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Yazdanpanah L, Shahbazian H, Hesam S, Ahmadi B, Zamani AM. Two-year incidence and risk factors of diabetic foot ulcer: second phase report of Ahvaz diabetic foot cohort (ADFC) study. BMC Endocr Disord 2024; 24:46. [PMID: 38622562 PMCID: PMC11017491 DOI: 10.1186/s12902-024-01572-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
AIM/INTRODUCTION This study was designed as the second phase of a prospective cohort study to evaluate the incidence and risk factors of diabetic foot ulcers (DFU). MATERIALS AND METHODS The study was conducted in a university hospital in Iran. Each participant was checked and followed up for two years in terms of developing newfound DFU as ultimate outcome. We investigated the variables using univariate analysis and then by backward elimination multiple logistic regression. RESULTS We followed up 901 eligible patients with diabetes for two years. The mean age of the participants was 53.24 ± 11.46 years, and 58.53% of them were female. The two-year cumulative incidence of diabetic foot ulcer was 8% (95% CI 0.071, 0.089) [Incidence rate: 49.9 /1000 person-years]. However, the second-year incidence which was coincident with the COVID-19 pandemic was higher than the first-year incidence (4.18% and 1.8%, respectively). Based on our analysis, the following variables were the main risk factors for DFU incidence: former history of DFU or amputation [OR = 76.5, 95% CI(33.45,174.97), P value < 0.001], ill-fitting foot-wear [OR = 10.38, 95% CI(4.47,24.12), P value < 0.001], smoking [OR = 3.87,95%CI(1.28, 11.71),P value = 0.016], lack of preventive foot care [OR = 2.91%CI(1.02,8.29),P value = 0.045], and insufficient physical activity[OR = 2.25,95% CI(0.95,5.35),P value = 0.066]. CONCLUSION Overall, the two-year cumulative incidence of diabetic foot ulcer was 8% [Incidence rate: 49.9 /1000 person-years]; however, the second-year incidence was higher than the first-year incidence which was coincident with the COVID-19 pandemic (4.18% and 1.8%, respectively). Independent risk factors of DFU occurrence were prior history of DFU or amputation, ill-fitting footwear, smoking, lack of preventive foot care, and insufficient physical activity.
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Affiliation(s)
- Leila Yazdanpanah
- Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, 61357-15794, Ahvaz, Iran.
| | - Hajieh Shahbazian
- Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, 61357-15794, Ahvaz, Iran
| | - Saeed Hesam
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Ahmadi
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Amir Mohammad Zamani
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Nakhaei P, Hamouda M, Malas MB. The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease. Ann Vasc Surg 2024:S0890-5096(24)00151-1. [PMID: 38599491 DOI: 10.1016/j.avsg.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages. METHODS This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD. RESULTS CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates. CONCLUSIONS The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.
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Affiliation(s)
- Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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Lingyan L, Liwei X, Han Z, Xin T, Bingyang H, Yuanyuan M, Peiwei Q, Peifen M. Identification, influencing factors and outcomes of time delays in the management pathway of diabetic foot: A systematic review. J Tissue Viability 2024:S0965-206X(24)00047-0. [PMID: 38594149 DOI: 10.1016/j.jtv.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/23/2024] [Accepted: 04/04/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE A systematic review was conducted to evaluate the time delays in the management of diabetic foot and explore influencing factors of these delays and potential outcomes. METHODS The researchers searched several electronic databases (Pubmed, Web of Science, Cochrane Library, EMbase, CNKI, WanFang, CBM and VIP) for English and Chinese studies that examined time delays in the management pathway of diabetic foot. Two authors independently screened and extracted data, and assessed the quality of the included studies using the Newcastle-Ottawa Scale and the Agency for Health Research and Quality checklist. Due to heterogeneity among the studies, descriptive analysis was performed. RESULTS The review included 28 articles, comprising 20 cohort studies and 8 cross-sectional studies, that met the inclusion criteria. Among these, 14 were deemed of high quality. The median times from symptom onset to primary health care or specialist care varied from 3 to 46.69 days. The median delay in referral by primary care specialists ranged from 7 to 31 days, and subsequent median times to definitive treatment ranged from 6.2 to 56 days. Multiple complex factors were found to contribute to these delays, including patient demographics (older age, lower education level and income level) and poor patient health-seeking behaviors (inaccurate self-treatment, incorrect recognition and interpretation of symptoms), inaccurate assessment or initial treatment by health primary professionals, complex referral pathways and clinical characteristics of diabetic foot (number of foot ulcers, Wagner grade scale, and hemoglobin A1c index). Negative outcomes associated with these delays included increased risk of major amputation and mortality, decreased wound healing rate, prolonged hospital stay, and increased hospital costs. CONCLUSIONS Time delays in the diabetic foot management pathway were both common and serious, contributing to negative health outcomes for patients with diabetic foot. Many complex factors related to patient's poor patient health-seeking behaviors, health system, and clinical characteristics of diabetic foot are responsible for these delays. Therefore, it is necessary to develop new strategies for standard referral practices and strengthen patient awareness of seeking care.
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Affiliation(s)
- Li Lingyan
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China
| | - Xu Liwei
- Department of Burns, The Second Hospital of Lanzhou University, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu Province, PR China
| | - Zhao Han
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China
| | - Tang Xin
- Department of Burns, The Second Hospital of Lanzhou University, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu Province, PR China
| | - He Bingyang
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China
| | - Ma Yuanyuan
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China
| | - Qin Peiwei
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China
| | - Ma Peifen
- School of Nursing, Lanzhou University, No. 28 Yanxi Road, Lanzhou, 730000, Gansu Province, PR China; Department of Nursing, The Second Hospital of Lanzhou University, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu Province, PR China.
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Ghai S, Hitzig SL, Eberlin L, Melo J, Mayo AL, Blanchette V, Habra N, Zucker-Levin A, Zidarov D. Reporting of Rehabilitation Outcomes in the Traumatic Lower Limb Amputation Literature: A Systematic Review. Arch Phys Med Rehabil 2023:S0003-9993(23)00522-1. [PMID: 37708929 DOI: 10.1016/j.apmr.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/09/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To synthesize the outcomes reported in the rehabilitation and community literature for adults with traumatic lower limb amputation (LLA). DATA SOURCES The search strategy was conducted in 3 databases (Medline, EMBASE, and CINAHL) from inception to April 2022. STUDY SELECTION To be eligible, articles could be of any design but were required to have at least 50% adult individuals with traumatic LLA and had to report on interventions and outcomes in either a rehabilitation or community setting. DATA EXTRACTION The extracted outcomes were classified using Dodd's framework, which is designed for organizing research outcomes. Heterogeneity was observed in the outcome measures (OMs) used for evaluation. Two reviewers independently conducted the data extraction, which was verified by a third reviewer. DATA SYNTHESIS Of the 7,834 articles screened, 47 articles reporting data on 692 individuals with traumatic LLA, met our inclusion criteria. Four core areas encompassing 355 OMs/indicators were identified: life effect (63.4%), physiological/clinical (30.1%), resource use (5.1%), and adverse events (1.4%). Physical functioning (eg, gait, mobility) was the most frequently reported outcome domain across studies, followed by nervous system outcomes (eg, pain) and psychiatric outcomes (eg, depression, anxiety). Domains such as global quality of life and role/emotional functioning were seldomly reported. CONCLUSION The study provides a list of outcome indicators explicitly published for adults with traumatic LLA, highlighting inconsistent reporting of outcome indicators. The lack of a standardized set of OMs is a barrier to performing meta-analyses on interventions, preventing the identification of effective care models and clinical pathways. Developing a core outcome set that includes OMs relevant to the needs of the traumatic LLA population may address these issues.
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Affiliation(s)
- Shashank Ghai
- Department of Political, Historical, Religious and Cultural Studies, Karlstads Universitet, Karlstad, Sweden; Centre for Societal Risk Research, Karlstads Universitet, Karlstad, Sweden; Psychology of Learning and Instruction, Department of Psychology, School of Science, Technische Universität Dresden, Dresden, Germany; Centre for Tactile Internet with Human-in-the-loop (CeTI), Technische Universität Dresden, Dresden, Germany.
| | - Sander L Hitzig
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Lindsay Eberlin
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Joshua Melo
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Amanda L Mayo
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Centre for Quality Improvement and Patient Safety (CQuIPS), Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Virginie Blanchette
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux de la Capitale-Nationale, Québec, Canada; Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Canada
| | - Natalie Habra
- Faculté de Médecine, Université de Montréal, Montréal, Canada; Centre de Recherche Interdisciplinaire en Réadaptation (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal (IURDPM), Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, Montréal, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
| | - Diana Zidarov
- Centre de Recherche Interdisciplinaire en Réadaptation (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal (IURDPM), Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal, Montréal, Canada; École de readaptation, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada.
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Tansley J, Collings R, Williams J, Paton J. Off-loading and compression therapy strategies to treat diabetic foot ulcers complicated by lower limb oedema: a scoping review. J Foot Ankle Res 2023; 16:56. [PMID: 37674176 PMCID: PMC10481591 DOI: 10.1186/s13047-023-00659-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Lower limb oedema is a common co-morbidity in those with diabetes and foot ulceration and is linked with increased amputation risk. There is no current guidance for the treatment of concurrent diabetic foot ulcers and lower limb oedema, leading to uncertainty around the safety and efficacy of combination approaches incorporating offloading and compression therapies. To determine indications and contraindications for such strategies and identify any other supplementary treatment approaches, a scoping review was undertaken to map the evidence relating to off-loading and compression therapy strategies to treat both diabetic foot ulcers and lower limb oedema in combination. METHODS Following the Joanna Briggs Institute (JBI) and PRISMA - Scoping Review (ScR) guidance, this review included published and unpublished literature from inception to April 2022. Literature was sourced using electronic databases including Cochrane Library, PubMed, CINAHL, AMED; websites; professional journals and reference lists of included literature. Eligible literature discussed the management of both diabetic foot ulceration and lower limb oedema and included at least one of the treatment strategies of interest. Data extraction involved recording any suggested off-loading, compression therapy or supplementary treatment strategies and any suggested indications, contraindications and cautions for their use. RESULTS Five hundred twenty-two publications were found relating to the management of diabetic foot ulcers with an off-loading strategy or the management of lower limb oedema with compression therapy. 51 publications were eligible for inclusion in the review. The majority of the excluded publications did not discuss the situation where diabetic foot ulceration and lower limb oedema present concurrently. CONCLUSIONS Most literature, focused on oedema management with compression therapy to conclude that compression therapy should be avoided in the presence of severe peripheral arterial disease. Less literature was found regarding off-loading strategies, but it was recommended that knee-high devices should be used with caution when off-loading diabetic foot ulcers in those with lower limb oedema. Treatment options to manage both conditions concurrently was identified as a research gap. Integrated working between specialist healthcare teams, was the supplementary strategy most frequently recommended. In the absence of a definitive treatment solution, clinicians are encouraged to use clinical reasoning along with support from specialist peers to establish the best, individualised treatment approach for their patients. TRIAL REGISTRATION Open Science Framework (osf.io/crb78).
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Affiliation(s)
- Justine Tansley
- Torbay and South Devon NHS Foundation Trust, Torquay, UK.
- University of Plymouth, Plymouth, UK.
| | - Richard Collings
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
- University of Plymouth, Plymouth, UK
| | - Jennifer Williams
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
- University of Plymouth, Plymouth, UK
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8
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Berger AG, Deiss-Yehiely E, Vo C, McCoy MG, Almofty S, Feinberg MW, Hammond PT. Electrostatically assembled wound dressings deliver pro-angiogenic anti-miRs preferentially to endothelial cells. Biomaterials 2023; 300:122188. [PMID: 37329684 PMCID: PMC10424785 DOI: 10.1016/j.biomaterials.2023.122188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
Chronic non-healing wounds occur frequently in individuals affected by diabetes, yet standard-of-care treatment leaves many patients inadequately treated or with recurring wounds. MicroRNA (miR) expression is dysregulated in diabetic wounds and drives an anti-angiogenic phenotype, but miRs can be inhibited with short, chemically-modified RNA oligonucleotides (anti-miRs). Clinical translation of anti-miRs is hindered by delivery challenges such as rapid clearance and uptake by off-target cells, requiring repeated injections, excessively large doses, and bolus dosing mismatched to the dynamics of the wound healing process. To address these limitations, we engineered electrostatically assembled wound dressings that locally release anti-miR-92a, as miR-92a is implicated in angiogenesis and wound repair. In vitro, anti-miR-92a released from these dressings was taken up by cells and inhibited its target. An in vivo cellular biodistribution study in murine diabetic wounds revealed that endothelial cells, which play a critical role in angiogenesis, exhibit higher uptake of anti-miR eluted from coated dressings than other cell types involved in the wound healing process. In a proof-of-concept efficacy study in the same wound model, anti-miR targeting anti-angiogenic miR-92a de-repressed target genes, increased gross wound closure, and induced a sex-dependent increase in vascularization. Overall, this proof-of-concept study demonstrates a facile, translational materials approach for modulating gene expression in ulcer endothelial cells to promote angiogenesis and wound healing. Furthermore, we highlight the importance of probing cellular interactions between the drug delivery system and the target cells to drive therapeutic efficacy.
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Affiliation(s)
- Adam G Berger
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elad Deiss-Yehiely
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Chau Vo
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael G McCoy
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Almofty
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam, 31441, Saudi Arabia
| | - Mark W Feinberg
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Paula T Hammond
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA.
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9
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Ge Q, Zhou Y, Liu Z. Analysis of pre-hospital delay in Chinese patients with diabetic foot ulcers: Based on 46 cases. Int Wound J 2023; 20:2657-2663. [PMID: 36916307 PMCID: PMC10410325 DOI: 10.1111/iwj.14139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
To study the causes of pre-hospital delay in Chinese patients with diabetic foot ulcers (DFUs). A retrospective study, investigating a case series of 46 DFUs treated at a single hospital, was conducted to evaluate wound condition, wound treatment, costs, and patients' complete medical records, and analyse the reasons causing the pre-hospital delay. We assessed 46 DFUs aged between 53 and 92 years old. The average pre-hospital delay was 5 months, with nearly 20% being delayed for more than 1 year. The average length of hospital stay in China was 21 days, with an average cost of $8672. Recurrence rate of DFUs was 21%, and three patients were recommended to transfer to upper-level hospital. Besides, the intervention was limited and homogenous and medical records were incomplete. Medical service users' limited understanding of diseases, high costs that patients need to afford, and unsatisfactory treatment by medical service providers are the main reasons for patients' delay in seeking treatment. Recommendations are offered to reduce the pre-hospital delay of Chinese patients with DFUs.
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Affiliation(s)
- Qiaoyue Ge
- West China School of Public HealthSichuan University/West China Fourth Hospital, Sichuan UniversityChengduChina
| | - Yue Zhou
- Health and Social Policy DivisionChengdu Preventive Medicine AssociationChengduChina
| | - Zhenmi Liu
- West China School of Public HealthSichuan University/West China Fourth Hospital, Sichuan UniversityChengduChina
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10
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Piñar-Gutiérrez A, Gros-Herguido N, Losada-Viñau F, Farfán-Díaz F, Enríquez-Macías M, Pérez-Morales A, González-Navarro I, Acosta-Delgado D, Guerrero-Vázquez R, Martínez-Ortega AJ, Pumar-López A, Mangas-Cruz MÁ, Bataller-de Juan E, Tallón-Aguilar L, Soto-Moreno A. Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2023; 70:381-388. [PMID: 37356875 DOI: 10.1016/j.endien.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/29/2021] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit. RESEARCH DESIGN AND METHODS Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ2 test for the comparison of proportions in qualitative variables were performed. RESULTS Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03). CONCLUSIONS The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Noelia Gros-Herguido
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fernando Losada-Viñau
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fátima Farfán-Díaz
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Ana Pérez-Morales
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | | | | | - Alfonso Pumar-López
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Luis Tallón-Aguilar
- UGC Cirugía General, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alfonso Soto-Moreno
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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11
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Zheng J, Li R, Dickey EE, Yan Y, Zayed MA, Zellers JA, Hastings MK. Regional skeletal muscle perfusion distribution in diabetic feet may differentiate short-term healed foot ulcers from non-healed ulcers. Eur Radiol 2023; 33:3303-3311. [PMID: 36719497 PMCID: PMC10121766 DOI: 10.1007/s00330-023-09405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The purpose of this study was to leverage a magnetic resonance imaging (MRI) approach to characterize foot perfusion distribution in patients with diabetes, with or without foot ulcers, and determine the ability of the regional perfusion measurements to identify ulcer-healing status. METHODS Three groups of participants (n = 15 / group) were recruited: controls (without diabetes), type II diabetes, and type II diabetes with foot ulcers. All participants underwent MRI evaluating foot perfusion in three muscle layers (from plantar to dorsal) at rest and during a standardized toe-flexion exercise. The exercise perfusion and perfusion reserve values were analyzed around and away from ulcers. Participants with foot ulcers were followed up 3 months after the MRI exams to determine the foot healing status. RESULTS Foot plantar muscle perfusion reserves were progressively lower from controls to diabetes, and to diabetes with foot ulcers (e.g., 2.58 ± 0.67, 1.48 ± 0.71, 1.12 ± 0.35, p < 0.001). In controls, the plantar layer had significantly higher perfusion reserve than the dorsal layer, whereas in either diabetes group, there was no significant difference in perfusion reserve among muscle layers. Using the ratio of total exercise perfusion around ulcers to that away from ulcers, the sensitivity and specificity to differentiate healing from non-healed ulcers were 100% and 86%, respectively. CONCLUSIONS Our study reveals significantly different foot perfusion distribution among controls, diabetes, and diabetes with foot ulcers. The prognostic value of MRI regional perfusion assessments has the potential to monitor interventions to improve ulcer healing outcomes. KEY POINTS • Contrast-free MRI permits quantitative assessment of regional foot muscle perfusion at rest and during isometric exercise. • Patients with diabetes and foot ulcers, without clinical evidence of peripheral arterial disease, had significantly impaired foot muscle perfusion and perfusion reserve. • Regional foot perfusion distribution may be used to predict the short-term healing status of foot ulcers in diabetes.
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Affiliation(s)
- Jie Zheng
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 4525 Scott Ave, Room 3114, St. Louis, MO, USA.
| | - Ran Li
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 4525 Scott Ave, Room 3114, St. Louis, MO, USA
| | - Erin E Dickey
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 4525 Scott Ave, Room 3114, St. Louis, MO, USA
| | - Yan Yan
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mohamed A Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer A Zellers
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary K Hastings
- Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO, USA
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12
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Graça Pereira M, Vilaça M, Pedras S, Carvalho A, Vedhara K, Jesus Dantas M, Machado L. Wound healing and healing process in patients with diabetic foot ulcers: A survival analysis study. Diabetes Res Clin Pract 2023; 198:110623. [PMID: 36907358 DOI: 10.1016/j.diabres.2023.110623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
AIMS This study aimed to identify demographic, clinical, and psychological contributors to DFU healing and favorable healing process. METHODS Patients with a chronic DFU were evaluated at baseline (T0; n = 153), two months later (T1; n = 108), and six months later (T2; n = 71). Patients were evaluated on health literacy, perceived stress, anxiety, depression, and illness perceptions. Cox proportional hazard models were built to analyze the predictors of DFU healing and favorable healing process (wound area reduction), including the assessment of time to achieve those outcomes. RESULTS More than half of patients had their DFU healed (56.1%) or showed a favorable healing process (83.6%). Median time for healing was 112 days, while for favorable process was 30 days. Illness perceptions were the only predictor of wound healing. Being female , with adequate health literacy, and a first DFU predicted a favorable healing process. CONCLUSIONS This is the first study showing that beliefs about DFU are significant predictors of DFU healing, and that health literacy is a significant predictor of a favorable healing process. Brief, comprehensive interventions should be implemented, at the treatment initial stage, in order to change misperceptions and to promote DFU literacy and better health outcomes.
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Affiliation(s)
- M Graça Pereira
- Psychology Research Center (CIPsi), School of Psychology, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal.
| | - Margarida Vilaça
- Psychology Research Center (CIPsi), School of Psychology, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal.
| | - Susana Pedras
- Angiology & Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUP), Largo Professor Abel Salazar, 4099-001 Porto, Portugal.
| | - André Carvalho
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Centro Hospitalar Universitário do Porto (CHUP), Largo Professor Abel Salazar, 4099-001 Porto, Portugal.
| | - Kavita Vedhara
- Division of Primary Care, University of Nottingham, University Park, Nottingham NG7 2RD, UK.
| | - M Jesus Dantas
- Department of Surgery, Centro Hospitalar Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007 Penafiel, Portugal.
| | - Luis Machado
- Department of Mathematics, University of Minho, Campus de Azurém, 4800-058 Guimarães, Portugal.
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13
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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14
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Annersten Gershater M, Apelqvist J, Alm Roijer C. Re-Ulceration Is Common in Persons with Diabetes and Healed Foot Ulcer After Participant-Driven Education in Group: A Randomized Controlled Trial. Adv Wound Care (New Rochelle) 2023; 12:117-126. [PMID: 35088617 DOI: 10.1089/wound.2021.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Objective: To compare the number of ulcer-free days during 24 months in persons with diabetes and a healed foot ulcer below the ankle provided with adjusted therapeutic shoes who were given standard information and participated in participant-driven group education compared with standard information alone. Methods: A randomized controlled trial was designed to evaluate the number of ulcer-free days after participant-driven group education in addition to standard information compared with standard information alone. The number needed to treat (N = 174) was not met, as only 138 persons with diabetes and previously healed foot ulcer were recruited (age median 63 years [34-79], 101 men/37 women). Results: A total of 138 persons were recruited, of whom 107 (77.5%) completed the study, 7 (5%) dropped out, and 12 (9%) deceased. No statistically significant difference was found between the intervention group compared with the control group after 6, 18, or 24 months. After 12 months, more patients in the intervention group had developed ulcers. Seventy-seven participants (56%) developed new foot ulcers, irrespective of side and site. Development of one ulcer appeared in 36 participants, two ulcers in 19, and 22 participants developed three ulcers. Forty-eight participants remained ulcer-free (35%) during the 24-month follow-up. Median ulcer-free days until first ulceration were 368 (4-720); until second ulceration, 404 (206-631); and until third ulceration, 660 (505-701). The participants wore prescribed therapeutic shoes during 88% of the follow-up visits. Conclusions: One-third of the participants remained ulcer-free for 24 months. Patient-driven education in groups did not give better results than standard information in this underpowered study. This study illustrates the challenges to perform comparative preventive studies in this group of patients with extensive comorbidity. Further studies are needed to evaluate interventions on ulceration in persons with a healed foot ulcer.
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Affiliation(s)
| | - Jan Apelqvist
- Department of Endocrinology, Skåne University Hospital, Malmö, Malmö, Sweden
| | - Carin Alm Roijer
- Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
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15
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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16
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Bundó M, Vlacho B, Llussà J, Bobé I, Aivar M, Ciria C, Martínez-Sánchez A, Real J, Mata-Cases M, Cos X, Dòria M, Viade J, Franch-Nadal J, Mauricio D. Prediction of outcomes in subjects with type 2 diabetes and diabetic foot ulcers in Catalonian primary care centers: a multicenter observational study. J Foot Ankle Res 2023; 16:8. [PMID: 36849888 PMCID: PMC9972716 DOI: 10.1186/s13047-023-00602-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 01/16/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Diabetic foot and lower limb complications are an important cause of morbidity and mortality among persons with diabetes mellitus. Very few studies have been carried out in the primary care settings. The main objective was to assess the prognosis of diabetic foot ulcer (DFU) in patients from primary care centers in Catalonia, Spain, during a 12-month follow-up period. METHODS We included participants with type 2 diabetes and a new DFU between February 2018 and July 2019. We estimated the incidence of mortality, amputations, recurrence and healing of DFU during the follow-up period. A multivariable analysis was performed to assess the association of these outcomes and risk factors. RESULTS During the follow-up period, 9.7% of participants died, 12.1% required amputation, 29.2% had a DFU recurrence, and 73.8% healed. Having a caregiver, ischemia or infection were associated with higher mortality risk (hazard ratio [HR]:3.63, 95% confidence interval [CI]:1.05; 12.61, HR: 6.41, 95%CI: 2.25; 18.30, HR: 3.06, 95%CI: 1.05; 8.94, respectively). Diabetic retinopathy was an independent risk factor for amputation events (HR: 3.39, 95%CI: 1.37; 8.39). Increasing age decreased the risk for a DFU recurrence, while having a caregiver increased the risk for this event (HR: 0.97, 95%CI: 0.94; 0.99). The need for a caregiver and infection decreased the probability of DFU healing (HR: 0.57, 95%CI: 0.39; 0.83, HR: 0.64, 95%CI: 0.42; 0.98, respectively). High scores for PEDIS (≥7) or SINBAD (≥3) were associated with an increased risk for DFU recurrence and a lower probability of DFU healing, respectively. CONCLUSIONS We observed high morbidity among subjects with a new DFU in our primary healthcare facilities. Peripheral arterial disease, infection, and microvascular complications increased the risk of poor clinical outcomes among subjects with DFU.
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Affiliation(s)
- Magdalena Bundó
- grid.452479.9DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain ,grid.22061.370000 0000 9127 6969Primary Health Care Center Ronda Prim, Gerència d’Àmbit d’Atenció Primària Metropolitana Nord de Barcelona, Institut Català de La Salut, Mataró, Spain
| | - Bogdan Vlacho
- grid.452479.9DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain ,grid.7080.f0000 0001 2296 0625Pharmacology Department, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain ,grid.413396.a0000 0004 1768 8905Institut de Recerca Hospital de La Santa Creu I Sant Pau, Barcelona, Spain ,grid.413448.e0000 0000 9314 1427CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Judit Llussà
- grid.22061.370000 0000 9127 6969Primary Health Care Centre Sant Roc, Gerència d’Àmbit d’Atenció Primària Metropolitana Nord de Barcelona, Institut Català de La Salut, Mataró, Spain Catalan Health Institute, Badalona, Spain
| | - Isabel Bobé
- grid.22061.370000 0000 9127 6969Primary Health Care Center La Mina, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Sant Adrià de Besòs, Spain
| | - Meritxell Aivar
- grid.22061.370000 0000 9127 6969Primary Health Care Centre Sants, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Barcelona, Spain
| | - Carmen Ciria
- grid.22061.370000 0000 9127 6969Primary Health Care Centre Ponts. Gerència d’Àmbit d’Atenció Primària Lleida, Institut Català de La Salut, Lleida, Spain
| | - Ana Martínez-Sánchez
- grid.22061.370000 0000 9127 6969Primary Health Care Centre El Carmel. Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Barcelona, Spain
| | - Jordi Real
- grid.452479.9DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain ,grid.410675.10000 0001 2325 3084Universitat Internacional de Catalunya, Epidemiologia I Salut Pública, Sant Cugat, Spain
| | - Manel Mata-Cases
- grid.452479.9DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain ,grid.413448.e0000 0000 9314 1427CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain ,grid.22061.370000 0000 9127 6969Primary Health Care Center La Mina, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Sant Adrià de Besòs, Spain
| | - Xavier Cos
- grid.452479.9DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain ,grid.22061.370000 0000 9127 6969Primary Health Care Center Sant Martí de Provençals, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Barcelona, Spain ,grid.22061.370000 0000 9127 6969Innovation office at Institut Català de La Salut, Barcelona, Spain
| | - Montserrat Dòria
- grid.413396.a0000 0004 1768 8905Department of Endocrinology & Nutrition, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Jordi Viade
- grid.411438.b0000 0004 1767 6330Department of Endocrinology & Nutrition, Hospital Germans Trias I Pujol, Badalona, Spain
| | - Josep Franch-Nadal
- DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain. .,Primary Health Care Center Raval Sud, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de La Salut, Barcelona, Spain.
| | - Dídac Mauricio
- DAP-Cat Group. Unitat de Suport a La Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 375, Entresuelo. 08025, Barcelona, Spain. .,Institut de Recerca Hospital de La Santa Creu I Sant Pau, Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain. .,Department of Endocrinology & Nutrition, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain. .,Department of Medicine, University of Vic - Central University of Catalonia, Vic, Spain.
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Sumpio BJ, Mezghani I, Wang E, Li Z, Valsami EA, Theocharidis G, Veves A. Experimental treatments in clinical trials for diabetic foot ulcers: wound healers in the pipeline. Expert Opin Investig Drugs 2023; 32:95-99. [PMID: 36749693 DOI: 10.1080/13543784.2023.2178418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Diabetes affects 400 million people globally and patients and causes nephropathy, neuropathy, and vascular disease. Amongst these complications, diabetic foot ulcers remain a substantial problem for patients and clinicians. Aggressive wound care and antibiotics remain important for the healing of these chronic wounds, but even when treated these chronic ulcers can lead to infection and amputations. AREAS COVERED This paper reviews the pathophysiology of diabetic foot ulcers and the current management strategies. Then, it discusses novel therapeutics such as topical oxygen therapy as well as autologous patches and macrophage creams. EXPERT OPINION Diabetic foot ulcers are a substantial problem for patients and clinicians. Early identification, aggressive wound care, and normoglycemia remain the standard of care, however when these fail it is important to adapt. Since each patient and wound vary drastically we believe they should be treated as such. For patient with intact perfusion, topical ON101 and sucrose octasulfate creams can help. While patient with peripheral arterial disease should consider topical oxygen therapy as an adjunct. However, as scientists gain a better understanding of the pathophysiology behind DFUs, the hope is that this new wave of therapeutics will emerge.
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Affiliation(s)
- Brandon J Sumpio
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ikram Mezghani
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Enya Wang
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhuqing Li
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eleftheria-Angeliki Valsami
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Georgios Theocharidis
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aristidis Veves
- Joslin-Beth Israel Deaconess Foot Center and the Rongxiang Xu, MD, Center for Regenerative Therapeutics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Validation of the Fast-Track Model: A Simple Tool to Assess the Severity of Diabetic Foot Ulcers. J Clin Med 2023; 12:jcm12030761. [PMID: 36769408 PMCID: PMC9917528 DOI: 10.3390/jcm12030761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/10/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
This study aimed to validate the association between the grades of severity of diabetic foot ulcers (DFUs) identified by the fast-tack model and specific outcomes. Three hundred and sixty-seven patients with new DFUs who were referred to a tertiary level diabetic foot service serving Rome, Italy, were included. The fast-track model identifies three levels of DFUs' severity: uncomplicated DFUs, including superficial wounds, not-infected wounds, and not-ischemic wounds; complicated DFUs, including ischemic wounds, infected wounds, and deep ulcers involving the muscles, tendons, or bones, and any kind of ulcers in patients on dialysis and/or with heart failure; and severely complicated DFUs, including abscesses, wet gangrene, necrotizing fasciitis, fever, or clinical signs of sepsis. Healing, minor and major amputation, hospitalization, and survival after 24 weeks of follow-up were considered. Among the included patients, 35 (9.6%) had uncomplicated DFUs, 210 (57.2%) had complicated DFUs, and 122 (33.2%) had severely complicated DFUs. The outcomes for patients with uncomplicated, complicated, and severely complicated DFUs were as follows, respectively: healing, 97.1%, 86.2%, and 69.8%; minor amputation, 2.9%, 20%, and 66.4%; major amputation, 0%, 2.9%, and 16.4%; hospitalization, 14.3%, 55.7%, and 89.3%; survival, 100%, 96.7%, and 89.3%. DFU severity was an independent predictor of healing, amputation, hospitalization, and survival. The current study shows an association between the grade of severity of DFUs identified by the fast-track model and the considered outcomes. The fast-track model may be a useful tool for assessing the severity and prognosis of DFUs.
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Meloni M, Bellia A, Giurato L, Lauro D, Uccioli L. Below-the-ankle arterial disease: a new marker of coronary artery disease in patients with diabetes and foot ulcers. Acta Diabetol 2022; 59:1331-1338. [PMID: 35864261 DOI: 10.1007/s00592-022-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/29/2022] [Indexed: 11/01/2022]
Abstract
AIM The aim of the current study is to evaluate the association between below-the-ankle (BTA) arterial disease and coronary artery disease (CAD) in patients with diabetic foot ulcers (DFUs). METHODS The study group was composed of patients with an active neuro-ischaemic DFUs managed in a tertiary care diabetic foot clinic. All patients received a pre-set limb salvage protocol including lower limb revascularization. By a retrospective analysis of individual angiograms, patients were divided in two groups: below-the-ankle (BTA) and above-the-ankle (ATA) arterial disease groups. The rate of CAD at baseline assessment and the new events of acute myocardial ischaemia (AMI) during 1-year of follow-up were evaluated and compared between the two groups. RESULTS Two hundreds seventy-two (272) patients were included, 120 (44.1%) showed BTA arterial disease while 152 (55.9%) ATA arterial disease. The mean age was 68.9 ± 9.6 years, 198 (72.8%) were male, 246 (90.4%) had type 2 diabetes, the mean diabetes duration was 20.7 ± 11.6 years, the mean HbA1c was 7.8 ± 4.2% (62 ± 22 mmmol/mol). The whole population reported CAD in 172 cases (63.4%), and the rate in the BTA group was significantly higher than in ATA group, respectively, 90 (75.4%) vs 82 (54.1%), p < 0.0001. During the follow-up, BTA group had 5% of new cases of AMI in comparison to 1.3% in ATA group (p < 0.001). At the multivariate analysis BTA resulted an independent marker of CAD [OR 1.9 CI 9 5% (1.3-4.5) p = 0.0001]. CONCLUSION The current study shows a significant association between BTA arterial disease and CAD. A close cardiovascular screen should be required in patients with DFUs.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy.
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- CTO Andrea Alesini Hospital, Division of Endocrinology and Diabetes Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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López-Moral M, Molines-Barroso RJ, García-Álvarez Y, Álvaro-Afonso FJ, García-Madrid M, Lázaro-Martínez JL. Clinical Efficacy of a 3D Foot Scanner app for the Fitting of Therapeutic Footwear in Persons with Diabetes in Remission: A Randomized and Controlled Clinical Trial. INT J LOW EXTR WOUND 2022:15347346221124645. [PMID: 36066032 DOI: 10.1177/15347346221124645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To evaluate the ability of high-risk patients with diabetes in remission to select proper therapeutic footwear (TF) and validate a novel 3D foot scanner app for selecting the proper fitting TF. We conducted a randomized and controlled clinical trial enrolling 30 patients with a previously healed diabetic foot ulcer carried out in a specialized diabetic foot unit between November 2021 and June 2022. All patients were recommended to TF with extra depth volume and rocker sole. The control group could acquire the TF size and model according to aesthetic preferences, while the experimental group had to acquire a specific size and model according to the result of a novel mobile app 3D feet scan. TF was recommended to change when the ill-fitting reasons were found, excessive length or tightness or compromise with toes. The primary outcome measure was the requirement of TF change after prescription because of ill-fitting. A total of seven patients required TF change, one of them (6.7%) in the experimental group and six patients (40%) in the control group (p = .031, 95% CI [0.011-1.04]). Reasons for ill-fitting were as follows: four patients due to excessive length and three patients due to toe compromise. The relative risk reduction for the need to change the TF via the foot scan compared to the control group was 83%, and the number needed to treat was 20. High-risk patients with diabetes tend to select TF with inadequate fitting (length or capacity), and they should be guided hand to hand to acquire proper TF.
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Affiliation(s)
- Mateo López-Moral
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
| | - Raúl J Molines-Barroso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
| | - Francisco J Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
| | - Marta García-Madrid
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, 16734Universidad Complutense de Madrid. Instituto, Hospital Clínico San Carlos; IdISSC, Madrid, Spain
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21
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Aga F, Dunbar SB, Kebede T, Guteta S, Higgins MK, Gary RA. Foot self-care behaviour in type 2 diabetes adults with and without comorbid heart failure. Nurs Open 2022; 9:2473-2485. [PMID: 35678585 PMCID: PMC9374405 DOI: 10.1002/nop2.1265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/15/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS To compare the correlates of foot self-care behaviours among type 2 diabetes mellitus (T2D) adults with and without comorbid heart failure (HF). DESIGN Cross-sectional, correlational, comparative design. METHODS A 210 T2D adults (105 with HF and 105 without HF) participated from August-December 2020. Foot self-care behaviour was measured using the foot care subscale of the Summary of Diabetes Self-Care Activities (SDSCA) instrument. A stepwise logistic regression analysis was used to explore variables predicting foot self-care behaviour. RESULTS The participants' mean age was 58.7 ± 10.9 years. Poor foot self-care behaviour was reported in T2D adults both with (53.3%) and without (54.3%) HF. Participants with HF-comorbidity were statistically significantly older and had higher total daily medication intake. Household income and the total number of daily medications statistically significantly predicted foot self-care behaviour in HF-comorbid T2D adults. Marital status, social support and body mass index predicted foot self-care behaviour in the non-HF group.
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Affiliation(s)
- Fekadu Aga
- School of Nursing & Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sandra B Dunbar
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Tedla Kebede
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Senbeta Guteta
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Melinda Kay Higgins
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Rebecca A Gary
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
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22
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Adeleye OO, Williams AO, Dada AO, Ugwu ET, Ogbera AO, Sodipo OO. Sequelae of Hospitalization for Diabetic Foot Ulcers at LASUTH Ikeja Lagos: A Prospective Observational Study. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:889264. [PMID: 36992777 PMCID: PMC10012119 DOI: 10.3389/fcdhc.2022.889264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022]
Abstract
AbstractDiabetic foot ulcers (DFUs) remain important sequelae of diabetes (DM) which cause debilitating effects on the sufferer. The evolution of some aspects of epidemiology and the current clinical impact of DFUs was examined.MethodsA single-center prospective observational study. Study subjects were consecutively recruited.ResultsTotal medical admissions during the study period were 2288, 350 were DM related, out of these 112 were admitted for DFU. 32% of total DM admissions were for DFU. The mean age of the study subjects is 58 ± 11.0 range is from 35 years to 87 years. Males were slightly predominant (51.8%). Most of them were actively employed (92%), and the majority were in the 55 to 64 years age category. Most of them had not been diabetic for longer than 8 years (61%). The mean duration of DM is 8.32±7.27 years. The mean duration of ulcer at presentation was 72.0±138.13 days. The majority of the patients (80.3%) presented with severe (grades 3 to 5) ulcers, Wagner grade four was the most predominant. Regarding clinical outcome, 24 (24.7%) had an amputation, 3 of which were minor. The factor that was associated with amputation was concomitant heart failure – OR 6.00 CI 0.589-61.07, 0.498-4.856. Death occurred in 16 (18.4%). The factors associated with mortality were severe anemia OR 2.00 CI 0.65 – 6.113, severe renal impairment requiring dialysis OR 3.93 CI 0.232-66.5, concomitant stroke OR 8.42 CI 0.71-99.6, and peripheral arterial disease- OR 18.33 CI 2.27 -147 p-value- 0.006.ConclusionThe hallmark of DFU in this report is late presentation, it accounted for a significant proportion of the total medical admissions, although the case fatality of DFU reduced from previous reports from the center, mortality, and amputation rates are still unacceptably high. Concomittant heart failure was a factor of amputation. Mortality was associated with severe anemia, renal impairment and peripheral arterial disease.
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Affiliation(s)
- Olufunmilayo Olubusola Adeleye
- Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Nigeria
- *Correspondence: Olufunmilayo Olubusola Adeleye,
| | | | - Akin Olusola Dada
- Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Nigeria
| | - Ejiofor T. Ugwu
- Department of Medicine, Enugu State University of Science and Technology, Enugu, Nigeria
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López-Moral M, Molines-Barroso RJ, García-Álvarez Y, Sanz-Corbalán I, Tardáguila-García A, Lázaro-Martínez JL. Safety and Efficacy of Several Versus Isolated Prophylactic Flexor Tenotomies in Diabetes Patients: A 1-Year Prospective Study. J Clin Med 2022; 11:jcm11144093. [PMID: 35887856 PMCID: PMC9316570 DOI: 10.3390/jcm11144093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Background: To assess long-term clinical outcomes of patients who underwent isolated versus several percutaneous flexor tenotomies for the treatment of toe deformities and previous diabetic foot ulcers; Methods: Twenty-three patients (mean age 66.26 ± 11.20, years) who underwent prophylactic percutaneous flexor tenotomies secondary to tip-toe ulcers participated in this 1-year prospective study. The study was stratified into two groups for analyses: (1) isolated tenotomies patients, and (2) several tenotomies patients (two or more tenotomies). Outcome measures were toe reulceration and recurrence, minor lesions, digital deformities, and peak plantar pressure (PPP—N/cm2) and pressure/time Integral (PTI—N/cm2/s) in the hallux and minor toes after a 1-year follow-up period; Results: Patients with isolated tenotomies (n = 11, 35.48%) showed a higher rate of reulceration (n = 8, 72.7%, p < 0.001) in the adjacent toes, additionally, we found more prevalence of hyperkeratosis (n = 11, 100%), minor lesions (n = 9, 81%), and claw toes (n = 11, 100%) (p < 0.001). In several tenotomies patients (n = 20, 64.52%), we found a higher rate of floating toes (n = 16, 80%) in comparison with isolated tenotomies patients (p < 0.001). PPP and PTI in the non-tenotomy toes were higher in the group of patients who underwent isolated tenotomies (p < 0.001); Conclusions: Patients who underwent several tenotomies had better clinical outcomes after a 1-year follow-up period compared to isolated tenotomies.
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Affiliation(s)
- Mateo López-Moral
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Raúl J. Molines-Barroso
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34–913942218
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Irene Sanz-Corbalán
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Aroa Tardáguila-García
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain; (M.L.-M.); (Y.G.-Á.); (I.S.-C.); (A.T.-G.); (J.L.L.-M.)
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
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Lee DW, Kwak SH, Kim JH, Choi HJ. Prediction of diabetic foot amputation using newly revised DIRECT coding system: Comparison of accuracy with that of five existing classification systems. Int Wound J 2022; 20:359-371. [PMID: 35811359 PMCID: PMC9885474 DOI: 10.1111/iwj.13884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Diabetes mellitus (DM) causes various complications over time, one such complication is diabetic foot ulcers (DFU), which are challenging to treat and can lead to amputation. Additionally, a system for accurate prediction of amputation has yet to be developed. In total, 131 patients were included in the study after retrospectively collecting data from 2016 to 2020 about DFU. The collected data were used for comparison of the accuracy between five existing classification systems and the newly revised DIRECT coding system, and investigation of risk factors for lower extremity amputation (LEA). The existing five classification systems and DIRECT system can effectively predict LEA. The DIRECT3 system has three elements, C-reactive protein (CRP), ulcer history (UH), and hypertension (HTN) in addition to those of the DIRECT system. It had a high predictive value and accuracy similar to that of Wagner and University of Texas (UT) on depth among the five classification systems. Among the statistically significant risk factors, duration of DM and HTN, haemoglobin (Hb), CRP, and UH showed an association with LEA. The DIRECT coding system is effective for predicting LEA and explaining appropriate treatment methods for DFU, and is widely applicable because of its user accessibility and convenience.
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Affiliation(s)
- Da Woon Lee
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea,Institute of Tissue Regeneration, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
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Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Winkler E, Schöni M, Krähenbühl N, Uçkay I, Waibel FWA. Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes. Foot Ankle Int 2022; 43:957-967. [PMID: 35582923 PMCID: PMC9260474 DOI: 10.1177/10711007221088552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited. METHODS In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed. RESULTS Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors. CONCLUSION In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Elin Winkler
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland,Elin Winkler, MD, Department of
Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich, 8008,
Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and
Applied Research and Infectiology, Balgrist University Hospital, Zurich,
Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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Bandarian F, Qorbani M, Nasli-Esfahani E, Sanjari M, Rambod C, Larijani B. Epidemiology of Diabetes Foot Amputation and its Risk Factors in the Middle East Region: A Systematic Review and Meta-Analysis. INT J LOW EXTR WOUND 2022:15347346221109057. [PMID: 35730157 DOI: 10.1177/15347346221109057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aimed to review epidemiology of diabetic foot (DF) amputation and provide a pooled estimation of DF amputation rate in the region. A comprehensive search was performed in Web of Science, PubMed, Scopus and EMBASE databases using appropriate search term. Obtained records were entered endnote software and after removing duplicats were screened by title, abstract and full text. Data was extracted from the remained documents. Random effect meta-analysis was used to pool the estimated prevalence rate due to sever heterogeneity between studies. Finally 17 articles in diabetes, 20 in patients with DFU (diabetic foot ulcer) and two in both remained after screening and included in meta-analysis. Overall pooled amputation rate in diabetes was 2% (95% CI: 1%-3%) which was not significantly different between countries. The pooled prevalence of amputation rate in DFU patients was 33% (24%-43%) and the pooled prevalence in Saudi Arabia was significantly higher than in other countries. The estimated rate of foot amputation in diabetes patients and those with DFUs in the Middle East region is approximately high, which may indicate low quality of preventive foot care, low socioeconomics and low patients awareness or education in countries with high amputation rate.
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Affiliation(s)
- Fatemeh Bandarian
- Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular- Cellular Sciences Institute, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, 391934Alborz University of Medical Sciences, Karaj, Iran
| | - Ensieh Nasli-Esfahani
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Camelia Rambod
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular -Cellular Sciences Institute, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, 48439Tehran University of Medical Sciences, Tehran, Iran
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28
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Local Random Flaps for the Diabetic Foot. Clin Podiatr Med Surg 2022; 39:321-330. [PMID: 35365329 DOI: 10.1016/j.cpm.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Diabetic foot wounds should be treated in a timely fashion to prevent infection and potential limb loss. When local wound care and traditional off-loading fails, surgeons may consider local random flaps for definitive closure. Wound size, location, and type are characteristics that should be considered for selection of the best flap. This article reviews the application of local random flaps in the treatment of diabetic foot wounds.
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Zhang Y, Cramb S, McPhail SM, Pacella R, van Netten JJ, Cheng Q, Derhy PH, Kinnear EM, Lazzarini PA. Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months. Diabetes Res Clin Pract 2022; 185:109239. [PMID: 35131379 DOI: 10.1016/j.diabres.2022.109239] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/27/2022] [Accepted: 02/01/2022] [Indexed: 12/17/2022]
Abstract
AIMS To investigate factors independently associated with time-to-(being)-ulcer-free, time-varying effects and predict adjusted ulcer-free probabilities, in a large prospective cohort with diabetes-related foot ulcers (DFU) followed-up for 24 months. METHODS Patients presenting with DFU(s) to 65 Diabetic Foot Services across Queensland, Australia, between July-2011 and December-2017 were included. Demographic, comorbidity, limb, ulcer, and treatment factors were captured at presentation. Patients were followed-up until ulcer-free (all DFU(s) healed), amputation, death or two years. Factors associated with time-to-ulcer-free were investigated using both Cox proportional hazards and flexible parametric survival models to explore time-varying effects and plot predicted adjusted ulcer-free probability graphs. RESULTS Of 4,709 included patients (median age 63 years, 69.5% male), median time-to-ulcer-free was 112 days (IQR:40->730), with 68.4% ulcer-free within two years. Factors independently associated with longer time-to-ulcer-free were each year of age younger than 60 years, living in a regional or remote area, smoking, neuropathy, peripheral artery disease (PAD), ulcer size >1 cm2, deep ulcer and mild infection (all p < 0.05). Time-varying effects were found for PAD and ulcer size limiting their association to six months only. Shorter time-to-ulcer-free was associated with recent DFU treatment by a podiatrist and receiving knee-high offloading treatment (both p < 0.05). Predicted adjusted ulcer-free probability graphs reported largest differences in time-to-ulcer-free over 24-months for geographical remoteness and PAD factors. CONCLUSIONS Multiple factors predicted longer and shorter time-to-ulcer-free in people presenting with DFUs. Considering these factors, their time-varying effects and adjusted ulcer-free probability graphs, should aid the prediction of the likely time-to-(being)-ulcer-free for DFU patients.
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Affiliation(s)
- Yuqi Zhang
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Centre for Data Science, Queensland University of Technology, Brisbane, Australia.
| | - Susanna Cramb
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Centre for Data Science, Queensland University of Technology, Brisbane, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Clinical Informatics Directorate, Metro South Health, Brisbane, Australia
| | - Rosana Pacella
- Institute for Lifecourse Development, University of Greenwich, Greenwich, London, UK
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands
| | - Qinglu Cheng
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Patrick H Derhy
- Clinical Access and Redesign Unit, Queensland Health, Brisbane, Australia
| | - Ewan M Kinnear
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
| | - Peter A Lazzarini
- Australian Centre for Health Services Innovation & Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia; Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
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Lalieu R, Raap RB, van Hulst R. Hyperbaric oxygen therapy: when pressure is good for diabetic foot ulcers. Br J Community Nurs 2022; 27:S6-S12. [PMID: 35274985 DOI: 10.12968/bjcn.2022.27.sup3.s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The diabetic foot ulcer (DFU) as a common complication of diabetes. Even with adequate treatment, up to 35% of these ulcers do not heal. This is due to the effect of aging, repeated ischemia-reperfusion (IR) injury, bacterial colonisation of the wound and chronic hypoxia. All wound-healing processes are highly dependent on oxygen, so hyperbaric oxygen therapy (HBOT) can be employed to improve wound healing and correct the four pathophysiological factors for chronic wounds. It is, in fact, internationally recognised as a treatment option for non-healing DFUs. Several trials and systematic reviews have been performed on its efficacy, which show a positive trend towards increased wound healing and reduced amputation risk. Some controversy exists due to contradictory results in these studies, which may be due to grouping patients with and without peripheral arterial occlusive disease (PAOD) together. Side effects are usually mild and transient, and the treatment is considered safe.
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Affiliation(s)
- Rutger Lalieu
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands, and Amsterdam University Medical Centers, location AMC, Department of Anaesthesiology
| | - René Bol Raap
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands
| | - Rob van Hulst
- Amsterdam University Medical Centers, location AMC, Department of Anaesthesiology and Hyperbaric Department
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Four in one—Combination therapy using live Lactococcus lactis expressing three therapeutic proteins for the treatment of chronic non-healing wounds. PLoS One 2022; 17:e0264775. [PMID: 35226700 PMCID: PMC8884502 DOI: 10.1371/journal.pone.0264775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/17/2022] [Indexed: 01/03/2023] Open
Abstract
Diabetes mellitus is one of the major concerns for health care systems, affecting 382 million people worldwide. Among the different complications of diabetes, lower limbs chronic ulceration is a common, severe and costly cause of morbidity. Diabetic foot ulcers are a leading cause of hospitalization in diabetic patients and its rate exceed the ones of congestive heart failure, depression or renal disease. Diabetic non-healing ulcers account for more than 60% of all non-traumatic lower limb amputations and the five-year mortality after amputation is higher than 50%, being equal to several types of advanced cancer. The primary management goals for an existing diabetic foot ulcer are to achieve primary healing as expeditiously as possible and to achieve a reduction of the amputation rate in the patients. Unfortunately, approximately a quarter of patients do not partially or fully respond to the standard of care. Advanced therapies for chronic wounds are existing, however, recent guidelines including the latest reviews and meta-analyses of the scientific and clinical evidence available from current treatment strategies and new therapeutic agents revealed that there is a lack of clinical data and persistent gap of evidence for many of the advanced therapeutic approaches. In addition, no pharmacological wound healing product has gained authority approval for more than 10 years in both US and EU, constituting a highly unmet medical need. In this publication we present data from a live biopharmaceutical product AUP1602-C designed as a single pharmaceutical entity based on the non-pathogenic, food-grade lactic acid bacterium Lactococcus lactis subsp. cremoris that has been genetically engineered to produce human fibroblast growth factor 2,interleukin4 and colony stimulating factor 1. Designed to address different aspects of wound healing (i.e. fibroblast proliferation, angiogenesis and immune cell activation) and currently in phase I clinical study, we show how the combination of the individual components on the wound micro-environment initiates and improves the wound healing in chronic wounds.
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Aritzmendi Pérez M, Bravo Ruiz E, Torre Puente R, Baraia-Etxaburu Artetxe JM, Etxeberria Martín E, Pascual Huerta J. Tratamiento y evolución de úlceras de pie diabético con sospecha de osteomielitis en una Unidad de Pie Diabético de nueva creación. REVISTA ESPAÑOLA DE PODOLOGÍA 2022. [DOI: 10.20986/revesppod.2022.1624/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Meza-Torres B, Cunningham SG, Heiss C, Joy M, Feher M, Leese GP, de Lusignan S, Carinci F. Adherence to General Diabetes and Foot Care Processes, with Prompt Referral, Are Associated with Amputation-Free Survival in People with Type 2 Diabetes and Foot Ulcers: A Scottish National Registry Analysis. J Diabetes Res 2022; 2022:7414258. [PMID: 35746918 PMCID: PMC9213182 DOI: 10.1155/2022/7414258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 05/10/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS To compare different packages of care across care providers in Scotland on foot-related outcomes. METHODS A retrospective cohort study with primary and secondary care electronic health records from the Scottish Diabetes Registry, including 6,845 people with type 2 diabetes and a first foot ulcer occurring between 2013 and 2017. We assessed the association between exposure to care processes and major lower extremity amputation and death. Proportional hazards were used for time-to-event univariate and multivariate analyses, adjusting for case-mix characteristics and care processes. Results were expressed in terms of hazard ratios with 95% confidence intervals. RESULTS 2,243 (32.7%) subjects had a major amputation or death. Exposure to all nine care processes at all ages (HR = 0.63; 95% CI: 0.58-0.69; p < .001) and higher foot care attendance in people aged >70 years (HR = 0.88; 0.78-0.99; p = .03) were associated with longer major amputation-free survival. Waiting time ≥ 12 weeks between ulceration and clinic attendance was associated with worse outcomes (HR = 1.59; 1.37-1.84; p < .001). In people > 70 years, minor amputations were associated with improved major amputation-free survival (HR = 0.69; 0.52-0.92; p = .01). CONCLUSIONS Strict adherence to a standardised package of general diabetes care before foot ulceration, timely foot care after ulceration, and specific treatment pathways were associated with longer major amputation-free survival among a large cohort of people with type 2 diabetes in Scotland, with a larger impact on older age groups.
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Affiliation(s)
- Bernardo Meza-Torres
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Scott G. Cunningham
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Graham P. Leese
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Fabrizio Carinci
- Department of Statistical Sciences, University of Bologna, Italy
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Jifar WW, Atnafie SA, Angalaparameswari S. A Review: Matrix Metallopeptidase-9 Nanoparticles Targeted for the Treatment of Diabetic Foot Ulcers. J Multidiscip Healthc 2021; 14:3321-3329. [PMID: 34880623 PMCID: PMC8646228 DOI: 10.2147/jmdh.s343085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/23/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetes foot ulcers are a leading cause of death in diabetic individuals. There are very few medicines and treatments that have received regulatory clearance for this indication, and numerous compounds from various pharmacological classes are now in various stages of clinical studies for diabetic foot ulcers treatment. Multiple risk factors contribute to diabetic foot ulcers, including neuropathy, peripheral artery disease, infection, gender, cigarette smoking, and age. The present difficulties in diabetic foot ulcers treatment are related to bacterial resistance to currently utilized antibiotics. Inhibition of the quorum sensing (QS) system and targeting matrix metallopeptidase-9 (MMP-9) are promising. This study focuses on the difficulties of existing treatment, current treatment technique, and novel pharmacological targets for diabetic foot ulcer. The electronic data base search diabetic for literature on foot ulcers treatment was carried out using Science Direct, PubMed, Google-Scholar, Springer Link, Scopus, and Wiley up to 2021. Becaplermin, a medication that targets MMP-9, glyceryl trinitrate, which inhibits the bacterial quorum sensing system, probiotic therapy, and nano technological solutions are just a few of the novel pharmaceuticals being developed for diabetic foot ulcers treatment. A combination of therapies, rather than one particular agent, will be the best option for treatment of Diabetes foot ulcer since it is multifactorial factors that render occurs of diabetic foot ulcer.
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Affiliation(s)
- Wakuma Wakene Jifar
- Mettu University, College of Health Sciences, Department of Pharmacy, Mettu, Ethiopia
| | - Seyfe Asrade Atnafie
- University of Gondar, College of Medicine and Health Sciences, School of Pharmacy, Department of Pharmacology, Gondar, Ethiopia
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Hamilton EJ, Scheepers J, Ryan H, Perrin BM, Charles J, Cheney J, Twigg SM. Australian guideline on wound classification of diabetes-related foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2021; 14:60. [PMID: 34861898 PMCID: PMC8641146 DOI: 10.1186/s13047-021-00503-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/24/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU. METHODS Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting. RESULTS After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer. CONCLUSIONS We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.
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Affiliation(s)
- Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Australia
| | - Joanna Scheepers
- St John of God Midland Public and Private Hospitals, Midland, WA, Australia
| | - Hayley Ryan
- Wounds Australia Limited, WoundRescue Pty Ltd, Canberra, ACT, Australia
| | - Byron M Perrin
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - James Charles
- National Indigenous Knowledge's, Education, Research and Innovation Institute, Faculty of Arts and Education, Deakin University, Geelong, Australia
| | | | - Stephen M Twigg
- Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, Australia.
- University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Sydney, NSW, 2006, Australia.
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Bonnet JB, Sultan A. Narrative Review of the Relationship Between CKD and Diabetic Foot Ulcer. Kidney Int Rep 2021; 7:381-388. [PMID: 35257052 PMCID: PMC8897302 DOI: 10.1016/j.ekir.2021.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/23/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023] Open
Abstract
Diabetic foot ulcer (DFU) and chronic kidney disease (CKD) are 2 significant complications of diabetes mellitus (DM). Up to 40% of patients with DM are expected to also develop CKD, and 19% to 34% will suffer from DFU during their lifetimes. However, data on the link between podiatric risk and the extent of CKD are scarce. Neuropathy, a key element of the International Working Group on the Diabetic Foot (IWGDF) classification, nevertheless appears to be related to the CKD stage. The incidence of DFU and its poor evolution also appear to be linked to the stage of CKD, with mortality reaching its peak in patients with end-stage renal disease (ESRD). Whatever, the decrease in the rate of diabetic foot amputation observed worldwide, especially for major amputations, is also observed in patients with ESRD. Specific actions taken for patients undergoing dialysis seems to improve the DFU prognosis. CKD and DFU share a number of elements of pathophysiology, the first of which is peripheral arterial disease (PAD). Uremic neuropathy and nutritional status also seem to create a link between the development of the 2 complications. This literature review provides an update on the complex and dynamic relationship between DFU and CKD. It examines the epidemiologic link between CKD and diabetic foot risk, CKD and DFU occurrence, and CKD and DFU prognosis. It focuses on the pathophysiological links between these 2 complications. Finally, it highlights the actions taken to improve management in the ESRD population that have reduced the rate of major amputations in this population by more than half.
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Bundó M, Llussà J, Serra M, la Iglesia PPD, Gimbert RM, Real J, Vlacho B, Mata-Cases M, Cos X, Franch-Nadal J, Mauricio D. Incidence and characteristics of diabetic foot ulcers in subjects with type 2 diabetes in Catalonian primary care centres: An observational multicentre study. Prim Care Diabetes 2021; 15:1033-1039. [PMID: 34419365 DOI: 10.1016/j.pcd.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/19/2022]
Abstract
AIMS The main objective was to assess the incidence of diabetic foot ulcers in type 2 diabetes individuals from primary care centres in Catalonia, Spain. METHODS Prospective observational study in 36 Primary Care centres in Catalonia during February 2018 and July 2019 was conducted. We included participants with type 2 diabetes and a new foot ulcer. We estimated the annual foot ulcer incidence and described the characteristics: presence of comorbidities, clinical parameters and the characteristics of the diabetic foot ulcers (DFU) at inclusion in the study. RESULTS The incidence of a new DFU during the 12-month recruitment period was 0.42%. The mean age of the participants was 72.2 years (± 12.7), the majority of them were males (n = 178; 69.5%). Overall, 43.8% of DFUs were located on the dorsal aspect of toes or interdigital spaces. A percentage of 43.4% of the participants had ulcers of less than 1 cm2 surface. Further, 44.1% of the participants had a neuroischemic, 20.3% a neuropathic, 20.3% an ischemic ulcer. A 25.3% of ulcers with a concomitant peripheral artery disease were infected. CONCLUSIONS Although the incidence found was low, our study shows the great complexity of patients with foot ulcers treated in primary care.
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Affiliation(s)
- Magdalena Bundó
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Primary Health Care Center Ronda Prim, Gerència d'Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Mataró, Spain
| | - Judit Llussà
- Primary Health Care Centre Sant Roc, Gerència d'Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Mataró, Spain Catalan Health Institute, Badalona, Spain
| | - Marta Serra
- Primary Health Care Centre Ca n'Oriac, Gerència d'Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Sabadell, Spain
| | - Paloma Prats de la Iglesia
- Primary Health Care Centre Raval Sud, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain
| | - Rosa M Gimbert
- Primary Health Care Centre El Carmel, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Jordi Real
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Universitat Internacional de Catalunya, Epidemiologia i Salut Pública, Sant Cugat, Spain
| | - Bogdan Vlacho
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Pharmacology Department, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Manel Mata-Cases
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Xavier Cos
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Innovation office at Institut Català de la Salut, Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Primary Health Care Centre Raval Sud, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.
| | - Dídac Mauricio
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain; Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Departament of Medicine, University of Vic - Central University of Catalonia, Vic, Spain; CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.
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Li M. Guidelines and standards for comprehensive clinical diagnosis and interventional treatment for diabetic foot in China (Issue 7.0). J Interv Med 2021; 4:117-129. [PMID: 34805959 PMCID: PMC8562298 DOI: 10.1016/j.jimed.2021.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/22/2023] Open
Abstract
Diabetic foot (DF) is one of the most common complications of diabetes and is associated with high morbidity, disability, lethality and low cure-rate. The clinical diagnosis and treatment of DF need to be standardized. The Chinese Diabetic Foot Cell and Interventional Therapy Technology Alliance has released six editions of guidelines and standards for clinical diagnosis and interventional treatment of DF, which filled the gap in the domestic DF treatment standard and played an important role in improving the level of diagnosis and treatment in China. In line with the latest developments in diagnosis and treatment, the Alliance, along with other 89 institutions, developed and issued the new edition based on the sixth edition to help standardize the clinical diagnosis and treatment of DF in China.
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Affiliation(s)
- Maoquan Li
- China Alliance of Cellular and Interventional Therapy Techniques for Diabetic Foot, China.,Technical Committee on Interventional Medicine and Bioengineering of Chinese Intervention Physicians Branch, China.,National Centre for Clinical Medical Research on Radiation and Treatment, China.,Department of Interventional and Vascular Surgery, Affiliated Tenth People's Hospital of Tongji University, China.,Interventional Vascular Institute of Tongji University, Shanghai 200072, China
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Wound Healing and Therapy in Soft Tissue Defects of the Hand and Foot from a Surgical Point of View. Med Sci (Basel) 2021; 9:medsci9040071. [PMID: 34842788 PMCID: PMC8628974 DOI: 10.3390/medsci9040071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/10/2021] [Indexed: 01/02/2023] Open
Abstract
Wounds and tissue defects of the hand and foot often lead to severe functional impairment of the affected extremity. Next to general principles of wound healing, special functional and anatomic considerations must be taken into account in the treatment of wounds in these anatomical regions to achieve a satisfactory reconstructive result. In this article, we outline the concept of wound healing and focus on the special aspects to be considered in wounds of the hand and foot. An overview of different treatment and dressing techniques is given with special emphasis on the reconstruction of damaged structures by plastic surgical means.
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Meloni M, Lazaro-Martínez JL, Ahluwalia R, Bouillet B, Izzo V, Di Venanzio M, Iacopi E, Manu C, Garcia-Klepzig JL, Sánchez-Ríos JP, Lüedemann C, De Buruaga VRS, Vouillarmet J, Guillaumat J, Aleandri AR, Giurato L, Edmonds M, Piaggesi A, Van Acker K, Uccioli L. Effectiveness of fast-track pathway for diabetic foot ulcerations. Acta Diabetol 2021; 58:1351-1358. [PMID: 33942178 PMCID: PMC8413149 DOI: 10.1007/s00592-021-01721-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 01/22/2023]
Abstract
AIM To investigate the effectiveness of fast-track pathway (FTP) in the management of diabetic foot ulceration (DFU) after 2 years of implementation. METHODS The study group was composed of patients who referred to a specialized DF centre due to DFUs. Those were divided in two groups: early referral (ER) and late referral (LR) patients. According to FTP, ER were considered patients who referred after 2 weeks in the case of uncomplicated non-healing ulcers (superficial, not infected, not ischemic), within 4 days in the case of complicated ulcers (ischemic, deep, mild infection) and within 24 h in the case of severely complicated ulcers (abscess, wet gangrene, fever). Healing, healing time, minor and major amputation, hospitalization, and survival were evaluated. The follow-up was 6 months. RESULTS Two hundred patients were recruited. The mean age was 70 ± 13 years, 62.5% were male, 91% were affected by type 2 diabetes with a mean duration of 18 ± 11 years. Within the group, 79.5% had ER while 20.5% had LR. ER patients showed increased rates of healing (89.9 vs. 41.5%, p = 0.001), reduced healing time (10 vs. 16 weeks, p = 0.0002), lower rates of minor (17.6 vs. 75.6%, p < 0.0001) and major amputation (0.6 vs. 36.6%, p < 0.0001), hospitalization (47.1 vs. 82.9%, p = 0.001), and mortality (4.4 vs. 19.5%, p = 0.02) in comparison to LR. At multivariate analysis, ER was an independent predictor of healing, while LR was an independent predictor for minor and major amputation and hospitalization. CONCLUSION After the FTP implementation, less cases of LR were reported in comparison to ER. ER was an independent predictor of positive outcomes such as healing, healing time, limb salvage, hospitalization, and survival.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | | | - Raju Ahluwalia
- Department of Trauma and Ortophaedic Department, King ́s College Hospital, London, UK
| | | | - Valentina Izzo
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | | | - Elisabetta Iacopi
- Diabetic Foot Section, University of Pisa, Ospedale Di Cisanello, Pisa, Italy
| | - Chris Manu
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, UK
| | | | | | | | | | | | | | | | - Laura Giurato
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Micheal Edmonds
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, UK
| | - Alberto Piaggesi
- Diabetic Foot Section, University of Pisa, Ospedale Di Cisanello, Pisa, Italy
| | | | - Luigi Uccioli
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
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41
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Lalieu RC, Mulder W, Raap RDB, Stolk S, Smit C, Dubois EF, van Hulst RA. Hyperbaric oxygen treatment for University of Texas grade 3 diabetic foot ulcers: a retrospective cohort study. J Wound Care 2021; 30:722-728. [PMID: 34554839 DOI: 10.12968/jowc.2021.30.9.722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Hard-to-heal diabetic foot ulcers (DFUs) may increase the risk of amputation. This study reports the positive influence of hyperbaric oxygen therapy (HBOT) on hard-to-heal DFUs involving underlying bone. METHOD A single-centre, retrospective cohort study reporting the results of HBOT and wound care on hard-to-heal University of Texas grade 3 DFUs (i.e., involving underlying bone) between 2013 and 2019. Outcome measures were primarily (near-) complete wound healing (i.e., ≥80% ulcer surface area reduction) and amputation rate (minor or major), and secondarily the number of hyperbaric sessions and improvement in quality of life (QoL) and pain score. RESULTS The study included 206 patients, of whom 74 (36%) achieved complete wound healing, and 75 (36%) near-complete healing. Amputations were performed in 27 patients (13%): 12 (6%) minor and 15 (7%) major. The median number of HBOT sessions was 42. Participants who achieved complete healing received a median of 43 sessions, compared with 10 for those who required major amputation. Patients with at least 30 sessions were less likely to undergo amputation (odds ratio: 0.08; 95% confidence interval (CI): 0.03-0.21). Mean QoL increased by 7.6 points (95%CI: 3.9-11.3; p<0.01) and median pain score fell from 3 to 1 (0-3) (p<0.01). CONCLUSIONS The addition of HBOT to standard wound care may lead to a decreased amputation risk, improved wound healing and increased QoL for people with a University of Texas grade 3 DFU. An adequate number of HBOT sessions is required to achieve optimal clinical results. Objective selection criteria and shared decision-making are suggested to improve dropout rates.
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Affiliation(s)
- Rutger C Lalieu
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands.,Amsterdam University Medical Centers, Department of Anesthesiology, Amsterdam, the Netherlands
| | - Willem Mulder
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands
| | | | - Saskia Stolk
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands
| | - Casper Smit
- Hyperbaar Geneeskundig Centrum, Rijswijk, the Netherlands.,Reinier de Graaf Gasthuis, Department of Surgery, Delft, the Netherlands
| | | | - Rob A van Hulst
- Amsterdam University Medical Centers, Department of Anesthesiology, Amsterdam, the Netherlands.,Amsterdam University Medical Centers, Department of Surgery, Hyperbaric Dept, Amsterdam, the Netherland
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The Association between Foot and Ulcer Microcirculation Measured with Laser Speckle Contrast Imaging and Healing of Diabetic Foot Ulcers. J Clin Med 2021; 10:jcm10173844. [PMID: 34501291 PMCID: PMC8432122 DOI: 10.3390/jcm10173844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/30/2022] Open
Abstract
Diagnosis of peripheral artery disease in people with diabetes and a foot ulcer using current non-invasive blood pressure measurements is challenging. Laser speckle contrast imaging (LSCI) is a promising non-invasive technique to measure cutaneous microcirculation. This study investigated the association between microcirculation (measured with both LSCI and non-invasive blood pressure measurement) and healing of diabetic foot ulcers 12 and 26 weeks after measurement. We included sixty-one patients with a diabetic foot ulcer in this prospective, single-center, observational cohort-study. LSCI scans of the foot, ulcer, and ulcer edge were conducted, during baseline and post-occlusion hyperemia. Non-invasive blood pressure measurement included arm, foot, and toe pressures and associated indices. Healing was defined as complete re-epithelialization and scored at 12 and 26 weeks. We found no significant difference between patients with healed or non-healed foot ulcers for both types of measurements (p = 0.135-0.989). ROC curves demonstrated moderate sensitivity (range of 0.636-0.971) and specificity (range of 0.464-0.889), for LSCI and non-invasive blood pressure measurements. Therefore, no association between diabetic foot ulcer healing and LSCI-measured microcirculation or non-invasive blood pressure measurements was found. The healing tendency of diabetic foot ulcers is difficult to predict based on single measurements using current blood pressure measurements or LSCI.
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Gong JH, Dong JY, Xie T, Zhao Q, Lu SL. Different therapeutic effects between diabetic and non-diabetic adipose stem cells in diabetic wound healing. J Wound Care 2021; 30:S14-S23. [PMID: 33856928 DOI: 10.12968/jowc.2021.30.sup4.s14] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE This study aimed to investigate how adipose tissue-derived stem cells (ASCs) from diabetic and from non-diabetic rats affect wound healing in different microenvironments. METHOD The two types of ASC-rich cells were distinguished by characteristic surface antigen detection. The ASC-rich cells were transplanted into the wounds of diabetic and non-diabetic rats. Wound healing rates were compared and the healing process in the wound margin sections was used to determine how ASC-rich cells affect wound healing in different microenvironments. RESULTS ASC density was decreased in diabetic rats. The generation time of ASC-rich cells from diabetic rats (d-ASC-rich cells) was longer than that of ASC-rich cells from non-diabetic rats. The number of pre-apoptotic cells in the third generation (passage 3) of d-ASC-rich cells was higher than that among the ASC-rich cells from non-diabetic rats. CD31 and CD34 expression was higher in d-ASC-rich cells than in ASC-rich cells from non-diabetic rats, whereas CD44 and CD105 expression was lower than that in ASC-rich cells from non-diabetic rats. Transplantation of ASC-rich cells from non-diabetic rats promoted wound healing in both non-diabetic and diabetic rats. In contrast, d-ASC-rich cells and enriched nuclear cells only promoted wound healing in non-diabetic rats. ASC-rich cell transplantation promoted greater tissue regeneration than d-ASC-rich cell transplantation. CONCLUSION ASC-rich cells promoted wound healing in diabetic and non-diabetic rats. ASC density was lower in the adipose tissue of diabetic rats compared with non-diabetic rats. d-ASC-rich cells did not promote wound healing in diabetic rats, suggesting that caution is warranted regarding the clinical use of diabetic adipose stem cell transplantation for the treatment of diabetic wounds.
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Affiliation(s)
- Jia-Hong Gong
- Shanghai Burn Institute, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiao-Yun Dong
- Shanghai Burn Institute, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Xie
- Shanghai 9th people's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingnan Zhao
- University of Texas MD Anderson Cancer Center, Houston, Texas 77054, US
| | - Shu-Liang Lu
- Shanghai Burn Institute, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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44
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Economic Evaluation of Sucrose Octasulfate Dressing for the Treatment of Diabetic Foot Ulcers for Type 2 Diabetes Patients. Can J Diabetes 2021; 46:126-133. [DOI: 10.1016/j.jcjd.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/05/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
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45
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Elgzyri T, Apelqvist J, Lindholm E, Örneholm H, Annersten Gershater M. Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene. SAGE Open Med 2021; 9:20503121211029180. [PMID: 34262765 PMCID: PMC8246462 DOI: 10.1177/20503121211029180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Forefoot gangrene in patients with diabetes is a severe form of foot ulcers with risk of progress and major amputation. No large cohort studies have examined clinical characteristics and outcome of forefoot gangrene in patients with diabetes. The aim was to examine clinical characteristics and outcome of forefoot gangrene in patients with diabetes admitted to a diabetic foot centre. Methods Patients with diabetes and foot ulcer consecutively presenting were included if they had forefoot gangrene (Wagner grade 4) at initial visit or developed forefoot gangrene during follow-up at diabetic foot centre. Patients were prospectively followed up until final outcome, either healing or death. The median follow-up period until healing was 41 (3-234) weeks. Results Four hundred and seventy-six patients were included. The median age was 73 (35-95) years and 63% were males. Of the patients, 82% had cardiovascular disease and 16% had diabetic nephropathy. Vascular intervention was performed in 64%. Fifty-one patients (17% of surviving patients) healed after auto-amputation, 150 after minor amputation (48% of surviving patients), 103 had major amputation (33% of surviving patients) and 162 patients deceased unhealed. Ten patients were lost at follow-up. The median time to healing for all surviving patients was 41 (3-234) weeks; for auto-amputated, 48 (10-228) weeks; for minor amputated, 48 (6-234) weeks; and for major amputation, 32 (3-116) weeks. Conclusion Healing without major amputation is possible in a large proportion of patients with diabetes and forefoot gangrene, despite these patients being elderly and with extensive co-morbidity.
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Affiliation(s)
- Targ Elgzyri
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Jan Apelqvist
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Eero Lindholm
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Hedvig Örneholm
- Department of Orthopaedic Surgery, Skåne University Hospital, Malmö, Sweden
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46
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Li W, Jiang YX, Chen QY, Wang GG. Recombinant fusion protein by lysozyme and antibacterial peptide enhances ischemic wound healing via angiogenesis and reduction of inflammation in diabetic db/db mice. PeerJ 2021; 9:e11256. [PMID: 33959422 PMCID: PMC8054754 DOI: 10.7717/peerj.11256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 03/21/2021] [Indexed: 01/11/2023] Open
Abstract
Background & aims Lysozyme and antibacterial peptides have been reported to broad-spectrum antibacterial activity and can further improve wound healing. The aim of this study was to assess the effectiveness of a recombinant fusion protein created by combining lysozyme and an antibacterial peptide in forming new vessels and wound healing in an ischemic hind limb. Methods An ischemic hind limb model was established by isolation and ligation of the femoral artery in diabetic db/db mice. Cutaneous wounds were created with or without ischemia. Adductor muscles and wounds were treated with or without the fusion protein. Results The fusion protein accelerated ischemic diabetic wound healing and attenuated impairment of ischemic adductor muscle . Further, the fusion protein elevated expression of platelet derived growth factor (PDGF) and vascular endothelial growth factor (VEGF) protein and mRNA in ischemic adductor muscle, reduced levels of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) in serum and expression of phosphorylated nuclear factor κB (p-NF-κB) and p-IKB α in ischemic adductor. The fusion protein also enhanced levels of phosphorylated VEGF and PDGF receptors in the ischemic adductor muscles from diabetic db/db mice. Conclusion The data showed that the beneficial effects of the fusion protein on ischemic wound healing may be associated with angiogenesis and reduction of inflammatory response in the ischemic adductor muscles of diabetic db/db mice.
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Affiliation(s)
- Wei Li
- Department of Pathophysiology, School of Basic Medicine, Wannan Medical College, Wuhu, Anhui, China
| | - Yu-Xin Jiang
- Department of Basic Medicine, School of Medicine, Jiaxing University, Jiaxing, Zhejiang, China
| | - Qing-Ying Chen
- Department of Integrated traditional and western medicine, General Hospital of Jinan Military Command, Jinan, Shandong, China
| | - Guo-Guang Wang
- Department of Pathophysiology, School of Basic Medicine, Wannan Medical College, Wuhu, Anhui, China
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47
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Kristianto H, Waluyo A, Gayatri D. Relationship between diabetic foot ulcers profile and ankle brachial index score: A preliminary study. ENFERMERIA CLINICA 2021. [DOI: 10.1016/j.enfcli.2020.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Zheng J, Li R, Zayed MA, Yan Y, An H, Hastings MK. Pilot study of contrast-free MRI reveals significantly impaired calf skeletal muscle perfusion in diabetes with incompressible peripheral arteries. Vasc Med 2021; 26:367-373. [PMID: 33749394 DOI: 10.1177/1358863x21996465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Patients with diabetes mellitus (DM) are more likely to have densely calcified lesions in the below-the-knee tibial arteries. However, the relationship between peripheral arterial calcification and local skeletal muscle perfusion has not been explored. Thirty subjects were prospectively recruited into three groups in this pilot study: (1) Non-DM: 10 people without DM; (2) DM, ABI < 1.3: 10 people with DM and normal ankle-brachial index (ABI) (0.9-1.3); and (3) DM, ABI ⩾ 1.3: 10 people with DM and ABI ⩾ 1.3. All subjects underwent calf perfusion measurements at rest and during an isometric plantarflexion contraction exercise within the magnetic resonance imaging (MRI) system. The noncontrast MRI techniques were applied to quantitatively assess skeletal muscle blood flow (SMBF) and oxygen extraction fraction (SMOEF) in medial gastrocnemius and soleus muscles. Both SMBF and SMOEF reserves were calculated as the ratio of the exercise value to the resting value. Exercise SMBF and SMOEF values in the medial gastrocnemius muscle were lower in the two DM groups than in the non-DM group (p < 0.05). The SMBF reserve in medial gastrocnemius was significantly lower in the DM, ABI ⩾ 1.3 group compared to the DM, ABI < 1.3 group (p < 0.05). This study demonstrates that people with DM and calcified arteries had lower perfusion in gastrocnemius muscle compared to those without DM and those with DM and a normal ABI.
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Affiliation(s)
- Jie Zheng
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Ran Li
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Mohamed A Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Yan Yan
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Hongyu An
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Mary K Hastings
- Physical Therapy Program, Washington University School of Medicine, St Louis, MO, USA
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49
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Wang L, Wang C, Chen H, Chen Y, Li J, Xiao L, Zhu D, Yang C. The Combined Use of a Non-Invasive Skin-Stretching Device and the Negative-Pressure Wound Therapy Technique in the Treatment of Postoperative Diabetic Foot. Diabetes Metab Syndr Obes 2021; 14:3523-3532. [PMID: 34385827 PMCID: PMC8352599 DOI: 10.2147/dmso.s322757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The present study explored the effectiveness of using a non-invasive skin-stretching device (NSSD) combined with negative-pressure wound therapy (NPWT) for the postoperative wound repair of diabetic foot (DF) gangrene. METHODS The treatment group in this study involved 42 patients with Wagner grade 3-4 DF and undergone concomitant toe amputation or debridement, who were given NPWT combined with the use of a NSSD. The control group comprised 42 patients with similar trauma areas (±20%) that were matched at a ratio of 1:1. Following surgery, these patients received NPWT combined with the use of conventional dressings. A comparison was made of the postoperative wound healing rates and wound healing times of the two groups, with Kaplan-Meier survival analysis being used to compare the healing rate over time. RESULTS The three-month wound healing rate was higher in the treatment group than in the control group (38 of 42 [90.5%] vs 25 of 42 [59.5%], p = 0.002), and the wound healing time was shorter in the treatment group (44 days [95% CI 40.0-48.0]) than that in the control group (76 days [95% CI 63.0-89.0], p = 0.000). Taking the end of the final NPWT as the starting point, the comparison of wound healing time revealed that this period was shorter in the treatment group than that in the control group and the difference was statistically significant (11 days [95% CI 9.0-13.0] vs 42 days [95% CI 23.0-ND], p = 0.000). CONCLUSION The use of the NPWT technique combined with a NSSD can shorten the wound healing time and improve the wound healing rate of DF gangrene patients during the postoperative wound repair period.
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Affiliation(s)
- Liangchen Wang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Chenrui Wang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Hongmei Chen
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Ying Chen
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Juan Li
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Li Xiao
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Di Zhu
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
| | - Caizhe Yang
- Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of China
- Correspondence: Caizhe Yang Department of Endocrinology, Air Force Medical Center, PLA, Beijing, 100142, People’s Republic of ChinaTel/Fax +86 1066928242 Email
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50
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Vainieri E, Ahluwalia R, Slim H, Walton D, Manu C, Taori S, Wilkins J, Huang DY, Edmonds M, Rashid H, Kavarthapu V, Vas PRJ. Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study. Exp Clin Endocrinol Diabetes 2020; 130:165-171. [PMID: 33352595 DOI: 10.1055/a-1322-4811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. METHODS Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. RESULTS Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. CONCLUSIONS In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.
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Affiliation(s)
- Erika Vainieri
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Raju Ahluwalia
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hani Slim
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Daina Walton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris Manu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Surabhi Taori
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, Kings College, London, United Kingdom
| | - Jason Wilkins
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Dean Y Huang
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mike Edmonds
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hisham Rashid
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Venu Kavarthapu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Prashanth R J Vas
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, United Kingdom
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