into consideration that hospitalisation and, if necessary, amputation represent the greatest area of expense to the healthcare system for such patients. This analysis focuses on the treatment provided to these patients in public hospitals in the region of Valencia (Spain), registered in the Spanish Minimum Basic Data Set, during the period 2009⁻2013. The number of acute hospital admissions in this respect is increasing and has a high socioeconomic cost. During the study period, there were over 2700 hospital admissions, an average of nearly 550 per year. The total hospital stay for these patients was 30,886 days, with an average of 11.4 days and a cost of €7633 per admission. Preventive policies and the deployment of multidisciplinary teams are essential to reduce these costs and avoid future complications such as amputation.

Risk of lower limb amputation in a national prevalent cohort of patients with diabetes

AIMS/HYPOTHESIS

Lower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand.

METHODS

A national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period.

RESULTS

A total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3 years of their procedure (57%).

CONCLUSIONS/INTERPRETATION

Using a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.

A long-term mechanistic computational model of physiological factors driving the onset of type 2 diabetes in an individual

A computational model of the physiological mechanisms driving an individual's health towards onset of type 2 diabetes (T2D) is described, calibrated and validated using data from the Diabetes Prevention Program (DPP). The objective of this model is to quantify the factors that can be used for prevention of T2D. The model is energy and mass balanced and continuously simulates trajectories of variables including body weight components, fasting plasma glucose, insulin, and glycosylated hemoglobin among others on the time-scale of years. Modeled mechanisms include dynamic representations of intracellular insulin resistance, pancreatic beta-cell insulin production, oxidation of macronutrients, ketogenesis, effects of inflammation and reactive oxygen species, and conversion between stored and activated metabolic species, with body-weight connected to mass and energy balance. The model was calibrated to 331 placebo and 315 lifestyle-intervention DPP subjects, and one year forecasts of all individuals were generated. Predicted population mean errors were less than or of the same magnitude as clinical measurement error; mean forecast errors for weight and HbA1c were ~5%, supporting predictive capabilities of the model. Validation of lifestyle-intervention prediction is demonstrated by synthetically imposing diet and physical activity changes on DPP placebo subjects. Using subject level parameters, comparisons were made between exogenous and endogenous characteristics of subjects who progressed toward T2D (HbA1c > 6.5) over the course of the DPP study to those who did not. The comparison revealed significant differences in diets and pancreatic sensitivity to hyperglycemia but not in propensity to develop insulin resistance. A computational experiment was performed to explore relative contributions of exogenous versus endogenous factors between these groups. Translational uses to applications in public health and personalized healthcare are discussed.

Optimizing Glycemic Control in Adults With Type 1 or Type 2 Diabetes Attending a Multidisciplinary Foot Clinic

OBJECTIVES

To determine the impact of a diabetes nurse educator (DNE) on glycemic control in a multidisciplinary diabetes foot (MDF) clinic.

METHODS

A prospective cohort trial to measure the impact of a DNE on glycemic control was conducted in an MDF clinic. Change in glycated hemoglobin (A1C) levels over time was measured against the percentage of patient visits (PPVs) accompanied by a glucose meter and/or diary.

RESULTS

Increasing PPVs were significantly associated with decline in A1C levels in females. Every 10% increase in PPVs resulted in a 0.18% decrease in A1C levels (p<0.0001). To achieve a clinically important decrease of 1% in A1C levels, a 56% increase in PPVs was required. Increased A1C levels were significantly associated with higher baseline A1C levels (p<0.001) and increased hospital days for foot complications (p<0.0052).

CONCLUSIONS

Regular, face-to-face contact with a DNE in an MDF clinic has a positive impact on glycemic control in females.

Prevalence, severity and factors associated with peripheral neuropathy among newly diagnosed diabetic patients attending Mulago hospital: a cross-sectional study

AIMS

To determine the prevalence and associated risk factors of diabetic peripheral neuropathy (DPN) among newly diagnosed diabetes mellitus patients in Mulago Hospital.

METHODS

A cross-sectional study was conducted among 248 newly diagnosed adult diabetic patients. Using the standard Neuropathy Symptom Score (NSS) and Neuropathy Disability Score (NDS) criteria, we screened them for neuropathy. Data on the socio-demographics, age, duration of symptoms and history of diabetic ulcer were analyzed using a multiple logistic regression. A p-value <0.05 was considered significant.

RESULTS

The majority of study patients (62.1%) were male. The overall prevalence of DPN was 29.4 %. Nearly sixteen percent had moderate neuropathy and only five percent had severe neuropathy. Age above 60 years was significantly associated with the presence of DPN; (OR 3.72; 95% CI 1.25 - 11.03; p=0.018). The history of ever having a foot ulcer was significantly associated with peripheral neuropathy (OR 2.59; 95% CI: 1.03 - 6.49, p = 0.042).

CONCLUSION

DPN occurs in 1 in 4 of newly diagnosed diabetic patients in Mulago hospital. Two thirds of these patients had moderate to severe neuropathy. DPN was independently associated with increasing age. Early diagnosis of diabetes mellitus, increased diabetes knowledge and regular blood sugar screenings would play an important role in identifying this problem.

Evaluation of glycated albumin (GA) and GA/HbA1c ratio for diagnosis of diabetes and glycemic control: A comprehensive review

Diabetes Mellitus (DM) is a group of metabolic diseases characterized by chronic high blood glucose concentrations (hyperglycemia). When it is left untreated or improperly managed, it can lead to acute complications including diabetic ketoacidosis and non-ketotic hyperosmolar coma. In addition, possible long-term complications include impotence, nerve damage, stroke, chronic kidney failure, cardiovascular disease, foot ulcers, and retinopathy. Historically, universal methods to measure glycemic control for the diagnosis of diabetes included fasting plasma glucose level (FPG), 2-h plasma glucose (2HP), and random plasma glucose. However, these measurements did not provide information about glycemic control over a long period of time. To address this problem, there has been a switch in the past decade to diagnosing diabetes and its severity through measurement of blood glycated proteins such as Hemoglobin A1c (HbA1c) and glycated albumin (GA). Diagnosis and evaluation of diabetes using glycated proteins has many advantages including high accuracy of glycemic control over a period of time. Currently, common laboratory methods used to measure glycated proteins are high-performance liquid chromatography (HPLC), immunoassay, and electrophoresis. HbA1c is one of the most important diagnostic factors for diabetes. However, some reports indicate that HbA1c is not a suitable marker to determine glycemic control in all diabetic patients. GA, which is not influenced by changes in the lifespan of erythrocytes, is thought to be a good alternative indicator of glycemic control in diabetic patients. Here, we review the literature that has investigated the suitability of HbA1c, GA and GA:HbA1c as indicators of long-term glycemic control and demonstrate the importance of selecting the appropriate glycated protein based on the patient's health status in order to provide useful and modern point-of-care monitoring and treatment.

Sex-gender-related therapeutic approaches for cardiovascular complications associated with diabetes

Diabetes is a chronic disease associated with micro- and macrovascular complications and is a well-established risk factor for cardiovascular disease. Cardiovascular complications associated with diabetes are among the most important causes of death in diabetic patients. Interestingly, several sex-gender differences have been reported to significantly impact in the pathophysiology of diabetes. In particular, sex-gender differences have been reported to affect diabetes epidemiology, risk factors, as well as cardiovascular complications associated with diabetes. This suggests that different therapeutic approaches are needed for managing diabetes-associated cardiovascular complications in men and women. In this review, we will discuss about the sex-gender differences that are known to impact on diabetes, mainly focusing on the cardiovascular complications associated with the disease. We will then discuss the therapeutic approaches for managing diabetes-associated cardiovascular complications and how differences in sex-gender can influence the existing therapeutic approaches.

Cross-sectional correlations between the toe brachial index and lower limb complications in older people

The aim of the study was to investigate the relationship between the toe brachial index (TBI) and foot ulceration and amputation in older people. Two hundred and sixty-one participants meeting guidelines for lower limb vascular assessment had their toe and brachial blood pressure measured, medical records audited and signs and symptoms of peripheral arterial disease (PAD) recorded. Pearson's correlation and linear regression analyses were performed to determine the strength of relationships between variables. Significant correlations were found between the TBI and painful symptoms (r = -0·35, P < 0·05) and foot complications (r = -0·31, P < 0·05). After adjusting for traditional risk factors for foot complications, participants with a TBI <0·70 were 19 times more likely to have a history of foot wounds or amputation (odds ratio = 19·20, 95% confidence interval (CI): 2·36-155·96, P < 0·001) than those with higher TBI values (>0·70). This preliminary study supports a TBI threshold of 0·70 for PAD diagnosis and indicates that lower values are associated with painful symptoms, history of ulceration and amputation. Future longitudinal investigation of the predictive capacity is now warranted.

Muscle dysfunction in type 2 diabetes: a major threat to patient's mobility and independence

Type 2 diabetes, a common metabolic disease in older people, is a major risk factor for functional limitation, impaired mobility, and loss of independence. In older people, the pathogenesis of functional limitation and disability is complex and multifactorial. A number of potential pathways are involved including cardiovascular disease, peripheral neuropathy, overweight, osteoarthritis, visual deficit, and cognitive impairment, conditions that are all more prevalent among patients with diabetes. Sarcopenia, a geriatric condition characterized by a progressive and generalized loss of skeletal muscle mass and strength, is also involved in the pathogenesis of functional limitations and disability. Recent research has shown that older patients with type 2 diabetes are often affected by skeletal muscle impairment, leading to reduced muscle strength and physical function. Insulin resistance, hyperglycemia, muscle fat infiltration, and peripheral neuropathies are hypothesized as the fundamental biological mechanisms leading to muscle impairment in people with diabetes. This review summarizes the current literature on the biological pathways responsible for skeletal muscle dysfunction in type 2 diabetes and analyzes the role of decline in muscle strength and quality on the association between diabetes and mobility disability.

The amputation prevention initiative

BACKGROUND

The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.

METHODS

To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).

RESULTS

The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.

CONCLUSIONS

These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.

Diabetic lower extremity complications, fear of falling and associated HbA1c levels: A cross-sectional study of the East Harlem population

The primary aim of this study was to determine if HbA1c is a positive predictor of the lower extremity complications commonly manifested in diabetes. A secondary objective was to investigate if the progression of diabetes-related complications had any affect on the fear of falling. This was a study of 38 patients enrolled at the Foot Center of New York. Prospective subjects were recruited if they reported an International Classification of Diseases (ICD) code consistent with diabetes using electronic medical records, expressed a desire to participate, conformed with the inclusion and exclusion criteria for the study (they were over 18 years of age and considered alert and thereby able to consent to the study), and provided informed consent. A total of 38 patients were enrolled in the study. Most of the participants were male and African American. The mean number of podiatric manifestations in the group was 4.43 (SD=62.35). The mean HbA1c level for the group was 8.23% (SD=1.94). Several predictors of podiatric manifestations were examined in the study, including mean MFES (Modified Falls Efficiency Scale) score, age, concurrent treatments for neuropathy, and HbA1c levels. Simple correlational analyses revealed that there was no correlation between HbA1c and the number of podiatric manifestations. Several follow-up regression analyses were performed to assess the ability of HbA1c to predict podiatric manifestations when controlling for individual parameters such age and duration of diabetes. HbA1c did not predict number of podiatric manifestations after controlling for age and diabetes duration, age alone or diabetes duration alone. The study did find that patients receiving neuropathy drugs reported lower MFES scores (notably, lower MFES scores are associated with a higher risk of falling). HbA1c levels of patients receiving neuropathy drugs did not differ significantly from the HbA1c levels of patients not receiving neuropathy drugs. The podiatric manifestations of patients with diabetes in East Harlem, where this study was carried out, are wide-ranging and include nail and skin disorders, which are both recognized as common precursors to infections and amputations. Predictive tools could help reduce the economic burden of diabetes. This study assessed the ability of HbA1c to predict the total number of podiatric manifestations in diabetic patients. In the end, HbA1c was not a good predictor of the number of podiatric manifestations. The weak correlation between HbA1c levels and the total number of podiatric manifestations in this study might be due to the small sample size. Future studies, ideally involving a larger sample size, are needed to more accurately assess the potential of HbA1c for predicting lower extremity complications.

The Alphabet strategy — a tool to achieve clinical trial standards in routine practice?

The Steno-2 study and UKPDS showed that targeted intensified intervention on modifiable cardiovascular risk factors in patients with type 2 diabetes reduces morbidity and mortality. The Alphabet POEM strategy (Practice Of Evidence-based Medicine) assessed the effect of systematic application of the Alphabet Strategy to care of patients with type 2 diabetes. In comparison to the Steno-2 intensive cohort, Alphabet POEM fared similarly with regard to diastolic blood pressure (BP), HbA1C, aspirin and angiotensin-converting enzyme (ACE) inhibitor use, but less well with respect to systolic BP, total cholesterol and use of statins. Alphabet POEM achieved better systolic and diastolic BP than UKPDS but glycaemic control was significantly worse. The standards achieved in the Steno-2 study and UKPDS are in principle, at least, partially achievable in a district general hospital in the UK, but fully achieving them in practice will probably need a radical restructuring, and greater provision of resources.

Improvements in clinical diabetes care in the first year of the new General Medical Services contract in the UK

The prevalence of diabetes and the cost of providing services will increase dramatically over the next ten years. There is a wide consensus that the way forward is for primary care to provide more care to higher clinical standards. The new General Medical Services contract (GMS2) offers incentives to achieve diabetes management targets. We compared the performances of health centres in North Warwickshire in the pre-contract year 2004 and post-contract in 2005. The audit tool comprised the GMS2 quality indicators in Alphabet Strategy format. There were statistically significant improvements in performance against almost all the quality indicators. We conclude with some reservations that GMS2 has considerably improved the quality of diabetes care in our locality.

An Audit of Lower Extremity Complications in Octogenarian Patients with Diabetes Mellitus

Podiatric pathology is common in the elderly patient population per se. Whether the presence of diabetes mellitus in the elderly imposes an additional risk for podiatric problems is questionable. The purpose of this study was to determine if the prevalence of podiatric problems in octogenarian diabetic patients differed from that found in a similarly aged group of nondiabetic patients. For this study, the prevalence of lower extremity complications in octogenarian patients (age 80) with diabetes and without diabetes was estimated using data from the 1996 through 2002 National Hospital Discharge Survey. The diabetic octogenarian patients had twice the risk for developing an ulcer; 3 times the risk of developing a foot abscess, and a 4-fold risk of developing osteomyelitis. Furthermore, the octogenarian diabetic patient is nearly twice as likely to undergo ulceration debridement and 3 to 5 times more likely to have a lower leg amputation, toe amputation, or any amputation. The incidence of amputations, ulcerations, and other serious conditions is significantly higher in the diabetic group compared to normal age-matched control patients. This study shows that in the octogenarian patient the presence of diabetes imposes an additive risk for complications.

Debridement of the Diabetic Foot: A Podiatric Perspective

High plantar pressures are a risk factor for diabetic foot ulcers that are common chronic wounds. In patients with peripheral neuropathy, plantar ulcers may be managed by debridement of callus, a process that has been shown to reduce peak plantar pressures. Callus debridement is clearly an important ulcer prevention strategy. The scalpel skills used by the podiatrist to remove callus are best suited to achieve safe, local sharp wound debridement. Current podiatric practice in the United Kingdom is based on sound theoretical principles. However, good scientific data recommending its efficacy are scarce. The role of podiatry in debridement and wound management needs careful examination, a major aim of this article.

Review of Treatment for Onychomycosis: Consideration for Special Populations

This article provides a brief discussion of onychomycosis treatment in special populations such as children, the elderly, and patients with diabetes, human immunodeficiency virus (HIV), or Down syndrome. These subjects are generally not included in clinical trials, and few data on antifungal therapy are available in the literature. Issues with onychomycosis infection and treatment affecting each group are discussed, and where treatment reports exist, efficacy and safety data are presented. The discussion is restricted to agents approved for use in onychomycosis in Canada: oral terbinafine, oral itraconazole, and ciclopirox 8% nail lacquer. Although sparse, the literature demonstrates that onychomycosis therapies can be used safely and effectively in these special populations, although it is likely that the appropriateness of such treatment would have to be assessed on a case-by-case basis. Typically, oral medications are used reluctantly in these groups as the potential for adverse liver or kidney effects and medication interactions may be significant. Ciclopirox nail lacquer has recently become available for use and may offer an alternative to oral therapy in the future for mild to moderate cases of onychomycosis; however, the efficacy in these patients has not typically been reported. It remains to be seen what impact this medication will have for special populations. More knowledge of treatment in special populations must be accumulated in the literature before more formal treatment guidelines may be formulated.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

BACKGROUND

End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.

OBJECTIVE

The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.

METHODS

A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.

RESULTS

We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p < 0.001), history of foot ulceration (OR 81 [18.20-360.48] p < 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p < 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p < 0.001), foot deformity (OR 23.62 [5.82-95.93] p < 0.001), retinopathy (OR 6.08 [2.64-14.02] p < 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p < 0.05).

CONCLUSION

There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

A Systematic Review of Cost-Effectiveness Models in Type 1 Diabetes Mellitus

BACKGROUND

Critiques of cost-effectiveness modelling in type 1 diabetes mellitus (T1DM) are scarce and are often undertaken in combination with type 2 diabetes mellitus (T2DM) models. However, T1DM is a separate disease, and it is therefore important to appraise modelling methods in T1DM.

OBJECTIVES

This review identified published economic models in T1DM and provided an overview of the characteristics and capabilities of available models, thus enabling a discussion of best-practice modelling approaches in T1DM.

METHODS

A systematic review of Embase(®), MEDLINE(®), MEDLINE(®) In-Process, and NHS EED was conducted to identify available models in T1DM. Key conferences and health technology assessment (HTA) websites were also reviewed. The characteristics of each model (e.g. model structure, simulation method, handling of uncertainty, incorporation of treatment effect, data for risk equations, and validation procedures, based on information in the primary publication) were extracted, with a focus on model capabilities.

RESULTS

We identified 13 unique models. Overall, the included studies varied greatly in scope as well as in the quality and quantity of information reported, but six of the models (Archimedes, CDM [Core Diabetes Model], CRC DES [Cardiff Research Consortium Discrete Event Simulation], DCCT [Diabetes Control and Complications Trial], Sheffield, and EAGLE [Economic Assessment of Glycaemic control and Long-term Effects of diabetes]) were the most rigorous and thoroughly reported. Most models were Markov based, and cohort and microsimulation methods were equally common. All of the more comprehensive models employed microsimulation methods. Model structure varied widely, with the more holistic models providing a comprehensive approach to microvascular and macrovascular events, as well as including adverse events. The majority of studies reported a lifetime horizon, used a payer perspective, and had the capability for sensitivity analysis.

CONCLUSIONS

Several models have been developed that provide useful insight into T1DM modelling. Based on a review of the models identified in this study, we identified a set of 'best in class' methods for the different technical aspects of T1DM modelling.

Communication Barriers and the Clinical Recognition of Diabetic Peripheral Neuropathy in a Diverse Cohort of Adults: The DISTANCE Study

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.

The cost of illness attributable to diabetic foot and cost-effectiveness of secondary prevention in Peru

BACKGROUND

Diabetes mellitus is a public health challenge worldwide, and roughly 25% of patients with diabetes in developing countries will develop at least one foot ulcer during their lifetime. The gravest outcome of an ulcerated foot is amputation, leading to premature death and larger economic costs.

METHODS

This study aimed to estimate the economic costs of diabetic foot in high-risk patients in Peru in 2012 and to model the cost-effectiveness of a year-long preventive strategy for foot ulceration including: sub-optimal care (baseline), standard care as recommended by the International Diabetes Federation, and standard care plus daily self-monitoring of foot temperature. A decision tree model using a population prevalence-based approach was used to calculate the costs and the incremental cost-effectiveness ratio (ICER). Outcome measures were deaths and major amputations, uncertainty was tested with a one-way sensitivity analysis.

RESULTS

The direct costs for prevention and management with sub-optimal care for high-risk diabetics is around US$74.5 million dollars in a single year, which decreases to US$71.8 million for standard care and increases to US$96.8 million for standard care plus temperature monitoring. The implementation of a standard care strategy would avert 791 deaths and is cost-saving in comparison to sub-optimal care. For standard care plus temperature monitoring compared to sub-optimal care the ICER rises to US$16,124 per death averted and averts 1,385 deaths.

CONCLUSION

Diabetic foot complications are highly costly and largely preventable in Peru. The implementation of a standard care strategy would lead to net savings and avert deaths over a one-year period. More intensive prevention strategies such as incorporating temperature monitoring may also be cost-effective.

A clinical trial of Integra Template for diabetic foot ulcer treatment

Individuals with diabetes mellitus are at an increased risk of developing a diabetic foot ulcer (DFU). This study evaluated the safety and efficacy of Integra Dermal Regeneration Template (IDRT) for the treatment of nonhealing DFUs. The Foot Ulcer New Dermal Replacement Study was a multicenter, randomized, controlled, parallel group clinical trial conducted under an Investigational Device Exemption. Thirty-two sites enrolled and randomized 307 subjects with at least one DFU. Consented patients were entered into the 14-day run-in phase where they were treated with the standard of care (0.9% sodium chloride gel) plus a secondary dressing and an offloading/protective device. Patients with less than 30% reepithelialization of the study ulcer after the run-in phase were randomized into the treatment phase. The subjects were randomized to the control treatment group (0.9% sodium chloride gel; n = 153) or the active treatment group (IDRT, n = 154). The treatment phase was 16 weeks or until confirmation of complete wound closure (100% reepithelialization of the wound surface), whichever occurred first. Following the treatment phase, all subjects were followed for 12 weeks. Complete DFU closure during the treatment phase was significantly greater with IDRT treatment (51%) than control treatment (32%; p = 0.001) at sixteen weeks. The median time to complete DFU closure was 43 days for IDRT subjects and 78 days for control subjects in wounds that healed. The rate of wound size reduction was 7.2% per week for IDRT subjects vs. 4.8% per week for control subjects (p = 0.012). For the treatment of chronic DFUs, IDRT treatment decreased the time to complete wound closure, increased the rate of wound closure, improved components of quality of life and had less adverse events compared with the standard of care treatment. IDRT could greatly enhance the treatment of nonhealing DFUs.

Risk factors for amputation in patients with diabetic foot ulcer in southwest Iran: a matched case-control study

OBJECTIVES:

Amputation is a multifactorial complication in diabetic patients. The aim of this study was to determine the risk factors associated with amputation in patients with diabetic foot ulcers.

METHODS:

This matched case-control study was conducted based on new cases of amputation from March 2012 to November 2014. We selected new cases who had undergone amputation, and the control group was chosen from the cities or areas where the cases resided. Each case was matched with two controls based on the duration of diabetes and location. Conditional logistic regression was used to evaluate the associations between potential risk factors and amputation.

RESULTS:

A total of 131 cases were compared with 262 controls. The results of the adjusted model showed that sex (odds ratio [OR], 8.66; 95% confidence interval [CI], 2.68 to 27.91), fewer than two hemoglobin A1c (HbA1c) tests per year (OR, 13.97; 95% CI, 4.97 to 39.26), unsuitable shoes (OR, 5.50; 95% CI, 2.20 to 13.77), smoking (OR, 3.44; 95% CI, 1.45 to 8.13), and body mass index (OR, 1.20; 95% CI, 1.03 to 1.41) were associated with amputation in diabetic patients.

CONCLUSIONS:

The most important factors associated with amputation were females, irregular monitoring of HbA1c levels, improper footwear, and smoking. Developing educational programs and working to ensure a higher quality of care for diabetic patients are necessary steps to address these issues.

Improving pancreatic islet in vitro functionality and transplantation efficiency by using heparin mimetic peptide nanofiber gels

Pancreatic islet transplantation is a promising treatment for type 1 diabetes. However, viability and functionality of the islets after transplantation are limited due to loss of integrity and destruction of blood vessel networks. Thus, it is important to provide a proper mechanically and biologically supportive environment for enhancing both in vitro islet culture and transplantation efficiency. Here, we demonstrate that heparin mimetic peptide amphiphile (HM-PA) nanofibrous network is a promising platform for these purposes. The islets cultured with peptide nanofiber gel containing growth factors exhibited a similar glucose stimulation index as that of the freshly isolated islets even after 7 days. After transplantation of islets to STZ-induced diabetic rats, 28 day-long monitoring displayed that islets that were transplanted in HM-PA nanofiber gels maintained better blood glucose levels at normal levels compared to the only islet transplantation group. In addition, intraperitoneal glucose tolerance test revealed that animals that were transplanted with islets within peptide gels showed a similar pattern with the healthy control group. Histological assessment showed that islets transplanted within peptide nanofiber gels demonstrated better islet integrity due to increased blood vessel density. This work demonstrates that using the HM-PA nanofiber gel platform enhances the islets function and islet transplantation efficiency both in vitro and in vivo.

Laser therapy for onychomycosis in patients with diabetes at risk for foot complications: study protocol for a randomized, double-blind, controlled trial (LASER-1)

Background

In a sham-controlled double-blind trial, we aim to establish the efficacy and safety of the local application of laser therapy in patients with diabetes, onychomycosis and risk factors for diabetes-related foot complications. Onychomycosis leads to thickened and distorted nails, which in turn lead to increased local pressure. The combination of onychomycosis and neuropathy or peripheral arterial disease (PAD) increases the risk of developing diabetes-related foot complications. Usual care for high-risk patients with diabetes and onychomycosis is completely symptomatic with frequent shaving and clipping of the nails. No effective curative local therapies exist, and systemic agents are often withheld due to concerns for side effects and interactions.

Methods/Design

The primary aim is to evaluate the efficacy of four sessions of Nd:YAG 1064 nM laser application on the one-year clinical and microbiological cure rate in a randomized, double-blind, sham-controlled design with blinded outcome assessment. Mandatory inclusion criteria are diagnosis of diabetes, risk factors for developing foot ulcers defined as a modified Simm’s classification score 1 or 2 and either neuropathy or PAD. A total of 64 patients are randomized to intervention or sham treatment performed by a podiatrist.

Discussion

This study will be the first double-blind study that investigates the effects of local laser therapy on onychomycosis, specifically performed in patients with diabetes with additional risk factors for foot complications.

Trial registration

Clinical trials.gov as NCT01996995, first received 22 November 2013.

Pedorthic management of the diabetic foot

BACKGROUND

Conservative pedorthic management of the diabetic foot has been shown to be an effective method to prevent ulcers, amputations, and re-amputations. This article exhibits why and how pedorthics plays such an important role via modalities such as footwear, shoe modifications, custom foot orthoses, and partial foot prostheses.

OBJECTIVE

The objective of this article is to demonstrate how pedorthics has been shown to be an integral part of conservative diabetic foot care. The authors' goal was to educate the reader about the different modalities that are available for use.

STUDY DESIGN

This article is based largely on review of previously published research and scholarly articles, augmented by the more than 60 years of pedorthic and orthotic clinical experience of the authors.

METHODS

Approximately 60 journal articles and book chapters were reviewed by the authors. Articles were located via online resources such as PubMed as well as the authors' own libraries.

RESULTS

It was repeatedly noted that pedorthic modalities such as shoes, foot orthoses, and shoe modifications may be utilized in the treatment and prevention of diabetic foot wounds and other complications.

CONCLUSION

Pedorthic devices may be successfully integrated into a comprehensive treatment plan for patients with diabetes and foot ulcers.

CLINICAL RELEVANCE

This information is of special interest to those who treat patients with diabetes. The article demonstrates the efficacy of pedorthic intervention through the compilation and review of relevant previously published data.

The association between urinary lgM excretion and diabetic retinopathy in diabetic patients

Background

Diabetic Retinopathy is one of the most common causes of blindness among adults. Microvascular complications may have common origins. The objective of the present study is to analyze the correlation between urinary IgM excretion and diabetic retinopathy based on the type of diabetes.

Methods

The present study is cross-sectional analytic and was carried out on 140 type2 diabetic patients (of which 70 patients diagnosed with retinopathy) and 76 type1 diabetic patients (of which 37 patients diagnosed with retinopathy). For every patient in each of the test groups, fasting plasma glucose, triglyceride, cholesterol, creatinin and HbA1c tests were done. The value of IgM, the albumin- to- creatinine ratio and the urine analysis test were also used to rule out the significant proteinuria of the patients. Then, IgM Index was measured using the following equation: Igm Index = Urine IgM/Urine Cr.

Results

The level of IgM index in the diabetic patients (type1 and type2) had no significant correlation with retinopathy. Cut point = 1.49, sensitivity = 0.703 and specificity = 0.308 in type1 diabetes were used for screen retinopathy. In type1 diabetic patients, the duration of diabetes had a significant correlation with urinary protein while in type 2 diabetic patients, the diabetes duration and HbA1c were significantly correlated with retinopathy.

Conclusion

The results of this study demonstrate that the level of urinary IgM in diabetic patients has no difference in those who have or lack retinopathy, but the urinary IgM level of more than 1.49 mg/dl can be considered as a cut point in type1 diabetic patients to screen retinopathy.

Microvascular perfusion heterogeneity contributes to peripheral vascular disease in metabolic syndrome

A major challenge facing public health is the increased incidence and prevalence of the metabolic syndrome, a clinical condition characterized by excess adiposity, impaired glycaemic control, dyslipidaemia and moderate hypertension. The greatest concern for this syndrome is the profound increase in risk for development of peripheral vascular disease (PVD) in afflicted persons. However, ongoing studies suggest that reductions in bulk blood flow to skeletal muscle may not be the primary contributor to the premature muscle fatigue that is a hallmark of PVD. Compelling evidence has been provided suggesting that an increasingly spatially heterogeneous and temporally stable distribution of blood flow at successive arteriolar bifurcations in metabolic syndrome creates an environment where a large number of the pre-capillary arterioles have low perfusion, low haematocrit, and are increasingly confined to this state, with limited ability to adapt perfusion in response to a challenged environment. Single pharmacological interventions are unable to significantly restore function owing to a divergence in their spatial effectiveness, although combined therapeutic approaches to correct adrenergic dysfunction, elevated oxidant stress and increased thromboxane A2 improve perfusion-based outcomes. Integrated, multi-target therapeutic interventions designed to restore healthy network function and flexibility may provide for superior outcomes in subjects with metabolic syndrome-associated PVD.