Diabetic Foot & Ankle最新文献

Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot lesions (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with a diagnosis of DF and CLI. All patients were followed-up for at least 1 year and/or total recovery. The primary endpoint was 1-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At 1 year, AFS, limb salvage, and survival rates were 34%, 34%, and 83%, respectively. Lesions located proximal to the Lisfranc joint were associated with major amputation (HR 2.1 [1.2-3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log-rank p = 0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02-59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had a greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival.

Background: Foot complications such as ulceration and neuropathy are common complications of diabetes mellitus (DM). Previous reports have demonstrated a possible increased risk of these complications in diabetic patients with low levels of serum vitamin D.Objectctive: The purpose of this study is to compare serum vitamin D levels in diabetic patients with and without Charcot neuroarthropathy (CN), peripheral arterial disease (PAD), infection (DFI), ulceration (DFU), and peripheral neuropathy (DPN). Design: A retrospective chart review of all patients undergoing foot and ankle surgery with a history of DM over a 13 month period was performed. From this cohort, fifty subjects with CN were matched with 50 without CN and preoperative lab values were compared. A secondary evaluation was performed on the subjects' other comorbidities including PAD, DFI, DFU, and DPN. Results: Seventy-eight percent of our patients had vitamin D deficiency or insufficiency. Preoperative serum vitamin D levels were not significantly different between diabetic patients with and without CN (p = 0.55). Diabetic patients with PAD (p = 0.03), DFI (p = 0.0006), and DFU (p = 0.04) were all found to have significantly lower serum vitamin D levels than diabetic patients without these complications. Lower levels of serum albumin and higher serum creatinine were also noted with subjects with PAD, DFI, DPN, and DFU. While seasonal serum vitamin D level fluctuation was noted, this difference did not reach statistical significance with the numbers available. Conclusion: We found various lower extremity complications to be associated with low serum vitamin D including PAD, DFI, and DFU. While other studies have questioned the role of vitamin D and CN, we were unable to identify any significant difference between diabetic patients with and without Charcot neuroarthropathy. Level of evidence: Level 2.

Background: Diabetic foot remains a challenge in most low-middle-income countries (LMICs). A severe deficit in data exists on them in sub-Saharan Africa (SSA). Up-to-date data on the longitudinal trajectories and determinants can provide a benchmark for reducing diabetic foot complications in SSA. Objective: The primary objective of this study was to estimate trends in the incidence of diabetic foot and determine predictors in an adult Ghanaian diabetes cohort. Design: The study is a retrospective longitudinal study over a 12 year period. Methods: We applied Poisson regression analysis and Cox proportional hazard models to demographic and clinical information obtained from patients who enrolled in a diabetes specialist clinic in Ghana from 2005 to 2016 to identify longitudinal trends in incidence and predictors of diabetic foot. Results: The study comprised 7383 patients (63.8% female, mean follow-up duration: 8.6 years). The mean incidence of foot disorders was 8.39% (5.27% males and 3.12% females). An increase in the incidence of diabetic foot ranging from 3.25% in 2005 to 12.57% in 2016, p < 0.001, was determined. Diabetic foot, with adjusted hazard ratio (HR; 95% confidence interval (CI)), was predicted by disease duration, that is, for every 5-year increase in diabetes duration: 2.56 (1.41-3.06); male gender: 3.51 (1.41-3.06); increased body mass index (BMI), that is, for every 5 kg/m²: 3.20 (2.51-7.52); poor glycaemic control, that is, for every percentage increase in HbA1c: 1.11 (1.05-2.25), hypertension: 1.14 (1.12-3.21); nephropathy: 1.15 (1.12-3.21); and previous foot disorders: 3.24 (2.12-7.21). Conclusions: We have found a trend towards an increased incidence of diabetic foot in an outpatient tertiary diabetes setting in Ghana. Systemic and individual-level factors aimed at preventive foot screening as well as vascular risk factor control should be intensified in diabetic patients in Ghana and other LMICs. Abbreviations: BMI: Body Mass Index, BP: Blood Pressure, CI: Confidence Interval, HR: Hazard Ratio, HbA1c: Glycated Hemoglobin, PAD: Peripheral Arterial Disease, NCDs: Non Communicable Disease, SSA: Sub Saharan Africa.

Introduction: Diabetic foot ulcers are one of the most frequent complications of diabetes; such ulcers cause an increase in the costs of the health care of the diabetic patient and can even cause disability due to amputation in the patient. Although a proportion of patients achieve a spontaneous closure of ulcers, others require medical or surgical treatment. Objective: To determine the cost-effectiveness of the intra- and perilesional application of recombinant human epidermal growth factor (rhEGF), as opposed to conventional therapy for the management of patients diagnosed with Wagner's 3 or 4 diabetic foot ulcer in Colombia. Methodology: Using a Markov model, the process of care of a diabetic patient with diagnosis of Wagner's 3 or 4 ulcer receiving conventional treatment, or intra- and perilesional rhEGF, is configured. The evaluation cycles of the treatments are weekly over a 5-year horizon and the outcomes evaluated are quality-adjusted life years (QALYs) and the number of amputations avoided by each treatment scheme, in addition to the total costs for treatments. Results: For the analysed base case, in the outcome of amputations, it was found that the factor presents 39 fewer amputations, in a cohort of 100 patients, compared with conventional treatment. Likewise, QALYs are 0.65 more with the use of rhEGF in an average patient. The estimated cost-utility ratio for the base case would be below the threshold established for Colombia. Conclusions: The intra- and perilesional application of rhEGF is a more effective therapeutic option than conventional therapy in the treatment of patients with Wagner's 3 or 4 diabetic foot ulcers and is cost-effective, taking as an outcome the QALYs for Colombia from the perspective of the health system.

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.

Background: Ill-defined areas of water-like signal on bone magnetic resonance imaging (MRI), characterized as bone marrow edema or edema-equivalent signal-changes (EESC), is a hallmark of active-stage pedal neuro-osteoarthropathy (Charcot foot) in painless diabetic neuropathy, and is accompanied by local soft-tissue edema and hyperthermia. The longitudinal effects on EESC of treating the foot in a walking cast were elucidated by reviewing consecutive cases of a diabetic foot clinic. Study design: Retrospective observational study, chart review Material and methods: Cases with active-stage Charcot foot were considered, in whom written reports on baseline and follow-up MRI studies were available for assessment. Only cases without concomitant infection or skin ulcer were chosen, in whom both was documented, onset of symptomatic foot swelling and patient compliance with cast treatment. Results: From 1994 to 2017, 45 consecutive cases in 37 patients were retrieved, with 95 MRI follow-up studies (1-6 per case, average interval between studies 13 weeks). Decreasing EESC was documented in 66/95 (69%) follow-up studies. However, 29/95 (31%) studies revealed temporarily increasing, migrating or stagnating EESC. Conclusion: EESC on MRI disappear in response to prolonged offloading and immobilizing treatment; however, physiologic as well as pathologic fluctuations of posttraumatic EESC have to be considered when interpreting the MR images. Conventional MRI is useful for surveillance of active-stage Charcot foot recovery.

Over the past generation, limb preservation programs and diabetic foot services have begun to proliferate within academic health science centers as well as within health-care systems in general. We describe four key components for a successful program that, developed sequentially with temporal overlap, can allow the program to scale. The first component includes establishment of a 'hot foot line' for urgent emergency department/inpatient referral. The second includes development of a wound-healing clinic to address outpatient care through to remission. The third component focuses on the diabetic foot in remission to maximize ulcer-free days following healing. The fourth and final component focuses on implementation of local and widespread screening clinics to identify and triage patients into appropriate therapeutic and surveillance programs for healing, remission, and primary prevention. Along with developing each of these components, we describe discrete methods to quantify success.

Background: One of the complications of the diabetes mellitus is the amputation of the lower limbs. This complication may be developed after an insidious ulcer, that may be raised by the peripheral neuropathy or the ischaemic limb, and that the ulcer get infected. That is, to develop an ulcer, in the diabetic patient, three factors should be taken into the account, the autonomic nervous system, the blood supply and the inmune system. Methods: In this work, the thermogram is used to identify regions on the plantar skin with blood supply deficiencies and the behaviour of the thermoregulation process. Within the thermogram of the plantar skin, it can be identify local regions with low and high temperatures that corresponds to ischemic or inflammatory process on that part of the skin. Results: The findings within the 186 thermograms of diabetic patients, obtained from three hospitals and from INAOE facilities, showed, first, the thermograms of the plantar skin of two diabetic patients, acquired in two different times show that the temperature distribution and the average temperatures, vary slightly for a period of weeks. Second, the thermograms of two patients, who both developed insidious ulcers which evolved favourable, demonstrated the importance of the immune system and the drug therapy. These patients are, one who has a Charcot foot, and in the second one, the patient had loss the sensibility of the feet. Finally, the thermograms of two patients, showing abrupt temperature change within small regions in the plantar skin, are discussed. Conclusion: A diabetic patient, with an asymmetric thermogram, as physiological interpretation of the thermoregulation, may indicate a decrease of the blood supply, which may be corroborated by vascular ultrasound. The regions of abrupt temperature change, cold or hot spots, may correspond to ischaemic or inflammatory processes.

Background: Diabetic foot (DF) disease causes severe suffering around the world, and appropriate self-care activities are needed to prevent and treat this condition. However, all too often, self-care activities are less than optimal and clinicians find themselves unable to influence them in a positive direction. Clinicians' and researchers' mental models of the DF tend to be dichotomous: either the patient has or does not have an active ulcer or other DF disease. This mode of thinking hides the long-term perspective of DF disease, where patients' previous experiences and expectations for the future influence their current behavior. Thus, there is a need for a different perspective on DF disease to better understand patients' perspectives and thereby improve self-care, leading to more effective prevention and treatment. Objective: To present a novel framework, the process perspective on the DF, which can explain inadequate self-care behaviors not easily understood with a dichotomous perspective, and how they can be changed. Results: Three fictive clinical examples are used to illustrate how the process perspective on the DF can be used to understand how patients' previous experiences and expectations for the future influence their current behavior. In particular, this process perspective is used to understand how patients' beliefs and behaviors are sometimes self-reinforcing, resulting in stable behavior patterns, here referred to as 'DF cycles'. These cycles are quite common in clinical practice but are difficult to analyze using a dichotomous perspective on DF disease. The process perspective on the DF is used to analyze specific 'vicious' DF cycles of inadequate patient behavior and to find ways to transform them into 'virtuous' DF cycles, resulting in effective prevention and treatment. Conclusions: The process perspective on the DF seems suitable for understanding inadequate patient behaviors not easily understood with a dichotomous perspective on DF disease, opening up new avenues for clinical practice and research to help patients live a life with long remission phases, few relapses, and a high quality of life.

Background: Diabetic patients are susceptible to developing foot ulcers with serious complications such as osteomyelitis and amputations. Treatment approaches are still empirical and the benefit of usual procedures such as surgical debridement has not been properly evaluated. Photodynamic Therapy (PDT) is a non-invasive and highly efficient method for the treatment of the diabetic foot, being able to eradicate the infection and to stimulate healing, decreasing considerably the amputation risk. In the day-to-day practice of our service, we have been faced with the question whether debridement is necessary before PDT. In here, we designed a study to answer that question. Methods: Patients were divided in two groups: In one of the groups (n = 17), debridement was performed before PDT and in the other (n = 40) only PDT treatment was performed. PDT sessions were performed once a week in all patients until healing was achieved, as indicated by visual inspection as well as by radiographic and laboratory exams. At the start of the study, the two groups had no statistical differences concerning their clinical features: average age, gender, insulin use, diabetes mellitus onset time and previous amputations. Results: PDT was effective in the treatment of 100% of the patients showing no relapses after one year of follow up. The group submitted to PDT without previous debridement had a statistically significant (p = 0.036, Mann-Whitney) shorter cure time (29 days, ~27%). Conclusion: Our data indicates that debridement is not necessary in the treatment of diabetic foot in patients that have enough peripheral arterial perfusion. In addition, we reproduced previous studies confirming that PDT is an efficient, safe, simple and affordable treatment method for the diabetic foot.