Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre

The Efficacy of Diabetic Foot Treatment in a "TOSF" Pattern: A Five-Year Retrospective Study

Aim

To evaluate the advantages and problems in the diagnosis and treatment of diabetic foot (DF) patients by analyzing the results of a 5-year follow-up of the organ system based (TOSF) treatment model.

Methods

A retrospective study was conducted in 229 patients with diabetic foot. Chi-square test and rank-sum test were used to analyze the effects of patients' general condition, behavioral and nutritional status, degree of infection (inflammatory markers), comorbidity, diabetic foot grade/classification, and revascularization on readmission rate, amputation rate, all-cause mortality, incidence of other complications, and wound healing time. Logistic regression was used to analyze the risk factors affecting the prognosis of diabetic foot. Kaplan-Meier survival curve was used to analyze the differences in amputation rate and mortality rate at each time point.

Results

This study showed that nutritional status, degree of infection, and revascularization influenced readmission rates. General condition, behavior and nutritional status, degree of infection, Wagner grade and revascularization affect the amputation rate. General conditions, behavioral and nutritional status, degree of infection, comorbidities, classification and revascularization affect the mortality of patients. Age and white blood cell(WBC) count affected the incidence of other complications. Influence of infection degree and Wagner grade and revascularization in patients with wound healing time. Revascularization was an independent protective factor for readmission, amputation, and mortality.Elevated serum inflammatory markers are an independent risk factor for amputation. Hypoproteinemia is an independent risk factor for mortality.

Conclusion

In the "TOSF" diagnosis and treatment pattern, diabetic foot patients have a good prognosis. Special attention should be paid to the screening and revascularization of lower extremity vascular disease in patients with diabetic foot.

Are current wound classifications valid for predicting prognosis in people treated for limb-threatening diabetic foot ulcers?

This study aims to investigate whether the current wound classifications were valid for the treatment prognosis of subjects treated for limb-threatening diabetic foot ulcers (LTDFU). A total of 1548 patients with LTDFU and infection were studied, with wounds recorded using the Wagner, Texas, PEDIS and WIfI classifications while major lower extremity amputations (LEAs) or in-hospital mortality incidences were defined as poor outcomes. Among them, 153 (9.9%) patients received major LEAs and 38 (2.5%) patients died. After adjustments, the Wagner classification and Texas stage as well as clinical factors such as comorbidity with major adverse cardiac events (MACE), being under dialysis and having serum levels of C-reactive protein (CRP) and albumin were independent factors for prognosis. For patients without dialysis, Wagner and Texas stage stood out independently for prognosis. For patients on dialysis, only levels of CRP (odds ratio [OR] = 2.2 in Wagner, OR = 2.0 in WIfI, OR = 2.2 in Texas, OR = 2.3 in PEDIS) and albumin (OR = 0.4 in four classifications) were valid predictors. The Wagner system and Texas stage were valid for predicting prognosis in treatment for LTDFUs, suggesting a role of vascular perfusion. MACE history, levels of CRP and albumin level should assist in prediction; more significantly, only levels of CRP and albumin appeared valid for those subjects undergoing dialysis.

An index to prevent major limb amputations in diabetic foot

Objective. Besides the early detection and treatment of diabetic foot ulcers, being aware of the risk factors for major amputation plays a crucial role in preventing the major lower limb amputations. Major lower limb amputations are not just mentally and physically hard for patients, but also have an effect on patient's survival and are a financial burden on both patients and healthcare systems. Subjects and Methods. We defined 37 potential risk factors for major amputation and these risk factors were investigated among 507 patients who had ulcers in their feet and were seen by the diabetic foot ulcer council at Ege University Faculty of Medicine. In our study, 106 (20.9%) patients ended up undergoing major lower limb amputation. Results. The univariate analysis showed that 24 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, 6 risk factors remained statistically significant. Multivariate-adjusted hazard ratios were 4.172 for hyperlipidemia, 3.747 for albumin <3.365 g/dL, 3.368 for C-reactive protein (CRP) >2.185 mg/L, 2.067 for presence of gangrenous Wagner stage, 1.931 for smoking tobacco >30 pack/year, and 1.790 for hematocrit (HCT) <31.5%. Most patients with major amputation presented with a neuroischemic foot (58%). Gender and age were not found to be risk factors for major amputation. Having less than 7% of hemoglobin A1c (HbA1c) levels had a direct proportion with major amputation numbers. The mortality rates in one year, two and three years after the major amputation operations were 24.6%, 30%, and 35.9%, respectively. Conclusion. Being familiar with these risk factors for major amputation is crucial for multi-disciplinary teams to take good care of patients with diabetic foot ulcers and to lower the need for major amputations.

Machine Learning Models for Predicting the Risk of Hard-to-Heal Diabetic Foot Ulcers in a Chinese Population

BACKGROUND

Early detection of hard-to-heal diabetic foot ulcers (DFUs) is vital to prevent a poor prognosis. The purpose of this work was to employ clinical characteristics to create an optimal predictive model of hard-to-heal DFUs (failing to decrease by >50% at 4 weeks) based on machine learning algorithms.

METHODS

A total of 362 DFU patients hospitalized in two tertiary hospitals in eastern China were enrolled in this study. The training dataset and validation dataset were split at a ratio of 7:3. Univariate logistic analysis and clinical experience were utilized to screen clinical characteristics as predictive features. The following six machine learning algorithms were used to build prediction models for differentiating hard-to-heal DFUs: support vector machine, the naïve Bayesian (NB) model, k-nearest neighbor, general linear regression, adaptive boosting, and random forest. Five cross-validations were employed to realize the model's parameters. Accuracy, precision, recall, F1-scores, and AUCs were utilized to compare and evaluate the models' efficacy. On the basis of the best model identified, the significance of each characteristic was evaluated, and then an online calculator was developed.

RESULTS

Independent predictors for model establishment included sex, insulin use, random blood glucose, wound area, diabetic retinopathy, peripheral arterial disease, smoking history, serum albumin, serum creatinine, and C-reactive protein. After evaluation, the NB model was identified as the most generalizable model, with an AUC of 0.864, a recall of 0.907, and an F1-score of 0.744. Random blood glucose, C-reactive protein, and wound area were determined to be the three most important influencing factors. A corresponding online calculator was created (https://predicthardtoheal.azurewebsites.net/).

CONCLUSION

Based on clinical characteristics, machine learning algorithms can achieve acceptable predictions of hard-to-heal DFUs, with the NB model performing the best. Our online calculator can assist doctors in identifying the possibility of hard-to-heal DFUs at the time of admission to reduce the likelihood of a dismal prognosis.

Risk factors that predict major amputations and amputation time intervals for hospitalised diabetic patients with foot complications

Diabetes‐related lower extremity amputations are an enormous burden on global health care and social resources because of the rapid worldwide growth of the diabetic population. This research aimed to determine risk factors that predict major amputation and analyse the time interval from first hospitalisation to amputation by using standard management protocols and Kaplan–Meier survival curves. Data from 246 patients with diabetes mellitus and diabetic foot ulcers from the Division of Plastic and Reconstructive Surgery of the Department of Surgery at XXX Hospital between January 2016 and May 2020 were analysed. Univariate and multivariate analyses of 44 potential risk factors, including invasive ulcer depth and C‐reactive protein levels, showed statistically significant differences for those at increased risk for major amputation. The median time from hospitalisation to lower extremity amputation was approximately 35 days. Most patients with abnormal C‐reactive protein levels and approximately 70% of patients with ulcers invading the bone were at risk for lower extremity amputations within 35 days. Therefore, invasive ulcer depth and C‐reactive protein levels are significant risk factors. Other potential risk factors for major amputation and the time intervals from first hospitalisation to amputation should be analysed to establish further prediction strategies.

Analysis of routine blood markers for predicting amputation/re-amputation risk in diabetic foot

Diabetic foot is challenging progressive disease which requires multisystemic control. Neuropathy, arteriopathy, and cellular responses should treated collaboratively. Despite all medical advances, diabetic foot can highly resulted with amputation and also re-amputation can be required because of failed wound healing. In this study, we aimed to investigate the relation between blood parameters and amputation events. Diabetic 323 patients include to the study who referred to orthopaedic clinic for amputation. Amputation levels (amputation levels phalanx, metatarsal, lisfranc, syme, below knee, knee-disarticulation, above-knee amputation) and re-amputations recorded and compared with routine blood parameters. Re-amputation was observed at 69 patients. The significant difference detected between lower albumin, higher HbA1c, higher CRP levels (P < 0.05) in regards to gross amputation levels, and increased wound depth. Furthermore, lower albumin levels and higher levels of WBC, HbA1c, CRP, and Creatinine were detected in re-amputation levels. Especially, HbA1c, CRP, and Creatinine levels were found as upper bound of reference line for re-amputation. The statistically optimal HbA1c cutoff point for diabetes was ≥7.05%, with a sensitivity of 86% and a specificity of 59%. In according to our results, simple blood parameters can be useful for observing the progress of amputation in diabetic foot. Particularly, lower albumin, and higher HbA1c, CRP, and Creatinine levels detected as related with poor prognosis. Besides, screening of HbA1c level seems to be highly sensitive for detecting of re-amputation possibility.

Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation

Diabetes mellitus is a common metabolic disorder. Among various complications, diabetic neuropathy and peripheral vascular disorders are closely associated with diabetic foot ulcers (DFUs). Lower extremity ulcers and amputations are ongoing problems among individuals with diabetes. There are several classification systems for DFUs; however, no prognostic system has to date been accepted as the gold standard or the optimum prediction tool for amputations. A retrospective study was designed. Demographic data and baseline laboratory data were gathered and scored or evaluated using five representative DFU classification systems. These included (i) the diabetic ulcer severity score (DUSS); (ii) University of Texas (UT) diabetic wound classification; (iii) Meggitt-Wagner classification; (iv) depth of the ulcer, extent of bacterial colonisation, phase of ulcer and association aetiology (DEPA) scoring system; and (v) site, ischaemia, neuropathy, bacterial infection and depth (SINBAD) score. Finally, a statistical analysis was performed. A total of 137 patients were included in this study. During the follow-up, DFU had healed in 51·1% of subjects and 48·9% of the individuals underwent lower extremity amputations (LEAs). In a univariable logistic regression analysis, history of previous DFU, hypertension, neuropathy, haemoglobin, C-reactive protein (CRP) and ankle-brachial index (ABI) showed a statistically significant difference between the healed group and the LEA group. Moreover, the stages, grades or overall prognostic ability of all five classifications were highly associated with the overall occurrence of LEA. On multivariable logistic regression analysis of the risk of LEA, all classifications showed a significant positive trend with an increased number of amputations. All the five classification systems exhibited high sensitivity, specificity, classification accuracy, positive predictive, negative predictive and area under the curve (AUC) values. They showed substantial accuracy and their main variables were associated with LEA occurrence. The Wagner and UT systems, although they are relatively simple to assess, were better predictors of LEA.

Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis in the Eurodiale subgroup

Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of and risk factors for DFU recurrence after healing during a 3-year follow-up period. At our site, 93 Eurodiale-enrolled patients had a healed DFU. Among these, 14 were not alive; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study, we assessed demographic factors (age, sex and distance from hospital); diabetes-related factors [duration, and glycated haemoglobin (HbA1c) levels]; comorbidities (obesity, renal failure, smoking and alcohol abuse) and DFU-related factors [peripheral arterial disease, ulcer infection, C-reactive protein (CRP) and; foot deformities]. During the 3-year follow-up period, a DFU had recurred in 42 patients (57.5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location [odds ratio (OR) 8.62, 95% confidence interval (CI) 2.2-33.2]; presence of osteomyelitis (OR 5.17, 95% CI 1.4-18.7); HbA1c > 7.5% ([DCCT], OR 4.07, 95% CI 1.1-15.6) and CRP > 5 mg/l (OR 4.27, 95% CI 1.2-15.7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3-year follow-up period, despite intensive foot care. The findings at diagnosis of the initial DFU were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) and define those at high risk for recurrence, but may be amenable to targeted interventions.

Acute phase reactants predict the risk of amputation in diabetic foot infection

BACKGROUND

prediction of amputation would aid clinicians in the management of diabetic foot infections. We aimed to assess the predictive value of baseline and post-treatment levels of acute phase reactants in the outcome of patients with diabetic foot infections.

METHODS

we collected data prospectively during minimum follow-up of 6 months in patients with infected diabetic foot ulcers hospitalized in Dokuz Eylul University Hospital between January 1, 2003, and January 1, 2008. After excluding patients who did not attend the hospital for follow-up visits regularly (n = 36), we analyzed data from 165 foot ulcer episodes.

RESULTS

limb ischemia and osteomyelitis were much more frequent in patients who underwent amputation. Wagner grade, which assesses ulcer depth and the presence of osteomyelitis or gangrene, was higher in patients who needed amputation. Ulcer size was slightly larger in the amputation group. Baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, white blood cell counts, and platelet counts were significantly elevated in patients who underwent amputation. Albumin levels were significantly suppressed in the amputation group. Univariate analysis showed that a 1-SD increase in baseline and post-treatment C-reactive protein levels, erythrocyte sedimentation rates, and white blood cell counts and a 1-SD decrease in post-treatment albumin levels were significantly associated with increased risk of amputation. Post-treatment C-reactive protein level was strongly associated with amputation risk.

CONCLUSIONS

circulating levels of acute phase reactants were associated with amputation risk in diabetic foot infections.

Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital

OBJECTIVES

The aim of this study was to evaluate the incidence of amputation among patients with diabetic foot ulcer (DFU) and risk factors for amputations.

METHODS

This is a retrospective study of 450 inpatients treated in a multi-discipline based diabetic centre, 306th Hospital of PLA during the period of January 2000-September 2009. Hospital admission and discharge information including patient profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. The risk factors for amputation were determined using univariate and stepwise logistic regression analysis.

RESULTS

The overall amputation rate among DFU was 21.5%. Significant univariate risk factors for amputation were peripheral vascular disease (PVD), white blood cell (WBC) counts, neutrophil granulocyte percentage, hemoglobin, triglyceride, cholesterol, LDL-C, HDL-C and serum sCRP. Upon stepwise logistic regression analysis, only PVD (odds ratio 4.529, 95% CI 1.500-13.676), WBC (odds ratio 1.146, 95% CI 1.075-1.222), sCRP (odds ratio 1.041, 95% CI 1.002-1.082) and triglyceride (odds ratio -0.488, 95% CI 0.433-0.869) were significant risk factors.

CONCLUSIONS

The risk factors for amputation were presence of PVD, increased WBC, sCRP and decreased triglyceride.

Clinical outcomes of diabetic foot management with Circulat

Major and minor lower-extremity amputation is a common complication among diabetics. Various sources indicate diabetic foot ulcer prevalence at between 2.2% and 15% in diabetics. This study evaluates the efficacy and tolerance of a standardized plant extract combination, Circulat, developed for the prevention and treatment of severe manifestations of type 2 diabetes, such as necrotic damage of the foot. Thus, a retrospective cohort study was carried out in 174 patients treated with Circulat with diabetic foot grades D1-D3, according to The University of Texas Wound Classification System, in 50 medical centers, from 2004 to 2007. Circulat obtained 50.57% complete cure of diabetic foot, significant improvement in 37.9% and prevented amputation in 88.5% of the study's total population. The treatment was well tolerated. Four patients (2.3%) had slight gastrointestinal unrest which did not warrant suspension of treatment.

The diabetic foot in end stage renal disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5-10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies--neuropathy, ischemia, and infection--are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.