Comparative Doppler Ultrasound Findings of Foot Arteries in Patients with Type 2 Diabetes Mellitus and Normoglycaemic Patients

The Value of Pressure Indexes in Predicting the Outcome of Diabetic Foot Ulcers as a Guide to Further Management

INTRODUCTION

Diabetic foot ulcers (DFUs) stand out as a prevalent and debilitating condition. Furthermore, the progression of diabetes-related hyperglycemia and associated conditions such as peripheral arterial disease exacerbates the risks of DFUs, including complications like infection and gangrene. Given the significant burden of DFUs, there is a pressing need to improve preventive and therapeutic strategies. This study investigates the clinical profiles of patients with DFUs, including the importance of smoking and intermittent claudication, evaluates management strategies based on the vascular status assessed through Doppler scans, and provides insights into the importance of ankle-brachial pressure index (ABPI) and toe brachial index (TBI) values, which play a vital role in predicting and managing ulcer healing outcomes, highlighting the importance of vascular assessment in treatment planning.

AIM

The study aims to assess the clinical profile of patients with DFUs based on their vascularity status using Doppler scans, predict the outcome of the ulcer using indexes like ABPI and TBI values, and decide on further management.

MATERIALS AND METHODS

This prospective study was conducted over 24 months, from August 2022 to July 2024, at the Department of General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. The study included 50 patients presenting with DFUs. Approval was obtained from the Institutional Ethics Committee, and informed consent was obtained from all participants. A detailed history was taken, including the history of smoking and intermittent claudication, and a thorough examination of the ulcer was performed. HbA1c levels were measured, Doppler scans of the lower limbs were done, and the ABPI and TBI values were calculated. Management strategies were determined based on the assessed vascular status, leading to either medical or surgical interventions.

RESULTS

Twenty-one (42%) patients who presented with DFUs had a positive history of intermittent claudication, demonstrating a significant association between the history of intermittent claudication and the Doppler findings. Thirty-seven (74%) patients gave a positive history of smoking, which revealed a significant association between the history of smoking and Doppler findings. Thirty-eight (76%) patients had an ABPI of <0.9, out of which 33 (66%) patients showed an improved outcome of the ulcer after necessary management. There is also a statistically significant association between the ABPI and Doppler findings. Sixteen (32%) of patients had a TBI of <0.65, of which all showed an improvement. There is a highly significant association between TBI and the Doppler findings.

CONCLUSION

This study concludes that integrated routine assessment of ABPI and TBI into DFU management protocols is necessary to guide treatment decisions and monitor response to therapy. Treatment and prevention of diabetes-related complications affecting the lower extremities require a dedicated interdisciplinary approach.

Diabetic Foot Complications in Saudi Arabia: A Retrospective Study

REVIEW

A common chronic health problem among Saudi Arabians is diabetes mellitus (DM). One of the most serious complications of diabetes is diabetic foot (DMF).

AIM

The objective of this study was to identify the most common complications that develop among patients with DMF. In addition, we conducted a demographic analysis of chronic diabetic complications related to DMF.

MATERIAL AND METHODS

The study involved 100 DMF attending the Jeddah clinic of Dr Soliman Fakeeh Hospital. Several chronic complications associated with DMF were reported, including peripheral arterial disease (PAD), coronary artery disease (CAD), retinopathy, nephropathy, and neuropathy. We examined the feet for ulcers, gangrene, amputations, bone deformities, Charcot joints, osteoarthritis, septic arthritis, and osteomyelitis. By using B-mode ultrasound and spectral Doppler imaging, we imaged the posterior tibial and anterior tibial arteries.

RESULTS

People with poorly controlled diabetes mellitus type 2 (T2DM) are more likely to develop diabetic feet. The most common foot complications were foot ulcers (81%), foot amputations (31%), foot gangrene (29%) (29/100), bone deformities (22%) (22/100), ingrown toenails (17%) (17/100), Charcot's foot (10%) (10/100), and calluses (9%) (9/100). The majority of the patients suffered from hypertension and half had anaemia. Diabetic peripheral neuropathy affected about half of the patients, diabetic nephropathy affected one-third, and diabetic retinopathy affected 14%. Approximately a quarter (25/100) of the patients had CAD and less than half had PAD. There was atherosclerosis in 43% (43/100) of popliteal/infra-popliteal arteries. Twenty-two percent (22/100) of the anterior tibial arteries and 25% (25/100) of the posterior tibial arteries were stenotic or occluded. A biphasic mode was observed in 21% (21/100) of anterior tibial arteries, a monophasic mode in 9% (9/100), and a non-flowing mode in 3% (3/100). Twenty-three percent (23/100) of the posterior tibial arteries displayed biphasic Doppler modes, 5% (5/100) displayed monophasic modes, and 6% (6/100) displayed non-flowing modes. Conclusion: Diabetes foot is common among older males with poorly controlled T2DM. The most common foot complications were amputations, gangrene, foot ulcers, bone deformities, ingrown toenails, Charcot's foot, and calluses. Most DMF patients were anemic and hypertensive. Diabetes-related microvascular complications, such as diabetic peripheral neuropathy, nephropathy, and retinopathy, as well as macrovascular complications, such as coronary artery disease and peripheral arterial disease, were associated with DMF.

Diabetic Plantar Foot Segmentation in Active Thermography Using a Two-Stage Adaptive Gamma Transform and a Deep Neural Network

Pathological conditions in diabetic feet cause surface temperature variations, which can be captured quantitatively using infrared thermography. Thermal images captured during recovery of diabetic feet after active cooling may reveal richer information than those from passive thermography, but diseased foot regions may exhibit very small temperature differences compared with the surrounding area, complicating plantar foot segmentation in such cold-stressed active thermography. In this study, we investigate new plantar foot segmentation methods for thermal images obtained via cold-stressed active thermography without the complementary information from color or depth channels. To better deal with the temporal variations in thermal image contrast when planar feet are recovering from cold immersion, we propose an image pre-processing method using a two-stage adaptive gamma transform to alleviate the impact of such contrast variations. To improve upon existing deep neural networks for segmenting planar feet from cold-stressed infrared thermograms, a new deep neural network, the Plantar Foot Segmentation Network (PFSNet), is proposed to better extract foot contours. It combines the fundamental U-shaped network structure, a multi-scale feature extraction module, and a convolutional block attention module with a feature fusion network. The PFSNet, in combination with the two-stage adaptive gamma transform, outperforms multiple existing deep neural networks in plantar foot segmentation for single-channel infrared images from cold-stressed infrared thermography, achieving an accuracy of 97.3% and 95.4% as measured by Intersection over Union (IOU) and Dice Similarity Coefficient (DSC) respectively.