The Stress of Measuring Plantar Tissue Stress in People with Diabetes-Related Foot Ulcers: Biomechanical and Feasibility Findings from Two Prospective Cohort Studies

Reducing high mechanical stress is imperative to heal diabetes-related foot ulcers. We explored the association of cumulative plantar tissue stress (CPTS) and plantar foot ulcer healing, and the feasibility of measuring CPTS, in two prospective cohort studies (Australia (AU) and The Netherlands (NL)). Both studies used multiple sensors to measure factors to determine CPTS: plantar pressures, weight-bearing activities, and adherence to offloading treatments, with thermal stress response also measured to estimate shear stress in the AU-study. The primary outcome was ulcer healing at 12 weeks. Twenty-five participants were recruited: 13 in the AU-study and 12 in the NL-study. CPTS data were complete for five participants (38%) at baseline and one (8%) during follow-up in the AU-study, and one (8%) at baseline and zero (0%) during follow-up in the NL-study. Reasons for low completion at baseline were technical issues (AU-study: 31%, NL-study: 50%), non-adherent participants (15% and 8%) or combinations (15% and 33%); and at follow-up refusal of participants (62% and 25%). These underpowered findings showed that CPTS was non-significantly lower in people who healed compared with non-healed people (457 [117; 727], 679 [312; 1327] MPa·s/day). Current feasibility of CPTS seems low, given technical challenges and non-adherence, which may reflect the burden of treating diabetes-related foot ulcers.

What Are Diabetic Foot Ulcers?

This JAMA Patient Page describes diabetic foot ulcers and their evaluation and treatment.

Microenvironment-Based Diabetic Foot Ulcer Nanomedicine

Diabetic foot ulcers (DFU), one of the most serious complications of diabetes, are essentially chronic, nonhealing wounds caused by diabetic neuropathy, vascular disease, and bacterial infection. Given its pathogenesis, the DFU microenvironment is rather complicated and characterized by hyperglycemia, ischemia, hypoxia, hyperinflammation, and persistent infection. However, the current clinical therapies for DFU are dissatisfactory, which drives researchers to turn attention to advanced nanotechnology to address DFU therapeutic bottlenecks. In the last decade, a large number of multifunctional nanosystems based on the microenvironment of DFU have been developed with positive effects in DFU therapy, forming a novel concept of "DFU nanomedicine". However, a systematic overview of DFU nanomedicine is still unavailable in the literature. This review summarizes the microenvironmental characteristics of DFU, presents the main progress of wound healing, and summaries the state-of-the-art therapeutic strategies for DFU. Furthermore, the main challenges and future perspectives in this field are discussed and prospected, aiming to fuel and foster the development of DFU nanomedicines successfully.

Worldwide Research Trends on Diabetic Foot Ulcers (2004-2020): Suggestions for Researchers

OBJECTIVES

Diabetic foot ulcer (DFU) is one of the devastating complications of diabetes. It has high mortality and disability rates. The number of research articles on DFUs has increased. This study was designed to explore the global trends and research hotspots of DFUs to benefit researchers in shaping future research directions.

METHODS

Literatures relating to DFU from 2004 to 2020 were retrieved from the Science Citation Index Expanded (SCI-expanded) of Web of Science Core Collection (WoSCC). The current status of DFU research (including publications, journals, the performances of relevant countries, institutions, and authors and the research trends and hotspots of DFU) was analyzed with the WoSCC. VOSviewer v1.6.10.0 was utilised for cocitation, coauthorship, cooccurrence analyses, and bibliographic coupling.

RESULTS

A total of 5869 publications on DFUs were retrieved. We performed a longitudinal review of publications over 17 years: 4500 articles and 865 review articles on DFUs published from 2004 to 2020 were analyzed. The total citation was 107,296. The USA (n = 1866), England (n = 606), and China (n = 599) were the three largest contributors. The University of Washington had the greatest number of publications within this time period (n = 103), and it had the most cooperative units and was in the core position in all research institutions, followed by the University of Manchester (n = 94) and the University of Miami (n = 92). Armstrong DG (91/1.69%) and Lavery LA (55/1.19%) should be regarded as scholars who have made outstanding contributions. The top journal with the greatest total link strength was Diabetes Care. Analysis showed that the global research hotspots of DFU focused on lower limb amputation, diabetic foot infection, and treatment and management of DFU. Studies on osteomyelitis, wound therapy and management, multidisciplinary integration and mechanism of DFUs, and its related diseases are the research fronts that should be closely watched in the future.

CONCLUSIONS

This study revealed the current research status and hotspots in the domain of DFU over the past 17 years, which can help researchers to further pinpoint potential perspectives on hot topics and research frontiers.

Ginsenoside Rg1 promoted the wound healing in diabetic foot ulcers via miR-489-3p/Sirt1 axis

PURPOSE

Diabetic foot ulcers (DFUs) are common complications of high severity for diabetes. Ginsenoside Rg1 (Rg1) has the potential for diabetes and cardiovascular diseases therapy. This research aimed at exploring the regulation of Rg1 on DFUs treatment and the underlying mechanism.

METHODS

Human umbilical vein endothelial cells (HUVECs) incubated with high-glucose culture medium were established for induction of diabetes model. The MTT assay, Annexin V/PI assay and oxidative stress detection were carried out on high-glucose-induced HUVECs. Dual-luciferase reporter assay was performed to prove the interaction of miR-489-3p and Sirt1. DFUs model was established to determine the efficiency of Rg1 and miR-489-3p in wound closure of DFUs in vivo.

RESULTS

Rg1 promoted cell proliferation, migration and angiogenesis, and reduced cell apoptosis in high-glucose-induced HUVECs. Knockdown of miR-489-3p alleviated the high-glucose-induced damage to HUVECs, while overexpression of miR-489-3p attenuated the protection effects of Rg1. Overexpression Sirt1 promoted wound healing in DFUs and Sirt1 was a direct target of miR-489-3p. In addition, animal experiments demonstrated that Rg1 promoted wound closure by regulating miR-489-3p/Sirt1 axis.

CONCLUSIONS

Rg1 alleviated the DFUs by increasing Sirt1 expression via miR-489-3p downregulation and promoting activation of PI3K/AKT/eNOS signaling.

Associations between Nutrients and Foot Ulceration in Diabetes: A Systematic Review

We reviewed the literature to evaluate potential associations between vitamins, nutrients, nutritional status or nutritional interventions and presence or healing of foot ulceration in diabetes. Embase, Medline, PubMed, and the Cochrane Library were searched for studies published prior to September 2020. We assessed eligible studies for the association between nutritional status or interventions and foot ulcers. Fifteen studies met the inclusion criteria and were included in this review. Overall, there is a correlation between poor nutritional status and the presence of foot ulceration or a delay in healing. However, there is not enough data to reach conclusions about whether the relationships are causal or only association. Further research is required to test whether any forms of nutritional supplementation improve foot ulcer healing.

Deteriorated regional calf microcirculation measured by contrast-free MRI in patients with diabetes mellitus and relation with physical activity

OBJECTIVE

To evaluate regional calf muscle microcirculation in people with diabetes mellitus (DM) with and without foot ulcers, compared to healthy control people without DM, using contrast-free magnetic resonance imaging methods.

METHODS

Three groups of subjects were recruited: non-DM controls, DM, and DM with foot ulcers (DM + ulcer), all with ankle brachial index (ABI) > 0.9. Skeletal muscle blood flow (SMBF) and oxygen extraction fraction (SMOEF) in calf muscle were measured at rest and during a 5-min isometric ankle plantarflexion exercise. Subjects completed the Yale physical activity survey.

RESULTS

The exercise SMBF (ml/min/100 g) of the medial gastrocnemius muscle were progressively impaired: 63.7 ± 18.9 for controls, 42.9 ± 6.7 for DM, and 36.2 ± 6.2 for DM + ulcer, p < 0.001. Corresponding exercise SMOEF was the lowest in DM + ulcers (0.48 ± 0.09). Exercise SMBF in the soleus muscle was correlated moderately with the Yale physical activity survey (r = 0.39, p < 0.01).

CONCLUSIONS

Contrast-free MR imaging identified progressively impaired regional microcirculation in medial gastrocnemius muscles of people with DM with and without foot ulcers. Exercise SMBF in the medial gastrocnemius muscle was the most sensitive index and was associated with HbA1c. Lower exercise SMBF in the soleus muscle was associated with lower Yale score.

The impact of the COVID-19 pandemic on people with diabetes and diabetes services: A pan-European survey of diabetes specialist nurses undertaken by the Foundation of European Nurses in Diabetes survey consortium

AIM

To describe diabetes nurses' perspectives on the impact of the COVID-19 pandemic on people with diabetes and diabetes services across Europe.

METHODS

An online survey developed using a rapid Delphi method. The survey was translated into 17 different languages and disseminated electronically in 27 countries via national diabetes nurse networks.

RESULTS

Survey responses from 1829 diabetes nurses were included in the analysis. The responses indicated that 28% (n = 504) and 48% (n = 873) of diabetes nurses felt the COVID-19 pandemic had impacted 'a lot' on the physical and psychological risks of people with diabetes, respectively. The following clinical problems were identified as having increased 'a lot': anxiety 82% (n = 1486); diabetes distress 65% (n = 1189); depression 49% (n = 893); acute hyperglycaemia 39% (n = 710) and foot complications 18% (n = 323). Forty-seven percent (n = 771) of respondents identified that the level of care provided to people with diabetes had declined either extremely or quite severely. Self-management support, diabetes education and psychological support were rated by diabetes nurse respondents as having declined extremely or quite severely during the COVID-19 pandemic by 31% (n = 499), 63% (n = 1,027) and 34% (n = 551), respectively.

CONCLUSION

The findings show that diabetes nurses across Europe have seen significant increases in both physical and psychological problems in their patient populations during COVID-19. The data also show that clinical diabetes services have been significantly disrupted. As the COVID-19 situation continues, we need to adapt care systems with some urgency to minimise the impact of the pandemic on the diabetes population.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers.

Plantar soft tissues and Achilles tendon thickness and stiffness in people with diabetes: a systematic review

BACKGROUND

Diabetes mellitus is associated with changes in soft tissue structure and function. However, the directionality of this change and the extent to which either tissue thickness or stiffness contributes to the pathogenesis of diabetes-related foot ulcerations is unclear. Hence, this systematic review aims to summarise the existing evidence for soft tissue structural differences in the feet of people with and without diabetes.

METHODS

In compliance with MOOSE and PRISMA guidelines, AMED, CINAHL, MEDLINE, ProQuest Health & Medical Collection, ProQuest Nursing & Allied Health Database, and Web of Science electronic databases were systematically searched for studies published from database inception until 1st October 2020 [Prospero CRD42020166614]. Reference lists of included studies were further screened. Methodological quality was appraised using a modified critical appraisal tool for quantitative studies developed by McMaster University.

RESULTS

A total of 35 non-randomised observational studies were suitable for inclusion. Within these, 20 studies evaluated plantar tissue thickness, 19 studies evaluated plantar tissue stiffness, 9 studies evaluated Achilles tendon thickness and 5 studies evaluated Achilles tendon stiffness outcomes. No significant differences in plantar tissue thickness were found between people with and without diabetes in 55% of studies (11/20), while significantly increased plantar tissue stiffness was found in people with diabetes in 47% of studies (9/19). Significantly increased Achilles tendon thickness was found in people with diabetes in 44% of studies (4/9), while no significant differences in Achilles tendon stiffness were found between people with and without diabetes in 60% of studies (3/5).

CONCLUSIONS

This systematic review found some evidence of soft tissue structural differences between people with and without diabetes. However, uncertainty remains whether these differences independently contribute to diabetes-related foot ulcerations. The heterogeneity of methodological approaches made it difficult to compare across studies and methodological quality was generally inadequate. High-quality studies using standardised and validated assessment techniques in well-defined populations are required to determine more fully the role of structural tissue properties in the pathogenesis of diabetes-related foot ulcerations.

Differentiation of Diabetic Foot Ulcers Based on Stimulation of Myogenic Oscillations by Transient Ischemia

PURPOSE

Diabetic foot ulceration is a chronic complication characterized by impaired wound healing. There is a great demand for a diagnostic tool that is able to monitor and predict wound healing.

PATIENTS AND METHODS

Oscillations in the microcirculation, known as flowmotion, can be monitored very distinctly and precisely using the Flow Mediated Skin Fluorescence (FMSF) technique. The flowmotion response to hypoxia was measured quantitatively in 42 patients with diabetic foot ulcers.

RESULTS

The flowmotion response to hypoxia parameters FM(R) and HS were used to differentiate the diabetic foot ulcers and correlate them with clinical status. In some cases, FMSF measurements were continued over the period of a year in order to monitor disease progress. The clinical status of the quarter of patients with the highest HS values (group A, HS = 50.2±18.3) was compared to the quarter with the lowest HS values (group B, HS = 4.3±1.7). The patients in the group B were identified as having low prognosis for healing and were characterized by higher incidences of hypertension, hyperlipidemia, prevalent CVD, neuropathy and nephropathy.

CONCLUSION

Impaired flowmotion responses to hypoxia induced by transient ischemia can be used for differentiation of diabetic foot ulcers and identification of cases with low prognosis for healing.

Foot ulcer recurrence, plantar pressure and footwear adherence in people with diabetes and Charcot midfoot deformity: A cohort analysis

AIMS

To investigate people with Charcot midfoot deformity with regard to plantar pressure, footwear adherence and plantar foot ulcer recurrence.

METHODS

Twenty people with diabetes, Charcot midfoot deformity, plantar foot ulcer history and custom-made footwear were assessed with regard to barefoot and in-shoe plantar pressures during walking, footwear adherence (% of daily steps over 7-day period) and plantar foot ulcer recurrence over 18 months. In a cohort design, they were compared to 118 people without Charcot foot (non-Charcot foot group) with custom-made footwear and similar ulcer risk factors.

RESULTS

Median (interquartile range) barefoot midfoot peak pressures were significantly higher in the Charcot foot group than in the non-Charcot foot group [756 (260-1267) vs 146 (100-208) kPa; P<0.001]. In-shoe midfoot peak pressures were not significantly higher in the Charcot foot group [median (interquartile range) 152 (104-201) vs 119 (94-160) kPa] and significantly lower for all other foot regions. Participants in the Charcot foot group were significantly more adherent, especially at home, than participants in the non-Charcot foot group [median (interquartile range) 94.4 (85.4-95.0)% vs. 64.3 (25.4-85.7)%; P=0.001]. Ulcers recurred in 40% of the Charcot foot group and in 47% of the non-Charcot foot group (P=0.63); midfoot ulcers recurred significantly more in the Charcot foot group (4/8) than in the non-Charcot foot group (1/55; P=0.001).

CONCLUSIONS

Effective offloading and very high footwear adherence were found in people with diabetes and Charcot midfoot deformity. While this may help protect against plantar foot ulcer recurrence, a large proportion of such people still experience ulcer recurrence. Further improvements in adherence and custom-made footwear design may be required to improve clinical outcome.

The role of infrared dermal thermometry in the management of neuropathic diabetic foot ulcers

AIM

This prospective observational study evaluated the role of infrared (IR) dermal thermometry in the management of diabetic foot ulcers.

METHODS

Thirty participants with unilateral neuropathic diabetic foot ulcers of University of Texas grade 1 or 2 (stage A) were followed up monthly for 1 year. At each visit, skin temperatures were measured with an IR dermal thermometer at corresponding sites on both feet, using the contralateral feet without ulcers as controls.

RESULTS

Average temperature and ulcer temperature in affected feet were significantly higher than in unaffected feet, with a mean difference of 1.2 °C [95% confidence interval (CI) 0.7 to 1.7] and 3.1 °C (95% CI 2.3 to 3.9), respectively. Although the gradient between average temperature of affected foot and that of unaffected foot normalized (mean difference 0.2 °C, 95% CI -0.2 to 0.7) at healing, the temperature gradient between the ulcer and a corresponding site on the unaffected foot decreased but did not normalize (mean difference 2.1 °C, 95% CI 1.2 to 3.1) even at healing, as documented by skin closure, and persisted for up to 1 month after skin closure. A gradient of ≥1 °C between average temperature of affected foot and that of unaffected foot at initial presentation or at any time during ulcer healing was found to predict impaired healing and should alert clinicians to ulcers requiring more attention. An incremental trend in temperature gradient (median difference 2.2 °C; range 0.1-6.3 °C) at a site on the foot was predictive of a recurrent ulcer involving the same site.

CONCLUSIONS

IR dermal thermometry may have a role in predicting diabetic foot ulcer healing, in determining the completeness of healing and in guiding the duration of offloading. Serial monitoring of the temperature gradient may predict the development of recurrent diabetic foot ulcers.

Severe metabolic disorders coexisting with Werner syndrome: a case report

Werner syndrome, also called adult progeria, is a heritable autosomal recessive human disorder characterized by the premature onset of numerous age-related diseases including juvenile cataracts, dyslipidemia, diabetes mellitus (DM), osteoporosis, atherosclerosis, and cancer. Werner syndrome is a segmental progeroid syndrome whose presentation resembles accelerated aging. The most common causes of death for WS patients are atherosclerosis and cancer. A 40-year-old female presented with short stature, bird-like facies, canities with alopecia, scleroderma-like skin changes, and non-healing foot ulcers. The patient reported a history of delayed puberty, abortion, hypertriglyceridemia, and juvenile cataracts. A clinical diagnosis of WS was made and subsequently confirmed. We discovered two WRN gene mutations in the patient, Variant 1 was the most common WRN mutation, nonsense mutation (c.1105C>T:p.R369Ter) in exon 9, which caused a premature termination codon (PTC) at position 369. Variant 2 was a frameshift mutation (c.1134delA:p.E379KfsTer5) in exon 9, which caused a PTC at position 383 and has no published reports describing. Patients with WS can show a wide variety of clinical and biological manifestations in endocrine-metabolic systems (DM, thyroid dysfunction, and hyperlipidemia). Doctors must be cognizant of early manifestations of WS and treatment options.

Data-driven CAD-CAM vs traditional total contact custom insoles: A novel quantitative-statistical framework for the evaluation of insoles offloading performance in diabetic foot

Background

Elevated plantar pressures represent a significant risk factor for neuropathic diabetic foot (NDF) ulceration. Foot offloading, through custom-made insoles, is essential for prevention and healing of NDF ulcerations. Objective quantitative evaluation to design custom-made insoles is not a standard method. Aims: 1) to develop a novel quantitative-statistical framework (QSF) for the evaluation and design of the insoles’ offloading performance through in-shoe pressure measurement; 2) to compare the pressure-relieving efficiency of traditional shape-based total contact customised insoles (TCCI) with a novel CAD-CAM approach by the QSF.

Methods

We recruited 30 neuropathic diabetic patients in cross-sectional study design. The risk-regions of interest (R-ROIs) and their areas with in-shoe peak pressure statistically ≥200kPa were identified for each patients’ foot as determined on the average of peak pressure maps ascertained per each stance phase. Repeated measures Friedman test compared R-ROIs’ areas in three different walking condition: flat insole (FI); TCCI and CAD-CAM insoles.

Results

As compared with FI (20.6±12.9 cm²), both the TCCI (7±8.7 cm²) and the CAD-CAM (5.5±7.3 cm²) approaches provided a reduction of R-ROIs mean areas (p<0.0001). The CAD-CAM approach performed better than the TCCI with a mean pressure reduction of 37.3 kPa (15.6%) vs FI.

Conclusions

The CAD-CAM strategy achieves better offloading performance than the traditional shape-only based approach. The introduced QSF provides a more rigorous method to the direct 200kPa cut-off approach outlined in the literature. It provides a statistically sound methodology to evaluate the offloading insoles design and subsequent monitoring steps. QSF allows the analysis of the whole foot’s plantar surface, independently from a predetermined anatomical identification/masking. QSF can provide a detailed description about how and where custom-made insole redistributes the underfoot pressure respect to the FI. Thus, its usefulness extends to the design step, helping to guide the modifications necessary to achieve optimal offloading insole performances.

Identifying major predictors of lower-extremity amputation in patients with diabetic foot ulcers

BACKGROUND

The aim of the present study was to investigate the risk factors for amputation in patients with diabetic foot ulcer (DFU).

METHODS

Between 2012 and 2017, 646 patients with DFU were admitted to our diabetic foot care center. A retrospective chart review was performed, and the end point was limb salvage and minor or major amputation. Chi-square test, dependent t test, and a multivariate logistic regression analysis were performed to identify risk factors in patients with DFUs.

RESULTS

A total of 399 male and 247 female patients (mean age 64.6 years) were included in this study, of whom 159 (24.6%) underwent lower limb amputation (minor, 17.5; major, 7.1%). Independent risk factors of amputation were peripheral arterial disease (PAD) (odds ratio [OR], 3.196; p < 0.001), C-reactive protein (CRP) level (OR, 1.046; p = 0.001), and hospital stay (OR, 1.019; p = 0.001). Subgroup analysis based on all patients with PAD who underwent amputation showed that endovascular intervention (OR, 0.271; p = 0.049) was a protective factor for major amputation in addition to CRP level (OR, 1.116; p = 0.008).

CONCLUSION

DFU remains a major medical and public health issue. PAD, CRP level, and hospital stay are independent risk factors for amputation. Endovascular intervention is an independent protective factor against major amputation among patients with PAD who underwent amputation.

Saphenous nerve to posterior tibial nerve transfer: A new approach to restore sensations of sole in diabetic sensory polyneuropathy

BACKGROUND

Loss of sensations in the sole following diabetic sensorimotor polyneuropathy (DSPN) leads to diabetic foot ulcers and its sequelae. We hypothesized that sensory reinnervation of sole by transfer of saphenous nerve (SN) to sensory fascicles of posterior tibial nerve (PTN) in these patients may reverse the neuropathy.

METHODS

This prospective interventional case series included patients with advanced DSPN and intact sensory supply of SN. PTN was neurotized by transfer of SN nerve in the tarsal tunnel and postoperatively sensations of the sole were tested. Any existing ulcers on sole were noted and their healing was monitored.

FINDING

A total of 17 patients (22 feet), 9 male and 8 female, were included. Seven patients had ulcers in the feet. At 6 months follow-up all patients developed protective sensation in the sole. The average 2 PD improved from 60 mm to 45.5 mm, average vibration perception improved from 34.12 V to 24.33, Medical Research Council (MRC) score improved from S0 in 12 feet and S1 in 10 feet to S3+ in 13 feet, S3 in 5 feet, and S2 in 2 feet at 6 months along with healing of ulcers in all 7 feet.

INTERPRETATION

Transfer of SN to PTN for sensory neurotization is an innovative and simple option to prevent complications of DSPN. This procedure has the potential to change the natural history of DSPN.

Autologous Platelet-Rich Plasma for Diabetic Foot Ulcer

Application of autologous platelet-rich plasma (PRP), especially leukocyte- and platelet-rich fibrin (L-PRF), has emerged as a promising adjuvant therapy for the treatment of diabetic foot ulcers (DFUs). Conflicting results of PRP efficacy can be attributed to the lack of standardization in the PRP preparation process in addition to a paucity of well-designed randomized clinic trials (RCTs).

Correlation Between Extracutaneous Microvascular Complications and Diabetic Foot Ulcers in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetes is a metabolic disease that is taking an epidemic proportion around the world. The occurrence of microvascular complications and diabetic foot ulcer is associated with an increased mortality and morbidity incidence, which is the most serious complication of this disease, which significantly reduce the quality of patient life.

OBJECTIVE

The aim of the study was to determine the correlation of extracutaneous microvascular complications with diabetic foot ulcer in patients with type 2 diabetes.

METHOD

The study was prospective, and included 160 patients with type 2 diabetes. It was conducted at the University Clinical Center of the Republic of Srpska in the period from January 2016 until December 2019. The respondents were adults, of both sexes, suffering from type 2 diabetes, in whom complications of this disease are present. Glycemic control was established based on a target HbA1c value of 7%.

RESULTS

Of the 160 patients in the study, 53.8% were men and 46.2% were women. The average age of the patients was 70.11%±10.05 years. Extracutaneous microvascular complications were present in 85 patients (53.1%); of which 30.2% had well-regulated glycemia (HbA1c≤7.0%), while 61.5% (p<0.001) had unregulated glycemia (HbA1c≥7.0). Polyneuropathy was present in 23.3% of patients with HbA1c≤7.0%, while 41.0% of patients had HbA1c≥7.0% (p<0.043). Nephropathy with HbA1c≤7.0% was present in 36.8% of cases compared to patients with HbA1c≥7.0 in whom the prevalence was 36.8% (p<0.004). Out of total, 25.6% had retinopathy with HbA1c≤7.0%, while in 41.9% of patients with HbA1c≥7.0% (p <0.067). Diabetic ulcer foot was present in 13 patients with HbA1c≥7 (11.1%) compared to patients with HbA1c≤7.0% where there was no occurrence of this complication 0.0% (p<0.021). At the same time, 5.6% of patients had a diabetic foot ulcer with polyneuropathy (p=0.010), 4.4% had neuropathy (p=0.058) and 5.6% had retinopathy (p=0.014).

CONCLUSION

The high incidence of extracutaneous microvascular complications and diabetic foot ulcer in patients with type 2 diabetes requires a multidisciplinary approach of medical professionals that includes prevention of risk factors and good regulation of glycemia.

Evaluation of Polyvinyl Alcohol/Cobalt Substituted Hydroxyapatite Nanocomposite as a Potential Wound Dressing for Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) caused by diabetes are prone to serious and persistent infections. If not treated properly, it will cause tissue necrosis or septicemia due to peripheral blood vessel embolism. Therefore, it is an urgent challenge to accelerate wound healing and reduce the risk of bacterial infection in patients. In clinical practice, DFUs mostly use hydrogel dressing to cover the surface of the affected area as an auxiliary treatment. Polyvinyl alcohol (PVA) is a hydrophilic hydrogel polymer widely used in dressings, drug delivery, and medical applications. However, due to its weak bioactivity and antibacterial ability, leads to limited application. Filler adding is a useful way to enhance the biocompatibility of PVA. In our study, cobalt-substituted hydroxyapatite (CoHA) powder was prepared by the electrochemically-deposited method. PVA and PVA-CoHA nanocomposite were prepared by the solvent casting method. The bioactivity of the PVA and composite was evaluated by immersed in simulated body fluid for 7 days. In addition, L929 cells and E. coli were used to evaluate the cytotoxicity and antibacterial tests of PVA and PVA-CoHA nanocomposite. The results show that the addition of CoHA increases the mechanical properties and biological activity of PVA. Biocompatibility evaluation showed no significant cytotoxicity of PVA-CoHA composite. In addition, a small amount of cobalt ion was released to the culture medium from the nanocomposite in the cell culture period and enhanced cell growth. The addition of CoHA also confirmed that it could inhibit the growth of E. coli. PVA-CoHA composite may have potential applications in diabetic trauma healing and wound dressing.

Quality of life assessment in chronic wound patients using the Wound-QoL and FLQA-Wk instruments

OBJECTIVES

To evaluate changes in the quality of life of patients with chronic wounds.

METHODS

Quantitative research with a cross-sectional design performed with 100 patients with chronic wounds from a university hospital and a Basic Health Unit in southern Brazil. The mean values of the domains of the instruments Wound Quality of Life (Wound-QoL) and Freiburg Life Quality Assessment Wound were compared with sociodemographic variables of age, sex and education.

RESULTS

The average age of the participants was 60.98 years old; 41% (n = 41) had diabetic ulcers and 83% (n = 83) treated the wounds for more than 24 months. The total quality of life value was below the mean with 37.50/100 with (Wound-QoL) and 44.20/100 with (FLQA-Wk). The variables of gender, and educational level were not correlated with either of the two instruments used to assess the quality of life. The age variable was significantly correlated with the satisfaction item of the FLQA-Wk.

CONCLUSIONS

The quality of life of patients with chronic wounds was considered poor. The age variable was correlated with the satisfaction domain, showing that the older the age, the lower the satisfaction. The use of instruments to evaluate the quality of life of patients with chronic wounds may help an effective treatment plan.

Split Thickness Skin Graft of the Foot and Ankle Bolstered With Negative Pressure Wound Therapy in a Diabetic Population: The Results of a Retrospective Review and Review of the Literature

Split thickness skin graft (STSG) is a versatile procedure performed for the treatment of wounds resulting from varying pathology. This remains very useful because of its ability for quick healing and low complication rate. The surface of the foot and ankle is an area frequently affected by severe skin and soft tissue structure infections (SSTIs) whose treatment results in wounds. These infections and resultant surgical wounds are commonly seen patients with diabetes. The objective of the present study was to retrospectively evaluate initial healing and immediate post-operative outcomes following STSG application in a diabetic population when negative pressure wound therapy (NPWT) was used as a bolster. Ten patients were identified, including 11 surgical wounds, who underwent STSG bolstered with NPWT from January 2016 to October 2018. Mean follow-up was 13 months (range 1-33 months) with an average time to heal of 17 days (range 14-30 days) for 11 surgical wounds averaging 57 cm2 (range 6.3 - 91 cm2). Consistent improved outcomes have been demonstrated when compared to alternative bolstering techniques available in the literature making a STSG bolstered with NPWT a powerful tool in the reconstruction of diabetic foot wounds resulting from the treatment of infection.Levels of Evidence: Level IV.

Developing and Evaluating a Mobile Foot Care Application for Persons With Diabetes Mellitus: A Randomized Pilot Study

Ulceration of the foot is a major complication of diabetes mellitus, and optimal self-care may help prevent its development. Research suggests that mobile applications (apps) may affect behavioral change.

OBJECTIVE

The purpose of this study was to develop the Mobile Diabetic Foot Personal Care System (m-DAKBAS) and evaluate its effectiveness for patients with diabetes.

METHOD

During Phase 1, a mobile app that included communication features, remote patient monitoring, and information was developed and pilot-tested among 10 patients. The Phase 2 study, conducted from June 2017 to April 2018, used a 2-group, pre-test/post-test design to evaluate the effect of the app on patients' knowledge, behavior, and self-efficacy scores when used for 6 months. Both the experimental (app) and control groups participated in 1 education session at the start of the study.

RESULTS

Of 106 patients who enrolled, 88 completed the study (44 in the experimental group and 44 in the control group). Only 6 patients had received education about foot care previously. The average age of all participants was 51.63 years (SD = 8.08). There were significantly more women in the experimental group than in the control group (65% vs. 45.5%; P = 0.5). Each participant used the app for 24 weeks, and the data entry rate was 72.9%. Throughout the study, participants had 1977 data entries (blood glucose and foot observation) in total. Differences between pre- and post-intervention test scores were significantly higher for knowledge, behavior, and self-efficacy in both groups, but the difference was greater in the experimental group (P < .05). Only post-test knowledge scores were significantly higher in the experimental compared with the control group (P < .05). Compared to the start of the study, the proportion of participants with cracked/dry skin and inappropriate footwear was significantly lower in the experimental group but not in the control group.

CONCLUSION

In this study, education and follow-up via the mobile app and verbal-only instruction increased the knowledge, behavior, and self-efficacy scores of patients in both groups. Post-study knowledge scores were significantly higher in the experimental group than in the control group. Patient education remains a crucial component of optimal care, and further development, refinement, and testing of mobile applications to improve self-efficacy and reduce the risk of diabetic foot are warranted.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis

PURPOSE

A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients.

METHODS

The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU.

CONCLUSIONS

Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.

Physiological wound assessment from coregistered and segmented tissue hemoglobin maps

A handheld near-infrared optical scanner (NIROS) was recently developed to map for effective changes in oxy- and deoxyhemoglobin concentration in diabetic foot ulcers (DFUs) across weeks of treatment. Herein, a coregistration and image segmentation approach was implemented to overlay hemoglobin maps onto the white light images of ulcers. Validation studies demonstrated over 97% accuracy in coregistration. Coregistration was further applied to a healing DFU across weeks of healing. The potential to predict changes in wound healing was observed when comparing the coregistered and segmented hemoglobin concentration area maps to the visual area of the wound.

Heel Pressure Injuries: Consensus-Based Recommendations for Assessment and Management

Significance: A systematic approach to develop experts-based recommendations could have a favorable impact on clinical problems characterized by scarce and low-quality evidence as heel pressure ulcers. Recent Advances: A systematic approach was used to conduce a formal consensus initiative. A multidisciplinary panel of experts identified relevant clinical questions, performed a systematic search of the literature, and created a list of statements. GRADE Working Group guidelines were followed. An independent international jury reviewed and voted recommendations for clinical practice. Consent was developed according to Delphi rules and GRADE method was used to attribute grade of strength. Critical Issues: The extensive search of the literature retrieved 42 pertinent articles (26 clinical studies, 7 systematic reviews or meta-analysis, 5 other reviews, 2 consensus-based articles, and 2 in vitro studies). Thirty-five recommendations and statements were created. Only 1 of 35, concerning ankle-brachial pressure index reliability in diabetic patients, was rejected by the panel. No sufficient agreement was achieved on toe brachial index test to rule out the orphan heel syndrome, removing dry eschar in adult patients without vascular impairment, and using an antimicrobial dressing in children with infected heel pressure injuries. Eleven recommendations were approved with a weak grade of strength. Experts strongly endorsed 20 recommendations. Offloading, stages I and II pressure injuries, and referral criteria were areas characterized by higher level of agreement. Future Directions: We believe that the results of our effort could improve practice, especially in areas where clear and shared opinions emerged. Barriers and limits that could hinder implementation are also discussed in the article.

Assessment of Mineral Pathophysiology in Patients with Diabetic Foot Ulcer

Chronic non-healing diabetic foot ulcers (DFU) with a recurrence rate of over 50% in 3 years account for more than 1,08000 non-traumatic lower extremity amputations. Reports of altered mineral status and their role in pathogenesis of diabetes are well documented. However, little is known regarding their status and impact on severity of complications like foot ulcer. A hospital-based case control study was conducted in 64 subjects aged 40-60 years, attending the Podiatric and the Diabetes clinic of the institutional hospitals. Study subjects included were 32 diagnosed cases of type 2 diabetes having foot ulcers along with 32 age-matched diabetics without foot ulcer as controls. Fasting and post-prandial plasma glucose were estimated by glucose oxidase peroxidase method and HbA1c by high-performance liquid chromatography method. Serum zinc, magnesium and copper levels were estimated by colorimetric methods in semi-autoanalyser. Serum levels of zinc, copper and magnesium were significantly decreased in DFU cases as compared with diabetics without ulcers (p < 0.05). Correlation analysis revealed a significant inverse correlation of these minerals with all the glycaemic indices; the association being the strongest in case of zinc in both groups. The higher degree of mineral insufficiencies in the foot ulcer group of this study could be responsible for worsening the glycaemic control in diabetics leading to delayed healing of foot ulcers. The observed decrease of serum copper, magnesium and zinc levels in diabetics with foot ulcers appears to be proportionally related to the length of the diabetic disease. Thus, continuous monitoring and dietary supplementation of minerals in case of severe deficiencies might be beneficial in halting the progression of such complications.

Compounding Pearls -- Wound Care: Diabetic Foot Ulcers, Part 1

The often-debilitating ulcers that develop on the feet of patients with diabetes (i.e., "diabetic foot ulcers") are among the most common types of chronic wounds. Their persistent failure to heal despite treatment is a significant cause of morbidity in a patient population often challenged by concomitant health conditions and quality-of-life issues. When a commercially manufactured therapy does not adequately heal such lesions, a compounded formulation may offer an effective alternative. In those customized medications, several drugs with different mechanisms of action can be combined in strengths or titrations compatible with each patient's pharmacogenomics profile, and the formulation of a compound can be easily altered as healing progresses and/or the patient's medical needs change. In this first in a series of 2 articles on compounding for the treatment of diabetic foot ulcers, the types, pathophysiologic causes, risk factors, and treatment of those lesions are discussed and formulations that promote their healing are provided. In part 2 of the series, differences in the healing of acute and chronic wounds are examined, the results of pharmacotherapy in treating diabetic foot ulcers are reviewed, the effectiveness of several drugs that promote chronic-wound healing is assessed, and additional formulations effective in treating nonhealing wounds are presented.

Offloading for the Diabetic Foot: Considerations and Implications

Offloading the diabetic foot remains the major consideration for ulceration prevention and healing. This narrative literature review presents a brief overview of current guidelines for offloading the diabetic foot and discusses the implications that come with offloading treatment modalities and their effects on the kinetic chain of the lower extremity. We also present the latest innovative studies from the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science that advance the knowledge in this field and provide avenues for future research opportunities.

Major Improvement in Wound Healing Through Pharmacologic Mobilization of Stem Cells in Severely Diabetic Rats

Current therapeutic strategies for diabetic foot ulcer (DFU) have focused on developing topical healing agents, but few agents have controlled prospective data to support their effectiveness in promoting wound healing. We tested a stem cell mobilizing therapy for DFU using a combination of AMD3100 and low-dose FK506 (tacrolimus) (AF) in streptozocin-induced type 1 diabetic (T1DM) rats and type 2 diabetic Goto-Kakizaki (GK) rats that had developed peripheral artery disease and neuropathy. Here, we show that the time for healing back wounds in T1DM rats was reduced from 27 to 19 days, and the foot wound healing time was reduced from 25 to 20 days by treatment with AF (subcutaneously, every other day). Similarly, in GK rats treated with AF, the healing time on back wounds was reduced from 26 to 21 days. Further, this shortened healing time was accompanied by reduced scar and by regeneration of hair follicles. We found that AF therapy mobilized and recruited bone marrow-derived CD133⁺ and CD34⁺ endothelial progenitor cells and Ym1/2⁺ M2 macrophages into the wound sites, associated with enhanced capillary and hair follicle neogenesis. Moreover, AF therapy improved microcirculation in diabetic and neuropathic feet in GK rats. This study provides a novel systemic therapy for healing DFU.

Clinical study for external washing by traditional Chinese medicine in the treatment of multiple infectious wounds of diabetic foot: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Diabetic foot (DF) is among the most serious complications of type 2 diabetes. DF infection (DFI) is a key factor in the deterioration and development of DF, so controlling infection plays an important role in the treatment of the disease. Traditional Chinese medicine foot bath has been widely used in China as a complementary and alternative therapy to improve circulation and infection control of DF. However, the existing evidence shows that its efficacy and safety are still insufficient. We report a study protocol about a multicenter, double-blind, randomized, placebo controlled trial which aims to make well-designed clinical trials to evaluate the efficacy and safety of herbal medicine foot bath decoction (FBD) and explore the mechanism of external washing of Chinese herbs in DFI.

METHODS

This study is a multicenter, double-blind, randomized, placebo controlled clinical trial in which 60 eligible participants were randomly divided into an experimental group and control group at a 1:2 ratio. Both groups received the same basic treatment for DF disease, the experimental group used FBD and ordinary dressing changes, while half of the patients in the control group received placebo and ordinary dressings, and the other half received placebo and silver ion dressings. Patients in both groups will be evaluated weekly for efficacy during the intervention. The primary efficacy indicators include the types of wound pathogens, interleukin 6 and tumor necrosis factor α. Secondary efficacy indicators included blood glucose, blood lipids, wound area, lower extremity blood vessel diameter, blood flow speed, walking speed, walking distance, and traditional Chinese medicine syndrome scores. We will also conduct a safety evaluation of the drug at the end of the trial.

DISCUSSION

This multicenter, double-blind, randomized, placebo clinical trial not only provides data on the efficacy and safety of FBD, but also provides a novel treatment strategy for clinicians and DF patients.

Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis

PURPOSE OF STUDY

To investigate toe systolic blood pressure and/or toe-brachial pressure index in predicting healing post minor diabetic foot amputations.

KEY METHODS

A systematic search of EMBASE and PubMed (including Medline and The Cochrane Library) was conducted from database inception to 9 March 2020. Two authors independently reviewed and selected relevant studies. Quality was assessed with a modified Critical Appraisal Skill Programme checklist.

MAIN RESULTS

Ten studies met the inclusion criteria. Nine studies investigating toe systolic blood pressure reported healing occurred at mean toe systolic blood pressure values ⩾30 mmHg, ranging between 30 and 83.6 mmHg. The meta-analysis (four studies) found toe systolic blood pressure <30 mmHg had 2.09 times the relative risk of non-healing post amputation, compared to toe systolic blood pressure ⩾30 mmHg (relative risk = 2.09, 95% confidence interval: 1.37-3.20, p = 0.001). Two studies investigating toe-brachial pressure index report successful healing where toe-brachial pressure index >0.2, with one study reporting a higher value of 0.8.

MAIN CONCLUSIONS

Successful post-amputation healing outcomes were reported at mean toe systolic blood pressure ⩾30 mmHg, and the results varied considerably between the studies. Further research should identify whether variables, including amputation level, method of wound closure and length of post-operative follow-up periods, affect the values of toe systolic blood pressure and toe-brachial pressure index observed in this review.

Chronic Wounds: Evaluation and Management

Chronic wounds are those that do not progress through a normal, orderly, and timely sequence of repair. They are common and are often incorrectly treated. The morbidity and associated costs of chronic wounds highlight the need to implement wound prevention and treatment guidelines. Common lower extremity wounds include arterial, diabetic, pressure, and venous ulcers. Physical examination alone can often guide the diagnosis. All patients with a nonhealing lower extremity ulcer should have a vascular assessment, including documentation of wound location, size, depth, drainage, and tissue type; palpation of pedal pulses; and measurement of the ankle-brachial index. Atypical nonhealing wounds should be biopsied. The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound. After these general measures have been addressed, treatment is specific to the ulcer type. Patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention. Treatment of venous ulcers involves compression and elevation of the lower extremities, plus exercise if tolerated. Diabetic foot ulcers are managed by offloading the foot and, if necessary, treating the underlying peripheral arterial disease. Pressure ulcers are managed by offloading the affected area.

Monitoring wound progression to healing in diabetic foot ulcers using three-dimensional wound imaging

AIM

3D wound imaging has provided clinicians with even greater wound measurement options. No data is available to guide clinicians as to which 3D measurements may yield the most reflective marker of wound progression to healing.

METHOD

A prospective pilot study was undertaken to assess the accuracy of five 3D wound measurements that best reflect metrics of interest to clinicians. Twenty-one diabetic foot ulcers were enrolled from initial ulcer presentation, through to healing. The relationship between mean wound healing measurement variables was examined using linear regression and Pearsons correlation coefficient, in addition to assessing clinician inter-rater reliability of measurements using Intra-class correlation coefficients (ICC).

RESULTS

Statistical analysis demonstrated a linear healing slope for each wound measurement as having a value greater than R 0.70 and a statistical significance of p = 0.0001. This suggests that all five wound measurements are useful prognostic markers of wound progression to healing. Low variability of measurements between users indicates good inter-observer reliability.

CONCLUSION

3D wound measurements demonstrate a linear correlation between the measurement and time to healing. This suggests they could be effective prognostic markers of a wounds progression to healing and closure. It may also provide important early identification of wounds not responding to standard care. Larger studies are required to validate our results.

Diabetic foot and disaster; risk factors for amputation during the Syrian crisis

BACKGROUND

Diabetic foot patients in Syria faced many challenges and difficulties during the recent long term crisis that has prevailed since 2011. This study establishes the risk factors of diabetic foot amputation, either minor or major amputation. It also suggests facilities to improve diabetic foot care in the disaster.

METHODS

This is a retrospective study that reviewed diabetic foot outpatients' charts between Jan 2012 and Dec 2017 in Diabetic Foot Clinic in Damascus Teaching Hospital, Syria. We classified the lesions according to the final outcome into: non-amputation, minor and major amputation. We predicted the independent risk factors of lower extremity amputation (LEA).

RESULTS

A total of 2317 diabetic patients visited our clinic regularly with 2722 diabetic foot symptoms. We studied 2006 lesions belong to 1630 diabetic foot patients. They were divided into: group A (outcome without amputation, n = 1372), group B (outcome with minor amputation, n = 528) and group C (final outcome with major amputation, n = 106). Males were slightly predominant (56.73%; n = 1138), but with clearly higher risk of major amputation (6.77%; n = 77). 15.10% of patients was older than 70 years, with no significant relationship between age and amputation risk. According to Meggitt-Wagner classification system, the major amputation rate was (5.28%) in the lesions grade 1 through 5, it went up to (87.30) in isolated grade 5 lesions. The study recorded a degree of infection in (42.07%; n = 844) of the cases. The amputation rate went up in this group of patients to 38.5% and 8.44% for minor and major amputation, respectively. The presence of peripheral occlusive artery disease (PAD) doubled the minor amputation incidence one time (44.02%), and major amputation incidence five times (15.16%). The heel ulcer showed a great tendency toward the major amputation (18.80%), while the incidence rate in the DFUs spared heel was (3.36%). The war injuries of the diabetic foot was followed up in three cases that were treated conservatively and didn't considered an independent risk factor for amputation as long as the standard care was applied.

CONCLUSION

This article is the first one that discussed the reality of the diabetic foot care in disasters. It figures out that diabetic foot patients are obviously at higher risk of neglect during the crisis. In the absence of early detecting of wounds, deformities and PAD, DFUs likely come to the podiatrists in advanced stages. The unhealthy environment drives DFUs toward injuries, cellulites and infection. Non-Governmental Organizations (NGOs) and local institutions that work in crisis areas should pay attention for special care requirements of diabetic foot patients, for the standard care of the diabetic foot and the regular follow-up till the healing eventually.

The hemodynamic and pain impact of peripheral nerve block versus spinal anesthesia in diabetic patients undergoing diabetic foot surgery

PURPOSE

Comparison of hemodynamic profiles and pain scores in diabetic patients undergoing diabetic foot surgery receiving peripheral nerve block (PNB) or spinal anesthesia [subarachnoid block (SAB)].

METHODS

This was a prospective, randomised controlled trial. We recruited diabetic patients aged > 18 years, American Society of Anesthesiologists class II-III, who were scheduled for unilateral diabetic foot surgery below the knee. All patients were assessed for autonomic dysfunction using the Survey of Autonomic Symptoms score. Participants were randomly assigned to receive either PNB or SAB for the surgery. Hemodynamic data, including usage of vasopressors, were recorded at 5-min intervals for up to 1 h after the induction of anesthesia. Pain scores were recorded postoperatively, and follow-up was done via telephone 6 months later.

RESULTS

Compared to the PNB group, the SAB group had a larger number of patients with significant hypotension (14 vs. 1; p = 0.001) and more patients who required vasopressor boluses (6 vs. 0 patients). Compared to SAB group, the patients in the PNB group had a longer postoperative pain-free duration (9 vs. 4.54 h; p = 0.002) and lower pain scores 1 day after surgery (3.63 vs. 4.69; p = 0.01).

CONCLUSION

Peripheral nerve block should be considered, whenever possible, as the first option of anesthesia for lower limb surgery in diabetic patients as it provides hemodynamic stability and superior postoperative pain control compared to SAB.

TRIAL REGISTRATION

Clinical trial registry: ClinicalTrials.gov. ID NCT02727348.

The role of Sudoscan feet asymmetry in the diabetic foot

The aim of this study was to investigate the role of Sudoscan asymmetry parameters in the diabetic foot.

PATIENTS AND METHODS

In this study we included 165 participants: 84 type 2 diabetes patients divided into three HbA1c matched groups - group 1: newly diagnosed diabetics (n = 31), group 2: people with longer diabetes duration and established neuropathy (n = 33), group 3: patients with diabetic foot ulcer (n = 20), and a control group of 81 people with prediabetes. All subjects underwent peripheral sudomotor evaluation using Sudoscan device (Impeto Medical, Paris).

RESULTS

Patients with diabetic foot had significantly higher Sudoscan feet asymmetry (19.6%) compared to those with only diabetic neuropathy (7.9%), compared to the group with newly diagnosed diabetes (7.44%), and compared to controls (2.5%). This test has shown a good discriminative value (with a threshold of 9.5%) for diabetic foot with area under the ROC curve of 0.955 (p = 0.001). Additionally, in a regression model feet asymmetry proved its predictive value for participants with diabetic foot.

CONCLUSION

In this study Sudoscan feet asymmetry proved to be a novel discriminator and predictor for diabetic foot patients. It might be considered as a marker for early damage in the neuropathy evaluation protocol.

Use of a Remote Temperature Monitoring Mat for the Early Identification of Foot Ulcers

INTRODUCTION

Diabetic foot ulcers (DFUs) are responsible for considerable morbidity, mortality, and cost. Remote temperature monitoring (RTM) is an evidenced-based and recommended component of standard foot care for at-risk patients. Although previous research has demonstrated the value of RTM for foot ulcer prevention, its benefits related to the early identification of diabetic foot complications may be underappreciated.

OBJECTIVE

This article presents a case series supporting the use of RTM for early identification of DFUs.

MATERIALS AND METHODS

The cases of 4 veteran patients who presented consecutively with inflammation, which was detected by a telemedicine temperature monitoring mat, are reported. The authors collected subjective history from each patient via telephone outreach and triaged these patients according to standard diabetic foot care recommendations.

RESULTS

Each patient required a clinical exam prompted by the mat and the patient's subjective history. In each case, the patient required callus debridement upon which a pre-ulcerative lesion or partial-thickness wound was discovered. The DFUs in these 4 cases healed quickly and without complication. In 2 of the cases, the outreach prompted by the mat reestablished specialist foot care after a prolonged period without routine exam.

CONCLUSIONS

In each of these cases, the RTM mat detected inflammation accompanying a preulcerative lesion or a partial-thickness wound, allowing for timely intervention and treatment, including debridement and offloading, which may have the potential to improve care and reduce morbidity, mortality, and costs.

Study protocol for a randomized controlled trial on the effect of the Diabetic Foot Guidance System (SOPeD) for the prevention and treatment of foot musculoskeletal dysfunctions in people with diabetic neuropathy: the FOotCAre (FOCA) trial I

BACKGROUND

This study is part of a series of two clinical trials. Taking into account the various musculoskeletal alterations of the foot and ankle in people with diabetic peripheral neuropathy (DPN) and the need for self-care to avoid more serious dysfunctions and complications, a self-manageable exercise protocol that focuses on strengthening the foot muscles is presented as a potentially effective preventive method for foot and gait complications. The aim of this trial is to investigate the effect of a customized rehabilitation technology, the Diabetic Foot Guidance System (SOPeD), on DPN status, functional outcomes and gait biomechanics in people with DPN.

METHODS/DESIGN

Footcare (FOCA) trial I is a randomized, controlled and parallel two-arm trial with blind assessment. A total of 62 patients with DPN will be allocated into either a control group (recommended foot care by international consensus with no foot exercises) or an intervention group (who will perform exercises through SOPeD at home three times a week for 12 weeks). The exercise program will be customized throughout its course by a perceived effort scale reported by the participant after completion of each exercise. The participants will be assessed at three different times (baseline, completion at 12 weeks, and follow-up at 24 weeks) for all outcomes. The primary outcomes will be DPN symptoms and severity classification. The secondary outcomes will be foot-ankle kinematics and kinetic and plantar pressure distribution during gait, tactile and vibration sensitivities, foot health and functionality, foot strength, and functional balance.

DISCUSSION

As there is no evidence about the efficacy of rehabilitation technology in reducing DPN symptoms and severity or improving biomechanical, clinical, and functional outcomes for people with DPN, this research can contribute substantially to clarifying the therapeutic merits of software interventions. We hope that the use of our application for people with DPN complications will reduce or attenuate the deficits caused by DPN. This rehabilitation technology is freely available, and we intend to introduce it into the public health system in Brazil after demonstrating its effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04011267. Registered on 8 July 2019.

Mechanical Noise Improves the Vibration Perception Threshold of the Foot in People With Diabetic Neuropathy

BACKGROUND

Mechanical noise may improve somatosensation at the dorsal side of the foot, but the effect at the plantar side of the foot, the side most at risk for foot ulceration, is unknown. Moreover, techniques used in research so far have several problems that limit applicability in daily practice. Piezoelectric actuators may provide mechanical noise with better clinical applicability. We assessed the effects of piezoelectric actuators generating mechanical noise on the vibration perception threshold (VPT) at the plantar side of the foot in people with diabetic neuropathy.

METHODS

Double-blind within-subjects design in a controlled laboratory setting including participants with diabetic neuropathy (N = 40; 18 male; mean age 69.6 years; mean duration of diabetes 14.1 years; mean BMI 30.5). VPT was measured at three plantar foot locations with and without mechanical noise applied via piezoelectric actuators.

RESULTS

Mechanical noise improved VPT at metatarsophalangeal joint (MTP) 1 (left 39.3V vs 43.5V; right 39.0 vs 42.6 V), MTP5 (left 37.5V vs 41.7V; right 34.5V vs 40.8V) and the heel (left 40.0V vs 44.0V; right 39.3V vs 41.0V), all P < .001.

CONCLUSIONS

Mechanical noise improves VPT at the plantar side of the foot in people with diabetic neuropathy. This is an important step for further development of insoles using mechanical noise that may have the potential to improve VPT and decrease the risk of foot ulceration.

Diabetic Foot Surveillance Using Mobile Phones and Automated Software Messaging, a Randomized Observational Trial

BACKGROUND

Early detection of diabetic foot ulcers can improve outcomes. However, patients do not always monitor their feet or seek medical attention when ulcers worsen. New approaches for diabetic-foot surveillance are needed. The goal of this study was to determine if patients would be willing and able to regularly photograph their feet; evaluate different foot-imaging approaches; and determine clinical adequacy of the resulting pictures.

METHODS

We recruited adults with diabetes and assigned them to Self Photo (SP), Assistive Device (AD), or Other Party (OP) groups. The SP group photographed their own feet, while the AD group used a selfie stick; the OP group required another adult to photograph the patient's foot. For 8 weeks, we texted all patients requesting that they text us a photo of each foot. The collected images were evaluated for clinical adequacy. Numbers of (i) submitted and (ii) clinically useful images were compared among groups using generalized linear models and generalized linear mixed models.

RESULTS

A total of 96 patients consented and 88 participated. There were 30 patients in SP, 29 in AD, and 29 in OP. The completion rate was 77%, with no significant differences among groups. However, 74.1% of photographs in SC, 83.7% in AD, 92.6% in OP were determined to be clinically adequate, and these differed statistically significantly.

CONCLUSIONS

Patients with diabetes are willing and able to take photographs of their feet, but using selfie sticks or having another adult take the photographs increases the clinical adequacy of the photographs.Level of Evidence: II.

ARTERIAL INSUFFICIENCIES: Hyperbaric Oxygen Therapy for Selected Problem Wounds

The use of hyperbaric oxygen (HBO2) for the treatment of selected problem wounds has focused almost entirely on the diabetic foot ulcer (DFU) in recent years. The prevalence of DFUs in today's patient population and the reimbursement available for the treatment of DFUs have given it priority status in discussions about problem wounds, but there are sound fundamental reasons why additional oxygen may have benefits in the treatment of non-DFU wounds.

A Synoptic Overview of Neurovascular Interactions in the Foot

Diabetes is a worldwide public health concern as it is associated with various complications. One of the major complications of diabetes is diabetic foot syndrome that results in catastrophic events such as ulceration and amputation. Therefore, the main four strategies of diabetic foot care involve risk prediction, prevention, and early diagnosis and prompt intervention. The drivers of ulceration are multifactorial, and importantly, include microcirculatory changes in the diabetic skin. Cutaneous microcirculation on the foot is greatly influenced by the small fibers which mediate thermal sensation and pain perception in addition to sympathetic activities such as thermoregulation and vasodilation. The interdependence between the neurovascular elements means with the loss of small fiber functions, the corresponding microcirculatory responses may be compromised. Thus, it can be hypothesized that the impairment of the microcirculation may follow the order of the corresponding small fiber nerve dysfunction or vice versa. In this review, select neurovascular investigations that inform the cutaneous microcirculatory and small fiber nerve function in response to pain, cold, and heat and pressure stimuli are reviewed and discussed in this order of sensory loss: the loss of pain, cold, warmth, touch and deep pressure sensation. We also discuss the neurological and vascular characteristics of each of these neurovascular responses. This review highlights the influence of small fibers on cutaneous microcirculation and the need for prospective studies that can determine the course of microcirculatory impairment over time. This, in turn, may help clarify the exact role of microcirculatory changes in the pathway of ulceration. The insights from this review can be pertinent to understand key microcirculatory disturbances and given that the microcirculatory impairment develops at an early stage, relevant interventions can be implemented to possibly reverse or regress the course of the disease. Therefore, knowledge of the neurovascular interactions aids to map the disease progression for early diagnosis and prevention of adverse complications.

Clinical Utility of the Ankle-Brachial Index and Toe Brachial Index in Patients with Diabetic Foot Ulcers

BACKGROUND

This cross sectional study investigated the clinical use of the ankle-brachial index (ABI) and toe brachial index (TBI) in 91 type 2 diabetic foot ulcer patients who visited the diabetic foot clinic, Prince Sultan Military Medical City, Saudi Arabia during July 2017 and January 2018.

MATERIALS AND METHODS

The ABI and TBI facilitated the detection of peripheral arterial disease (PAD) and the patients' medical records were used to collect the clinical and demographic variables. The variables of duration (p = 0.047) and treatment (p = 0.046) of the ABI showed significant differences. Age (p = 0.034) and duration (p = 0.001) were the factors related to the diagnosis of TBI by the "χ2" test.

RESULTS

From the TBI, 26.4% of the patients were found to have PAD, while the ABI showed that 21.8% of patients had the condition. However, no statistical significance was noted. From the regression analysis, the variable duration of diabetes (≥ 20 years of age) was recognized as an independent risk factor for TBI.

CONCLUSION

In conclusion, it is recommended both the ABI and TBI to be used as screening tests for PAD in diabetic foot ulcer patients.

Infrared 3D Thermography for Inflammation Detection in Diabetic Foot Disease: A Proof of Concept

BACKGROUND

Thermal assessment of the plantar surface of the foot using spot thermometers and thermal imaging has been proven effective in diabetic foot ulcer prevention. However, with traditional cameras this is limited to single spots or a two-dimensional (2D) view of the plantar side of foot, where only 50% of the ulcers occur. To improve ulcer detection, the view has to be extended beyond 2D. Our aim is to explore for proof of concept the combination of three-dimensional (3D) models with thermal imaging for inflammation detection in diabetic foot disease.

METHOD

From eight participants with a current diabetic foot ulcer we simultaneously acquired a 3D foot model and three thermal infrared images using a high-resolution medical 3D imaging system aligned with three smartphone-based thermal infrared cameras. Using spatial transformations, we aimed to map thermal images onto the 3D model, to create the 3D visualizations. Expert clinicians assessed these for quality and face validity as +, +/-, -.

RESULTS

We could replace the texture maps (color definitions) of the 3D model with the thermal infrared images and created the first-ever 3D thermographs of the diabetic foot. We then converted these models to 3D PDF-files compatible with the hospital IT environment. Face validity was assessed as + in six and +/- in two cases.

CONCLUSIONS

We have provided a proof of concept for the creation of clinically useful 3D thermal foot images to assess the diabetic foot skin temperature in 3D in a hospital IT environment. Future developments are expected to improve the image-processing techniques to result in easier, handheld applications and driving further research.

Cellular Senescence as the Pathogenic Hub of Diabetes-Related Wound Chronicity

Diabetes is constantly increasing at a rate that outpaces genetic variation and approaches to pandemic magnitude. Skin cells physiology and the cutaneous healing response are progressively undermined in diabetes which predisposes to lower limb ulceration, recidivism, and subsequent lower extremities amputation as a frightened complication. The molecular operators whereby diabetes reduces tissues resilience and hampers the repair mechanisms remain elusive. We have accrued the notion that diabetic environment embraces preconditioning factors that definitively propel premature cellular senescence, and that ulcer cells senescence impair the healing response. Hyperglycemia/oxidative stress/mitochondrial and DNA damage may act as major drivers sculpturing the senescent phenotype. We review here historical and recent evidences that substantiate the hypothesis that diabetic foot ulcers healing trajectory, is definitively impinged by a self-expanding and self-perpetuative senescent cells society that drives wound chronicity. This society may be fostered by a diabetic archetypal secretome that induces replicative senescence in dermal fibroblasts, endothelial cells, and keratinocytes. Mesenchymal stem cells are also susceptible to major diabetic senescence drivers, which accounts for the inability of these cells to appropriately assist in diabetics wound healing. Thus, the use of autologous stem cells has not translated in significant clinical outcomes. Novel and multifaceted therapeutic approaches are required to pharmacologically mitigate the diabetic cellular senescence operators and reduce the secondary multi-organs complications. The senescent cells society and its adjunctive secretome could be an ideal local target to manipulate diabetic ulcers and prevent wound chronification and acute recidivism. This futuristic goal demands harnessing the diabetic wound chronicity epigenomic signature.

Prevalence of Obstructive Sleep Apnea in Patients With Diabetic Foot Ulcers

Objectives: Diabetic foot ulcers (DFUs) are a considerable burden on patients and the healthcare service system. Patients with DFUs have many risk factors that might contribute to obstructive sleep apnea (OSA). The purposes of this study were to assess the prevalence of OSA and associated features in patients with DFUs. Methods: Between July 2017 and June 2019, we recruited 245 consecutive patients who sought for treatment at West China Hospital because of DFUs. Polysomnography data from 127 Patients were included in the final analysis. Results: Of the 127 patients, with a median age of 64 years (interquartile range, 55-73 years; range, 36-86 years) and a mean body mass index (BMI) 24.09 ± 0.37 kg/m², 91 (72%) were men. The prevalence of OSA [apnea-hypopnea index (AHI) ≧5/h] was 92% in men and 97% in women (P = 0.304). Moderate to severe OSA (AHI ≧15/h) was noted in 44 men (48%) and 26 women (72%) (P = 0.015). The risk factors associated with the severity of OSA were sex, age, smoking, alcohol use, and duration of diabetes. After multivariable adjustment, duration of diabetes and age were independent predictive factors of the severity of OSA. No significant association was observed between BMI, waist circumference, Epworth score, and the severity of OSA. There were no significant associations between OSA and ischemic heart disease, cerebral infarction, hypertension, diabetic retinopathy, diabetic kidney disease, and peripheral artery disease. Conclusions: The prevalence of OSA was high in patients with DFUs, with moderate to severe OSA accounting for more than half of the patients. Age and duration of diabetes were independent predictive factors of the severity of OSA.

Describing Normative Foot Temperatures in Patients With Diabetes-Related Peripheral Neuropathy

BACKGROUND

Prior research shows increased foot temperatures are predictive of diabetes-related foot complications. Our aim was to describe normative skin foot temperatures for individuals with diabetic peripheral neuropathy to better inform new technologies. We also explored for potential risk factors which correlate with changes in foot temperatures.

METHODS

We conducted a retrospective chart review of adult patients >18 years of age with diabetes mellitus and clinically diagnosed diabetic peripheral neuropathy with pedal digital thermometry performed between 2009 and 2018. A total of 58 patients met these criteria. Univariate modeling was based on covariates that may affect foot temperature including age, peripheral arterial disease, toe pressure, seasonality of measurement, smoking pack-years, caffeine use, insulin use, and calcium channel blocker use.

RESULTS

In patients with diabetic peripheral neuropathy, mean toe temperatures of 27.67°C (6.300°C), forefoot of 28.58°C (5.36°C), midfoot of 29.21°C (3.81°C), and rearfoot of 29.88°C(3.83°C) were demonstrated. A modest negative correlation between seasonality and toe and metatarsal temperatures (r = -0.38, P < .05; r = -0.43 P < .01, respectively) was demonstrated. Midfoot temperatures were modestly and positively correlated to the presence of small fiber symptoms (r = 0.33, P = .03). Positive modest correlation with rearfoot temperatures and amount of pack-year history (r = 0.30, P = .03) was seen.

CONCLUSION

Normative foot temperatures in neuropathic patients were found to be inversely associated with seasonality at the toe and metatarsal level. Smoking and pack-year history demonstrate modest correlation previously unseen in temperature analyses and warrant further exploration. Normative temperatures in neuropathic patients can better inform new technologies for the prevention of diabetic foot ulcer and Charcot neuroarthropathy.

Dryness of Foot Skin Assessed by the Visual Indicator Test and Risk of Diabetic Foot Ulceration: A Prospective Observational Study

Research Question: Previous cross-sectional studies have shown an association between sudomotor dysfunction and diabetic foot ulceration (DFU). The aim of this prospective multicenter study was to determine the role of dryness of foot skin and of established neurological modalities in the prediction of risk for foot ulceration in a cohort of individuals with diabetes mellitus (DM). Design: The study was conducted from 2012 to 2017. A total of 308 subjects with DM without history of DFU or critical limb ischemia completed the study. Diabetic neuropathy was assessed using the neuropathy symptom score (NSS) and neuropathy disability score (NDS). In a subset of participants, vibration perception threshold (VPT) was evaluated. Dryness of foot skin was assessed by the visual indicator plaster method (IPM). The diagnostic performance of the above neurological modalities for prediction of DFU was tested by receiver operating characteristic curve (ROC) analysis. Results: During the 6-year follow-up, 55 patients (annual ulceration incidence 2.97%) developed DFU. Multivariate Cox-regression analysis after controlling for the effect of age, gender, and DM duration demonstrated that the risk (hazard ratio, 95% confidence intervals) of DFU increased significantly with either abnormal IPM (3.319, 1.460-7.545, p = 0.004) or high (≥6) NDS (2.782, 1.546-5.007, p = 0.001) or high (≥25 volts) VPT (2.587, 1.277-5.242, p = 0.008). ROC analysis showed that all neurological modalities could discriminate participants who developed DFU (p < 0.001). IPM testing showed high sensitivity (0.86) and low specificity (0.49), while high vs. low NDS and VPT showed low sensitivity (0.40 and 0.39, respectively) and high specificity (0.87 and 0.89, respectively) for identification of patients at risk for DFU. Conclusion: Dryness of foot skin assessed by the IPM predicts the development of DFU. IPM testing has high sensitivity, whereas high NDS and VPT have high specificity in identifying subjects at risk for DFU. The IPM can be included in the screening methods for identification of the foot at risk.

Infrared Thermography and Vascular Disorders in Diabetic Feet

AIM

Diabetes mellitus (DM) and related foot complications constitute a growing healthcare burden. Diabetes mellitus is associated with lower-limb amputation, but diabetic foot assessment is challenging. Here, we evaluated a novel noninvasive diagnostic method-infrared thermography (IRT) -assessing its diagnostic potential compared to conventional noninvasive measurements.

METHODS

This study included patients with DM (n = 118) and healthy controls (n = 93). All participants underwent ankle brachial index and toe pressure (TP) measurements, and IRT using a standardized protocol with temperature measurement at five foot areas.

RESULTS

Compared to controls, patients with DM generally had warmer feet and exhibited a significantly greater temperature difference between feet (P < .001). Mean temperatures were highest in patients with DM with neuroischemia, followed by neuropathy. Patients with DM with angiopathy showed the lowest mean temperature-similar to controls and noncomplicated diabetics. Mean temperatures at all measurement sites were significantly higher with abnormal TP (<50 mmHg) than normal TP (≥50 mmHg) (P < .001). Infrared thermography revealed differences between angiosome areas, subclinical infections, and plantar high-pressure areas.

CONCLUSION

Infrared thermography revealed local temperature differences in high-risk diabetic feet. Normal skin surface temperature varies between individuals, but in combination with other tools, IRT might be useful in clinical screening.

CLINICALTRIALS ID

14212016.