Outcome Of Diabetic Foot Ulcers Research Articles

Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study.

The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU. The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing. The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004-0.332). This was followed by PAD (OR 0.093; 95% CI 0.028-0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030-0.395), anemia (OR 0.179; 95% CI 0.056-0.571). Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.

Prospective observational study evaluating association of sociodemographic parameters, Wagner’s grading, peripheral arterial disease and diabetic peripheral neuropathy with the outcomes of diabetic foot ulcers

Background: The present study was conducted to determine the association of sociodemographic parameters, comorbid conditions and complications of diabetes mellitus (DM) with the treatment outcomes of diabetic foot ulcers.Methods: The present prospective observational study enrolled 105 participants aged 30-85 years with diabetic foot ulcers presenting to general surgery department during a period of 18 months. Participants who were terminally ill, who had trophic ulcers of Hansen’s disease and filariasis and its sequelae were excluded. The study was approved by institutional ethics committee and written informed consent was obtained from all study participants. Data was analyzed using R and the test of significance was chi square test, p&lt;0.05 was considered statistically significant.Results: Higher proportion of male participants and those aged between 50-69 years were encountered. Male participants were of higher age and the mean duration of DM in participants with diabetic foot ulcer was 8 years. The mean HbA1C of study participants was 8.1%, 38.1% participants had high plasma glucose. Food deformity was observed in 41% participants. 62.9% and 66.7% participants had diabetic peripheral neuropathy and peripheral arterial disease respectively. The mean time required for healing among participants with diabetic foot ulcers was 45.8 Significant association of major amputation with diabetic peripheral neuropathy (p=0.02), Wagner’s grading (p&lt;0.001) and peripheral arterial disease (PAD) (p=0.006) was observed.Conclusions: The presence of diabetic peripheral neuropathy and PAD were risk factors for major amputations in diabetic foot ulcers. Lower Wagner’s grading was associated with lower chances of major amputation.

Prospective observational study evaluating the predictive value of ankle branchial pressure index on the outcomes of diabetic foot ulcers

Background: The study was conducted to determine the diagnostic accuracy of ankle branchial pressure index (ABPI) in predicting major amputation and duration of wound healing in diabetic foot ulcers.Methods: 105 participants (30-85 years) admitted in general surgery inpatient with diabetic foot ulcers during 18 months were enrolled in the present prospective observational study. Institutional ethics committee approved the study and written informed consent was obtained from all study participants. Data was analyzed using R and the tests of significance were chi square test and ANOVA. Area under curve (AUC) of receiver operator characteristic (ROC) was used to describe the diagnostic accuracy of ABPI. P&lt;0.05 was considered statistically significant.Results: The mean ABPI of study participants was 0.7 with 23.8% participants having normal ABPI. Lower ABPI was associated with longer duration of ulcer healing (p=0.003). All participants with ABPI &lt;0.3 required more than 120 days for wound healing (p&lt;0.001) and required above knee amputation (p&lt;0.001). AUC ROC of ABPI and major amputation is 0.987 with 92.9% sensitivity and 98.9% specificity. Significantly higher proportion of participants with ABPI ≤0.48 underwent major amputation. The AUC of ROC of ABPI on duration of wound healing was 0.953 with 84.9% sensitivity and 98.1% specificity. Conclusions: ABPI can be used as a routine tool in all patients with diabetic foot ulcers for screening peripheral arterial disease so that the decision for amputation can be made early during diabetic foot ulcers.

Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies

ObjectiveTo evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs). Research design and methodsMedline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842). ResultsOf 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes. ConclusionsOur findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.

Improving clinical outcomes of diabetic foot ulcers by the 3-month self- and family management support programs in Indonesia: A randomized controlled trial study

Background and aimsDiabetic foot ulcers are the leading cause of lower extremity amputations, which require more effective prevention. Even though previous nursing studies on diabetic foot ulcers have been well performed, programs implementing self- and family management are limited and even underexplored. Therefore, the purpose of the study was to investigate the effect of 3-month self- and family management support programs on clinical outcomes among Indonesians with diabetic foot ulcers. MethodThe randomized controlled trial design was used to answer the research question of the study. A total of 56 eligible participants were enrolled, with 27 in the experimental group and 29 in the control group. The experimental group received self- and family management support programs for three months. Meanwhile, the control group received usual care. Descriptive statistics, multivariate analysis of variance, and Generalized Estimating Equations were used to analyze the data. The significance level was considered at .05 for hypothesis testing. ResultsThe study showed that there were statistically significant improvements in self-management, family supports, hemoglobin A1c, and wound size after implemented the programs for three months (p < .05). ConclusionsWith regard to the result of the study, implementing the 3-month self- and family management support programs improves the patients’ and families’ abilities to perform diabetic foot ulcer care at home.

Risk factors and outcomes of diabetic foot ulcer among diabetes mellitus patients admitted to Nekemte referral hospital, western Ethiopia: Prospective observational study

ObjectivesDiabetic foot ulcer is one of the complications of diabetes mellitus. The diabetic patients with foot infections especially gangrene require long-term hospitalization and carry the risk of limb amputation. Despite these challenges, there are a scarce studies done on risk factors and no finding on outcomes of diabetic foot ulcers in Ethiopia.Patients and methodsA prospective observational study was conducted among diabetes patients with diabetic foot ulcer at Nekemte referral hospital from March 15 to June 15, 2018.ResultsOf the 115 diabetes foot ulcer patients admitted to Nekemte referral hospital, 64(55.65%) were males and the mean age of participants was 44.4 ± 14.7 years. Fifty-eight (50.43%) of the patients had chronic health problems and 56(48.69%) had diabetic complications. Of patients with complications, 35(30.43%) were undergone amputations. Diabetic foot ulcer grade ≥4 (AOR = 1.7; 95% CI: 1.604, 4.789), inappropriate antibiotics use (AOR = 2.526; 95% CI: 1.767, 8.314), overweight (AOR = 2.767; 95% CI: 1.827, 9.252), obesity (AOR = 3.020; 95% CI: 2.556, 16.397), poor blood glucose control (AOR = 2.592; 95% CI: 1.937, 7.168) and neuropathy (AOR = 1.565; 95% CI: 1.508, 4.822) were predictors of amputation up on multivariable logistic regression analysis.ConclusionBlood glucose level, higher body mass index, inappropriate antibiotics use, neuropathy and advanced grade of diabetic foot ulcer were independent predictors of amputation. Thus, special emphasis for patients having neuropathy and advanced grade of diabetic foot ulcer as well as weight reduction, managing hyperglycaemia, and appropriate antibiotics prescription practice would decrease untoward effects of diabetic foot ulcer.

Impact of multidisciplinary foot care team on outcome of diabetic foot ulcer in term of lower extremity amputation at a tertiary care unit in Karachi, Pakistan

To compare the outcomes of diabetic foot ulcers (DFU) in terms of healing and lower extremity amputation (LEA) rate before and after training of multidisciplinary foot care team (MDFCT). Subjects were categorised into two groups; Group-A cases seen between 1997 and 2006 (before upgrading of training and services of MDFCT) and Group-B cases seen between 2007 and 2016 (after upgrading of training and services of MDFCT). Baseline demographic characteristics, biochemical results, and outcomes of DFU in terms of healing or amputation were analysed by using statistical package social science (SPSS) version 20. Total 7994 DFU cases seen, 888 in group A and 7106 in group B. Mean age of patients was 53.80 ± 10.40 years and mean haemoglobin (HbA1c) was 10.12 ± 2.44. Overall, decreasing trends of amputations were observed from baseline 27.5% to 3.92% during the period of 20 years. In group A, 479 (78.8%) subjects healed completely compared with 3806 (89.1%) in group B. Significant reduction in toe amputations ([13.81%] vs [8.11%]) and below knee amputations [(5.26%) vs (1.82%)] were seen. Similarly, rates of above knee amputation ([1.80%] vs [0.35%] P-value 0.008) in two groups was also significant. Significant improvement was observed in outcomes of DFU in terms of amputation through multidisciplinary team approach.

Allogeneic Skin Substitutes Versus Human Placental Membrane Products in the Management of Diabetic Foot Ulcers: A Narrative Comparative Evaluation of the Literature.

Outcomes following standard wound care (SWC) for diabetic foot ulcers (DFUs) remain suboptimal. Supplementing SWC with tissue engineered allogeneic cellular wound therapies represents an emerging treatment strategy. This review aimed to evaluate the efficacy and safety of allogeneic skin substitutes and human placental membrane allografts in the management of DFUs. Ovid MEDLINE and Embase databases were searched from inception to October 2017. Any randomized controlled trial (RCT) with an allogeneic skin substitute or placental membrane allograft intervention group was included. Our primary outcome measure was the proportion of completely healed ulcers. Secondary outcome measures included time to complete wound healing and local adverse event rates. Each study was assessed for risk of bias and the quality of evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Moderate quality evidence from 11 included RCTs demonstrated that both allogeneic cellular approaches improve the proportion of completely healed ulcers at 6 and 12 weeks. One RCT showed that a placental membrane allograft was superior to an allogeneic skin substitute, although this has yet to be repeated in other studies. The addition of allogeneic cellular wound products to SWC improves DFU outcomes. Further studies are required to conclusively establish if placental membrane allografts are superior to allogeneic skin substitutes.

Assessment of the Outcome of Diabetic Foot Ulcers in Basrah, Southern Iraq: A Cohort Study

Background: Diabetic foot ulcers are one of the most severe and costly complications of diabetes. Foot ulcers result from a combination of multiple causes including peripheral neuropathy and peripheral arterial disease. Patients with diabetic foot ulcers frequently require amputation of the lower limb. Objectives: The aim of this study was to assess the outcome of diabetic foot ulcers among Iraqi patients with diabetes and to examine the effect of some risk factors on healing of the ulcer. Methods: A cohort study was conducted on 100 patients from January to August 2017 at the Diabetic Foot Clinic, Alfayha Teaching Hospital, Basrah, Iraq. Results: A total of 100 patients with diabetic foot ulcers were included. The ulcers of 60% of the patients healed, whereas 8% persisted unhealed; 25% of the patients had a minor amputation, 5% had a major amputation, 1% had recurrent ulcers, and 1% died. The study showed statistically significant associations between diabetic foot ulcer healing and the following variables: patients’ age, glycated HbA_1c, duration of diabetes, complications of diabetes like peripheral neuropathy, and ulcer size. Conclusions: Diabetic foot ulcer outcomes can be predicted by several factors, some of which are modifiable. Modification of the modifiable factors, such as better control of diabetes, treatment of peripheral neuropathy, and early management of ulcers, may improve the outcome and facilitate healing.

Impaired quality of life and diabetic foot disease in Saudi patients with type 2 diabetes: A cross-sectional analysis.

Objectives:This study aimed to assess the overall health-related quality of life in type 2 diabetes mellitus patients with diabetic foot disease compared to diabetic patients without diabetic foot and to identify the clinical utility of this assessment.Methods:A total of 250 consecutive patients with type 2 diabetes mellitus (100/150 with/without diabetic foot, respectively) were interviewed. The questionnaires of the 36-item short-form survey and region-specific foot and ankle ability measure were applied. Wagner–Meggitt wound classification was used for foot-ulcer evaluation. Follow-up of patients for 3–6 weeks was done to identify the potential clinical short outcomes of diabetic foot ulcers.Results:Type 2 diabetes mellitus patients with diabetic foot exhibited poor mental and physical health consequences. Females had more prevalence of forefoot lesions, larger ulcer size, advanced Wagner grade, and higher frequency of unhealed ulcers. Receiver operating characteristic curve analysis demonstrated high value of foot and ankle ability measure and 36-item short-form questionnaires to discriminate type 2 diabetes mellitus patients with and without diabetic foot at cutoff values of 66 and 49.6, respectively. Foot and ankle ability measure questionnaire also showed high performance for differentiating the clinical outcome of foot ulcer. Total foot and ankle ability measure subscale score above the cutoff value of 65.5 could discriminate patients with complete healing and unhealed ulcer lesions at a high sensitivity and specificity.Conclusion:The current findings confirm the impact of diabetic foot disease on type 2 diabetes mellitus overall health-related quality of life reflected in 36-item short-form questionnaire and foot and ankle ability measure questionnaire which showed high discriminative values for type 2 diabetes mellitus patient sub-grouping. Their application in routine clinical health assessment with continuous medical education programs is highly recommended to achieve a better health-related quality of life.

Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver.

Objective: To compare outcomes of diabetic foot ulcers (DFUs) treated with clostridial collagenase ointment (CCO) or silver-containing products, both in combination with sharp debridement as needed.Approach: One hundred two subjects with qualifying DFUs were randomized to daily treatment with either CCO or a silver-containing product for 6 weeks followed by a 4 -week follow-up period. The primary outcome was the mean percent reduction in DFU area. A secondary outcome was the incidence of ulcer infections between groups.Results: At the end of treatment, the mean percent reduction in area from baseline of DFUs treated with CCO was 62% (p < 0.0001) and with silver was 40% (p < 0.0001). The difference between groups—22%—was not statistically significant (p = 0.071). Among ulcers closed by the end of treatment, the mean time to closure was 31.1 ± 9.0 days versus 37.1 ± 7.7 days, respectively (not statistically significant). There was a numerically greater incidence of target ulcer infections in the silver group (11, 21.6%) than in the CCO group (5, 9.8%; p = 0.208). No clinically relevant safety signals were identified in either group.Innovation: CCO treatment can progress a wound toward closure. Ulcer infection prophylaxis may not be sacrificed when treating DFU with CCO in lieu of silver-containing products.Conclusion: Both CCO and silver-containing products promote significant reduction in DFU area over 6 weeks of treatment with no clinically relevant safety concerns. Mean percent reduction in lesion area was numerically (22%) but not significantly greater with CCO compared to silver, as was time to ulcer closure, with an incidence of ulcer infection at least as low as for silver-containing products.

A one year cross sectional study on role of Wagner’s classification in predicting the outcome in diabetic foot ulcer patients

Background: Diabetes mellitus-related foot ulceration is very common. Several classification systems for diabetic foot ulcers have been proposed. The present study was intended to assess the role of Wagner wound classification in predicting the outcome of diabetic foot ulcer and also know the grade of Wagner’s classification to which majority of diabetic foot ulcer patients.Methods: This present one year cross sectional study was carried out at the Department of General Surgery. A total of 100 patients with diabetic foot ulcer who presented during the study period were included. The diabetic foot ulcers were graded according to the Wagner’s classification. The relative risk of amputation in different grades of diabetic foot ulcer based on Wagner classification was determined.Results: In this study majority of the patients were males (79%) and the male to female ratio was 3.76:1. The mean age was noted as 55.8±10.45 years. Majority of the patients had duration of ulcer less than one month (88%). Surrounding skin was inflamed in 60% of the patients, necrosis was present in 40% and slough was noted in 98% while 44% of the patients had necrotic tissue. Based on Wagner’s Classification, most of the patients (48%) had Grade II diabetic foot ulcers. With regard to management, in 44% of the patients’ debridement was done and 36% of the patients had disarticulation or amputation in 36%. Of the 48 patients with grade II ulcer, 79% of the patients had healing without amputation. Of the 58 patients with grade I and II diabetic foot ulcers, 82.76% had healing without amputation compared to 17.24% of the patients who needed amputation. Patients with Grade III, IV and V had 3.59 times higher risk of amputation compared to patients with grade I and II. (p&lt;0.001; 95% CI- 1.95 to 6.62).Conclusions: Grading of diabetic foot ulcer based on Wagner’s classification affects and predicts the outcome and the risk of amputation increases with increasing grade. Most of the patients admitted for diabetic foot ulcers in our hospital belonged to Wagner’s grade II (48%).

Cortisol Synthesis Enzyme CYP11B1 as Tissue Biomarker for Diabetic Foot Ulcers

An urgent need exists to identify predictive biomarkers to guide management of diabetic foot ulcers (DFUs). The steroid hormone, cortisol, is elevated in chronic inflammatory states and its pathogenic role and/or prognostic role for poor outcomes across a range of diseases has been suggested. However, the role of cortisol in DFUs is not well understood and the significance of local, tissue-specific cortisol regulation in DFUs remains unclear. We performed a multi-center study of 63 well vascularized, superficial neuropathic, non-infected DFU subjects receiving standard care and used wound biopsy obtained at baseline study to quantify expression levels (via immunohistochemistry) of the major cortisol synthesis enzymes CYP11B1 and 11BHSD1, and other inflammatory cytokines. Subjects were predominantly men in their late-fifties (58±10 years) with poor glycemic control (HbA1C 8.9±2.3%); while hemoglobin (12.6±1.8g/dl), creatinine (1.27±0.5mg/dl) and albumin (4.1±0.42g/dl) were within the normal range. We found high cutaneous levels of CYP11B1 strongly linked to failure to heal DFUs at 6 weeks (p≤0.016), while 11BHSD1 did not correlate with healing (p=0.351). In the logistic regression analyses controlling for demographics and disease characteristics, higher levels of CYP11B1 (10-based log-transformed) were predictive of non-healing of DFU at 6 weeks (OR = 6.83, p =.010). High local tissue levels of the pro-inflammatory TNFalpha were also significantly associated with lack of ulcer healing (p≤0.019). This observation is consistent with reports that TNFalpha is essential for local induction of CYP11B1. In turn, local induction of CYP11B1 and subsequent induced tissue cortisol levels activate membranous glucocorticoid receptor triggering PLC/PKC/GSK-3beta/beta-catenin pathway that inhibits healing. Taken together, these data suggest CYP11B1 is a potential predictive biomarker for DFU outcomes, and may serve as a future target for therapeutic interventions. Disclosure L. Vileikyte: None. B. Shen: None. I. Pastar: None. A.J. Boulton: None. R. Kirsner: None. M. Tomic-Canic: None. M. Hardman: None.

Does Improving Glycemic Control Accelerate Healing of Diabetic Foot Ulcers?

Diabetic foot ulcers (DFU) are common, complex and costly. Chronic hyperglycemia is associated with delayed wound healing and lower limb amputations. We performed a systematic review of literature looking for studies that assessed the impact of change in glycemic control on DFU healing. Our search included key words such as ’glycemic control’, ’glycated hemoglobin (HbA1c)’, cross-linking them with text such as ’diabetic foot ulcer’, and ’wound healing’. We included published articles and studies in English with at least one component of observation or intervention that included effect of change in glycemic control and/or HbA1c on DFU healing; we excluded studies involving only DFU related amputations as outcome. Six studies were identified- 1 randomized controlled trial (RCT), 2 observational studies, 1 pre-post study, 1 case report and 1 pooled analysis. All studies were heterogeneous in design, sample size, duration, patient characteristics, DFU characteristics, and end points or outcomes, including the manner in which glycemia was measured. While the RCT was inconclusive due to recruitment failure, the observational studies did show a relationship between wound healing and improvement in glycemic control. The pre-post study and case report described considerable improvement in healing rates of DFU that had been previously resistant to conventional care, after strictly controlling glycemia. The pooled analysis demonstrated that worsening glycemic control during DFU treatment significantly decreased the odds of wound healing. Surprisingly, there exists a major gap of evidence with regards to whether prospectively lowering glycemic exposure improves DFU outcomes in patients with diabetes. The absence of a proper RCT, the heterogeneity of the existing studies, and the lack of consistency in their findings warrant a well designed prospective, randomized, controlled study to clearly establish whether aggressive glycemic control should be a standard in the management of diabetic foot ulcers. Disclosure M.D. Patil: None. U. Gunasekaran: None. J. La Fontaine: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Sanofi US, Novo Nordisk Inc.. Advisory Panel; Self; Intarcia Therapeutics, Inc.. Other Relationship; Self; American Diabetes Association.

Bedside Blind Bone Biopsy (B4) for Suspected Diabetic Foot Osteitis–A Reliable Tool to Manage Medical Treatment?

Performed by a diabetologist, B4 has been recently shown as an easy and safe procedure. To assess Exclusive Medical Treatment (EMT: offloading, wound care ± antibiotherapy) determined by B4 in suspected Diabetic Foot Ulcer (DFU) osteitis, we compared DFU outcome between proved (B4+) and ruled out osteitis (B4-) with microbial culture.A prospective observational study was conducted in our Diabetology Unit during a 16-month period (12.17.2015-09.04.2017). Among 244 patients admitted with DFU, we included 31 (13%) consecutive patients with type 2 diabetes mellitus (T2DM) and clinical and/or radiological suspicion of osteitis. For each, B4 was decided by our DFU multidisciplinary board. B4 was performed ≥ 2 weeks after antibiotics discontinuation in case of prior exposure. A 6-weeks targeted antibiotherapy was indicated for proven osteitis by prolonged culture (B4+). In case of negative cultures (B4-), no antibiotherapy was prescribed. The primary outcome was the complete DFU healing with EMT at 6 months.Patients characteristics and results are summarized in Table 1. Around 50% of suspected osteitis was B4-, which prevented from unneeded antibiotics without poorer healing outcomes.B4 might be a reliable tool for managing EMT in suspected DFU osteitis. Disclosure F. Féron: None. D. Gauthier: None. J. Gautier: None. J. Kevorkian: None.

Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis

BackgroundAmong non-communicable diseases, diabetes represents a growing public health problem in Africa, where diabetes-related needs remain mostly unmet and the disabling features of foot are worsened by hygienic, cultural, and healthcare issues. We aimed to review clinical characteristics, prevalence, and outcomes of patients with diabetic foot ulcer in Africa. MethodsWe searched the literature for cross-sectional and longitudinal studies reporting the characteristics of patients with diabetic foot in African countries, with a particular focus on ulcer prevalence, amputation rate, and mortality. FindingsFifty-five full-text papers and ten abstracts were retrieved, reporting data from 19 African countries on 56,173 diabetic patients. According to the data collected, the overall prevalence of foot ulcers was 13% and increased over time, especially since 2001. Approximately 15% of patients with foot lesions underwent major amputation and 14.2% died during hospitalization. In patients with diabetic ulcers, insulin therapy was uncommon and neuropathy was the most common predisposing factor, but the prevalence of peripheral arterial disease correlated with amputation rates. Amputation and mortality decreased over time, probably as result of the implementation of screening programs in the last ten years. Mortality was directly related to previous amputation. InterpretationThe diabetic foot disease in Africa is a growing problem and is burden by high rate of in-hospital mortality. Educational interventions and screening programs including evaluation of the vascular status may play a crucial role to counter diabetic foot disease in Africa.

Risk factors deciding the prevention and healing of diabetic foot ulcer: a prospective study in Chennai Medical College Hospital and Research Center Irungalur, Trichy, Tamil Nadu, India; a rural based tertiary medical care centre

Background: Diabetic foot ulcer is the one among and the most common complication of diabetes mellitus patients. Various studies from over the world for the past 2 decades discuss the important risk factors that decide the prevention and outcome of diabetic foot ulcer. In our prospective study we have discussed the risk factors focused on prevention and treatment of diabetic foot ulcer in a rural tertiary medical care centre.Methods: Totally 940 patients with the clinical diagnosis of diabetic foot ulcer admitted in our hospital surgical department were studied prospectively with their clinical symptoms and signs of diabetic foot ulcer and various evaluations done for the comorbid conditions with the help of other specialty departments. All these risk factors studied in our rural based tertiary medical centre were collected in a designed format were studied and discussed in comparison to the chosen data available in various studies done at various countries.Results: All the 940 patients admitted for diabetic foot ulcer who underwent a methodical evaluation for risk factor showed an elevated HbA1c more than 8 in 720 (77.5%) patients, bony involvement like osteomyelitis in 274 patients (29%) , peripheral vascular disease in 421 (44.9%), neuropathy in 533 patients (56.7%), nephropathy 163 (17.34%), retinopathy in 102 (10.85%) and heart disease in 375 (39.89%).Conclusions: Proper protocols to the prevention and management of foot ulcer in diabetic patients have not reached many health care centres and it is imperative to stress on the related comorbid risk factors which influence the prevention and healing of diabetic foot ulcer. Present study done at a rural tertiary health care centre is mainly focused on the incidence of risk factors which modulates and modify the diabetic foot ulcer prevention and management. This study aims to support the health professionals to identify the risk factors apart from the clinical picture of diabetic foot ulcer that may enhance the efficient management and avoid the unnecessary morbidity and mortality.

Association between QTc interval prolongation and outcomes of diabetic foot ulcers: Data from a 4-year follow-up study in China

ObjectivesTo examine whether QTc interval prolongation is an independent risk factor of outcomes in patients with diabetic foot ulcers (DFU). Research design and methods331 patients with type 2 diabetes and DFU hospitalized in a Chinese tertiary hospital were recruited.ECG was done at baseline and QTc interval was calculated through Bazett's formula. Participants were classified into 2 groups according to the QTc interval as prolonged (≥440 ms) or not (<440 ms). These patients were followed-up for an average of 48 months to observe the outcomes, including ulcer healing, ulcer recurrence, nonfatal cerebral or cardiovascular events (NCCVE), cerebral cardiovascular death, cardiac death and all-cause death. The associations between the risk of outcomes and QTc interval prolongation, as well as per 1-SD increase in QTc interval were analyzed by Cox proportional-hazards models. ResultsIn terms of the univariate Cox proportional hazard models, patients with QTc interval prolongation had a higher all-cause mortality (HR = 1.621, 95%CI: 1.040–2.526, P = .013), higher cardiac mortality (HR = 2.011 95%CI: 1.106–3.657, P = .019), higher cerebral cardiovascular mortality (HR = 1.525, 95%CI: 0.8151–2.852, P = .045). The multivariate analysis showed that QTc prolongation was an independent risk factor for cardiac death (HR = 5.465, 95%CI: 2.818–8.112, P = .039). Similar results were obtained when QTc interval was used as a continue variable, a 1-SD increase in QTc interval was associated with an 5.883 times risk for cardiac mortality (HR = 6.883, 95%CI: 4.153–9.613, P = .012). The association between QTc interval prolongation with ulcer healing, recurrence and NCCVE were not observed either in univariate or multivariate analysis (P > .05). ConclusionQTc interval prolongation was a plausible predictor for cardiac death in DFU patients, but it cannot accurately predict ulcer healing or recurrence.

Update on management of diabetic foot ulcers.

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

Diabetic foot ulcer outcomes from a podiatry led tertiary service in Kuwait.

ABSTRACT Objective: This single-centred study aims to evaluate the incidence, risk factors and treatment outcomes of a podiatry led, evidence-based diabetic foot ulcer (DFU) clinic. Research design and methods: Data from the DFU database and patient electronic health records were retrospectively collected from patients with new DFUs who were referred for treatment to the Department of Podiatry, Dasman Diabetes Institute, Kuwait, from 1 October 2014, to 31 December 2016. Patients were followed-up until healing occurred or until 6 months after the study end date, whichever came first. Results: All data were analysed using IBM SPSS version 24 software. Data were collected from 230 patients with 335 DFUs. Most DFUs (67%) were present for <3 months from the time of the first podiatry appointment. A total of 56% of DFUs were classified as neuropathic. Most (72%) DFUs healed, with a median healing time of 52.0 days. Chronic kidney disease (p = 0.001), retinopathy (p = 0.03), smoking (p = 0.02), ulcer location (p = 0.03), peripheral arterial disease (PAD) (p = 0.004) and osteomyelitis (p = 0.05) were found to have a meaningful association with DFU outcome. The number of days to heal was associated with ulcer classification (p = 0.005), bacterial infection (p = 0.002), osteomyelitis (p = < 0.001) and PAD (p = < 0.001). Conclusions: The incidence of new DFUs in our tertiary clinic is 3.4%. The incidence of diabetic foot ulceration, days to heal, healing rate and the risk factors influencing healing are in accordance with other multidisciplinary facilities with podiatry input.