Cost of diabetic foot in France, Spain, Italy, Germany and United Kingdom: A systematic review

Economic burden of podiatric care for diabetic foot ulcers in the Czech Republic: A prospective multicenter study

OBJECTIVE

Diabetic foot (DF), especially DF ulcers (DFUs) are a relatively frequent and financially burdensome late-stage complication of diabetes. However, data on the costs of podiatric care in the Czech Republic are scarce. The aim of this prospective multicenter study was to determine the total costs associated with long-term podiatric care in selected foot clinics across the Czech Republic.

RESEARCH DESIGN AND METHODS

A total of 119 patients with DFUs (mean age of 68 ± 11 years, diabetes duration of 19 ± 11 years, HbA1c level of 62 ± 14 mmol/mol, composite WIfI score of 3 ± 2, 33 % had new DFUs, 37 % previous amputations, and 50 % had peripheral artery disease (PAD)) from 10 podiatric foot clinics in the Czech Republic were enrolled in our financial analysis. Direct and indirect costs associated with podiatric care - diagnostic and treatment methods - including angiological, radiological, and microbiological examinations, blood sampling, prescribed materials for local therapy, antibiotics, surgical procedures, offloading devices, hospital services and additional expenses such as patient transportation, doctors' visits, home care assistance, and work incapacity - were monitored over a 6-month period using an electronic database.

RESULTS

The average cost of podiatric care per patient over a 6-month period was €2,506 with median €1,320. The largest expenses were spent on therapeutic procedures (51.4 %). Costs for patients hospitalized during the study period were significantly higher than for outpatients (€7,923 vs. €1,304 on average; P < 0.001). Among hospitalized patients, the main costs were hospital services (32 %), therapeutic procedures (26 %), and antibiotic and local therapies (20 %). Among outpatients, therapeutic procedures accounted for 74 % of the total costs. Newly developed DFUs or PAD were not linked to significantly increased costs. The composite WIfI score, primarily the wound component, was the only parameter that significantly positively correlated with the total podiatric costs (r = 0.434; 95 % CI 0.279-0.559; P < 0.0001). Other patient characteristics such as age, diabetes duration, DFU duration, and HbA1c level did not show significant cost correlations.

CONCLUSIONS

On average, podiatric care for patients with DFUs in the Czech Republic is 3 to 9 times more expensive than standard diabetes healthcare. The expenses for hospitalized patients are almost 6 times higher than for outpatients. The composite WIfI score was the most significant indicator of podiatric financial burden.

Efficacy and safety of a bio-absorbable antibiotic delivery in calcium sulphate granules for the treatment of osteomyelitis in patients with diabetic foot: A randomized, double blinded, controlled clinical study The BIG D-FOOT study

BACKGROUND

Diabetic foot osteomyelitis (DFO) is associated with a considerably high risk of incident major amputations, disability and mortality. To assess the effects of a local antibiotic delivery system on the incidence of post-surgical infective complications in patients with DFO.

METHODS

This is a double-blind, placebo-controlled, parallel series, randomized controlled trial (RCT) aimed at verifying the efficacy and safety of a local calcium-sulphate bio-absorbable antibiotic delivery (either with tobramycin or vancomycin) in patients with DFO treated with surgical procedures. The trial enrolled adult patients with diabetes and Texas 3 grade ulcers complicated by osteomyelitis and accompanied by deep tissues infection. The primary end-point was the percentage of infective complications (composite end-point of dehiscence, infection, DFO recurrence and new DFO in adjacent sites) at 12 weeks.

RESULTS

The study was prematurely terminated after the completion of the first 20 cases, because of the significant superiority of the active treatment arm. After 12 weeks of treatment, five of 20 wounds (25%) achieved the primary composite end-point. All post-surgical infective complications occurred in the placebo group, with a significant between-group difference (unadjusted p = 0.010). No between-group differences in overall costs were observed.

CONCLUSIONS

This is the first RCT in patients with DFO showing that the use of antibiotic-impregnated calcium-sulphate granules is economically sustainable and has the potential of improving the prognosis of DFO.

Role of therapeutic treatment with antiseptic solutions in the care of diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers (DFUs) are a prevalent and severe complication of diabetes, leading to significant morbidity, impaired health-related quality of life (HRQoL) and economic burden on healthcare systems. The complexity of DFUs often results in prolonged healing and high recurrence rates. Effective management strategies are crucial for improving outcomes and reducing complications.

AIM

This study aimed to review the efficacy of antiseptic solutions in the treatment and care of DFUs.

METHOD

A literature analysis was conducted to review clinical studies and guidelines on the use and efficacy of antiseptic solutions, particularly Octenisept® (0.1% octenidine dihydrochloride and 2% 2-phenoxyethanol). The review focused on the antimicrobial properties, biofilm-disruption capabilities and wound healing outcomes associated with the use of antiseptic solutions in DFU management.

RESULTS

Antiseptic solutions have potential to reduce bioburden, disrupt biofilm and modulate healing. There is a need to balance antimicrobial clinical efficacy with tolerability and cytotoxicity. The use and choice of adjunctive antiseptic solutions must be tailored to the patient, as antimicrobial efficacy can vary for antiseptic solutions, particularly for hypochlorous solutions. It is important to use products according to their instructions, with consideration of minimum contact time to maximise clinical efficacy. Low-pressure irrigation is adjunctive, and concurrent wound-bed preparation, including debridement, frequent inspection, infection and moisture control, remain important.

CONCLUSIONS

The therapeutic application of antiseptic solutions in DFU care presents a promising approach to enhancing wound healing and reducing infection risks. Integrating these solutions into standard wound care protocols could lower the incidence of complications, improve HRQoL and decrease the economic burden associated with diabetic foot disease. Further large-scale studies are recommended to validate these findings and refine guidelines for antiseptic use in DFU management.

Electrochemical skin conductance: a tool for risk stratification and early anticipation of diabetic foot ulcers

Introduction

Diabetic foot ulcers (DFUs) are a major complication of diabetes, leading to high morbidity, mortality, and healthcare costs. Current DFU risk stratification relies on clinical examination, which can be subjective. Electrochemical Skin Conductance (ESC), measured via Sudoscan, offers an objective assessment of small fiber dysfunction. This study evaluates the association between ESC and DFU risk stratification.

Methods

A retrospective analysis of 2,157 diabetic patients from four tertiary centers in France was conducted. DFU risk was classified using the 2016 International Working Group on Diabetic Foot (IWGDF) grading system. ESC measurements were analyzed alongside age, sex, diabetes type, and monofilament test results. Regression and ROC analyses assessed predictive performance.

Results

ESC values correlated with DFU grades (p<0.001), with lower foot ESC (FESC) in higher-risk patients. ROC analysis showed strong predictive value for severe DFUs (AUC = 0.82 for grade 3) but limited performance for early stages. Notably, ESC identified at-risk patients within grade 0, undetected by standard classification.

Discussion

ESC provides a reproducible, operator-independent tool for DFU risk assessment, improving early detection beyond monofilament testing. These findings support its potential role in DFU prevention, reducing amputations and enhancing patient outcomes. Further studies are needed to validate its prognostic value and integration into clinical care.

Skin Micro-Fragments for the Management of Diabetic Foot Ulcers: A Case Series

This prospective case series evaluated the clinical outcomes of skin micro-fragment therapy in managing hard-to-heal diabetic foot ulcers (DFU). A total of ten patients with chronic DFU, who were treated in a specialized diabetic foot unit, were included in this study. The primary outcome was the wound healing rate at 12 weeks. Secondary outcomes comprised the time to complete epithelialization, wound area reduction (WAR) at 4 and 12 weeks, and the incidence of adverse events. After treatment with hy-tissue micrograft (HT-MG), 6 (60%) of patients achieved complete wound closure within 12 weeks. The mean healing time was 7.8 ± 2.4 weeks. The mean WAR at 4 and 12 weeks was 67.2% ± 23.5% and 87.5% ± 24% respectively. The procedure was well tolerated with no complications observed in the donor site such as pain or infection. No adverse effects related to the infiltration procedure at wound site were recorded with a promising wound healing rate during the follow-up period. These results suggest that HT-MG could be a safe and effective treatment option for chronic DFU, promoting noteworthy wound healing and reducing healing times. Further studies are required to confirm these findings and assess long-term outcomes.

Major Amputation In Non-Healing Ulcers: Outcomes and Economic Issues. Data from a Cohort of Patients with Diabetic Foot Ulcers

Background: Foot ulcers have a relevant economic impact on Health Care Systems and the cost-effectivenesseffectiveness of options is not clear. The aim of this study was the assessment of costs for ulcers treatment after 6, 12, and 18 months of follow-up, compared to those for major amputation. Methods: A retrospective study was carried out on 196 types 2 diabetic patients with foot ulcers. The principal endpoints were 1) the proportion of recovered patients among those with ulcers not healed after 6 and 12 months; 2) the assessment of direct costs for treatment of ulcers 6, 12, and 18 months of follow-up, as compared to the cost of major amputation. The economic evaluation was performed considering the perspective of the local health system. Results: Out of 196 patients, 85(46.2%), 131(71.6%), and 140(85.9%) healed within 6, 12, and 18 months, respectively. The average health cost during the 18-month follow-up was 5402€ per patient. We calculated hypothetical costs for three different scenarios, in which patients who did not heal within 6 months underwent a major amputation at 6, 1,2, or 18 months. Costs for the standard of care for all these scenarios (6,094, 7,256, and 7649€ for 6, 12, or 18 months, respectively) were significantly lower than that for major amputations (21,065€). Conclusions: A conservative approach appears more convenient than major amputations in ulcers not healing after 6 months, irrespective of the estimated risk of individual patients.

In-hospital costs of diabetic foot infection at a national referral hospital in Jakarta, Indonesia

Aims

To determine the in-hospital costs of patients with diabetic foot problems who either require or do not require amputation.

Methods

We conducted a retrospective cross-sectional study of 213 subjects with low, moderate and high ulcer grades from January 2019 to December 2022 at a national referral hospital in Jakarta, Indonesia. Data were taken from the medical admissions record unit, electronic health records (EHR), hospital integrated system (HIS) and the foot registry system in the metabolic endocrine division, in relation to diabetic foot infection (DFI) as the primary or secondary diagnosis. We analysed data referring to patient characteristics, in-hospital costs and length of stay (LOS), with further comparison based on amputation status.

Results

The total DFI costs were estimated at IDR 13.833 billion (median IDR 51.225 [min - max; 10.309-507.281) million]). The total costs were estimated at IDR 64.95 ± 50.89 million per patient. All cost variables were driven by intervention costs estimated at IDR 5.176 billion (median IDR 19.676 [min - max; 1.245-136.348) million per patient). Daily costs were IDR 3.281 million per patient per day. The total treatment costs for amputation and non-amputation were IDR 6.99 billion (median IDR 61.398 (18.785-268.768) million) and IDR 6.842 billion (median IDR 45.016 (10.309-507.282) million, respectively. The average LOS was 19.79 ± 10.77 days per DFI episode, which did not differ significantly between the amputation and non-amputation groups (p > 0.176) but not for total costs (p < 0.003). DFI is associated with high costs and long-term hospital stays.

Conclusions

Our study provides evidence on in-patient hospital costs by capturing the real costs of DFI treatment, with the total treatment costs for amputation being higher than for non-amputation. This information might benefit for health practitioners in clinical practice improvements and policy adjustments, including INA-CBGs tariff for DFI patients.

Risk factors for 30-day hospital readmission in patients with diabetic foot

INTRODUCTION

Diabetic foot (DF) is part of the natural history of diabetes mellitus, ulceration being a severe complication with a prevalence of approximately 6.3 %, which confers a significant economic burden. Hospital readmission in the first thirty (30) days is considered a measure of quality of healthcare and it's been identified that the most preventable causes are the ones that occur in this period. This study seeks to identify the risk factors associated with readmission of patients with DF.

METHODS

A case-control study was done by performing a secondary analysis of a database. Descriptive statistics were used for all variables of interest, bivariate analysis to identify statistically significant variables, and a logistic regression model for multivariate analysis.

RESULTS

575 cases were analyzed (113 cases, 462 controls). A 20 % incidence rate of 30-day readmission was identified. Statistically significant differences were found in relation to the institution of attention (Hospital Universitario de la Samaritana: OR 1.9, p value < 0.01, 95 % CI 1.2-3.0; Hospital Universitario San Ignacio: OR 0.5, p value < 0.01, 95 % CI 0.3-0.8) and the reasons for readmission before 30 days, especially due to surgical site infection (SSI) (OR 7.1, p value < 0.01, 95 % CI 4.1-12.4), sepsis (OR 8.4, p value 0.02, 95 % CI 1.2-94.0), dehiscence in amputation stump (OR 16.4, p value < 0.01, 95 % CI 4.2-93.1) and decompensation of other pathologies (OR 3.5, p value < 0.01, 95 % CI 2.1-5.7).

CONCLUSION

The hospital readmission rate before 30 days for our population compares to current literature. Our results were consistent with exacerbation of chronic pathologies, but other relevant variables not mentioned in other studies were the hospital in which patients were taken care of, the presence of SSI, sepsis, and dehiscence of the amputation stump. We consider thoughtful and close screening of patients at risk in an outpatient setting might identify possible readmissions.

Effect of flexor tendon tenotomy of the diabetic hammertoe on plantar pressure: a randomized controlled trial

INTRODUCTION

The aim of this study was to evaluate the effects of flexor tendon tenotomy treatment of the diabetic hammertoe deformity on plantar pressure.

RESEARCH DESIGN AND METHODS

The study was a substudy including participants from a randomized study on tenotomy treatment of diabetic hammertoes. This study was conducted between December 20, 2019 and June 22, 2021. Participants were randomized to tenotomy and standard non-surgical treatment or standard non-surgical treatment alone. Barefoot plantar pressure measurement was performed pre-intervention and 3 months post-intervention. Primary outcome was change in peak plantar pressure post tenotomy treatment.

RESULTS

Of the 95 participants screened in the original study, 45 (57.8% male) were included andcompleted this substudy. Of the 45 participants, 22 were randomized to intervention. The average age of participants was 65.6 ((SD±) 9.5) years and 30 (66.7%) had type 2 diabetes.The average peak plantar pressure (PPP) in toe regions of the participants in the intervention group was significantly (p<0.0001) reduced from 205.6 kPa ((Q1-Q3) 152.0-289.1) pre-intervention to 61.3 kPa (39.1-100.5) post-intervention. The average reduction in PPP of toe regions for participants in the intervention group (-145.3 kPa (-225.9 to -56.2)) was significantly (p=0.00017) higher than what was observed for participants in the control group (-1.6 kPa (-30.2 to 27.9)).

CONCLUSION

This study found that tenotomies of the diabetic hammertoe reduces plantar pressure affecting the treated toes. This likely explains the positive effects of tenotomy treatment on diabetic foot ulcers.

The Immune-Centric Revolution Translated into Clinical Application: Peripheral Blood Mononuclear Cell (PBMNC) Therapy in Diabetic Patients with No-Option Critical Limb-Threatening Ischemia (NO-CLTI)-Rationale and Meta-Analysis of Observational Studies

Chronic limb-threatening ischemia (CLTI), the most advanced form of peripheral arterial disease (PAD), is the comorbidity primarily responsible for major lower-limb amputations, particularly for diabetic patients. Autologous cell therapy has been the focus of efforts over the past 20 years to create non-interventional therapeutic options for no-option CLTI to improve limb perfusion and wound healing. Among the different available techniques, peripheral blood mononuclear cells (PBMNC) appear to be the most promising autologous cell therapy due to physio-pathological considerations and clinical evidence, which will be discussed in this review. A meta-analysis of six clinical studies, including 256 diabetic patients treated with naive, fresh PBMNC produced via a selective filtration point-of-care device, was conducted. PBMNC was associated with a mean yearly amputation rate of 15.7%, a mean healing rate of 62%, and a time to healing of 208.6 ± 136.5 days. Moreover, an increase in TcPO2 and a reduction in pain were observed. All-cause mortality, with a mean rate of 22.2% and a yearly mortality rate of 18.8%, was reported. No serious adverse events were reported. Finally, some practical and financial considerations are provided, which point to the therapy's recommendation as the first line of treatment for this particular and crucial patient group.

Epidemiology and Impact of Limb Loss in the United States and Globally

The main causes of limb loss include trauma, complications from diabetes and peripheral arterial disease, malignancy, and congenital limb deficiency. There are significant geographic variations in the incidence of upper and lower, and major and minor limb loss worldwide. Limb loss is costly for patients and the health care system. The availability of orthotic and prosthetic services, along with cost of services, represents barrier to care and contributes to morbidity and mortality. More research is needed, especially in low-income and middle-income countries to describe the extent of limb loss.

Amputation versus circular external fixation in the treatment of diabetic foot with osteomyelitis: a cost and quality-of-life analysis

Background

Charcot foot is a severe complication of diabetes mellitus. Amputation is associated with 5-year mortality rates as high as 70%, and the overall treatment cost for diabetic foot surpasses that of conditions such as cancer or depression.

Objectives

To compare clinical, quality-of-life, and cost outcomes related to Charcot foot management through two distinct treatments: amputation and resection with stabilization using circular external fixation (CEF).

Methods

This retrospective study included all adult patients treated at our unit between 2008 and 2022 for acute diabetic foot with infected ulcers. The allocation to treatment groups was based on the timing of patient enrollment. We gathered anthropometric, diagnostic, and surgical data, documenting individualized costs for preoperative, postoperative, and rehabilitation phases. Health status was assessed using the EQ-5D-3L questionnaire, and recorded data included mortality.

Results

A total of 31 patients (18 amputations; 13 CEF) were included. Amputees exhibited significantly higher mortality compared to those with a CEF (44.8% vs 7.7%, p = 0.045). The estimated 3-year survival was 60.8% for amputees and 90% for the CEF group (log-rank test, p = 0.096). In terms of quality of life (EQ-5D-3L), amputees reported a reduction of 14.67 points while CEF patients reported an increase of 40.39 points (p < 0.001). The EQ-5D-3L index improved by 1.8 points for amputees, as compared with 62.3 points in the CEF group (p < 0.001). The total mean cost of managing an amputated patient was €222,864, practically identical to the €224,438 incurred in the CEF group (p = 0.767). No statistically significant differences were found in the time distribution of costs. However, some specific expense items demonstrated statistical significance.

Conclusion

In treating infected diabetic foot ulcers, external fixation leads to a better quality of life compared to amputation. There's also a trend suggesting higher survival rates with external fixation, and both approaches have similar costs.

Exploring potential risk factors for lower limb amputation in people with diabetes-A national observational cohort study in Sweden

AIMS

Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how 1/demographic and socioeconomic, 2/medical, and 3/lifestyle risk factors may be associated with LLA in people with newly diagnosed diabetes.

METHODS

Using the Swedish national diabetes register from 2007 to 2016, we identified all individuals ≥18 years with an incident diabetes diagnosis and no previous amputation. These individuals were followed from the date of diabetes diagnosis to amputation, emigration, death, or the end of the study in 2017 using data from the In-Patient Register and the Total Population Register. The cohort consisted of 66,569 individuals. Information about demographic, socioeconomic, medical, and lifestyle risk factors was ascertained around the time of the first recorded diabetes diagnosis, derived from the above-mentioned registers. Cox proportional hazard models were used to obtain hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

During the median follow-up time of 4 years, there were 133 individuals with LLA. The model adjusting for all variables showed a higher risk for LLA with higher age, HR 1.08 (95% CI 1.05-1.10), male sex, HR 1.57 (1.06-2.34), being divorced, HR 1.67 (1.07-2.60), smokers HR 1.99 (1.28-3.09), insulin treated persons HR 2.03 (1.10-3.74), people with low physical activity (PA) HR 2.05 (1.10-3.74), and people with an increased foot risk at baseline HR > 4.12. People with obesity had lower risk, HR 0.46 (0.29-0.75).

CONCLUSIONS

This study found a higher risk for LLA among people with higher age, male sex, who were divorced, had a higher foot risk group, were on insulin treatment, had lower PA levels, and were smokers. No significant association was found between risk for LLA and education level, country of origin, type of diabetes, blood glucose level, hypertension, hyperlipidemia, creatinine level, or glomerular filtration rate. Obesity was associated with lower risk for LLA. Identified variables may have important roles in LLA risk among people with diabetes.

Diabetic foot ulcers: evaluating the role of the specialist advanced practice nurse in complex chronic wounds

OBJECTIVES

To determine the profile of diabetes patients with neuropathic and neuro-ischaemic lesions who are referred to the advanced practice nurse (APN) in complex chronic wounds; to determine whether a training strategy aimed at primary care nurses and nursing homes that care for patients with diabetic foot disease influences the performance of professionals; and to assess the extent, follow-up and evaluation of diabetic foot disease in patients with neuropathic ulcers and neuro-ischaemic ulcers referred to the specialist APN before and after the training.

METHODS

The characteristics of patients referred to the APN over a period of 6.5 years were analysed, as well as the numbers of amputations and deaths pre- and post-training.

RESULTS

of the total of 103 patients, 78 were men; across both sexes the average age was 69 years. Fifty patients had neuropathic ulcers and 53 had neuro-ischaemic ulcers, with healing rates of 59%. There were 50 amputations and 37 deaths over the study period.

CONCLUSION

Prevention of diabetic foot ulcers depends on having in place a fast, agile, practical clinical pathway between primary care and hospital, with the role of the APN, including the co-ordination of care between primary and secondary settings, being key.

Early screening for foot problems in people with diabetes is the need of the hour: 'Save the Feet and Keep Walking Campaign' in India

INTRODUCTION

Evidence on the prevalence of foot problems among people with diabetes in India at a national level is lacking. Hence, this study was aimed to assess the burden of high-risk (HR) feet in people with diabetes across India.

RESEARCH DESIGN AND METHODS

A cross-sectional national-level project 'Save the Feet and Keep Walking' campaign was conducted by the Research Society for the Study of Diabetes in India (RSSDI) from July 10, 2022 to August 10, 2022. A modified version of 3 min foot examination was used to assess the foot problems. Around 10 000 doctors with RSSDI membership were trained online to conduct foot screening and provided a standardised monofilament for detection of loss of protective sensation. People with diabetes aged >18 years who visited the clinics during the study period were examined for foot problems. Data were collected online using the semi-structured questionnaire. A total of 33 259 participants with complete information were included for the final analysis. The foot at risk was categorised based on International Working Group on the Diabetic Foot guidelines 2023.

RESULTS

Nearly 75% of the participants were aged above 45 years. Around 49% had diabetes duration >5 years and uncontrolled diabetes (hemoglobin A1c >8%). Presence of history of foot ulcer (20%), lower limb amputation (15.3%), foot deformities (24.5%) and absence of diminished dorsal pedis and posterior tibial pulses (26.4%) was noted in the study participants. Around 25.2% of them had HR feet and highly prevalent among males. Diabetic kidney and retinal complications were present in 70% and 75.5% of people with HR feet. Presence of heel fissures (OR (95% CI) 4.6 (4.2 to 5.1)) and callus or corns (OR (95% CI) 3.6 (3.3 to 4.0)) were significantly associated with HR feet.

CONCLUSIONS

One-fourth of people with diabetes were found to have HR feet in India. The findings are suggestive of regular screening of people with diabetes for foot problems and strengthening of primary healthcare.

Changes in daily nursing needs and self-care capability of people with diabetes after in-hospital treatment for foot complications: A descriptive study

AIM

A limited number of studies discuss the changes in patients' self-care skills and needs for assisted self-care after discharge from in-patient treatment due to diabetes foot ulcer-related complications. The aim of this study was to examine the ability to perform self-care and needs for assisted nursing interventions at hospital discharge, compared to pre-admission, for people with diabetes admitted and treated for foot ulcer-related complications.

DESIGN

Retrospective patient record study.

METHODS

A retrospective assessment was done on the medical records of a total of 134 patients with diabetes consecutively admitted to a specialist in-patient unit due to foot ulcer complications, between 1 November 2017 and 30 August 2018. Data on daily self-care needs and home situations at admission and discharge were recorded.

RESULTS

The median age was 72 years (38-94), 103 (76.9%) were men and 101 (73.7%) had diabetes type 2. The median length of admission was 10 days (2-39). Infection was the most common cause of admission (51%), with severe ischaemia in 6%, and a combination of both in 20% of patients. Surgical treatment was performed in 22% and vascular intervention in 19% of patients. The percentage of patients discharged to their home without assistance was 48.1% compared to 57.5% before admission, discharge to home with assistance was 27.4% versus 22.4% before admission and 9.2% were discharged to short-term nursing accommodation versus 6% before admission. Three patients died during their stay in hospital. The need for help with medications increased from 14.9% of patients at admission to 26.7% at discharge and for mobility assistance from 23.1% to 35.9%. Social services at home were increased in 21.4% of patients at discharge.

Acellular fish skin grafts in the treatment of diabetic wounds: Advantages and clinical translation

Diabetic wounds cannot undergo normal wound healing due to changes in the concentration of hyperglycemia in the body and soon evolve into chronic wounds causing amputation or even death of patients. Diabetic wounds directly affect the quality of patients and social medical management; thus researchers started to focus on skin transplantation technology. The acellular fish skin grafts (AFSGs) are derived from wild fish, which avoids the influence of human immune function and the spread of the virus through low-cost decellularization. AFSGs contain a large amount of collagen and omega-3 polyunsaturated fatty acids and they have an amazing effect on wound regeneration. However, after our search in major databases, we found that there were few research trials in this field, and only one was clinically approved. Therefore, we summarized the advantages of AFSGs and listed the problems faced in clinical use. The purpose of this paper is to enable researchers to better carry out original experiments at various stages.

Decreasing lifetime prevalence of diabetes-related foot ulcers in Norway: repeated cross-sectional population-based surveys from the HUNT study (1995-2019)

Background and aims

Diabetes-related foot ulcers (DFU) are a persistent healthcare challenge, impacting both patients and healthcare systems, with adverse effects on quality of life and productivity. Our primary aim was to examine the trends in lifetime prevalence of DFU, as well as other micro- and macrovascular complications in the Trøndelag Health Study (HUNT) in Norway.

Methods

This study consists of individuals ≥20 years with diabetes participating in the population-based cross-sectional HUNT surveys (1995-2019). Prevalence ratios, comparing the lifetime prevalence of DFU and other relevant micro- and macrovascular complications between the HUNT surveys, were calculated using Poisson regression.

Results

The lifetime prevalence (95% confidence interval (CI)) of a DFU requiring three or more weeks to heal was 11.0% (9.5-12.7) in HUNT2, 7.5% (6.3-8.8) in HUNT3 and 5.3% (4.4-6.3) in HUNT4. The decrease in DFU prevalence from 1995 to 2019 was observed in both men and women, for all age groups, and for both type 1 and type 2 diabetes. The highest lifetime prevalence of DFU was found among those with type 1 diabetes. The decrease in HbA1c from HUNT2 to HUNT4 did not differ between those with and without a DFU. The prevalence of chronic kidney disease (eGFR <60 mL/min/1.73 m2 (eGFR categories G3-G5)) increased in both individuals with and without a DFU.

Conclusion

Results from the HUNT surveys show a substantial decline in the lifetime prevalence of DFU from 1995 to 2019.

Photodynamic Therapy With RLP068 and 630-nm Red LED Light in Foot Ulcers in Patients With Diabetes: A Case Series

The management and healing of lower extremity ulcers have always been a complex health problem because the clinical course is typically chronic, the results are often poor, and the socioeconomic impact is considerable. The healing process of foot ulcers of people with diabetes is further hindered by the concomitant presence of obstructive arterial disease, neuropathy, and foot malformation. It is frequently associated with multiresistant infections and often results in micro/macro amputations. Photodynamic therapy employs a photosensitizer activated by light of a specific wavelength able to generate reactive oxygen species, which initiate further oxidative responses locally with components of the bacteria. The experience of the treatment center for the lower extremity ulcers in 17 persons with diabetes in Acerra (Italy) with photoactivated RLP068, reported here, corroborates the results of the clinical trials and of the previous case reports. In all cases, examined photodynamic therapy with photosensitizer RLP068 and red light at 630 nm was found to reduce lesion area and inflammation and to ensure the decrease of bacterial load, hence reducing treatment times and antibiotics use, improving patient outcomes, and reducing the incidence of amputations. The simultaneous combination of photodynamic therapy with other ancillary physical-based treatments such as therapeutic magnetic resonance or Bio-Electro-Magnetic-Energy-Regulation was observed to be safe, time-saving, and able to lead to faster healing.

Gene therapy for diabetic foot ulcers: Interim analysis of a randomised, placebo-controlled phase 3 study of VM202 (ENGENSIS), a plasmid DNA expressing two isoforms of human hepatocyte growth factor

To evaluate the status of a 7-month phase 3 study conducted to test the effect of intramuscular injections of VM202 (ENGENSIS), a plasmid DNA encoding human hepatocyte growth factor, into the calf muscles of chronic nonhealing diabetic foot ulcers with concomitant peripheral artery disease. The phase 3 study, originally aimed to recruit 300 subjects, was discontinued because of slow patient recruitment. An unprespecified interim analysis was performed for the 44 subjects enrolled to assess the status and determine the future direction. Statistical analyses were carried out for the Intent-to-Treat (ITT) population and separately for subjects with neuroischemic ulcers, using a t-test and Fisher's exact test. A logistic regression analysis was also conducted. VM202 was safe and potentially should have benefits. In the ITT population (N = 44), there was a positive trend toward closure in the VM202 group from 3 to 6 months but with no statistical significance. Levels of ulcer volume or area were found to be highly skewed between the placebo and VM202 groups. Forty subjects, excluding four outliers in both arms, showed significant wound-closing effects at month 6 (P = .0457). In 23 patients with neuroischemic ulcers, the percentage of subjects reaching complete ulcer closure was significantly higher in the VM202 group at months 3, 4, and 5 (P = .0391, .0391, and .0361). When two outliers were excluded, a significant difference was evident in months 3, 4, 5, and 6 (P = .03 for all points). A potentially clinically meaningful 0.15 increase in Ankle-Brachial Index was observed in the VM202 group at day 210 in the ITT population (P = .0776). Intramuscular injections of VM202 plasmid DNA to calf muscle may have promise in the treatment of chronic neuroischemic diabetic foot ulcers (DFUs). Given the safety profile and potential healing effects, continuing a larger DFU study is warranted with modifications of the current protocol and expansion of enrolling sites.

INDIFURUTO: A novel tool for assessing diabetic foot recurrence risk in type 2 diabetes

This study aimed to evaluate diabetic foot ulcer recurrence using the Indonesia Diabetic Foot Ulcer Recurrence Assessment Tool (INDIFURUTO), a new diabetic foot risk recurrence assessment tool. This study used a prospective cohort design. A total of thirty-three participants met the inclusion criteria. We used sensitivity, specificity values, AUC, and, respectively, a 95% confidence interval (CI) to calculate prognostic accuracy measures. The results showed that this study had an AUC of 0,97 [95% confidence interval (CI) 0.91-1.00]. The cut-off point (Youden Index) was <45, with sensitivity and specificity values of 100% and 90%, respectively. The utilization of this model can facilitate the monitoring and enhancement of foot ulcer recurrence prevention in individuals diagnosed with diabetes. This study showed that the new model had a high prediction. Therefore, this model better stratifies people at high risk of foot ulceration.

Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot

BACKGROUND

One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital.

METHODS

We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared.

RESULTS

A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001).

CONCLUSIONS

The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Fibroblast-Derived Extracellular Vesicle-Packaged Long Noncoding RNA Upregulated in Diabetic Skin Enhances Keratinocyte MMP-9 Expression and Delays Diabetic Wound Healing

Accurate communication between fibroblasts and keratinocytes is crucial for diabetic wound healing. Extracellular vesicles are being explored as essential mediators of intercellular communication in the skin. However, the mechanisms underlying wound healing mediated by fibroblast-derived extracellular vesicles (Fib-EVs) remain unclear. The present study evaluated the role of long noncoding RNA upregulated in diabetic skin (lnc-URIDS) packed in Fib-EVs in the wound healing of streptozotocin-induced diabetes and the potential mechanisms of the effects. We demonstrated that high glucose induced the enrichment of lnc-URIDS in Fib-EVs, facilitated the transfer of lnc-URIDS to primary rat epidermal keratinocytes, and increased the expression of matrix metalloproteinase-9. Mechanistically, the binding of lnc-URIDS to YTH domain family protein-2 enhanced the degradation of YTH domain family protein-2 in the lysosomes, which increased the translational activity of the messenger RNA of matrix metalloproteinase-9 and ultimately induced the degradation of collagen for wound healing. The results provided an insight into the crosstalk and cooperation between fibroblasts and keratinocytes in collagen homeostasis in diabetic wounds and clarified the mechanism by which lnc-URIDS degrades collagen for diabetic wound healing.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs

OBJECTIVE

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy).

DATA SOURCES/STUDY SETTING

Administrative healthcare data of Tuscany region, with 2018 as the base year.

STUDY DESIGN

Retrospective study assessing a longitudinal cohort of patients with T2D.

DATA COLLECTION/EXTRACTION METHODS

Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes.

METHODS

We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs.

PRINCIPAL FINDINGS

Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800).

CONCLUSIONS

DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

Effectiveness of a foot self-management intervention that utilized commercially available infrared thermometers: Mixed methods research incorporating a pilot RCT

OBJECTIVE

To evaluate the effectiveness of a foot self-management strategy that utilized a commercially-available infrared thermometer (CAIT) for prevention of diabetic foot ulcers.

RESEARCH DESIGN AND METHODS

In this six-month pilot randomized controlled trial, Phase 2 of a three-phase mixed methods research study, 62 participants were randomized to a thermometer and education group (n = 34) and an education-only group (n = 26). Both groups received foot care education and were assessed by a certified orthotist. All participants recorded their number of steps and recorded a foot assessment in a logbook daily. The thermometer and education group also recorded their daily temperature assessment. A temperature difference of >4° Fahrenheit (F) between the two feet prompted participants to rest their feet. Participants were directed to see their healthcare provider if the temperature difference did not decrease to below 4° F in two days. Phase 3 of the study explored the Phase 2 results to understand the findings further.

RESULTS

The strategy improved foot assessment and action: the thermometer and education group had significantly more days with any assessment completed than the education-only group (150.98/180 vs. 119.84/180, p = 0.02). Phase 3 findings showed that the thermometer engaged participants, prompted action, and offered reassurance regarding foot health.

CONCLUSIONS

A CAIT is a tool that could support foot self-management and may offer several benefits, such as promoting and providing structure for a foot assessment and direction for action.

CLINICAL TRIAL REG NO

NCT0306776 clinicaltrials.gov.

Diabetes mellitus and inequalities in the equipment and use of information technologies as a socioeconomic determinant of health in Spain

Inequalities in the equipment and use of information and communications technology (ICT) in Spanish households can lead to users being unable to access certain information or to carry out certain procedures. Accessibility to ICT is considered a social determinant of health (SDOH) because it can generate inequalities in access to information and in managing access to health services. In the face of a chronic illness such as diabetes mellitus (DM)-for which a comprehensive approach is complex and its complications have a direct impact on current healthcare systems-all the resources that patients may have are welcome. We aimed to analyze hospitalizations and amputations as direct consequences of DM among the autonomous communities of Spain (ACS) in 2019, along with socioeconomic factors related to health, including inequalities in access to ICT between territories, as well as citizens' interest in online information searches about DM. We used different databases such as that of the Ministerio de Sanidad (Spain's health ministry), Ministerio de Asuntos Económicos y transformación (Ministry of Economic Affairs and Digital Transformation), Google Trends (GT), and the Instituto Nacional de Estadística (Spain's national institute of statistics). We examined the data with R software. We employed a geolocation approach and performed multivariate analysis (specifically factor analysis of mixed data [FAMD]) to evaluate the aggregate interest in health information related to DM in different regions of Spain grounded in online search behavior. The use of FAMD allowed us to adjust the techniques of principal component analysis (PCA) and multiple correspondence analysis (MCA) to detect differences between the direct consequences of DM, citizen's interest in this non-communicable disease, and socioeconomic factors and inequalities in access to ICT in aggregate form between the country's different ACS. The results show how SDOH, such as poverty and education level, are related to the ACS with the highest number of homes that cite the cost of connection or equipment as the reason for not having ICT at home. These regions also have a greater number of hospitalizations due to DM. Given that in Spain, there are certain differences in accessibility in terms of the cost to households, in the case of DM, we take this issue into account from the standpoint of an integral approach by health policies.

Distribution of microbes and antimicrobial susceptibility in patients with diabetic foot infections in South China

BACKGROUND

To investigate the distribution of microbes and drug susceptibility in patients with diabetic foot infections (DFI) and provide guidance for clinical empirical treatment and the rational selection of antibacterial drugs.

METHODS

Retrospective analysis of the pathogenic bacterium distribution and antimicrobial susceptibility isolated from 581 DFI patients with different Wagner grades.

RESULTS

The 534 positive samples included 473 cases (88.58%)) of monomicrobial infections and 61 cases (11.42%) of polymicrobial infections before antibiotic therapy. A total of 656 strains were cultivated, including 387 (58.99%) strains of gram-positive organisms (GPOs), 235 (35.82%) gram-negative bacilli (GNB), and 21 (3.20%) fungal strains. Polymicrobial infections mainly occurred in patients with Wagner grade 3-4 ulcers. GPOs were predominant in Wagner grades 1-3 (grade 1: 96.67%, grade 2: 76.52%, grade 3 62.81%), and the most common was Staphylococcus aureus (grade 1: 31.66%, grade 2: 33.04%, grade 3 35.53%). GNB were predominant in grades 4-5 (grade 4: 51.46%, grade 5:60%), and the most common GNB in Wagner grades 4-5 was Proteus (grade 4:27.88%, grade 5: 42.86%), while the most common GPO was Enterococcus (grade 4:34.48%, grade 5:25.00%). Staphylococcus (including MRSA) and Enterococcus were still highly sensitive to vancomycin, linezolid, and tigecycline. Most GNB were still highly sensitive to meropenem, tigecycline, ertapenem, and amikacin. Proteus was most sensitive to amikacin (97.14%), followed by meropenem (92%) and ertapenem (80%).

CONCLUSION

The distribution of microbes and antimicrobial susceptibility in DFI patients varied with different Wagner grades. The most appropriate antimicrobial therapy should be selected based on the pathogen culture and antimicrobial susceptibility.

Bottom-up approach to build a 'precision' risk factor classification for diabetic foot ulcer healing. Proof-of-concept

AIMS

Diabetic foot ulcers (DFU) have a complex multifactorial pathophysiology. It is crucial to identify essential prognostic variables to streamline therapeutic actions and quality-of-care audits. Although SINBAD and University of Texas (UT), the most frequently used prognostic classification systems, were prospectively validated, not all individual parameters were shown to have consistent associations with healing. In this study, we used a bottom-up approach relying on robust methods to identify independent predictors of DFU healing.

METHODS

1,664 DFU patients were included by 34 Belgian diabetic foot clinics (DFCs). Twenty-one patient- and foot-related characteristics were recorded at presentation. Predictors of healing were identified using multivariable Cox proportional hazard regression. Multivariable models were built using backward regression with multiple imputation of missing values and bootstrapping.

RESULTS

Five essential independent variables were identified: presentation delay, history of minor amputation, ulcer location, surface area and ischemia. This 5 variable-model showed a better performance compared to models based on existing classification systems.

CONCLUSIONS

A bottom-up approach was used to build a prognostic classification for DFU healing based on large databases. It offers new insights and allows to tailor the classification to certain clinical settings. These 5 parameters could be used as a 'precision classification' for specialized DFCs.

Health economics of diabetic foot ulcer and recent trends to accelerate treatment

Diabetic foot ulcer is a preventable complication of diabetes that imposes a significant burden on the community. It leads to amputation and increased disability if left untreated and thus bears profound implications on the individual, the community and the health system at large. Diabetic foot (DF) is an area of research interest where interdisciplinary researchers are trying to elucidate the best strategy to halt the progression of chronic diabetic wounds. It is an area where tissue engineering research is making a strong impact through the use of scaffolds and skin substitutes for diabetic wound healing. This review aims at discussing the geographical health economics, its impact on healing and factors influencing financial costs of DFU. The upcoming economic and clinical impacts due to disease outbreak such as the 2020 COVID-19 has also been discussed. Finally, it will discuss novel therapy available with emphasis on skin tissue engineering scaffolds with a cost-benefit analysis. The review aims at promoting better management of people with diabetes with emphasis on emerging treatments and technologies.

Novel topical allogeneic bone-marrow-derived mesenchymal stem cell treatment of hard-to-heal diabetic foot ulcers: a proof of concept study

Aim

The aim of this study was to investigate safety of treating diabetic foot ulcers with a topically administered mesenchymal stem cell product.

Method

Individuals with diabetes, peripheral neuropathy, toe blood pressure > 39 mmHg and non-infected foot ulcers with duration of four to fifty-two weeks were screened. Participants were treated with a one-time application of a topically applied allogeneic cellular product containing CD362 enriched mesenchymal stem cells suspended in a collagen solution. Participants were subsequently followed for seven months to gather information on adverse event and serious adverse events.

Results/discussion

A total of sixteen individuals were screened, of whom two were included. The included participants incurred a total of seven adverse events and one serious adverse event. Increased exudation from the treated diabetic foot ulcer was observed for both participants and a connection to investigational medicinal product was suspected. The increased exudation was resolved within one week after application of investigational medicinal product, without any further complications. The serious adverse event consisted of a hospital admission due to neurological symptoms, which were assumed to be caused by hypoglycemia, with no suspected correlation to the investigational medicinal product. None of the other observed adverse events were suspected to be associated with the investigational medicinal product.

Conclusion

This study presents data from two individuals with a diabetic foot ulcer treated with a novel topical mesenchymal stem cell product. An adverse event observed for both participants was suspected to be associated to the investigational medicinal product, i.e., increased exudation, which was resolved within one week, did not lead to further complications and can easily be remedied by choosing bandages with higher absorption capacity or increasing frequency of bandage changes. This study lays the groundwork for further large scale randomized clinical studies.

Trial registration: EudraCT number 2015-005580-16. Registered 12/06-2018.

The Effect of Foot Care Education for Patients with Diabetes on Knowledge, Self-Efficacy and Behavior: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to synthesize randomized controlled trials on the impact of foot care education on knowledge, self-efficacy and behavior in patients with diabetes. A search was made using PubMed, Web of Science, Science Direct, Google Scholar, YOK National Thesis Center and Google Scholar electronic databases for studies published between March 2003-January 2022. The search medical subject headings (MeSH) terms were diabetic foot, knowledge, self-efficacy, and behavior. Studies suitable for the systematic review and the meta-analysis met the following criteria (PICOS): target participants would be diagnosed with diabetes (population), diabetic foot education (intervention), comparison of the group receiving diabetic foot care education and routine care education, and the control group receiving only routine care education (comparison), studies evaluating the levels of knowledge, self-efficacy and behavior (outcome), randomized controlled trials (study design). Twenty-six studies were included in systematic review. Three studies for knowledge, 5 studies for behavior, 8 studies for self-efficacy were included in the meta-analysis (total sample: 2534, experiment: 1464, control: 1071). All of the studies had low reporting bias. The mean duration of educations for knowledge was 5.2 months. This duration was 4.8 months for behavior and 4.5 months for self-efficacy. In the random effect (since the homogeneity test: P < .001, this model was used), there were significantly difference in terms of knowledge (standardized mean difference (SMD): 1.656, 95% [CI]: 1.014-2.299, P < .001), and behavior (SMD: 1.045, 95% CI: 0.849-1.242, P < .001). But no difference was observed in terms of self-efficacy (SMD: 0.557, 95%CI: -0.402-1.517, P > .05). The results of a systematic review of twenty-six studies and a meta-analysis of 9 studies showed that diabetic foot education improved the level of knowledge and behavior of patients with diabetes, while not affecting their self-efficacy. Educational interventions with long-term follow-up are needed to address the growing health care needs of patients with diabetes.

TLC-Ag dressings: a prospective, multicentre study on 728 patients with wounds at risk of or with local infection

OBJECTIVE

This study aimed to evaluate the management of an unselected cohort of patients with wounds at risk of or with clinical signs of local infection, treated with two antimicrobial contact layers impregnated with silver (TLC-Ag healing matrix), under real-life conditions during the COVID-19 pandemic.

METHOD

A large, prospective, multicentre, observational study with two TLC-Ag dressings (UrgoTul Ag/Silver and UrgoTul Ag Lite Border, Laboratoires Urgo, France) was conducted in Germany between May 2020 and May 2021. The main outcomes included a description of the treated patients and their wound management, the changes in wound infection and wound healing outcomes over a maximum period of four weeks of treatment, as well as the overall clinical assessment of the performance, local tolerance and acceptability of dressings.

RESULTS

A total of 728 patients with wounds of various aetiologies and wound infection status were treated with the evaluated dressings in 39 centres for a mean duration of 26±19 days, with an intermediate visit conducted in 712 (97.8%) patients after a mean period of 12±9 days. At the initial visit, it was established that the majority of patients (60.4%) had a wound infection, while the remaining cohort presented first clinical signs of a local wound infection (25.1%) or were at risk of wound infection (13.2%) (unclear status in 1.2%). Throughout the study period, all the parameters of wound infection continuously decreased, resulting at the final visit in a reduction by 78.9% of the prevalence of local wound infections and by 72.0% of the clinical signs of wound infection, the most rapidly diminished clinical sign being wound deterioration. Concurrently, in terms of the healing process, 92.1% of the wounds healed or improved, 3.2% remained unchanged and 1.7% worsened (data missing for 3.0%), and an improvement of the periwound skin was reported in 65.7% of the patients. Overall, the two dressings were 'very well accepted' by the majority of patients, with no uncomfortable feeling at wearing and no pain at dressing removal, and were assessed by the physicians as 'very useful' in the majority of the cases with a 'very good' efficacy in terms of antimicrobial activity and promotion of the wound healing process. Similar results were reported regardless of the wound type treated or of the TLC-Ag dressing evaluated.

CONCLUSION

These results are consistent with previous clinical evidence on TLC-Ag dressings. They support the good efficacy, good tolerability and usefulness of these antimicrobial dressings in the management of patients with wounds at risk or with clinical signs of local infection, in association with appropriate standard of care.

Cost-Effectiveness Analysis for the Treatment of Diabetic Foot Ulcer in France: Platelet-Rich Plasma vs Standard of Care

INTRODUCTION

Diabetic chronic foot ulcers (DFU) lead to pain, reduced quality of life and represent a severe economic burden for patients and health systems. The clinical results of PRP effectiveness in the treatment of DFU are promising; on the other hand, the costs associated with treating DFUs with PRP are higher than those using standard therapy. Therefore, this study aims to determine the cost-effectiveness of platelet-rich plasma (PRP) therapy compared to standard therapy from the French healthcare system perspective.

METHODS

A cost-effectiveness analysis (CEA) was performed using a decision Markov model with a cohort of patients with chronic DFU (duration of >3 weeks) with high orthopaedic risk and with ulcers graded 3A according to University of Texas classification. The effectiveness outcomes are reported in terms of quality adjusted life year (QALY). The costs are reported in euro (€) currency evaluated in 2019. A micro-costing approach alongside a clinical study was used to assess resource use. Deterministic sensibility analyses are reported to evaluate the robustness of the results. The analyses were carried out in the French setting.

RESULTS

The incremental cost-effectiveness ratio (ICER) of PRP treatment is -€613/ QALY, which, being lower than zero, indicates the dominance of the PRP therapy. Deterministic and probabilistic sensitivity analysis underlines the main parameter affecting CE results. Lowest number of standard of care weekly medications (from 5 to 3) leads to a €622/QALY while increasing PRP weekly medication (from 1 to 4) has an ICER of €732/QALY.

DISCUSSION

PRP is a cost-effective or even a cost-saving alternative in the French setting. PRP has higher cost for the complete medication, but, in the absence of wound complications, has the potential to involve lower consumption of resources in the form of routine medication over a 1-year time horizon.

Effect of thermometry on the prevention of diabetic foot ulcers: a systematic review with meta-analysis

OBJECTIVE

to analyze the effect of cutaneous foot thermometry in people with Diabetes Mellitus, compared with the standard prevention of foot ulcers adopted in these patients.

METHOD

a systematic review with meta-analysis. Protocol registered with PROSPERO (CRD42020202686). The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed. The search was performed in the following data sources: SCOPUS, Web of Science, MEDLINE via PubMed, MEDLINE via EBSCO, MEDLINE via Biblioteca Virtual em Saúde, Embase, CINAHL, Cochrane Library, LILACS via Biblioteca Virtual em Saúde, Google Scholar, Biblioteca Digital Brasileira de Teses e Dissertações, Catálogo de Teses & Dissertações-Capes, Open Grey and ProQuest Dissertations and Theses. The risk of bias was assessed by the Cochrane Collaboration Risk of Bias Tool (RoB 2), the meta-analysis was performed in the Review Manager 5.4 software and the Certainty of evidence in the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

of the 670 records, five articles were eligible. The meta-analysis was calculated for the prevention of the incidence of diabetic foot ulcers outcome, with effect summarization (RR 0.53; 95%CI 0.29-0.96; p=0.02), with certainty of moderate evidence.

CONCLUSION

thermometry showed a protective effect on the incidence of diabetic foot ulcers when compared to standard foot care.

Efecto de la termometría en la prevención de las úlceras del pie diabético: revisión sistemática con metaanálisis

Resumen Objetivo: analizar el efecto de la termometría cutánea del pie en personas con diabetes mellitus, en comparación con la prevención estándar de las úlceras del pie adoptada en estos pacientes. Método: revisión sistemática con metaanálisis. Protocolo registrado en PROSPERO (CRD42020202686). Se siguieron las recomendaciones de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). La búsqueda se realizó en las fuentes de datos: SCOPUS, Web of Science, MEDLINE a través de PubMed, MEDLINE a través de EBSCO, MEDLINE a través de la Biblioteca Virtual en Salud, Embase, CINAHL, Cochrane Library, LILACS a través de la Biblioteca Virtual en Salud, Google Scholar, Biblioteca Digital Brasileña de Tesis y Disertaciones, Catálogo de Tesis y Disertaciones-Capes, Open Grey y ProQuest Dissertations and Theses. El riesgo de sesgo se evaluó mediante la Cochrane Collaboration Risk of Bias Tool (RoB 2), el metaanálisis se realizó con el software Review Manager 5.4 y la certeza de la evidencia se evaluó mediante el sistema Grading of Recommendations Assessment, Development and Evaluation. Resultados: de los 670 registros, cinco artículos fueron elegibles. El metaanálisis se calculó para el resultado prevención de la incidencia de úlceras del pie diabético, con sumarización del efecto (RR 0,53; IC95% 0,29, 0,96; p=0,02), con certeza de evidencia moderada. Conclusión: la termometría mostró un efecto protector sobre la incidencia de úlceras del pie diabético en comparación con el cuidado estándar del pie.

Effect of thermometry on the prevention of diabetic foot ulcers: a systematic review with meta-analysis*

Objective:

to analyze the effect of cutaneous foot thermometry in people with Diabetes Mellitus, compared with the standard prevention of foot ulcers adopted in these patients.

Method:

a systematic review with meta-analysis. Protocol registered with PROSPERO (CRD42020202686). The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed. The search was performed in the following data sources: SCOPUS, Web of Science, MEDLINE via PubMed, MEDLINE via EBSCO, MEDLINE via Biblioteca Virtual em Saúde, Embase, CINAHL, Cochrane Library, LILACS via Biblioteca Virtual em Saúde, Google Scholar, Biblioteca Digital Brasileira de Teses e Dissertações, Catálogo de Teses & Dissertações-Capes, Open Grey and ProQuest Dissertations and Theses. The risk of bias was assessed by the Cochrane Collaboration Risk of Bias Tool (RoB 2), the meta-analysis was performed in the Review Manager 5.4 software and the Certainty of evidence in the Grading of Recommendations Assessment, Development and Evaluation system.

Results:

of the 670 records, five articles were eligible. The meta-analysis was calculated for the prevention of the incidence of diabetic foot ulcers outcome, with effect summarization (RR 0.53; 95%CI 0.29-0.96; p=0.02), with certainty of moderate evidence.

Conclusion:

thermometry showed a protective effect on the incidence of diabetic foot ulcers when compared to standard foot care.

Antimicrobial Resistance Patterns in Diabetic Foot Infections, an Epidemiological Study in Northeastern Italy

This study is a retrospective epidemiological assessment of bacterial species isolated from a cohort of out-patients with diabetic foot infections referred to our “Diabetic Foot Unit” over one year, with particular attention to index pathogens, as identified by the EARS Network. Staphylococcus aureus and Pseudomonas aeruginosa accounted for 33.5% and 11.9% of cases, respectively. MRSA was isolated in 27.1% of patients, with 14.06% showing additional resistance to three antimicrobial classes. Pseudomonas aeruginosa presented extensive resistance to fluoroquinolones (57.3%), which was associated with resistance to piperacillin in 17.6% or to carbapenems in 23.5% of cases. Other pathogens, such as methicillin resistantStaphylococcus epidermidis, Escherichia coli and Morganella morganii ESBL and Enterococcus faecium VRE, were also found.

Hyperbaric oxygen treatment for University of Texas grade 3 diabetic foot ulcers: a retrospective cohort study

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.

Diabetic foot ulcer, the effect of resource-poor environments on healing time and direct cost: A cohort study during Syrian crisis

Diabetic foot ulcer (DFU) is one of the slowest healing wounds that hurt the human body. Many studies from developed countries are concerned about materials, procedures, and equipment that accelerate the healing time. In Sweden, the diabetic foot management costs around 24965$/patient. In this review, we would evaluate the healing time of DFUs during what is considered one of the worst humanitarian crisis of the 21st century. 1747 DFUs were studied from the main diabetic foot clinic in Damascus (2014-2019). We predicted many variables that could prolong the healing time. The cost according to these variables was also reported. The SINBAD Classification was performed to grade the severity of ulcers. We noticed that the median healing time for DFUs was 8 weeks. Almost half of these ulcers healed between 3 and 12 weeks. The time of healing for men was significantly longer than that for women. While the presence of infection doubled the median time of healing, the presence of peripheral artery disease doubled the mean of the direct health care cost. The location of the ulcer acted as another independent risk factor. In conclusion, DFUs face many barriers to heal during a crisis.The environment with resource-poor settings should be added to the traditional risk factors that delay the healing of DFUs for months or even years. More studies from disaster are as are needed to evaluate low-cost materials that could be cost effective in applying standard care of the diabetic foot.

The level of evidence of the publications on conservative surgery for the treatment of diabetic forefoot ulcers: A scoping review

OBJECTIVE

The diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost. While standard non-surgical care is the mainstay of treatment of diabetic foot ulcers (DFU), many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes. Nevertheless, the quality of surgical articles dealing with diabetic ulcers of the forefoot is thought to be average. This paper aimed to quantify the level of evidence of the DFU surgical papers published in the literature.

LITERATURE SURVEY

PubMed was searched from inception till Feb 2020. All study designs but case reports were accepted for inclusion. Two outcomes were searched for: a) study design and b) level of evidence. The level of evidence of the studies was based on the classification developed by the Oxford Center for Evidence-based Medicine.

RESULTS

In total, 90 articles were included for analysis. Only 6 studies (6.7%) had a Level 1 level of evidence. One study had a Level 2 (1.1%) and 13 studies (14.4%) a Level 3. The majority of the included studies had a Level 4 of level of evidence with 70 studies (77.8%) being case-series.

CONCLUSION

It is surprising that a disease with such enormous health-related and financial burden did not generate enough interest among surgeons to invest more into high quality research. The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection. Large comparative prospective high quality trials to assess the available surgical methods are needed.

Reviving the debate: Articular cartilage preservation during disarticulation at the lower limb? A systematic review

BACKGROUND

The need for preservation(P) or removal(R) of articular cartilage during disarticulations remains unanswered.

METHODS

Medline database was used to conduct a systematic review regarding all types of minor disarticulations and some types of major disarticulations in patients with diabetes mellitus, peripheral arterial disease or trauma related disarticulations. Fisher-exact statistical test was used to perform calculations for the entire group as for subgroups.

RESULTS

A total of 444 disarticulations at the Chopart joint, ankle and knee were included (P = 255 vs. R = 189). There was no difference in wound healing, functionality and mortality. Reamputation rate was lower in the P-group (9.4% vs. 16.9%). Infection rate was not significantly different. Differences in reamputations (R = 10.6% vs. P = 1.0%) and infections (R = 4.4% vs. P = 22.6%) were only present for the ankle subgroup.

CONCLUSIONS

There is no difference in wound healing, functionality and mortality between the preservation and removal of articular cartilage in the lower limb.

Validation of living with chronic illness scale in a type 2 diabetes mellitus population

Background

Worldwide, type 2 diabetes mellitus (T2DM) is one of the most prevalent chronic diseases and one of those producing greatest impact on patients’ day-to-day quality of life. Our study aim is to validate the “Living with Chronic Illness Scale” for a Spanish-speaking T2DM population.

Methods

In this observational, international, cross-sectional study, 582 persons with T2DM were recruited in primary care and outpatient hospital consultations, in Spain and Colombia, during the period from May 2018 to June 2019. The properties analysed were feasibility/acceptability, internal consistency, reliability, precision and (structural) content-construct validity including confirmatory factor analysis. The COSMIN checklist was used to assess the methodological/psychometric quality of the instrument.

Results

The scale had an adequate internal consistency and test retest reliability (Cronbach’s alpha = 0.90; intraclass correlation coefficient = 0.96, respectively). In addition, the instrument is precise (standard error of measurement = 3.34, with values < ½SD = 8.52) and correlates positively with social support (DUFSS) (r_s = 0.56), quality of life (WHOQOL-BREF) (r_s = 0.51–0.30) and ssatisfaction with life (SLS-6) (r_s = 0.50–0.38). The original 26-items version of the scale did not support totally the confirmatory factor analysis. The COSMIN checklist is favourable for all the properties analysed, although weaknesses are detected for structural validity.

Conclusions

The LW-CI-T2DM is a valid, reliable and accurate instrument for use in clinical practice to determine how a person’s life is affected by the presence of diabetes. This instrument correlates well with the associated constructs of social support, quality of life and satisfaction. Additional research is needed to determine how well the questionnaire structure performs when robust factor analysis methods are applied.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01715-x.

Social Deprivation and Incident Diabetes-Related Foot Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study

OBJECTIVE

To investigate the relationship between social deprivation and incident diabetes-related foot disease (DFD) in newly diagnosed patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A population-based open retrospective cohort study using The Health Improvement Network (1 January 2005 to 31 December 2019) was conducted. Patients with type 2 diabetes free of DFD at baseline were stratified by Townsend deprivation index, and risk of developing DFD was calculated. DFD was defined as a composite of foot ulcer (FU), Charcot arthropathy, lower-limb amputation (LLA), peripheral neuropathy (PN), peripheral vascular disease (PVD), and gangrene.

RESULTS

A total of 176,359 patients were eligible (56% men; mean age 62.9 [SD 13.1] years). After excluding 26,094 patients with DFD before/within 15 months of type 2 diabetes diagnosis, DFD incidentally developed in 12.1% of the study population over 3.27 years (interquartile range 1.41-5.96). Patients in the most deprived Townsend quintile had increased risk of DFD compared with those in the least deprived (adjusted hazard ratio [aHR] 1.22; 95% CI 1.16-1.29) after adjusting for sex, age at type 2 diabetes diagnosis, ethnicity, smoking, BMI, HbA_1c, cardiovascular disease, hypertension, retinopathy, estimated glomerular filtration rate, insulin, glucose/lipid-lowering medication, and baseline foot risk. Patients in the most deprived Townsend quintile had higher risk of PN (aHR 1.18; 95% CI 1.11-1.25), FU (aHR 1.44; 95% CI 1.17-1.77), PVD (aHR 1.40; 95% CI 1.28-1.53), LLA (aHR 1.75; 95% CI 1.08-2.83), and gangrene (aHR 8.49; 95% CI 1.01-71.58) compared with those in the least.

CONCLUSIONS

Social deprivation is an independent risk factor for the development of DFD, PN, FU, PVD, LLA, and gangrene in newly diagnosed patients with type 2 diabetes. Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities.

New Perspective to Improve Care of Patients with Infected Diabetic Foot Ulcer: Early Economic Impact of the Use of Photodynamic Therapy with RLP068 (Based) System

Objective

To perform an early economic evaluation of a system based on photodynamic advanced adjuvant therapy with photosensitizer RLP068/CI to facilitate the healing process of foot/leg skin lesions/ulcers with an excellent safety profile.

Design

An early short-term (10 weeks) cost-effectiveness and a budget impact analysis (over 5 years) comparing photodynamic therapy with photosensitizer RLP068/CI based (PDT-RLP068) system added to Standard of Care (SoC) vs SoC alone.

Setting

The Italian National Healthcare System perspective considering both the outpatient and the day-hospital regimen.

Participants

Hypothetical patients with diabetic foot infection (DFI) grades I/IIB.

Interventions

The PDT-RLP068 system as an add-on to Standard of Care (SoC) vs SoC alone as the first-line treatment for the management of DFIs.

Main Outcomes

Days within which the clinical target was achieved and direct health costs for patients' management.

Results

Additional costs generated by the use of the PDT-RLP068 system progressively decreased as time to reach the target induced by the novel system decreased. In the outpatient regimen, when time to reach clinical target decreased in the range 7-28 days, ICERs varied from about 1€ to 70€ for each additional day gained with clinical target achieved. The system was dominant when halving time to reach the target in the outpatient regimen and even for modest reduction of time in day-hospital regimen. In terms of budget impact, when considering day-hospital regimen, if the PDT-RLP068 based system allowed a shortened duration to reach the clinical target of between 7-28 days, BI was 8,100,000€ to 700,000€, with saving less than 2,000,000€ with 50% reduction of time. Considering the inpatient setting, the use of the PDT-RLP068 system would result in saving even with the modest impact on the time needed to activate the healing process.

Conclusion

The early economic evaluation performed suggested that, if the claimed effectiveness of the technology demonstrated in case reports and in preliminary clinical studies can be confirmed in larger population studies, and allowing for shortening of the time needed to activate the healing process, the PDT-RLP068 system could offer the chance to improve care for DFI patients without compromising the sustainability of the system.

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden. Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%. Infection develops in 50%-60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers. Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.

Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres

Diabetic peripheral neuropathy (DPN) is the most common complication of both type 1 and 2 diabetes. As a result, neuropathic pain, diabetic foot ulcers and lower-limb amputations impact drastically on quality of life, contributing to the individual, societal, financial and healthcare burden of diabetes. DPN is diagnosed at a late, often pre-ulcerative stage due to a lack of early systematic screening and the endorsement of monofilament testing which identifies advanced neuropathy only. Compared to the success of the diabetic eye and kidney screening programmes there is clearly an unmet need for an objective reliable biomarker for the detection of early DPN. This article critically appraises research and clinical methods for the diagnosis or screening of early DPN. In brief, functional measures are subjective and are difficult to implement due to technical complexity. Moreover, skin biopsy is invasive, expensive and lacks diagnostic laboratory capacity. Indeed, point-of-care nerve conduction tests are convenient and easy to implement however questions are raised regarding their suitability for use in screening due to the lack of small nerve fibre evaluation. Corneal confocal microscopy (CCM) is a rapid, non-invasive, and reproducible technique to quantify small nerve fibre damage and repair which can be conducted alongside retinopathy screening. CCM identifies early sub-clinical DPN, predicts the development and allows staging of DPN severity. Automated quantification of CCM with AI has enabled enhanced unbiased quantification of small nerve fibres and potentially early diagnosis of DPN. Improved screening tools will prevent and reduce the burden of foot ulceration and amputations with the primary aim of reducing the prevalence of this common microvascular complication.

Diabetic foot and peripheral arterial disease. Single centre experience

OBJECTIVES

To determine the prevalence of vasculopathic diabetic foot and the associated factors in a Saudi tertiary center. Methods: This retrospective chart review included adult patients (≥18 years) diagnosed with diabetic foot between May 2015 and July 2019 in King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. Based on clinical presentation and laboratory results, the patients were categorized into 2 groups namely, "vascular induced diabetic foot group" and "non-vascular induced diabetic foot group".

RESULTS

A total of 404 diabetic patients were enrolled in the study. The mean age of the patients was 62.03±12.30 years; 61.9% were males. Most of the diabetic foot cases had a non-vascular etiology (n=327, 80.9%), while 77 cases (19.1%) were due to vasculopathy. Patient in the vascular group had a significantly higher incidence of coronary artery disease (32.5% versus 14.4%; p greater than 0.001), and a higher incidence of peripheral artery disease (PAD) in the unaffected limb (22.1% versus 2.1%; p less than 0.001). Conclusion: Most cases of diabetic foot were due to non-vascular causes. Old age, history of coronary artery disease, or PAD in the unaffected limb were factors that were significantly associated with diabetic foot due to arterial disease.

Videocapillaroscopy of the Oral Mucosa in Patients with Diabetic Foot: Possible Diagnostic Role of Microangiopathic Damage?

INTRODUCTION

Diabetic foot represents one of the most serious and expensive complications of diabetes and is subject to a high percentage of amputations that are almost always preceded by ulcers ascribable to neuropathy and/or vasculopathy. Videocapillaroscopy (VCS) can be a valuable aid in order to uncover morpho-structural anomalies in the vascular bed, both at the level of the oral mucosa and at the level of the terminal vessels of the lower limb.

MATERIALS AND METHODS

Sixty subjects divided into 4 groups were enrolled: 15 healthy subjects; 15 patients with diabetes for more than 10 years without ulcerative foot lesions; 15 patients with neuropathic diabetic foot (clinical diagnosis, MDNS); 15 patients with ischemic diabetic foot (clinical diagnosis, ABI, lower limb doppler). A complete videocapillaroscopic mapping of the oral mucosa was carried out on each patient. The areas investigated were: labial mucosa, the retro-commissural region of the buccal mucosa, and the vestibular masticatory mucosa (II and V sextant).

RESULTS

The analysis of the morphological and densitometric characteristics of the capillaries revealed the following: a significant reduction in capillary density in neuropathic (mean ± SD 7.32 ± 2.1) and ischemic patients (mean ± SD 4.32 ± 3.2) compared to the control group of patients (both diabetic mean ± SD 12.98 ± 3.1 and healthy mean ± SD 19.04 ± 3.16) (ANOVA test and Bonferroni t test p < 0.05); a reduction in the average length of the capillaries and a significant increase in tortuosity (ANOVA test and Bonferroni t test p < 0.05). In the neuropathic patients, a recurrent capillaroscopic pattern that we defined as "sun" was found, with capillaries arranged radially around an avascular area.

CONCLUSIONS

The data obtained from this preliminary study suggest a potential diagnostic role of oral capillaroscopy in the early and subclinical identification of microangiopathic damage in patients with diabetic foot.