Wound, Ischemia, Foot Infection (Wifi) Classification System And Its Predictive Ability Concerning Amputation-Free Survival, Mortality And Major Limb Amputation In A Portuguese Population: A Single Center Experience

INTRODUCTION

Commonly used chronic limb-threatening ischemia (CLTI) classifications lack granularity and detail to precisely stratify patients according to risk of limb loss, expected revascularization benefit and mortality. The aim of this study is to evaluate in a Portuguese population the prognostic value of an updated CLTI classification based on Wound, Ischemia, and foot Infection (WIfI) proposed by the Society for Vascular Surgery.

MATERIALS AND METHODS

Single-center retrospective evaluation of prospectively collected data of consecutive patients with CLTI submitted to lower limb revascularization from January to December of 2017. All consecutive patients with chronic peripheral artery disease with ischemic rest pain or tissue loss were included. The exclusion criteria were patients with intermittent claudication, vascular trauma, acute ischemia, non-atherosclerotic arterial disease and isolated iliac intervention. The primary end-point was major limb amputation, mortality and amputation-free survival (AFS) at 30 days, 1 year and 2 year follow-up. Secondary end-points were minor amputation, wound healing time (WHT) and rate (WHR).

RESULTS

A total of 111 patients with CLTI were submitted to infra-inguinal revascularization: 91 endovascular and 20 open surgery. After categorizing them according to the WIfI: 20 had stage 1 (18.52%), 29 stage 2 (26.85%), 38 stage 3 (35.19%) and 21 stage 4 (19.44%). Overall mortality rate was 1.8%, 17% and 22.3% at 30 days, 1 year and 2 years follow-up. Major amputation rate was 0.9%, 2.7% and 2.7% at 30 days, 1 year and 2 years follow-up. AFS rate was 97.3%, 82.1%, and 76.8% at 30 days, 1 year, 2 years follow-up. In multi-variable analysis, higher WIfI score was the only predictive factor for mortality and AFS. WIfI 3 and 4 were also associated with increased risk of non-healing ulcer.

CONCLUSION

This study proved the prognostic value of the WIfI classification in a Portuguese population by showing an association between higher scores and increased mortality, lower AFS and non-healing ulcer.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

[Development of a Diabetic Foot Ulceration Prediction Model and Nomogram]

PURPOSE

This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM).

METHODS

This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients' electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow-Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples.

RESULTS

The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ² = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years.

CONCLUSION

The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.

Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic

BACKGROUND

Along with significant case transmission, hospitalizations, and mortality experienced during the global Sars-CoV-2 (COVID-19) pandemic, there existed a disruption in the delivery of health care across multiple specialties. We studied the effect of the pandemic on inpatients with diabetic foot problems in a level-one trauma center in Central Ohio.

METHODS

A retrospective chart review of patients necessitating a consultation by the foot and ankle surgery service were reviewed from the first 8 months of 2020. A total of 270 patients met the inclusion criteria and divided into pre-pandemic (n = 120) and pandemic groups (n = 150). Demographics, medical history, severity of current infection, and medical or surgical management were collected and analyzed.

RESULTS

The odds of undergoing any level of amputation was 10.8 times higher during the pandemic versus before the pandemic. The risk of major amputations (below-the-knee or higher) likewise increased with an odds ratio of 12.5 among all patients in the foot and ankle service during the pandemic. Of the patients undergoing any amputation, the odds for receiving a major amputation was 3.1 times higher than before the pandemic. Additionally, the severity of infections increased during the pandemic and a larger proportion of the cases were classified as emergent in the pandemic group compared to the pre-pandemic group.

CONCLUSIONS

The effect of the pandemic on the health-care system has had a deleterious effect on people with diabetes-related foot problems resulting in more severe infections, more emergencies, and necessitating more amputations. When an amputation was performed, the likelihood it was a major amputation also increased.Editor's Note: This Original Article accompanies "Diabetes-Related Amputations: A Pandemic within a Pandemic," by Lee C. Rogers, DPM, Robert J. Snyder, DPM, and Warren S. Joseph, DPM, FIDSA, available at https://doi.org/10.7547/20-248.

Diagnosis and treatment of necrotising otitis externa and diabetic foot osteomyelitis - similarities and differences

OBJECTIVE

Necrotising otitis externa is a severe inflammatory process affecting soft tissue and bone, mostly in diabetic patients. Diabetic patients are also at risk of diabetic foot osteomyelitis, another inflammatory condition involving soft tissue and bone. This review aimed to describe the similarities and differences of these entities in an attempt to further advance the management of necrotising otitis externa.

METHOD

A PubMed search was conducted using the key words 'otitis externa', 'necrotising otitis externa', 'malignant otitis externa', 'osteomyelitis' and 'diabetic foot'.Results and conclusionThe similarities regarding patient population and pathophysiology between necrotising otitis externa and diabetic foot osteomyelitis raise basic questions concerning the effects of long-standing diabetes on the external ear. The concordance between local swabs and bone cultures in diabetic foot osteomyelitis is less than 50 per cent. If this holds true also to necrotising otitis externa, the role of deep tissue cultures should be strongly considered. Similar to diabetic foot osteomyelitis, magnetic resonance imaging should be considered in selected necrotising otitis externa subgroups.

Factors Affecting Length of Hospital Stay and Mortality in Infected Diabetic Foot Ulcers Undergoing Surgical Drainage without Major Amputation

This study aimed to investigate factors affecting length of hospital stay and mortality of a specific group of patients with infected diabetic foot ulcer who underwent surgical drainage without major amputation, which is frequently encountered by orthopedic surgeons. Data on length of hospital stay, mortality, demographics, and other medical information were collected for 79 consecutive patients (60 men, 19 women; mean age, 66.1 [SD, 12.3] yr) with infected diabetic foot ulcer who underwent surgical drainage while retaining the heel between October 2003 and May 2013. Multiple linear regression analysis was performed to determine factors affecting length of hospital stay, while multiple Cox regression analysis was conducted to assess factors contributing to mortality. Erythrocyte sedimentation rate (ESR, P=0.034), glycated hemoglobin (HbA1c) level (P=0.021), body mass index (BMI, P=0.001), and major vascular disease (cerebrovascular accident or coronary artery disease, P=0.004) were significant factors affecting length of hospital stay, whereas age (P=0.005) and serum blood urea nitrogen (BUN) level (P=0.024) were significant factors contributing to mortality. In conclusion, as prognostic factors, the length of hospital stay was affected by the severity of inflammation, the recent control of blood glucose level, BMI, and major vascular disease, whereas patient mortality was affected by age and renal function in patients with infected diabetic foot ulcer undergoing surgical drainage and antibiotic treatment.

Quantification of the differential expression levels of microRNA-203 in different degrees of diabetic foot

BACKGROUND

As a common and important complication of diabetes, foot ulcers are characterized by high incidence, poor prognosis and variation in the clinical presentation. The current methods for classification of the diabetic foot are many, but few of them are validated owing to the lack of specific and accurate laboratory index. Thus, the development of new bio-markers to assess and manage diabetic foot is of high importance.

METHODS

46 patients who had undergone wound repairing operation were included in this study and skin tissue samples around the ulcers were collected during the operation. In accordance with The Wound Score of Strauss, all subjects were divided into four groups, such as normal skins group, healthy wounds group, problem wounds group and futile wounds group, and respectively, there are 6, 4, 22, 14 individuals in each group. For each group, we assessed the expression profile of microRNAs (miRNAs) in each skin tissue sample by TaqMan probe-based qRT-PCR assay.

RESULT

Skin-enriched microRNA-203 (miR-203) was readily detected in skin tissue samples, and, in contrast to normal skin tissue, samples from patient with diabetic foot ulcers significantly have a higher expression level in miR-203. Moreover, our study demonstrated the first time that expression profile of miR-203 was positively correlated with the severity of diabetic foot ulcers. Compared with other parameters in wound scoring systems for the assessment of severity of diabetic foot ulcers, the determination for miR-203 was more accurate and validated.

CONCLUSION

Our results demonstrated that expression profile of miR-203 in diabetic foot had a positive correlation with the severity of diabetic foot ulcers, which indicated that miR-203 can be served as a new, accurate and validated bio-marker for evaluating the severity of diabetic foot ulcers in clinic. The significant finding of the study: Quantification of miR-203 in different degrees of diabetic foot. This study adds a new bio-marker for evaluation and management of diabetic foot.