C-reactive protein and diabetic foot ulcer infections: A meta-analysis

Analysis of risk factors for foot ulcers in diabetes patients with neurovascular complications

BACKGROUND

Diabetic foot ulcers (DFU), characterized by open sores or wounds primarily occurring on the feet of diabetes patients, are a serious and highly morbid complication of long-standing diabetes, accounting for significant morbidity and mortality. These ulcers develop when diabetes damages both nerves and blood vessels, a combination known as neurovascular complications. Neurovascular disease is a well-established risk factor. While studies have extensively examined risk factors for DFU, few have specifically focused on patients with diabetic neurovascular disease. Therefore, we assess the prevalence and risk factors for DFU in diabetic patients with established neurovascular complications.

METHODS

This study analyzed data from 6722 patients with diabetic neurovascular disease aged over 18 years old from the Southern Medical University Nanfang Hospital (SMUNFH) database (2018-2023) and 2689 patients with the same condition and age range from the National Institutes of Health (NIH) Integrated Surveillance System (NIS) database (2017-2019). The incidence of DFU was determined using information from the NIS database and SMUNFH databases. A binary logistic regression model was employed to explore the risk factors for DFU.

RESULTS

The incidence of DFU among neurovascular disease patients was 13.4% at SMUNH and 25.9% in the NIS Asian population. Multiple regression analysis identified several factors associated with DFU in the SMUNH database, including diabetic retinopathy, diabetic nephropathy, osteomyelitis, coronary heart disease, tinea pedis (fungal foot infection), sepsis, ability to sense a 128 Hz tuning fork (both left and right sides), C-reactive protein (CRP) levels, and urinary albumin-to-creatinine ratio (ACR). Analysis of NIS data revealed that in the broader Asian population, peripheral vascular disorders and osteomyelitis were associated with DFU.

CONCLUSION

The prevalence of DFU is higher in Asia than in China. Focusing on peripheral vascular disorders and osteomyelitis can effectively reduce the prevalence of DFU in the Asian population while addressing diabetic retinopathy, diabetic nephropathy, osteomyelitis, coronary heart disease, tinea pedis, ability to sense a 128 Hz tuning fork, CRP levels, and urinary ACR can be effective in China.

Intact fish skin graft a new hope for the treatment of diabetic foot ulcers: A case report

BACKGROUND

Diabetic foot ulcers (DFUs) are a real public health problem which carry a high risk of amputation. The treatment of DFUs is based on general management such as the treatment of infection, arterial disease, and offloading, but recent studies have shown that the quality of the local covering can impact the healing rate.

CASE SUMMARY

We report the case of a 39-year-old man, living with diabetes since the age of 15, who developed DFU on the dorsum of his left foot, with muscle and tendon involvement. Conventional management with intensive diabetes control, surgery, treatment of infection and negative pressure therapy gave only limited results. The patient benefited from the application of an intact fish skin graft with complete epithelialisation of the ulcer after 10 weeks of treatment.

CONCLUSION

The use of intact fish skin graft appears to be a promising option for deep DFUs.

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

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

Association between inflammatory markers and anemia in patients with diabetic foot ulcer

Aim: Anemia of inflammation (AI) is common among patients with diabetic foot ulcers (DFU). This study aimed to investigate the specific relationship between inflammation indicators and anemia in patients with DFU.Materials & methods: This cross-sectional study was carried out among patients with DFU between 2018 and 2023. Clinical data were gathered before treatment. Restricted cubic spline regression was employed to investigate the non-linear associations between inflammation and anemia.Results: A total of 395 patients with Wagner grades 2-4 were enrolled in the study. About 63.54% of the patients with DFU had anemia which was primarily presented with normocytic hypopigmentation anemia. Elevated IL-6 levels (39.10-369 pg/ml) were significantly associated with an increased likelihood of anemia (OR = 4.84; 95% CI: 1.97-11.90). Similarly, high CRP levels (48.56-385 mg/l) were linked to a higher prevalence of anemia (OR = 5.01; 95% CI: 2.35-10.68). Furthermore, a nonlinear relationship was observed between CRP levels and anemia, suggesting that CRP values exceeding 53.889 mg/l may trigger anemia in patients with diabetic foot ulcers.Conclusion: Inflammation is identified as an independent risk factor for AI in patients with DFU. The inflammation indicators (CRP and IL-6) and anemia exhibit an L-shaped nonlinear correlation in patients with DFU.

Systematic review and meta-analysis of the diagnostic accuracy of inflammatory markers for infected diabetic foot ulcer

BACKGROUND

The aim was to evaluate the diagnostic value of ESR, CPR, PCT, and WBC in patients with infected diabetic foot ulcer (DFU).

METHODS

The MEDLINE, Embase, BIOSIS, Cochrane databases, and Web of Knowledge databases were searched, without language restriction, to July 2023. Original studies were selected that reported the performance of ESR, CPR, PCT, and WBC in diagnosing infected DFU. To assess the diagnostic value of biomarkers for infected DFU, pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic curve (ROC-AUC) were calculated.

RESULTS

Ten studies with 765 patients were identified in our meta-analysis. The pooled sensitivity and specificity of ESR was 0.82 (95 % CI: 0.68-0.91) and 0.83 (95 % CI: 0.69-0.91) respectively. The pooled sensitivity and specificity of CRP was 0.81 (95 % CI: 0.65-0.91) and 0.91 (95 % CI: 0.79-0.96) respectively. The pooled sensitivity and specificity of PCT was 0.76 (95 % CI: 0.65-0.85) and 0.89 (95 % CI: 0.78-0.95) respectively. The pooled sensitivity and specificity of WBC was 0.75 (95 % CI: 0.64-0.83) and 0.79 (95 % CI: 0.67-0.88) respectively. CRP showed the best diagnostic accuracy at distinguishing infected DFU from noninfected DFU with an AUC of 0.93, followed by PCT (AUC of 0.89), ESR (AUC of 0.89), and WBC (AUC of 0.84).

CONCLUSION

CPR levels had high efficiency in distinguishing infected DFU from noninfected DFU, followed by PCT, ESR and WBC. All of these biomarkers could be helpful for early diagnosis of infected DFU. New biomarkers for improving medical decision in diagnosis of infected DFU are highly desirable.

Diabetic Foot Care: Assessing the Knowledge and Practices of Diabetic Patients at Aldaraga Centre, Gezira State, Sudan, 2021

Introduction

Improving diabetic patients' foot care behaviours is crucial in the incidence reduction of diabetic foot ulceration-associated complications.

Objective

This study assessed the knowledge and practice of diabetic patients towards diabetic foot care and their general understanding of diabetes causes, complications, and treatment.

Methods

A cross-sectional study was conducted at Aldaraga Clinic Centre, Sudan, with a sample size of 100 diabetic patients. A questionnaire and checklist were used to collect data for this study. The data was analyzed through SPSS Version 16 software.

Results

The majority of respondents were females (62%), above 40 years old (66%), married, with a low educational level, and moderate-income (76%). The study revealed that most respondents did not attend any educational program about diabetes, indicating poor or no knowledge about diabetes mellitus. However, respondents had good knowledge of most signs and symptoms of diabetes, with the highest percentage (88%) for extreme thirst. Concerning the knowledge of respondents about complications of diabetes, it was generally poor, except for retinal diseases (70%). Participants' knowledge of signs and symptoms of hypoglycemia was found to be poor at 25%. The study showed that most respondents did not know what diabetes gangrene is. Foot infections were the most dominant cause of hospitalization among diabetic patients, often leading to amputations.

Conclusion

Enhancing foot care behaviours in diabetic patients is crucial to reduce diabetic foot ulceration risks. Patient-friendly educational interventions and regular physician reinforcement are urgently needed, including awareness programs, specialized diabetes centres, and health education through mass media to improve foot care practices and prevent complications like amputations.

The Potential Role of Presepsin in Predicting Severe Infection in Patients with Diabetic Foot Ulcers

Background/Objectives: Diabetic foot ulcers are one of the complications in patients with diabetes, which can be caused by infection, neuropathy, and blood vessel disorder. Among them, infection is the most common cause, and if it becomes worse, amputation may be necessary. So, it is important to detect and treat infections early, and determining indicators that can confirm infection is also important. Known infection markers include white blood cells (WBCs), the erythrocyte sediment rate (ESR), C-reactive protein (CRP), and procalcitonin, but they are not specific to diabetic foot ulcers. Presepsin, also known as soluble CD14, is known to be an early indicator of sepsis. Recent studies have reported that presepsin can be used as an early indicator of infection. This study investigated whether presepsin could be used as an early marker of severe infection in patients with diabetic foot ulcers. Methods: We retrospectively studied 73 patients who were treated for diabetic foot ulcerations from January 2021 to June 2023 at Yeungnam University Hospital. Results: Out of a total of 73 patients, 46 patients underwent amputations with severe infections, and the WBC level, ESR, and CRP, procalcitonin, and presepsin levels were significantly higher in the group of patients who underwent amputations. The cutoff of presepsin, which can predict serious infections that need amputation, was 675 ng/mL. A regression analysis confirmed that presepsin, HbA1c, and osteomyelitis significantly increased the risk of severe infections requiring amputation. Conclusions: Presepsin will be available as an early predictor of patients with severe infections requiring amputations for diabetic foot ulcerations.

Preclinical study of diabetic foot ulcers: From pathogenesis to vivo/vitro models and clinical therapeutic transformation

Diabetic foot ulcer (DFU), a common intractable chronic complication of diabetes mellitus (DM), has a prevalence of up to 25%, with more than 17% of the affected patients at risk of amputation or even death. Vascular risk factors, including vascular stenosis or occlusion, dyslipidemia, impaired neurosensory and motor function, and skin infection caused by trauma, all increase the risk of DFU in patients with diabetes. Therefore, diabetic foot is not a single pathogenesis. Preclinical studies have contributed greatly to the pathogenesis determination and efficacy evaluation of DFU. Many therapeutic tools are currently being investigated using DFU animal models for effective clinical translation. However, preclinical animal models that completely mimic the pathogenesis of DFU remain unexplored. Therefore, in this review, the preparation methods and evaluation criteria of DFU animal models with three major pathological mechanisms: neuropathy, angiopathy and DFU infection were discussed in detail. And the advantages and disadvantages of various DFU animal models for clinical sign simulation. Furthermore, the current status of vitro models of DFU and some preclinical studies have been transformed into clinical treatment programs, such as medical dressings, growth factor therapy, 3D bioprinting and pre-vascularization, Traditional Chinese Medicine treatment. However, because of the complexity of the pathological mechanism of DFU, the clinical transformation of DFU model still faces many challenges. We need to further optimize the existing preclinical studies of DFU to provide an effective animal platform for the future study of pathophysiology and clinical treatment of DFU.

The infected diabetes-related foot: Comparison of erythrocyte sedementation rate/albumin and C-reactive protein/albumin ratios with erythrocyte sedimentation rate and C-reactive protein to differentiate bone and soft tissue infections

The objective of this study was to evaluate the effectiveness of C-reactive protein (CRP)/albumin, erythrocyte sedimentation rate (ESR)/albumin ratio, ESR, CRP and albumin to differentiate bone and soft tissue infection in persons with diabetes. We retrospectively evaluated 242 individuals admitted to hospital with diabetes-related foot infections (DFI). We categorised DFI cases as either bone (OM) or soft tissue infection based on bone culture and/or histology. We evaluated the diagnostic accuracy of CRP, ESR, albumin, CRP/albumin and ESR/albumin as biomarkers to diagnose OM in persons with diabetes. The median age was 53 years (74% male). There were 224 diabetes-related patients of which 125 had been diagnosed with osteomyelitis. The ESR/albumin and CRP/albumin ratios cut-points were >17.84 and >1.83, respectively. ESR/albumin and CRP/albumin ratios had similar diagnostic parameters: AUC (0.71, 0.71), sensitivity (70.0%, 57.0%), specificity (62.0%, 75.0%), positive predictive value (67.0%, 71.0%) and negative predictive value (66.0% and 71.0%). In contrast diagnostic efficiency of CRP and ESR were AUC 0.71 and 0.71, sensitivity (45.6%, 71.2%), specificity (85.5%, 60.7%), positive predictive value (70.0%, 65.9%) and negative predictive value (59.5%, 66.4%), respectively. When comparing area under the curves, the results showed that ESR/albumin was not significantly different to ESR alone (Delong test pvs ESR  >0.1). Similarly, CRP/albumin was not significantly different to CRP alone (Delong test pvs CRP  >0.1). In conclusion, ESR/albumin and CRP/albumin ratios provided comparable results as using ESR and CRP alone.

Effect of matrix metalloproteinases on the healing of diabetic foot ulcer: A systematic review

BACKGROUND

This study aims to discuss the expression of matrix metalloproteinase in wound healing of diabetic foot ulcers and further summarize the strategies of targeted matrix metalloproteinase and its inhibitors in the treatment of diabetic foot ulcers.

METHODS

Following PRISMA-SCR guidelines, databases (PubMed, Home-PMC-NCBI, CINAHL, Web of Science) were systematically searched from inception to 19 June 2022. Newcastle-Ottawa Scale (NOS) was used to evaluate the bias risk of the included studies.

RESULTS

Eight studies are finally eligible for our systematic review. The combined data analysis of 8 studies showed that there were no significant difference in age(p = 0.110), duration of diabetes(p = 0.197), glycosylated hemoglobin content(p = 0.489), size(p = 0.133) and depth(p＞0.05) of initial ulcer between the ulcer wound healing group and the non-healing group. MMP-1, 2, 8, 9, and TIMP-1, 2 affected the healing of DFUs. In the DFUs healing group, the concentrations of MMP (MMP-1, 2, 8, 9) decreased, and the concentration of TIMP-1 increased.

CONCLUSION

Our study showed that high levels of MMP-1, 2, 9 delayed the healing of diabetic foot ulcers, and high expression of MMP-8 in tissues improved wound healing. This study also summarized the effective intervention strategies for the treatment of diabetic foot ulcers.

APPLICATION OF PROBIOTIC ANTISEPSIS FOR PURULENT COMPLICATIONS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

OBJECTIVE

The aim: To improve the results of surgical treatment of patients with type 2 diabetes and purulent-necrotic wounds by using probiotic antiseptics.

PATIENTS AND METHODS

Materials and methods: 66 patients with type 2 diabetes and purulent-necrotic complications took part in this study. Probiotic antiseptics were used for local treatment in the experimental group (n=31), and traditional antiseptics were used in the control group (n=35). The levels of pro-inflammatory markers in the blood (IL-6, TNF-a, CRP) were studied; microscopic material was taken to study the type of cytogram during bandaging, before wound treatment with antiseptics or debridement on admission to the hospital (1st day), on the 3rd day and on the 7th day.

RESULTS

Results: Analysis of dynamic changes in pro-inflammatory markers between the first and seventh days proved that only in the experimental group there was a statistically significant difference (IL-6 (Р=0.004), TNF-a (Р=0.001), CRP (Р=0.018)). Detection of regenerative-inflammatory and regenerative cytogram types on the 7th day in the experimental group had a statistically significant difference compared to the control group (p=0.002 and p<0.001, respectively).

CONCLUSION

Conclusions: the use of probiotic antisepsis accelerates wound healing in patients with type 2 diabetes and purulent-necrotic complications.

Diabetic foot infection - diagnosis and treatment

Diabetic foot (DF) is one of the most serious complications of diabetes, leading to high morbidity and mortality in patients with diabetes, significantly affecting their quality of life and placing a huge burden on the healthcare system. Diabetic foot infection (DFI) is a major factor in the non-healing of diabetic ulcerations of the lower limbs, increases the number of hospital admissions, prolongs their duration and is a frequent cause of increased number of amputations. The most serious form of foot infection is osteomyelitis. Management of infection in SDN includes proper diagnosis, including obtaining appropriate specimens for culture, indication of rational antimicrobial therapy or early surgical intervention, and provision of all other necessary wound care and overall patient care to prevent recurrence of DFI.

Single nucleotide variations in the development of diabetic foot ulcer: A narrative review

Diabetes mellitus has become a global health problem, and the number of patients with diabetic foot ulcers (DFU) is rapidly increasing. Currently, DFU still poses great challenges to physicians, as the treatment is complex, with high risks of infection, recurrence, limb amputation, and even death. Therefore, a comprehensive understanding of DFU pathogenesis is of great importance. In this review, we summarized recent findings regarding the DFU development from the perspective of single-nucleotide variations (SNVs). Studies have shown that SNVs located in the genes encoding C-reactive protein, interleukin-6, tumor necrosis factor-alpha, stromal cell-derived factor-1, vascular endothelial growth factor, nuclear factor erythroid-2-related factor 2, sirtuin 1, intercellular adhesion molecule 1, monocyte chemoattractant protein-1, endothelial nitric oxide synthase, heat shock protein 70, hypoxia inducible factor 1 alpha, lysyl oxidase, intelectin 1, mitogen-activated protein kinase 14, toll-like receptors, osteoprotegerin, vitamin D receptor, and fibrinogen may be associated with the development of DFU. However, considering the limitations of the present investigations, future multi-center studies with larger sample sizes, as well as in-depth mechanistic research are warranted.

Severe Diabetic Foot Infections without Systemic Inflammatory Response Syndrome. Prospective Validation of a New Category

We aimed to validate the prognostic value of subclassifying moderate diabetic foot infections into two categories: moderate and moderate/severe. We conducted a prospective study of a cohort of 200 patients with moderate and severe infections. Moderate infections were subclassified after applying a previously published score. Variables associated with prognosis were: need for any amputation, major amputation, need for hospitalization, length of hospitalization, length of antibiotic therapy, reinfection rate and infection-related mortality. Infections were moderate in 111 cases (55.5%) and severe in 89 (44.5%). Osteomyelitis was diagnosed in 114 cases (57%), 73 moderate (36.5%) and 41 severe (20.5%). Patients with severe OM had a higher rate of amputations, major amputations, hospitalizations and need for antibiotic therapy, and a longer duration of antibiotics when compared with moderate OM. After applying the score, moderate infections were subclassified into 73 moderate cases (65.7%) and 38 moderate/severe cases (34.3%). Moderate/severe had a higher rate of amputations, major amputations, hospitalizations and need for antibiotics than moderate ones. No differences regarding prognosis were found between moderate/severe and severe infections with systemic inflammatory response syndrome. Moderate/severe diabetic foot infections, which could also be known as severe infections without systemic inflammatory response syndrome, should be recognized as a new subgroup. We propose to merge severe diabetic foot infections with and without systemic inflammatory response syndrome into a unique category due to its prognostic value. Furthermore, osteomyelitis should be added to both moderate and severe new categories of diabetic foot infections. This article is protected by copyright. All rights reserved.