Foot Ulcer Patients Research Articles

Interpretation of 2019 International Working Group on Diabetic Foot guidelines on the prevention and management of diabetic foot disease

The 8th World International Symposium on the Diabetic Foot (ISDF) Conference which was sponsored by the International Working Group on Diabetic Foot (IWGDF) was held in the Hague between May 22nd and May 25th, 2019. The conference issued the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease. The update to the 2015 edition of the guidelines involves the following 6 chapters: prevention of foot ulcers in patients with diabetes; offloading foot ulcers in patients with diabetes; diagnosis, prognosis, and management of peripheral arterial disease in patients with a foot ulcer and diabetes; diagnosis and treatment of foot infection in patients with diabetes; interventions to enhance healing of foot ulcers in patients with diabetes; classification of diabetic foot ulcers. This guideline has been changed more than the previous edition. In this paper, the guidelines will be interpreted to provide cutting-edge information for domestic diabetic foot researchers.

Correlation Between Extracutaneous Microvascular Complications and Diabetic Foot Ulcers in Patients with Type 2 Diabetes Mellitus.

Background:Diabetes is a metabolic disease that is taking an epidemic proportion around the world. The occurrence of microvascular complications and diabetic foot ulcer is associated with an increased mortality and morbidity incidence, which is the most serious complication of this disease, which significantly reduce the quality of patient life.Objective.The aim of the study was to determine the correlation of extracutaneous microvascular complications with diabetic foot ulcer in patients with type 2 diabetes.Method.The study was prospective, and included 160 patients with type 2 diabetes. It was conducted at the University Clinical Center of the Republic of Srpska in the period from January 2016 until December 2019. The respondents were adults, of both sexes, suffering from type 2 diabetes, in whom complications of this disease are present. Glycemic control was established based on a target HbA1c value of 7%.Results. Of the 160 patients in the study, 53.8% were men and 46.2% were women. The average age of the patients was 70.11%±10.05 years. Extracutaneous microvascular complications were present in 85 patients (53.1%); of which 30.2% had well-regulated glycemia (HbA1c≤7.0%), while 61.5% (p<0.001) had unregulated glycemia (HbA1c≥7.0). Polyneuropathy was present in 23.3% of patients with HbA1c≤7.0%, while 41.0% of patients had HbA1c≥7.0% (p<0.043). Nephropathy with HbA1c≤7.0% was present in 36.8% of cases compared to patients with HbA1c≥7.0 in whom the prevalence was 36.8% (p<0.004). Out of total, 25.6% had retinopathy with HbA1c≤7.0%, while in 41.9% of patients with HbA1c≥7.0% (p <0.067). Diabetic ulcer foot was present in 13 patients with HbA1c≥7 (11.1%) compared to patients with HbA1c≤7.0% where there was no occurrence of this complication 0.0% (p<0.021). At the same time, 5.6% of patients had a diabetic foot ulcer with polyneuropathy (p=0.010), 4.4% had neuropathy (p=0.058) and 5.6% had retinopathy (p=0.014).Conclusion:The high incidence of extracutaneous microvascular complications and diabetic foot ulcer in patients with type 2 diabetes requires a multidisciplinary approach of medical professionals that includes prevention of risk factors and good regulation of glycemia.

Drug Susceptibility Pattern of Bacterial Pathogens associated with Diabetic Foot Ulcers of Patients in Kano North –Western Nigeria

Diabetic foot ulcer has become the major cause of amputation in people with diabetes. Infected foot ulcers are a cause of morbidity and hospitalization in diabetic patients. The aim of the current study was to isolate and ascertain antimicrobial susceptibility pattern of bacterial pathogens associated with diabetic foot infection in Kano North – West, Nigeria. Samples were collected from 100 patients with diabetic foot ulcers using sterile cotton swab and transported to the laboratory for analysis. The male: female ratio was 3:1. Mono bacterial nature of diabetic foot infection was observed in 68% of the samples while mixed bacterial infection was observed in 21% of the samples. The study showed that Gram negative bacteria (84%) was the most frequently isolated pathogen and E. coli was found to be predominant (27%) followed by Klebsiella species (21%) and Proteus species (19%).Among the Gram positive bacteria, S. aureus (16%) was the predominant pathogen. The result also showed that most of the isolated bacteria were sensitive to Ciprofloxacin, Ofloxacin, Nitrofurantoin and Gentamicin. However, they showed resistance to Augumentin, Cefixime, Ceptaxidime and Cefuroxime. Further studies needs to be carried out to explore anaerobic pathogens related to diabetic wound and to ascertain the causes of resistance to antibiotics for proper management of diabetic foot ulcer in the study area.&#x0D;

Correlation between Serum Level of Vitamin D and Severity Degree of Diabetic Foot Ulcer in Patients with Normal Ankle Brachial Index

Introduction: Diabetes mellitus can cause various complications, including diabetic foot ulcers (DFU). Vitamin D levels are known to be correlated with wound healing and insulin resistance. Method: This cross-sectional study aimed to determine the correlation between the serum level of vitamin D and the severity degree of DFU. Thirty DFU patients with normal ankle- brachial index, grouped into degrees according to the Wagner classification, were included in this study. Their serum level of vitamin D was examined using the chemiluminescent immunoassay method. The correlation between these two variables was analyzed. Results: Patients were 18 males (60%) and 12 females (40%) with an average age of 57 years. The average serum level of vitamin D was 10.58 ng/mL. A significant correlation was found between the serum level of vitamin D and the severity of DFU (r= -0.901, p &lt;0.001). Conclusion: The serum level of vitamin D screening in DFU patients was strongly correlated with the degree of DFU. Keywords: diabetes mellitus, diabetic foot ulcer, vitamin D, Wagner classification

The Effect of Shear Force on Skin Viability in Patients with Type 2 Diabetes.

Background Shear is a major risk factor in the development of diabetic foot ulcers, but its effect on the skin of patients with type 2 diabetes mellitus (DM) remains to be elucidated. The aim was to determine skin responses to shear in DM patients with and without diabetic polyneuropathy (DNP). Methods The forearm skin was loaded with 14.5 N shear (+2.4 kPa pressure) and with 3.5 kPa pressure for 30 minutes in 10 type 2 DM patients without DNP, 10 type 2 DM patients with DNP, and 10 healthy participants. A Sebutape collected IL-1α (measure of tissue damage). A laser Doppler flowmeter measured cutaneous blood cell flux (CBF) as a measure of the reactive hyperaemic skin response. Findings Reactive hyperaemia and IL-1α release was significantly increased after shear loading in all three groups and was higher compared to the responses to pressure loading. The reactive hyperaemic response after shear loading was impaired in patients with type 2 DM compared to healthy participants but did not differ between patients with and without DNP. The reactive hyperaemic response was negatively correlated with the blood glucose level but did not correlate with the DNP severity score. Interpretation Shear is important in the development of tissue damage, but the reparative responses to shear are impaired in patients with type 2 DM. DNP was not associated with altered skin responses, suggesting that the loss of protective sensation to sense shear to skin remains a key factor in the development of diabetic foot ulcers in patients with DNP.

The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe

Claw deformity of the foot is frequently seen in patients with diabetes mellitus. Percutaneous flexor tenotomy is a simple surgical procedure for the treatment of foot ulcers on the distal end of the toe caused by this deformity. This procedure can also be performed to prevent ulcers in claw toes that are at risk of ulceration. The aim of this study is to investigate whether percutaneous flexor tenotomy is an effective surgical method for treatment and prevention of toe ulcers in patients with claw deformity. This retrospective study, with a median follow-up of 13.4 (1 to 66.7) months, included all consecutive patients who underwent percutaneous flexor tenotomy in 2 hospitals between July 2012 and April 2017. In total, 101 feet underwent flexor tenotomy: 84 (83.3%) therapeutic and 17 (16.7%) prophylactic. Of the 84 therapeutic procedures, 95.1% healed, with a median healing time of 27 days. In 11 (13.3%) therapeutic procedures, a reulceration was recorded. In the therapeutic group, 4 (4.8%) infections and 1 (1.2%) amputation of the digit occurred. In the 17 prophylactic procedures, local bleeding was recorded in 1 (5.9%). In the prophylactic group, 2 ulcers occurred. In 77 (76.2%) of all procedures, patients had diabetes mellitus. In conclusion, percutaneous flexor tenotomy is an effective, safe, and minimally invasive procedure for the treatment and prevention of toe ulcers in patients with claw deformity.

Association Between Onychomycosis and Foot Ulcers in Patients with Diabetes Mellitus

Objective: Diabetes mellitus (DM) is associated with many serious health complications such as diabetic foot ulcer (DFU). Onychomycosis increases the risk for foot disorders and limb amputation in DM patients, and if untreated, can result in tissue degradation and DFU. Therefore, this study aimed to determine the association between the incidences of onychomycosis and DFU.Methods: This study included 40 DM patients with DFU (study group) and 40 DM patients without FU (control group). Samples were obtained from the most affected part of the nail. The deep-nail plaque of the right toe was preferred in patients with normal toenail appearance. In addition, mycological examinations were conducted. Values of p&amp;lt;0.01 were considered as significant.Results: No significant difference was observed between the two groups with respect to age, sex, and hemoglobin A1c levels (p&amp;lt;0.01). However, the incidence of onychomycosis and use of insulin were significantly higher in the study group than in the control group (p&amp;lt;0.01 and p&amp;lt;0.001, respectively).Conclusion: Onychomycosis might be associated with development of FU in patients with DM. By treating onychomycosis early, foot amputation can be prevented

Role of hyperbaric oxygen therapy in the treatment of chronic ulcers of the foot in patients with type II diabetes mellitus

Background: The aim of this study is to evaluate the effect of hyperbaric oxygen therapy (HBOT) in healing of chronic foot ulcers in patients with type II diabetes mellitus.Methods: A case control study included 40 type II diabetic patients with chronic foot ulcers not healing for more than 4 weeks. It has been conducted at Naser Institute for Research and Treatment and Menoufia University Hospital during the period between April 2017 and September 2018. Patients with non-healing diabetic foot ulcers were referred by physicians and were also identified through a number of wound care clinics in various hospitals.Results: Most ulcers were observed in the sole and heel in both groups A and B (n=14 and 9 respectively), while the rest of ulcers were distributed in other areas of the foot, namely the medial and lateral malleoli, dorsum and toes. On comparing the wound related complications developing during the treatment period, no statistically significant difference was found between both groups (p=0.147). As regards Wagner's grade, 7 patients (17.5%) had grade 4 ulcers, 18 patients (45%) had grade 3 ulcers and 15 patients (37.5%) had grade 2 ulcers, showing no statistically significant difference between both groups before treatment (p=0.259).Conclusions: HBOT is a useful adjunct in the treatment of non-healing diabetic foot ulcers, and that the cost of HBOT itself will be reduced as it becomes more widely available in the clinical setting, and as further knowledge of its other advantages, such as limited side effects and relative safety, become more widely appreciated.

Evaluation the effect of continuing nursing based on diabetic foot risk in type 2 diabetic patients

Objective To establish the effects of the continuing nursing model for prevention of diabetic foot in patients with type 2 diabetics. Methods A total of 188 patients with type 2 diabetes were divided into high ankle-brachial index(ABI) group (ABI≥0.9) and low ABI group (ABI<0.9) with 94 cases each. High ABI group was divided into intervention group 1 and control group 1 and low ABI group was divided into intervention group 2 and control group 2 with 47 cases each by random digits table method. Finally intervention group 1 and intervention group 2 were combined into intervention group, control group 2 and control group 1 were combined into control group. Patients in control group were given usual care. Patients in intervention group could consult and communicate with specialized nurse in diabetic foot in Wechat, they were assessed by specialty nurse every 3 months. All the patients received intervention for 9 months. The effect of nursing were evaluated through Diabetic Foot Knowledge-Attitude-Practice(KAP) Questionnaire as well as glycosylated hemoglobin. Results After intervention, KAP scores of the knowledge, attitude, behavior and glycosylated hemoglobin was (93.73±25.88), (18.45±3.08), (38.06±6.43) points and (8.81±2.24)% in intervention group, (93.34±26.06), (18.23±3.03), (37.73±6.58) points and (9.46±2.33)% in control group, there was significant difference between two groups(t=-3.310-5.249, P <0.01). KAP score of knowledge was (94.02±30.58) points in intervention group 1 and (93.72±30.84) points in control group 1,KAP scores of the knowledge, attitude, behavior was (93.45±20.47), (18.70±3.10), (36.40±5.89) points in intervention group 2 and (92.96±20.54), (18.36±3.07), (35.83±6.20) points in control group 2, there was significant difference(t=2.092-3.251, P<0.05 or 0.01). The level of glycosylated hemoglobin was (8.97±2.85)% in intervention group 1 and (8.65±1.42)% in intervention group 2,(9.28±2.97)%, (9.64±1.44)% in control group 1 and control group 2, there was significant difference(t=2.376, 4.953, P<0.05 or 0.01). Conclusions The continuing nursing model is effective in preventing diabetic foot ulcers in patients with low and high ABI. Key words: Diabetic foot; Ankle-brachial index; Continuing nursing

Healing of Diabetic Foot Ulcers in Patients Treated at the Copenhagen Wound Healing Center in 1999/2000 and in 2011/2012.

Aim To describe differences in healing time of diabetic foot ulcers for patients treated at the Copenhagen Wound Healing Center, Bispebjerg Hospital, between the years 1999/2000 and 2011/2012. The Center is highly specialized and receives diabetes patients with hard-to-heal foot ulcers. A further aim is to attempt to find predictors of healing time of diabetic foot ulcers. Methods A retrospective descriptive study of records from patients with diabetic foot ulcer treated at the Copenhagen Wound Healing Center in 1999, 2000, 2011, or 2012. Follow-up data was collected until the 3rd of August 2018. Results Median time (range) to healing was 6 (61.3) months in 1999/2000 and 6.6 (67.8) in 2011/2012 (p = 0.2). About 33% of ulcers were healed, 17% were minor or major amputated, and 1.5% were dead within one year in 1999/2000, whereas 30% of ulcers were healed (p = 0.6), 14% were amputated (p = 0.2), and 12.8% were dead within one year in 2011/2012 (p < 0.001). The single factor found significantly associated with longer ulcer duration was infection. Related to shorter ulcer duration were toe localization of the ulcer and good glycemic control. Conclusion The median time to healing of a diabetic foot ulcer was long, around 6 months and with a high recurrence rate in 1999/2000 as well as in 2011/2012. Some factors were found to be significantly related to healing time, and intervention addressing these may improve the time to heal, although such interpretations must be taken with precaution from the present study and should be proven in randomized prospective intervention trials.

Clinical features and burden of new onset diabetic foot ulcers post simultaneous pancreas kidney transplantation and kidney only transplantation

BackgroundPatients with diabetes and kidney disease are at risk of diabetes-related foot ulcers (DFU). Whether this risk is modified post simultaneous pancreas-kidney (SPK) or kidney only (KO) transplant is unknown. MethodsWe evaluated the incidence of new onset DFU post SPK and KO transplant in 235 patients with diabetic kidney disease and diabetic neuropathy. In total 90 (51% male) SPK patients and 145 KO (66% male, 26% Type 1 DM) were evaluated in a single centre retrospective study. Median (range) follow up was 6 (3 to 13) years for both cohorts. ResultsWe observed that 16 (17%) of SPK and 22 (15%) KO patients respectively developed a DFU during follow up. In both cohorts a history of peripheral arterial disease [37.5% vs. 4%] and pre-transplant history of DFU were associated with post transplant DFU (p ≪ 0.05).In KO cohort, patients who developed a DFU were more likely to have T1DM than T2DM (29% vs. 10%), p ≪ 0.05. There was no impact of DFU on SPK transplant failure. In contrast patients with DFU post KO transplant had more than five fold increased hazard ratio (HR) of transplant failure as compared to those without DFU independent of other risk factors [HR 5.19 95% CI (2.05 to 13.18) p = 0.001]. ConclusionNearly 1 in 7 patients develop a new onset DFU post KO or SPK transplantation and DFU also significantly increases risk of failure of the transplanted kidney. Our results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Research in contextEvidence before this studyPatients with diabetes and kidney disease are at enhanced risk of diabetic foot ulcers (DFU). Whether this risk is modified post successful kidney only (KO) or simultaneous pancreas and kidney (SPK) transplantation is unknown. Small case series and studies with short term follow up report varied rates of incidence and are from historical cohorts before the use of modern anti-transplant medications and treatments. Short term studies also suggest that post SPK the resultant normoglycaemia may reverse some features and risk markers of DFU. There are no long term studies on the incidence and impact of diabetic foot ulcers in patients with diabetic kidney disease post SPK or KO transplantation.Added value of this studyWe report the long term follow up results on DFU incidence, clinical features and related impact on transplant viability in 235 patients with diabetic kidney disease and neuropathy post successful SPK and KO transplant at a single centre. We observed that nearly 1 in 7 patients developed a DFU during follow up and that in patients who received KO transplant onset of DFU was associated with more than 5 fold increase of transplant failure.Implications of all the available evidenceOur results highlight the need for greater awareness of regular foot examination, DFU prevention and risk evaluation in post-transplant patients. Despite normoglycaemia post SPK there is a residual burden and risk of DFU. Our work establishes a clinical rationale for further research to explore putative mechanisms that could explain the association between DFU and renal transplant dysfunction.

Plantar pressure distribution in diverse stages of diabetic neuropathy.

Diabetic Foot Ulceration in patients with diabetes could be associated with high plantar pressure caused by diabetes neuropathy. Therefore, it seems that one of the ways of identifying high-risk legs in diabetic patients with neuropathy would be characterization of elevated plantar pressure distributions. Comparing the plantar pressure distribution in diabetic patients who suffered neuropathy with those without neuropathy. Plantar pressure distribution was recorded in the following categories: 38 diabetic patients without neuropathy, 30, 40 and 34 patients with mild neuropathy, moderate and severe neuropathy respectively. Patients suffered from severe neuropathy suggested higher maximum peak plantar pressure at midfoot, heel, and medial forefoot. The peak pressure of midfoot was significantly different in the following categories as well: patient without neuropathy (32.3 ± 17.9kPa), mild neuropathic (24.0 ± 17.9kPa), moderate neuropathic (21.5 ± 12.6kPa), and severe neuropathic (22.9 ± 10.7kPa) groups (p = 0.02). The progression of diabetic neuropathy would have been increased followed by the peak plantar pressure.

Can diabetic polyneuropathy and foot ulcers in patients with type 2 diabetes be accurately identified based on ICD-10 hospital diagnoses and drug prescriptions?

Purpose: We examined whether diabetic polyneuropathy (DPN) and diabetic foot ulcers in type 2 diabetes can be accurately identified using International Classification of Diseases, 10th revision discharge diagnosis codes, surgery codes, and drug prescription codes.Methods: We identified all type 2 diabetes patients in the Central Denmark region, 2009–2016, who had ≥1 primary/secondary diagnosis code of “diabetes with neurological complication” (E10.4-E14.4), “diabetic polyneuropathy” (G63.2), or “polyneuropathy, unspecified” (G62.9). Patients with potential painful DPN and non-painful DPN were identified based on prescription history for serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants, or gabapentinoids. Likewise, type 2 diabetes patients with potential foot ulcers were identified based on diagnosis or surgery codes. We used medical record review as the reference standard and calculated positive predictive values (PPVs).Results: Of 53 randomly selected patients with potential painful DPN, 38 were classified as having DPN when validated against medical records; of these, 18 also had neuropathic pain, yielding a PPV of 72% (95% CI: 58–83%) for DPN and 34% (95% CI: 22–48%) for painful DPN. Likewise, among 54 randomly selected patients with potential non-painful DPN, 30 had DPN based on medical record data; of these, 27 had non-painful DPN, yielding PPVs of 56% (95% CI: 41–69%) and 50% (95% CI: 36–64%), respectively. Secondary E-chapter codes often denoted stroke or mononeuropathies, rather than DPN. Excluding secondary E-chapter codes from the algorithm increased the PPV for DPN to 78% (95% CI: 63–89%) for the painful DPN cohort and to 74% (95% CI: 56–87%) for the non-painful DPN cohort. Of 53 randomly selected patients with potential diabetic foot ulcer, only 18 diagnoses were confirmed; PPV=34% (95% CI: 22–48%).Conclusion: G-chapter and primary E-chapter diagnosis codes can detect type 2 diabetes patients with hospital-diagnosed DPN, and may be useful in epidemiological research. In contrast, our diabetic foot ulcer algorithm did not perform well.

A clinicopathogical study on diabetic foot ulcer with special reference to the causative factors and its management

Background: Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. The present study was done to identify the incidence and related risk factors of diabetic foot ulcers in study participants.Methods: This was a prospective done on 50 patients with diabetic foot ulcers. All the patients were examined thoroughly and related laboratory investigations were done. Wound culture and sensitivity was done in all cases.Results: Mean age of onset with foot ulcers was 53.5 yrs in male and 55 yrs in females. Nephropathy was present in 12 (24%) patients. Sensorimotor neuropathy was present in 29 (58%) cases and autonomic neuropathy was present in 06 (12%) cases. Most common infection identified in diabetic foot ulcers was due to gram-negative bacteria (E. coli in 45 cases). Major amputation was done in 2 (4%) patients.Conclusions: Implementation of management strategies at early stages prevents the development of complications related to diabetic foot ulcers in patients.

Evaluation of Risk Factors Associated with Diabetic Foot Ulcers in Saudi Arabia.

Considering that diabetic foot ulceration is one of the major health issues globally, we aimed to evaluate the risk factors associated with foot ulcers in patients with type 2 diabetes mellitus (T2DM). A total of 81 T2DM patients (age range: 40-80 years) registered at the Diabetes Treatment Center, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia between April and September 2015 were included in this cross-sectional study after purposive selection and assigning of patient numbers. The selected participants were interviewed and examined, and their medical records were reviewed for sensory, vibratory, and painful neuropathies; vascular insufficiency; retinopathy; and dermatological variations. The Wagner's classification system was employed to evaluate the stage of patients' foot ulcers. Among the study participants [mean age range: 56.4 ± 6.72 years; 53 males (65.4%)], cases of loss of protective sensation, foot deformity, amputation history, and dermatological abnormalities were notable. The Wagner gradation value of ulcers were grade 0 for 16% study population, grade 1 for 35.8%, grade 2 for 45.7%, grade 3 for 2.5%, and grades 4 and 5 for 0%. Approximately 19% of the patients had a previous case of amputation and 29.6% had nail disease. The most common footwear reported to be used by the patients was sandals shoes (46%). The issues of loss of protective sensation, vascular insufficiency, deformity, previous amputations, and dermatological abnormalities of the lower limbs were found to be most common among the foot ulceration patients. The study findings thus recommend regular foot examination, following basic hygiene habits, encouragement of the use of appropriate footwear, patient education about foot ulcers, and prompt treatment for minor injuries to prevent further ulceration in DM patients.

Biomechanical properties of heel-pad and metatarsal head soft tissue and foot ulcers in patients with systemic sclerosis – a case control study

Background: Systemic sclerosis is a chronic disease of connective tissue accompanied with increased risk of foot ulcers. Biomechanical indexes (soft tissue thickness and compressibility) could affect the risk of this phenomenon.Objective: The aim of this study was assessment of heel pad and first metatarsal head soft tissue thickness and compressibility index in scleroderma patients with and without foot ulcers and comparison with healthy individuals.Methods: Heel pad thickness in standing(loaded) and lying(unloaded) positions was measured in 40 scleroderma patients by means of lateral foot radiography. Compressibility index was measured as the ratio of loaded to unloaded thickness. Also, soft tissue thickness of first metatarsal head was measured with ultrasound. Results were compared with 40 healthy controls of matched age and body mass index.Results: Among 40 scleroderma patients (36 females, 4 males) with mean age of 45 (±12) years and mean body mass index of 25.5 (±4) and mean disease duration of 10 years (±9.6), 8 (20%) had foot ulcers. Heel pad thickness (p-value 0.03) and compressibility index (p-value 0.005) in the dominant side and both-sides metatarsal head soft tissue thickness (P-value

RELATIONSHIP OF HEAVY METAL IN DIABETES AND NON-DIABETIC FOOT ULCER PATIENTS.

01Mar 2019 RELATIONSHIP OF HEAVY METAL IN DIABETES AND NON-DIABETIC FOOT ULCER PATIENTS. Prasanta Kumar Bhattacharyya , Priyanka Biswas , Debarshi Jana , Jayanta Ranjan Mukherjee and Madhusanta De. KPC Medical College & Hospital, Kolkata. Ramakrishna Mission SevaPratishthan, Kolkata. Institute of Post-Graduate Medical Education and Research, A.J.C. Bose Road, Kolkata-700020, West Bengal, India.

The effect of transitional care on the prevention of diabetic foot ulcers in patients at high risk for diabetic foot

To study the effect of transitional care on the prevention of diabetic foot ulcers (DFU) in patients at high risk for diabetic foot. A total of 284 diabetic patients at high risk for DFU were randomly divided into case and control groups (142 cases in each group). The control group was provided with conventional care in hospital. The case group received the transitional care intervention, including individualized education about diabetes mellitus and DFU, instruction in foot care, and the assistant management of calluses and the evaluation on quality of life. Both groups were followed up for 2 years. The levels of blood glucose, blood pressure and serum lipids, and foot dorsal artery pulse, 10-g monofilament nylon fiber probe test, knowledge of foot care, and diabetes quality of life (DQOL) in two groups were compared before and after transitional care intervention. There were statistically significant improvements in the case group compared with the control group in plasma glucose and blood pressure levels, and in foot dorsal artery pulse, 10-g monofilament nylon fiber probe test, knowledge of foot care, and DQOL. The incidence of DFU was lower, and the ulcers also were milder in the case group than in the control group. Transitional care was beneficial to the prevention of DFU and could reduce the development of DFU and improve the patients’ quality of life.

Long-Term Outcomes of BMMSC Compared with BMMNC for Treatment of Critical Limb Ischemia and Foot Ulcer in Patients with Diabetes

We first compared long-term clinical outcomes in treating critical limb ischemia (CLI) and foot ulcer in patients with diabetes between autologous bone marrow mesenchymal stem cell (BMMSC) and bone-marrow-derived mononuclear cell (BMMNC) transplants. Forty-one patients were enrolled and followed up for 3 years. They received an 18-day standard treatment before stem cell transplantation. Patients with bilateral CLI and foot ulcer were injected intramuscularly or basally with BMMSC, BMMNC, or normal saline (NS). Cox model analysis showed significant differences in the hazard ratio (HR) for amputation with treatment by BMMSC (HR 0.21 [95% CI (0.05, 0.95)], P = 0.043), infection of foot (HR 5.30 [95% CI (1.89, 14.92)], P = 0.002), and age ≥64 (HR 3.01 [95% CI (1.11, 8.15)], P = 0.030), but no significant differences by BMMNC at 9 months after transplantation. Regarding ulcer healing and recurrence rate, the BMMSC group demonstrated a significant difference from the NS group during the 3–6 months after transplantation or healing, but the BMMNC group did not. This trial suggests that, compared with BMMNC treatment, BMMSC treatment leads to a longer time of limb salvage and blood flow improvement, and, when compared with conventional therapy, it can promote limb blood flow and ulcerative healing, and reduce ulcer recurrence and amputation within 9 months.

Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes?

AimsThe aim of this study was to identify the biomechanical, neurological and clinical parameters along with other demographics and lifestyle risk factors that could explain the presence of foot ulcer in patients with diabetes in Africa. MethodsA total of 1270 (M/F:696/574) patients; 77(M/F:53/24) with ulcerated vs 1193 (M/F: 643/550) with non-ulcerated feet; participated in this study. A set of 28 parameters were collected and compared between the participants with and without active foot ulcers. Multivariate logistic regression was utilised to develop an explanatory model for foot ulceration. ResultsFoot swelling (χ2(1,n = 1270) = 265.9,P = 0.000,Phi = 0.464) and impaired sensation to monofilament (χ2(2,n = 1270) = 114.2,P = 0.000,Cramer'sV = 0.300) showed strong association with presence of ulceration. A lower Temperature sensitivity to cold stimuli and limited ankle joint mobility were observed to be significant (P < 0.05) contributors to ulceration. The logistic regression model can justify the presence of foot ulceration with 95.3% diagnostic accuracy, 99.1% specificity and 37.3% sensitivity. ConclusionParticipants with ulcerated foot show distinct characteristics in few foot related parameters. Swollen foot, limited ankle mobility, and peripheral sensory neuropathy were significant characteristics of patients with diabetic foot ulcer. One out of three patients with ulcerated foot showed common characteristics that could be justified by the model.