The pathway to foot ulceration in diabetes

[Multidisciplinary management of diabetic foot ulcer infection]

Infection is one of the most common complications of diabetic foot ulceration resulting in lower extremity amputations and early mortality in this population. Several factors influence the course of diabetic foot ulceration infection and in that context, integrated multidisciplinary management is required as soon as possible. In fact, a holistic interdisciplinary approach should be the standard of care. Whether the infection is categorized as mild, moderate or severe, with or without bone infection, the overall individual's characteristics must be addressed, in addition to local wound care, offloading and antibiotic therapy. Some severe infections have potential indications for hospitalization and are considered as surgical emergencies. In some DFU cases, surgical revascularization of the limb is mandatory to treat the infection. However, surgical interventions and amputations, are sometimes inevitable, they are predictors of bad prognosis. Although some adjuvant therapies are effective to promote wound healing, their use is not recommended to treat diabetic foot ulcer infection. Infection management can be divided into three general interventions: proper clinical diagnosis, microbiological and imaging investigations, and treatment. This review is an update on the up-to-date evidences in scientific literature and includes the latest recommendations from the International Working Group on the Diabetic Foot (IWGDF).

Prevalence and Risk Evaluation of Diabetic Complications of the Foot Among Adults With Type 1 and Type 2 Diabetes in a Large Canadian Population (PEDAL Study)

OBJECTIVES

The lower limb complications of diabetes contribute significantly to patient morbidity and health-care costs in Canada. Despite practice guidelines, awareness of and screening for modifiable early pathologies has been inconsistent. Our study objective was to determine the prevalence and types of early foot pathology in a large, Canadian, community care-based diabetes population.

METHODS

This study was a retrospective, observational analysis of the LMC Diabetes & Endocrinology foot care program launched in 2017. We examined foot pathologies associated with vascular, nerve, nail and dermatologic complications, as well as foot deformities. Individuals ≥18 years of age and with diabetes, assessed by an LMC chiropodist in Ontario between February 2018 and April 2019, were included in the analysis.

RESULTS

Of the 5,084 individuals assessed, 470 with type 1 diabetes and 3,903 with type 2 diabetes met the study criteria. Mean age, body mass index and diabetes duration was 61.5 years, 31.3 kg/m² and 13.9 years, respectively. Reduced pedal pulses, sensory neuropathy and onychomycosis were reported in 8.9%, 16.7% and 14.5% of those in the type 1 diabetes group, and 19.4%, 26.6% and 28.7% of those in the type 2 group, respectively. Hyperkeratosis was present in 51% and foot deformities were present in 44.5% among both groups. Foot ulcer prevalence was 1.7% and pedal pulses, sensory neuropathy, hyperkeratosis and onychauxis, adjusted for age, sex, body mass index and diabetes duration, were each significantly associated with ulceration.

CONCLUSIONS

In a large foot screening program of community-based adults with diabetes, modifiable early foot pathologies were prevalent and provided further evidence of the value of consistent screening to alleviate the morbidity and economic burden of lower limb complications.

Metatarsal Head Resection Versus a Removable Mechanical Device for Offloading of the Neuropathic Diabetic Plantar Forefoot Ulcer

Although surgical offloading seems a more permanent solution for prevention and treatment of neuropathic plantar diabetic forefoot ulcers (DFUs), the evidence for this assumption is weak and needs further studies to be established. The aim of this retrospective study is to compare the healing efficacy, associated morbidity, and recurrence rates of surgical versus removable knee-high offloading for neuropathic plantar (DFUs) healing. From January 2016 to January 2018, 70 neuropathic plantar forefoot DFUs were nonrandomly assigned to either removable knee-high cam-walker (n = 35), or metatarsal head, or accessory bone resection (n = 35). The primary endpoints were the frequency and rate of complete healing, and the rate of ulcer area reduction within 4 months. The secondary endpoints were 4 months morbidity and ulcer recurrence within 12 months. After 4 months, complete healing was significantly inferior with cam-walker compared with surgical offloading; 24 (67.6%) versus 31 patients (88.6%), respectively, P = .015. Ulcer area reduction was 2.4 cm² (66.7%) versus 2.6 cm² (83.9%), P = .001, in the mechanical versus the surgical groups, respectively. The mean healing time was 3.6 ± 2.1 versus 2.8 ± 0.6 months in the mechanical versus the surgical groups, respectively, P = .012. Morbidity and recurrence show nonsignificant differences between both groups. Ulcer recurrence was noted in 5/35 (14.3%) versus 2/35 (5.7%), in mechanical versus surgical groups, respectively, P = .23. Therefore, metatarsal head/accessory bone resection offered improved healing efficacy but similar morbidity and recurrence to the removable cam-walker.

The effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, double-blind, placebo-controlled trial

This study was conducted to determine the effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer (DFU). The current randomized, double-blind, placebo-controlled trial was conducted among 60 patients with grade 3 DFU. Participants were randomly allocated into two groups (30 participants each group), received either 80 mg nanocurcumin daily for 12 weeks or placebo. Primary endpoints in this study were serum insulin levels and insulin resistance. Curcumin intake significantly decreased fasting plasma glucose (p = .02), insulin (p = .01), insulin resistance (p = .02), and significantly increased insulin sensitivity (p = .008) compared with the placebo. Moreover, curcumin intake led to a significant reduction in total- (p < .001), LDL-cholesterol (p < .001), and a significant increase in total antioxidant capacity (TAC) (p < .001) and total glutathione (GSH) (p = .01) compared with the placebo. However, there was no significant improvement in wound healing parameters. Overall, our study demonstrated that nanocurcumin intake in patients with DFU resulted in a significant improvement of glycemic control, total- and LDL-cholesterol, TAC, and GSH but did not affect the indicators of ulcer size.

Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

Gene-activated dermal equivalents to accelerate healing of diabetic chronic wounds by regulating inflammation and promoting angiogenesis

Diabetic chronic wound, characterized by prolonged inflammation and impaired angiogenesis, has become one of the most serious challenges in clinic and pose a significant healthcare burden worldwide. Although a great variety of wound dressings have been developed, few of encouraged achievements were obtained so far. In this study, the gene-activated strategy was applied to enhance sustained expression of vascular endothelial growth factor (VEGF) and achieve better healing outcomes by regulating inflammation and promoting angiogenesis. The gene-activated bilayer dermal equivalents (Ga-BDEs), which has good biocompatibility, were fabricated by loading the nano-sized complexes of Lipofectamine 2000/plasmid DNA-encoding VEGF into a collagen-chitosan scaffold/silicone membrane bilayer dermal equivalent. The DNA complexes were released in a sustained manner and showed the effective transfection capacities to up-regulate the expression of VEGF in vitro. To overcome cutaneous contraction of rodents and mimic the wound healing mechanisms of the human, a reformative rat model of full-thickness diabetic chronic wound was adopted. Under the treatment of Ga-BDEs, speeding wound healing was observed, which is accompanied by the accelerated infiltration and phenotype shift of macrophages and enhanced angiogenesis in early and late healing phases, respectively. These proved that Ga-BDEs possess the functions of immunomodulation and pro-angiogenesis simultaneously. Subsequently, the better regeneration outcomes, including deposition of oriented collagen and fast reepithelialization, were achieved. All these results indicated that, being different from traditional pro-angiogenic concept, the up-regulated expression of VEGF by Ga-BDEs in a sustained manner shows versatile potentials for promoting the healing of diabetic chronic wounds.

Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities

Of all the late complications of diabetes, those involving the foot have traditionally required more face-to-face patient visits to clinics to treat wounds by debridement, offloading, and many other treatment modalities. The advent of the coronavirus disease 2019 (COVID-19) pandemic has resulted not only in the closing of most outpatient clinics for face-to-face consultations but also in the inability to perform most laboratory and imaging investigations. This has resulted in a paradigm shift in the delivery of care for those with diabetic foot ulcers. The approaches to this challenge in two centers with an interest in diabetic foot disease, including virtual consultations using physician-to-patient and physician-to-home nurse telemedicine as well as home podiatry visits, are described in this review and are illustrated by several case vignettes. The outcomes from these two centers suggest that we may be witnessing new possibilities in models of care for the diabetic foot.

Neuropathy, claw toes, intrinsic muscle volume, and plantar aponeurosis thickness in diabetic feet

BACKGROUND

The objective of this study was to explore the relationships between claw toe deformity, peripheral neuropathy, intrinsic muscle volume, and plantar aponeurosis thickness using computed tomography (CT) images of diabetic feet in a cross-sectional analysis.

METHODS

Forty randomly-selected subjects with type 2 diabetes were selected for each of the following four groups (n = 10 per group): 1) peripheral neuropathy with claw toes, 2) peripheral neuropathy without claw toes, 3) non-neuropathic with claw toes, and 4) non-neuropathic without claw toes. The intrinsic muscles of the foot were segmented from processed CT images. Plantar aponeurosis thickness was measured in the reformatted sagittal plane at 20% of the distance from the most inferior point of the calcaneus to the most inferior point of the second metatarsal. Five measurement sites in the medial-lateral direction were utilized to fully characterize the plantar aponeurosis thickness. A linear mixed-effects analysis on the effects of peripheral neuropathy and claw toe deformity on plantar aponeurosis thickness and intrinsic muscle volume was performed.

RESULTS

Subjects with concurrent neuropathy and claw toes had thicker mean plantar aponeurosis (p < 0.006) and may have had less mean intrinsic muscle volume (p = 0.083) than the other 3 groups. The effects of neuropathy and claw toes on aponeurosis thickness were synergistic rather than additive. A similar pattern may exist for intrinsic muscle volume, but results were not as conclusive. A negative correlation was observed between plantar aponeurosis thickness and intrinsic muscle volume (R² = 0.323, p < 0.001).

CONCLUSIONS

Subjects with concurrent neuropathy and claw toe deformity were associated with the smallest intrinsic foot muscle volumes and the thickest plantar aponeuroses. Intrinsic muscle atrophy and plantar aponeurosis thickening may be related to the development of claw toes in the presence of neuropathy.

Survival at 10 years following lower extremity amputations in patients with diabetic foot disease

BACKGROUND

Amputations are associated with markedly reduced long-term survival in patients with diabetic foot disease. However, there is paucity of long-term survival data in published literature.

METHODS

We searched the electronic case records and laboratory details of patients who underwent amputations between 1997 and 2006 to obtain at least 10 years of follow up data after the surgery to assess the survival rates and possible risk factors reducing survival in the year 2016. Amputation level below ankle was considered as minor and above ankle as major amputations.

RESULTS

Of the 233 cases (159 males; median age 68 years), 161 had major amputations. Of the 72 cases who had minor amputations initially, 63 needed a further amputation or contralateral amputation on follow up. One hundred seventy-seven patients (76%) were not alive after 10 years of follow up. The survival rates at 1, 3, 5, 7, and ≥10 years were 64%, 50%, 40%, 34%, and 24%, respectively. Maximum number of deaths occurred within 4 months of amputations. There was no difference between survival rates following major or minor amputations and among males or females. The only statistically significant parameter affecting lower survival rate was age ≥70 years, with each additional year of age increasing the hazard by a factor of 1.039 (95% CI: 1.024-1.054) or 3.9% (2.4-5.4%).

CONCLUSIONS

Five-year and 10-year survival rates were 40% and 24%, respectively, following diabetic foot amputations. Higher age ≥70 years was associated with lower survival rate compared with younger age groups after lower extremity amputations.

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis

Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower extremity amputations (LEAs), but there is heterogeneity between team members and interventions. Podiatrists have been suggested as “gatekeepers” for the prevention and management of DFUs. The purpose of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a systematic review of available literature. Data’s heterogeneity about DFU outcomes made it impossible for us to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for MDTs that include podiatry. We found statistical significance in favour of an MDT approach including podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54–0.89, I² = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23–0.90, I² = 67%, P < 0.02). Our systematic review, with a standard search strategy, is the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for DFU management. Our observations support the literature that MDTs including podiatrists have a positive effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in team approach in daily practice and in published literature.

A Metabolic Insight Into the Neuroprotective Effect of Jin-Mai-Tong (JMT) Decoction on Diabetic Rats With Peripheral Neuropathy Using Untargeted Metabolomics Strategy

Jin-Mai-Tong (JMT) decoction is a traditional Chinese compound prescription for treating diabetic peripheral neuropathy (DPN). The aim of this study is to investigate the neuroprotective effect of JMT decoction on diabetic rats with peripheral neuropathy and to elucidate the potential mechanism based on a metabolomics approach. Sprague-Dawley (SD) rats were randomly divided into four groups: control group, Streptozotocin (STZ) induced model group, JMT low dose (JMT-L) treated group and JMT high dose (JMT-H) treated group. After 12 weeks of treatment, behavioral changes, small fiber loss, and histopathological damages of sciatic nerves were estimated. Serum samples were collected for untargeted metabolomics analysis based on UPLC/QTOF-MS and multivariate statistics. As a result, JMT treatment at two dosages (13.9 and 27.8 g/kg⋅d) evidently improved the mechanical pain threshold (P < 0.05), increased the intraepidermal nerve fiber density (IENFD) and subepidermal nerve fiber density (SNFD) (P < 0.05), and renovated the demyelination and axonal atrophy of sciatic nerves on DPN rats. Furthermore, metabolomics study revealed that the serum metabolic profiles altered significantly among the control group and the STZ-induced model group. A total of 21 metabolites were identified as potential biomarkers related to the therapeutic effect of JMT decoction. Among them, 16 biomarkers were found in both JMT-H and JMT-L treated groups, while the five others were specific to JMT-H group. These metabolites mainly involved in lipid metabolism, tricarboxylic acid (TCA) cycle, amino acid metabolism, and so on. Besides, correlation analysis indicated that both mechanical pain threshold and distal nerve fiber density were negatively correlated with the serum levels of metabolites from lipid metabolism and TCA cycle. In conclusion, the results demonstrated that JMT decoction has an obvious protective effect against DPN, which could be mediated via ameliorating the metabolic disorders in diabetic rats with peripheral neuropathy.

Impact of socioeconomic status on the clinical profile of patients with non-traumatic lower-limb amputation

INTRODUCTION

To analyse the influence of socioeconomic status on the clinical profile of patients undergoing non-traumatic lower-limb amputation.

METHODS

Retrospective study of 697 lower-limb amputee patients in an Angiology and Vascular Surgery Department during a 5-year period. Patients were classified according to their socioeconomic status (low, medium and high). We analysed demographic (age and gender) and clinical variables (cause of amputation, comorbidity, cardiovascular risk factors and amputation level).

RESULTS

Mean age was 70.5 ± 11.9 years, and the median was 72 years. The low socioeconomic status group presented a higher frequency of amputations in men. Cardiovascular risks factors were more frequent in this socioeconomic group, and the difference was statistically significant for diabetes (85.8% low, 69.3% medium, 65% high; P<.01) and obesity (31.4% low, 22.6% medium, 12.5% high, P<.01). Diabetic retinopathy was the only comorbidity with a significant association with low socioeconomic status (21.1% low, 15.3% medium, 12.5% high, P<.03). Regarding the cause for amputation, there was no difference in terms of socioeconomic status. The low socioeconomic level showed a higher frequency of major amputation, which was a significant difference (63.6% low, 41.2% medium, 55% high, P<.04) and a higher predisposition for this amputation level.

CONCLUSIONS

The low socioeconomic status has been shown to determine an unfavourable vascular risk profile in lower-limb non-traumatic amputees and a higher predisposition of a major amputation. This socioeconomic level demonstrates a negative influence on these patients' diabetes, obesity and diabetic retinopathy.

Gait changes in persons with diabetes: Early risk marker for diabetic foot ulcer

Background Increasing prevalence of diabetic foot ulcer (DFU) and subsequent foot amputation in persons with type 2 diabetic neuropathy is a well known fact. The present study was aimed to identify the initial risk marker for DFU. Methods Dynamic plantar pressure analysis was done for persons with type 2 diabetes mellitus (T2DM) without neuropathy (D), patients with diabetic neuropathy (DN) with normal foot profile and healthy persons with normal foot profile (C). Results The data showed a significant difference in dynamic peak plantar pressure between C and DN (P = 0.035) and no significant difference between D and DN (P = 0.997). The dynamic segmental peak plantar pressure results showed significant difference only in the medial heel region (P = 0.009) among the three groups. Conclusions Gait variations and restrictions in subtalar and first metatarsophalangeal joint are found in persons with diabetic neuropathy even before the onset of foot deformity.

25-Hydroxyvitamin D Deficiency: Impacting Deep-Wound Infection and Poor Healing Outcomes in Patients With Diabetes

BACKGROUND

The Kingdom of Bahrain has a high incidence of diabetes and associated foot complications. Simultaneously, low 25-hydroxyvitamin D (25[OH]D) levels are common in this population and may be associated with the traditional clothing used in desert climates.

METHODS

This investigation compared 25(OH)D levels and glycemic control with quantifiable wound healing parameters in a prospective, analytic, nonexperimental, cross-sectional pilot study. Consecutive consenting adult patients (N = 80) who presented to the regional wound care unit in January 2016 with either an existing or new wound were included. Collected data included three-dimensional wound photography, NERDS and STONEES criteria, and an X-ray with a positive probe-to-bone test. Blood values for 25(OH)D and hemoglobin A1c (HbA1c) were collected simultaneously.

RESULTS

Diabetes mellitus (types 1 and 2) was present in 90% of the sample patients. No patient had sufficient 25(OH)D levels; 15% had insufficient levels (30-50 ng/mL), and deficiency (levels <#20 ng/mL) was found in 85% of the sample. Males were slightly less affected by 25(OH)D deficiency compared with females (82.4% vs 91.3%). Poor glycemic control (HbA1c levels >#6.8%) was found in 69.4% (n = 50) of the persons with diabetes included in the sample. Those with both diabetes mellitus and a 25(OH)D deficiency (76.3%; n = 61) were more likely to demonstrate healing difficulty (40.9%; n = 25) or present with a stalled or deteriorating wound (44.2%, n = 27). A 3° F or higher periwound surface temperature elevation over a mirror image site was present in 82.5% of all wounds. Exposed bone in the ulcer base was found in 50% of the cases. For persons with diabetes, general linear modeling statistical analysis (adjusted R value = 47.9%) linked poor wound healing with three studied variables: 25(OH)D deficiency, poor glycemic control, and an exposed bone in the wound bed.

CONCLUSIONS

Vitamin D may be an overlooked factor in the pathophysiology of diabetic foot ulcer development and subsequent delay in wound healing outcomes. The authors recommend adding 25(OH)D deficiency to the list of multifactorial aggravating factors providers should consider correcting in this subgroup of patients.

Altered touch perception and associated risk factors in individuals with diabetes mellitus

ABSTRACT Objective: To evaluate the prevalence of altered touch perception in the feet of individuals with diabetes mellitus and the associated risk factors. Method: Cross-sectional study with 224 individuals with diabetes mellitus conducted in an endocrinology clinic at a public hospital in Campina Grande, Paraíba. The evaluation used touch sensitivity and perception, and a descriptive and multivariate analysis with Poisson regression was performed. Results: We found the prevalence of altered touch perception to be 53.1%. The risk factors that had a significant and joint impact on its occurrence were: female gender; previous ulcer; diabetes mellitus type 2; burning sensation, cracks, fissures, calluses, and Charcot foot. Conclusions: This study found a high prevalence of altered perception of touch, and this should support the planning of actions aimed at preventing the problem. The study showed the relevance of the phenomenon as a nursing diagnosis that could be included in NANDA-International.

Focused shockwave therapy in diabetic foot ulcers: secondary endpoints of two multicentre randomised controlled trials

OBJECTIVE

The objective of this paper is to present the secondary safety and efficacy outcomes from two studies of focused extracorporeal shockwave therapy (ESWT) used adjunctively with standard care in the treatment of neuropathic diabetic foot ulcers (DFU) (1A or 2A on the University of Texas grading scheme), compared with sham treatment and standard care.

METHOD

We carried out two multicentre, multinational, randomised, sham-controlled, double-blinded, phase III clinical studies using standard care with adjunctive focused ESWT compared with sham treatment and standard care in patients with a DFU. DFUs that did not reduce in volume by at least 50% over two weeks' standard treatment were included. DFUs were randomised and managed with standard care and focused ESWT (pulsed acoustic cellular expression; dermaPACE System, SANUWAVE Health, Inc.) active therapy, or with standard care and sham treatment, four times over a two-week treatment phase in study 1 and up to eight times over 12 weeks in study 2. Standard care continued in both studies throughout the 12-week treatment phase. Secondary outcomes were indicators of wound closure and progression, pain, infection, amputation and recurrence, and device reliability. Efficacy-related secondary endpoints were measured at 12, 20 and 24 weeks. The studies were analysed separately and following statistical comparison to justify the method, as a pooled data set.

RESULTS

Wound area reduction (48.6% versus 10.7%, p=0.015, intention to treat (ITT) population with last observation carried forward (LOCF)) and perimeter reduction (46.4% versus 25.0%, p=0.022, ITT population with LOCF) were significantly greater in the active therapy group compared with the sham-treated group, respectively. The difference in time to wound closure in the pooled ITT population was significantly in favour of the active therapy group (84 days versus 112 days for 25% of subjects to reach wound closure in the active and sham-treated groups, respectively; p=0.0346). The proportion of subjects who achieved wound area reduction (WAR) from baseline at week 12 of ≥90% was significantly higher in the active therapy group. The incidence and nature of infection were consistent with previously published studies, and pain was not increased in the active therapy group. Amputation was insignificantly higher in the sham-treated group and recurrence did not differ. The ESWT device was found to be reliable.

CONCLUSION

The outcomes for the primary and secondary endpoints from these studies show that ESWT administered adjunctively with standard care is an effective advanced therapy for neuropathic DFUs (grade 1A and 2A) that do not respond to two weeks' standard care alone by reducing wound volume by at least 50%.

A new waterborne chitosan-based polyurethane hydrogel as a vehicle to transplant bone marrow mesenchymal cells improved wound healing of ulcers in a diabetic rat model

Foot ulcers, a common complication of diabetes, can cause physical incapacity and are derived from several factors, including poor wound healing. New therapeutic strategies are needed to minimize this complication for the sake of patients' health. We therefore developed a new chitosan- polyurethane hydrogel membrane (HPUC) and the test results confirmed that HPUC present low cytotoxicity and improved wound healing when used with mononuclear bone marrow fraction cells in the diabetic rat model. The biodegradable hydrogels were produced in block copolymer networks with a combination of chitosan blocks and biodegradable polyurethane. The membranes were characterized by FTIR, ¹³C-NMR and thermogravimetry. Swelling and hydrolytic degradation were also evaluated. The non-solubility of the membranes in good solvents and the chemical characterization confirmed that the network structure was formed between the PU and the chitosan through urea/urethane bonds. The findings confirm that the HPUC have interesting properties that make them suitable for wound healing applications.

Vehicle ergonomics contributing to a diabetic foot ulcer

Background

Diabetes mellitus continues to be a rising concern in the United States. It affects an estimated 9.4% of the population and approximately 1.5 million Americans are diagnosed annually. Approximately 85% of diabetic foot ulcers are associated with diabetic peripheral neuropathy and an infected diabetic foot ulcer is often the first sign of diabetes. There are countless studies within the literature that investigate how insensate feet and the manifestation of a foot ulcer further decrease quality of life and increase risk for mortality. Literature focuses on gait and kinematics that contribute to the formation of a diabetic foot ulcer. While pressure and shear forces are etiologic factors that may lead to the formation of diabetic foot ulcers, the position of the foot while driving an automobile has been ignored as a possible risk factor.

Case presentation

The clinical case will describe the events of healing a neuropathic diabetic foot ulcer beyond the standard of care treatment plan. It is one of the first case reports to describe vehicle ergonomics as an etiologic factor contributing to a diabetic foot ulcer. Once the patient becomes aware of the unnecessary source of pressure, education and care is provided to manage this likely source of daily pressure to the neuropathic foot.

Conclusion

The article emphasizes the importance of a complete assessment, including nontraditional factors, which may lead to diabetic complications.

Current Therapeutic Strategies in Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are the fastest growing chronic complication of diabetes mellitus, with more than 400 million people diagnosed globally, and the condition is responsible for lower extremity amputation in 85% of people affected, leading to high-cost hospital care and increased mortality risk. Neuropathy and peripheral arterial disease trigger deformities or trauma, and aggravating factors such as infection and edema are the etiological factors for the development of DFUs. DFUs require identifying the etiology and assessing the co-morbidities to provide the correct therapeutic approach, essential to reducing lower-extremity amputation risk. This review focuses on the current treatment strategies for DFUs with a special emphasis on tissue engineering techniques and regenerative medicine that collectively target all components of chronic wound pathology.

Diabetic foot ulcer treatment with focused shockwave therapy: two multicentre, prospective, controlled, double-blinded, randomised phase III clinical trials

OBJECTIVE

To investigate the efficacy of focused extracorporeal shockwave therapy (ESWT) as an adjunctive treatment for neuropathic diabetic foot ulcers (DFU) (1A or 2A on the University of Texas grading scheme), compared with sham treatment.

METHOD

We performed two multicentre, randomised, sham-controlled, double-blinded, phase III clinical trials using focused ESWT compared with sham examining DFUs that did not reduce in volume by ≥50% over 2 weeks' standard treatment immediately prior to randomisation. Patients were enrolled into the trials and randomised for either standard care and focused ESWT (pulsed acoustic cellular expression. dermaPACE System, SANUWAVE Health Inc.) active therapy, or standard care and sham therapy. Both active and sham therapy were administered four times in 2 weeks in study 1 and a maximum of eight times over 12 weeks in study 2. Standard care continued in both studies throughout the 12-week treatment phase. The proportion of DFUs that closed completely by 12, 20 and 24 weeks was measured.

RESULTS

The two studies evaluated 336 patients; 172 patients treated with active therapy and 164 managed with a sham device. The demographic characteristics of patients in the two arms of both studies were balanced and statistical comparison of the two studies justified pooling datasets for analysis. Statistically significantly more DFU healed at 20 (35.5% versus 24.4%; p=0.027) and 24 weeks (37.8% versus 26.2%; p=0.023) in the active treatment arm compared with the sham-controlled arm. At 12 weeks the active therapy arm trended to significance (22.7% versus 18.3%).

CONCLUSION

The outcome of these two trials suggests that ESWT is an effective therapeutic modality in combination with standard care for neuropathic DFU that do not respond to standard care alone.

Epidemiology of Peripheral Neuropathy and Lower Extremity Disease in Diabetes

PURPOSE OF REVIEW

Diabetic peripheral neuropathy eventually affects nearly 50% of adults with diabetes during their lifetime and is associated with substantial morbidity including pain, foot ulcers, and lower limb amputation. This review summarizes the epidemiology, risk factors, and management of diabetic peripheral neuropathy and related lower extremity complications.

RECENT FINDINGS

The prevalence of peripheral neuropathy is estimated to be between 6 and 51% among adults with diabetes depending on age, duration of diabetes, glucose control, and type 1 versus type 2 diabetes. The clinical manifestations are variable, ranging from asymptomatic to painful neuropathic symptoms. Because of the risk of foot ulcer (25%) and amputation associated with diabetic peripheral neuropathy, aggressive screening and treatment in the form of glycemic control, regular foot exams, and pain management are important. There is an emerging focus on lifestyle interventions including weight loss and physical activity as well. The American Diabetes Association has issued multiple recommendation statements pertaining to diabetic neuropathies and the care of the diabetic foot. Given that approximately 50% of adults with diabetes will be affected by peripheral neuropathy in their lifetime, more diligent screening and management are important to reduce the complications and health care burden associated with the disease.

Risk Factors of Diabetic Foot Amputation in Pakistani Type II Diabetes Individuals

Introduction

The major grave outcome of diabetic complications is the amputation of lower limb extremities. Recurrent foot infections, trauma, ischemia, and peripheral neuropathy play a crucial role in predicting foot amputation. The aim of this study is to identify the risk factors of diabetic foot amputations in Pakistani patients.

Methods

Patients admitted with diabetic foot-related complications were followed throughout their hospital stay. Their sociodemographic and disease-related characteristics were recorded. Patients who were advised foot amputation were taken as group A, and patients who were managed conservatively were termed as group B. Their characteristics were then compared.

Results

Out of 226 study participants, there were 51 (22.5%) patients in group A who were advised foot amputation. There were more men in group A as compared to group B (72.5% vs. 30.8%; p<0.00001). Group A also had a longer duration of diabetes (15.23 ± 8.52 years vs. 11.98 ± 9.69; p=0.03). Group B included more patients taking insulin therapy (44.5% vs. 37.3%; p=0.002). All three risk factors of atherosclerosis - smoking, hyperlipidemia, and hypertension - were significantly associated with group A (p≤0.05). This coexistence of diabetic nephropathy and retinopathy were more common in group A (p≤0.05).

Conclusion

The incidence of foot amputation in diabetic patients is high. Crucial risk factors include male gender, smoking, hyperlipidemia, hypertension, cardiac history, and the coexistence of diabetic nephropathy and retinopathy.

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

Background: Approximately 2-4% of individuals worldwide with diabetes mellitus have foot ulcers. This study aims to assess the factors affecting the outcomes of severe foot ulcers in diabetic individuals. Methods: An analytical prospective cohort study was conducted from March 1st, 2015, to March 1st, 2017. A total of 34 individuals was selected. The study included patients with foot ulcers below the ankle who were at risk of amputation. All tests used a <5% level of significance and confidence interval of 95%. A Pearson's chi-squared test and binary multiple regression were performed to assess the factors related to healing. Results: Only 11.7% of the individuals required amputation; ulcers classified as 2/B according to the University of Texas Diabetic Foot Ulcer Classification System healed before the 1/B ulcers. Neuropathic ulcers were the most prevalent (58.8%); 61.8% healed after 1 year. Most of the individuals were overweight, 47.1% had reduced glomerular filtration rates, and 78.8% had glycated hemoglobin >7%. Body mass index and osteomyelitis were the two significant variables in logistic regression. Conclusions: In this study, osteomyelitis was the main complication related to the risk of amputation, and elevated body mass index and osteomyelitis were the significant factors that induced a slower healing time.

Risk Factors for Major Amputation on Hindfoot Ulcers in Hospitalized Diabetic Patients

Objective: The purpose of this study was to investigate the risk factors for major amputation in patients hospitalized with diabetic foot ulcers involving the hindfoot. Approach: Between January 2003 and October 2017, a total of 1,657 diabetic patients were admitted to the diabetic wound center of Korea University Guro Hospital, for the management of foot ulcers. Among the admitted patients, 117 diabetic patients with hindfoot ulcers were included in this study. One hundred and four patients (89%) healed without major amputation, while 13 patients (11%) healed with major amputation. Data related to 88 potential risk factors, including demographics, ulcer condition, vascularity, bioburden, neurology, and serology, were collected from patients in these two groups for comparison. Results: Among the 88 potential risk factors, 15 showed statistically significant differences between the two groups. In univariate analysis of 88 potential risk factors, nine showed statistically significant differences. In stepwise multiple logistic regression analysis, three of the nine risk factors remained statistically significant. Multivariate-adjusted odds ratios for pulmonary disorders, erythrocyte sedimentation rate (ESR) levels, and total iron-binding capacity (TIBC) levels were 38.525, 1.047, and 0.976, respectively. Innovation: Compared with forefoot and midfoot ulcers, diabetic foot ulcers involving the hindfoot are at increased risk of major amputation because infection may spread proximal to the ankle. However, large-scale cohort studies that specifically discuss the outcomes and characteristics of diabetic hindfoot ulcers are not widely available. Conclusion: Risk factors for major amputation in patients hospitalized with diabetic hindfoot ulcers include pulmonary disorders, high levels of ESR, and decreased TIBC levels.

Advancing pharmacotherapy for diabetic foot ulcers

INTRODUCTION

Standard treatment for diabetic foot ulcers (DFUs) includes off-loading, debridement, moisture balance, management of infection and peripheral arterial disease (PAD) as well as adequate glycemic control. The outcomes so far are unsatisfactory.

AREAS COVERED

Herein, the authors provide an outline of newer pharmacological agents for the management of DFUs and give their expert perspectives on future treatment strategies.

EXPERT OPINION

Evidence-based healthcare calls for high quality evidence from large RCTs before the implementation of new guidelines for the management of DFUs. Empagliflozin and liraglutide can be recommended for glucose control in patients with DFUs and PAD, while intensive lipid lowering therapy with evolocumab when primary cholesterol goals are not met could be offered to patients with DFUs. Further clinical studies are warranted to develop a structured algorithm for the treatment of DFUs that fail to heal after four weeks of current standard of care. Sucrose octasulfate dressings, becaplermin gel, and platelet-rich plasma (PRP) could also be considered as advanced treatment options for the management of hard to heal DFUs.

Neurovascular Response to Pressure in Patients With Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) is a problem worldwide, and prevention is crucial. We hypothesized that the inability of the skin to respond to pressure is involved in DFU pathogenesis and could be an important predictive factor to take into account. We included 29 patients with DFU and 30 patients with type 2 diabetes without DFU. Neuropathy and skin blood flow at rest were assessed in response to acetylcholine, sodium nitroprusside, local heating (42°C), and to nonnoxious locally applied pressure. Results were compared with those obtained from 10 healthy age-matched control subjects. Vasodilatation in response to pressure was significantly impaired in both groups with diabetes compared with healthy subjects. The vasodilator capacity to pressure was significantly lower in patients with DFU compared with those without DFU, despite the absence of significant difference in cutaneous pressure perception threshold and vascular reactivity to acetylcholine, sodium nitroprusside, and heat. This pronounced alteration of neurovascular response to pressure in patients with DFU is a good marker of skin vulnerability and could be used to better predict individuals at risk.

Adjuvant Hyperbaric Oxygen Therapy Enhances Healing of Nonischemic Diabetic Foot Ulcers Compared With Standard Wound Care Alone

Recent systematic reviews and meta-analyses have produced conflicting results about the efficacy of hyperbaric oxygen therapy (HBOT) in improving the healing rate for chronic diabetic foot wounds. This study aimed to assess the efficacy of systemic HBOT in healing of chronic nonischemic diabetic foot ulcer. Thirty adult patients having Wagner’s grade 2 or 3 chronic diabetic foot ulcers, in whom the response to 30 days of standard wound care was not favorable, were prospectively randomized to have either HBOT (20-40 sessions) plus conventional treatment (n = 15) or conventional treatment alone (n = 15). Ischemic wounds and patients with contraindications to systemic HBOT were excluded. The primary end point was complete healing of the target ulcer. Secondary endpoints included the following: rate of ulcer healing at the end of treatment period and at 4 and 8 weeks thereafter as well as rate of amputation. A significantly greater percentage of HBOT-treated wounds (33.3%, 5/15) achieved complete closure than conventional therapy–treated wounds (0%, 0/15; P = .014) at the end of treatment. This significant difference was maintained throughout the 8 weeks of follow-up. Complications frequency was nonsignificantly different between both groups. Our study showed that HBOT plus conventional therapy appears as safe as and probably more effective than conventional therapy alone for the healing of chronic nonischemic diabetic foot wounds. Larger studies are required to confirm its specific indications.

Molecular imaging of diabetes and diabetic complications: Beyond pancreatic β-cell targeting

Diabetes is a chronic non-communicable disease affecting over 400 million people worldwide. Diabetic patients are at a high risk of various complications, such as cardiovascular, renal, and other diseases. The pathogenesis of diabetes (both type 1 and type 2 diabetes) is associated with a functional impairment of pancreatic β-cells. Consequently, most efforts to manage and prevent diabetes have focused on preserving β-cells and their function. Advances in imaging techniques, such as magnetic resonance imaging, magnetic resonance spectroscopy, positron emission tomography, and single-photon-emission computed tomography, have enabled noninvasive and quantitative detection and characterization of the population and function of β-cells in vivo. These advantages aid in defining and monitoring the progress of diabetes and determining the efficacy of anti-diabetic therapies. Beyond β-cell targeting, molecular imaging of biomarkers associated with the development of diabetes, e.g., lymphocyte infiltration, insulitis, and metabolic changes, may also be a promising strategy for early detection of diabetes, monitoring its progression, and occurrence of complications, as well as facilitating exploration of new therapeutic interventions. Moreover, molecular imaging of glucose uptake, production and excretion in specified tissues is critical for understanding the pathogenesis of diabetes. In the current review, we summarize and discuss recent advances in noninvasive imaging technologies for imaging of biomarkers beyond β-cells for early diagnosis of diabetes, investigation of glucose metabolism, and precise diagnosis and monitoring of diabetic complications for better management of diabetic patients.

ADIE - Nursing Interventions of Diabetic Foot Ulcer: An Integrative Review of the Literature

BACKGROUND AND AIMS

Diabetic foot ulcer is recognized as a consequence of peripheral neuropathy and peripheral arterial disease amid individuals with diabetes. As is well known, this situation still remains a crucial problem in nursing practice. Available studies describing an algorithm of inter- related nursing interventions concerned with diabetic foot ulcers are limited. Therefore, this integrative review was aimed to present evidence-based practice for overcoming the complications of diabetic foot ulcer as well as preventing lower extremity amputation.

METHODS

This integrative review retrieved scientific literature from PubMed, CINAHL, ProQuest, SAGE Publishing and ScienceDirect databases as published from 2008 to 2017. Thirty-seven studies that met the inclusion criteria were included in this study.

RESULTS

Our findings present that neurologic and circulatory assessments were considered as primary steps prior to conducting interventions. Formulating a diagnosis based upon the assessment results is a principal part to determine appropriate interventions. Multiple experimental studies displayed the effectiveness of certain interventions consist of applying wound cleansing, advanced modern wound dressing, topical therapy, offloading, intensive diabetes education and advanced treatment modalities. Hemoglobin A1c, high-density lipoprotein, procalcitonin, the potential of hydrogen of wound fluid, wound size, neurological and circulatory status were determined as the outcomes measurement which must be correctly evaluated.

CONCLUSION

This review contributes an algorithm for intervening diabetic foot ulcer thereby generating the given name: ADIE (Assessment, Diagnosis, Interventions, and Evaluation). A collaborative care amid multidisciplinary diabetes team is needed for implementing along with evaluating the feasibility of the study findings. Moreover, active family participation also plays a crucial role to achieve successful management of diabetic foot ulcer at home.

Efficacy of Cellular Therapy for Diabetic Foot Ulcer: A Meta-Analysis of Randomized Controlled Clinical Trials

Diabetes mellitus is a widely spread chronic disease with growing incidence worldwide, and diabetic foot ulcer is one of the most serious complications of diabetes. Cellular therapy has shown promise in the management of diabetic foot ulcer in many preclinical experiments and clinical researches. Here, we performed a meta-analysis to evaluate the efficacy and safety of cellular therapy in the management of diabetic foot ulcer. We systematically searched PubMed, MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2017 for randomized controlled trials assessing the efficacy of cellular therapy in diabetic foot ulcer, and a meta-analysis was conducted. A total of 6 randomized controlled clinical trials involving 241 individuals were included in this meta-analysis. The results suggested that cellular therapy could help accelerating the healing of diabetic foot ulcer, presented as higher ankle-brachial index (mean difference = 0.17, 95% confidence interval [CI] = 0.11 to 0.23), higher transcutaneous oxygen pressure (standardized mean difference [SMD] = 1.43; 95% CI, 1.09– to 1.78), higher ulcer healing rate (relative risk [RR] = 1.78; 95% CI, 1.41 to 2.25), higher amputation-free survival (RR = 1.25; 95% CI, 1.11 to 1.40), and lower scale of pain (SMD = −1.69; 95% CI, −2.05 to −1.33). Furthermore, cellular therapy seemed to be safe, with no serious complications and low risk of short-term slight complications. Cellular therapy could accelerate the rate of diabetic foot ulcer healing and may be more efficient than standard therapy for diabetic foot treatment.

Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot

OBJECTIVE

The main purpose of this study was to investigate the diagnostic value of dynamic contrast-enhanced MRI (DCE-MRI) in differentiating osteomyelitis from acute neuropathic arthropathy in the diabetic foot.

MATERIALS AND METHODS

This prospective study was carried out on 30 diabetic foot patients, with a mean age of 51 years. The patients all underwent clinical examinations, laboratory examinations and DCE-MRI. The DCE-MRI parameters (K^trans, K_ep and V_e) of the regions of acute neuropathic arthropathy and osteomyelitis were calculated. Receiver operating characteristic curves (ROCs) were used to identify the DCE-MRI parameters that showed the highest accuracy in differentiating the acute neuropathic arthropathy from the osteomyelitic regions. Pearson correlation coefficients were used to assess the correlations among the DCE-MRI parameters, the level of C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR).

RESULTS

The K^trans, K_ep and V_e values of the osteomyelitic regions were higher than those of the acute neuropathic arthropathy regions, and significant differences were found between the two groups (P = 0.000, P = 0.000, P = 0.000). The ROC analysis showed that K^trans and V_e performed best in differentiating osteomyelitis from acute neuropathic arthropathy, both with an area under the curve of 0.938. The Pearson correlation coefficients showed that the DCE-MRI parameters correlated significantly with the level of CRP and ESR (P = 0.000, P = 0.014, P = 0.000; P = 0.000, P = 0.000, P = 0.013).

CONCLUSIONS

Our results showed that DCE-MRI may provide reproducible parameters that can reliably differentiate osteomyelitis from acute neuropathic arthropathy.

Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis on 33 870 patients

AIMS

The diabetic foot syndrome (DFS) is a serious complication in patients with diabetes increasing the risk for minor/major amputations. This analysis aimed to examine differences in diabetes patients with or without DFS stratified by type 1 (T1D) or type 2 diabetes (T2D).

MATERIAL AND METHODS

Adult patients (≥20y of age) with diabetes from the German/Austrian diabetes patients follow-up registry (DPV) were included. The cross-sectional study comprised 45 722 subjects with T1D (n_DFS  = 2966) and 313 264 with T2D (n_DFS  = 30 904). In DFS, minor/major amputations were analysed. To compare HbA_1C , neuropathy, nephropathy, cardiovascular disease risk factors, and macrovascular complications between patients with or without DFS, regression models were conducted. Confounders: age, sex, diabetes duration.

RESULTS

In patients with DFS, a minor amputation was documented in 27.2% (T1D) and 25.9% (T2D), a major amputation in 10.2% (T1D) and 11.3% (T2D). Regression models revealed that neuropathy was more frequent in subjects with DFS compared with patients without DFS (T1D: 70.7 vs 29.8%; T2D: 59.4% vs 36.9%; both P < 0.0001). Hypertension, nephropathy, peripheral vascular disease, stroke, or myocardial infarction was more common compared with patients without DFS (all P < 0.0001). In T1D with DFS, a slightly higher HbA_1C (8.11% vs 7.95%; P < 0.0001) and in T2D with DFS a lower HbA_1C (7.49% vs 7.69%; P < 0.0001) was observed.

CONCLUSIONS

One third of the patients with DFS had an amputation of the lower extremity. Especially neuropathy or peripheral vascular disease was more prevalent in patients with DFS. New concepts to prevent DFS-induced amputations and to reduce cardiovascular risk factors before the occurrence of DFS are necessary.

MicroRNAs in diabetic wound healing: Pathophysiology and therapeutic opportunities

Diabetic wound healing is an incompletely understood pathophysiological state. It comprises a range of potentially devastating and common complications of diabetes mellitus (DM) leading to intractable infections, lower extremity amputations, and associated cardiovascular morbidity and mortality. MicroRNAs (miRNAs) have emerged as important regulators in various physiological processes in health and disease through their ability to fine-tune cellular responses. Herein, we summarize the versatile roles of miRNAs implicated in diabetic wound healing in key stages including inflammation, angiogenesis, re-epithelialization, and remodeling. Furthermore, we highlight current evidence through which miRNAs exert control of gene expression and signaling pathways in the reparative response that may provide opportunities for therapeutic intervention for this potentially devastating disease state.

Usefulness of the vibration perception thresholds measurement as a diagnostic method for diabetic peripheral neuropathy: Results from the Rio de Janeiro type 2 diabetes cohort study

AIMS

To investigate the associated factors with the vibration threshold perception (VPT) in patients with type 2 diabetes and to assess whether it is useful for detection of diabetic peripheral neuropathy (DPN).

METHODS

VPTs were measured with Vibration Sensory Analyzer (VSA-3000) in 426 diabetic patients. The diagnosis of DPN was based on Neuropathy Symptom Score and Neuropathy Disability Score (NDS). ROC curve analysis and multiple linear and logistic regressions were performed to investigate the associations between VPT and DPN.

RESULTS

Values of VPT were progressively higher according to NDS stages. Age, height, diabetes duration, and mean cumulative HbA1c exposure (partial correlation coefficients: 0.34; 0.27; 0.10; and 0.13; respectively) were the variables independently associated with VPT. Area under ROC curve of VPT for detection of DPN was 0.71 (95% CI: 0.66-0.75) and >8.9 μm was its best cut-off value. VPT, age, female sex, height, diabetes duration and mean HbA1c levels were the independent correlates of the presence of DPN. An increased VPT triplicate the likelihood of having DPN (OR: 3.24; 95% CI: 2.05-5.11).

CONCLUSIONS

VPT, measured by an automatic device, shares common correlates with DPN and is strongly associated with its presence. VPT testing may be useful as a screening tool for DPN assessment.

Illness Perception as a Predictor of Foot Care Behavior Among People With Type 2 Diabetes Mellitus in Indonesia

INTRODUCTION

Illness perception may contribute to foot care behavior because people with type 2 diabetes mellitus (T2DM) in Indonesia may have different beliefs that influence their foot care behaviors. This study aimed to determine the relationships among foot care knowledge, illness perception, local beliefs, and foot care behaviors in people with T2DM in Indonesia.

METHODS

Cross-sectional study with a convenience sampling technique was used to recruit 200 people with T2DM from the Outpatient Department of Islamic Hospital. The Foot Care Knowledge, Brief Illness Perception, Local Beliefs, and Foot Self-Care Behavior questionnaires were administered.

RESULTS

The predictors of foot care were having a family member or friend with diabetic foot ulcer ( p = .001), diabetes mellitus duration ( p = .026), foot care knowledge ( p < .001), consequences ( p < .001), treatment control ( p < .001), and local beliefs ( p = .017).

DISCUSSION

Health care providers may cultivate a spiritual approach, providing success stories to create positive images of the disease's outcomes and increase patients' confidence to control the disease.

Evaluation of safety tool for ambulatory leprosy patients at risk of adverse outcome

BACKGROUND

Leprosy is a potentially debilitating disease of the skin and nerves that requires a complex management approach consisting of laboratory monitoring, screening for factors that will adversely affect outcome with corticosteroids, engagement of allied health services, and prolonged follow-up. Given the complexities of leprosy management, a safety tool was developed and implemented in the Tropical Disease Unit at Toronto General Hospital. Our objective was to evaluate the utility of the tool using a retrospective chart review.

METHODS

We reviewed the charts of patients with leprosy treated over a 3.5-year period: up to 3 years prior to tool implementation, and 6-months following implementation. Pre-determined outcomes of interest included: loss to follow-up; monitoring of laboratory parameters; allied health services engagement; baseline ophthalmologic assessment; and risk mitigation interventions.

RESULTS

Of 17 patients enrolled, 8 were treated pre-implementation, and 9 post-implementation. Five (29.4%) pre-implementation patients were lost to follow-up compared to none post-implementation (p = 0.009). One (12.5%) pre-implementation patient was sent for baseline ophthalmologic assessment versus 8 (88.9%) post-implementation (p = 0.0034). Only post-implementation patients received referrals for occupational therapy and social work, with 77.8% (n = 7) receiving occupational therapy (p = 0.0023) and 33.3% (n = 3) social work (p = 0.2059). Laboratory parameters such as hemoglobin, hepatic transaminases, and methemoglobin were routinely monitored for patients on dapsone irrespective of tool implementation.

CONCLUSIONS

Implementation of a leprosy-specific safety tool has established a user-friendly method for systemizing all elements of care, and ensuring the involvement of allied health services necessary for optimizing health outcomes.

Corneal confocal microscopy as a non-invasive test to assess diabetic peripheral neuropathy

OBJECTIVE

To evaluate the efficacy of corneal confocal microscopy (CCM) as a non-invasive test to assess diabetic peripheral neuropathy in Chinese patients diagnosed with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Diabetic distal symmetric polyneuropathy (DSPN) and its severity degrees were assessed based on the modified Toronto diagnostic criteria in 128 patients with type 2 diabetes (No DSPN [n = 49], mild DSPN [n = 43], moderate-to-severe DSPN [n = 36]) and 24 age-matched controls. CCM was also examined in all enrolled subjects. Corneal nerve fiber length (CNFL), corneal nerve branch density (CNBD) and corneal nerve fiber density (CNFD) were analyzed by Fiji imaging analysis software. The efficacy of CCM as a non-invasive test to assess diabetic peripheral neuropathy was determined.

RESULTS

CNFL was 17.99 ± 0.66, 15.82 ± 0.64, 14.98 ± 0.63, and 12.49 ± 0.93 in healthy controls, T2DM patients with no, mild, and moderate-to-severe DPN, respectively. CNFL in type 2 diabetes patients with no, mild, and moderate-to-severe DSPN demonstrated a significant reduction than in healthy controls (P = .012, .003 and <.001, respectively). CNFL in patients with moderate-to-severe DSPN was significantly shorter than in patients with no or mild DSPN (P < .001 and .004, respectively). CNBD was 41.48 ± 3.35, 33.02 ± 2.50, 30.91 ± 2.33, and 18.00 ± 2.33 in healthy controls, T2DM patients with no, mild, and moderate-to-severe DPN, respectively. CNBD in healthy control was significantly higher than in type 2 diabetes patients with no, mild, and moderate-to-severe DSPN (P = .036, 0.016 and < .001, respectively). CNBD in patients with moderate-to-severe DSPN was significantly lower than in patients with no or mild DSPN (P < .001 for both). CNFD was 35.32 ± 1.18, 35.68 ± 1.10, 34.54 ± 1.12, and 32.28 ± 1.76 in healthy controls, T2DM patients with no, mild, and moderate-to-severe DPN, respectively. CNFD did not differ among the four groups. In an analysis that divided CNFL, CNFD and CNBD into quartiles, there were no significant differences in electromyography findings and vibration perception threshold among the 4 groups; however, significant differences were seen in the positive distribution of temperature perception measurements following CNFL and CNBD stratification (P = .001 and < .001, respectively).

CONCLUSION

CCM might be a non-invasive method for detecting DSPN and its severity degree in Chinese patients diagnosed with type 2 diabetes.

Hyperbaric Oxygen Therapy in the Treatment of Ischemic Lower- Extremity Ulcers in Patients With Diabetes: Results of the DAMO2CLES Multicenter Randomized Clinical Trial

OBJECTIVE

Conflicting evidence exists on the effects of hyperbaric oxygen therapy (HBOT) in the treatment of chronic ischemic leg ulcers. The aim of this trial was to investigate whether additional HBOT would benefit patients with diabetes and ischemic leg ulcers.

RESEARCH DESIGN AND METHODS

Patients with diabetes with an ischemic wound (n = 120) were randomized to standard care (SC) without or with HBOT (SC+HBOT). Primary outcomes were limb salvage and wound healing after 12 months, as well as time to wound healing. Other end points were amputation-free survival (AFS) and mortality.

RESULTS

Both groups contained 60 patients. Limb salvage was achieved in 47 patients in the SC group vs. 53 patients in the SC+HBOT group (risk difference [RD] 10% [95% CI -4 to 23]). After 12 months, 28 index wounds were healed in the SC group vs. 30 in the SC+HBOT group (RD 3% [95% CI -14 to 21]). AFS was achieved in 41 patients in the SC group and 49 patients in the SC+HBOT group (RD 13% [95% CI -2 to 28]). In the SC+HBOT group, 21 patients (35%) were unable to complete the HBOT protocol as planned. Those who did had significantly fewer major amputations and higher AFS (RD for AFS 26% [95% CI 10-38]).

CONCLUSIONS

Additional HBOT did not significantly improve complete wound healing or limb salvage in patients with diabetes and lower-limb ischemia.

Outcomes in diabetic foot ulcer patients with isolated T2 marrow signal abnormality in the underlying bone: should the diagnosis of "osteitis" be changed to "early osteomyelitis"?

OBJECTIVE

To evaluate the variability of clinical treatment and outcomes based on reporting of diabetic foot ulcer MRI findings of adjacent marrow T2 hyperintensity with normal T1 signal.

MATERIALS AND METHODS

A retrospective review was conducted of 46 MRI examinations evaluating diabetic foot ulcers that demonstrated normal T1 marrow signal, but T2 marrow hyperintensity deep to the ulcer. The cohort was divided based on MRI report impressions into three groups; "osteitis without osteomyelitis" (OW), "osteitis but cannot exclude early osteomyelitis" (OCEO) and "early osteomyelitis" (EO). Patient demographics (age, gender) and accessory MRI findings of ulcer and sinus tract depth were recorded. Initial clinical assessment and medical treatment (route and duration of antibiotics), healing versus disease progression and histology or microbiology results were recorded.

RESULTS

The isolated marrow T2 signal hyperintensity was reported as OW in 12 patients, OCEO in 18, and EO in 16. No statistical difference in clinical assessment was demonstrated between the OW, OCEO, and EO groups. Pathological condition was available in 15 patients within 0-7 days (mean 2.4 days) of the MRI examination, with 14 (93%) of these positive for osteomyelitis by histopathology or positive cultures. Initial diagnosis of or progression to osteomyelitis was shown in 28 patients (61%).

CONCLUSION

Treatment of suspected osteomyelitis is heavily determined by clinical factors. Patients who initially demonstrate only T2 marrow signal abnormality under a diabetic ulcer are eventually diagnosed as osteomyelitis in 61% of cases and deserve aggressive treatment as early osteomyelitis when meeting clinical parameters.

From Inflammation to Current and Alternative Therapies Involved in Wound Healing

Wound healing is a complex event that develops in three overlapping phases: inflammatory, proliferative, and remodeling. These phases are distinct in function and histological characteristics. However, they depend on the interaction of cytokines, growth factors, chemokines, and chemical mediators from cells to perform regulatory events. In this article, we will review the pathway in the skin healing cascade, relating the major chemical inflammatory mediators, cellular and molecular, as well as demonstrating the local and systemic factors that interfere in healing and disorders associated with tissue repair deficiency. Finally, we will discuss the current therapeutic interventions in the wounds treatment, and the alternative therapies used as promising results in the development of new products with healing potential.

Pedobarography as a clinical tool in the management of diabetic feet in New Zealand: a feasibility study

Background

The peripheral complications of diabetes mellitus remain a significant risk to lower-limb morbidity. In New Zealand, risk of diabetes, comorbidity and lower-limb amputation are highly-differential between demographic groups, particularly ethnicity. There is growing and convincing evidence that the use of pedobarography – or plantar pressure measurement – can usefully inform diabetic foot care, particularly with respect to the prevention of re-ulceration among high-risk patients.

Methods

For the current feasibility study, we embedded pedobarographic measurements into three unique diabetic foot clinic settings in the New Zealand context, and collected pedobarographic data from n = 38 patients with diabetes using a platform-based (Novel Emed) and/or in-shoe-based system (Novel Pedar). Our aim was to assess the feasibility of incorporating pedobarographic testing into the clinical care of diabetic feet in New Zealand.

Results and Conclusions

We observed a high response rate and positive self-reported experience from participants. As part of our engagement with participants, we observed a high degree of lower-limb morbidity, including current ulceration and chronic foot deformities. The median time for pedobarographic testing (including study introduction and consenting) was 25 min. Despite working with a high-risk population, there were no adverse events in this study. In terms of application of pedobarography as a clinical tool in the New Zealand context, the current feasibility study leads us to believe that there are two avenues that deserve further investigation: a) the use of pedobarography to inform the design and effectiveness of offloading devices among high-risk diabetic patients; and b) the use of pedobarography as a means to increase offloading footwear and/or orthoses compliance among high-risk diabetic patients. Both of these objectives deserve further examination in New Zealand via clinical trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-017-0205-6) contains supplementary material, which is available to authorized users.

Trends in the incidence of lower limb amputation after implementation of a Multidisciplinary Diabetic Foot Unit

BACKGROUNDS AND OBJECTIVE

Incidence of lower extremity amputations (LEA) in the population with and without diabetes mellitus (DM) was assessed after implementation of a Multidisciplinary Diabetic Foot Unit (MDFU) during 2008.

MATERIAL AND METHODS

Non-traumatic LEA were analyzed, and those performed before (2001-2007) and after (2008-2014) introduction of the MDFU were compared. LEA were grouped by age and sex. Their incidence was expressed as a rate per 100,000 population per year, adjusted to the standard European population.

RESULTS

A total of 664 LEA were performed during the 2001-2014 period, 486 (73%) of them in patients with DM. Total LEA incidence was 11.2/10⁵ population in DM versus 3.9/10⁵ in the population without DM. Incidence of major LEA in patients with DM significantly decreased from 6.1/10⁵ population in the 2001-2007 period to 4.5/10⁵ in the 2008-2014 period (p=.03). Joinpoint regression analysis also showed a reduction in the trend of incidence of major LEA in patients with DM, with an annual percentage change of -3.3% [95% CI, -6.2-0.3] (p=.025). No significant differences were found for all other incidences and trends in the diabetic and non-diabetic populations.

CONCLUSIONS

Implementation of a MDFU has been shown to be associated with a significant reduction in major amputation rate in the diabetic population, although the results are not optimal yet. Both results and work at the MDFU should be improved.