Active Diabetic Foot Ulcer Research Articles

6909 Mortality and Readmission Rates for Inpatients with Diabetic Foot Ulcer in a Tertiary, Urban Medical Center: A Five-Year Retrospective Review

Abstract Disclosure: A. Herrera Chancay: None. R. Lopez Fanas: None. H. Tabassum: None. J. Daily: None. A. Myers: None. Background: Diabetic Foot Ulcer (DFU) is a severe complication of diabetes mellitus and is associated with high rates of morbidity and mortality. The incidence of DFUs and amputation disproportionately impact Black and Hispanic populations. DFU is also associated with a high rate of hospital readmissions and prolonged length of stay (LOS). The goal of this study was to examine 1-year mortality data, LOS and readmission rate. Methods: This study was a retrospective chart review of 1348 patients admitted to three hospitals in our system in the Bronx from 6/1/16 to 5/31/21. Data was extracted from the EPIC® electronic health records, based on the diagnoses ICD 10 codes, E10.621 and E11.622. Inclusion criteria was patients admitted with an active DFU regardless of other admission diagnosis, age 18 years or above. The index admission was defined as the first admission in our medical records within the date range. Patients were excluded if their index admission was not accessible through our EMR. Simple logistic regression and multiple logistic regression were used to analyze the association between variables of interest and mortality at index admission and at 1-year, LOS and re admissions. Results: Of the 650 eligible patients, the mean age was 59 + 13 years, 70% of patients were male, and majority were non-White (88%). Mortality was 1% during the index admission and the risk increased to 6% at 1 year after the index admission. Readmission with an active DFU from the index admission occurred in 15% of patients within 30-days, 32% of patients within 90 days, and 55% of patients within 1 year. The mean length of stay was 9 +7.5 days. Discussion: Our study in an urban region has identified high rates of mortality and costs associated with DFU, which has been reported in many settings. This patient population is high risk for poor outcomes and targeted programs are needed to reduce mortality and provide care to reduce readmissions. Future studies that explore the challenges of DFU health care and that test interventions are needed to improve DFU related health outcomes. Presentation: 6/2/2024

Foot self-care behaviour in primary care patients with diabetic foot ulcers: Structural equation modelling of psychological predictors.

Diabetic foot ulcers (DFUs) are one of the most prevalent and costly diabetes complications, associated with diminished quality of life and poor prognosis. Management of DFUs relies heavily on patients' foot self-care behaviour. This study aims to explore psychological determinants of this important behaviour among primary care patients. A total of 186 patients with active DFUs self-reported their illness perception, diabetes distress, self-efficacy, and foot self-care behaviour. Structural equation modelling was performed to examine interrelationships among measured variables. The final model demonstrated satisfactory fit, CFI = 0.933, TLI = 0.913, RMSEA = 0.050, SRMR = 0.073, χ2(95) = 132.256 (p = 0.004), and explained 51.1% of the variance of foot self-care. Illness threat perceptions (i.e., consequence, timeline, identity, concern, and emotion) had a direct positive effect on foot self-care behaviours, but also indirectly decreased foot self-care through increasing diabetes distress. Control perceptions (i.e., personal control, treatment control, and coherence) were not directly associated with foot self-care behaviours, but indirectly improved foot self-care by reducing diabetes distress and increasing foot care confidence. These findings suggest illness perceptions, diabetes distress, and self-care confidence as modifiable predictors to be targeted in self-management interventions for patients with DFUs.

Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome.

The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.

Protocol for metadata and image collection at diabetic foot ulcer clinics: enabling research in wound analytics and deep learning

BackgroundThe escalating impact of diabetes and its complications, including diabetic foot ulcers (DFUs), presents global challenges in quality of life, economics, and resources, affecting around half a billion people. DFU healing is hindered by hyperglycemia-related issues and diverse diabetes-related physiological changes, necessitating ongoing personalized care. Artificial intelligence and clinical research strive to address these challenges by facilitating early detection and efficient treatments despite resource constraints. This study establishes a standardized framework for DFU data collection, introducing a dedicated case report form, a comprehensive dataset named Zivot with patient population clinical feature breakdowns and a baseline for DFU detection using this dataset and a UNet architecture.ResultsFollowing this protocol, we created the Zivot dataset consisting of 269 patients with active DFUs, and about 3700 RGB images and corresponding thermal and depth maps for the DFUs. The effectiveness of collecting a consistent and clean dataset was demonstrated using a bounding box prediction deep learning network that was constructed with EfficientNet as the feature extractor and UNet architecture. The network was trained on the Zivot dataset, and the evaluation metrics showed promising values of 0.79 and 0.86 for F1-score and mAP segmentation metrics.ConclusionsThis work and the Zivot database offer a foundation for further exploration of holistic and multimodal approaches to DFU research.

Can Weight Bearing Aerobic Exercise be Done Safely with an Active Diabetic Plantar Foot Ulcer and Can It Improve Healing Time

Introduction Diabetic foot ulcer (DFU) is a huge economic burden on the National Health Service (NHS). Research on the benefits of aerobic exercise on the vascular system in diabetics is vast, however research on the benefits of aerobic exercise on diabetics with active plantar DFU is slim. The purpose of this review is to determine whether weight bearing aerobic exercise can be safely undertaken with an active plantar DFU and whether exercise can in fact improve ulcer healing time. Method Five papers that included patients with active DFU taking part in weight bearing or semi weight bearing aerobic exercise programmes >10-weeks were found and reviewed. Findings Non-weight-bearing or semi-weight bearing exercise in the presence of DFU alongside severe diabetic neuropathy (DN) is safer and more feasible in the aim to try and stop the regression of diabetic complications. It has not been concluded whether aerobic exercise improves ulcer healing time. Proposal A pre-test, post-test randomized controlled trial (RCT), 30 participants (15 male, 15 female) with type 2 diabetics (T2D) and active plantar DFU, recruited from the Peter Mount Diabetes and Endocrine clinic at the Manchester Royal Infirmary, randomized into an evenly split intervention group/control group. Intervention group will take part in fully supervised 12-week semi weight bearing aerobic/resistance-based exercise programme: 3×per week working at 40-60% heart rate reserve (HRR) (Karvonen method) at the rehabilitation gym, Manchester Royal Infirmary (MRI). Participants will wear a removable air cast walker or equivalent. Monthly motivational interviewing and bi-weekly foot checks will be undertaken. Control group will continue usual wound care plan from the diabetic clinic. Outcome Measures: Baseline, 6, 12-weeks: transparent ruler measurement, toe brachial pressure index (TBPI) toe pressures, SPO2 , ankle brachial index (ABI), fasting blood glucose (FBG), blood cholesterol levels, Semmes monofilament test, blood pressure (BP), body mass index (BMI). Statistically analysed by statistical package for social sciences (SPSS) version 28 at p<0.05.

Diagnostic Performance of Ultrasonography for Diabetic Foot Osteomyelitis.

Objective: This study aims to analyze the potential diagnostic capability of ultrasonography (US) in detecting diabetic foot osteomyelitis (DFO) in patients with diabetic foot ulcers (DFUs). Approach: A 1-year prospective study was conducted on 47 consecutive patients with active DFUs and suspicion of DFO at a specialized diabetic foot unit. The following ultrasonographic features were evaluated at baseline: (1) periosteal reaction; (2) periosteal elevation; (3) cortical disruption; (4) sequestrum; and (5) positive power Doppler. The primary outcome measure aimed to establish the effectiveness of ultrasonographic features compared with aseptic bone culture for diagnosing DFO. Receiver operating characteristic (ROC) curves were utilized to evaluate the diagnostic performance of ultrasonographic features. Sample size could not be determined as it is the first study to assess ultrasonographic features for the diagnosis of DFO. The research adhered to the guidelines for diagnostic accuracy studies (Standards for Reporting of Diagnostic Accuracy Studies [STARD] 2015). Results: All patients (n = 24) diagnosed with DFO exhibited positive power Doppler, resulting in a sensitivity (S) and specificity (SP) of 1 and an area under the curve (AUC) of 1 (p < 0.001 [1-1]). Cortical disruption was present in 23 patients (95.8%) with DFO, yielding an S of 0.93, SP of 1, and AUC of 0.96 (p < 0.001 [0.88-1]). Innovation: It validates the diagnostic value of US for DFO as it is the first and largest study of its kind to establish a clear reference standard to guide clinician decision-making. Conclusion: This study demonstrates the effectiveness of cortical disruption and positive power Doppler in assessing DFO through US.

A qualitative exploration of adherence to wearing removable cast walkers in patients with diabetic foot ulcers

Objective: To explore adherence to wearing removable cast walkers (RCWs) among patients with diabetic foot ulcers (DFUs). Method: A qualitative study was conducted by interviewing patients with active DFUs and using knee-high RCWs as their offloading treatment. The interviews were undertaken at two diabetic foot clinics in Jordan, using a semi-structured guide. Data were analysed through content analysis by developing main themes and categories. Results: Following interviews with 10 patients, two main key themes with a total of six categories were identified: theme 1—reporting of adherence levels was inconsistent, included two categories: i) a belief in achieving optimal adherence, and ii) non-adherence was often reported indoors; and theme 2—adherence was a consequence of multiple psychosocial, physiological and environmental factors, which included four categories: i) specific offloading knowledge or beliefs influenced adherence; ii) severity of foot disease influenced adherence; iii) social support benefitted adherence; and iv) physical features of RCWs (the usability of the offloading device) impacted adherence. Conclusion: Patients with active DFUs reported inconsistent levels of adherence to wearing RCWs which, after deeper investigation, seemed to be due to participants' misperceptions of the optimal adherence. Adherence to wearing RCWs also seemed to be impacted by multiple psychosocial, physiological and environmental factors.

Exploring barriers and enablers of self-management behaviours in patients with diabetic foot ulcers: A qualitative study from the perceptions of patients, caregivers, and healthcare professionals in primary care.

Exploring barriers and enablers of self-management behaviours in patients with diabetic foot ulcers: A qualitative study from the perceptions of patients, caregivers, and healthcare professionals in primary care.

Patients' Perceptions of Reasons Contributing to Delay in Seeking Help at the Onset of a Diabetic Foot Ulcer: A Grounded Theory Study.

The purpose of this study was to explore patients' perception of reasons contributing to delay in seeking help and referral to a wound care specialist at the onset of a diabetic foot ulcer (DFU). Constructivist grounded theory study. The sample comprised 30 individuals with active DFU attending a wound care clinic in southeastern Ontario, Canada. Participants were selected through purposive and theoretical sampling. Semistructured interviews were conducted with participants until no new properties of the patterns emerged. All interviews were transcribed, coded, and analyzed using methods informed by constructivist grounded theory. The reasons contributing to delay to seek help and referral to a wound care specialist were (1) limited knowledge about foot care, (2) unaware of diabetic foot problems, (3) underestimation of ulcer presentation, (4) I thought I could fix it myself, (5) inaccurate diagnosis, and (6) trial and error approach by a nonspecialized wound care provider. Study findings suggest that patients and primary healthcare providers need additional education regarding the management of diabetic foot disease and DFU.

The Use of Point-of-Care Bacterial Autofluorescence Imaging in the Management of Diabetic Foot Ulcers: A Pilot Randomized Controlled Trial.

To estimate comparative healing rates and decision-making associated with the use of bacterial autofluorescence imaging in the management of diabetic foot ulcers (DFUs). This is a single-center (multidisciplinary outpatient clinic), prospective pilot, randomized controlled trial (RCT) in patients with an active DFU and no suspected clinical infection. Consenting patients were randomly assigned 1:1 to either treatment as usual informed by autofluorescence imaging (intervention), or treatment as usual alone (control). The primary outcome was the proportion of ulcers healed at 12 weeks by blinded assessment. Secondary outcomes included wound area reduction at 4 and 12 weeks, patient quality of life, and change in management decisions after autofluorescence imaging. Between November 2017 and November 2019, 56 patients were randomly assigned to the control or intervention group. The proportion of ulcers healed at 12 weeks in the autofluorescence arm was 45% (n = 13 of 29) vs. 22% (n = 6 of 27) in the control arm. Wound area reduction was 40.4% (autofluorescence) vs. 38.6% (control) at 4 weeks and 91.3% (autofluorescence) vs. 72.8% (control) at 12 weeks. Wound debridement was the most common intervention in wounds with positive autofluorescence imaging. There was a stepwise trend in healing favoring those with negative autofluorescence imaging, followed by those with positive autofluorescence who had intervention, and finally those with positive autofluorescence with no intervention. In the first RCT, to our knowledge, assessing the use of autofluorescence imaging in DFU management, our results suggest that a powered RCT is feasible and justified. Autofluorescence may be valuable in addition to standard care in the management of DFU.

A Feasibility and Safety Study of a Novel Human Decellularized Dermal Matrix to Accelerate Healing of Neuropathic Diabetic Foot Ulcers in People With Type 1 and Type 2 Diabetes

ObjectivesThe purpose of this study was to determine the feasibility and safety of a novel decellularized dermal matrix (DDM) for the treatment of chronic diabetic foot ulcers (DFUs). MethodsAn interventional, single-arm, prospective study of DDM for DFU treatment was conducted in 2 Canadian centres from July 1, 2016, to May 30, 2017. Individuals ≥18 years of age with an active DFU of ≥2 weeks and ulcer area ≥1 cm2 before debridement and who consented to participate were enrolled in this clinical trial. ResultsA total of 11 patients were enrolled, with 9 patients (82%) having achieved 100% closure between 2 and 8 weeks. The mean and median times to wound closure for these patients were 3.3 and 2.5 weeks, respectively. The mean and median reductions in wound area at 4 weeks posttreatment were 87% and 100%, respectively. The proportion of patients having achieved complete healing at 12 weeks was 82%. All patients received only 1 DDM application to achieve these results. There were no adverse events related to use of the product. No cases of recurrence during a 1-year follow-up after completion of the study were reported for patients who achieved wound closure. ConclusionsThese findings provide evidence that this DDM may be safe and effective for the treatment of chronic, hard-to-heal neuropathic DFUs. Specifically, DDM demonstrated the potential to accelerate healing of DFUs when compared with reported times of 8 to 12 weeks required to achieve closure using the current standard of care.

IDF21-0128 Diabetic Foot Ulcers: Factors Related to Greater Clinical Severity at Presentation

Background: Diabetic foot ulcer (DFU) is an important diabetes complication associated to higher mortality and lower quality of life. DFU severity strongly depends on depth and the presence of infection. Previous studies have tried to identify factors related to DFU severity, most of them using the Wagner classification as the discriminative criteria. A number of factors have already been pointed out: smoking, higher body mass index, older age, insulin therapy, ulcer’s duration and localization. There are no data published on this subject in the Portuguese population, although it has already been stated that greater clinical severity at presentation is associated with increased risk of short-term amputation. Aim: To evaluate the factors related to infected and deep (and thus more severe) DFU at presentation. Method: Cross-sectional study including patients that attended a first diabetic foot appointment at our unit during the year of 2018. Only adult patients with an active DFU were included. Ulcers were classified as infected if they were graded a score ≥2 on the PEDIS classification and/or a stage B or D on the Texas classification; deep if they were graded a score ≥2 on the Texas classification and/or a grade ≥2 on the Wagner classification. Results: 435 patients were included, most of which were men (62.1%). Their median age was 70.0 (IQR 58.0-79.0) years and the mean diabetes duration was 20.0 (IQR 10.0-25.0) years. DFU infection was associated to poor nail care, both according to PEDIS (p=0.004) and Texas (p=0.005) classifications (OR≈2.000). The same association was found with peripheral artery disease (p=0.025 and p=0.009; OR≈1.800), lesion duration shorter than one month (p=0.023 and p=0.029; OR≈1.700) and dorsal and interdigital ulcer location (p=0.022 and p=0.018). Structural deformities were associated with infected DFU according to Texas classification (p=0.045). Diabetes duration over 10 years was associated with deeper wounds, both according to Texas (p=0.030) and Wagner (p=0.031) classifications (OR≈2.700). Being already on antibiotics at the time of the first appointment was associated with both infected and deep DFU. No association was found with patients’ age, HbA1c level (<7 vs ≥7%), neuropathy, education level or insulin therapy. Discussion: As other authors have described, we found that peripheral artery disease and dorsal ulcers are associated with increased lesion severity. We also found an association between interdigital ulcer location and infection, meaning that DFU in this location also tend to be more severe. This might be due to the fact that this area typically accumulates humidity and is often neglected in diabetic foot examination. Individuals with infected DFU are twice more likely to have poor nail care. Toenails may be a reservoir for bacterial and fungal colonization and thus may be associated to DFU severity. We also point out structural deformities and longer diabetes duration to be associated with more severe lesions. Previous medication with antibiotics by primary care physicians and need for quicker referral to our center also seem to be a sign of severity.

Characterizing palliative care needs in people with or at risk of developing diabetic foot ulcers.

Diabetic foot ulcers (DFUs) have a significant impact on a patient's quality of life and life expectancy, with mortality rates comparable with malignant diseases. However, there is a lack of data regarding palliative care needs in this population. We aimed to characterize palliative care needs in people under diabetic foot surveillance using the Integrated Palliative care Outcome Scale (IPOS) and EuroQol-5D three-level version (EQ-5D-3L) and to assess differences between those with and without a DFU. We conducted a cross-sectional study with consecutive sampling inclusion of patients followed in a tertiary hospital's Diabetic Foot Clinic between February and October 2019 with (n = 20) and without (n = 42) active DFU. The most frequent symptoms encountered were pain, weakness or lack of energy, sore or dry mouth and drowsiness. Patients with an active DFU were significantly more likely to report feeling anxious or worried in comparison with those without (95% versus 55%, p = 0.002). Only 10% of the participants with an active DFU said that they were always able to share how they felt with family and friends as much as they wanted in comparison with 45% of those without (p = 0.006). Our study identified palliative care needs in patients under diabetic foot surveillance with and without DFU, including a significant presence of physical symptoms. Patients in both groups showed signs of emotional/psychological distress, with a higher manifestation in patients with DFU. To the best of our knowledge, this is the first study addressing and characterizing palliative care needs in this population.

The evaluation of podiatrists, with knowledge and training in diagnostic musculoskeletal ultrasound, to describe sonographic images of diabetic foot wounds in the United Kingdom and Australia

AimsCurrently, wound management decisions are based largely on visual observations such as photographs, descriptors or measurements which can lack detail and do not always capture the sub-wound area. A previous case series suggests that there is benefit in using ultrasound imaging (USI) to evaluate diabetic foot ulcers (DFU) at point-of-care, however no guidance exists to inform its use. This scoping exercise explores the capacity of podiatrists with experience in interpreting musculoskeletal structures using USI to interpret sonographic images of DFU.MethodsFollowing a short briefing session, podiatrists with previous musculoskeletal (MSK) USI training were asked to review and report on previously recorded static sonographic images (n = 8) of active DFU. Content analysis was utilised to identify recurring keywords within the podiatrists’ reports which were coded and assigned to categories to gain context to the data.ResultsSeven podiatrists participated in the study. Four categories were constructed for the purposes of analysis:Frequency of reporting, 2) Language used in reporting, 3) Observations, 4) Clinical impressionFrequently, the reported findings between podiatrists were found to be similar, especially those related to bone morphology. However greater variability was seen in the reporting of wound specific soft-tissue observations.ConclusionThis scoping exercise has shown that podiatrists can translate their existing USI skills to make rudimentary reports on clinical findings in DFU. All participants were consistently able to identify and describe characteristics associated with DFU from a single b mode static wound ultrasound image. Findings from this investigation can be used as a foundation for further work to establish accuracy and reliability to validate DFU sonography. In conjunction the development of protocols and training materials will enable the adoption of USI to assess DFU in clinical practice. This will in turn, contribute to improved patient care and establish a new paradigm for wound surveillance which is translatable to other wound types.

Investigation of the relationship between lower extremity selective motor control, center of pressure distribution, and gross motor function: Plot study

The purpose of this study was to investigate the feasibility and safety of a novel Decellularized Dermal Matrix (DDM) for the treatment of chronic Diabetic Foot Ulcers (DFUs).An interventional, single-arm, prospective study of DDM for DFU treatment was conducted in two Canadian from July 1st, 2016 to May 30th, 2017. Individuals 18 or older, with an active DFU for at least 2 weeks, ulcer area of ≥1 cm2 prior to debridement who consented to participate were enrolled in this clinical trial.A total of 11 patients were enrolled with 9 patients (82%) having achieved 100% closure between 2-8 weeks. The mean and median times to wound closure for these patients was 3.3 and 2.5 weeks, respectively. The mean and median reduction in wound area at 4 weeks post-treatment was 87 and 100 %, respectively. The proportion of patients having achieved complete healing at 12 weeks was 82%. All patients received only 1 application of the DDM to achieve these results. There were no adverse events related to the product. No cases of recurrence during a one-year follow-up after completion of the study have been reported for patients who achieved wound closure in the study.These findings provide evidence that this DDM may be safe and effective for the treatment of chronic, hard to heal neuropathic DFUs. Specifically, it demonstrated the potential to accelerate the healing rate of DFUs when compared with reported times of 8-12 weeks required to achieve closure using standard of care.

Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers.

The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) major amputation. Outcomes for SFP and FFP were respectively: healing (89.3 vs. 9.1%, p < 0.0001), minor amputation (44.7 vs. 78.8%, p = 0.0001), major amputation (2.1 vs. 36.3%, p < 0.0001). Failed foot revascularization resulted an independent predictor of non-healing, minor amputation, and major amputation. Foot revascularization is mandatory to achieve healing and avoid major amputation in persons with ischaemic DFU and BTA arterial disease.

269-OR: Thermal Regulation of the Diabetic Foot and Its Impact on Blood Perfusion

Diabetic foot ulcers (DFU) cause approximately 100,000 amputations every year in the US. Current preventive methods provide suboptimal prevention as several reports indicated that amputation rates are on the rise or have not decreased. Our group has previously developed temperature regulating insoles (TRI) that maintain plantar temperatures at 28°C, as previous research demonstrated that cooler tissue is resistant to ulceration. Our purpose in this study was to explore whether blood perfusion is affected by the cooling effect, via quantifying tissue oxygen saturation (StO2). Twelve subjects were recruited after providing informed consent. Inclusion criterion included being able to walk w/o assistance and not having active DFU. All subjects wore the instrumented shoes, with TRI only in the right shoe. Subjects completed two bouts of 5-minute walking on treadmill at self-selected speeds. Plantar temperatures and StO2 images were collected before and after treadmill walking with hyperspectral (Kent Imaging, CA) and thermal (FLIR® Systems, Inc, USA) cameras. Results indicated that while temperature regulation was on target in the forefoot and heel areas around 28°C (~4°C reduction compared to control side) the average difference in StO2 was only 3.0% (standard deviation of difference=2.8%, p=0.22). This suggests that cooling of the diabetic foot to prevent DFU does not necessarily lead to impaired blood perfusion. Disclosure A. Ersen: None. R. T. Myers: None. K. M. Raspovic: Consultant; Self; Orthofix Medical Inc. M. Ramos-roman: None. T. Lalli: None. Y. Salem: None. G. B. Hirschman: Board Member; Self; Vivonics Inc., Stock/Shareholder; Self; Vivonics Inc. M. Yavuz: None. Funding National Institutes of Health (R43DK109858, UL1TR001105)

Virtual triage and outcomes of diabetic foot complications during Covid-19 pandemic: A retro-prospective, observational cohort study.

Limb and patient outcomes in people with diabetic foot complications including diabetic foot ulcer (DFU) provided virtual triage and personalized video consultations during COVID-19 pandemic are not known. Patients with foot complications attending the diabetic foot clinic prior to lockdown who sought teleconsultations during COVID-19 lockdown underwent virtual triage to include clinical history, visual inspection of feet, domiciliary wound care (community nurse assisted dressings) and offloading instructions. The subsequent ulcer, limb and mortality outcomes during the following 24 weeks of COVID-19 lockdown (April-September 2020, group 1) were assessed and compared with those who attended foot clinic during the same period in 2019 (April-September, group 2). Group 1 included 561 participants with foot complications provided with teleconsultations, median age 57 (51 to 63) years and diabetes duration of 10 (5 to 16) years. Twelve patients with severe DFU were excluded and 549 patients [357 (65%) neuropathic foot, 104 (18.9%) ischemic foot and 88 (16%) chronic Charcot foot with deformities] were evaluated. There were 227 (41.3%) participants with active DFU at start of lockdown, 32 (5.8%) with new onset ulcer during lockdown (47.1%) and 290 patients without ulcers. Group 2 included 650 participants; active foot ulcer was present in 366 patients. Wound closed or reduced in area in 78.4% of participants of group 1 compared to 76.0% (p = 0.318) in group 2. Fourteen (5.4%) patients required amputations [3 major and 11 minor] in group 1 during the study period compared to 6.8% in group 2 (p = 0.191). Twenty-one (3.8%) and 28 (4.3%) patients died (p = 0.532) during 24 weeks of follow up in group 1 and 2, respectively. Targeted foot-care service through virtual triage and teleconsultations during COVID-19 pandemic for people with foot complications have similar ulcer and limb outcomes compared to face-to-face foot care delivery.

Differences in initial versus recurrent diabetic foot ulcers at a specialized tertiary diabetic foot care center in China.

ObjectiveTo investigate the characteristics of diabetic foot ulcer (DFU) recurrence.MethodsA total of 573 patients with DFUs were recruited and divided into an initial group (395 patients) and a recurrence group (178 patients). The factors related to recurrence were analyzed using multivariate regression.ResultsThe recurrence group had longer diabetes duration (odds ratio [OR] 192; 95% confidence interval 120, 252 vs. 156; 96, 240); lower glycated hemoglobin levels (OR 8.1; 95% CI 6.8, 9.6 vs. 9.1; 7.4, 10.5), and higher rates than the initial group of amputation (37.5% vs. 2.0%), history of vascular intervention (21.3% vs. 3.9%), retinopathy (77.7% vs. 64.7%), callus (44.4% vs. 20.8%), foot deformity (51.2% vs. 24.6%), and outdoor sports shoe wearing (34.0% vs. 21.2%). Multiple factor logistic regression analysis showed that diabetes duration (OR 1.004), callus (OR 2.769), vascular intervention (OR 2.824) and amputation (OR 22.256) were independent risk factors for DFU recurrence.ConclusionDiabetes duration, callus, history of vascular intervention, and amputation were independent risk factors for recurrent DFUs in a cohort of Chinese patients with active DFU. The prevention and treatment of DFUs, especially callus treatment, foot care, and blood glucose control, should be improved in China.

Cumulative long-term recurrence of diabetic foot ulcers in two cohorts from centres in Germany and the Czech Republic

AimsOur aim was to comprehensively estimate the incidence of diabetic foot ulcer (DFU) recurrence and corresponding risk factors in two cohorts. MethodsProspective data from patients with active DFU from two diabetes centres in Germany (GER, n = 222) and the Czech Republic (CZ, n = 99) were analysed. Crude cumulative incidences were obtained. Additionally, time to recurrence and risk factors were investigated using multivariate Cox models. Results69%(154) of patients in GER and 70%(69) in CZ experienced at least one DFU recurrence; 25%(56) in DEU and 15%(15) in CZ died; 5%(11) and 9%(9) were lost to follow-up. The crude cumulative incidence in the first year was 28% in GER and 25% in CZ; 68%/70% within ten years, and 69%/70% in 15 years. In GER, renal replacement therapy was associated with shorter time to recurrence (HR = 3.71, 95%CI:1.26–10.87); no history of DFU before the index lesion with longer time to recurrence (HR = 0.62, 0.42–0.92). In CZ, type 2 diabetes (HR = 2.57, 1.18–5.62) and index ulcer treatment by minor amputation (HR = 2.11, 1.03–4.33) were associated with shorter time to recurrence. ConclusionsCumulative DFU recurrence was approximately 70% in 15 years in both cohorts. We found a significantly higher risk of future recurrence in patients having a consecutive ulcer compared with the first ever ulcer.