Wagner's Classification as a Tool for Treating Diabetic Foot Ulcers: Our Observations at a Suburban Teaching Hospital

The Relationship Between Plasma Fibrinogen Levels and the Severity of Diabetic Foot Ulcers in Diabetic Patients

Background Diabetic foot ulcers (DFUs) are a common and debilitating complication of diabetes mellitus, often leading to hospitalization, amputation, and reduced quality of life. Monitoring biomarkers that reflect inflammatory processes can be crucial for assessing DFU severity and guiding treatment. This study explores the relationship between plasma fibrinogen levels and DFU severity, along with its association with various clinical and inflammatory biomarkers. Objective To assess the relationship between plasma fibrinogen levels and DFU severity, vascular health, infection risk, and other biomarkers in diabetic patients, with the aim of improving the prediction and management of DFU outcomes. Methods A cross-sectional, observational study was conducted at Mardan Medical Complex from June 2024 to January 2025, involving 93 diabetic patients with active DFUs. The severity of DFUs was classified using the Wagner system, and vascular health was assessed using the Ankle-Brachial Index (ABI) and Doppler ultrasound. Plasma fibrinogen levels, along with other biomarkers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fasting blood glucose, were measured through fasting blood samples. Data analysis included statistical tests such as Kruskal-Wallis, Mann-Whitney, ANOVA, Decision Trees, Box Plots, Violin Plot, Histograms, and Regression models to explore the associations between fibrinogen levels and DFU severity, vascular impairment, and inflammatory markers. Significance was set at p < 0.05. Results The study examined 93 diabetic patients (mean age: 59.02 ± 7.86 years), comprising 49 males (52.68%) and 44 females (46.32%). Among the participants, 28 (30.11%) presented with severe ulcers (Wagner Grade 5), and 53 (56.99%) exhibited critical ischemia. Bacterial infections were identified in 71 (76.34%) of the patients. The mean plasma fibrinogen level was significantly elevated at 681 ± 160 mg/dL, surpassing the normal range. Plasma fibrinogen levels increased with ulcer severity, with medians of 503.51 mg/dL for Wagner Grade 2, 623.45 mg/dL for grade 3, 627.32 mg/dL for grade 4, and 720.77 mg/dL for grade 5 ulcers. Higher fibrinogen levels were also associated with greater ulcer depth (p = 0.046). Additionally, vascular impairment was significantly correlated with fibrinogen levels, with non-palpable pedal pulses and severe peripheral arterial disease showing associations with elevated fibrinogen levels (p = 0.0083 and p = 0.0478, respectively). Furthermore, fibrinogen levels were positively correlated with CRP (r = 0.50) and with comorbidities such as hypertension in 66 (70.97%) patients and chronic kidney disease in 20 (21.51%) patients. Conclusion Plasma fibrinogen levels are strongly associated with DFU severity and could serve as an effective biomarker for predicting disease progression. Monitoring fibrinogen, along with other biomarkers, may help clinicians stratify patients based on their risk of complications and guide more targeted treatment strategies.

Nutritional Status in a Group of Patients with Wounds Due to Diabetic Foot Disease and Chronic Venous Insufficiency

Background: Wound healing is a complex physiological process that begins immediately upon injury. Nutritional status significantly affects the course of regenerative processes. Malnutrition can prolong the inflammatory phase, limit collagen synthesis, and increase the risk of new wound formation. The issue of malnutrition is becoming increasingly prevalent and remains a significant concern, particularly among older adults dealing with chronic conditions. Methods: The study was conducted at the Wound Treatment Clinic of the Specialist Hospital at the Podkarpackie Oncology Center in Brzozów, Poland, over 12 months (31 December 2022 to 31 December 2023). A prospective assessment was carried out on 106 patients with chronic wounds. The sample selection was purposeful, based on the following criteria: individuals with hard-to-heal vascular wounds related to diabetic foot disease or venous insufficiency, who provided informed consent to participate after reviewing the study concept. The assessment included a questionnaire and biochemical blood analysis. Further evaluations covered wound characteristics and classification based on clinical scales. The morphotic and biochemical blood parameter assessment included albumin concentration, hemoglobin, C-reactive protein (CRP), and the nutritional risk index (NRI). Results: A larger wound area was associated with lower morphotic values in both groups. Exudate levels and severity in chronic venous insufficiency (CVI) patients and diabetic foot disease (DFD) were associated with lower hemoglobin, albumin, and NRI values. At the same time, the depth of tissue structure damage correlated with the measured biochemical parameters. Conclusions: NRI values and morphotic blood parameters, along with albumin, hemoglobin, and CRP levels, are closely associated with wound characteristics, including surface area, exudate level, and the severity of tissue destruction. The greater the destruction of tissue structures, the higher the risk of malnutrition and wound infection, as indicated by biochemical assessment.

Wound management, healing, and early prosthetic rehabilitation: Part 1 - A scoping review of healing and non-healing definitions

BACKGROUND

Following lower limb amputation, timely prosthetic fitting enhances mobility and quality of life. However, inconsistent definitions of surgical site healing complicate prosthesis readiness assessment and highlight the need for objective wound management measures.

OBJECTIVE

This review aimed to compile definitions of healing and non-healing provided in the literature investigating biomarkers of healing of the tissues and structures found in the residual limbs of adults with amputation.

METHODOLOGY

A scoping review was conducted following JBI and PRISMA-ScR guidance. Searches using "biomarkers," "wound healing," and "amputation" were performed on May 6, 2023, on Web of Science, Ovid MEDLINE, Ovid Embase, Scopus, Cochrane, PubMed, and CINAHL databases. Inclusion criteria were: 1) References to biomarkers and healing; 2) Residuum tissue healing; 3) Clear methodology with ethical approval; 4) Published from 2017 onwards. Articles were assessed for quality (QualSyst tool) and evidence level (JBI system).

FINDINGS

Of 3,306 articles screened, 219 met the inclusion criteria and are reviewed in this article, with 77% rated strong quality. 43% of all included sources did not define healing, while the remainder used specific criteria including epithelialization (14%), wound size reduction (28%), gradings scales (3%), scarring (1%), absence of wound complications (2%), hydroxyproline levels (0.5%), no amputation (0.5%), or neovascularization (0.5%). 84% of included sources did not provide definitions of non-healing. Studies defining non-healing used criteria like wound complications (4%), the need for operative interventions (4%), or lack of wound size reduction (1%). For 10% of included sources, healing and non-healing definitions were considered not applicable given the research content. Total percentages exceed 100% for both healing and non-healing definitions because some sources used two definition classifications, such as epithelialization and wound size reduction. The findings indicate a lack of standardized definitions irrespective of study type.

CONCLUSION

This review reveals significant gaps in current definitions of healing and non-healing, often based on superficial assessments that overlook deeper tissue healing and mechanical properties essential for prosthesis use. It emphasizes the need for comprehensive definitions incorporating biomarkers and psychosocial factors to improve wound management and post-amputation recovery.

Analysis of clinical characteristics in patients with diabetic foot ulcers undergoing amputation and establishment of a nomogram prediction model

To assess the accuracy of a nomogram for predicting the risk of lower-extremity amputation (LEA) in individuals with diabetic foot ulcers (DFUs). We retrospectively analyzed data from 144 patients with DFUs at the Department of Orthopedics of the First Affiliated Hospital of Nanchang University, collected between January 2020 and December 2023. Univariate analysis determined primary predictive factors for amputation, followed by single and multifactor logistic regression analyses to indentify independent factors. These were utilized to develop a prediction model using R4.3.3, and a nomogram was created. Its performance was verified using receiver operating characteristic (ROC), corrected calibration, and clinical decision curves. Twelve primary predictive factors were identified from 20 variables, including age, Wagner grades, peripheral angiopathy of diabetes (PAD), chronic kidney disease(CKD), C-reactive protein(CRP) and the number of blood sugar abnormalities(BSA) etc. Multivariate logical regression analysis illustrated that Wagner grades, PAD, CRP, CKD, and the number of BSA were independent risk factors. The area under the curve (AUC) of the ROC curve was 0.967, and the revised calibration curve of the nomogram demonstrated strong fitting ability. This prediction model is a valuable tool for screening LEA risk and preventing DFU from progressing into amputation.

Clinical Effects of Thread-Dragging Therapy on Gangrene of Non-ischemic Diabetic Foot Ulcers

OBJECTIVE

To investigate the clinical effects of thread-dragging therapy on gangrene of non-ischemic diabetic foot ulcers (NIDFU).

METHODS

A total of 136 patients with NIDFU were recruited from the Department of Peripheral Vascular Surgery, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between June 21, 2021 and February 1, 2023, and randomized into an intervention group and a control group, with 68 cases in each group. Both groups received basic treatment. The intervention group was treated with thread-dragging therapy, while the control group was treated with debridement combined with routine dressing changes after surgery. Both groups were treated continuously for 2 months. The amputation rates and changes in the ulcer area were compared between the groups. The inflammatory response index including peripheral white blood cells (WBCs), neutrophil percentage (NEUT%), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and interleukin 6 (IL-6) were compared between the two groups.

RESULTS

After treatment, the ulcer areas in the intervention group were significantly smaller than that of the control group (8.50±3.88 cm2 vs. 10.11±4.61 cm2, P<0.05). The amputation rates of the two groups were not statistically significant (4.4% vs. 5.9%, P>0.05). Differences of WBCs count, CRP, and ESR before and after therapy in the intervention group were better than the control group (P<0.05). However, there were no significant differences in changes of NEUT%, PCT, and IL-6 between the two groups (P>0.05).

CONCLUSION

Thread-dragging therapy may be effective in the treatment of NIDFU, with the additional advantages of less tissue damage after healing. (Registration No. ChiCTR2100047496).

The relationship between dietary phytochemical index and novel anthropometric indices and the severity of diabetic foot ulcers in adults with type 2 diabetes: a cross-sectional study

BACKGROUND

Research on the relationship between dietary phytochemical intake and the anthropometric indices as well as the diabetic foot ulcers (DFUs) remains inconsistent. We aimed to investigate the associations of dietary phytochemical index (DPI) with the novel anthropometric indices and the severity of DFUs.

METHODS

This cross-sectional study was conducted on 339 adults with type 2 diabetes. Dietary intake was assessed using three 24-hour dietary recalls. To quantify the phytochemical content of the diet, the DPI estimation was done through an equation proposed by McCarty. The International Working Group on the Diabetic Foot (IWGDF) criteria and Wagner classification system were applied to assess DFUs. New anthropometric indices including a body shape index (ABSI), body roundness index (BRI) and abdominal volume index (AVI) were calculated based on formulas. We employed analysis of variance (ANOVA), analysis of covariance (ANCOVA) and logistic regression to explore associations between DPI and the anthropometric indices and DFU variables.

RESULTS

Our results revealed no significant association between DPI and the foot ulcer indices, following adjusting for the possible covariates. Furthermore, we also examined the relationship between diabetic neuropathy, as measured by monofilament score, and the DPI. Similarly, we did not find any substantial relationship between the DPI and monofilament score (OR: 1.18; 95% CI: 0.66-2.09; Ptrend = 0.56), as well as biochemical indices. Our analysis did not reveal any significant associations between the DPI and ABSI (OR: 0.70; 95% CI: 0.35-1.38; Ptrend = 0.30), BRI (OR: 0.80; 95% CI: 0.33-1.95; Ptrend = 0.59), and AVI (OR: 1.99; 95% CI: 0.92-4.33; Ptrend = 0.08).

CONCLUSIONS

Our study revealed no significant links between the DPI and foot ulcer indices, neuropathy measures, and anthropometric indices. These findings imply that factors beyond dietary phytochemical intake may exert greater influence on the development of foot ulcers in diabetes.

Lifestyle Medicine Approach to Wound Management

Chronic wounds impact 4.5% of the US population, necessitating a comprehensive understanding of their types and underlying mechanisms. Diabetic foot ulcers (DFUs), prevalent in 25% of individuals with diabetes, contribute significantly to lower limb amputations. The pathophysiology involves neuropathy, peripheral arterial disease, impaired immunity, glycemic control, and mechanical stress. Lifestyle medicine emerges as a pivotal aspect of care, offering both prevention and treatment by integrating plant-predominant nutrition, physical activity, stress management, avoidance of harmful substances, restful sleep, and social connectedness. These interventions impact gene interactions, immune function, and tissue regeneration, playing a crucial role in chronic wound management. The standard of care involves a multidisciplinary approach, emphasizing infection and vascular management, pressure offloading, conducive wound healing environments, and lifestyle adjustments. As diabetes prevalence rises, a proactive integration of lifestyle interventions is crucial, offering a promising avenue to alleviate the growing healthcare burden associated with chronic wounds.

Role of Autologous Platelet-Rich Fibrin in Chronic Non-healing Ulcers With Various Etiologies in a Tertiary Care Rehabilitation Centre: A Case Series

Introduction Chronic non-healing ulcers are defined as a discontinuity or break in the integrity of skin that is not healing in a reasonable period of time due to an underlying systemic etiology. Despite using conventional initial treatment and many other available dressing options, such wounds are difficult to completely heal, thus affecting the progress of rehabilitation measures and compromising functional improvement and quality of life. Materials and methods In this case series, platelet-rich fibrin (PRF) was applied to eight wounds from six patients. The patients included had various etiologies (including spinal cord injury, peripheral vascular disease, Guillain-Barré syndrome, and diabetic foot ulcer) with chronic non-healing wounds over different anatomical locations on the body. Pressure ulcer scale for healing (PUSH) score, surface area, and volume of the wounds were evaluated and monitored weekly after PRF dressing. We have applied PRF every week. On average, two PRF dressings were applied, the maximum being three applications. Results The maximum healing rate in terms of PUSH score was observed to be 3.84% per day, and the minimum was 1.19% per day. The maximum healing rate in terms of surface area was observed to be 5.89% per day, and the minimum was 1.78% per day. Three of the wounds showed complete closure. The maximum follow-up period was 10 weeks. The percentage mean Functional Independence Measure (FIM) improvement was calculated to be 15.87% ± 14.04 during the course of hospitalization after PRF application. Conclusion Based on the results, we can conclude that PRF showed accelerated improvement in the healing of chronic non-healing ulcers of various etiologies at different anatomical locations. It has proven to be a safe and effective method, thereby improving their quality of life and functional independence in performing activities of daily living. To our knowledge till date, no other study in a rehabilitation setting has been done on patients having non-healing ulcers due to various etiologies and at different anatomical locations.

Smart diabetic foot ulcer scoring system

Current assessment methods for diabetic foot ulcers (DFUs) lack objectivity and consistency, posing a significant risk to diabetes patients, including the potential for amputations, highlighting the urgent need for improved diagnostic tools and care standards in the field. To address this issue, the objective of this study was to develop and evaluate the Smart Diabetic Foot Ulcer Scoring System, ScoreDFUNet, which incorporates artificial intelligence (AI) and image analysis techniques, aiming to enhance the precision and consistency of diabetic foot ulcer assessment. ScoreDFUNet demonstrates precise categorization of DFU images into "ulcer," "infection," "normal," and "gangrene" areas, achieving a noteworthy accuracy rate of 95.34% on the test set, with elevated levels of precision, recall, and F1 scores. Comparative evaluations with dermatologists affirm that our algorithm consistently surpasses the performance of junior and mid-level dermatologists, closely matching the assessments of senior dermatologists, and rigorous analyses including Bland-Altman plots and significance testing validate the robustness and reliability of our algorithm. This innovative AI system presents a valuable tool for healthcare professionals and can significantly improve the care standards in the field of diabetic foot ulcer assessment.

Challenging the angiosome concept: Delineating peripheral arterial disease patterns in diabetic foot ulcers

OBJECTIVES

The angiosome concept has significantly impacted diabetic foot ulcer management by highlighting the vascular anatomy's role in wound healing. However, its clinical applicability and validity remain debated due to complexities in foot blood supply and ulcer location determination.

METHODS

A cross-sectional study was conducted on 84 individuals with diabetic foot ulcers undergoing lower limb angiography. Demographics, ulcer characteristics, and angiographic data were collected and analyzed using descriptive statistics and relevant tests.

RESULTS

Digital subtraction angiography assessed 89 limbs with diabetic foot ulcers; males comprised 54.8%, primarily type 2 diabetes (96.4%), averaging 64.36 ± 10.09 years. Of 129 angiosomes, angiosome 2 (40.3%) had the highest ulcer incidence. Posterior tibial artery (PTA) involvement was predominant (72.9%), while external iliac artery (EIA) and profunda femoris artery (PFA) were least affected (2.4% each). Posterior tibial artery showed 46.5% complete occlusion. Angiosome 2 correlated notably with anterior tibial artery (ATA), peroneal artery (CPA), and PTA, but categorizing angiosomes by supply patterns showed no significant artery correlation (p > .05).

CONCLUSIONS

The research indicates inconsistent support for below-the-knee artery involvement correlating with foot ulcer locations in angiosomes. While aiding vascular comprehension, the angiosome concept may not fully elucidate lower limb vascular complexities and ulcer genesis. Factors like collateral circulation should be noticed to understanding ulcer localization and severity, extending beyond angiosomal arterial supply.

[National expert consensus on the diagnosis and surgical treatment of diabetic foot ulcers complicated with lower extremity vasculopathy (2024 version)]

Diabetic foot ulcers complicated with lower extremity vasculopathy possess the characteristics of high incidence, slow healing, and poor prognosis, which may eventually lead to amputation or even life-threatening if not treated properly. The treatment of complicated lower extremity vasculopathy is vital to improve the healing process of diabetic foot ulcers, which has gradually received attention in clinical practice. Recently, a number of clinical trials on diabetic foot ulcers complicated with lower extremity vasculopathy were reported. In order to further standardize the clinical diagnosis and treatment of diabetic foot ulcers complicated with lower extremity vasculopathy, an expert group headed by Burns and Trauma Branch of Chinese Geriatrics Society, Chinese Burn Association, and Wound Repair Professional Committee of Chinese Medical Doctor Association deliberated and compiled the National expert consensus on the diagnosis and surgical treatment of diabetic foot ulcers complicated with lower extremity vasculopathy (2024 version) together. This consensus is based on evidences from the literature, covers the disease characteristics, evidence-based evidence of clinical diagnosis and treatment, as well as the application of new technologies and new treatment approaches of diabetic foot ulcers complicated with lower extremity vasculopathy. The goal of this consensus is to provide clear guidance to practitioners on the best approaches for screening, diagnosing, and treating diabetic foot ulcers complicated with lower extremity vasculopathy in individuals, hoping to provide a normative clinical practice basis for medical staff engaged in the treatment of diabetic foot wounds.

A Systematic Review of the Microbial Landscape of Diabetic Foot Ulcers in Uganda

Background

Diabetes is a growing health concern globally. Poorly managed diabetes may result in diabetic foot ulcers (DFU), which can become a source of chronic infection known as diabetic foot infections. The increasing trend of diabetes in Uganda speaks to the potential for diabetic foot ulcers which may eventually become infected and their attendant impact on the quality of life of diabetic patients. This review assesses the microbial diversity of DFUs in Uganda, aiming to guide treatment and identify research gaps.

Main Body of the Abstract

We searched PubMed, Scopus and Embase for studies conducted in Uganda that reported isolating microorganisms from diabetic foot ulcers. Following the preferred reporting items for systematic reviews and meta-analysis (PRISMA), we included two eligible studies that reported isolating 122 bacteria spread across eleven (11) species using swab samples and conventional culture methods. Significant isolates included World Health Organization priority pathogens including: Enterobacter specie, Staphylococcus aureus, Klebsiella pneumoniae, and Acinetobacter specie. Methicillin resistant Staphylococcus aureus (MRSA) constituted 33.3% of Staphylococci species and 26% of all bacterial isolates while extended-spectrum beta-lactamase producing Escherichia coli and Klebsiella specie constituted 14.29% of total microbial isolates. Most bacteria showed susceptibility to Imipenem, Vancomycin, Ciprofloxacin, and Clindamycin, but resistance to Cotrimoxazole and Ampicillin was noted.

Short Conclusion

We conclude that data on the microbiology of DFUs in Uganda is scarce; however, the bioburden of DFUs in the country is similar to those in other parts of the world, and MRSA poses a challenge to antibiotic therapy. Consequently, the continued use of swab samples and conventional culture and sensitivity methods may limit the isolation, identification, and presentation of other important isolates. We recommend characterization of bacterial isolates to better understand their genetic makeup, and the development of a national guideline for managing diabetic foot infections.

Analysis of risk factors of infection in diabetic foot patients

This cross-sectional study assessed the risk factors for infection in 150 diabetic foot patients admitted to the Xiamen University Hospital between October 2020 and October 2022. Patients were categorised as infected (n = 80) or uninfected (n = 70) cohorts. The diabetic foot was evaluated using the American Diabetic Foot Grading system, whereas ulcers were categorised using Wagner's method. Analysed were patient-specific information, clinical data and risk factors including neuropathy, arterial disease and foot deformities. Our findings revealed no statistically significant differences between infected and uninfected cohorts concerning age, body mass index, gender, duration of diabetes or ankle-brachial index values (p > 0.05). However, infected group had a higher proportion of smokers and reduced socio-economic status (p < 0.05). Wagner grades indicated a greater severity in the infected group, with grade 3, grade 4 and grade 5 differing significantly (p < 0.05). Comparative analysis of ulcer characteristics revealed no statistically significant differences in ulcer surface area and depth, but the infected group had a higher prevalence of osteomyelitis and a greater number of ulcers (p > 0.05). Blood vessel complications, retinopathy, the presence of three or more ulcers, osteomyelitis and diabetic nephropathy were substantially more prevalent in the infected group, as determined by univariate analysis (p < 0.05). Subsequent multivariate logistic analysis revealed that patients with blood vessel complications, retinopathy, osteomyelitis, diabetic nephropathy and three or more ulcers were at increased risk for infection (p < 0.05). In addition, lifestyle factors, such as smoking, sedentary behaviour, inadequate foot hygiene, obesity and poor glycaemic control, were also associated with higher infection rates. A multivariate analysis of foot wound factors revealed that deeper, longer and recurrent lesions increased the likelihood of infection. Escherichia coli was the most frequently isolated bacterium from the infected group's bacterial culture, followed by Pseudomonas aeruginosa and Staphylococcus aureus. The study enhanced our comprehension of the multifactorial risk factors associated with infections in diabetic foot patients, highlighting the need for thorough clinical evaluation, lifestyle modification and vigilant infection control.

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

Gangrene is a grave complication of peripheral vascular disease (PVD), characterised by tissue necrosis due to inadequate blood supply. This review article comprehensively explores gangrene in PVD, encompassing its prevalence, aetiology, clinical presentation, diagnostic modalities, management strategies, prognosis, and future directions. Key factors influencing outcomes, including the timeliness of intervention and the choice between limb salvage and amputation, are identified. Moreover, this review underscores the importance of early detection and multidisciplinary care, emphasising the significance of patient-centred approaches. It also calls for increased awareness, continued research, and innovative solutions to improve the lives of individuals grappling with gangrene in the context of PVD.

Molecular Characterization and Antibiotic Susceptibility Pattern of Bacterial Strains Isolated From Wound of Patients With Diabetes

BACKGROUND

 Diabetic wound infections are susceptible to various pathogens, particularly bacteria, due to the immunocompromised state of diabetic patients. Staphylococcus aureus is frequently implicated in diabetic wounds. To ascertain the presence of multiple antibiotic resistance in bacterial pathogens derived from diabetic wound infections, a comprehensive analysis is required.

MATERIALS AND METHODS

The present cross-sectional investigation was carried out at a tertiary care facility. The samples were collected in aseptic conditions from the Endocrinology unit, specifically from local in-hospital patients (n=140). These samples were then assessed for their susceptibility to the commonly used antibacterial medications within the study area. The specimens were obtained from the lesions of individuals diagnosed with diabetes. The subjects were subjected to inoculation using various media and cultures.

RESULTS

The findings of this study revealed that a collective sum of 122 bacterial isolates was acquired. The conclusions of the antibiotic susceptibility analysis revealed that the gram-positive isolates had a higher level of resistance to penicillin G (93.18%). However, they demonstrated sensitivity to vancomycin (100%) and linezolid (LZD) (95%). The gram-negative isolates exhibited complete resistance, at a rate of 100%, to penicillin, specifically amoxicillin (AMC), as well as to sulfonamides, such as sulfamethoxazole/trimethoprim (SXT), which belong to the antibiotic classes mentioned.

CONCLUSION

In conclusion, there has been a notable rise in antibiotic resistance.

Diabetic Foot Ulcers and Their Surgical Management: Our Experience at Hayatabad Medical Complex, Peshawar

BACKGROUND

Surgeons face a therapeutic challenge while treating diabetic foot ulcers (DFUs), particularly in underdeveloped nations with limited healthcare resources and a high proportion of patients who arrive at medical institutions with advanced foot ulcers.

OBJECTIVE

To assess the effectiveness of treatment in patients with DFUs and to demonstrate how early surgical intervention and appropriate bedside medical care can improve results.

MATERIAL AND METHODS

This prospective study was carried out at Hayatabad Medical Complex, Peshawar, Pakistan, to assess how DFUs changed over a period between November 2021 and December 2022 at the wards and at the outpatient department of endocrinology and general surgery. A diabetic patient's foot is first screened for ulceration in the endocrinology department, and only those with active ulcers are referred to the surgical department.

RESULTS

According to the Wagner classification, there were six (13.6%) cases in grade I, 11 (25%) in grade 2, 10 (22.7%) in grade 3, 13 (29.5%) in grade 4, and four (9%) in grade 5. Among comorbidities, a family history of diabetes mellitus was noted in 25 (56.8%) patients, followed by tobacco chewing and alcohol in 10 (22.7%) and hypertension in nine (20.4%) patients.

CONCLUSION

Diabetes foot ulceration is the most common reason for non-traumatic lower limb amputation in people with diabetes mellitus and is a significant cause of morbidity and mortality.

Marine Biomaterials: Hyaluronan

The marine-derived hyaluronic acid and other natural biopolymers offer exciting possibilities in the field of biomaterials, providing sustainable and biocompatible alternatives to synthetic materials. Their unique properties and abundance in marine sources make them valuable resources for various biomedical and industrial applications. Due to high biocompatible features and participation in biological processes related to tissue healing, hyaluronic acid has become widely used in tissue engineering applications, especially in the wound healing process. The present review enlightens marine hyaluronan biomaterial providing its sources, extraction process, structures, chemical modifications, biological properties, and biocidal applications, especially for wound healing/dressing purposes. Meanwhile, we point out the future development of wound healing/dressing based on hyaluronan and its composites and potential challenges.

Predictive Factors for Lower Limb Amputation in Type 2 Diabetics

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major public health problem. Foot-related complications are common in diabetic patients. The aim of this study is to identify predictive factors for lower limb amputation (LLA) in order to better identify this at-risk population.

METHODS

This was a cross-sectional study involving 134 patients who were hospitalised for the management of T2DM complicated by diabetic foot, in the department of endocrinology and diabetology. We included patients with T2DM whose diabetes was diagnosed 10 years ago or more, and who had a diabetic foot problem. Statistical differences between predictors of amputations were tested using: t-tests for numerical variables and chi-square tests for categorical variables. Significant variables were analysed by logistic regression to determine significant predictors.

RESULTS

The mean duration of diabetes was 17±7 years. We found that 70% of patients with LLA were older than 50 years (p<10-3). The prevalence of LLA was higher (p=0.015) in patients with diabetes for more than 20 years. We noted that 58% of patients who underwent LLA were hypertensive (p<10-3). The majority of patients with LLA (58%) had abnormal micro-albuminuria (p<10-3). We found that 70% (n=12) of patients with LLA had low-density protein cholesterol levels above the target value (p<10^-3). Diabetic foot grade ≥4 (4 or 5) according to Wagner's classification, was present in 24% of amputee patients. Based on a 95% confidence interval level, the independent significant predictive factors for LLA in our patients were: T2DM for more than 20 years, hypertension and diabetic foot grade ≥4.

CONCLUSIONS

After multivariate analysis, the significant independent predictive factors associated with LLA were: T2DM for more than 20 years, hypertension, and diabetic foot grade ≥4. Early management of diabetic foot problems is therefore recommended to avoid amputations.

A case series of autologous platelet-rich plasma injection in treating chronic ulcers conducted in Saudi Arabia

Objective

This is a case series study of 14 cases of chronic unhealed ulcers involving patients of 19-85 years, aimed to demonstrate the positive therapeutic outcomes of using autologous platelet rich plasma (PRP) in diabetic foot ulcer (DFU) and other chronic wound healing.

Methods

This is a formal consecutive clinical case series. Patients with chronic unhealed ulcers were enrolled from the amputation prevention clinic by an interdisciplinary team includes podiatrist, general surgeon, orthopedic, vascular surgeon, and wound care nurses at Kahel Specialized Centre, a specialized center for managing foot and ankle diseases, located in Riyadh, Saudi Arabia. Those patients who presented with chronic wounds and showed no significant wound reduction despite following the standard wound care protocol were included in the study. There were no specific predetermined exclusion criteria when considering patients for treatment with this modality.

Results

In this case series, majority (80%) of the patients were above 50 years of age, and 10 (66.7%) patients were male and 5 (33.3%) were female. Of all the cases presented to the amputation prevention clinic, majority (73.3%) reported suffering from type 2 diabetes mellitus (DM) and also, one reported type 1 DM [6.7%]). All the cases of DFU received a combination of hydrogel and autologous PRP treatment and were put of suitable offloading devices, except one case received a combination of Cadexomer iodine, hydrogel and PRP treatment. In the present case series involving 3-14 weeks of the treatment duration, only 2-3 doses of autologous PRP provided complete healing and or maximum wound closure.

Conclusion

Autologous PRP therapy is efficacious in facilitating, enhancing wound healing and aids in complete wound closure. This case series was limited in term of the sample size which is the number patients enrolled for the study, hence, the study finding remain inconclusive to some extent and hence, further study is required with greater number of sample size. The strength of this study is that it is the first study in Saudi Arabia and gulf region, to report the beneficial effect of PRP in chronic unhealed ulcers including diabetic ulcers.

The Association of the Neutrophil-Lymphocyte Ratio With the Outcome of Diabetic Foot Ulcer

Introduction One of the most common lower-extremity impediments in people suffering from diabetes mellitus (DM) is foot ulceration. Neutrophil-lymphocyte ratio (NLR) is a useful measure in predicting disease-specific morbidity and mortality. Objectives The objective is to study the association between diabetic foot ulcer healing and the NLR. Methodology A prospective analytical study was conducted among 100 patients with diabetic foot ulcers admitted to a surgical ward in a teaching hospital between April and November 2022. Basic demographic details, ulcer examination, and NLR were evaluated on the day of admission, and the status of ulcers was assessed after six weeks and the outcome was compared with the NLR value. Data analysis was done using SPSS version 20 software (SPSS, Inc., Chicago, IL). Results The average neutrophils, lymphocytes, and neutrophil-lymphocyte ratio were, respectively, 94.73%, 14.97%, and 6.65%. 58% had healing ulcers, and 42% had non-healing ulcers. 44% of study subjects had NLR <6, which is normal, and 56% had NLR >6, which is abnormal. Among 58 subjects with healing ulcers, 75.9% had NLR < 6, and among 42 subjects with non-healing ulcers, 100% had NLR >6, which was statistically significant. The mean NLR in the healing group was 5.15 and in the non-healing group was 8.205; this was statistically significant. This shows an increased NLR has a predisposition towards non-healing chronic ulcers with a poor prognosis. Conclusion NLR can be used as a reliable indicator for determining the healing status of diabetic foot ulcers.

Identification and antibiotic susceptibility of microorganisms isolated from diabetic foot ulcers: A pathological aspect

Diabetic foot ulcers infected with microorganisms increase the risk of amputation. The presence of drug-resistant bacteria in diabetic foot ulcers creates a big challenge during the treatment. The objective of the present study was to determine the bacterial prevalence and antibiotic resistance among bacteria isolated from Chinese patients with diabetic foot ulcers. The present study studied the microbial colonization of diabetic foot ulcers of patients from a single center in China. Wound swabs from 89 patients with diabetic foot ulcers were collected and the presence of microorganisms detected. The isolated microorganisms were subjected to antibiotic susceptibility testing by the disk diffusion method. Of 89 patients, 56 (62.9%) were male and 33 (37.1%) were female, the mean age of patients was 53.2±5.4 years, the mean duration of diabetes was 14.8±2.9 years, the mean random blood sugar was 301±87 mg/dl, mean HbA1c was 7.9±1.4%. Patients with Wanger ulcer grade III (36.0%; P=0.034) and patients within the weight range of 51-75 kg (59.6%; P=0.012) were significantly higher. The prevalence rate of diabetic foot ulcers was 11.3%. Among 153 microorganisms, gram-positive bacteria (52.3%) were more prevalent than gram-negative bacteria (44.4%). Most of the patients with polymicrobial infection were classified to have Wanger III ulcer grade diabetic foot ulcers. Staphylococcus aureus (38.2%) was the most predominant bacteria isolated followed by Staphylococcus epidermidis (29.2%) and Escherichia coli (28.1%). Most of the gram-positive and gram-negative bacteria were resistant to dicloxacillin (73.8%, P=0.021) and cefotaxime (50%), respectively and ~53.4% of the isolates were multi-drug resistance isolates, 61.8% of the Staphylococcus aureus were identified as methicillin-resistant Staphylococcus aureus and 61.8% of the gram-negative bacteria were extended-spectrum β-lactamase producers. Staphylococcus aureus and Escherichia coli were the predominant gram-positive and gram-negative bacteria isolated, respectively. Penicillin resistance was significantly higher among the gram-negative bacteria (P=0.019). Staphylococcus aureus and Escherichia coli were the predominant gram-positive and gram-negative bacteria isolated and levofloxacin and nitrofurantoin were the most effective antibiotics among the gram-positive and gram-negative bacterial isolates, respectively.