Foot Ulcer and Risk of Lower Limb Amputation or Death in People With Diabetes: A National Population-Based Retrospective Cohort Study

Risk factors for diabetic foot ulcer in diabetic patients at the Tehran diabetes clinic: a case-control study

Background and objective

: Diabetic foot ulcer (DFU) is one of the main health challenges of diabetes complications worldwide. A wide range of factors may increase the risk of DFU. This study aimed to investigate the risk factors of DFU among diabetic patients.

Methods

This case-control study was conducted on 800 diabetic patients at the Tehran diabetes clinic of the Endocrinology and Metabolism Research Institute in Iran. The case group included 400 diabetic patients diagnosed with DFU, while the control group included 400 diabetic patients without DFU. Data were collected through medical records, validated questionnaires, and clinical examinations. The association between factors and the risk of DFU was analyzed using both crude and adjusted logistic regression models, adjusting for confounders based on a directed acyclic graphs.

Results

The final adjusted model demonstrated significant direct associations between the risk of DFU with a longer duration of diabetes, a history of previous DFU, peripheral neuropathy, retinopathy, high blood pressure, severe kidney function loss, and good foot self-care. However, there were significant inverse associations between DFU risk with female gender, higher education levels, being married, use of oral diabetes drugs, higher hemoglobin levels, and high physical activity.

Conclusions

The risk of DFU was significantly associated with the following factors: diabetes duration, previous DFU history, peripheral neuropathy, retinopathy, blood pressure, kidney function, foot self-care, gender, education levels, marital status, diabetes drugs, hemoglobin levels, and physical activity. Further studies, especially ones in multicenter cohorts with a special focus on novel risk factors, are warranted to expand on our findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01582-z.

The application of 3D printing technology in the treatment of diabetic foot ulcers: an integrated strategy for glycemic control and wound care

INTRODUCTION

Diabetic foot ulcers (DFUs) are a severe complication of diabetes, often leading to amputation. Hyperglycemia induced nerve and vascular damage significantly increases DFU risk. The advent of 3D printing technology presents a revolutionary concurrently address glycemic control and wound management, potentially improving patient adherence and offering a more holistic treatment strategy.

METHODS

This article reviews current oral antidiabetic medications and explores the potential of innovative 3D printing technology to develop extended release tablets in two distinct release profiles. Additionally, it investigates the application of this technology in creating novel wound dressing solutions aimed at facilitating DFU healing. .

RESULTS

The integration of 3D printing technology enables the production of customized, extended-release oral medications that optimize glycemic control while minimizing fluctuations in blood sugar levels. Furthermore, 3D-printed wound dressings demonstrate promising potentialfor enhancing wound healing by providing personalized structural support and controlled drug delivery.

CONCLUSION

A multidisciplinary approach that integrates advanced wound care and diabetes management is crucial to address the escalating challenges posed by DFUs. Leveraging3D printing technology to develop sustained-release medications and innovative wound dressingsmay significantly improve DFU outcomes and improve the quality of life for individuals with diabetes.

HbA1c and the Risk of Lower Limb Ulcers Among Diabetic Patients: An Observational and Genetics Study

Aims: A lower limb ulcer is a serious complication of diabetes. The association between glycated hemoglobin (HbA1c) and lower limb ulcers needs further clarification. We aimed to comprehensively evaluate the relationship between HbA1c and lower limb ulcer risk in diabetic patients through multivariable-adjusted observational analyses and Mendelian randomization (MR) approaches. Methods: This prospective cohort study included 23,434 individuals with prevalent diabetes in the UK Biobank. The Cox proportional hazard model was used to evaluate the association between HbA1c levels and lower limb ulcer risk. Furthermore, a one-sample MR analysis was conducted to explore the potential causal effect. Results:Over a follow-up period of 290,677 person-years (median length: 13.3 years), 1101 lower limb ulcers cases were documented. The multivariable-adjusted hazard ratios across categories of HbA1c of ≤ 42, 42-53, 53-64, 64-75, 75-86, and > 86 mmol/mol were 0.93 (0.76-1.15), 1.00, 1.24 (1.05-1.46), 1.98 (1.65-2.39), 2.68 (2.13-3.37), and 4.52 (3.62-5.65), respectively. The restrictive cubic spline model showed that lower limb ulcer risk increased steeply when HbA1c concentration exceeded 53 mmol/mol. One-sample linear and nonlinear MR analyses provided a positive but not significant association between genetically proxied HbA1c and lower limb ulcer risk among diabetic patients. Conclusions: High HbA1c levels increase the risk of lower limb ulcers in diabetic patients. MR analyses validated the positive but not significant association between genetically proxied HbA1c levels and lower limb ulcer risk. The results recommended an HbA1c goal of < 53 mmol/mol to decrease the incidence of diabetic ulcers.

Long-term mortality rates after lower extremity amputation in individuals with and without diabetes mellitus (DUDE-10): A retrospective matched cohort study

BACKGROUND/OBJECTIVES

To determine mortality rates after lower extremity amputation (LEA) in individuals with and without diabetes mellitus (DM).

METHODS

Retrospective, observational study using data from a database covering >99 % of the Dutch population. LEAs in 2016 were identified, and mortality data from 2016 to 2021 were analyzed. Study group 1 (SG1) included individuals with DM and LEA (DM+/LEA+) with two control groups (CG), DM+/LEA- (matched by age, sex, without (1a) and with (1b) socioeconomic status matching). Study group 2 (SG2) (DM+/LEA+) was composed after matching with non-DM individuals with LEA (DM-/LEA+ (2a)).

RESULTS

Among 5145 individuals with LEA in 2016, 56 % had DM. Five-year mortality was 61.2 % in SG1 (DM+/LEA+) and 27.9 % in CG1a (DM+, LEA-) and 1b. Study group 2 (DM+/LEA+) had a 62.6 % five-year mortality rate, compared to 56.4 % in CG2a (DM-/LEA+).

CONCLUSIONS

Mortality after LEA is high, especially in DM; socioeconomic status (SES) does not significantly impact mortality.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Electrospinning strategies targeting fibroblast for wound healing of diabetic foot ulcers

The high incidence and prevalence of diabetic foot ulcers (DFUs) present a substantial clinical and economic burden, necessitating innovative therapeutic approaches. Fibroblasts, characterized by their intrinsic cellular plasticity and multifunctional capabilities, play key roles in the pathophysiological processes underlying DFUs. Hyperglycemic conditions lead to a cascade of biochemical alterations that culminate in the dysregulation of fibroblast phenotype and function, which is the primary cause of impaired wound healing in DFUs. Biomaterials, particularly those engineered at the nanoscale, hold significant promise for enhancing DFU treatment outcomes. Electrospun nanofiber scaffolds, with their structural and compositional similarities to the natural extracellular matrix, serve as an effective substrate for fibroblast adhesion, proliferation, and migration. This review comprehensively summarizes the biological behavior of fibroblasts in DFUs and the mechanism mediating wound healing. At the same time, the mechanism of biological materials, especially electrospun nanofiber scaffolds, to improve the therapeutic effect by regulating the activity of fibroblasts was also discussed. By highlighting the latest advancements and clinical applications, we aim to provide a clear perspective on the future direction of DFU treatment strategies centered on fibroblast-targeted therapies.

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.

Developing a Smart Sensing Sock to Prevent Diabetic Foot Ulcers: Qualitative Focus Group and Interview Study

BACKGROUND

Diabetic foot ulcers are common and costly. Most cases are preventable, although few interventions exist to reliably support patients in performing self-care. Emerging technologies are showing promise in this domain, although patient and health care provider perspectives are rarely incorporated into digital intervention designs.

OBJECTIVE

This study explored patient and health care provider feedback on a smart sensing sock to detect shear strain and alert the wearer to change their behavior (ie, pause activity and check their feet) and considered how patient experience and attitudes toward self-care are likely to impact uptake and long-term effective engagement with the device to curate guiding principles for successful future intervention development.

METHODS

This qualitative study combined semistructured interviews and a focus group alongside a participant advisory group that was consulted throughout the study. In total, 20 people with diabetic neuropathy (n=16, 80% with history of diabetic foot ulcers) and 2 carers were recruited directly from podiatry clinics as well as via a recruitment network and national health mobile app for one-to-one interviews either in person or via landline or video call. A total of 6 podiatrists were recruited via professional networks for 1 virtual focus group. Participants were asked about their experience of diabetic foot health and for feedback on the proposed device, including how it might work for them in daily life or clinical practice. The data were analyzed thematically.

RESULTS

Three main themes were generated, each raising a barrier to the use of the sock complemented by potential solutions: (1) patient buy-in-challenged by lack of awareness of risk and potentially addressed through using the device to collect and record evidence to enhance clinical messaging; (2) effective engagement-challenged by difficulties accepting and actioning information and requiring simple, specific, and supportive instructions in line with podiatrist advice; and (3) sustained use-challenged by difficulties coping, with the possibility to gain control through an early warning system.

CONCLUSIONS

While both patients and podiatrists were interested in the concept, it would need to be packaged as part of a wider health intervention to overcome barriers to uptake and longer-term effective engagement. This study recommends specific considerations for the framing of feedback messages and instructions as well as provision of support for health care providers to integrate the use of such smart devices into practice. The guiding principles generated by this study can orient future research and development of smart sensing devices for diabetic foot care to help optimize patient engagement and improve health outcomes.

Effects of modified reverse sural neurocutaneous flap repair on wound healing in patients with soft tissue defects of the foot and ankle

OBJECTIVE

The surgical team in this study examined the efficacy of a modified reverse sural neurocutaneous flap repair in treating soft tissue defects of the ankle and foot caused by accidents.

METHODS

This study enrolled 89 patients treated for soft tissue defects of the ankle or foot between January 2007 and December 2023. The patients were divided into two groups: 44 patients underwent a modified reverse sural neurocutaneous flap repair, while 45 received traditional treatment. The modified technique involved repairing various anatomical structures, including fascia, the saphenous nerve, the great saphenous vein, subcutaneous tissue, and skin, with flap sizes ranging from 14 to 152 cm². In the traditional treatment group, the distal perforator of the peroneal artery was identified 5 cm above the lateral malleolus. Island fasciocutaneous flaps were designed along the sural nerve and lesser saphenous vein, elevated subfascially, rotated 180 degrees, and inset without tension. Donor sites were closed with grafts or direct sutures.

RESULTS

Of the 44 patients, who underwent the modified technique, 35 were male and 9 were female. Follow-up periods ranged from 2 to 24 weeks to monitor outcomes and recovery. The average size of the affected soft tissue was 71 cm2. Thirty-nine flaps survived completely, while three experienced partial necrosis and two had marginal necrosis. No cases of severe venous congestion were reported. The complication rate was lower with the modified method compared to the traditional repair (p < 0.05).

CONCLUSION

The modified reverse neurocutaneous flap repair is a reliable and structured approach to treating soft tissue defects of the ankle and foot. This method has demonstrated favorable patient outcomes and presents a promising avenue for future studies and clinical practice.

Age Characteristics of Patients With Type 2 Diabetic Foot Ulcers and Predictive Risk Factors for Lower Limb Amputation: A Population-Based Retrospective Study

Background: Limited data are available about the epidemiological characteristics and the risk factors for amputation, particularly in developing countries from Asia, especially in China. Objective: We aim to investigate the age features of patients with Type 2 diabetic foot ulcers (DFUs) and analyze the critical influencing factors predicting lower extremity amputation and major amputation. Methods: Data were retrieved from the electric medical record system to identify patients aged > 18 years with Type 2 DFU from January 1, 2017, to December 31, 2023. A logistic regression model was adopted to analyze the risk factors for amputation and major amputation. Results: Nine hundred eighteen patients with Type 2 DFU were eligible for our study, 68.2% of whom were male. In patients with Type 2 diabetes in the hospitals we studied, the prevalence of Type 2 DFU was 1.07%. A majority of patients with DFU were in the 70-79 age group in the winter season, and deaths also peaked in this age group. A total of 38.8% of patients aged 50-59 years underwent amputation. Vascular CTA, complications, history of amputation, and infection sites were the important contributing factors in patients with DFU lower extremity amputation. History of amputation and hemoglobin were the main influencing factors of patients with major amputation resulting from DFU. Conclusion: Most patients with DFU were in the age group of 50-59 years, but the majority of deaths occurred in the 70-79-year age group. Several factors influence the amputation, and those findings provide new insights into the relationship between the severity of narrowed blood vessels and the likelihood of amputation.

Association between sarcopenia and the foot-ankle function in type 2 diabetic foot ulcer

BACKGROUND

The diabetic foot (DF) ulcer is the severe complication of type 2 diabetes mellitus (T2DM). Sarcopenia is characterized as the loss of muscle mass and strength, resulting in the increased risk of fracture and physical disability. Sarcopenia may affect the foot-ankle function in DF ulcer patients, compromise the quality of life.

OBJECTIVE

The aim was to clarify the effect of sarcopenia on foot-ankle function in patients with DF ulcer.

METHODS

In total of 108 T2DM patients with DF ulcer were enrolled. Based on the examination of muscle mass by dual energy X-ray absorptiometry (DXA) and grip strength and 5x sit-to-stand test, the DF patients were divided into sarcopenia and non-sarcopenia groups. The severity of DF ulcer was evaluated by Wagner classification. The foot-ankle function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score.

RESULTS

DF patients with sarcopenia showed advanced age, lower BMI, longer duration of T2DM, and more severe Wagner classification, reduced appendicular skeletal muscle mass index (ASMI), grip strength, transcutaneous oxygenpressure (TcPO2) and prolonged time of 5X sit-to-stand test. The stratified comparison analysis indicated that severity of sarcopenia and DF ulcer, reduced TcPO2, and grip strength were aggravated with the impaired foot-ankle function (P < 0.05). Multivariate Logistic analysis showed that age, TcPO2, and severe sarcopenia were risk factors deteriorating the foot-ankle function.

CONCLUSION

The sarcopenia is a key risk factor of decreasing foot-ankle function in patients with DF ulcer. Thus, the prevention of muscle mass and strength loss could be considered as part of comprehensive therapy for DF ulcer.

Combination therapy of negative pressure wound therapy and antibiotic-loaded bone cement for accelerating diabetic foot ulcer healing: A prospective randomised controlled trial

Negative pressure wound therapy (NPWT) and antibiotic-loaded bone cement (ALBC) are commonly used treatments for diabetic foot ulcers (DFUs). However, the combined efficacy of these two modalities remains unclear. This clinical study aimed to assess the effectiveness and underlying mechanisms of NPWT&ALBC in the management of DFUs. A total of 28 patients were recruited, 16 of whom served as controls and received only NPWT, whilst 12 received NPWT&ALBC. Both groups underwent wound repair surgery following the treatments. Blood samples were obtained to detect infections and inflammation. Wound tissue samples were also collected before and after the intervention to observe changes in inflammation, vascular structure and collagen through tissue staining. Compared with the NPWT group, the NPWT&ALBC group exhibited a superior wound bed, which was characterised by reduced inflammation infiltration and enhanced collagen expression. Immunostaining revealed a decrease in IL-6 levels and an increase in α-SMA, CD68, CD206 and collagen I expression. Western blot analysis demonstrated that NPWT&ALBC led to a decrease in inflammation levels and an increase in vascularization and collagen content. NPWT&ALBC therapy tends to form a wound bed with increased vascularization and M2 macrophage polarisation, which may contribute to DFUs wound healing.

Effects of continuous negative pressure suction combined with autologous platelet-rich gel on the levels of CRP, IL-6, wound healing and length of stay in clients with diabetic foot

OBJECTIVE

Continuous passive pressure suction and APG gel therapy effect diabetic foot IL-6, CRP, wound healing, and hospitalization.

METHODS

Clinicopathological data from 102 diabetic foot ulcer patients treated at our institution between March 2018 and May 2022 was examined. Tables generated 51 joint and controlling teams randomly. The observation team received passive pressure suction and APG gel whereas the controlled team received conventional treatment. Teams monitored therapy outcomes, adverse responses, wound healing, hospital stay, and costs. Both teams compared blood uric acid, cystatin C, homocysteine, and serum IL-6, IL-10, and CRP before and after medication.

RESULTS

The joint team had higher hospitalization costs, shorter stays, and faster wound healing than the controlled team. Diaparity was significant (P < 0.05). The united team worked 100 %, unlike the controlling team. This difference was significant (P < 0.05). Both teams showed significant decreases in CRP, IL-6, and IL-10 levels after therapy (P < 0.05). After therapy, both the combined and controlled teams had substantial differences in blood CRP, IL-6, and IL-10 levels (P < 0.05). Both teams had significantly decreased uric acid, cystatin C, and homocysteine after treatment. The combined team showed significantly decreased uric acid, cystatin C, homocysteine levels following therapy compared to the control team (P < 0.05).

CONCLUSION

The joint team experienced considerably fewer adverse events (3.92 % vs. 17.65 %) than the controls team (P < 0.05). Permanent passive pressure suction and APG gel therapy lower inflammatory response, blood uric acid, cystatin C, and homocysteine, speeding wound healing, reducing side effects.

Outcomes for Patients with Diabetic Foot Ulcers Following Transition from Medicaid to Commercial Insurance

Objective

This study investigates the outcomes of Medicaid beneficiaries with diabetic foot ulcers (DFUs) who had transitioned to commercial insurance.

Methods

We utilized the PearlDiver claims database to identify adult patients diagnosed with a new DFU between 2010 and 2019. The study cohort comprised 8856 Medicaid beneficiaries who had at least three years of continuous enrollment after DFU diagnosis. Medicaid beneficiaries who transitioned to Medicare during follow-up were excluded. Adjusted comparisons of outcomes were performed by propensity matching the two groups for age, gender, and Charlson Comorbidity Index (CCI) in a 1:1 ratio. We used logistic regression and Kaplan-Meier estimate to evaluate the association between insurance change (from Medicaid to commercial insurance) and major amputation.

Results

Among the 8856 Medicaid beneficiaries with DFUs, 66% (n = 5809) had transitioned to commercial insurance coverage during follow-up. The overall major amputation rate was 2.8% (n = 247), with a lower rate observed in patients who transitioned to commercial insurance compared to those with continuous Medicaid coverage (2.6% vs. 3.2%, p < 0.05). In multivariable analysis, Medicaid beneficiaries who transitioned to commercial insurance had a 27% lower risk of major amputation (study cohort: odds ratios [OR] 0.75, 95% CI 0.56-0.97, p = 0.03; matched cohort: OR 0.65, 95% 0.22, 0.55, p = 0.01) compared to those with continuous Medicaid coverage.

Conclusions

Transitioning from Medicaid to commercial insurance may be associated with a lower risk of major amputation among Medicaid beneficiaries with DFUs.

Effectiveness of continuous home wound care on patients with diabetic foot ulcers

AIMS

To explore the effectiveness of continuous home wound care on patients with diabetic foot ulcers (DFUs).

DESIGN

A non-randomized parallel controlled non-inferiority trial.

METHODS

Patients with Wagner grade I-III DFUs hospitalized in two distant campuses of the same hospital were included. All patients received infection treatment and wound bed preparation during hospitalization; after discharge, patients in one of the campuses received routine outpatient wound care, and those treated in the other received continuous home wound care. The per-protocol analysis was performed to compare ulcer healing indicators, knowledge, health belief, self-management behaviour and medical expenses of the two groups.

RESULTS

Between October 2021 and December 2022, 116 patients were enrolled in the study; 107 completed. The home care was not inferior in terms of ulcer healing rate and demonstrated significant enhancements in the understanding of warning signs, health belief and self-management behaviour. Additionally, the home care saved 220.38 yuan (24.32 UK pounds) in direct medical expenses for each additional one square centimetre of ulcer healing.

CONCLUSION

The continuous home wound care enhanced self-management behaviour of the patients and saved their medical expenses while not compromising ulcer healing.

IMPACT

This is to date the first study to conduct continuous home wound care practice for patients with DFUs and confirmed its safety and non-inferiority in ulcer healing, and supported its superiority in improving self-management behaviour and saving medical expenses.

REPORTING METHOD

We have adhered to the transparent reporting of evaluations with nonrandomized designs statements and the corresponding checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

The patients and their primary caregivers were involved in intervention design, we received input from them about the factors that facilitate and hinder patient self-management behaviours to develop intervention strategies.

Diabetes and infection: review of the epidemiology, mechanisms and principles of treatment

An association between diabetes and infection has been recognised for many years, with infection being an important cause of death and morbidity in people with diabetes. The COVID-19 pandemic has re-kindled an interest in the complex relationship between diabetes and infection. Some infections occur almost exclusively in people with diabetes, often with high mortality rates without early diagnosis and treatment. However, more commonly, diabetes is a complicating factor in many infections. A reciprocal relationship occurs whereby certain infections and their treatments may also increase the risk of diabetes. People with diabetes have a 1.5- to 4-fold increased risk of infection. The risks are the most pronounced for kidney infection, osteomyelitis and foot infection, but are also increased for pneumonia, influenza, tuberculosis, skin infection and general sepsis. Outcomes from infection are worse in people with diabetes, with the most notable example being a twofold higher rate of death from COVID-19. Hyperglycaemia has deleterious effects on the immune response. Vascular insufficiency and neuropathy, together with altered skin, mucosal and gut microbial colonisation, contribute to the increased risk of infection. Vaccination is important in people with diabetes although the efficacy of certain immunisations may be compromised, particularly in the presence of hyperglycaemia. The principles of treatment largely follow those of the general population with certain notable exceptions.

Causes, prevention, and management of diabetes-related foot ulcers

In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.

Recurrence of Diabetic Foot Complications: A Domino Effect Leading to Lethal Consequences-Insights From a National Longitudinal Study

Background

Foot complications are common in people with diabetes mellitus (DM), leading to increased health care utilization, heightened mortality risk, and notable recurrence rates even after treatment. This retrospective cohort study aimed to investigate the impact of repeated occurrence of DM-related foot complications on the risk of all-cause mortality and to identify the potential risk factors associated with repeated events.

Methods

People with DM admitted with foot complications (ulcer, skin and soft tissue infection, or osteomyelitis) from 2012 to 2014 were identified from Taiwan's National Health Insurance Research Database, with a 3-year follow-up for repeated events. We categorized the study subjects based on their cumulative number of hospital admissions with foot complications. Logistic regression was conducted to explore the potential risk factors associated with repeated diabetic foot events. Kaplan-Meier curves and Cox proportional hazard models were used to examine the associations between repeated diabetic foot events and all-cause mortality.

Results

In this study, 28 754 eligible individuals were enrolled and classified into 3 groups: no repeated diabetic foot events (76.1%), 1 repeated event (16.0%), and 2 or more repeated events (7.9%). Logistic regression revealed that advanced age, male sex, congestive heart failure, dyslipidemia, hypertension, nephropathy, retinopathy, neuropathy, peripheral vascular disease, diabetes-related preventable hospitalizations, and outpatient visits due to diabetic foot were significantly associated with repeated events of diabetic foot complications. Compared with those with no repeated events, the adjusted hazard ratios for all-cause mortality were 1.26 (95% CI, 1.19-1.34) for 1 repeated event and 1.36 (95% CI, 1.26-1.47) for 2 or more repeated events.

Conclusions

The significant association between repeated diabetic foot and elevated mortality risk highlights the critical necessity for proactive and targeted patient care within clinical practice. More research to delve into the predictive factors related to the repeated occurrence of diabetic foot is needed to provide additional insights for prevention strategies.

Level of and factors associated with foot self-care among people with diabetes in Idlib Province of Northwest Syria: A cross-sectional study

Background and aims

Diabetic foot and lower limb problems are among the most neglected complications during the Syrian armed conflict due to the absence of a functioning health infrastructure, including early detection and timely management of limb-threatening wounds. This study aimed to determine self-reported diabetes-related foot disease (DRFD), adherence to recommended foot self-care (FSC) practices, and associated factors among people with diabetes in war-torn Northwest Syria (NWS).

Methods

This was a cross-sectional study conducted at six primary care clinics in Idlib, NWS, between March 27 and April 17, 2022, utilizing the validated interviewer-administered Diabetes Foot Disease and Foot Care Questionnaire. Data on demographic characteristics, DRFD, and FSC practices were collected. FSC score was determined by adding the points from all 12 FSC items, with a maximum score of 48, and were categorized into very poor (≤12), poor (13-24), moderate (25-36), and good (37-48). A convenience sample of 331 consecutive Syrians, aged ≥18 years, with diabetes, were invited. Multiple linear regression was used to identify variables associated with FSC practices.

Results

A total of 328 patients completed the questionnaire (response rate: 99.1%). The overall FSC score was average (mean total score 27.24, SD 7.03). Over one-third (37.8%) had a very poor/poor score, 50.3% had an average score, and 11.9% had a good score. Household income/month of ≥51 USD (β = 2.6, 95% confidence interval [95% CI]:1.06-4.1, p = 0.001) and diabetes duration of ≥10 years (β = 1.8, 95% Cl: 0.2-3.4, p = 0.027) significantly predicted better FSC practice.

Conclusion

A significant proportion of participants had inadequate adoption FSC behaviors. Higher socioeconomic status was associated with better FSC practices. Future research should evaluate diabetic foot education and professional foot care in this population.

Exploring the Pathways of Diabetes Foot Complications Treatment and Investigating Experiences From Frontline Health Care Professionals: Protocol for a Mixed Methods Study

BACKGROUND

Diabetes affects more than 4.3 million individuals in the United Kingdom, with 19% to 34% developing diabetes-related foot ulceration (DFU) during their lifespan, which can lead to an amputation. In the United Kingdom, every week, approximately 169 people have an amputation due to diabetes. Preventing first-ever ulcers is the most effective strategy to reduce the occurrence of diabetes-related amputations, but research in this space is lacking.

OBJECTIVE

This protocol seeks to document the experiences and perspectives of frontline health care professionals who work with people who have diabetes and diabetes-related foot problems. Special attention is given to their perceptions of barriers to effective care, their views about barriers to effective and inclusive engagement with people with diabetes, and their experience with the first-ever DFU. Another aspect of the study is the focus on whether clinical management is affected by data sharing, data availability, and interoperability issues.

METHODS

This is a mixed methods explanatory protocol, which is sequential, and its purpose is to use the qualitative data to explain the initial quantitative data collected through a survey of frontline health care professionals. Data analysis of quantitative data will be completed first and then synthesized with the qualitative data analysis. Qualitative data will be analyzed using the framework method. This study will use joint displays to integrate the data. Ethical approval has been granted by the ethics committee of Staffordshire University.

RESULTS

The quantitative data collection started in March 2023 and will close in May 2024. The qualitative interviews commenced in November 2023 with volunteer participants who initially completed the survey.

CONCLUSIONS

This study's survey focuses on data interoperability and the interviews focus more on the perspectives and experiences of clinicians and their perceived barriers for the effective management of diabetes foot ulcers. Including a geographically relevant and diverse cohort of health care professionals that spans a wide range of roles and care settings involved in diabetes-related foot care is very important for the successful application of this protocol. Special care is given to advertise and promote participation as widely as possible. The qualitative part of this protocol is also limited to 30-40 interview participants, as it is not realistic to interview higher numbers, due to time and resource constraints.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54852.

The Combination of Vascular Endothelial Growth Factor A (VEGF-A) and Fibroblast Growth Factor 1 (FGF1) Modified mRNA Improves Wound Healing in Diabetic Mice: An Ex Vivo and In Vivo Investigation

BACKGROUND

Diabetic foot ulcers (DFU) pose a significant health risk in diabetic patients, with insufficient revascularization during wound healing being the primary cause. This study aimed to assess microvessel sprouting and wound healing capabilities using vascular endothelial growth factor (VEGF-A) and a modified fibroblast growth factor (FGF1).

METHODS

An ex vivo aortic ring rodent model and an in vivo wound healing model in diabetic mice were employed to evaluate the microvessel sprouting and wound healing capabilities of VEGF-A and a modified FGF1 both as monotherapies and in combination.

RESULTS

The combination of VEGF-A and FGF1 demonstrated increased vascular sprouting in the ex vivo mouse aortic ring model, and topical administration of a combination of VEGF-A and FGF1 mRNAs formulated in lipid nanoparticles (LNPs) in mouse skin wounds promoted faster wound closure and increased neovascularization seven days post-surgical wound creation. RNA-sequencing analysis of skin samples at day three post-wound creation revealed a strong transcriptional response of the wound healing process, with the combined treatment showing significant enrichment of genes linked to skin growth.

CONCLUSION

f-LNPs encapsulating VEGF-A and FGF1 mRNAs present a promising approach to improving the scarring process in DFU.

Exploring the Therapeutic Potential of Royal Jelly in Metabolic Disorders and Gastrointestinal Diseases

Metabolic disorders, encompassing diabetes mellitus, cardiovascular diseases, gastrointestinal disorders, etc., pose a substantial global health threat, with rising morbidity and mortality rates. Addressing these disorders is crucial, as conventional drugs often come with high costs and adverse effects. This review explores the potential of royal jelly (RJ), a natural bee product rich in bioactive components, as an alternative strategy for managing metabolic diseases. RJ exhibits diverse therapeutic properties, including antimicrobial, estrogen-like, anti-inflammatory, hypotensive, anticancer, and antioxidant effects. This review's focus is on investigating how RJ and its components impact conditions like diabetes mellitus, cardiovascular disease, and gastrointestinal illnesses. Evidence suggests that RJ serves as a complementary treatment for various health issues, notably demonstrating cholesterol- and glucose-lowering effects in diabetic rats. Specific RJ-derived metabolites, such as 10-hydroxy-2-decenoic acid (10-HDA), also known as the "Queen bee acid," show promise in reducing insulin resistance and hyperglycemia. Recent research highlights RJ's role in modulating immune responses, enhancing anti-inflammatory cytokines, and suppressing key inflammatory mediators. Despite these promising findings, further research is needed to comprehensively understand the mechanisms underlying RJ's therapeutic effects.

A Tunable Self-Offloading Module for Plantar Pressure Regulation in Diabetic Patients

Plantar pressure plays a crucial role in the pathogenesis of foot ulcers among patients with diabetes and peripheral polyneuropathy. Pressure relief is a key requirement for both the prevention and treatment of plantar ulcers. Conventional medical practice to enable such an action is usually realized by means of dedicated insoles and special footwear. Another technique for foot pressure offloading (not in medical practice) can be achieved by sensing/estimating the current state (pressure) and, accordingly, enabling a pressure release mechanism once a defined threshold is reached. Though these mechanisms can make plantar pressure monitoring and release possible, overall, they make shoes bulkier, power-dependent, and expensive. In this work, we present a passive and self-offloading alternative to keep plantar pressure within a defined safe limit. Our approach is based on the use of a permanent magnet, taking advantage of its non-linear field reduction with distance. The proposed solution is free from electronics and is a low-cost alternative for smart shoe development. The overall size of the device is 13 mm in diameter and 30 mm in height. The device allows more than 20-times the tunability of the threshold pressure limit, which makes it possible to pre-set the limit as low as 38 kPa and as high as 778 kPa, leading to tunability within a wide range. Being a passive, reliable, and low-cost alternative, the proposed solution could be useful in smart shoe development to prevent foot ulcer development. The proposed device provides an alternative for offloading plantar pressure that is free from the power feeding requirement. The presented study provides preliminary results for the development of a complete offloading shoe that could be useful for the prevention/care of foot ulcers among diabetic patients.

Development of a resource-use measure to capture costs of diabetic foot ulcers to the United Kingdom National Health Service, patients and society

Background

Diabetic foot ulcers (DFUs) add a significant burden to the lives of people with diabetes in the United Kingdom. They can have a considerable impact on a patient's daily life, with treatment requiring frequent changes of dressings and clinic attendances. Nurses and other allied health professionals (AHPs) within the community provide most wound care representing the primary cost driver.

Aims

To collaboratively explore key resource use related to the management of DFUs to develop, and pilot, a participant-reported measure to inform economic evaluations.

Methods

A literature search and semi-structured interviews determined health and non-health resource use in management of DFUs. A consensus view of the selected items was established in a modified Delphi study and further tested for acceptability and validity in a pilot study.

Results

Primary care consultations with a podiatrist or orthotist, district nurse visits, out-of-hours and emergency care, scans and investigations, and consumables provided in clinics were rated as the most important resource use items.

Conclusions

This work has informed the development of a measure that captures resource use considered important by the people most affected by DFUs; patients, family members and carers, and the healthcare professionals key to DFU management.

Risk factor analysis for diabetic foot ulcer-related amputation including Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio

Diabetic foot ulcer often leads to amputation, and both nutritional status and immune function have been associated with this process. We aimed to investigate the risk factors of diabetic ulcer-related amputation including the Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio biomarker. We evaluated data from hospital in patients with diabetic foot ulcer, performing univariate and multivariate analyses to screen for high-risk factors and Kaplan-Meier analysis to correlate high-risk factors with amputation-free survival. Overall, 389 patients underwent 247 amputations over the follow-up period. After correction to relevant variables, we identified five independent risk factors for diabetic ulcer-related amputation: ulcer severity, ulcer site, peripheral arterial disease, neutrophil-to-lymphocyte ratio and nutritional status. Amputation-free survival was lower for the moderate-to-severe versus mild cases, for the plantar forefoot versus hindfoot location, for the concomitant peripheral artery disease versus without and in the high versus low neutrophil-to-lymphocyte ratio (all p < 0.01). The results showed that ulcer severity (p < 0.01), ulcer site (p < 0.01), peripheral artery disease (p < 0.01), neutrophil-to-lymphocyte ratio (p < 0.01) and Controlling Nutritional Status score (p < 0.05) were independent risk factors for amputation in diabetic foot ulcer patients and have predictive values for diabetic foot ulcer progression to amputation.

Collaboration and Partnership in a 5-Level Engagement Framework for Diabetic Foot Ulcer Management: A Patient-oriented Scoping Review

OBJECTIVE

The management of diabetic foot ulcers (DFUs) is complex, and patient engagement is essential for DFU healing, but it often comes down to the patient's consultation. Therefore, we sought to document patients' engagement in terms of collaboration and partnership for DFUs in 5 levels (direct care, organizational, policy level, research, and education), as well as strategies for patient engagement using an adapted engagement framework.

METHODS

We conducted a scoping review of the literature from inception to April 2022 using the Joanna Briggs Institute method and a patient-oriented approach. We also consulted DFU stakeholders to obtain feedback on the findings. The data were extracted using PROGRESS+ factors for an equity lens. The effects of engagement were described using Bodenheimer's quadruple aims for value-based care.

RESULTS

Of 4,211 potentially eligible records, 15 studies met our eligibility criteria, including 214 patients involved in engagement initiatives. Most studies were recent (9 of 15 since 2020) and involved patient engagement at the direct medical care level (8 of 15). Self-management (7 of 15) was the principal way to clinically engage the patients. None of the studies sought to define the direct influence of patient engagement on health outcomes.

CONCLUSIONS

Very few studies described patients' characteristics. Engaged patients were typically men from high-income countries, in their 50s, with poorly managed type 2 diabetes. We found little rigorous research of patient engagement at all levels for DFUs. There is an urgent need to improve the reporting of research in this area and to engage a diversity of patients.

Effectiveness of continuous home wound care on wound healing, self-management behavior, and medical expenses of patients with diabetic foot ulcers

OBJECTIVE

To explore the effectiveness of continuous home wound care on wound healing, self-management behavior, and medical expenses of patients with diabetic foot ulcers.

MATERIALS AND METHODS

Patients were grouped by the campuses they were hospitalized. One group received home wound care, and the other one received outpatient wound care after their discharge. Non-inferiority testing was performed to compare ulcer healing. Their Diabetes-related Foot Ulcer Self-Management Behavior Scale (DFUSMBS) scores and medical expenses were compared.

RESULTS

Between October 2021 and December 2022, fifty-five patients in the home wound care group and fifty-two in the outpatient wound care group completed the study. The home wound care was non-inferior concerning ulcer complete healing rate in total or stratified by Wagner grade or baseline ulcer area. Concerning wound healing time, the home wound care group was inferior for Wagner Grade Ⅲ ulcers (hazard ratio = 0.7772, 95 % CI = 0.2799-2.1581). In contrast, for ulcers with baseline area>5 cm2, the home care group was non-inferior and even can be superior, although the superiority was not statistically significant (Log-rank X2 = 0.257, p = 0.612). Moreover, the home wound care group showed significant improvement concerning timely wound treatment (t = 23.045, p < 0.001, Cohen's d = 4.460, Effect Size = 0.912) and wound care behavior (t = 33.410, p < 0.001, Cohen's d = 6.454, Effect Size = 0.955), while that of diabetes self-management was not statistically significant (t = -0.673, p = 0.502, Cohen's d = 0.128, Effect Size = 0.064). The medium direct medical expense per capita of the patients in the outpatient care group was statistically significantly heavier than that of the home wound care group (Z = -6.877, p < 0.001).

CONCLUSION

The home wound care practice did not compromise ulcer healing, enhanced timely wound treatment and wound care behavior of the patients, and saved their medical expenses, hopefully providing a feasible wound care alternative with economic benefits for the physically and economically devastated patients.

Rational Design and Efficacy of Glucose-Responsive Insulin Therapeutics and Insulin Delivery Systems by Computation Using Connected Human and Rodent Models

Glucose-responsive insulins (GRIs) use plasma glucose levels in a diabetic patient to activate a specifically designed insulin analogue to a more potent state in real time. Alternatively, some GRI concepts use glucose-mediated release or injection of insulin into the bloodstream. GRIs hold promise to exhibit much improved pharmacological control of the plasma glucose concentration, particularly for the problem of therapeutically induced hypoglycemia. Several innovative GRI schemes are introduced into the literature, but there remains a dearth of quantitative analysis to aid the development and optimization of these constructs into effective therapeutics. This work evaluates several classes of GRIs that are proposed using a pharmacokinetic model as previously described, PAMERAH, simulating the glucoregulatory system of humans and rodents. GRI concepts are grouped into three mechanistic classes: 1) intrinsic GRIs, 2) glucose-responsive particles, and 3) glucose-responsive devices. Each class is analyzed for optimal designs that maintain glucose levels within the euglycemic range. These derived GRI parameter spaces are then compared between rodents and humans, providing the differences in clinical translation success for each candidate. This work demonstrates a computational framework to evaluate the potential clinical translatability of existing glucose-responsive systems, providing a useful approach for future GRI development.

Is the duration of diabetic foot ulcers an independent risk factor for developing diabetic foot osteomyelitis?

OBJECTIVE

This study aimed to determine whether the prolonged duration of diabetic foot ulcers was associated with an increased incidence of diabetic foot osteomyelitis.

STUDY DESIGN

A retrospective cohort study METHODS: The medical records of all patients who participated in the diabetic foot clinic between January 2015 and December 2020 were reviewed. Patients with new diabetic foot ulcers were monitored for diabetic foot osteomyelitis. The collected data included the patient's profile, comorbidities and complications, the ulcer profile (area, depth, location, duration, number of ulcers, inflammation, and history of the previous ulcer), and outcome. Univariate and multivariate Poisson regression analyses were used to assess risk variables for diabetic foot osteomyelitis.

RESULTS

Eight hundred and fifty-five patients were enrolled; 78 developed diabetic foot ulcers (cumulative incidence 9% over 6 years, average annual incidence 1.5%) and among these diabetic foot ulcers, 24 developed diabetic foot osteomyelitis (cumulative incidence 30% over 6 years, average annual incidence of 5%, incidence rate 0.1/person-year). Statistically significant risk factors for the development of diabetic foot osteomyelitis were ulcers that were deep to the bone (adjusted risk ratio 2.50, p = 0.04) and inflamed wounds (adjusted risk ratio 6.20, p = 0.02). The duration of diabetic foot ulcers was not associated with diabetic foot osteomyelitis (adjusted risk ratio 1.00, p = 0.98).

CONCLUSION

The duration was not an associated risk factor for diabetic foot osteomyelitis, while bone-deep ulcers and inflamed ulcers were found to be significant risk factors for the development of diabetic foot osteomyelitis.

Data-driven digital health technologies in the remote clinical care of diabetic foot ulcers: a scoping review

Background

The availability and effectiveness of Digital Health Technologies (DHTs) to support clinicians, empower patients, and generate economic savings for national healthcare systems are growing rapidly. Of particular promise is the capacity of DHTs to autonomously facilitate remote monitoring and treatment. Diabetic Foot Ulcers (DFUs) are characterised by high rates of infection, amputation, mortality, and healthcare costs. With clinical outcomes contingent on activities that can be readily monitored, DFUs present a promising focus for the application of remote DHTs.

Objective

This scoping review has been conducted as a first step toward ascertaining fthe data-related challenges and opportunities for the development of more comprehensive, integrated, and individualised sense/act DHTs. We review the latest developments in the application of DHTs to the remote care of DFUs. We cover the types of DHTs in development and their features, technological readiness, and scope of clinical testing.

Eligibility criteria

Only peer-reviewed original experimental and observational studies, case series and qualitative studies were included in literature searches. All reviews and manuscripts presenting pre-trial prototype technologies were excluded.

Methods

An initial search of three databases (Web of Science, MEDLINE, and Scopus) generated 1,925 English-language papers for screening. 388 papers were assessed as eligible for full-text screening by the review team. 81 manuscripts were found to meet the eligibility criteria.

Results

Only 19% of studies incorporated multiple DHTs. We categorised 56% of studies as 'Treatment-Manual', i.e. studies involving technologies aimed at treatment requiring manual data generation, and 26% as 'Prevention-Autonomous', i.e. studies of technologies generating data autonomously through wearable sensors aimed at ulcer prevention through patient behavioural change. Only 10% of studies involved more ambitious 'Treatment-Autonomous' interventions. We found that studies generally reported high levels of patient adherence and satisfaction.

Conclusions

Our findings point to a major potential role for DHTs in remote personalised medical management of DFUs. However, larger studies are required to assess their impact. Here, we see opportunities for developing much larger, more comprehensive, and integrated monitoring and decision support systems with the potential to address the disease in a more complete context by capturing and integrating data from multiple sources from subjective and objective measurements.

Impact of Second-Line Combination Treatment for Type 2 Diabetes Mellitus on Disease Control: A Population-Based Cohort Study

BACKGROUND

Type 2 diabetes mellitus is a chronic disease affecting millions of people worldwide. Achieving and maintaining glycemic control is essential to prevent or delay complications and different strategies are available as second-line treatment options for patients with type 2 diabetes who do not achieve glycemic control with metformin monotherapy.

OBJECTIVE

The aim of this work is to describe the impact of initiating a combination treatment to reduce glycated hemoglobin in patients with type 2 diabetes with insufficient glycemic control.

METHODS

We included patients with a type 2 diabetes diagnosis between 2015 and 2020 at the Information System for Research in Primary Care (SIDIAP) database in Catalonia, Spain. The primary outcome was the time to glycated hemoglobin control (≤ 7%) during the first 720 days, expressed as the restricted mean survival time. Adjusted differences of the restricted mean survival time were compared to analyze the performance of each treatment versus the combination with a sulfonylurea. Adherence was calculated as the medication possession ratio using an algorithm to model treatment exposure.

RESULTS

A total of 28,425 patients were analyzed. The most frequent combinations were those with sulfonylureas and dipeptidyl peptidase-4 inhibitors. All treatments reduced glycated hemoglobin and the restricted mean survival time for the sulfonylurea treatment was 455 (451-459) days although combinations with glucagon-like peptide-1 and insulin reached glycemic control earlier, - 126 days (- 152 to - 100, p < 0.001) and - 69 days (- 88 to - 50, p < 0.001), respectively. Adherence was high in all groups apart from the insulin combination and had a significant effect in reducing glycated hemoglobin except in sodium-glucose cotransporter type 2 inhibitors and insulin. Glucagon-like peptide-1 and sodium-glucose cotransporter type 2 inhibitors showed significant reductions in weight.

CONCLUSIONS

Patients achieved the glycated hemoglobin goal with second-line treatments. Glucagon-like peptide-1 and insulin combinations achieved the goal earlier than sulfonylurea combinations. Adherence significantly reduced the time to glycated hemoglobin control except for the combination with sodium-glucose cotransporter type 2 inhibitors.

Screening for the loss of protective sensation in people without a history of diabetic foot ulceration: validation of two simple tests in India

The ability of the Ipswich touch test (IpTT) and Vibratip^TM to detect loss of protective sensation (LOPS) was tested against a neurothesiometer in an outpatient diabetic population without a history for ulceration. Our results support the use of the IpTT as a screening tool for LOPS, but not of Vibratip^TM.

Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.

Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis

AIMS/HYPOTHESIS

This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020.

METHODS

Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated.

RESULTS

23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men.

CONCLUSIONS

Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.

Using Data to Improve the Management of Diabetes: The Tayside Experience

Tayside is a region in the East of Scotland and forms one of nine local government regions in the country. It is home to approximately 416,000 individuals who fall under the National Health Service (NHS) Tayside health board, which provides health care services to the population. In Tayside, Scotland, a comprehensive informatics network for diabetes care and research has been established for over 25 years. This has expanded more recently to a comprehensive Scotland-wide clinical care system, Scottish Care Information - Diabetes (SCI-Diabetes). This has enabled improved diabetes screening and integrated management of diabetic retinopathy, neuropathy, nephropathy, cardiovascular health, and other comorbidities. The regional health informatics network links all of these specialized services with comprehensive laboratory testing, prescribing records, general practitioner records, and hospitalization records. Not only do patients benefit from the seamless interconnectedness of these data, but also the Tayside bioresource has enabled considerable research opportunities and the creation of biobanks. In this article we describe how health informatics has been used to improve care of people with diabetes in Tayside and Scotland and, through anonymized data linkage, our understanding of the phenotypic and genotypic etiology of diabetes and associated complications and comorbidities.

Research priorities to prevent and treat diabetic foot ulcers-A digital James Lind Alliance Priority Setting Partnership

AIM

To establish outcomes of a priority setting partnership between participants with diabetes mellitus and clinicians to identify the top 10 research priorities for preventing and treating diabetic foot ulcers (DFUs).

METHODS

Due to the COVID-19 pandemic, the James Lind Alliance Priority Setting Partnership process was adapted into a digital format which involved a pilot survey to identify understandable uncertainties with high relevance for participants tested by calculating the content validity index; a main survey answered by 53 participants living with diabetes and 49 clinicians; and a final digital workshop to process and prioritise the final top 10 research priorities.

RESULTS

The content validity index was satisfactory for 20 out of 25 uncertainties followed by minor changes and one additional uncertainty. After we processed the 26 uncertainties from the main survey and seven current guidelines, a list of 28 research uncertainties remained for review and discussion in the digital workshop. The final top 10 research priorities included the organisation of diabetes care; screening of diabetes, impaired blood circulation, neuropathy, and skin properties; vascular surgical treatment; importance of self-care; help from significant others; pressure relief; and prevention of infection.

CONCLUSION

The top 10 research priorities for preventing and treating DFUs represent consensus areas from persons living with diabetes and clinicians to guide future research. These research priorities can justify and inform strategic allocation of research funding. The digitalisation of James Lind Alliance methodology was feasible.

Cohort profile: the Scottish Diabetes Research Network national diabetes cohort - a population-based cohort of people with diabetes in Scotland

PURPOSE

The Scottish Diabetes Research Network (SDRN)-diabetes research platform was established to combine disparate electronic health record data into research-ready linked datasets for diabetes research in Scotland. The resultant cohort, 'The SDRN-National Diabetes Dataset (SDRN-NDS)', has many uses, for example, understanding healthcare burden and socioeconomic trends in disease incidence and prevalence, observational pharmacoepidemiology studies and building prediction tools to support clinical decision making.

PARTICIPANTS

We estimate that >99% of those diagnosed with diabetes nationwide are captured into the research platform. Between 2006 and mid-2020, the cohort comprised 472 648 people alive with diabetes at any point in whom there were 4 million person-years of follow-up. Of the cohort, 88.1% had type 2 diabetes, 8.8% type 1 diabetes and 3.1% had other types (eg, secondary diabetes). Data are captured from all key clinical encounters for diabetes-related care, including diabetes clinic, primary care and podiatry and comprise clinical history and measurements with linkage to blood results, microbiology, prescribed and dispensed drug and devices, retinopathy screening, outpatient, day case and inpatient episodes, birth outcomes, cancer registry, renal registry and causes of death.

FINDINGS TO DATE

There have been >50 publications using the SDRN-NDS. Examples of recent key findings include analysis of the incidence and relative risks for COVID-19 infection, drug safety of insulin glargine and SGLT2 inhibitors, life expectancy estimates, evaluation of the impact of flash monitors on glycaemic control and diabetic ketoacidosis and time trend analysis showing that diabetic ketoacidosis (DKA) remains a major cause of death under age 50 years. The findings have been used to guide national diabetes strategy and influence national and international guidelines.

FUTURE PLANS

The comprehensive SDRN-NDS will continue to be used in future studies of diabetes epidemiology in the Scottish population. It will continue to be updated at least annually, with new data sources linked as they become available.

A review on contemporary nanomaterial-based therapeutics for the treatment of diabetic foot ulcers (DFUs) with special reference to the Indian scenario

Diabetes mellitus (DM) is a predominant chronic metabolic syndrome, resulting in various complications and high mortality associated with diabetic foot ulcers (DFUs). Approximately 15-30% of diabetic patients suffer from DFUs, which is expected to increase annually. The major challenges in treating DFUs are associated with wound infections, alterations to inflammatory responses, angiogenesis and lack of extracellular matrix (ECM) components. Furthermore, the lack of targeted therapy and efficient wound dressings for diabetic wounds often results in extended hospitalization and limb amputations. Hence, it is essential to develop and improve DFU-specific therapies. Nanomaterial-based innovative approaches have tremendous potential for preventing and treating wound infections of bacterial origin. They have greater benefits compared to traditional wound dressing approaches. In this approach, the physiochemical features of nanomaterials allow researchers to employ different methods for diabetic wound healing applications. In this review, the status and prevalence of diabetes mellitus (DM) and amputations due to DFUs in India, the pathophysiology of DFUs and their complications are discussed. Additionally, nanomaterial-based approaches such as the use of nanoemulsions, nanoparticles, nanoliposomes and nanofibers for the treatment of DFUs are studied. Besides, emerging therapeutics such as bioengineered skin substitutes and nanomaterial-based innovative approaches such as antibacterial hyperthermia therapy and gene therapy for the treatment of DFUs are highlighted. The present nanomaterial-based techniques provide a strong base for future therapeutic approaches for skin regeneration strategies in the treatment of diabetic wounds.

Mortality Risk Associated with Diabetic Foot Complications in People with or without History of Diabetic Foot Hospitalizations

The aim of this study was to evaluate the risk of death after hospitalizations for diabetic foot (DF) complications, comparing two different cohorts of people with or without a prior history of DF hospitalizations across the years 2011 to 2018 in Tuscany, Italy. The DF complications were categorized by administrative source datasets such as: amputations (both major and minor), gangrene, ulcers, infections, Charcot and revascularizations. A further aim was to present the trend over time of the first ever incidents of diabetic foot hospitalizations in Tuscany. The eight-year-mortality rate was higher in the cohort with prior hospitalizations (n = 6633; 59%) compared with the cohort with first incident DF hospitalizations (n = 5028; 44%). Amputations (especially major ones) and ulcers had the worst effect on survival in people without basal history of DF hospitalizations and respectively in those with a history of prior DF hospitalizations. In both cohorts, revascularization procedures, when compared to ulcers, were associated with a significantly reduced risk of mortality. The prevalence rate of minor amputations showed a slightly rising trend over time. This result agrees with the national trend. Conversely, the progressive increase over time of revascularizations, associated with the fractional decrease in the rate of gangrene, suggests a trend for more proactive behavior by DF care teams in Tuscany.

Three Nutritional Indices Are Effective Predictors of Mortality in Patients With Type 2 Diabetes and Foot Ulcers

Introduction

Malnutrition has been associated with mortality in various diseases. This retrospective cohort study aimed to investigate the relationship between three nutritional indices and all-cause mortality in patients with diabetic foot ulcers (DFUs).

Materials and Methods

A total of 771 patients diagnosed with DFUs in the First Affiliated Hospital of Wenzhou Medical University from 2015 to 2019 were included in this retrospective cohort study. Patients were classified as high nutritional risk groups or low nutritional risk groups according to the optimal cut-off values of the geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), and controlling nutritional status (CONUT), respectively. The associations of three nutritional indices with all-cause mortality were evaluated by multivariable Cox regression analyses.

Results

Log-rank tests indicated that patients with high nutritional risk had lower overall survival rates (all p < 0.001). The multivariable Cox regression revealed that low GNRI (adjusted HR 2.01, 95% CI: 1.37–2.96, P < 0.001), low PNI (adjusted HR 2.04, 95% CI: 1.29–3.23, P = 0.002) and high CONUT (adjusted HRs 1.54, 95% CI: 1.07–2.23, P = 0.021) were independently associated with high all-cause mortality. In subgroup analyses, only GNRI predicted higher all-cause mortality in patients with severe DFUs, while all of the three indices persisted as independent prognostic factors in patients with no severe DFUs.

Discussion

The present study demonstrated that three nutritional indices were effective predictors of all-cause mortality in patients with DFUs. Routine screening for malnutrition using any of the three nutritional indices might be a simple and effective way to identify high-risk patients with DFUs. GNRI can be used as an independent prognostic indicator in patients with severe DFUs.

A comprehensive review of methods based on deep learning for diabetes-related foot ulcers

BACKGROUND

Diabetes mellitus (DM) is a chronic disease with hyperglycemia. If not treated in time, it may lead to lower limb amputation. At the initial stage, the detection of diabetes-related foot ulcer (DFU) is very difficult. Deep learning has demonstrated state-of-the-art performance in various fields and has been used to analyze images of DFUs.

OBJECTIVE

This article reviewed current applications of deep learning to the early detection of DFU to avoid limb amputation or infection.

METHODS

Relevant literature on deep learning models, including in the classification, object detection, and semantic segmentation for images of DFU, published during the past 10 years, were analyzed.

RESULTS

Currently, the primary uses of deep learning in early DFU detection are related to different algorithms. For classification tasks, improved classification models were all based on convolutional neural networks (CNNs). The model with parallel convolutional layers based on GoogLeNet and the ensemble model outperformed the other models in classification accuracy. For object detection tasks, the models were based on architectures such as faster R-CNN, You-Only-Look-Once (YOLO) v3, YOLO v5, or EfficientDet. The refinements on YOLO v3 models achieved an accuracy of 91.95% and the model with an adaptive faster R-CNN architecture achieved a mean average precision (mAP) of 91.4%, which outperformed the other models. For semantic segmentation tasks, the models were based on architectures such as fully convolutional networks (FCNs), U-Net, V-Net, or SegNet. The model with U-Net outperformed the other models with an accuracy of 94.96%. Taking segmentation tasks as an example, the models were based on architectures such as mask R-CNN. The model with mask R-CNN obtained a precision value of 0.8632 and a mAP of 0.5084.

CONCLUSION

Although current research is promising in the ability of deep learning to improve a patient's quality of life, further research is required to better understand the mechanisms of deep learning for DFUs.

Nutritional Interventions May Improve Outcomes of Patients Operated on for Diabetic Foot Infections: A Single-Center Case-Control Study

AIM

While a patient's nutritional status is known to generally have a role in postoperative wound healing, there is little information on its role as therapy in the multifaceted problem of diabetic foot infections (DFIs).

METHODS

We assessed this issue by conducting a retrospective case-control cohort study using a multivariate Cox regression model. The nutrition status of the DFI patients was assessed by professional nutritionists, who also orchestrated the nutritional intervention (counselling, composition of the intrahospital food) during hospitalization.

RESULTS

Among 1,013 DFI episodes in 586 patients (median age 67 years; 882 with osteomyelitis), 191 (19%) received a professional assessment of their nutrition accompanied by between 1 and 6 nutritional interventions. DFI cases who had professional nutritionists' interventions had a significantly shorter hospital stay, had shorter antibiotic therapies, and tended to fewer surgical debridements. By multivariate analysis, episodes with low Nutritional Risk Status- (NRS-) Scores 1-3 were associated with significantly lower failure rates after therapy for DFI (Cox regression analysis; hazard ratio 0.2, 95% confidence interval 0.1-0.7).

CONCLUSIONS

In this retrospective cohort study, DFI episodes with low NRS-Score were associated with lower rates of clinical failure after DFI treatment, while nutritional interventions improved the outcome of DFI. We need prospective interventional trials for this treatment, and these are underway.