Diabetic Foot Ulcer Identification: A Review

Racial Disparities in Foot Examination among People with Diabetes in Brazil: A Nationwide Survey, 2019

Objective

To assess the absence of diabetic foot examination in Brazil and how ethnicity affected this outcome.

Design

This is an analysis of a nationwide survey held in Brazil in 2019. Participants with diabetes and that were 15 years of age or older were eligible for inclusion in the analysis. Adjusted Poisson regression with robust variance was used to calculate prevalence ratios (PRs) and 95% confidence intervals (95% CIs) of never having had the foot examined, with separate models according to ethnicity. Stata 14.2 was used for all calculations.

Results

We included 6216 individuals with diabetes; 52.1% (95%CI: 50.0%-54.2%) reported never having had their feet examined by a health care professional and 61% self-declared as Black (Black and Brown [Brazilian mixed race]). A higher frequency of negligence was observed among Black individuals (55.3%; 52.5%-58.1%) than among White individuals (48.2%; 45.0%-51.5%). Negligence was higher between 15- to 39-year-old participants (PR = 1.34, 1.14-1.57), lower educational level (PR = 1.37, 1.13-1.65), higher alcohol consumption (PR = 1.18, 1.06-1.31), fair health status (PR = 1.11, 1.01-1.21), and diabetes diagnosis of up to 10 years (PR = 1.42, 1.28-1.57). Among Blacks, tobacco use and other factors increased the frequency of the outcome, whereas participation in the Brazilian Unified Health System primary care program was a protection factor (P<.05).

Conclusion

Black Brazilians with diabetes had higher negligence of foot examination by health care professionals. Strengthening primary care would help mitigate systemic racism in Brazil.

Association between anemia and diabetic lower extremity ulcers among US outpatients in the National Health and Nutrition Examination Survey: a retrospective cross-sectional study

Purpose

The aim of this study was to explore the relationship between hemoglobin levels, anemia and diabetic lower extremity ulcers in adult outpatient clinics in the United States.

Methods

A retrospective cross-sectional study was conducted on 1673 participants in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004. Three logistic regression models were developed to evaluate the relationship between anemia and diabetic lower extremity ulcers. Model 1 adjusted for demographic and socioeconomic variables (age, sex, race and ethnicity, educational level, family income, and marital status). Model 2 included additional health-related factors (BMI, cardiovascular disease, stroke, family history of diabetes, hyperlipidemia, alcohol and smoking status). Model 3 further included clinical and laboratory variables (HbA1c, CRP, total cholesterol, and serum ferritin levels). Stratified analyses were also conducted based on age, sex, HbA1c level, body mass index (BMI), and serum ferritin level.

Results

The study included 1673 adults aged 40 years and older, with a mean age of 64.7 ± 11.8 years, of whom 52.6% were male. The prevalence of diabetic lower extremity ulcers (DLEU) was 8.0% (136 participants). Anemia was found in 239 participants, accounting for 14% of the study group. Model 1 showed an OR of 2.02 (95% CI=1.28~3.19) for anemia, while Model 2 showed an OR of 1.8 (95% CI=1.13~2.87). In Model 3, the OR for DFU in patients with anemia was 1.79 (95% CI=1.11~2.87). Furthermore, when serum ferritin was converted to a categorical variable, there was evidence of an interaction between DLEU status and serum ferritin in increasing the prevalence of DLEU.

Conclusion

After adjusting for confounding variables, higher levels of anemia were proportionally associated with an increased risk of incident DLEU. These results suggest that monitoring T2DM patients during follow-up to prevent the development of DLEU may be important. However, further prospective studies are needed to provide additional evidence.

Artificial intelligence in wound care: diagnosis, assessment and treatment of hard-to-heal wounds: a narrative review

OBJECTIVE

The effective assessment of wounds, both acute and hard-to-heal, is an important component in the delivery by wound care practitioners of efficacious wound care for patients. Improved wound diagnosis, optimising wound treatment regimens, and enhanced prevention of wounds aid in providing patients with a better quality of life (QoL). There is significant potential for the use of artificial intelligence (AI) in health-related areas such as wound care. However, AI-based systems remain to be developed to a point where they can be used clinically to deliver high-quality wound care. We have carried out a narrative review of the development and use of AI in the diagnosis, assessment and treatment of hard-to-heal wounds. We retrieved 145 articles from several online databases and other online resources, and 81 of them were included in this narrative review. Our review shows that AI application in wound care offers benefits in the assessment/diagnosis, monitoring and treatment of acute and hard-to-heal wounds. As well as offering patients the potential of improved QoL, AI may also enable better use of healthcare resources.

In vitro inhibition of biofilm and virulence factor production in azole-resistant strains of Candida albicans isolated from diabetic foot by Artemisia vulgaris stabilized tin (IV) oxide nanoparticles

The advent of nanotechnology has been instrumental in the development of new drugs with novel targets. Recently, metallic nanoparticles have emerged as potential candidates to combat the threat of drug-resistant infections. Diabetic foot ulcers (DFUs) are one of the dreadful complications of diabetes mellitus due to the colonization of numerous drug-resistant pathogenic microbes leading to biofilm formation. Biofilms are difficult to treat due to limited penetration and non-specificity of drugs. Therefore, in the current investigation, SnO2 nanoparticles were biosynthesized using Artemisia vulgaris (AvTO-NPs) as a stabilizing agent and were characterized using ultraviolet-visible (UV-vis) spectroscopy, Fourier transform infrared spectroscopy (FT-IR), X-ray diffraction (XRD), scanning electron microscopy (SEM), and energy-dispersive X-ray spectroscopy (EDX). Furthermore, the efficacy of AvTO-NPs against biofilms and virulence factors of drug-resistant Candida albicans strains isolated from DFUs was assessed. AvTO-NPs displayed minimum inhibitory concentrations (MICs) ranging from 1 mg/mL to 2 mg/mL against four strains of C. albicans. AvTO-NPs significantly inhibited biofilm formation by 54.8%-87%, germ tube formation by 72%-90%, cell surface hydrophobicity by 68.2%-82.8%, and exopolysaccharide (EPS) production by 69%-86.3% in the test strains at respective 1/2xMIC. Biosynthesized NPs were effective in disrupting established mature biofilms of test strains significantly. Elevated levels of reactive oxygen species (ROS) generation in the AvTO-NPs-treated C. albicans could be the possible cause of cell death leading to biofilm inhibition. The useful insights of the present study could be exploited in the current line of treatment to mitigate the threat of biofilm-related persistent DFUs and expedite wound healing.

The Metabolic Characteristics of Patients at the Risk for Diabetic Foot Ulcer: A Comparative Study of Diabetic Patients with and without Diabetic Foot

Backgrounds and Objective

Diabetic foot is a relatively severe complication in patients with type 2 diabetes (T2D), with peripheral neuropathy and angiopathy frequently serving as risk factors. However, it is unknown how the other major systemic metabolic factors impacted the profile of these patients, besides glucose management. Thus, we investigated the distinct characteristics of patients with diabetic foot ulcers and their relationships with angiopathy.

Materials and Methods

We obtained the laboratory data of 334 diabetic patients at Shanghai Pudong Hospital from 2020 to 2023. The comparisons were performed between the groups with or without diabetic foot, including glucose metabolism, lipids profile, liver and kidney function, thyroid function, and serum iron. The association between metabolic factors and lower extremity computed tomography angiography (CTA) was analyzed.

Results

We found significant disparities between groups in relation to age, serum protein content, liver transferase, serum creatinine, estimated glomerular filtration rate (eGFR), serum uric acid (UA), small dense low-density lipoprotein (sdLDL), lipoprotein A (LP(a)), apolipoprotein A1 (APOA1), thyroid function, serum iron, and hemoglobin (Hb) (p<0.05). The Spearman correlational analyses showed that the severity of CTA, categorized by the unilateral or bilateral plaque or occlusion, was positively significantly correlated with UA (r=0.499), triglyceride (TG) (r=0.751), whereas inversely correlated with serum albumin (r=-0.510), alanine aminotransferase (r=-0.523), direct bilirubin (DBil) (r=-0.494), total bilirubin (TBil) (r=-0.550), Hb (r=-0.646).

Conclusion

This cross-section investigation showed that compared to T2D only, the patients with diabetic foot ulcer (DFU) might display similar glucose metabolic control context but adverse metabolic profiles, and this profile is associated with macrovascular angiopathy characteristics and their severity.